Mongolia: Reducing Persistent Chronic Malnutrition in Children in Mongolia

Sovereign Project | 42155-012

Summary

The overall objective is to improve the nutritional status of children under 36 months of age in Mongolia. The specific development objectives are to

(i) conduct a participatory analysis of obstacles that are preventing the Ministry of Health (MOH), private sector, nongovernment organizations (NGOs), and communities from effectively addressing chronic child malnutrition;

(ii) in project areas with contrasting socioeconomic resource settings, (a) identify and test various nutrition delivery approaches with emphasis on micronutrients for children and women; and (b) develop and implement parallel, tailor-made information, education, and communication (IEC) and/or behavior change communication (BCC) to increase the awareness, skills, and habits for reduced chronic malnutrition in disadvantaged communities;

(iii) pilot test and institutionalize a revised public health nutrition (PHN) training curriculum for primary health center (PHC) workers; and

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Project Name Reducing Persistent Chronic Malnutrition in Children in Mongolia
Project Number 42155-012
Country Mongolia
Project Status Closed
Project Type / Modality of Assistance Grant
Source of Funding / Amount
Grant 9131-MON: Reducing Persistent Chronic Malnutrition in Children in Mongolia
Japan Fund for Poverty Reduction US$ 2.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Partnerships
Sector / Subsector For classification - For classification
Gender Equity and Mainstreaming Some gender elements
Description

The overall objective is to improve the nutritional status of children under 36 months of age in Mongolia. The specific development objectives are to

(i) conduct a participatory analysis of obstacles that are preventing the Ministry of Health (MOH), private sector, nongovernment organizations (NGOs), and communities from effectively addressing chronic child malnutrition;

(ii) in project areas with contrasting socioeconomic resource settings, (a) identify and test various nutrition delivery approaches with emphasis on micronutrients for children and women; and (b) develop and implement parallel, tailor-made information, education, and communication (IEC) and/or behavior change communication (BCC) to increase the awareness, skills, and habits for reduced chronic malnutrition in disadvantaged communities;

(iii) pilot test and institutionalize a revised public health nutrition (PHN) training curriculum for primary health center (PHC) workers; and

(iv) capture the experience and produce evidence of successful approaches by rigorous monitoring and evaluation, then use the results to inform and improve the nutrition policies of the Government of Mongolia.

Project Rationale and Linkage to Country/Regional Strategy The project is in line with the development agenda for inclusive economic growth of ADB?s long-term strategic framework 2008?2020 (Strategy 2020) and supports the Mongolia country partnership strategy pillar of inclusive social development. The proposed Project is consistent with the health, nutrition, and social protection priority sector of the country operations business plan 2008?2010. The CPS update for Mongolia (2007-2009) confirmed a priority focus on poverty reduction and MDGs. The health road map of the CPS (2009?2013), in preparation, identifies persistent chronic malnutrition among children (stunting) and disparities in nutritional status between urban and rural areas as important issues in Mongolia. The Government Health Sector Master Plan (2006-2015) identifies nutrition as a priority issue and makes the improvement of the nutritional status of the population, particularly micronutrient status among children and women, part of the overall outcomes to be attained until 2015.
Impact Improved nutritional status of children under 36 months.
Project Outcome
Description of Outcome Availability, awareness and demand for micronutrients increased in project areas.
Progress Toward Outcome

At the end of the project, PHC services (FGPs and soum health centers/SHC) in the project area have provided (and are able to continue to provide) products and services to reduce child chronic malnutrition to most under-3 year old children of their catchment population.

To achieve this objective, the project supported three main activities at the level of PHC services: (i) distribution of micronutrient powder (MMP sprinkles); (ii) procurement of standard child growth measuring equipment; and (iii) training of PHC services providers.

The following data comes from the baseline and the end-of project surveys.

(i) During project implementation, MMP was distributed in PHC services during 75,900 consultations for children under-3. During these visits, information on the appropriate consumption of MMP was also systematically provided to the mothers/parents/care-takers.

The end-of-project survey shows that 77 % of the surveyed children 6-35 months old had received MMP from PHC services, and 69.4% actually consumed it (a 38% increase from the baseline survey).

