Improving Vitamin A Nutrition and Deworming for Poor and ...

Grant Assistance Report

Project Number: 40024 November 2006

Grant Assistance Socialist Republic of Viet Nam: Improving Vitamin A Nutrition and Deworming for Poor and Vulnerable Children (Financed by the Japan Fund for Poverty Reduction)

CURRENCY EQUIVALENTS

(as of 1 November 2006)

Currency Unit – dong (D) D1.00 = $0.000064 $1.00 = D15,524

ABBREVIATIONS

ADB – Asian Development Bank CSP – Country Strategy and Program EA – executing agency GIU – grant implementation unit Hb – hemoglobin JFPR – Japan Fund for Poverty Reduction MOH – Ministry of Health NGO – nongovernment organization NIMPE – National Institute Malaria, Parasitology and Entomology NIN – National Institute of Nutrition PEMCP – Protein Energy Malnutrition Control Program PIU – project implementation unit PHC – preventive health center PIU – project implementation unit UNICEF – United Nations’ Children’s Fund VAD – vitamin A deficiency VDG – Viet Nam Development Goal VWU – Viet Nam Women’s Union WHO – World Health Organization

NOTES

(i) The fiscal year of the Government of Viet Nam ends on 31 December. (ii) In this report, “$” refers to US dollars.

Vice President C. Lawrence Greenwood, Jr., Operations Group 2 Director General R. Nag, Southeast Asia Department (SERD) Director S. Lateef, Social Sectors Division, SERD Team leader L. Studdert, Health Specialist, SERD

Gulf of Thailand

SOUTH CHINASEA

Gulf of Tonkin

Hai Phong

HANOI

Son LaDien Bien

Lai Chau

Lao Cai

Ha GiangCao Bang

Bac Kan

Lang Son

Yen Bai

Tuyen Quang

Thai Nguyen

Thai Binh

Ninh Binh

Thanh Hoa

Hoa Binh

Bac Giang

Ha Long

Vinh

Ha Tinh

Dong Hoi

Dong Ha

Hue

Da Nang

Quang Ngai

Hoi An

Pleiku

Kon Tum

Quy Nhon

Tuy Hoa

Buon Ma Thuot

Dak Nong

Da Lat

Phan Thiet

Phan Rang-Thap Cham

Bien Hoa

Ho Chi Minh City

Vung TauMy Tho

Rach Gia

Long Xuyen

Can Tho

Vinh Long

Hau Giang

Soc Trang

Tra Vinh

Ben Tre

Bac LieuCa Mau

Tan An

Thu Dau Mot

Tay Ninh

HaiDuong

Nha Trang

BinhLong

Phu ThoVinh Phuc

Lai ChauDien BienSon LaLao CaiPhu ThoTuyen QuangHa GiangYen BaiCao BangBac KanThai NguyenVinh PhucHa NoiBac NinhHung YenLang SonQuang NinhBac GiangHai DuongHa TayHai PhongThai BinhHoa BinhHa NamNinh BinhNam DinhThanh HoaNghe AnHa TinhQuang BinhQuang TriThua Thien HueDa NangQuang NamQuang NgaiKon TumGia LaiBinh DinhPhu YenDak LakDak NongKhanh HoaLam DongNinh ThuanBinh PhuocTay NinhBinh DuongDong NaiBinh ThuanBa Ria - Vung TauHo Chi MinhLong AnTien GiangDong ThapAn GiangKien GiangHau GiangCan ThoVinh LongBen TreTra VinhSoc TrangBac LieuCa Mau

1.2.3.4.5.6.7.8.9.

10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.36.37.38.39.40.41.42.43.44.45.46.47.48.49.50.51.52.53.54.55.56.57.58.59.60.61.62.63.64.

PROVINCES

63

64

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2

3

4

5

6

7

8

9

10

11

1213

14

15

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1718

19

20 21

2223 24

25 26

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3233

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4142

4344

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47 4849

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535455

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5859

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LAO PEOPLE'SDEMOCRATIC REPUBLIC

CAMBODIA

PEOPLE'S REPUBLICOF CHINA

Project Province

National Capital

City/Town

Provincial Boundary

International Boundary

Boundaries are not necessarily authoritative.

