India - Second Tamil Nadu Integrated Nutrition Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No.: 17755 IMPLEMENTATION COMPLETION REPORT INDIA SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (CREDIT 2158-IN) April 24, 1998 Health, Population and Nutrition Unit South Asia Region T}iis document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (as of January 23, 1998) Currency Unit = Indian Rupee (Rs.) Rupee 1 = US$0.025 US$1.00 = Rupee 39.50 GOVERNMENT FISCAL YEAR April 1 - March 31 ABBREVIATIONS AND ACRONYMS APERP Andhra Pradesh Economic Restructuring Project ANM Auxiliary Nurse-Midwife CDPO Child Development Project Officer CNC Community Nutrition Center CNS Community Nutrition Supervisor CNW Community Nutrition Worker CNI Community Nutrition Instructress CSSM Child Survival and Safe Motherhood Project CTC Communications and Training Center CWO Community Welfare Organizers DEA Department of Economic Affairs DWCD Department of Women and Child Development DWCRA Developing Women and Children in Rural Areas GOI Government of India GOTN Government of Tamil Nadu ICDS Integrated Child Development Services IDA International Development Association IEC Information Education and Communication IMR Infant Mortality Rate LBW Low Birth Weight MTS Mid Term Survey NCHS National Center for Health Statistics NFHS National Family Health Survey NGO Non-Governmental Organization NNMP Nutritious Meals Program NMC Nutritious Meals Center NNMB National Nutrition Monitoring Bureau PMU Project Management Unit SAR Staff Appraisal Report SRS Sample Registration System TINP Tamil Nadu Integrated Nutrition Project VHN Village Health Nurse WCDP Women and Child Development Project Vice President Mieko Nishimizu Director Edwin Lim Sector Manager : Richard Skolnik Team Leader Anthony Measham  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT 1NDIA SECOND TAMIL NADU INTEGRATED NUTRMTON PROJECT (CREDIT 2158-IN) CONTENTS Page No. Preface i Evaluation Summary ii PART I: Project Implementation Assessment A. Project Objectives 1 B. Achievement of Project Objectives 3 C. Major Factors Affecting Project Implementation 12 D. Project Sustainability 13 E. Bank Performance 13 F. Borrower Performance 14 G. Assessment of Outcome 14 H. Future Operation 15 I. Lessons Leamed 15 PART II: Statistical Tables Table 1: Summary of Assessments 18 Table 2: Related Bank Credits 20 Table 3: Project Timetable 23 Table 4: Credit Disbursements: Cumulative Estimated and Actual 24 Table 5: Key Indicators for Project Implementation 25 Table 6: Studies Included in the Project 26 Table 7A: Project Costs 28 Table 7B: Project Financing 29 Table 8: Status of Legal Covenants 30 Table 9: Compliance with Operational Manual Statements 35 Table 10: Bank Resources: Staff Inputs 36 Table 11: Bank Resources: Missions 37 APPENDICES Appendix A. The ICR Mission's Aide-Memoire Appendix B. Borrower's Contribution to the ICR This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not oth'erwise be disclosed without. World Bank authorization.  i IMPLEMENTATION COMPLETION REPORT INDIA SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (CREDIT 2158-IN) PREFACE This is the Implementation Completion Report (ICR) for the Second Tamil Nadu Integrated Nutrition Project in India (Credit No. 21 58-IN). A total IDA credit of US$95.8 million (SDR 73.5 million equivalent) was approved on June 14, 1990 and made effective on December 5, 1990. This amount was subsequently reduced to US$72.8 million. The credit closed on the original closing date of December 31, 1997. The credit amount was fully disbursed, with the last disbursement taking place in January 1998. This ICR was prepared by Anthony Measham (Team Leader) and Stuart Gillespie (Consultant), with technical assistance from Kathleen Finn, Meera Priyadarshi, R. Sethuraman, Alaka Singh, P. Subramaniyam, and Krishna D. Rao. Nira Singh provided office technology assistance. The ICR was reviewed by Richard Skolnik (Sector Manager, SASHP) and Kazuko Uchimura (Project Advisor, SARRI). Preparation of this ICR began during the October 1997 supervision mission. It is based on material in the project files, field visits, and discussions with beneficiaries, project staff, Government officials and Bank staff. The Borrower contributed to the preparation of the ICR by preparing its own evaluation of the project's preparation and execution. Comments on the report drafts were received from the Borrower and taken into account in the final version. The cooperation and assistance of Government of India (GOI) and the Government of Tamil Nadu (GOTN) are gratefully acknowledged.  