Tackling Maternal and Child
Undernutrition in Zambia
(phase 2)
Business Case
November 2012
1
Glossary
Malnutrition: an abnormal physiological condition caused by deficiencies, excesses or
imbalances in energy, protein and/or other nutrients.
Undernutrition: when the body contains lower than normal amounts of one or more
nutrients, i.e. deficiencies in macro-nutrients (food) and/or micro-nutrients. Undernutrition
encompasses stunting, wasting and deficiencies of essential vitamins and minerals
(collectively referred to as micronutrients).
Stunting: refers to short stature (or low height for age) and is an indicator of long-term
nutritional status.
Wasting: refers to acute loss (or low weight for height) and is an indicator of short-term
nutritional status.
Severe Acute Malnutrition (SAM): a weight-for-height measurement of 70% or less
below the median or 3 standard deviation of more below the mean international reference
values, or a mid-upper arm circumference of less than 115 millimetres in children 6 to 60
months old.
Low birth weight: refers to a birth weight of less than 2,500 grams. This may be due to
prematurity, growth restriction, or a combination of the two.
Micronutrient deficiencies: refer to inadequate intake and/or absorption of vitamins and
minerals that are essential for healthy growth and survival. Globally, the most critical
deficiencies are Vitamin A, iron, iodine, zinc and folic acid, due to their importance in the
immune system, organ development and growth. Micronutrient deficiencies are measured
by a variety of indicators, including biomarkers and clinical signs.
Food security: when all people, at all times, have physical, social and economic access
to sufficient, safe and nutritious food that meets their dietary needs and food preferences
for an active and healthy life.
Nutrition security: is achieved when secure access to appropriately nutritious food is
coupled with a sanitary environment – alongside adequate health services and care, this
ensures a healthy and active life for all household members.
Hunger: is often used to refer in general terms to MDG 1 (to eradicate extreme poverty
and hunger) and food security. Acute hunger occurs when lack of food is temporary, and is
often caused when shocks such as drought or war affect vulnerable populations. Chronic
hunger is a constant or recurrent lack of food and results in underweight and stunted
children, and high infant mortality. “Hidden hunger” is a lack of essential micronutrients in
diets.
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Contents
Acronyms ................................................................................................................ 5
Intervention Summary ............................................................................................ 7
1.
Strategic Case ............................................................................................... 10
A. Context and need for a DFID intervention ....................................................... 10
B. Impact, Outcome and Output ......................................................................... 17
2.
Appraisal Case .............................................................................................. 19
A. Feasible options that address the need set out in the Strategic case …… ..... 19
B. Assessing the strength of the evidence base for each feasible option ........... 30
C. Costs and benefits of each feasible option ...................................................... 35
D. Measures to be used to assess Value for Money for the intervention .............. 42
E. Summary Value for Money Statement for the preferred option ........................ 42
3.
Commercial Case .......................................................................................... 43
A. Procurement/commercial requirements for intervention…………………… ..... .43
B. How the intervention design uses competition to drive commercial
advantage for DFID ............................................................................................. 43
C. How we expect the market place will respond to this opportunity .................... 43
D. Key cost elements that affect overall price. How value is added and how we
will measure and improve this ............................................................................. 43
E.
Intended
Procurement
Process
to
support
contract
award………………………................................................................................... 44
F. How contract & supplier performance will be managed through the life of the
intervention .......................................................................................................... 44
3.
Financial Case ............................................................................................... 46
A. Costs, how they are profiled and how we will ensure accurate forecasting ...... 46
B. How it will be funded: capital/programme/admin.............................................. 47
C. How funds will be paid out .............................................................................. 47
D. Assessment of financial risk and fraud ............................................................ 47
E. How expenditure will be monitored, reported, and accounted for .................... 47
4.
Management Case ........................................................................................ 48
A. Management Arrangements for implementing the intervention ........................ 48
B. Perceived risks and how these will be managed……………………………....... 51
C. Conditions that apply (for financial aid only) .................................................... 52
D. How progress and results will be monitored, measured and evaluated ........... 52
Bibliography
3
ANNEXES - See separate documents
Annex 1: Project Logframe
Annex 2: Terms of Reference for the SUN Fund
Annex 3: Institutional and Governance Appraisal
Annex 4: Social Appraisal
Annex 5: Unit costs and coverage of nutrition interventions
4
Acronyms
AIDS
ANI
ART
BAZ
BCC
BFHI
BMI
CAADP
CBO
CBGMP
CHAZ
CHWs
Acquired Immune Deficiency Syndrome
African Nutrition Initiative
Anti-Retroviral Therapy
Breastfeeding Association of Zambia
Behaviour Change Communication
Baby Friendly Hospital Initiative
Body Mass Index
Comprehensive African Agricultural Development Program
Community Based Organization
Community-based Growth Monitoring and Promotion
Churches’ Association of Zambia
Child Health Weeks
CSH
Communications Support for Health (CSH) Project
CSO
CSOs
DES
DFID
Central Statistical Office
Civil Society Organisations
Dietary Energy Supply
Department for International Development
EMLIP
Essential Medicines Logistic Improvement Programme
EPI
EU
FBO
FNDP
GAIN
GMP
GRZ
HIV
IBFAN
IMAM
ITNs
IYCF
LNS
M&E
MAL
MAM
MCDs
MCH
MCHCD
MDGs
MG
MI
MICS
MIS
MLGHECDE
Expanded Programme for Immunisation
European Union
Faith Based Organisation
Fifth National Development Plan
Global Alliance for Improved Nutrition
Growth Monitoring and Promotion
Government of the Republic of Zambia
Human Immunodeficiency Virus
International Baby Food Action Network
Integrated Management of Acute Malnutrition
Insecticide Treated Nets
Infant and Young Child Feeding
Lipid-based nutrition supplement
Monitoring and Evaluation
Ministry of Agriculture and Livestock
Moderate Acute Malnutrition
Most Critical Days
Maternal and Child Health
Ministry of Community Development, Mother and Child Health
Millennium Development Goals
Ministry of Gender (check this)
Micronutrient Initiative
Multiple Indicator Cluster Survey
Malaria Indicator Survey
Ministry of Local Government and Housing, Early Child
Development and Environment
Micronutrient Powder
Ministry of Health
Middle Upper Arm Circumference
Monitoring and Evaluation
National Food and Nutrition Commission
National Food and Nutrition Strategic Plan
MNP
MoH
MUAC
M&E
NFNC
NFNSP
5
OVC
PMTCT
NDP
NFNC
NFNSP
NGO
PF
RUTF
RDA
SAM
SCN
SCT
SNDP
SUN
THET
UN
UNDP
UNICEF
USAID
VAS
WBFTI
WFP
WHO
ZAMNIS
ZDHS
Orphans and Vulnerable Children
Prevention of mother to child transmission
National Development Plan
National Food and Nutrition Commission
National Food and Nutrition Strategic Plan
Non-Governmental Organisation
Patriotic Front
Ready to Use Therapeutic Food
Recommended Daily Allowances
Severe Acute Malnutrition
Standing Committee on Nutrition
Social Cash Transfer
Sixth National Development Plan
Scaling Up Nutrition
Tropical Health Education Trust
United Nations
United Nations Development Programme
United Nations Children’s Fund
United States Aid for International Development
Vitamin A Supplementation
World Breastfeeding Trends Initiative
World Food Programme
World Health Organisation
Zambia Nutrition Information System
Zambia Demographic Health Survey
6
Business Case and Intervention Summary
Intervention Summary
Title: Tackling Maternal and Child under nutrition in Zambia (phase 2)
What support will the UK provide?
The UK will provide up to £11,450,000 over three years (2013-2016) to:
a) Scale up direct and indirect nutrition interventionsi through supporting the
implementation of the new national “First 1000 Most Critical Days Programme” in at
least 14 of Zambia’s 84 districts
b) Provide technical assistance to the National Food and Nutrition Commission and key
line Ministries to ensure effective coordination and management of the 1000 Days
Programme
c) Support research priorities and ensure systematic documentation of what works for
reducing stunting (chronic undernutrition) in Zambia
Why is UK support required?
What need are we trying to address?
Zambia has one of the highest rates of childhood undernutrition in the world ii:
 46% of under-5 children are stunted (too short for their age), 5% acutely malnourished
(too thin for their height) and 15% underweight (too thin for their age).iii
 53% of children have Vitamin A deficiency and 46% have iron deficiency anaemia.iv
 9.3% of the children are born underweight indicating poor maternal nutritionv.
Undernutrition contributes up to 50% of deaths of children under five vi. Children who are
stunted by the age of two cannot reverse the damage caused by poor maternal and infant
nutrition and will never meet their full potential of physical and mental development.
…..”we know what works. The science is clear that the first 1000 days after conception are the
most important. Intervening within this period will have life-long and life-changing impacts on educational
attainment, labour capacity, reproductive health and adult earnings. If we wait until a child is two years
old, the effects of undernutrition are already irreversible”. DFID Nutrition Strategy, 2011
Direct nutrition interventions (eg promotion of breast-feeding, appropriate complementary
feeding practices and micro-nutrient supplementation) have been proven to be highly cost
effective when they reach children in the ‘critical 1000 days’ between conception and age two.
Despite this evidence, effective interventions are not carried out to scale in Zambia because of
weak health systems, lack of human resources, knowledge gaps, poor coordination and lack
of investment.
This programme is the second of two phases of support to nutrition in Zambia. There has been
good progress over the last year towards the first phase output targets including:
7