VIET NAMIMPROVING VITAMIN A

NUTRITION AND DEWORMING FORPOOR AND VULNERABLE CHILDREN

100

Kilometers

50 2000

N

06-3187 HR

103 00’Eo

103 00’Eo

108 00’Eo

108 00’Eo

12 00’No 12 00’No

20 00’No20 00’No

JAPAN FUND FOR POVERTY REDUCTION (JFPR)

JFPR Grant Proposal

I. Basic Data Name of Proposed Activity Improving Vitamin A Nutrition and Deworming for Poor

and Vulnerable Children

Country Socialist Republic of Viet Nam

Grant Amount Requested $1,000,000

Project Duration 3 years

Regional Grant Yes / No

Grant Type Project / Capacity building II. Grant Development Objective(s) and Expected Key Performance Indicators Grant Development Objectives (GDO): (i) Reduce child mortality and morbidity, and improve physical growth, cognitive development and future

productivity of 1.8 million children in poor provinces. (ii) Improve impact, reach and cost-effectiveness of Government investments to improve nutrition

including the reduction of anemia and vitamin A deficiencies.

Expected Key Performance Indicators (i) Build capacity of the National Institute of Nutrition (NIN), 18 provinces, 173 districts, and 27,498

local village health posts along with community volunteers and nongovernment organizations (The Women’s Union and others) for sustained community-based delivery of vitamin A and deworming tablets twice annually.

(ii) Biannual vitamin A capsule campaigns expanded to an additional 720,000 children from current coverage of approximately 900,000 children (those in cohort 6–36 months) to coverage of 1.8 million children (for cohort 6–60 months).

(iii) Biannual distribution of deworming medication (mebendazole) introduced to benefit approximately 1.8 million children in the cohort 12–60 months of age (currently none are receiving).

(iv) As a result of expanded vitamin A distribution and introduction of deworming, reduce prevalence of vitamin A deficiency (50%), anemia (75%), and parasitic infection prevalence (40–80%) in project areas.1

(v) Establish sustained government financing for biannual distribution of vitamin A capsules to all children 6–60 months and deworming tablets for children 12–60 months.

III. Grant Categories of Expenditure, Amounts and Percentage of Expenditures Category Amount of Grant Allocated ($) Percentage of

Expenditures 1. Equipment and Supplies 324,869 32.5 2. Training Workshops and Public Campaign 272,599 27.3 3. Consulting Services: 120,000 12.0 4. Grant Management: 92,000 9.2 5. Laboratory and Economic Assessments 150,000 15.0 6. Contingency 40,532 4.0 Total 1,000,000 Incremental Cost 50,000

1 Target figures are based on evidence from a similar program in Nepal where children had similar deficiency and

infection prevalence, and conditions were similar in other ways.

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JAPAN FUND FOR POVERTY REDUCTION

JFPR Grant Proposal Background Information

A. Other Data Date of Submission of Application 1 September 2006

Project Officer Lisa J. Studdert, Health Specialist Project Officer’s Division, E-mail, Phone

SESS, [email protected], +84 - 4 - 9331374 (Ext: 102)

Other Staff Who Will Need Access to Edit/Review the Report

S. Lateef, Director, SESS M.R. Ong, SESS/SERD

Sector Health, nutrition, and social protection Subsector Nutrition Themes Inclusive social development, capacity development Subtheme Human development Targeting Classification Targeted intervention Was JFPR Seed Money used to prepare this grant proposal?

Yes [ X ] No [ ]

Have SRC comments been reflected in the proposal?

Yes [ X ] No [ ]

Name of Associated ADB- Financed Operation(s)

Loan 2180/Grant 0016-VIE: Preventive Health System Support Project

Executing Agency

Ministry of Health 38 Giang Vo St, Hanoi

Grant-Implementing Agency

National Institute of Nutrition 48 Tang Bat Ho, Hanoi, Viet Nam Dr. Nguyen Cong Khan, Director Phone: 84-4-9716139 Fax: 84-4-9717885 Email: [email protected]

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B. Details of the Proposed Grant 1. Description of the Components, Monitorable Deliverables/Outcomes, and Implementation Timetable Component A Component Name Communications and Program Coordination Cost ($) $318,848 Component Description Activities for this component will support program development,

policy and communication activities at the national and provincial levels to integrate protocols and strategies into the annual cascade of training conducted by the Protein Energy Malnutrition Control Program (PEMCP) at district, commune, and village levels. The component includes the following activities: A national stakeholder meeting will function as the Project

