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PROJECT INFORMATION DOCUMENT (PID)
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Report No.: AB5838
Gambia Rapid Response Nutrition Security Improvement Project
AFRICA
Health (50%);Other social services (30%);Agricultural extension
and research (10%);Pre-primary education (10%)
P121509
GOVERNMENT OF THE GAMBIA
National Nutrition Agency (NaNA)
[ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined)
June 16, 2010
September 8, 2010
July 30, 2010
1. Key development issues and rationale for Bank involvement
The Gambia, a small country of approximately 1.7 million people, has enjoyed steady economic
growth of 6.2 percent between 2004 and 2008. The impact of the global economic slowdown on
the Gambian economy, although temporarily mitigated in 2008 by a significant rebound in crop
production due to relatively good rainfall, has resulted in a significantly lower, but still
overoptimistic projected annual GDP growth of 4.6 percent. Preliminary indications already
suggest that macro-economic projections will need to be further downgraded. Of particular
concern is that growth has not been pro-poor (poverty rates have largely remained stagnant) as
tourism, construction and telecommunications have been the main drivers of growth whereas
many of the poor work in agriculture and live in rural areas. Poverty is pervasive with 58
percent of the population below the poverty line. Rural residents count for 65 percent of the total
population and represent 77 percent of the nation’s poor. The Gambia received international
remittances at an annual average of 9.6 percent of GDP since 2003, significantly larger than the
average of 3.6 percent for developing countries. However, due to the economic downturn,
remittances have steadily declined from 14.2 percent in 2003 to 6.4 percent in 2008, thus raising
concerns with regards to the impact on the country’s growth and poverty. There is a serious risk
that poverty rates will increase rapidly as a result of these negative economic developments.
Food largely dominates household expenditures of the Gambians. The total share of food
consumption is 61 percent and is much greater in rural areas compared to urban areas, which
indicates that the rural poor are particularly vulnerable to large fluctuations in the price of food.
The Gambia has seen its domestic cereal production gradually decline since the early 1990s and
thus grown more exposed to the price fluctuations in the external markets. Two thirds of cereal
consumption consists of rice and The Gambia imports approximately 40 percent of their rice
supply. Therefore, the sharp increase in the price of rice (and other international commodities)
caused major concerns for The Gambia which is increasingly dependent on these imports.
Worrisomely, the Consumer Price Index indicates that inflation rates were much higher in rural
areas and much higher for food items. In 2008, the food inflation rate was estimated at 13.3
percent in rural areas compared to 8.3 percent in urban areas. Similarly, the cumulative inflation
rate for 2004-2008 was 41.2 percent for the food component in rural areas compared to the
national cumulative rate of 28.9 percent, thus hitting disproportionally the rural poor.
As a result of developments described above, living conditions of the poorest households are
deteriorating, with an increase in the level of household indebtedness and a reduction in the
quality and frequency of meals, thus increasing food insecurity and malnutrition. Of particular
concern is the decline in the quality of food intake and the risk of micronutrient deficiency
disorders. Iron deficiency anemia which is associated with retarded brain development and low
birth weight (estimated at 20 percent) is widespread in children under five (76 percent), pregnant
women (73 percent) and lactating mothers (57 percent). Iodine is also essential for brain
development and consumption of iodized salt was only 7 percent in 2006. Vitamin A is an
important factor in the child’s immunity and has been associated with almost a quarter of all
child deaths. Malnutrition is known to have long-term cognitive and productivity effects and
may generate cumulative economic costs, up to three percent of GDP annually. These deleterious
consequences outweigh the short-term fiscal savings from direct nutrition action to prevent
malnutrition and promote adequate growth in young children. Malnutrition during early
childhood has lifelong impacts on human capital. A large body of evidence illustrates that poor
nutrition during this period can reduce a child’s educational, cognitive, and physical potential,
leading to lower wages and reduced lifetime earnings.
The Government of The Gambia is committed to the fight against malnutrition as an integral part
of poverty-reduction efforts as evidenced in the Poverty Reduction Strategy Paper (2007) and the
National Nutrition Policy, issued in 2000 and updated in 2010. In 2000, the Government
established the National Nutrition Council for oversight and coordination and created the
National Nutrition Agency for day-to-day management and implementation. The Gambia has
made considerable progress on MDG related targets and seen a 35 percent reduction in
malnutrition rates between 1995 (26 percent) and 2000 (17 percent). Since then, progress has
stalled and malnutrition rates are creeping up again to 22 percent. Child mortality has come
down by 30 percent since 1990; however the declines have slowed in recent years. The sharply
risen food prices and economic slowdown, if left unattended, has the potential to undo the
progress of the last 10 years and put The Gambia right back at pre-1990 levels. The proposed
project will support appropriate cost-effective programs that seek to mitigate its consequences on
human development outcomes such as the health and nutrition status of children.
