Health / Health sector development and reform

The goal of the Project is to reinforce and sustain the reduction of iodine deficiency disorder (IDD) and iron deficiency anemia (IDA) among poor children and women in Central Asia

through parallel attention to supply (production and distribution); demand (public awareness and demand creation); and regulation (quality control, implementation of regulations and

legislation, and trade facilitation). The specific objectives are to (i) obtain and sustain use of iodized salt by 90% of households; (ii) sustain fortification of at least one third of wheat flour consumed domestically; (iii) build capacity of the private and public sectors to produce quality fortified food; (iv) develop regulatory institutions or incentive schemes to facilitate fortification and ensure the trade of quality fortified food among Central Asian countries; and (v) build awareness of consumers about prevention of IDD and IDA, and benefits of micronutrientenriched food.

The project aims to improve people's health, especially the poor and vulnerable, including women and children in targeted rural areas. The project targets reduction of MMR by 50%, IMR by 20%, and under-5 mortality rate by 20%. Project objectives are (i) improving the quality and use of rural health services; and (ii) building the health sector's capacity by extending reforms for sector efficiency, effectiveness, and sustainability, and institutional development, which were initiated by the first health sector reform project.

The crucial contribution of the Project comes from its regional approach, which will enable establishment of common standards of fortified salt and flour, achieve economies of scale, and merit cross-learning. ADB loans meant for one country will not have these advantages and will be unable to address regional issues such as trade and regulation.

The health-related projects mentioned aim to improve the health of the poor, especially children and women. The project frameworks almost exclusively work with the government service delivery system and have limited provisions for working with the private sector. Adding a food fortification component would complicate project designs, which are extremely intricate, and may negatively affect other important objectives of strengthening public health care. Financing the private sector may be theoretically possible through ADB's private sector development arm. However, given the small size of the financial needs of each private sector enterprise, and ADB's reluctance to be involved in direct financing of producers, a private sector loan is not a feasible solution. JFPR allows ADB to overcome the difficulties of public health and private sector loans.

Component A-Strengthening the Capacity of Salt Industries and Flour Mills Fortified wheat flour production in (i) Kazakhstan. During the period covering July September 2006, the wheat flour fortification was ongoing in all participating countries except for Uzbekistan. Despite the reduced number of participating flour mills (39 mills) during the period July September 2006, total, production of fortified wheat flour (Jan-Sep 2006) was 16% higher than the 2005 production. In Kazakhstan, the CPO and LGBK conducted negotiations with 15 new flour mills, 3 of which informed its intent to start production in November 2006. A local flour fortification workshop was held in Kazakhstan in July 2006 at LGBK's annual conference that addressed the wheat flour fortification issues; discuss partnership plans for the year 2006/2007. In (ii) Kyrgyz Republic. The Government, on the proposal of the country team, has adopted the standards on premix fortified wheat flour and bakery from the fortified wheat flour. In (iii) Mongolia. There has been

a shortage of wheat grain as the country is heavily dependent on importation.

Domestic consultants were recruited to assist the JFPR consultant in introducing

wheat flour fortification technology to the millers. In (iv) Tajikistan - Low wheat flour production is related to the country's dependence on imported wheat flour. To

ensure fortified wheat flour production, micro feeders were procured and installed

at 12 medium scale flour mills and 3 small scale mills. Salt iodization - The quality

salt iodization was ongoing in all participating countries. The amounts of produce

iodized salt by each country also increased, ranging from 44.3% to 94.17% of the total desired amount.

Component B-Strengthening the Capacity of the Governments

(i) Kazakhstan Country Project Office (CPO). Because of the Food Safety Law (enacted in April 2004), the government is adopting a schedule for introducing

wheat flour at large flour mills, from 2007 at medium size flour mills and 2008 at

other types of flour mills. The revised draft on wheat flour fortification law still remains; (ii) Kyrgyz Republic CPO. The revised draft on the law wheat fortification, submitted to the Parliament in May 2005, remains to be acted upon. The Govt has

also adopted several regulations in order to promote a demand for fortified wheat flour: the preferential procurement of wheat flour from public funds, and the mandatory fortification of flour are to be processed form the State Resource Fund. The Ministry of Education has also instructed all educational institutions on the mandatory use of fortified wheat flour and iodized salt for school breakfasts and lunches. However, there is no visible progress or import of their regulations; (iii) Mongolia CPO - assisted in conducting revisions of the national IDD Prevention

Program and also drafted the regulation on monitoring of the quality of fortified wheat flour; (iv) Tajikistan CPO. The legislation on the mandatory fortification of wheat flour has been adopted; (v) Uzbekistan CPO. Parliament has adopted the

draft USI Law on the hearing.