Inception Meeting with participation of stakeholders in current community-based distribution of vitamin capsules to all 6–36 months old children. The meeting will includemembers of the National Nutrition Strategy Steering Committee, PEMCP Steering Committee; key Ministry of Health (MOH) partners including NIN, National InstituteMalaria, Parasitology and Entomology (NIMPE), regional institutes and provincial preventative health centers (PHC); and international partners including World Health Organizations (WHO), United Nations Children’s Fund (UNICEF), and Asian Development Bank (ADB). This meeting will communicate the need for and benefits from the expanded vitamin A and mebendazole (for deworming)distribution program, secure final consensus on protocols for the administration of deworming tablets, review all planned project activities, and clarify the roles and responsibilities of stakeholders.

Workshops conducted annually by the PEMCP for the provincial health service to coordinate annual community child and maternal health activities (held in Hanoi for northern provinces and in Ho Chi Minh City (HCMC) for southern provinces) will include an additional2 1-day training for the 18 project provinces.3 The additional 1-day training will cover the substantial benefits of deworming; the need for expanding the target group for vitamin A capsule distribution; deliver training on the protocols to be used in the delivery of mebendazole (deworming medication); review added integrated delivery and reporting responsibilities; and pretest communications and education materials to be applied at district, commune, and village levels (during component C of the Project).

Training materials for provincial, district, and commune health personnel and village volunteers as well as communication materials for the general population and

2 Training is already provided on a regular basis to health workers for the delivery of the vitamin A capsules to

children 6–36 months of age. Expanded training will be needed to introduce knowledge and awareness on the deworming intervention (especially regarding possible side effects) and on the expanded target group for the vitamin A capsule distribution.

3 A preliminary selection of 18 JFPR project provinces has been conducted based on current coverage of vitamin A capsule distribution, poverty rates, child mortality, and prevalence of worm infection and vitamin A deficiencies among children under 5 years of age. In addition, selection criteria include geographic distribution among all Viet Nam’s ecological zones to facilitate future expansion as a national program. See Appendix 6 for project province profiles and selection criteria.

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participating mothers will be developed and pretested through consultative processes at the community level, particularly with mothers and community workers, to ensureefficacy and effectiveness with the target audience. Format, content, and design of these materials will be integrated into materials currently used by the PEMCP during vitamin A distribution activities and include:

An insert to the current backgrounder and training-of-trainers handbook used by provincial and district personnel.

Insert to informational booklet for commune health workers and village volunteers.

Audio tapes for use with loudspeakers at the village level In addition, simple leaflets for distribution to mothers at point of capsule distribution will include information about vitamin A and mebendazole (deworming) tablets as well as related nutrition education and hygiene behavior. The project implementation unit (PIU) within the NIN’s PEMCP will be established under this component and include a project coordinator, project accountant, and administrative assistant. The PIU staff will work under the direction of the NIN director and the PEMCP coordinator. A project implementation manual describing detailed implementation arrangements, including relevant ADB procedures, will be prepared at project inception. This component will provide for annual independent audit over the first 2 years of the Project and a final audit at the close of the 36 months of activity.

Monitorable Deliverables/Outputs (i) Publication of technical documents with MOH protocols (ii) Consensus statements of scientific and stakeholder workshops (iii) Reports of 2 provincial training workshops completed (iv) Project training messages developed and published including

250 district training handbooks 4,000 leaflet inserts for commune trainers 4,000 audio tapes for commune and village use 1,800,000 leaflets for distribution to mothers

(v) PIU office and staff operational

Implementation of Major Activities: Number of months for grant activities

6 months of grant-financed activities as follows: (i) Month 1: PIU recruitment and start-up; (ii) Month 1: Scientific workshop; (iii) Month 2: National advocacy meeting; (iv) Months 3–4: Materials design, pretest and production: 4 months

(simultaneous with above activities); and (v) Months 5–6: 2 provincial training sessions at NIN and regional

institutes. Component B Component Name Integrated Procurement, Distribution, and Delivery of Vitamin A