2. Proposed objective(s)
The DO is to promote healthy behaviors for maternal nutrition and child growth and improve
access to selected therapeutic and preventive public health nutrition services to vulnerable
populations, in particular children under five and pregnant and lactating woman in poor rural
areas.
3. Preliminary description
The project is designed in four components which all will contribute to the DO using different
approaches and targeting different beneficiaries and stakeholders of community nutrition:
Component 1: Capacity Strengthening for Program Management and Surveillance (US$0.9m)
NaNA is responsible for overseeing and coordinating the implementation of the National
Nutrition Policy (2010-2020). This component will focus on capacity strengthening of the NaNA
to respond to unpredictable, external crises and preempt downturns in specific health and
nutrition indicators. This component will complement a recently launched Non-Lending
Technical Assistance Project (P120632) on strengthening the institutional, organizational and
operational capacity for the implementation of the National Nutrition Policy.
This component will involve institutional strengthening through training and expansion of key
technical capabilities such as financial management and monitoring and evaluation, and
improvements of the M&E system of the project. Communities will be strengthened in their
operational capacity to implement nutrition activities in addition to supply and receive feed-back
on project monitoring data. This cycle in anticipated to generate interest of the communities to
sustain the activities beyond the project period.
The M&E system will include the use of community monitoring, Knowledge-Coverage-Practice
(KPC) surveys, the health and nutrition information systems, and the Lot Quality Assurance
Sampling (LQAS) on the basis of which supervision and support is provided to the VSGs. The
community integrated anemia control component will also measure hemoglobin levels through
sample surveys to monitor and evaluate the outcome of the activities. The importance of surveys
and data gathering is also evident from the Results Framework (attached). The NaNA has an
M&E officer in its new organogram, however, the post is still vacant due to lack of funding. This
component will finance the hiring of an M&E specialist to oversee the M&E activities. This
person will continue with NaNA on the national budget after the project closes.
NaNA also has a role in watching over and informing policy makers on the nutrition situation in
the population. The need for improved surveillance and advocacy was evident in the aftermath of
the food price, fuel and financial crises. This component will therefore support activities such as:
the conduct of a national nutrition survey; strengthening of the national surveillance system;
development of a nutrition-relevant data bank for real-time representative data; improved
communication between the regional and central levels; enhanced web based information; and
training in and application of nutrition advocacy tools (PROFILES).
This component will finance technical assistance services (e.g., consultants, training and
workshops), goods, equipment and incremental operating costs.
Component 2: Community maternal and child nutrition ( US$1.4m):
This component is built on the notion that the implementation of evidence-based nutrition
interventions should emphasize the practices and decisions made in the households rather than
on the diseases causing the mortalities related to malnutrition. This project builds on the
successful experience of the World Bank-supported Participatory Health Population Nutrition
Project (1998-2005) of which the nutrition component was rated highly satisfactory. This project
will thus scale-up a community-based approach that has been tried and found successful in The
Gambia - The Baby Friendly Community Initiative (BFCI)- in all of the six Regions. The BFCI
is a comprehensive nutrition and health education package, modeled on the UNICEF/WHO
global strategy of Baby Friendly Hospital Initiative (BFHI). The BFCI package includes
maternal nutrition, infant and young child nutrition, personal hygiene, environmental sanitation
and growth monitoring. Through improved and scaled-up project activities, targeted
communities will benefit from and improve their capacity to prevent and manage malnutrition.
The main component activities will be lead by community volunteers at the village level under
the aegis of the Village Development Committees (VDC). Each VDC will be trained to initiate
community-wide nutrition activities through the establishment of Village Support Group (VSG).
The VSG consists of 8 members - or more depending on the size of the village - and includes the
Village Health Workers (VHW), Traditional Birth Attendants (TBA) and 6 selected community
members in such a way that the VSG is composed of three male and five female members.
The training and supervision will be provided by regional teams of trainers composed of the
Community Health Nurse and/or selected members of the Health Facility Team, the Regional
Health Team and the Multi-Disciplinary Facilitation Team (MDFT) at the Local Government
level. The MDFT are technical resource teams to the Local Government Area Council on
community development and composed of members from the different disciplines including
cluster monitors, agricultural extension workers, health workers, NGOs and the Community
Development Assistants (CDA) who often heads the MDFT.