formulation of the new national First Most Critical 1000 Days Programme which phase
2 will support;
Provision of Vitamin A and deworming tablets for more than 80% of children under 5 in
nine of the districts with the worst nutrition indicators;
two innovative distribution trials underway – bio-fortification of maize and development
of a private sector distribution system for micro-nutrients and oral re-hydration salts;
establishment by the University of Zambia of its first BSc and MSc degree in nutrition to
address gaps in nutrition expertisevii.
What will we do to tackle this problem?
Decisively tackling undernutrition in Zambia needs a response that cuts across health, local
government and other sectors. DFID has advocated for this “multi-sector” response
internationally, launching a Nutrition Position Paper at the UN General Assembly in September
2011. DFID is a major supporter of the international Scaling Up Nutrition (SUN) movement.
This 2nd phase of the Zambia programme will support implementation of the First Most Critical
1000 Days Programme in at least 14 districts through:
1. direct interventions including: promotion of exclusive breastfeeding; support to
community-based distribution of iron and folic acid and deworming tablets; health
education; promotion of nutritionally adequate diets for pregnant women; pilot
distribution of multiple micronutrient powders (sprinkles) for pregnant women;
2. building long term Zambian institutional capacity through technical assistance to key
line Ministries and the National Food & Nutrition Commission (NFNC) which is
mandated to coordinate nutrition across Government;
3. supporting research to build the evidence base of how best to scale up what works to
tackle undernutrition in Zambia.
Who will implement the support we provide?
DFID funds will be channelled through a SUN Fund mechanism financed by several donors.
This will align contributions from funders to build a coherent and sustainable nation-wide
response to undernutrition. The interventions at field level will be delivered by GRZ district
staff mostly from the Ministry of Health, Ministry of Community Development and Local
Government & Housing. Given the initial limitations in NFNC’s capacity, DFID will
competitively procure a service provider to manage the SUN Fund (including DFID’s funds) in
close collaboration with the NFNC.
What are the expected results?
What will change as a result of our support to the 1000 Days Programme?
At impact level, the overall nutrition programme will contribute to improved health and
nutritional status of children under five, measured primarily by a reduction in stunting from
46% to 38.5% and a reduction in low-birth weight babies from 9.3% to 6% by 2016. With DFID
support, 100,000 fewer children under five will be stunted.
8
At outcome level will be measured by improvements in maternal and child nutrition practices
in the 14 targeted districts, specifically:
 An increase from 56% to 86% of pregnant women who receive iron and folic acid
 An increase from 37% to 65% in the number of children who are fed in accordance with
the World Health Organisation’s Infant & Young Child Feeding guidelines
What are the planned outputs attributable to UK support?
By 2016, the following outputs are planned to be achieved with UK support:
1. Priority direct interventions (see above) to improve maternal, infant and young child
feeding practices to reduce stunting scaled up in at least 14 districts (reaching 215,000
pregnant women and 350,000 children under 2)
2. At least 15,000 households (with pregnant women and children under 2) taught to grow,
preserve and consume a diverse range of more nutritious foods (eg green vegetables;
small livestock, etc)
3. Strengthened capacity in the NFNC and selected line Ministries to deliver well coordinated nutrition programmes
4. An effective and transparent SUN Fund established to channel resources to reduce
stunting and increased government resources for nutrition
5. Improved evidence base on the effectiveness of multi-sectoral approaches to address
stunting
In addition to this programme, in 2012 we have also supported the Government’s national
measles campaign. As part of this annual two week campaign, vitamin A and de-worming
tablets have been provided on a once-off basis to 2.1 million children under 5. Together these
programmes contribute to delivering DFID Zambia’s operational plan targets for nutrition.
How will we determine whether the expected results have been achieved?
Progress will be tracked intensively against indicators and estimated baselines set based on
national data. A baseline survey will be conducted at the beginning and repeated at the end of
year 3 to assess progress against all the higher level indicators in the target districts. In
addition, a process evaluation will be undertaken to understand how the programme can be
effectively scaled up.
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Business Case
Strategic Case
A. Context and need for a DFID intervention
Undernutrition is a huge problem in Zambia
In Zambia, undernutrition is a major challenge to human and economic development and is
also concentrated among the poorest. Good nutrition can be one of the fundamental drivers
of economic growth. The elimination of iodine deficiency, reduction in stunting by 1% point
per year and reduction of maternal anaemia by one third (all very achievable) would increase
Zambia’s productivity by $1.5 billion over the next 10 yearsviii. Yet there has been no
significant improvement in levels of undernutrition in the last 10 years. Chronic food
insecurity continues to affect low income groups such as the urban poor and small scale
farmersix.
Zambia has one of the highest rates of childhood undernutrition in the world:
 46% of under-5 children are stunted, 5% acutely malnourished (wasted) and 15%
underweight x
 53% of Zambian children have Vitamin A deficiency and 46% have iron deficiency
anaemia.xi
 4.4% of infants are low birth weight with prevalence increasing with mother’s low level
of education and poverty quintilexii.
Zambia is off track to meet MDG 1 to halve the proportion of people living in hunger by
2015, and infant and child mortality rates are very high (119 per 100,000)xiii. 70% of the
Zambian population cannot afford a minimum cost dietxiv. Undernutrition is likely to be the
most significant factor in child mortality and morbidity, contributing between 35 and 50% of
under-5 deaths in Zambiaxv. Chronic malnutrition or stunting – short height for age – is the
most common form of undernutrition in Zambia with higher rates (46%) than average for
Africa (42%)xvi. The World Health Organisation (WHO) considers a prevalence of stunting
higher than 40% as very serious. This indicates high levels of deprivation and poverty. In
Zambia, micronutrient deficiencies (lack of sufficient amounts of one or more essential
nutrients) due to poor dietary diversity and chronic food insecurity are the primary causes of
stunting. Poor sanitation and frequent infections further compound the problem. Other
factors such as gender, education, family size and HIV status also affect nutrition status. It is
the poor who are most vulnerable and among these women and children.
Children who are stunted by the age of 2 will never meet their full potential of physical and
mental development. Underweight and young mothers are more likely to have low-birth
weight babies and to die in childbirth. Wasting among children born to underweight mothers
is higher than among children born to mothers with a normal weight xvii. In addition, Zambia’s
severe HIV epidemic significantly overlaps with populations already experiencing low diet
quality and quantity, leading to worsened undernutrition for HIV positive men, women and
children.
Geographic inequalities
The 2011 MDG report for Zambia shows significant inequalities in nutritional status with
hunger more concentrated in rural areas, where 15.3% of under-5 children are underweight,
10
compared to 12.8% in urban areas (Figure 1). The average stunting rate is of 48% in rural
areas and 42% in urban areas. Northern, Eastern and Luapula provinces have all stunting
levels of 50% and above. Western, Central, Lusaka and Southern provinces have an
average of 40% stunting prevalence ratesxviii.
Figure 1: Prevalence underweight and stunting in children U5
56.3
60
40
36.2
32
30
23.9
21.9
17.3
17.7
20
10
49.5
49.3
50
15.1
12.8
12.7
4.2
3.1
2.9
2.1
0
Luapula
Severe Underweight
Northern
Moderate Underweight
Eastern
Severe stunting
Southern
Moderate Stunting
Source: Zambia Demographic Health Survey (2007)
Gender
There is no significant difference in undernutrition rates between girls and boys in Zambiaxix.
However, the time and knowledge available to mothers to care for their children and the
mothers’ level of education are known to be significant factors in preventing malnutrition.
There is international evidence that gender inequality can divert household expenditure
priorities: when women have access to resources they tend to spend on their children’s food,
health and education.
Gender empowerment - the realisation of women’s rights as human rights – and ending
hunger, are closely entwined goals. Gender analysis shows us that women literally 'feed the
world', as producers, processors, cooks and servers of food. However, women’s vast
contribution to food production, and their key role as consumers and family carers, is still
largely misunderstood and underestimated. A conservative estimate is that female farmers
cultivate more than 50% of all food grown xx. In developing countries, 45% of economically
active women report that their primary economic activity is agriculture, and in some least
developed countries, this figure rises to 75%.
Infant and young child feeding
In Zambia only about 60% of infants are exclusively breastfed for 6 months xxi. In
addition, the quantity and quality of the complementary food received after 6 months is
often inadequate, providing insufficient protein, fat or micronutrients for optimal growth
and development. Among the provinces with low proportions of children under-5 years
who are fed at least 3 times a day are Luapula (45%), Northern Province (53%) and
North-Western (57%)xxii.
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Food consumption
Available data on food consumption in Zambia
highlight deficiencies in terms of dietary frequency
and, most importantly, quality and diversity.
National survey data shows that 11% of
households can only afford 1 meal per day, 51%
of households can afford 2 meals per day, and
only 36% can afford 3 meals per dayxxiii. As
illustrated in Figure 2, the Zambian diet has an
over-reliance on maize. As a result, it is
Figure 2: % Dietary energy supply by food
insufficient to fulfil energy needs, insufficiently
group 2000-2003
diverse to provide adequate quantity and quality
Source: FAO Zambia Nutrition country profile
of protein, and is highly deficient in
micronutrients, all of which have serious implications for nutritional status. Addressing
nutrition sustainably will require a more diversified diet.
Preventing undernutrition requires both direct and indirect nutrition interventions
Direct nutrition interventions have been proven to be highly cost effective when they reach
children in the ‘critical 1000 days’ between conception and age 2. A Lancet (2008) review
concluded that universal coverage of a full package of proven interventions focused on
women and young children (including breast feeding promotion, vitamin A and zinc
supplementation and therapeutic feeding) could prevent one quarter of child deaths under 36
months of age, reduce the prevalence of stunting at 36 months by about one third and avert
60 million lost years of healthy life in the 36 worst affected countries, including Zambiaxxiv.
These interventions are highly cost effective: US$3-70 per year of healthy life saved for a
range of proven direct nutritional interventions, compared with US$11 for bed nets and
US$922 anti-retroviral therapy for HIV/AIDSxxv.
Undernutrition is caused by complex inter-related factors as illustrated in the following
UNICEF conceptual framework. To achieve a long lasting difference, it is imperative to
simultaneously focus on direct and indirect interventions that are intended to address
underlying and basic causes. However, there is less evidence about the effectiveness of
indirect interventions, compared to direct because these interventions rarely have a stated
nutrition objective and hence are not evaluated by this criterionxxvi.
A multi-sectoral approach is therefore necessary to tackle undernutrition, but also presents
numerous challenges which require strong national leadership, resources, capacity and
commitment across a range of sectors. The HIV epidemic has taught us many lessons about
multi-sectoral approaches and the ‘Three Ones’ principles adopted (one leading body, one
plan and one monitoring and evaluation system) are also relevant for the fight against
undernutrition.
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Figure 3: Framework of the causes of maternal and child undernutrition and its short term
consequences
Support to improve nutrition
Renewed political commitment to nutrition has been made at the global level, as manifested
by the UN-led Scaling Up Nutrition (SUN) movement which aims to address stunting with a
focus on the critical 1000 days of pregnancy and the first two years of the child’s life. Zambia
has been identified as one of the priority focus countries that are committed and needing
donor support.
In Zambia, the legal and policy framework for improving nutrition is set out in the NFNC Act
of Parliament (1967), the National Food and Nutrition Policy (2006), the Sixth National
Development Plan (2011-2015), which includes a chapter on food and nutrition, and Vision
2030. The National Food and Nutrition Strategic Plan (NFNSP) was (belatedly) finalised in
April 2012 and identifies addressing stunting as the countries number 1 priority objective in
nutrition.
A broad situation analysis (carried out with DFID support) included reviewing policy,
strategies, current nutrition programming, governance, institutional arrangements and
capacity, and identified the following key problems to improving nutrition:
 Lack of leadership: Nutrition programmes across sectors lack coordination; NFNC
institutional and organisational capacity weak
 Lack of human resources: Inadequate nutrition expertise available; no academic
training; Positions for nutritionists in key line Ministries lacking
 Ineffective and poor quality interventions due to weak health systems, lack of skills
13


and commodity gaps
Low awareness of correct diet even when food available
Monitoring, evaluation and research: No single M&E system used to inform planning;
Research not targeted or not available
The national ‘First 1000 Most Critical Days programme’ has been designed to respond to
the above gaps. The aim is to have integrated high-impact maternal and child nutrition
interventions with broad cross-sectoral and civil society participation, and rapid but phased
implementation. This will be supported by well-designed communication and an agreed
monitoring framework. The programme will be launched in December 2012. The programme
is organised under five strategic areas:
1. Policy and coordination for robust stewardship, harmonisation and coordination of the
Programme and more efficient use of resources.
2. Priority interventions across sectors to reduce stunting.
3. Institutional and capacity building. The NFNSP recognises that significant training and
capacity building will be needed and at various levels (national, provincial, local).
4. Communication and advocacy needed for the programmes’ key messages acceptance,
promotion and application.
5. Monitoring, evaluation and research is needed to measure progress against the targets,
assess the effectiveness of interventions, and to share lessons learned.
The First 1000 Most Critical Days Programme is not conceived as a parallel programme and
will not duplicate on-going activities of the different line ministries or NGOs. It will
supplement existing interventions that are known to work and that need strengthening and
scaling up. It will also explore innovative approaches in all sectors where there is an
opportunity for results in reducing stunting.
Roll out of the First 1000 Most Critical Days interventions will focus initially on districts where
nutrition indicators are worst and where there is some chance of success (some 1000 Days
related interventions already in place or starting with government and donor support). The
programme will be implemented in three phases. 14 districts for phase 1 have been
preliminary selected by NFNC, key line Ministries and CPs. xxvii Districts have been selected
on the basis of high undernutrition prevalence and opportunities for synergies across existing
programmes supported by DFID and other donors such as the family planning, social
protection, community health assistants and water and sanitation programmes.
While there is every indication that there is buy-in from the ruling political party, the
President, sector ministries and other stakeholders at national and sub-national levels,
sustained advocacy will be needed, and so First 1000 Most Critical Day Champions will
therefore be identified to ensure that there is understanding and support at all levels,
especially at community level.
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Figure 4: First 1000 Most Critical Days Framework
Other government ministries, who play an important role in nutrition, have been involved in
consultations about the First 1000 Most Critical Days Programme and will be expected to
incorporate nutrition into their plans. Among these are: the Ministry of Agriculture and
Livestock (MoAL) responsible for the production of food and to some extent its use, storage
and preservation; Ministry of Community Development, Mother and Child Health (MCDMCH),
charged with primary health care services, women and children’s issues; the Ministry of
Education (MoE) which provides the best opportunity to provide nutrition education in
schools and ultimately influence nutrition behaviour of the population, improve eating habits,
monitor growth of older children and encourage school gardens; the Ministry of Health
(MoH), which leads on most nutrition-specific interventions; and the Minister of Local
Government and Housing, responsible for sanitation and hygiene.
An alliance of national civil society organisations (CSOs) and international NGOs focused
on the First 1000 Most Critical Days was formed in 2011. While in its early stages, the role of
CSOs is important to support the implementation both of the National Food and Nutrition
Strategic Plan for Zambia 2011-2015 and the SUN framework. DFID and Irish Aid will cofund the work of the CSO SUN Alliance.
Why DFID?
DFID’s corporate Nutrition Strategy notes that “Undernutrition is a human disaster on a vast
scale and that undernutrition “must be addressed as a priority if DFID is to deliver on its
commitment to poverty reduction”. Although nutrition is a relatively new sector for DFID, we
are now key supporters of the Scaling Up Nutrition movement and have been advocating
internationally for a multi-sectoral response to undernutrition. DFID launched a revised
nutrition policy at the UNGA meeting in September 2011 confirming commitment to eradicate
poverty and hunger and to halve the prevalence of underweight children under five years of
15
age by 2015. We have also significantly increased our capacity by creating new nutrition
posts and we can access technical expertise through our centrally managed nutrition
framework agreement.
DFID is co-convening the SUN Cooperating Partners’ (CP) group in Zambia. DFID’s lead
roles in health and social protection, experience of working with a range of partners
(including the Government of the Republic of Zambia (GRZ), other CPs, NGOs and the
private sector) and interaction with Ministry of Finance and Cabinet Office put DFID in a
strong position to support a multi-sectoral response and strengthen national leadership.
A Business Case for Tackling Maternal and Child Undernutrition in Zambia was approved in
October 2011 for a first phase of DFID support to Zambia’s efforts to tackle undernutrition.
Under this phase, DFID identified some “quick wins” and promising innovative approaches.
Phase 1 is providing support to the University of Zambia to establish their first nutrition BSc
and MSc degrees to increase nutrition capacity in the country, supporting two innovative
trials (Colalife and bio-fortified maize) and funding the expansion of Vitamin A and deworming tablets for children under-5 in 9 under-performing districts through the Child Health
Weeks Programme. This first phase also included preparation of phase 2 and provision of
support to the NFNC to develop a national 1000 Days Programme. There has been good
progress towards phase one outputs. In addition to development of the national 1000 Days
Programme, one round of the Child Health Week programme (Vitamin A and deworming
tablets provision for children under 5) has taken place in the DFID focus districts, the two
innovative trials are well underway, the 2nd year of the nutrition BSc has been successfully
delivered and both the BSc and MSc curriculum have been revised to be in line with
Zambia’s nutrition priorities.
By taking a phased approach, we are being incremental in our support to nutrition in Zambia.
We will consider additional funding for scaling up successful interventions based on evidence
of impact.
In addition, DFID Zambia conducted a ‘nutrition audit’ of its programme portfolio to identify
opportunities to increase our impact on nutrition by adding specific nutrition activities or
components in a selection of our existing and planned programmes. The audit concluded
that many opportunities for integrating nutrition in DFID programmes exist. These can be
broken down as (1) introducing nutrition training or awareness rising in a number of
programmes (2) adding nutrition-specific activities to existing programs to influence policy
and programme impact (3) advocating for nutrition-sensitive policies and increased attention
to nutrition at the national level. By taking forward selected audit recommendations through
our programme portfolio and making some of our investments nutrition-sensitive, we have
the potential to achieve further nutrition impact with limited additional resources.
Programmes that offer particular potential include the social cash transfer programme,
where, in addition to the cash transfer, adding nutrition-specific interventions for the most
vulnerable families is needed to improve child nutritional status; the adolescent girls
programme, where by adding a nutrition counselling module we can impact on the nutritional
status of the girls and their future babies, and the governance programme, which gives us an
avenue to advocate through civil society and others for higher attention to nutrition.
There is increasing donor interest in nutrition and the Development of the 1000 Most Critical
Days Programme has attracted much attention. Irish Aid, the Swedish Government and the
European Union are all considering support to the programme. Other donors such as USAID
16
will continue to fund nutrition in the context of national plans, whilst multilateral agencies UNICEF, WFP and WHO will remain as key technical partners. These partners all look to
DFID to provide the lead on coordination and establish funding mechanisms to support a
harmonised, multi-sectoral approach.
If DFID does not invest in nutrition, a substantial change to stunting levels in Zambia is
unlikely to occur. While other donor partners will continue to implement discreet nutritional
interventions, these will not be sufficient to reduce stunting at the desired rate and will not
address the many underlying causes of poor maternal and child nutrition. Although Zambia is
committed to the SUN initiative, it is unlikely that any real action will be taken by the NFNC
without DFID’s support to build their capacity, promote an enabling environment and
coordinate an effective CP response.
B. Impact and Outcome that we expect to achieve
The expected impact of the three year programme will be improved health and nutritional
status of children under-5 measured primarily by a reduction in stunting from 47% to 38.5%
and a reduction in low-birth weight babies from 9.3% to 6% by 2016. This will mean at
least 100,000 less children under-5 will be stunted. Together with other investments in child
health, we expect a reduction in the child mortality rate from 119 to 56 per 100,000 by 2015.
A key performance indicator in the SNDP is reduction of stunting to 30% by 2015. This is a
laudable goal, but unlikely to be achieved. LCMS data indicates a 0.74% point reduction in
Under-5 stunting per year between 2004 and 2010. The proposed 1.6% point reduction is
therefore ambitious, but realistic.
The outcome of the programme will be a strengthened national nutrition response through
the launch and support of the 1000 Most Critical Days Programme focused on the reduction
of stunting. Improvements in maternal, infant and child nutrition will be measured by
improvements in maternal and child nutrition practices, specifically:


An increase from 56% to 86% of pregnant women who receive iron and folic acid
An increase from 37% to 65% in the number of children who are fed in accordance
with the World Health Organisation’s Infant & Young Child Feeding guidelines
Programme targets will be confirmed once the Micronutrient Assessment Survey, currently
underway, has been finalised in November 2012. A zinc coverage target will be added once
baseline data is available1.
Expected outputs of this second phase are:
1. Priority interventions to improve maternal, infant and young child feeding practices to
reduce stunting scaled up in at least 14 districts (reaching 215,000 pregnant women
and 350,000 children under 2)
2. At least 15,000 households (with pregnant women and children under 2) taught to
grow, preserve and consume a diverse range of more nutritious foods (e.g. green
17
vegetables; small livestock, etc)
3. Strengthened capacity in the NFNC and selected line Ministries to deliver well coordinated nutrition programmes
4. An effective and transparent SUN Fund established to channel resources to reducing
stunting and increased government resources for nutrition
5. Improved evidence base on the effectiveness of multi-sectoral approaches to address
stunting
18
Appraisal Case
A. What are the feasible options that address the need set out in the Strategic case?
There is global consensus that to address under-nutrition in the long-term, investment in both
direct, as well as indirect causes of malnutrition is needed. This was confirmed in the Zambian
context during the appraisal of phase 1.
The theory of change informing the identification of options (both for phase 1 and phase 2),
has been developed with reference to UNICEF’s conceptual framework for undernutrition (see
page 11) and includes the following:
1. Direct nutrition interventions to address the manifestation and immediate causes of
undernutrition – inadequate dietary intake and disease.
2. Nutrition-sensitive interventions to address underlying causes of undernutrition –
household food insecurity, inadequate care and unhealthy community level environments.
3. Interventions that address basic causes at societal level – institutions, economic
structure, political & ideological framework. These are needed to promote an enabling
environment through political leadership, nutrition awareness, social accountability
mechanisms and women’s empowerment.
The Lancet nutrition series (2008) summarise the evidence under-pinning the theory of
change:
Source: What works? Interventions for maternal and child undernutrition and survival.
The Lancet. Vol 371 February 2, 2008
In the figure below, double arrows refer to interventions and linkages for which there is a
strong evidence base. Single arrows reflect interventions and linkages for which the evidence
base is weaker and where good research is needed. Please refer to pages 27-31 for a
detailed review of the global evidence base. There are evidence gaps about how to scale up
effective interventions, particularly in Zambia. A strong process evaluation and operational
research for selected innovative interventions will be built into the programme to improve the
evidence base of what works in Zambia. Table 2 on page 28 filters down the possible options
from the theory of change to what DFID Zambia will focus on under this programme, as well
as a list of key activities that will lead to the expected outputs and outcomes. DFID focus
activities in the figure appear in bold.
19
Figure 5
INPUTS
Direct nutrition
interventions:
- Promotion of breastfeeding&
complementary
feeding practices
-Promotion of good
diet and care for
pregnant& lactating
mothers
-Micronutrient
supplementation &
fortification
-Promotion of hygiene
practices and use of
preventive healthcare
Nutrition sensitive
interventions:
- Agriculture & food
security
- Dietary diversification
- Cash transfers
- Women’s
empowerment
-Water& sanitation
Health systems
strengthening
Cross-cutting:
Nutrition relevant
policies, strong &
effective
institutions, good
governance &
accountability
mechanisms
PROCESS
-Review maternal
& IYCF strategy
-Nutrition
counselling
Community-based
distribution of Iron
& Folic Acid
-Targeted support
for malnourished
pregnant, lactating
& adolescents
-Research on
complementary
foods
Scale up IYCF
package in 14
districts
-Review of bestpractices
-Development of
guidelines for
proposals
-Support to
homestead food
interventions based
on potential for
scale up
-Gender screening
of proposals
-Support to NFNC &
selected Ministries
-Competitive tender
of SUN Pooled Fund
-Establishment of SC
for programme
oversight
-Impact evaluation
OUTPUTS
-Improved
nutrition
knowledge &
practices
-Improved
micronutrient
intake
-Improved
hygiene &
parasite
control
-Increased
access &
availability of
food through
homestead
food production
OUTCOMES
IMPACT
-Improved
maternal,
infant &
young child
feeding
Reduced
disease
burden &
nutrition
deficiencies
Improved
dietary intake
(quantity &
quality of food
consumption)
Improved child
health &
nutritional
status:
-Reduction in
stunting
-Reduction of
micro-nutrient
deficiencies
-Reduced lowbirth weight
babies
Improved
access to
health services
-Effective &
transparent
funding
mechanisms
-Improved
capacity and
M&E systems
-Increased &
harmonised
nutrition
resources
-Increased
knowledge of
what works in
Zambia
Strengthened
national
nutrition
response
Assumptions
1. A strengthened national nutrition response focused on direct and underlying causes
should result in improved health and nutritional status of children under-5.
2. Improved maternal nutrition and infant and young child feeding practices are necessary
for improving food intake
3. Increased and more diverse household food consumption will contribute to better
accessibility of food at the household level and improved nutrition status of children
4. Disease control and hygiene interventions will contribute to reducing disease burden
Based on this context, there are three options considered for this 2nd phase business plan:
Option 1:
Expanding the coverage of direct and indirect nutrition interventions in the
context of the First 1000 Most Critical Days programme through contracted service delivery
providers (in parallel with government efforts)
Option 2:
Option 1 plus supporting a multi-sectoral response and capacity building,
working with government in the context of the First 1000 Most Critical Days Programme
20
Option 3:
Doing nothing beyond current investments on nutrition under phase 1
Option 1: Expanding the coverage of direct and indirect nutrition interventions in the
context of the First 1000 Days programme in parallel with government efforts through
service delivery providers.
Adding to those supported under phase 1, this option would support the expansion of selected
direct interventions with a strong evidence base, and selected indirect interventions, both with
significant coverage gaps.
1. Maternal and adolescent nutrition: Pregnancy places enormous physical demands on a
woman. Good nutrition during pregnancy is essential for the health of the mother and
baby. Prevention of iron and iodine deficiency and early provision of folate (before
pregnancy) to reduce the risk of neurological problems for the baby are two key maternal
nutrition interventions. Iron and folate supplements for women can be best distributed
through maternal and child health services, including prevention of mother-to-child
transmission of HIV (PMTCT). There are however major coverage gaps and also
compliance issues in these services, with 56% of women not taking the required iron folate
supplementation. Community based distribution of supplements and/or piloting the use of
multiple micronutrient powders for pregnant women may be two options for increasing
early provision, adherence and coverage. The promotion of an adequate diet for the
mother during pregnancy is also important.
2. Infant & young child feeding: Optimal infant and young child feeding entails the initiation
of breast-feeding within one hour of birth; exclusive breastfeeding for the first six months
and age-appropriate diverse feeding of solid, semi-solid and soft foods from 6 months of
age. Increasing the rates of early initiation of breastfeeding and of exclusive breastfeeding
is critical to improving child survival. Complementary feeding is the most effective
intervention to reduce stunting during the first two years of life. Strategies to improve
infant and young child feeding rely largely on community-based behaviour change
(counselling to care givers) and on promotion at all levels of primary health care. In
addition, evidence indicates that significant improvements in exclusive breastfeeding are
possible if supported by an effective regulatory environment framework and guidelines
(maternity laws, compliance on the code of breast-milk).xxviii Approaches to improving
complementary feeding also include improving access to quality foods for poor families
through social protection schemes and the provision of micronutrients and fortified food
supplements when needed.
3. Fortification of staples. In 2006, Zambia embarked on a Maize Flour Fortification Project
with support from the Global Alliance for Improved Nutrition (GAIN) with the aim of
adopting mandatory fortification of commercial maize flour with micronutrients. Equipment
was supplied and legislation submitted when the programme was suspended in 2007 due
to concerns of toxicity, capacity to monitor, fears that maize meal prices would rise and
concerns around the consumer’s right to choose. In 2010, an advocacy plan of action was
developed by the National Fortification Alliance (NFA) that addressed the concerns for
resumption of the programme. Subsequent efforts to resume the programme have failed
but there are indications that there is an opportunity to re-engage with NFA members and
GAIN.
21
4. Management of acute malnutrition. In Zambia, 5% of children under-5 suffer from
moderate and acute malnutrition. Acute malnutrition can be successfully managed through
community based programmes, the use of take-home Ready-to-Use therapeutic Foods
(RUTF) for cases without medical complications, and hospital referral for cases with
medical complications. This is one of the most costly direct nutrition interventions, but it is
a life-saving intervention and still cost-effective. At present therapeutic foodsxxix are solely
funded by UNICEF, there are often financial gaps to support these foods and the roll-out of
the programme is limited to specific pockets of the country.
5. Homestead gardening with promotion of dietary diversification. In Zambia, most poor
households rely on maize as their main staple food and caloric source at the expense of
green vegetables, protein and fat intake. This excessive reliance on maize is a cause of
malnutrition, and high-level micronutrient deficiencies in particular. In addition, at present
there is minimal emphasis on homestead food processing and storage in Zambia. Food
produced in small-scale farms or homestead gardens is typically sold or consumed fresh
at time of harvest. With minimal food stores, households are vulnerable to malnutrition and
food insecurity at times when food is scarce. Off-season processing of food crops has the
potential to bridge the hunger gap in rural areas, and simple and inexpensive technologies
are available that can be utilised at the household, community or farm level. In addition,
the promotion of a more diversified diet coupled with support for households to diversify
their food production and consumption, would contribute to improving the nutrition status
of households. Food-based approaches are also more sustainable because they reduce
the need for direct nutrition interventions in the future.
What would option 1 support?
Based on their strong evidence-base and feasibility for scale up, this option would focus on
supporting the following:
 Expansion and strengthening of maternal nutrition interventions
 Expansion and strengthening of infant and young child feeding interventions, including
breast-feeding promotion
 Home-stead food-based approaches for the promotion of dietary diversification
In addition, some technical support for the expansion of CMAM (e.g. filling therapeutic food
gaps, training of Community Health Assistants through our forthcoming expanded human
resources programme) and supporting the on-going debate on the fortification of staples could
be considered.
The table below outlines the proposed DFID focus interventions under Option 1.
22
Table 1: Possible nutrition interventions and DFID focus under Option 1
Possible Interventions
(Programme focus in bold)
Key Proposed Activities
Nutrition sensitive
(to address
indirect causes)
Nutrition specific
(to address immediate causes)

-Breast-feeding& complementary
feeding practices
-Micronutrient supplementation &
fortification
-Promotion of good diet and care
for pregnant& lactating mothers
-Hygiene practices
-Immunization
-Use of preventive healthcare
-Agriculture & food security
-Poverty reduction & social
protection/safety nets
-Income generation
-Health systems strengthening
-Women’s empowerment
-Water& sanitation
Review of Maternal and Infant & Young Child Feeding strategy and action
plan and of ante-natal care guidelines to strengthen nutrition components
Maternal nutrition

Feasibility study to consider community-based distribution of iron and
folic acid and deworming tablets during pregnancy

Support community-based distribution of IFA and deworming tablets in up
to 14 districts

Promotion of nutritionally adequate diets for pregnant women and IFA
uptake through behaviour change communication and nutrition
counselling in at least 14 districts

Targeted food and nutrition support for malnourished pregnant, lactating
women and adolescent girls

Pilot distribution of multiple micronutrient powders (sprinkles) for pregnant
women
Infant & young child feeding

Review of Baby Friendly Initiative and action plan to promote breastfeeding support

Expansion of the IYCF package in at least 14 districts

Operational research on use of locally produced complementary food
supplements for children 6-24 months

At least 15,000 households with pregnant women and children under 2
reached through homestead food production, preservation & storage
projects
o
Review of best-practices and lessons learnt
o
Preparation of guidelines and calls for proposals
o
Support to homestead food-based interventions based on
potential for scale up and innovation

