Nutrition education in health centers (grant to Catholic Relief Services)

Evaluation covered the period 1979-4/86 and was based on document review, site visits, and interviews. The project failed to achieve its objectives. The nutrition education program reached only 534, or 30%, of the intended 1,400 MOH centers, and was only partially implemented at these. Nutrition education classes for mothers - the single most important element - were regularly held at about 342 centers. Further, only 39% of participating centers had both scales and growth charts, and only 47% regularly maintained charts. The project evaluation plan itself was only partially realized, since both time and funds with which to implement the growth monitoring system were lacking; as a result, no information on program impact is available. The single most important institution building output - establishing MOH nutrition cells at the governorate level - was not achieved, nor were other activities institutionalized as expected. However, evidence shows that that nutrition knowldge among health clinic nurses did improve and suggests limited improvements in mothers" behavior, e.g., in breastfeeding and weaning practices (the usefulness of these findings, however, is limited by major methodological weaknesses in data collection). While only modest progress was made in institutionalizing nutrition education, a willingness was created within the MOH to integrate it into health delivery. The primary cause of project shortfalls - particularly surprising given the success of the Phase I pilot - was an overambitious design. Phase II called for such major bureaucratic changes as nutrition cells and incentives for health workers, and development of a standardized growth chart; made a major strategic error in targeting quantity rather than quality; and lacked a systematic implementation plan. Lessons learned are that (1) design did not offer sufficient time and resources to complete its complex objectives, especially that of moving from a pilot to a national effort with major changes, and (2) implementation was too dependent on the project director; both a realistic initial assessment of the time key managers can commit and back-up strategies are necessary. While there are more cost-effective single channels than nurse training for changing mothers" behavior, the project underlined the importance of such training for reinforcing nutrition messages through other channels (e.g., mass media). USAID/E calls for a 2-year project extension with no additional funding and a simplified design to allow time for institutionalization.