Component C-Social Mobilization and Poverty Targeting

(i) Kazakhstan CPO. Confederation of the Nongovernmental Organization of Kazakhstan (CNOK) has arranged local activities on food fortification advocacy through its provincial branches. A youth conference was held in September 2006 in Akmola province on promotion of food fortification. A survey was also conducted whereby awareness on fortified food produces has increased from an initial 35% to 75%; (ii) Kyrgyz Republic CPO. The CPO finalized the workplan on NGOs and selected 8 NGOs to implement the communication and social mobilization activities; (iii) Mongolia CPO - took active part in celebrating the National IDD Prevention day

in September 2006; (iv) Tajikistan CPO. Conducted a workshop for the mass media in August 2006 which involved the editors from the national and local newspapers and TV broadcasting. The workshop's objective was food fortification advocacy and promotion of fortified food products.

Component D-Project Management, Monitoring, and Evaluation

A regional Mid-Term Review workshop was held from 11 to 14 September 2006 in the Kyrgyz Republic. The Mid Term review was aimed at jointly examining the

progress and analyzing the obstacles of the Project with the view to identify and

discuss key strategic actions to be undertaken in each country and by RCAO and

KAN during the remaining project period. The audit findings in Kazakhstan showed the need to improve the quality of reports by the NGOs, a weak control on the routine transaction works for the CPO. The auditors also noted that the CPO was not granted the VAT elimination though this was stated in the agreement between GOK and ADB. The auditors also noted some deficiencies in the project accounts in the countries of Kyrgyz, Mongolia and Tajikistan. Recommendations were given to improve the reporting system.

Strengthening the Capacity of Salt Industries and Flour Mills. This component aims to build the capacity of salt industries and flour mills to procure fortificants, equipment, and other essential items required for food fortification; and to assure the quality of fortified food. Salt industries are private except in Uzbekistan, where they are owned by the state. The Project will help establish and strengthen producers' associations, and train salt industries in procurement and food fortification technology. Technical assistance (TA) will help millers access the international premix market, including identifying the range of suppliers and procurement options.

Strengthening the Capacity of the Governments. This component aims to develop and strengthen the

implementation of food fortification legislation and regulations; improve governments' quality assurance system, including the border control of trade in salt; and help governments develop regulatory frameworks and agreements that will ease the trade of fortified food in the region. The Project will provide TA to the governments in developing legislation and regulations; training; and providing laboratory equipment to the sanitary epidemiological services (SES), which are responsible for food inspection.

Social Mobilization and Poverty Targeting. This component aims to promote public awareness and acceptance of micronutrient-enriched salt and wheat flour, and support innovative activities in communities to increase access of the poor to fortified salt and wheat flour. The Project will support an information, education, and communication campaign through different levels of media, and social mobilization and marketing by civil society. The activities will include quality testing of iodized salt by producers and retailers. The component will also support innovative activities to address country- or region-specific activities to improve access of the poor to fortified food. A few examples of such

innovative activities are collective fortification of wheat flour milled by small mills, and linking of food fortification efforts with support for oral forms of micronutrient supplements and in-home- fortificant packets that can be used to fortify homeprepared complementary foods.

Project Management, Monitoring, and Evaluation. The component will support the regional project administration office, which will oversee daily project activities in the participating countries, and each country project office (CPO) to implement investment plans. The Project will also support technical and supervisory workshops at 6-month intervals, including the midterm review workshop, and annual auditing.

The Project emphasizes rigorous evaluation through sentinel studies on the impact of fortified food, economic and financial analysis of food fortification, and other interventions to reduce IDD and IDA.

The Project will be implemented through three key alliances: (i) A public-private coalition that will motivate private sector investment by increasing consumers' preferences for iodized salt and fortified flour across the region. This will help reduce poverty and hidden hunger among mothers and

children. (ii) A regional partnership between multiple external agencies and developing countries to stimulate policy and trade reforms that will bring long-term improvement of child development in Central Asia. (iii) An alliance between governments and civil society involving NGOs and mass consumer organizations in the social-marketing campaign to promote iodized salt and fortified flour as well as supplemental iron or fortified complementary

foods for young children.

The Project emphasizes close cooperation among stakeholders in government organizations, private and government producers of salt and wheat flour, technical and research institutes, and a wide variety of consumer organizations and other NGOs in civil society. The broad participatory approach will be assured in the Project because it will build on the organizational achievements of the first project, which also emphasized broad participation. In the five

countries, civil-society project support groups have been formed and demonstrated their competency in social mobilization and social marketing.