We can improve these results: the survey shows that 90.2% used the MMP they had received, but 10% did not. Only 57% of the children who consumed MMP used 60 or more MMP sachets. And there are significant differences in the consumption of MMP among project sites (but not by gender).

(ii) The baseline survey revealed that 57,5% of the PHC workers (FGP, SHC and bag feldshers) in the project sites had no or inaccurate standard scales and length/height measuring boards for child growth monitoring. Under the project, the following growth measuring equipment was procured and distributed: 224 scales for children and mother, 340 hanging scales, 340 children weighting pants, 262 wooden height measurement equipment, and 472 bedding height measurement equipment, in accordance with a distribution schedule approved by Health Ministerial decree.

(iii) 1159 PHC workers of the project area (79.6% of the target group) attended training on Community Based Integrated Management of Child Illness (C-IMCI) with a particular focus on nutrition. In accordance with WHO recommendation, the initial training needs to be followed up with on-the-job training. Of the 1159 health workers who participated in the initial training, 472 (40.6%) attended follow-up on the job training. 28 trainers for the C-IMC were prepared and handbooks for the trainers and participants were developed and distributed. As a result of these interventions, the number of trained health workers has increased by 13.3% from the baseline level of 2010.

The number of PHC health workers who organized information sessions for the population of their service area increased by 24.0%.

Implementation Progress
Description of Project Outputs

Component A: Analysis of obstacles in addressing chronic child malnutrition, and policy recommendations

Component B: Approaches (methods, products and services) to reduce chronic malnutrition in mothers and children

Subcomponent B.1: Delivery of nutrition improvement approaches by primary health care workers in all project areas

Subcomponent B.2: Informed, tailor-made IEC/BCC methods, materials and activities for improved mother and child nutrition, developed and implemented

Subcomponent B.3: Pilot approaches for increased access to mother and child nutrition generated and supported, and delivered through MOH partners in selected project areas, and tested

Component C: Development and institutionalization of formal undergraduate and graduate PHN training

Component D: Project management and health policy development

Status of Implementation Progress (Outputs, Activities, and Issues)

The project successfully completed what was initially planned. MOH, the PIU, and ADB provided the necessary support to ensure a successful completion of the project activities.

Component A. The consultants prepared an in-depth analysis of the behavioral, operational, and structural issues hampering MOH's, private sector's, NGOs', and communities' performance in delivering PHN services: policy and strategy shortcomings, procedural and coordination imperfections, and practical constraints; and indicate directions for potential improvement. The analysis was accepted and provided a basis for communities, PHC workers, local government, NGOs, and the private sector to develop and test nutrition delivery approaches (component B) and offer information relevant to the revision and development of undergraduate and graduate PHN training programs in the Medical Sciences University (component C).

Core activities included (i) carrying out a comprehensive inventory of the food and nutrition sector and an assessment of its existing delivery systems; (ii) conducting an in-depth functional analysis of the institutional arrangements, mandates, funding and expenditures, and capacities in MOH institutions to deliver services, education, and research on nutrition of disadvantaged groups; (iii) analyzing the constraints faced by the private sector, NGOs, and communities in delivering effective services and goods aimed at reducing chronic malnutrition; (iv) holding a policy seminar and technical workshops for dialogue with and among the range of stakeholders and generating proposed improvements and solutions; and (v) producing a situational analysis report with draft policy recommendations.

Component B supported interventions directly aimed at reducing chronic malnutrition by (i) improving nutrition services at PHC level (FGPs and soum health centers/SHCs) in all project areas (subcomponents B.1 and B.2); and (ii) pilot testing innovative approaches to prevent and treat chronic malnutrition in infants, children below 3 years of age, and PLW in selected areas of Mongolia (subcomponent B3).