i I[MPLEMENTATION COMPLETION REPORT INDIA SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (CREDIT 2158-IN) EVALUATION SUMMARY Introduction 1. The Second Tarmil Nadu Integrated Nutrition Project (TINP II), launched in 1991, was the second nutrition operation supported by the World Bank in India. Its predecessor, TINP I, became well-known in international nutrition circles during the 1980s as a "success story", having achieved a highly significant reduction in severe early childhood malnutrition. Implementation of TINP II largely overlapped with that of two other IDA-supported Integrated Child Development Services (ICDS) projects. ICDS I, approved in 1990, covered the states of Andhra Pradesh and Orissa, while ICDS II, approved in 1993, covered the states of Bihar and Madhya Pradesh. Project Objectives 2. The overall goal of TINP II was to improve the nutrition and health status of children 0-72 months of age, with particular emphasis on 0-36 month olds, and pregnant and lactating women. Specifically, the project aimed to (i) reduce severe malnutrition among 6-36 month old children by 50% and 25% in new and existing project areas, respectively; (ii) increase the proportion of 6-36 month old children in normal and Grade I nutritional status by 50% and 35% in new and existing project areas, respectively; and (iii) to contribute towards a reduction in infant mortality rate from 84 to 55 per 1,000 live births and to a 50% reduction in the incidence of low birth weight. 3. The project covered a total of 318 of Tamil Nadu's 385 rural blocks in 19 of 23 districts, including the strengthening of activities in 122 existing (i.e., TINP I) blocks and expansion to 194 additional blocks. The remaining rural blocks were covered by the ICDS program. 4. The core strategies intended to realize these objectives were regular growth monitoring, nutrition eduction and health checks for all children, with therapeutic supplementary feeding of moderately and severely malnourished and growth-faltering children, and high-risk pregnant and lactating women. 5. Learning from TINP I, several new or strengthened strategies were proposed for TINP II, including (i) the inclusion of moderately malnourished children in the supplementary feeding program; (ii) improved coverage and quality of antenatal services aimed at improving maternal nutrition and reducing low birth weight incidence; (iii) improved coverage of small hamlets and outlying habitations through appropriate coverage strategies; (iv) strengthening of health referral services for diagnosis and treatment of severely malnourished children and high-risk pregnant  ii mothers; (v) improved child feeding and care practices through effective communications; (vi) improved co-ordination between nutrition and health personnel through effective joint training and supervision; and (vii) community education including the formation of new, and strengthening of existing, women's groups. Implementation Experience and Results 6. The project was successful in achieving its severe malnutrition and infant mortality rate reduction objectives. The moderate malnutrition reduction objective, which in retrospect was too ambitious, was not achieved, although some progress was made. Limited data render it difficult to come to a conclusion with regard to the low birth weight incidence objective. Although there is some evidence to suggest a significant improvement, it seems doubtful that the project made a major contribution to this change. It appears that the gender gap in child nutritional status which has existed since the inception of TINP I has narrowed. With regard to geographical targeting, for the hamlets that were covered, project performance was as effective as in larger, more accessible villages. Districts which were under TINP I in the 1 980s performed better on average than those newly-included in TINP II. 7. Service delivery was patchy with some of the most important process objectives not being achieved. Block-level training worked well, though there was a significant backlog in refresher training which compromised quality and led to serious gaps in knowledge and awareness. The existence of significant inter-district variations in some aspects of service delivery performance suggests the need for a modular, site-specific approach to training. 8. The communications component, which was based on sound formative research, was limited by its bias towards mass media approaches. More attention is required to the development of the CNW's inter-personal counseling skills. The geographical variation, as with service delivery, again suggests that strategies should be flexible, decentralized and problem-focused. 