Gender screening of proposals

Strengthen linkages with water and sanitation programme in selected
districts
How would Option 1 support scale up of the above interventions?
Option 1 would be implemented through contracts with service providers for the delivery of
interventions alongside government systems. Contracts would be awarded through
competitive calls for proposals from NGO’s and UN agencies based on government
guidelines for the 1000 Most Critical Days Programme.
Pros and Cons of Option 1: This option would contribute to scaling up evidence-based
interventions quickly by by-passing low capacity government systems. It would not support
coordination or capacity building and hence longer-term sustainability, ownership and national
scale up would be compromised.
23
Option 2: Option 1 plus supporting a multi-sectoral response and capacity building,
working with government in the context of the First 1000 Most Critical Days Programme
“A successful response to undernutrition requires a range of policies and programmes across several sectors: collective
action bound by a common goal. Nutrition is the business of neither the health sector nor the agriculture sector: it is the
responsibility of both but also involves tackling poverty, gender inequality, improving trade and markets, budget allocation
and planning and much more besides”. DFID Position Paper on undernutrition, 2011
This option would focus on scaling up the interventions appraised above, but would also
extend support to the multi-sectoral response through provision of technical assistance to the
NFNC and key line Ministries responsible for delivering nutrition outcomes. As such, it would
provide cross-cutting support to the new national 1000 Most Critical Days Programme across
its five strategic areas:
1. Policy and coordination. Coordinating a multi-sectoral programme of this complexity
requires robust stewardship by the NFNC and leadership from all sectoral ministries. In order
to minimise duplication and encourage harmonised approaches to reduce stunting, the ‘Three
Ones’ concept of: one overall leader (NFNC); one plan (NFNSP) and one M&E Framework
(long used for HIV and AIDS programming) will be promoted. This will help to ensure
maximum coverage of the programme, greater opportunities for linkages between sectors and
players, and adherence to evidence-based approaches.
2. Priority interventions across sectors to reduce stunting. The NFNC and various
stakeholders have agreed priority interventions for this programme that if strengthened and
scaled up are likely to have the greatest impact on the reduction of child stunting. 2 These
have already been appraised under Option 1.
3. Institutional and capacity building. The NFNSP recognises that significant training and
capacity building will be needed in some areas, alongside increased and improved
collaboration among sectors and organisations, better monitoring, enhanced support from
NGOs, and use of all forms of formal and non-formal media. The strategy also recognises the
need for greater community participation.
4. Communication and advocacy. A nationwide campaign is planned for the Programme.
Different messages, channels, and activities will be used at various levels to reach different
audiences about the importance of the First 1000 Most Critical days. Since lack of dietary
diversity and dependence on maize is an underlying cause of undernutrition, engaging the
Ministry of Agriculture in the programme will provide a useful platform for advocacy on
changing the current maize policy.
5. Monitoring, evaluation and research. Until now, there has been no over-arching system
that captures routine data related to nutrition from all sources, sectors and stakeholders.
Nutrition data currently comes from periodic surveys such as the Demographic Health Survey
(2007) and the Food Consumption Survey (on-going) and from the MOH health information
system. Under the First 1000 Most Critical Days Programme, a robust and comprehensive
M&E system will be developed in the NFNC to capture information from all stakeholders
across the sectors. A first and important step towards improving information collection and
2
While vitally important, family planning, immunisation and bednets for malaria are well supported by
other programmes, and are therefore not promoted as part of this plan.
24
analysis has been the launch of the Zambia Nutrition Information System (ZamNIS) by the
NFNC which now needs to become fully operational.
What will option 2 support?
Option 2 would support the 1000 Most Critical Days Programme across the 5 strategic areas
identified above with a focus on scaling up priority interventions. The plan is to roll-out a
comprehensive package of the 1000 Most Critical Days Programme interventions in up to 14
districts, to align current and future resources to the Programme and to agree a division of
labour among donors. Discussions about which priority activities under each area will be
supported by various donors, are still on-going.
Appraisal of priority nutrition interventions (strategic area 2) was carried out under option 1.
Below we consider how option 2 would support the other strategic areas, in particular the
leadership and strategic capacity which are needed for advancing the nutrition agenda. This
appraisal is informed by the institutional and capacity assessment of the NFNC and the key
line Ministries undertaken during the design of the 1000 Most Critical Days Programme. The
full appraisal is in Annex 3.
NFNC Institutional Capacity: The institutional and capacity assessment, in common with
past reviews, identified two sets of issues: 1) those related to the positioning of the NFNC and
its ability to coordinate nutrition across other sectors, and 2) those related to its organisational
management.
Key recommendations to strengthen the positioning of the NFNC include:
1. Obtaining a high-level mandate for the nutrition agenda and unifying thinking about
nutrition across sectors.
2. Obtaining consensus around nutrition needs and the way to address them.
3. Supporting and empowering the NFNC via an auxiliary body such as a Food and Nutrition
Steering Committee in the office of the Vice President or the Cabinet.
4. Applying lessons learned from coordination in the HIV sector.
In relation to the management of the NFNC, the appraisal notes that the NFNC is operating
with “inherited” management systems which are not fit for purpose. The day-to-day
management is done by a small operational team that consists of the Executive Director,
Financial Manager, Deputy Executive Director and the Heads of Departments. The
management is more related to the direct programme implementation than its coordination
role and the organisation does not follow established management procedures and systems
well.
A major achievement however, has been the endorsement of the National Food and Nutrition
Policy in 2006. The Policy provides a clear policy direction for the NFNC and stipulates the
strategies that should be implemented in order to strengthen coordination in the nutrition
sector of Zambia (details are provided in Annex 3).
A recent DFID funded case study conducted by the Institute for Development Studies (IDS):
“Nutrition Governance in Zambia”, illustrates that three main factors have contributed to
insufficient inter-sectoral cooperation around nutrition. These are: a lack of qualified staff, a
limited mandate to convene high-level actors by the NFNC and insufficient funding for
nutrition activities on the part of the government. There is a need to recruit adequate human
resources with the right skills mix and experience for the NFNC. A detailed organisational
25
management review will also need to be undertaken in order to develop and agree a suitable
organisational management strengthening programme of support.
The assessment identified 3 options to support the capacity building of the NFNC:
1. Resource-intense scenario: This would consist of an extensive re-engineering process. It
would require the full support of government and significant technical and financial support
for the implementation of a detailed transformational plan. Ideally, NFNC would be given
agency status, to give it greater operational flexibility.
2. Medium- resource scenario: A less intensive approach which would not aim at total reengineering of the NFNC, but which would support an organisational management plan to
improve existing human resource management systems, including leadership, governance
and accountability. Depending on other partners’ contribution, this option would also
include some support to financial management and monitoring systems.
3. Low-resource scenario: This would have a minimal focus on re-engineering of the NFNC
and would include only an organisational review and some management support for the
implementation of the 1000 Most Critical Days Programme through technical assistance.
Institutional Capacity in other line Ministries. In addition, the nutrition capacity assessment
conducted as part of the development of the 1000 Days Programme recommends the
provision of technical assistance (e.g. through funding positions) to 5 line Ministries, including
the MoH, MCDMCH, MoAL, MoE, MoLG, all of which will be involved in the implementation of
the 1000 Most Critical Days Programme. 10 positions have been recommended. It also
recommends provision of support to training institutions in the country in order to increase the
numbers of qualified nutritionists and nutrition skills across various medical cadres which
DFID is partly addressing through supporting UNZA’s new nutrition degrees. The Natural
Resource Development College (NRDC) is also planning to introduce a nutrition BSc.
However, at this stage there is no clear funding available and it is not harmonised with the
new UNZA programme.
Recommended way forward
For the NFNC. Given the current weak leadership and performance of the NFNC, and that
more work at higher political level is needed to re-position the Commission, a low resource
scenario is recommended at this stage. This would include:
1) Addressing key NFNC institutional issues (e.g. support to a possible re-positioning of
the NFNC) by high level engagement at the MoH and Cabinet Office
2) Support to strengthen the organisational management of the Commission and
provision of TA to support the coordination of the 1000 Days Programme.
Moving to a more medium resource scenario would be based on performance and
demonstrated government commitment to improve the effectiveness of the NFNC. The
likelihood that this will happen is quite high given the different activities and strategies that are
being put in place to raise the profile of nutrition in Zambia, namely:

the Civil Society SUN Alliance will be targeting the media and members of
parliament to raise awareness of the severity of stunting and its developmental
impacts
26

the Vice-President was invited by the UK PM to attend a high-level Hunger Event in
July 2012. Although he was not able to attend, he is now aware of the SUN
movement, the severity of malnutrition in Zambia and the 1000 Days Programme
and has been asked to become a “nutrition champion”. DFID will seek further
engagement with the VP on this issue.

the NFNC Act (1967) is scheduled to be revised in line with recommendations of
the National Nutrition Policy 2006

increased donor attention and the SUN movement are helping to raise attention to
nutrition and NFNC see this as their “first and last” opportunity to put nutrition high
on the agenda

as a middle-income country, the Zambian government will need to recognise that
this is not compatible with a very serious stunting situation (as classified by the
WHO).

DFID and our partners will use evidence on the economic rationale of investing on
nutrition.
Through our relationship with Cabinet Office, engagement in high-level policy discussions and
co-convening role of the nutrition CPs group, DFID Zambia is in a good position to
complement and facilitate nutrition advocacy efforts by civil society, academia, nutrition
associations and the NFNC. A coordinated advocacy plan for the nutrition CPs group has
been developed to address the institutional issues raised above, as well as to ask for
increased resources for nutrition from the Government of Zambia. Technical assistance to
support an organisational review of the NFNC and ensure appropriate staff are in place for
robust coordination of the 1000 Days Programme, as well as to key line Ministries, would be
provided under this option.
For key line Ministries: Further discussions with other donors and with MoH regarding
options and procedures for supporting 10 positions are needed before any decision can be
made. DFID funding could be allocated for supporting 3-4 positions, whilst encouraging
partners and GRZ to fund others.
27
Table 2: Possible interventions and DFID focus under Option 2
Possible
Interventions
(programme focus
in bold)
Key Activities
Resources, institutions, technology,
people (to address basic causes)
Nutrition sensitive
(to address indirect causes)
Nutrition specific
(to address immediate causes)

-Breast-feeding&
complementary feeding
practices
-Micronutrient
supplementation &
fortification
-Promotion of good diet
and care for pregnant &
lactating mothers
-Promotion of hygiene
practices
and use of preventive
healthcare
-Immunization
-Agriculture & food
security (homestead
food production)
-Poverty reduction & social
protection/safety nets
-Income generation
-Education
-Health systems
strengthening
-Women’s empowerment
-Water& sanitation
-Policies (agriculture,
trade, poverty reduction,
etc)
-Governance
-Conflict resolution
-Climate change
mitigation policies
Review of Maternal and Infant & Young Child Feeding strategy and action plan
and of ante-natal care guidelines to strengthen nutrition components
Maternal nutrition

Feasibility study to consider community-based distribution of iron and folic acid
and deworming tablets during pregnancy

Support community-based distribution of IFA and deworming tablets in up to 14
districts

Promotion of nutritionally adequate diets for pregnant women and IFA uptake
through behaviour change communication and nutrition counselling in at least
14 districts

Targeted food and nutrition support for malnourished pregnant, lactating women
and adolescent girls

Pilot distribution of multiple micronutrient powders (sprinkles) for pregnant
women
Infant & young child feeding

Review of Baby Friendly Initiative and action plan to promote breast-feeding
support

Expansion of the IYCF package in at least 14 districts

Operational research on use of locally produced complementary food
supplements for children 6-24 months

Review of best-practices and lessons learnt

Preparation of guidelines and calls for proposals

Support to homestead food-based interventions based on potential for scale up
and innovation (targeting at least 15,000 households with pregnant women
and children under 2)


Gender screening of proposals
Strengthen linkages with water & sanitation programme in selected districts

Support organisational review of the NFNC and development of a plan to
strengthen capacity & organisational management systems
Provide 2 technical assistance positions through the Pooled Fund service
provider
Provide 1nutrition expert in 3-4 key Ministries (MoH, MCDMCH, MoAL, MoE) to
strengthen capacity & coordination
Advocate for repositioning of the NFNC and the establishment of a Cabinet
Office Nutrition Committee
Agree ToR for the management of the Pooled Fund to establish an effective &
transparent financial mechanism to fund nutrition interventions
Competitive selection of service provider for management of the Pooled Fund
Sign JFA agreement with Irish Aid (and any additional funders)
Sign MoU with GRZ and non-pooling partners to establish ways of working
Set up Steering Committee
Specify district support mechanisms and allocation of resources during the
inception phase