Subcomponent B.1 helped improve PHC nutrition services as part of community integrated management of child illness (C-IMCI), managed by FGPs and SHCs. Core activities included (i) tailoring, delivering, and testing in-service and on- the-job training of FGPs and SHCs in C-IMCI, with focus on improved counseling skills on exclusive breastfeeding and appropriate timing, frequency, adequacy, and composition of complementary feeding of infants and young children; (ii) providing support to technical improvements and increased coverage of the growth monitoring of under-2-year-old children managed by FGPs and SHCs; (iii) procuring, delivering, and promoting the use of MOH-agreed sprinkles among children 6 24 months old and PLW; and (iv) treating malnourished and low birth weight infants and children under 3 with supplemental iron and vitamin D for anemic and rickety children, respectively, and for PLW.

Subcomponent B.2 developed and implemented IEC/BCC methods and materials to improve the community and family awareness, skills, and behaviors for reducing chronic child malnutrition. Core activities under subcomponent B.2 included (i) in contrasting socioeconomic resource environments, carrying out a study of the constraints that mothers face in providing good infant and young child feeding (IYCF); (ii) capturing locally available knowledge, attitudes, and skills of mothers on good IYCF practices; (iii) developing informed, tailor-made educational materials and methods focused on good mother, infant, and child care, as well as IYCF practices; and (iv) subcontracting a community-based NGO with a track record in public social education to deliver IEC/BCC campaigns on good community and household behaviors for mother and IYCF and nutrition practices.

Subcomponent B.3 involved financing at least 10 pilot approaches with a grant of up to $40,000 each in response to proposals by partners in the food and nutrition sector willing and able to implement innovative approaches aimed at the Project's general objective and that complement the PHC approach through FGPs and SHCs. The Project would initiate at least three rounds of invitations for proposals, approximately 6 months apart. Pilot approaches could be of different scale and duration and would not be allocated exclusively to the traditional community-oriented food and nutrition development organizations. Specific selection criteria would be publicly announced in an effort to mobilize potential partners at all levels. Core activities included (i) active solicitation of short letters of intent to develop and deliver innovative approaches, followed by transparent selection and invitation to submit complete proposals, while offering assistance if needed; (ii) review and priority ranking of high-quality proposals; (iii) project funds permitting, entering into subcontracts for implementation of the selected approaches; (iv) provision of supportive supervision during implementation of pilot approaches; and (v) advocacy for promoting continuation and/or scaling up of successful approaches upon subcontract expiry.

Component C supported and coordinated the Health Sciences University and MOH in the revision, development, and testing of a PHN training curriculum for adoption in undergraduate and graduate health education programs for PHC workers of Mongolia. Experiences and information from components A and B were to be used to inform and continuously update the PHN training modules. Core activities included (i) agree on terms of reference and support the Health Sciences University; (ii) conduct an assessment of PHN training needs and the needs for research and services; (iii) develop a PHN training curriculum across undergraduate and graduate levels and support the provision of key teaching resources to effectively test and deliver PHN training in existent pre-service PHC training programs; and (iv) advocate for acceptance of PHN training as a formal module in the health training colleges (undergraduate) and in the medical, public health, and nursing schools (graduate) of the Health Sciences University.

Component D monitored and supported effective implementation of the project components A, B and C; facilitated inter-institutional coordination and supported policy analysis and development based on the results (knowledge output); Core activities included (i) establishing the project implementation unit (PIU); (ii) preparing the grant implementation manual; (iii) procuring and distributing expendables; (iv) performing annual audits; (v) providing oversight of progress in the deliveries of subcomponent B.3 activities by MOH partners; (vi) conducting studies, follow-up surveys, and experience-sharing workshops during implementation; (vii) monitoring and evaluating outcomes of the approaches and combinations of approaches in the project areas; (viii) conducting policy seminars; (ix) using the project data and experiences to produce a knowledge product; and (x) submitting draft policies to the Government.