9. After a slow start, community mobilization, and women's group formation and training in particular, began to pick up in the latter stages of the project, although working groups need strengthening if real and sustainable community ownership is to be achieved. Linkages to other government-supported income-generation schemes for women are needed. Opportunities were realized to orient newly-elected panchayat members who themselves became advocates for the project. 10. The monitoring system remains one of the strengths of TINP II, as it was with TINP I. The system of tracking key process and outcome data, with built-in data quality checks and a streamlined set of registers, is efficient and action-oriented. Blocks that are found to be lagging are followed up by district-level officers, and project management is kept informed of district- level performance through a wall chart that is updated every month. However there are some serious gaps in monitoring implementation which need to be addressed. Evaluation has been  iii weak throughout the project, seriously delaying and limiting judgement of progress on objectives. 11. Overall, the timeliness, quality and utility of operational research was unsatisfactory. Improved assessment criteria for bidding agencies and better monitoring of progress is required to ensure timely, high quality work and results which can be used to improve the program during its lifetime. 12. Tamil Nadu is one of the five states involved in the forthcoming Woman and Child Development Project. From January 1998, all the 318 TINP I blocks were incorporated into the ICDS program, which is being universalized throughout India. 13. Overall, during the mid-project period from 1993-1995, there was a significant fall-off in cominitment, integrity and supervision from project management which percolated down to all levels, adversely affecting morale and motivation. This fall-off reflected major political turmoil which affected every sector in Tamil Nadu during the period. These problems were addressed in 1996 by a new project team which successfully set about revitalizing the project. Quality improvement planning, an open, action-oriented management style and supportive supervision were all institutionalized to this end. 14. Given the turbulent environment in which the project operated, it continued to function reasonably well. This owed much to the solid human resource foundation built by TINP I which was resilient in the face of deteriorating project management. The terminal evaluation impact findings provide some support for this supposition in that TINP I districts performed particularly well, and far better than the Phase V districts introduced in 1995. 15. Bank performance was mixed. On the plus side, assistance was satisfactory through appraisal and supervision missions were thorough and proactive in dealing with problems. However, in the several instances where action was not forthcoming, e.g., on emphasizing quality improvement as much as project expansion, in dealing with the problems of non-resident village workers, and on procurement irregularities, the Bank should have been more forceful in seeking appropriate remedies. Bank performance and Borrower performance both improved in the final two years of the project. Borrower performance compared unfavorably with that under TINP I on a number of counts, notably in not emphasizing quality of services, the key to reducing moderate malnutrition. Key Lessons Learned 16. The main lesson learned from TINP II is that the strategies adopted to deal with moderate malnutrition were broadly appropriate, but there is a continuing need to intensify the focus on localized capacity-building, community mobilization and targeted, inter-personal comnmunications. Severe malnutrition is now minimal but moderate malnutrition, with all its detrimental consequences, remains significant. There needs to be greater emphasis in future on improving home-based care and feeding of the youngest children to prevent them from becoming  iv malnourished. Geographically, targeting to remote hamlets needs to be prioritized, for example, through the establishment of mini-centers. 17. Community ownership should remain a priority goal. The experience in the latter half of the project with social mobilization should be drawn upon to facilitate active involvement of more of the community. 18. Overall, supportive counselling of caregivers and high-quality service delivery, allied with a concerted move towards social mobilization and participatory planning, should be the pillars of future nutrition improvement strategy. Decentralization, quality and ownership are key overriding concerns. For the most part, these lessons have already been woven into the project strategies of the forthcoming Woman and Child Development Project in Tamil Nadu, and indeed in other states, though they will need to be vigilantly monitored during its implementation. 