How would option 2 be implemented?
Given the complexity of the programme (covering priority interventions and other strategic
areas) and the opportunity to leverage other donor and GRZ resources, it is proposed that
option 2 be implemented through a pooled fund managed by a service provider. This is fully
in line with the principles of the SUN movement and as such would be called the SUN Fund.
28
The SUN Fund would support priority interventions based on realistic, quality district work
plans and proposals from a range of implementing organisations. Other strategic areas would
be supported based on co-funding available from other donors and opportunities for synergies
with on-going activities. The objective is to support the implementation of an overall package
in the selected districts and demonstrate that the programme approach works.
It is expected that about 60% of the funding will be earmarked for the district public set up.
Most direct nutrition interventions are currently delivered through the primary health
infrastructure and building on existing services is a more sustainable approach. Both UNICEF
and Irish Aid provide funds to districts successfully (through the Provincial Office or District
Councils). Irish Aid for example has provided euro 8.5 million (2008-2011) to Isoka, Luwingu,
Mbala and Mpika districts. These funds have been used by local government to build health
clinics, schools and training as planned. UNICEF works closely with local government by
providing technical support and monitoring project implementation regularly, and has found
that funds are overall used for their intended purposes. The SUN Fund service provider would
have the role of monitoring provincial and district channelled funds.
However, because of the human resource and coverage gaps mentioned above, the balance
of funding will be available to NGOs, UN, research organisations and private sector for
innovation and complementarity to scale up. Good operational research and monitoring will
be essential to see what works. Specific details of how best to support district level work and
the allocation of resources will be worked out with the service provider during the inception
phase. For example, district grants and grants to NGOs could be performance based.
Support to strengthening and scaling up priority direct nutrition interventions, which are largely
delivered through the primary health care set up, will include training, mentorship and
supervision of a range of community health workers and volunteers. The new cadre of
Community Health Assistants has huge potential (they are trained for a whole year and better
paid). The current pilot supported by DFID is already looking at strengthening the nutrition
component of their curriculum. DFID Zambia is also planning to support the expansion of the
Community Health Assistants programme.
The service provider will manage the pooled fund, provide necessary technical support (in
addition to UNICEF, NFNC) and monitor implementation. Calls for proposals will be quite
prescriptive and based on global evidence. A review of best-practice and lessons from past
nutrition projects and a gap analysis for the first 14 districts will be undertaken during the preinception phase.
Pros of Option 2: Establishing a SUN Fund will enable DFID to support implementation of the
1000 Most Critical Days priority interventions in addition to a broader set of supportive
activities. This option is likely to deliver very similar nutrition results but would also contribute
to strengthening government coordination and capacity, and thus provides a more sustainable
approach in the medium term. In addition, by pooling funds with other donors, aligning
resources behind the national programme and engaging other Ministries which currently are
not doing much to address nutrition concerns but have significant budgets (MoAL, MoE),
DFID Zambia could potentially leverage other resources for nutrition. The SUN Fund would
also allow building in some flexibility to respond to key gaps and allocate resources where
they are most needed.
29
Risks for Option 2: Efforts to support the NFNC and key line Ministries might not yield the
results expected unless higher political commitment for nutrition, both in terms of oversight
and increased resources is secured.
Option 3: Do nothing further beyond on-going nutrition investment
The Government of Zambia has stated its commitment to nutrition but it remains to be seen
how far this will be supported by human and financial resources, which are currently grossly
inadequate. If DFID does not invest in nutrition, a substantial change to stunting levels in
Zambia is unlikely to occur. While other donor partners will continue to implement discreet
nutritional interventions, these will not be sufficient to reduce stunting at the desired rate and
will not address the many underlying causes of poor maternal and child nutrition. It is also
unlikely that any real action will be taken by the NFNC without DFID’s support to build their
capacity, promote an enabling environment and coordinate an effective CP response.
B. Assessing the strength of the evidence base for each feasible option
In the table below the quality of evidence for each option is rated as either Strong, Medium or Limited
Table 3
Option
1
2
3
Evidence rating
Strong
Medium/Strong
Medium
The Lancet provides a strong body of evidence for the direct health-related interventions
which can reduce one third of stunting. There is less evidence for indirect interventions.
However, there is consensus that these can potentially address the remaining two-thirds of
stunting. There remain gaps, particularly about how best to scale up these interventions, and
the effectiveness and cost-effectiveness of nutritional interventions in national health systems
need urgent assessment.
Evidence for selected direct nutrition interventions (Lancet 2009)
Iron/Folate supplementation for pregnant women. Iron deficiency anaemia in women
contributes to maternal deaths. Universal iron and folate supplementation for pregnant women
could avert an estimated 84,000 maternal deaths and 2.5 million Disability Adjusted Life
Years (DALYs). In Zambia, iron folate for pregnant women is provided through ante-natal care
(ANC). However, although rates for 1st ante-natal care (ANC) visits are high, this is not the
case with follow up ANC visits, which explains why 56% of pregnant women do not take iron
folate. There are also compliance challenges.
Zinc supplementation. Although maternal zinc supplementation is associated with reduced
prematurity rates, it does not affect maternal health indicators, weight gain or intra-uterine
growth restriction. However, children who take zinc supplements have fewer episodes of
diarrhoea, persistent diarrhoea, and lower respiratory infections. A meta-analysis of zinc
30
supplementation indicates a 9% reduction in child mortality and a 15-24% reduction in the
duration of diarrhoea3. In Zambia, zinc supplements are distributed through the Integrated
Management of Childhood Illness programme, but with limited coverage as all procurement is
donor funded and done through UNICEF. There is a need to include zinc supplements in the
essential drugs list and to explore optimal mechanisms for distribution.
Food fortification with micronutrients. The Lancet assessed 22 studies on the effect of
fortification of various commodities, such as condiments, milk, and commercial foods, with
iron alone or with other micronutrients. Two studies assessed iron fortification as a single
micronutrient intervention in women of childbearing age and showed that it increased
haemoglobin concentrations, with a weighted mean difference of 5·70 (95% CI 0·02–11·38)
g/L. The only study to assess iron fortification in pregnant women also showed a 6·90 (2·74–
11·06) g/L increase in haemoglobin. No studies investigated iron fortification in children
younger than 5 years, but haemoglobin concentrations were 7·36 (2·88–11·84) g/L higher in
the intervention group than in the control group, together with a 70% reduction in the
prevalence of anaemia (two studies; relative risk 0·30, 95% CI 0·17–0·51). Beyond 12 months
of age the use of foods fortified with micronutrients (generally iron and other micronutrients
including zinc) has shown benefits.
Fortification of various commodities, including sugar, cooking oils, and monosodium
glutamate with vitamin A showed that mortality in children aged 6–49 months was reduced by
about 30%; these results were consistent with findings from other trials that used capsules.
Evidence for the effectiveness of these interventions is scarce, apart from large-scale sugar
fortification programmes in Central America, where assessments have shown high rates of
coverage (e.g. fortified sugar contributes over half the daily intake of vitamin A in toddlers in
Guatemala).
Evidence on impact of indirect nutrition interventions
Nutrition sensitive development involves adjusting and re-designing programmes which have
potential to address the causes of undernutrition to explicitly deliver this result. These
programmes have multiple objectives and casual chains and are difficult to measure.
However, they represent a huge untapped potential for reducing undernutrition and may hold
the key to much of the remaining 2/3 of the stunting problem. Programmes which offer the
greatest scope to improve nutrition include:
Food security and agriculture. Growth in this sector leads to reductions in stunting,
especially when this is concentrated in the rural poor. This relationship is even stronger in
food insecure contexts and when increased food availability results from agricultural growth.
Water, sanitation and hygiene promotion. There is a strong association between access to
improved sanitation and stunting. The Lancet series looked at the impact of hygiene
interventions (hand washing, water quality treatment, and sanitation and health education)
and concluded that they could contribute to a 2-3% reduction in stunting. The high prevalence
of diarrhoea in young children is a major cause of concern because of its known link to
malnutrition. Careful handling surrounding infant and young child’s faeces is often difficult to
control and therefore an issue that bears special priority. With children under two years of age
in a home, there is higher danger for faecal contamination of clothes, cleaning cloths, water
containers, hands, food and a mother’s breasts.
31
Dietary diversification. Interventions to diversify diets by enhancement of agriculture and
small-animal production (e.g. home gardening, livestock rearing, and dietary modifications)
are potentially promising and culturally relevant, but in general, have only been implemented
at a small scale, and have not been adequately assessed. Dietary modification techniques
(e.g. germination, fermentation, and malting), have been shown in small studies to improve
children’s intakes of micronutrients and their micronutrient status. Although some promising
multidisciplinary nutrition interventions have been implemented, dietary diversification
strategies have not been proven to affect nutritional status or micronutrient indicators on a
large scale. However, this is largely because very few rigorous evaluations of such strategies
have been conducted. In view of the weaker evidence for the effects of these interventions on
human nutrition, the Lancet did not attempt to estimate their effects.
In Zambia dietary diversity is extremely poor with very high dependence on maize, which has
nutritional consequences consistent with lack of other essential nutrients.
Health. It is acknowledged that good nutrition is essential for preventing and fighting diseases
and that childhood illness can result in undernutrition. In addition to delivering nutrition specific
interventions, the health sector also has a crucial role in addressing ill health which
contributes to undernutrition. Specifically, malaria frequently causes iron deficiency and
anaemia; measles and diarrhoeal infections increase the body‘s Vitamin A requirements and
can trigger severe forms of deficiency such as blindness; parasitic infections, particularly
hookworm cause iron deficiency and anaemia; and a wide range of infections often reduce
appetite and decrease the amount of food that is consumed, leading to weight loss and
micronutrient deficiencies. HIV positive individuals have lower resistance to fight other
opportunistic infections and are more prone to be malnourished. HIV infection has also shown
to increase the energy consumption needs of affected individuals, and anti-retroviral treatment
(ART) adherence improves significantly when combined with food and nutrition support xxx.
Disease control interventions are estimated to contribute to a 3% reduction in stunting though
not all possible interventions were included in this estimation.
In addition, the Lancet nutrition series cited in Table 3 below concludes by saying that “to
eliminate stunting in the longer term, these (direct) interventions should be supplemented by
improvements in the underlying determinants of undernutrition, such as poverty, poor
education, disease burden, and lack of women’s empowerment.”
32
Table 4: Evidence for general nutrition strategies
Source: What works? Interventions for maternal and child undernutrition and survival.
The Lancet. Vol 371 February 2, 2008
Additional evidence for Option 2
Evidence on multi-sectoral and institutional capacity building approaches.
There is evidence that a multi-sectoral response to malnutrition delivers greater impact than
the sum of individual sectoral investmentsxxxi. Brazil, Thailand, Tamil Nadu, Vietnam and
Mexico have all successfully reduced malnutrition by implementing strongly led multi-sectoral
strategies which entailed a combination of strong government commitment and leadership,
nutrition and food security policies and capacity building. But delivering a multi-sectoral
response is also challenging, requiring robust leadership to harmonise and coordinate public
and private sector partners in different sectors and working at different levels.
Although the evidence base for these approaches is weaker because of the lack of rigorous
impact evaluations, an increasing body of analytical studies and process-type evaluations
point to key factors that are needed to secure commitment, agenda setting, policy formulation
33
and implementation of nutrition-relevant strategies. For example, studies in Bangladesh,
Bolivia, Guatemala, Peru and Vietnam provide several insights for future efforts:
(a) high-level political attention to nutrition can be generated, but this requires sustained
efforts from policy entrepreneurs and champions;
(b) mid-level actors from ministries and external partners had great difficulty translating
political windows of opportunity for nutrition into concrete operational plans, due to capacity
constraints, differing professional views of undernutrition and disagreements over
interventions, ownership, roles and responsibilities; and
(c) the pace and quality of implementation was severely constrained in most cases by
weaknesses in human and organizational capacities from national to frontline levels.
These findings deepen our understanding of the factors that can influence commitment,
agenda setting, policy formulation and implementation. They also confirm and extend upon
the growing recognition that the heavy investment to identify efficacious nutrition
interventions is unlikely to reduce the burden of undernutrition unless or until these
systemic capacity constraints are addressed, with an emphasis initially on strategic
and management capacitiesxxxii,xxxiii.
Evidence for Option 3 or doing nothing
The high level of undernutrition rates in Zambia (and in other high-burden countries) are a
reflection of the long neglect for nutrition interventions. Zambia has shown almost no progress
towards reducing stunting in the last 20 years. Despite several years of unprecedented
economic growth, inequality has increased and there are no visible improvements in the
nutrition status of the majority of Zambians. Experience from countries that have successfully
addressed malnutrition such as Brazil, Vietnam and Peru demonstrate that specific nutrition,
health and social protection policies as well as capacity building at all levels are needed for
achieving significant impacts.
What is the likely impact (positive and negative) on climate change and environment
for each feasible option?
Categorise as A, high potential risk / opportunity; B, medium / manageable potential risk /
opportunity; C, low / no risk / opportunity; or D, core contribution to a multilateral organisation.
Table 5
Option
1
2
3
Climate change and environment risks Climate
change
and
environment
and impacts, Category (A, B, C, D)
opportunities, Category (A, B, C, D)
Low (C)
Low (C)
Low (C)
Low (C)
Medium (B)
Medium (B)
Overall, the impact of the project on climate change and environment will be positive.
There is potential of impact from adverse climatic conditions such as droughts, which could
lead to declines in yields and potentially decrease the impact of the programme. However,
there is potential for reduced CO2 emissions through improved agricultural practices and land
management with less slash and burn and only minor additional emissions likely from vehicle
use for service delivery.
34
There is a possible positive impact on the environment from better and more sustainable use
of agricultural land. The introduction of bio-fortified maize could be linked to growth in DFID’s
agriculture programme, which plans to increase the productivity of small famers. If demand for
orange maize grows steadily, farmers involved in its breeding should benefit. Bio-fortified
maize varieties planned to be introduced are drought resistant to some extend but climate
shocks would affect productivity, especially among small farmers, the target population.
There could also be positive impact on environmental services such as water, sanitation and
waste through an encouragement of sustainable, ecological and environmental sounded
technologies for their overall livelihood improvement. Water is a critical resource. The project
should promote access to water through support for rainwater harvesting and use of grey
water. It should also encourage maintenance of soil fertility and avoid erosion without external
inputs, using for example composting, green manures, etc. In this way, the programme will
contribute to building more resilient communities. Better nourished people, with access to
diversified diets are less vulnerable to climate change.
C. What are the costs and benefits of each feasible option?
Incremental Costs
Option 1
Under this option the incremental costsxxxiv would be £9.35m over three years, all attributable
to DFID. The costs would be broken down as follows:
Table 6: Option 1 Costs
Priority interventions
Management costs
M&E and Operational Research
DFID Advisor costs
Total
2013-14
£2.5 m
£0.33m
£0.2m
£0.05m
£3.08m
2014-15
£2.5m
£0.33m
£0.2m
£0.10m
£3.13m
2015-16
£2.5m
£0.33m
£0.2m
£0.10m
£3.13m
Total
£7.5m
£1.00m
£0.60m
£0.25m
£9.35m
In addition, £2.5 million could be allocated for scaling up successful interventions at the end of
years 2 and 3 of the programme (e.g. sprinkles). Funding approval for scaling up will be
sought through a cost-extension of the programme.
Assumptions underlying this costing are as follows:

DFID will fund the same amount of service delivery interventions and management
costs as under option 2. The implementing & management agents will be different
under this option, but for simplicity, costs are assumed to be the same.