Capsules and Deworming Tablets Cost ($) $223,400 Component Description This component will support the procurement, storage, and delivery

of mebendazole (deworming) tablets and an additional 900,000 (approximately) vitamin A capsules to expand the coverage of the vitamin A distribution program to children 37–60 months (current

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coverage only for 6–36 months old). Procurement is based on population of children 6–60 months old (or 12–60 months for the deworming) in 18 project provinces plus 10% wastage allowance. Procurement will be according to ADB procedures. The scope of procurement is projected as follows:

Vitamin A capsules are currently procured twice annually through UNICEF’s supply division in Copenhagen. The Project will order approximately 900,000 additional capsules (direct contracting procurement method) per distribution round through this existing system to cover the additional coverage of children aged 37–60 months. It is anticipated that for the over five campaign distribution rounds included inthe Project, an additional 4.5 million vitamin A capsules will be ordered through this system. Vitamin A capsules are budgeted at $0.016 each based on costs of current program.

1.8 million mebendazole tablets will be needed for each distribution to cover all 1.6 million children aged 12–60 months in the 18 project provinces. The deworming tablet cost of $0.017 is based on costs currently incurred by school-based deworming programs in Viet Nam. Total procurement for 5 biannual campaign distributions is projected at approximately 9 million tablets. It should be noted that several domestic pharmaceutical companies are capable of supplying the needs of the Project. While these companies are not GMP4 certified, WHO has inspected their facilities and found these adequate. In addition, if supply is through these domestic companies, the WHO Regional Office laboratories in Manila will conduct the analysis to ensure quality. Procurement will be by the shopping procurement method.

It is estimated that 2–3 months lead time will be required for delivery of mebendazole from the pharmaceutical supplier to the NIN in Hanoi. An additional 3 months will be required for delivery to distribution points at communes and villages. Storage, inventory, and delivery to project distribution sites will be integrated with the current systems used to store and deliver vitamin A capsules targeting children 6–36 months, routed via truck and prepositioned at regional nutrition institutes and provincial PHCs, and finally delivered to district health centers and commune health stations during the month of distribution campaigns. The JFPR will finance 100% of tablet costs for distributions 1 and 2, 75% for distributions 3 and 4, and 25% for distribution 5. Thereafter, full financing is expected through the NIN’s PEMCP. All incremental record keeping, storage, and transport costs will be absorbed in the current PEMCP budget beginning with the first distribution round.

Monitorable Deliverables/Outputs (i) Report of receipt by NIN of 5 biannual purchases of 900,000 vitamin A capsules for 7–60 month olds.

(ii) Report of receipt by NIN of 5 biannual purchases of 2 million deworming tablets sufficient to cover all 12–60 month olds in project provinces.

(iii) Coordinated reports for delivery and distribution of all 4 GMP = Good Manufacturing Practice. It relates to a WHO-endorsed accreditation process for drug manufacturing.

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vitamin A and deworming tablets following current system and procedures for delivery of vitamin A for campaign-based community distribution.

(iv) Integrated reporting of all delivery and distribution following current system and procedures for delivery of vitamin A to community distribution campaigns.

(v) Phased transfer for payment to PEMCP budget as indicated in component description.


Procurement for 5 rounds over 30 months is projected at 8 months of grant-financed activities. Placements of order from pharmaceutical suppliers are planned for project months 1, 7, 13, 19, and 25. Time lapse from placement of order from pharmaceutical supplier to final delivery at communes is projected at 6 months per round.

Component C Component Name Community Mobilization, Capacity Building, and Integrated Vitamin

A and Deworming Tablet and Information, Education and Communication Materials Distribution

Cost ($) $219,834 Component Description Vitamin A distribution is currently implemented by a community

mobilization campaign in two rounds annually, during June in conjunction with Micronutrient Day and during December as an independent campaign (but linked to other community health activities). The JFPR Project will implement an “enhanced” portion of this campaign for five rounds of expanded vitamin A distribution for children 37–60 months and mebendazole (deworming treatment) distribution for all children 12–60 months. The “enhanced” campaign will be based on the community-based structure of the current vitamin A campaign with a sequence of activities as follows:

Village health volunteers identify all households with children 6–60 months (expanded from the current 6–36 months);

During the week before distribution, village health volunteers carry out loudspeaker promotions, and make house-to-house visits

During the week prior to distribution, commune health stations will take delivery of mebendazole and vitamin A capsules from district health centers.