19. Most of these substantive lessons are relevant beyond Tamil Nadu. Nutrition interventions which are targeted using nutritional criteria, integrated within a broader health system, and effectively supervised and managed can significantly reduce severe malnutrition. TINP has shown this. It has also shown that to go further and prevent children from becoming moderately malnourished is in many ways a harder task and one that requires a significant shift in emphasis. Nutrition programming in Tamil Nadu is still evolving towards such an approach which stresses human capacity-building for home-based action, a pro-active integration with the health system, and the mobilization of communities to sustain the process beyond the project. 20. For the Bank, the main lesson learned from TINP II is the need for firmer action in dealing with chronic and persistent problems, such as the failure to carry out the mid-term evaluation survey in a timely way or the construction of additional nutrition centers in the old blocks of the project. When delays or persistent problems endanger the achievement of the project's development objectives, the Bank must be ready to take a firm stand rather than wait in the hope that agreed actions will be taken. Assessment of Outcome 21. The project outcome was marginally satisfactory in that the development objectives were largely achieved, thus consolidating the gains made by TINP I. However, a marked shift of emphasis is now required towards support for home-based care if a sustainable reduction in the moderate malnutrition prevalence is to be achieved.  1 IMPLEMENTATION COMPLETION REPORT INDIA SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (CREDIT 2158-IN) PART I: PROJECT IMPLEMENTATION ASSESSMENT I. Tamil Nadu has been a leader in community-based nutrition programs for the last two decades. The first IDA-supported nutrition project in India was the Tamil Nadu Integrated Nutrition Project (TINP I) which had a highly significant and well-documented impact on early childhood malnutrition between 1980-89. In 1982, the state-funded Nutritious Meals Program (NMP) was introduced. This program provides a noon meal to children aged 2-14 years and functions through a state-wide network of feeding centers (NMCs) run by a cadre of Child Welfare Organizers (CWOs). The Second Tamil Nadu Integrated Nutrition Project (TINP II) was launched in Tamil Nadu in 19 of 23 districts in January 1991. 2. Implementation of TINP II largely overlapped with that of two IDA-supported Integrated Child Development Services (ICDS) projects. ICDS I (approved in 1990) covered the states of Andhra Pradesh and Orissa, while ICDS II (approved in 1993) covered the states of Bihar and Madhya Pradesh. In addition, the Bank appraised two new nutrition projects in 1997/98: the ICDS component of the Andhra Pradesh Economic Restructuring Project which is scheduled for the Board in June 1998, and the Woman and Child Development Project (WCD) in Kerala, Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh, which awaits Government of India (GOI) clearance. Other related Bank-assisted projects in India include seven population projects and the Child Survival and Safe Motherhood operation, which aimed at improving family health and reducing maternal and child morbidity and mortality. A. PROJECT OBJECTIVES 3. The overall goal of TINP II was to improve the nutrition and health status of children 0-72 months of age, with p.articular emphasis on 0-36 month-olds, and pregnant and lactating women. 4. Project Coverage. TINP II was intended to cover a total of 316 of Tamil Nadu's 385 rural blocks, including the strengthening of activities in 122 existing (i.e. TINP I) blocks and expansion to 194 additional blocks. The remaining rural blocks are covered by the ICDS program. In existing TINP bloc]ks, about 6,400 Community Nutrition Centers (CNCs) were to be amalgamated with the existing NMCs. In new blocks and 20% of villages in existing blocks where there existed significanat coverage gaps, a total of 12,000 NMCs were to be strengthened by the addition of a new worker who would provide TINP services to under-three year-old children. Finally, in 2,200 villages in new and existing blocks which were not covered by either TINP or the NMP, new centers were to be established with two workers and a helper. 