The M&E and research spending would be broadly the same as option 2, with the
exception of not funding the strengthening of an M&E system for GRZ.

The remaining elements of the 1000 Days Programme would not be funded by other
donors or GRZ.

The programme would require two-thirds of an A2 DFID advisor’s timexxxv to manage.
The incremental costs are lower in the first year as Option 3 requires one third of an
advisor’s time in 2012/13.
35
Option 2
Incremental costs of the entire 1000 Days Programme under option 2 would be £23.72m
spread over 3 years.
Table 7: Option 2 Overall Programme Costs
2012-13
2013-14
2014-15
Total
Priority Interventions
£1.86m
£3.46m
£5.17m
£10.49m
Management costs
£0.45m
£0.45m
£0.45m
£1.35m
M&E and Operational Research
£0.48m
£0.32m
£1.20m
£2.00m
Awareness raising & training
£1.28m
£1.06m
£1.06m
£3.40m
Technical assistance &
programme coordination
£2.59m
£2.32m
£2.32m
£7.23m
DFID Advisor costs
£0.05m
£0.10m
£0.10m
£0.25m
Total
£6.70m
£7.72m
£10.31m
£24.72m
This reflects the entirety of the investment envisaged by the 1000 Days Programme, plus
additional funding by DFID to support an end of term evaluation. As this option would work
closely with various GRZ departments, there may well be personnel and other additional costs
incurred by GRZ, but it is beyond the scope of this appraisal to quantify these.
Of the total presented above, 48% of the costs - £11.45m would be incurred by DFID.
Table 8: Option 2 Costs Attributed to DFID
2013-14
2014-15
2015-16
Total
Priority interventions
£2.50m
£2.50 m
£2.50m
£7.50m
Management costs
£0.33m
£0.33m
£0.33m
£1.0m
Impact Evaluation
M&E system & Operational
Research
Awareness raising & training
£0.20m
£0.20
£0.20
£0.60 m
£0.20m
£0.20
£0.10m
£0.50m
£0.20m
£0.30m
£0.10m
£0.60m
Technical assistance &
programme coordination
£0.30m
£0.35m
£0.35m
£1.00m
DFID Advisor costs
£0.05m
£0.10m
£0.10m
£0.25m
Total
£3.7m
£3.9m
£3.8m
£11.45m
As can be seen from the table, DFID funding would focus mainly on scaling up priority
interventions as well as technical assistance and programme coordination. A more detailed
estimated break-down is provided below:
36
Table 9: Detailed break-down of costs attributed to DFID
2013-14
Priority interventions
(support to breastfeeding and complementary
feeding, micronutrient supplementation &
£2.5m
fortification, promotion of good diet & care for
pregnant and lactating women, homestead
food production & dietary diversification)
Management costs (including programme
£0.33m
audit)
Impact Evaluation
£0.20m
M&E system strengthening & Operational
£0.20m
Research
Awareness raising
£0.10m
2014-15
2015-16
Total
£2.5m
£2.5m
£7.50m
£0.33m
£0.33m
£1.00m
£0.10m
£0.30m
£0.60m
£0.2m
£0.1m
£0.50m
£0.10m
£0.10m
£0.30m
Training
£0.10m
£0.10m
£0.10m
£0.30m
Technical assistance & programme
coordination for NFNC
£0.10m
£0.2m
£0.1m
£0.40m
Technical Assistance to line Ministries &
programme coordination
£0.10m
£0.20m
£0.20m
£0.50m
Programme audit costs
£0.033m
£0.033m
£0.033m
£0.1m
DFID Advisor costs
£0.05m
£0.10m
£0.10m
£0.25m
Total
£3.7m
£3.9m
£3.8m
£11.45m
Incremental Benefits
The major expected benefit from both Options 1 & 2 would be an increase in the population
covered by a variety of critical nutrition interventions, leading to a reduction in malnutrition &
stunting (Annex 5 shows the additional number of women and children that would be reached
by scaling up to agreed targets). These nutrition improvements could be expected to lead to
long term increases in cognitive capacity, adult stature and ultimately lifetime earnings xxxvi,
potentially contributing to long term economic growth in Zambia. However, this programme is
focused on the more specific nutrition and health goals and as such this appraisal will focus
on the health4 benefits of the different options, measured using Disability Adjusted Life Years
(DALYs).
Benefits are estimated using international evidencexxxvii from a variety of sources on the cost
per DALY of the different proposed interventions. These figures from the literature are
adjusted for inflation (given that much of the evidence is now rather out-dated) and also
adjusted upwards to reflect the fact that costs in Zambia are likely to be higher than the global
figures (the base case assumes a 20% premium). Table 10 below shows the cost/DALY data
that has been used for each intervention.
37
Table 10: Cost Per DALY estimated
Global Mid
Point
Estimate
Iron-folic acid
Vitamin A supplementation
Iodised oil capsules
Community food security
(seeds, poultry and
livestock)
Food fortification/Iron
fortification
Mother and Baby Friendly
Health Facility promotion
Distribution of
micronutrient powders -6
to 24 months
Management of acute
malnutrition
Adjusted for
Inflation ($
GDP deflator)
Adjusted for
Higher Costs in
Zambia
$66
$9
$35
$76.9
$11.1
$38.3
$92.3
$13.3
$46
$96
$105.1
$126.1
$68
$96.3
$115.5
$350
$394.2
$473.0
$9
$10.1
$12.2
$41
$42.5
$51.1
It is assumed that the management costs do not add to the overall benefits, but are necessary
to ensure the interventions can be delivered efficiently in line with the cost effectiveness ratios
set out below. The potential benefits that would accrue from a scale up of successfully piloted
approaches are not considered here as we do not know which interventions would end up
being funded and hence have no way of estimating their impacts. Any approaches that are
scaled up would be expected to have strong benefits, given that they will have been tested in
local conditions through a pilot phase (e.g. micronutrient powders for home fortification). The
funding would not be released unless there were options that were proven to be highly
effective. As we cannot calculate the expected benefits of this funding, we do not include the
costs of the funding within the cost effectiveness analysis below to avoid unfairly biasing
downwards the estimates.
Option 1
It is estimated that Option 1 would avert 150,130 DALYs from £7.5 m of direct spending on
service delivery. The benefits from each intervention are shown in table 5 below. The costs for
the various interventions are based on available cost per DALY data (see Table 10) and the
targets set by the programme to increase coverage of beneficiaries from current levels.
Table 11: Benefits of Option 1
Expenditure
Iron-folic acid
Community food security (seeds, poultry and livestock)/home-stead
gardening
Food fortification for staples (e.g. Iron fortification of staple foods such
as flour, and/or maize)
£410,000
£1,420,000
DALYs
Saved
7,110
18,020
£1,580,000
21,890
38
Mother and Baby Friendly Health Facility, promotion of breastfeeding,
complementary feeding, and hygiene behaviours.
Distribution of micronutrient powders
Community-based management of acute malnutrition. Delivery of
Ready-to-use-Food mainly Plumpy'Nut
Total
Note: numbers have been rounded
£2,120,000
7,170
65,570
£500,000
£970,000
30,370
150,130
£7,500,000
It is assumed that the interventions would be delivered during the three year life of the
programme, but that the interventions would stop once the funding ran out in 2016.
Option 2
It is estimated that the 1000 Days programme funded through Option 2 would overall avert an
estimated 235,980 DALYs from £10.48m of direct spending on service delivery. The costs for
the various interventions are based on available cost data and the targets set by the
programme to increase coverage of beneficiaries from current levels.
Table 12: Benefits of Option 2
Expenditure
DALYs Saved
Iron-folic acid
£710,000
12,310
Vitamin A
£450,000
54,140
Iodised oil capsules
£70,000
2,430
Community food security (seeds, poultry and livestock)
£1,600,000
20,300
Food fortification for staples. Iron fortification of staple foods
£2,770,000
such as flour, and/or maize
38,370
Mother and Baby Friendly Health Facility promotion of
breastfeeding, complementary feeding, and hygiene
£2,840,000
behaviours.
9,610
Distribution of micronutrient powders
£350,000
45,900
Community-based management of acute malnutrition.
£1,690,000
Delivery of Ready-to-use-Food mainly Plumpy'Nut
52,920
Total
£10,480,000
235,980
Note: the national programme includes support to interventions such as Vitamin A which have not
been included within the DFID costs given that we already support this intervention through our phase
one of the nutrition programme
Of these overall programme benefits, DFID would be able to claim attribution for 48%, or
about 150,130 DALYs. This is the same level of benefit as under option 1 as both options
envisage DFID spending £7.5 m on direct service delivery.
A significant part of the proposed programme under option 2 would be to work with and
through GRZ to improve both their understanding of nutrition issues and their capacity to
implement effective nutrition interventions. The implications of this are that:
1. The planned interventions may be delivered more slowly initially as GRZ workers and
facilities will need to be up-skilled before they can be rolled out. Hence the results may
take longer to accrue.
2. The systems put in place are likely to be significantly more sustainable than those under
option 1. Staff will still have the training they have received after the funding has finished
39
and the key GRZ institutions would also retain their clearer focus on nutrition and better
strategic planning and implementation.
As explained earlier in the business case, Option 2 would work with the NFNC, but would also
work with other key spending ministries such as the Ministries of Education and Agriculture &
Livestock. Supporting these institutions would be expected to lead to their work being more
focused on nutrition issues and hence delivering health benefits in the long run. It is beyond
the scope of this appraisal to estimate these long term benefits, but the potential is very large.
Though the annual budget of the NFNC is small (only just shy of $1 million), the budgets of
the five spending ministries that will be targeted are very large at nearly $2 billion per year,
making up over one third of all Zambian Government spending. If the 1000 Days programme
is able to leverage even a tiny proportion of this spending towards nutrition outcomes, then in
the long run benefits could far outweigh the direct benefits of the two options outlined above.
Cost Effectiveness
Table 13 below summarises the estimated results and cost effectiveness for the two different
options (along with the DFID attribution of option 2).
Table 13: Cost Effectiveness Estimates
Option 1
Option 2
Overall Programme
DFID attribution
Service Delivery Costs
£7.5m
£10.48m
£7.5m
Total Programme Costs
£9.35m
£24.72m
£11.45m
DALYs Saved
Service Delivery
Cost/DALY
Total Programme
Cost/DALY
150,130
235,980
150,130
£49.96
£44.41
£49.96
£62.28
£104.75
£76.27
From the table, it can be seen that the service delivery costs per DALY (the costs of just
delivering the interventions themselves) is the same across both options. Support to option 2
would result in significantly more DALYS being averted overall as the DFID support to the
1000 days programme would draw in funds from other donors and GRZ.
Once the total programme costs are added in (including management, M&E costs and the
cost of the other programme components), it appears that option 1 is slightly more cost
effective. However, as previously noted, these estimates do not include the potential longer
term benefits under option 2 of the interventions being sustained beyond the life of the DFID
funding, or the potential to leverage other GRZ spending. If these were properly taken into
account, it is likely that option 2 would seem much more favourable.
In any case, both options are highly cost effective, even without wider benefits being included.
The WHO suggest that an intervention can be classed as extremely cost effective if its cost
per DALY is below the country’s GDP per capita. Zambia’s GDP per capita was around £900
in 2011. Either option would seem to offer extremely good value for money.
Sensitivity Analysis
40
If DFID support is fungible (e.g. the Government of Zambia would have achieved say half of
the increases in coverage expected to be achieved with DFID support) this would affect the
cost effectiveness, although the direction of change is not clear. In this example the specific
benefits in terms of improved access to the selected nutrition services would half. Effectively
half of the DFID support would be programmed elsewhere and the impact would depend on
what the funds released were spent on. However, even if 50% of the funding is
reprogrammed and the reprogrammed funds generated no benefits (which is unlikely), the
cost/DALY averted for option 2 would remain around £200/DALY, still well within the WHO’s
cost effectiveness threshold.
As DFID is in negotiation with other donors about funding part of the package it may well be
that DFID may play a “lender of last resort” role funding the components other donors find
less attractive. With this in mind a sensitivity analysis was carried out to assess the effects of
DFID support being focused on less cost effective parts of the package. Even where DFID
solely funded the 5 least cost effective interventions out of the 9, the average cost per DALY
would remain below £170. It is also worth pointing out that the least cost effective intervention
– the Mother and Baby Friendly Hospital promotion package – costs an estimated £299 per
DALYs. This is still less than a third of any cut off at £900 (the average per capita income
figure).
Social and broader economic benefits
Undernutrition affects health, physical and cognitive development capacity as well as
productivity in adulthood. It is estimated that current levels of child stunting in Zambia if
unchanged, will cost US$775 million in productivity over a 10 year period (2004-2013)xxxviii.
The economic costs of undernutrition include direct costs such as the increased burden on
the health care system, and indirect costs of lost productivity. Childhood anaemia alone is
associated with a 2.5% drop in adult wages.
In addition, as highlighted throughout the business case, undernutrition is responsible for
more than 50% of child deaths in Zambia. Poor maternal nutrition also contributes to maternal
mortality and impacts negatively on women’s ability to care properly for their children. The
gender analysis has shown that gender inequality and undernutrition are inter-twined, and
how strategies that address women’s needs (time for caring after their children, cooking, etc.)
and increase their access to and control of food production can have significant impact on
nutrition.
These broader societal and economic benefits that would accrue if efforts to address
undernutrition are strengthened and effective interventions scaled-up therefore need to be
taken into account.
The preferred option
While the challenges of a multi-sectoral response are significant, given the pros and cons
identified for all options, Option 2 is the preferred option. Instead of focusing exclusively on
scaling up priority interventions as option 1, this option recognises the more challenging need
to further strengthen capacity, coordination across sectors, and across government levels,
robust monitoring and evaluation and the need for improved communications and nutrition
awareness at all levels.
41
This option will deliver similar nutrition results to option 1 and provides a more sustainable
approach in the medium to long term. By Pooling Funds with other donors, aligning resources
behind the national programme and engaging other Ministries which currently are not doing
much to address nutrition concerns but have significant budgets (MoAL, MoE), DFID Zambia
could leverage significant additional resources.
The proposed priority interventions are reflected in the three year First 1000 Most Critical
Days programme and detailed one year implementation plan. It is recommended that DFID
supports this programme, under the five strategic areas which include the recommendations
for support to NFNC and key line Ministries described above. A priority will be ensuring that
the Programme and plans are launched and adopted at political and ministerial levels.
It is anticipated that the SUN Fund will offer the opportunity for innovation with stronger focus
on the community level. In this regard, civil society organisations will have the opportunity to
apply for funds and implement programmes that are complementary to those of the public
sector.
D. What measures can be used to assess Value for Money for the intervention?
The management of DFID funds to support the 1000 MCD Programme will be competitively
tendered to a service provider.
While technical expertise will be given high consideration, value for money issues will be
paramount. Key cost elements include service delivery, systems supporting activities,
technical assistance and management fees.
In partnership with other supporting donors and government, priority interventions and
geographical areas will be selected based on the ability to scale up and opportunities for
complementarities. Collaboration and alignment of efforts behind district plans will lead to
more efficient resource allocation.
The service delivery covers costs for implementation of priority interventions through contracts
with a range of partners (NGOs, multilaterals, research institutions). Interventions comprise
personnel, supplies and equipment, community-outreach activities and training. The service
provider will be asked to ensure that sub-grantees have adequate value for money measures
in place and that their budgets are reasonable for the specific context. Best practice
procurement guidelines to ensure cost savings will be encouraged.
In addition, the contract will be based on milestone payments. Only expenditure actually
incurred will be reimbursed on submission of appropriate invoices.
E. Summary Value for Money Statement for the preferred option
The appraisal has demonstrated that the preferred option offers excellent value for money.
DFID will invest up to £11,450,000 which will result in at least 151,782 DALYs saved
attributed to DFID. The overall value for money is high because nutrition interventions are
known to be among the most cost-effective health interventions and there is a strong
evidence-base of what works. DFID will also support innovation, capacity and coordination,
all of which are expected to accrue longer-term and broader socio-economic benefits beyond
the project’s life time.
42
43
Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
An open tender process is required to select a suitable service provider through the Official
Journal of the European Union (OJEU) process for the management of the SUN Fund. The
procurement process will be managed by DFID Procurement Group (PrG).
B. How does the intervention design use competition to drive commercial advantage
for DFID?
An open procurement procedure will be used to identify the suitable service provider. The
contract requirements for the SUN Fund as outlined in the attached draft Terms of Reference
(ToRs) (Annex 2) will be advertised in the Official Journal of the European Union (OJEU).
DFID Zambia will develop separate ToRs for the independent process evaluation during the
pre-inception phase in consultation with the SUN Fund Steering Committee.
Prior to placement of an advertisement in OJEU, DFID Z will agree with PrG:
• the process for sifting expressions of interest
• the award criteria
• number of suppliers to be invited to tender, and
• details of other publications which will be used to advertise the requirements
DFID PrG will carry out an open competition amongst the potential bidders to select suitable
service providers.
While quality, technical expertise and innovation will be critical
considerations in the bidder’s selection, DFID will place a high level of importance on value
for money offered through commercial proposals giving high priority to efficiency and the
ability to deliver the required services in a cost-effective manner. The bidders’ past
performance in implementing programmes of similar nature at scale will also be considered
in order to ensure that optimum value for money is obtained.
C. How do we expect the market place will respond to this opportunity?
There is likely to be a limited range of suitable bidders in Zambia with significant capacity to
deliver the required services at scale so DFID Procurement Group will support the selection
of an appropriate bidder through the OJEU (Official Journal of the European Union) process.
D. What are the key cost elements that affect overall price? How is value added and
how will we measure and improve this?
The key cost elements include service delivery, systems supporting activities, technical
assistance and management.
The service delivery includes costs for implementation of priority interventions and covers
personnel, supplies, equipment and outreach activities. Priority interventions will entail
commodities, training of personnel, behaviour change communication materials, contracting
NGOs, travel to cover community areas, etc. Systems’ supporting activities will cover policy
and coordination, M&E and research, communications and advocacy, and specialised and
University training. Technical assistance is intended to build capacity and strengthen the
coordination function and organisational management of the NFNC as well as key line
44
government ministries. The management costs relate to the overall handling and
administration of the Fund, including audit costs.
DFID will request bidders to submit a programme proposal with detailed work-plans and
budgets. These will be carefully assessed to determine quality of planned activities so as to
ensure value for money.
It is envisaged that PrG will negotiate management charges as part of the programme
budget to ensure that these charges are set at an appropriate level to deliver programmes in
the Zambian context. Prior to formal contract signing, DFID and the service providers will
agree Key Performance Indicators (KPIs) during the post-tender clarification stage. These
will be annexed to the contracts and provide benchmarks against which satisfactory
performance is measured. Contracts will be designed in such a way that payments are
made upon fulfilment of the agreed action plans/KPIs. In order to guard against significant
cost fluctuations, the contracted bidders will be encouraged to identify savings within the
approved budget and use these to meet any shortfalls that might arise thereafter.
E. What is the intended Procurement Process to support contract award?
An open tender procedure will be used to support contract award.
F. How will contract & supplier performance be managed through the life of the
intervention?
The contracts will be drawn based on ToRs with a defined set of milestones and results
expected to be delivered by the successful service providers. The SUN Fund will be
supported by a group of Cooperating Partners interested in strengthening and scaling up
nutrition interventions in Zambia. On behalf of the SUN Cooperating Partners, DFID will
contract a service provider to manage and administer the Fund as a joint financing
mechanism to support the First 1000 Most Critical Days Programme. The contract will be
initially for a period of 1 year, subject to a successful inception period of 6 months. A further
2 year contract will be awarded based on performance during the first year.
The service providers will be required to provide regular consolidated programme narrative
and financial reports. KPIs will also ensure that the management of the contract is
undertaken as transparently as possible, and clarity of roles and responsibilities between
DFID and the service provider. In addition, DFID will:




Conduct annual reviews of the programme including assessment of service providers’
performance.
Track programme performance and budget execution through quarterly narrative and
financial reports and quarterly update meetings with the service provider.
Ensure that the service provider has quality assurance procedures in place so that goods
and services are fit for purpose. The service provider is expected to ensure that the
same level of quality assurance procedures is in place for sub-recipients of the Fund.
Agree and monitor a risk strategy, which sets out specific responsibilities for DFID and
the service provider for managing and mitigating risk.
The contracts will also incorporate steps to be taken in the event of poor performance and
failure to deliver the expected results and value for money.
45
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for this
intervention, with this development partner?
N/A
B. Value for money through procurement
N/A
46
Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate
forecasting?
The overall estimated programme cost is £23,700,000 over 3 years (2013/14 to 2015/16).
DFID will invest up to £11,450,000 – refer to table below for details. The other SUN
Cooperating Partners are expected to contribute towards the remaining balance of
£12,500,000. Subject to official approval, Irish Aid intends to commit euro 3 million
(£2,420,000), SIDA US$3 million (£1,875,000) and the EU US$1 million (£625,000) from
2013/14 to 2016/17. Other donors such as USAID will support the programme off-budget
through existing implementing partners. Taking these commitments into account, there is still
a financial gap of about £7,700,000, although this should be partly covered by off-budget
technical assistance (UNICEF) and USAID funds. A funding gap will mean that the
programme is unlikely to be scaled up to national level. Scale up will need to be phased
according to resources available to ensure enough intensity of coverage in programme
districts. As DFID funds will be focused on 14 districts, our investment will still be effective
regardless of a potential funding gap.
Table 14: Estimated breakdown of expenditure
%
2013-14
2014-15
2015-16
Total
£2.50
£2.50
£2.50
£7.50
£0.20
£0.20
£0.10
£0.50
£0.10
£0.10
£0.10
£0.30
2.6
£0.10
£0.10
£0.10
£0.30
2.6
£0.10
£0.10
£0.20
£0.40
£0.10
£0.20
£0.20
£0.50
£0.33
£0.33
£0.33
£1.00
8.9
£0.05
£3.58
£0.20m
£0.10
£0.05
£3.58
£0.20m
£0.10
£0.10
£10.60
£0.60m
£0.25
0.9
2. Impact Evaluation
3. DFID Advisor Costs
£00.0
£3.43
£0.20m
£0.05
Total
£3.7m
£3.9m
£3.8m
1. Funds channelled through
Pooled Fund
Priority interventions
M&E system strengthening &
Operational Research
Awareness raising
Training
Technical assistance &
programme coordination for
NFNC
Technical Assistance &
programme coordination for line
Ministries
Management costs
Programme audit costs
66
4.5
3.6
4.5
92
5.4
8
£11.45m 100
Note: Numbers have been rounded.
DFID Zambia has adequate funding for the proposed project within its resource allocation.
The project expenditure will extend beyond the current spending round and FCPD was
consulted to obtain HMT approval. Of the proposed funding, about 10% is earmarked for
monitoring and evaluation and operational research activities.
47
DFID Zambia will request the service provider to submit annual work-plans and budgets for
approval by the SUN CPs. It is envisaged that the service provider will be able to project
realistic expenditure forecasts on the basis of the approved work-plans and budgets. These
will be carefully reviewed on a quarterly basis so as to ensure that expenditure is incurred for
the intended purposes and in line with acceptable accounting procedures.
B. How will it be funded: capital/programme/admin?
The programme will be fully funded from programme resources which have been budgeted
for in DFID Zambia’s Operational plan (2011-15). There is no contingent or actual liabilities.
C. How will funds be paid out?
DFID intends to release funding to the service provider on a reimbursable basis preferably
once per quarter. However, the reimbursement schedule will be negotiated by PrG on behalf
of DFID Zambia.
D. What is the assessment of financial risk and fraud?
There is potential for financial risk and fraud to occur due to weak financial and procurement
management systems for some sub-recipients of the Fund. This is likely to affect timely
reporting by the service provider. As a mitigation measure, DFID will require particularly the
SUN Fund service provider to undertake due diligence checks on Fund applicants prior to
awarding of contracts or grant agreements.
The service provider will be responsible for ensuring that funds are not misused. Where
financial mismanagement or fraud is detected, DFID Zambia will immediately notify Counter
Fraud Unit (CFU) and consult with other JFA CPs on appropriate measures for recovery of
the misappropriated funds. Continued disbursement of funds will be contingent upon
adequate financial oversight mechanisms.
E. How will expenditure be monitored, reported, and accounted for?
DFID and the service providers will agree annual work-plans and budgets with key
performance indicators in line with the programme’s final log-frame. The service providers
will submit invoices for any payment. These will be scrutinised to ensure VfM and
compliance with the agreed annual/quarterly work plans and budgets. Where necessary,
DFID will request that independent audits be undertaken on the service provider.
The service providers will be required to maintain asset registers for items above a certain
value. The contracts will have provisions on management and disposal of the procured
assets.
The contracts will also incorporate steps to be taken in the event of poor performance and
failure to deliver the expected results and value for money. Any unspent funds at the end of
the project will be handled in accordance with relevant clauses in the signed contracts.
Alongside this financial rigour, DFID will carry out performance annual reviews, hold regular
meetings with the service provider, and undertake periodic visits to the project sites in order
to ensure effective and transparent delivery of the agreed results.
48
Management Case
A. What are the Management Arrangements for implementing the intervention?
A Steering Committee (SC) will be established from the outset of this programme with senior
representation from the NFNC, DFID, other CPs and the service provider. The SC will be
responsible for the overall quality control and managerial and technical oversight of the
programme. It will be co-chaired by the NFNC’s Executive Director and a CP. The service
provider will have a secretariat role. The SC will seek specific technical advice from
appropriate experts as needed. The SC will meet on a quarterly basis to review progress and
challenges. Other stakeholders (private sector partners, NGOs) will be invited to participate in
quarterly meetings as appropriate. The SC will regularly keep the MOH and MCDMCH up to
date with progress. Other line Ministries involved in the 1000 Days Programme will also be
kept regularly informed of developments. Once a functional multi-stakeholder platform is
established, the SC will report to this.
Key issues and lessons learnt from the implementation of the programme will be shared as
part of the overarching national arrangements proposed by the GRZ to improve collaboration
on nutrition actions: the National Food and Nutrition Ministerial Steering Committee at Cabinet
level and the National Food and Nutrition Multi-stakeholder Committee also chaired by the
NFNC, but not yet functional. The multi-stakeholder committee will include participation of key
government line ministries, CPs, Civil Society, and the Private sector.
Key issues, progress and lessons will also be fed to the relevant sectoral groups (SAGs),
including Health, Education, Gender and Social Protection.
In sum, the Steering Committee will:
 Oversee the efficient management of the programme
 Provide leadership for good functioning of the partnership, communications and results.
As noted in the commercial section, a third-party service provider will be selected through a
competitive tender process. The successful bidder will be appointed as the SUN Fund service
provider.
The SUN Fund service provider is expected to have capacity and expertise in fund
management and administration within the context of large health and social sector
programmes that are implemented in partnership with national government. Expertise in the
following areas is required:
 Financial management and administration, including grant administration and
contracting instruments;
 Programme and project management including project appraisal, administration of grant
agreements and programme reporting;
 Procurement of commodities, goods and services (including procurement of technical
assistance services);
 Monitoring and evaluation, with emphasis on performance monitoring, contract
monitoring and quality assurance;
 Technical expertise in nutrition related programming (across sectors) and technical
expertise in each of the Strategic Areas of the First 1000 Most Critical Days Programme
will be an advantage), in particular as regards provision of technical assistance and
capacity building.
49
Roles and functions of the service provider
The operations of the SUN Fund service provider will be organised around a set of key
functions.
Figure 6 summarises arrangements for the management of the SUN Fund:
The Steering Committee (co-chaired by the NFNC and a CP) will have overall oversight for
programme implementation and will report on progress and challenges to the MoH and other
key line Ministries. The service provider will have a secretarial function and manage provision
of technical assistance as well as the administration and channelling of funds to implementing
partners, including line Ministries (primarily through the district health office and/or district
nutrition coordination committees where established), NGOs, UN organisations and academia.
The funds will be subject to annual audits. Interventions will be implemented primarily at
community level with the involvement of community organisations, actors and community
health workers.
Figure 6: Proposed structure for management of SUN Fund
MOH
NFNC
MoCDMCH
MoALF,MoE
MoLG, MoE
Provincial
Level
District
Health Office
& Nutrition
Coordination
Committees
Steering
Committee
(NFNC, CPs)
Secretarial Role Service Provider
DFID Zambia
& other donors
External Audit
Pooled Fund
NGOs,
CBOs
FBOs, UN
Academia
Community organisations, CHWs
Key function 1: Provision of technical assistance to the NFNC and key line Ministries.
A core team of 2-3 experts will be needed to provide technical assistance to the NFNC across
three main areas: programme coordination/institutional strengthening, monitoring and
evaluation and communications. Short-term TA is also foreseen. The SUN Fund service
provider will help draft ToR for the short-term TA based on programme priorities and needs.
An organisational management assessment needs to be conducted at the start of the
programme with the view to implement an institutional strengthening plan.
50
Key function 2: Development of costed annual workplans, reporting, documentation
and dissemination of lessons learnt
The SUN Fund service provider will use the First 1000 Most Critical Days Programme design
documents to support the development of annual costed workplans. The workplans will
outline priority tasks for the year ahead and identify areas where the NFNC, line Ministries,
districts and other key stakeholders are likely to need specific support. Costed workplans will
be approved on an annual basis by the Fund Steering Committee.
The SUN service provider will develop quarterly and annual narrative and financial reports for
submission to the Steering Committee. These reports will be compiled from quarterly reports
submitted by grant recipients and will document progress against the costed annual workplan
for the SUN Fund. The reports will form the basis for review of progress in Fund
implementation at quarterly meetings of the SUN Fund Steering Committee.
Specifically, the reports compiled by the Fund service provider will include:
 A narrative description of progress in the last reporting period, highlighting particular
achievements or events;
 Progress against milestones and targets in the Fund monitoring and evaluation plan;
 A summary of any issues and concerns that need to be addressed;
 Priority actions and/or changes to the workplan for the next reporting period;
 An annex listing all technical assistance assignments and operational research
commissioned in the last quarter.
In addition, the Fund service provider will be responsible for documentation and dissemination
of lessons learnt, best practice and the findings of commissioned operational research.
DFID will include a clause noting its right to terminate any agreement entered in the event that
this ceases to represent value for money in each contract, MoU and AG signed under the
project.
Within DFID Zambia, the Health and Nutrition Adviser, funded through programme funds, will
have overall management oversight and report to the Human Development Team Leader.
Additional inputs on financial and administrative issues will be provided by the Deputy
Programme Manager and the Programme Finance Group.
Key function 3: Project appraisal
The SUN Fund service provider will have the responsibility for establishing an effective project
appraisal mechanism to ensure that all fund recipients have a) the required level of managerial