Geographical Location Arkhangai, Dundgov, Gobi ALtai, Sukhbaatar and Tuv aimags, and Chingeltei and Songinokhairkhan districts of Ulaanbaatar city
Safeguard Categories
Environment C
Involuntary Resettlement C
Indigenous Peoples C
Summary of Environmental and Social Aspects
Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design The Project was designed with inputs from Ministry of Health, Ministry of Agriculture, Nutrition Research Center, World Vision Mongolia, School of Public Health faculty, Action Contre la Faim, Health Sciences University faculty, Consumer Rights Association, and representatives of United Nations agencies and NGOs working on food and nutrition issues. Specific social analysis and perspectives of communities was generated during the comprehensive social assessments carried out for the JFPR-MON: Access to Health Services for the Poor and Vulnerable Groups In Ulaanbaatar and for the Third Health Sector Development Project. MOH has set up a multisectoral working group to prepare the project since January 2008. In April 2008, consultation meetings with MOH and key stakeholders (FAO, WHO, Unicef, universities, NGO) were held to discuss the proposed project. The Japanese Embassy in Ulaanbaatar and the MOH are both very supportive of ADB's initiatives.
During Project Implementation The Project Technical Working Group has been set up by the order of the Minster of Health which includes representatives of the EA and other stakeholders.
Business Opportunities
Consulting Services The Project will recruit one international (4 person-months, intermittent) and two national (12 person-months, intermittent) consultants on an individual basis. Based on previous JFPR experience and for reason of efficiency, the EA has requested ADB to hire the international consultant who will enter into a contract with the EA. The Project will also recruit several entities: (i) a national organization in charge of studies, assessment, monitoring, and evaluation; (ii) a nongovernment organization to deliver information and education communication and/or behavior change communication campaigns; (iii) Health Sciences University to revise, develop, and test the public health nutrition training component; and (iv) a health worker training college for delivering family group practice and soum health center training in community integrated management of child illness (IMCI). The national consultants and organizations will be recruited by the PIU of THSDP, with technical input from the project coordinator, in accordance with ADB's Guidelines on the Use of Consultants (2007, as amended from time to time). The Nutrition Research Center under the Public Health Institute is the only national organization in Mongolia having the necessary competence to meet the requirements under (i). Health Sciences University is the only national organization in Mongolia having the necessary competence to meet the requirements under (iii). The Nutrition Research Center and the department of the Health Sciences University will be hired through single source selection. All other entities will be hired through consultant qualification selection using biodata proposal. The terms of reference for consulting services are in Supplementary Appendix B.
Procurement

Procurement under the Project will be conducted in accordance with ADB's Procurement Guidelines (2007, as amended from time to time). Goods, services, and works estimated to cost the equivalent of $100,000 or less will be procured using ADB's shopping procedure. Goods, services, and works with estimated value of $500,000 or less will be procured using national competitive bidding procedure. The PIU of THSDP will be responsible for procurement, with technical inputs from the project coordinator. To procure items costing $10,000 or below, the PIU of THSDP may purchase the items directly from the supplier. In such cases, ADB should be satisfied that the price paid is reasonable. International competitive bidding is not envisaged under this Project. The procurement plan is in Supplementary Appendix C.

National competitive bidding procurement and procedures will be in accordance with the Mongolian Procurement Law, subject to modifications agreed with ADB.

Responsible ADB Officer Itgel Lonjid
Responsible ADB Department East Asia Department
Responsible ADB Division Mongolia Resident Mission
Executing Agencies
Ministry of Health_and SportsMs. J. Tsolmonmoh@moh.mnOlympic St 2, Governemnt Bldg 8, Ulaanbaatar, Mongolia 14210
Timetable
Concept Clearance 05 Jun 2008
Fact Finding 17 Jul 2008 to 12 Aug 2008
MRM -
Approval 16 Mar 2009
Last Review Mission -
PDS Creation Date 31 Mar 2009
Last PDS Update 27 Mar 2014

Grant 9131-MON

Milestones
Approval Signing Date Effectivity Date Closing
Original Revised Actual
16 Mar 2009 12 May 2009 12 May 2009 31 May 2013 30 Aug 2013 13 Mar 2014
Financing Plan Grant Utilization
Total (Amount in US$ million) Date ADB Others Net Percentage
Project Cost 2.15 Cumulative Contract Awards
ADB 0.00 16 Mar 2009 0.00 1.89 94%
Counterpart 0.15 Cumulative Disbursements
Cofinancing 2.00 16 Mar 2009 0.00 1.89 94%

Safeguard Documents

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Evaluation Documents

See also: Independent Evaluation

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