5. Specific Objectives. The impact objectives of TINP II were:  2 * to reduce severe malnutrition (Grade III and IV) among children 6-36 months by 50% and 25% in new and existing project areas, respectively; * to increase the proportion of children 6-36 months of age in normal and Grade I nutritional status by 50% and 35% in new and existing project areas, respectively; and * to contribute towards a reduction in infant mortality rate from 84 to 55 per 1,000 live births and to a 50% reduction in the incidence of low birth weight. Key process objectives are summarized in Table 5. 6. Project Strategy. The core strategies intended to realize these objectives were: * regular growth monitoring, nutrition education and health check-up of all children; and * therapeutic supplementary feeding of moderately and severely malnourished and growth-faltering children and high-risk pregnant and lactating women. 7. On the basis of lessons learned from TINP I, TINP II had several new or strengthened strategies, including: * inclusion of moderately malnourished children in the supplementary feeding program; * improved coverage and quality of antenatal services aimed at improving maternal nutrition and reducing low birth weight incidence; * improved coverage of smaller hamlets and outlying habitations through strategies such as women's working groups, adolescent girls, etc.; * strengthening of health referral services for diagnosis and treatment of severely malnourished children and high-risk pregnant mothers; * improved child feeding and care practices through effective communications; * pre-school education for 3-6 year-old children; * improved co-ordination between nutrition and health personnel through effective joint training and supervision; and * community education including formation of new, and strengthening of existing, women's groups.  3 B. ACHIEVEMENT OF PROJECT OBJECTIVES 8. Of the four impact objectives, two were definitely achieved - namely, reduction in severe malnutrition of 6-36 nnonth-old children and reduction in the infant mortality rate. The moderate malnutrition reduction objective - which was arguably most important -- was not achieved, although with hindsight it appears to have been too ambitious. Ex-TINP I districts notably performed better than newer districts, and there is evidence that girls are no longer more malnourished than boys. Finally, limitations with birth weight data recording preclude an accurate assessment of progress towards this objective, but there is evidence that suggests a significant improvement. However, it seems unlikely that the project made a major contribution to this change, given the relatively poor performance in providing ante-natal services, e.g., iron folate, Vitamin A and supplementary food. 9. To place the irnpact objectives in context, they can be compared with the secular trend of a 5.6% annual reduction in the prevalence of severe malnutrition (i.e., Grade III and IV weight- for-age) in Tamil Nadu during the 1980s, according to National Nutrition Monitoring Bureau (NNMB) data. This improvement occurred during the time that TINP I was underway in approximately half of the rural blocks of the state. TINP II sought to reduce severe malnutrition by 50% in seven years in new blocks - an annual decline of just over 7% and an achievable goal. Given the progress already achieved with TINP I, the other target of 25% severe malnutrition reduction in existing (ex-TINP I) blocks was also realistic. Importantly though, TINP II placed particular emphasis on reducing moderate malnutrition (i.e., Grade II weight-for-age), thus increasing the proportion of children in the combined Normal/Grade I category. 10. All currently available nutritional status data are presented in the table below. As expected, there is a strong similarity between the TINP-II (Phase I-III) baseline and the National Family Health Survey (NFHS) data collected during 1992-93. The Phase IV and V baseline carried out in 1995 shows a better nutritional situation than either of these latter surveys, implying appropriate early-targeting of TINP II in its first phases to blocks with high proportions of child malnutrition. Monitoring data suggest the nutrition situation was improving steadily over time, with prevalence consistently lower than reported in independent surveys. The one significant outlier data point comes from the 1996 mid-term evaluation survey which shows particularly high levels of severe malnutrition, but there are major concerns about the validity of these data. These doubts have since been confirmed by the terminal evaluation which reports significantly lower severe malnutrition prevalences, just a year later.  4 Table A: Comparison of 0-36 Month Child Nutritional Status (