and financial capacity to manage funds; b) appropriate governance arrangements in place and
c) the backing of the relevant government department with evidence of appropriate senior
management approval. Local government (districts), NGOs, research organisations, academia
and multi-laterals will be eligible to submit proposals.
Key function 4: Grant disbursement
The service provider will carry out due diligence, formalise grant arrangements, disburse
funds in advance/ quarterly in arrears depending on who the partner is, monitor financial
statements, arrange audits etc.
51
Key function 5: Routine monitoring and evaluation of the Fund
The service provider will be responsible for developing and implementing a monitoring and
evaluation plan for the SUN Fundxxxix. This monitoring and evaluation plan will describe
mechanisms for performance monitoring of fund recipients (based on routine financial
monitoring, activity, process and output monitoring), as well as commissioning of independent
evaluation to assess impact and delivery against expected results.
The service provider will also have responsibility for a) commissioning operational research
that is in line with the requirements of the First 1000 Most Critical Days Programme and b)
disbursing grants to implementing partners that successfully apply to undertake operational
research. Funding of all operational research will be subject to the guidance and approval of
the SUN Fund Steering Committee.
B. What are the risks and how these will be managed?
Table 15
Probability
(3 high,
1 low)
Impact
(3 high 1
low)
1 .Lack of strong
Political Leadership of
GRZ to address
undernutrition
2
2
2. NFNC cannot be repositioned, and
unwilling to be
restructured, so lacks
capacity for
stewardship of multisectoral programme
2
2
3. Financial fraud,
corruption or funds not
being used for planned
purposes.
1
2
Risks
Mitigation strategies
Given global attention on malnutrition and the prospects of
more and better coordinated support from donors, the new
Government is showing increasing commitment to addressing
undernutrition. The launch of the new National Food and
Nutrition Strategic Plan is planned for end-2012. The
approved support to the SUN Civil Society Alliance to roll out
an awareness rising and advocacy campaign on the 1000 Days
and the NFNSP will help mitigate this risk. Through our
relationship with Ministry of Finance and Cabinet Office and
general budget support programme, as well as our support to
other nutrition stakeholders, we will lobby for increased
resources to addressing malnutrition.
Currently NFNC open to change but lack of resolution of
status could undermine plans for reform and restructuring.
TA planned and new board to be appointed. Embedded TA of
high calibre to help move this forward. An organisational
management review of the NFNC will be conducted during
the pre-inception phase to take key recommendations
forward. If NFNC capacity and institutional issues fail to
improve at the pace envisaged, the programme will still be
delivered substantially by the SUN Fund service provider in
the target districts.
A SUN (pooled) fund for donor support to the First 1000 Most
Critical Days programme will be managed by an agency
selected through competitive bidding. No funding will be
channelled directly through government institutions. The
management agency will ensure that implementing partners
have adequate financial management capacity and systems.
The service provider will apply routine checks and balances
and periodic external audits. It is therefore anticipated that
the risk of misuse of funds is relatively low. Regular
monitoring of financial implementation of activities will take
place. We have allocated resources for additional audits of
52
4. Increased food
insecurity due to
unfavourable climatic
conditions
2
2
5. Weak human
2
1
1
1
resource capacity
6. Higher than
expected estimates of
micronutrient
deficiencies
project partners if necessary. However, a longer-term
sustainability strategy and the possibility of using government
systems towards the end of the programme life-time will
need to be considered.
In the long term, Zambia is expected to be significantly
affected by climate change and a number of initiatives to
minimise climate shocks in the country are underway. There
are areas – e.g. the South, which are more prone to droughts.
If this were to happen, chronic food insecurity can rapidly
escalate into acute food insecurity, especially for small
subsistence farmers. In this case, DFID would support a
humanitarian response from country resources. Excessive
reliance on one food crop – maize, makes Zambia more
vulnerable to food security shocks in the event of crop failure.
Support and advocacy to diversify agriculture will be part of
the 1000 Days Programme and will help to address part of
this risk.
Strengthening capacity at national (NFNC, key sectoral
ministries) and decentralised level (selected districts) will be a
key component of the project. We will support national and
sub-national capacity building, addressing systemic issues,
increasing technical expertise in the country, involving the
NFNC in the management of the project, and will not just
support short-term technical training courses and technical
assistance. In addition, the EU is planning to align to the 1000
Days Programme and to earmark funds for the provision of
technical assistance to districts, to help them prepare good
quality proposals and support implementation.
The ongoing food security and micronutrient survey might
reveal a worse malnutrition situation in some pockets of the
country than is currently thought. We will revise expected
outcomes accordingly and target our support to the worst
affected areas. The essence of the programme is to
encourage synergistic nutrition interventions which address
several direct and indirect causes of undernutrition.
C. What conditions apply (for financial aid only)?
N/A
D. How will progress and results be monitored, measured and evaluated?
Given the need to increase the evidence base for some nutrition interventions and identify
what the best delivery channels are, the project has a significant monitoring and evaluation
component. Embedding evaluation in nutrition has been identified as a key priority for DFID,
and this project will contribute to the evidence base for scaling up nutrition globally.
The monitoring and evaluation strategy will include the following components:
1) A routine programme monitoring plan. The project log-frame outlines the main
monitoring arrangements and expected results. In addition, the SUN Fund service
provider will be responsible for developing a monitoring plan incorporating process and
53
outcome indicators, to review progress against work plans. All interventions funded
through the project will have their own monitoring component which will include key
nutrition indicators. Some of these indicators will be collated and reported through the
Health Management Information System, others through special surveys (e.g. UNICEF
on-going micronutrient survey).
2) Operational research will be built into innovative pilots or projects for which the
evidence is weaker. This will be the case for homestead food-based interventions to
promote dietary diversification. A budget of £500,000 has been set aside to cover
operational research and some support to strengthen national M&E systems. This is
because there is a need for better consolidated and more regular nutrition data (e.g.
possibly collected via mobile phone technology to complement the currently sporadic
nutrition data (every 3 or 5 years) obtained from national surveillance systems.
3) In addition, a process evaluation of the 1000 Days Programme will be undertaken in
2-3 districts to see whether programme implementation is working as planned, identify
bottlenecks and address these throughout. A process evaluation determines whether
target populations are being reached, people are receiving the intended services, and
staff are adequately trained. It also assesses the extent to which the programme is
implemented as designed and thus provides validity for the relationship between the
intervention and its outcomes.
The Health and Nutrition Adviser will liaise with DFID’s Evaluation Department for inputs into
the research and evaluation components of the programme. A preliminary evaluation plan is
provided below:
1. A baseline, mid-term and end-line survey will be commissioned to be able to track
progress against indicators in a sample of districts given that national data will be
insufficient and not regular enough to tell us whether the programme is having an impact.
2. Although overall evidence of what nutrition interventions work is strong, evidence on how to
deliver an integrated package at scale and in the most cost-effective ways is weak. To see
how the 1000 Days Programme package of interventions can be scaled up nationally, a
process evaluation will be undertaken to collect information from the entire casual chain
and better understand what works and how. Findings from the evaluation will be key to
inform national scale up of the 1000 Days Programme.
3. The key users of the evaluation will be policy makers (MoH, MCDMCH, MOAL, NFNC),
cooperating partners (DFID, Irish Aid, WB, UNICEF), implementing agencies and bodies
(NGOS, CBOs, district health and nutrition teams) and the beneficiaries themselves. It is
expected that the programme will generate evidence for dissemination internationally.
4. Timing. The evaluation is integral to the implementation plan so the timing will be
determined by the NFNC and key partners. Data collection for the baseline will need to
start at the same time as the package of selected interventions begins implementation in
selected districts. Surveys should be carried out at baseline, midterm and endline for the
impact evaluation. Ideally, process evaluation will be carried out at least twice – once after
a year of programme operation and a second one in year three to assess programme
implementation at that point, and to determine whether lessons learned from the first
process evaluation round have been incorporated into programming.
54
The primary question will be: does the 1000 Days Programme package of interventions result
in improved child and maternal nutritional outcomes? There will also be a number of process
outcomes addressed, including:
 % of 4 ANC visits for pregnant women
 % of health workers trained
 % of scheduled outreach visits undertaken
 % of health centres with no iron, ORS and zinc stock-outs
 % of households with soap for hand-washing
 % of newborns breast-fed within one hour of birth
 % of children fed in line with IYCF guidelines
 % of pregnant women who receive IFA supplements
 % of pregnant & lactating women who have an adequate diet
5. The design methods envisaged are cross-sectional surveys at baseline, midline and
endline and a process evaluation. The surveys will tell us whether expected improvements
in selected nutrition indicators are taking place – that is, whether the programme works.
The process evaluation will help to identify bottlenecks and obstacles preventing optimal
implementation of the programme by scrutinising the impact pathway/theory of change. It is
recommended here because it will provide key stakeholders with actionable insights into
the strengths and weaknesses of programme implementation.
6. What is the role of stakeholders and how will they be involved? Stakeholders in this
evaluation will include DFID, other donors, NFNC, the Pooled Fund management agent,
programme managers and staff, implementing NGOs, field staff and local partners, the
Government of Zambia, and community representatives or beneficiary groups. The majority
of evaluation questions will be predetermined by the specific features of programme
implementation, although some input from stakeholders will be solicited. Stakeholders will
also provide input into the study design and information about activity scheduling and
logistical coordination. All stakeholders will be involved throughout the communications
strategy.
7. A budget of £600,000 has been set aside for the evaluation but other CPs might be willing
to co-fund this.
8. International expertise will be sought through the MQSUN, DFID’s central nutrition service
provider. The successful bidder will be expected to partner with local institutions in order to
ensure ownership and strengthen capacity.
9. Dissemination strategy. The evidence generated through this evaluation will be linked to
the policy dialogue on addressing stunting from the start of the programme. Stake-holders
workshops to discuss the approach of the evaluation will be held at the start, mid-term and
end of programme evaluation. Findings will be disseminated internationally through DFID’s
Global Nutrition Group and the SUN Task Forces. In Zambia, aside from the main
stakeholder workshops, periodic meetings will be held with a smaller number of
stakeholders. Policy notes will be produced throughout and at least 2 publications will be
prepared for publication.
The programme will also undergo an annual DFID review process.
Project log-frame – Quest Number 3739592
55
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xxxv
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xxxvi
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xxxvii
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xxxix
This monitoring and evaluation plan will be aligned with the broader monitoring and evaluation plan for the
First 1000 Most Critical Days Programme.
57