The role of the VSG is to promote healthy behaviors in families with young children 0-5 years
and pregnant women with a particular focus on the youngest children 0-24 months who are the
groups at high risk of nutritional complications resulting in potentially life-long impact. In order
to achieve this, the VSG will disseminate key messages on exclusive breastfeeding and
complementary feeding practices; promote hygienic and nutritious food preservation and
preparation techniques during cooking demonstrations; provide support to women and children
in vulnerable nutrition-related situations; support twice-yearly screening for severe acute
malnutrition; promote environmental hygiene (village cleaning); and oversee the community
management of acute malnutrition. These activities will increase the interest and awareness of
improved child feeding practices; create awareness on and visibility of malnourished children;
and complement the services provided through outreach strategies and at the health facility
including growth monitoring of children under two, vaccination, vitamin A supplementation, deworming, pre- and post-natal care, curative care, and the rehabilitation of severe acute
malnourished children with complications. The community level activities are introduced in a
phased manner starting with community mobilization and communication activities.
UNICEF, WHO, FAO, WFP and other organizations will be important partners in rolling out the
activities. The community management of acute malnutrition is composed of a new approach
that was introduced in The Gambia in 2009 with the elaboration of a new protocol and training
modules. This project will support the scaling up of this approach in the BFCI villages. WHO
provides technical support to the Ministry of Health s Primary Health Care program which is an
integral part of NaNA community nutrition program. FAO provides support to school education,
but also provides technical assistance for community initiatives promoting food and nutrition
security. Finally, WFP currently collaborates with NaNA on vulnerability assessments for early
warning.
The activities undertaken in this component will include: training; communication; provision of
simple equipment for cooking demonstrations, environmental sanitation, and management of
severe acute malnutrition; and counseling; monitoring and evaluation; and minor works such as
community sheds in rice fields for children to rest and mothers to breastfeed. This component
will finance technical advisory services (including training and workshops), minor
pharmaceutical drugs, goods and equipment for community activities, and incremental operating
costs.
Component 3: Community Integrated Anemia Control (US$0.7m)
Micronutrient deficiencies are widespread in The Gambia with the most vulnerable groups being
women and children. Current programs in The Gambia aimed at combating micronutrient
deficiencies include vitamin A supplementation, salt iodization, supplementation of pregnant
women with iron/folate tablets and Information-Education-Communication (IEC) strategies.
Although the supplementation of pregnant women with iron/folate tablet is an important strategy,
it alone is not adequate to substantially reduce the prevalence of anemia in women. This
component will address anemia in women and children through scaling up a successful pilot
experience of an integrated approach including the prevention of malaria through the promotion
of correct use of insecticide treated bed nets; early detection of pregnancy and anemia; the
provision of iron/folate supplements for pregnant women and multi-micro-nutrient powders for
young children; deworming; environmental sanitation; and the promotion of community gardens
for dietary diversification. This component will be implemented in two of the six Regions,
principally because this component, unlike the first component, will start from a low level in
terms of implementation. Given the funding and more importantly the time available, this
component would not be able reach sizable populations in all six regions.
The mobilization for and distribution of micronutrients and bed nets will be carried out by the
CHN and/or through the monthly outreach strategies. Establishing community gardens will
involve the mobilization of the VDC and the VSGs in each community with the support of the
CHN or other members of the MDFT.
The cascade training will be similar to component 1 which emphasizes training of trainers but
will involve a specific training program on iron deficiency anemia and the distribution of
micronutrients. Program communication strategies will include traditional media and local
theater in addition to village meetings through the VDC and the VSG.
The component activities will include training, communication, distribution of micronutrients,
provision of simple equipment for village cleaning and other environment sanitation activities,
and monitoring and evaluation. This component will finance technical advisory services
(including training and workshops), procurement of minor pharmaceutical drugs and equipment
and incremental operating costs.
4. Safeguard policies that might apply
[Guideline: Refer to section 5 of the PCN. Which safeguard policies might apply to the project
and in what ways? What actions might be needed during project preparation to assess
safeguard issues and prepare to mitigate them?]
The project is about community nutrition - which normally does not trigger any safeguards.
However, one component is on anemia control at community level, and the project wants to
conduct an impact evaluation study (base- and end-line household surveys) measuring
hemoglobin levels. The hemoglobin will be measured from a drop of blood. These are obtained
from little finger pricks, absorbed in cuvettes that can be read by portable Hb readers in the field.
The principal safeguard issue is the safe disposal of survey material.
The Task Team will review the Medical Waste Management Plan of the MOH to see if the plan
requires updating or if the project should elaborate a separate waste plan.
5. Tentative financing
Source:
Borrower
Rapid Social Response Program
Total
6. Contact point
Contact: Menno Mulder-Sibanda
Title: Sr Nutrition Spec.
Tel: (202) 458-7724
Fax:
Email: [email protected]
($m.)
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