During the campaign days, commune health personnel will administer vitamin A to children while village volunteers keep lists and record participation.

Reports from commune distribution points will be collated at the district level, forwarded to provincial PHC and forwarded to NIN.

Training and motivation will be required to integrate project activities into the ongoing biannual campaign preparation and implementationactivities. Based on training guidelines and materials developed in component A, communication and education for expanded vitamin A and mebendazole distribution will be introduced into the annual cascade training process used in the PEMCP for the past 15 years. An expanded training and communication program will be conducted for the first two rounds of the JFPR Project and will include the following:

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In 18 project provinces, 1 day of training will be added to regularly scheduled workshops for health workers from 173 districts;

In 173 project districts, an additional day of training will be added to ongoing training events for health workers from 2,676 communes;

In 27,498 project villages an additional half day will be added to the current biannual training; and

During the first round of the distribution, commune and village health workers will distribute a simple education leaflet to all participating mothers, estimated at about 1.8 million.

The JFPR Project will provide expenses for training and extra travel costs, while MOH will provide incremental time of provincial, district, and commune health personnel as in-kind donation. However, current incentives of D10000 per month provided to village health volunteers will be augmented by an additional D2,500 for the first two rounds to facilitate their participation in training and motivation to assume the added workload. After the first two rounds of distributions, all training and related incentives for the expanded vitamin A and mebendazole distribution will be fully integrated into the overall campaign.

Monitorable Deliverables/Outputs (i) Two additional 1-day training for district health officers in 18 project provinces.

(ii) Two additional 1-day training for commune health workers in173 project districts.

(iii) Two half-day additional training for 27,498 village health volunteers.

(iv) Distribution of leaflet to 1.8 million participating mothers during the first “enhanced” vitamin A distribution.

(v) Vitamin A capsule delivery and coverage of 1.8 million children 6–60 months old every 6 months and 1.6 million children aged 12–60 months for mebendazole. In addition to regular reporting,a random process monitoring survey will be conducted by a 3-person WHO-led team the month following each distribution.

(vi) After round 2, all reporting will be integrated into ongoing systems of reporting for Micronutrient Day in June and Health Day in January. This will include reports from province PHCsand district health centers of integration of enhanced program into ongoing cascade training during rounds 3–5 of the JFPR Project and sustained thereafter.


Eight months of grant-financed activities including: (i) Months 5 and 11: Training sessions at district level (ii) Months 6 and 12: Training sessions at commune level (iii) Months 6 and 12: Training sessions and campaign activities

at village level (iv) Months 18, 24, and 30: Monitoring of integrated campaign

for rounds 3–5 Component D Component Name Monitoring, Evaluation, and Policy Development Cost ($) $237,918 Component Description Major activities in this component include a series of evaluation

activities designed to build an evidence-based case for sustained financing and expansion of the program on a national basis. Key

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evaluation indicators will include coverage, decrease in prevalence,and load of parasite infections and also the impact of the expanded program on key national nutrition and health goals, namely, the reduction of vitamin A deficiency, anemia, and child growth. Evaluation activities will include the following:

Process indicators including delivery, coverage, public awareness and acceptance, and other community perceptions about the program will be gathered after each of five distribution rounds by a three-person team comprisingNIN, NIMPE, and WHO.

NIMPE will conduct baseline, midline, and final project survey with the assistance of WHO and the University of Melbourne.5 The baseline and final survey will measure changes in prevalence of worm infections and worm load as well as prevalence of low serum retinol, hemoglobin and basic child height and weight indicators. Midline survey after the second round of distribution will include simple indicators that can be gathered in the field, including worm infection and hemoglobin indicators.

Monitoring and evaluation processes will be designed to ensure data will be available for a final impact evaluation report.

Monitoring and evaluation activities will be closely tied to an advocacy process to confirm Government commitments for sustained financing and ultimately to expand coverage of the enhanced vitamin A with mebendazole (for deworming) model on a national basis. To this end, the evaluation and monitoring activities will be followed by communications activities as well as further analysis including the following:

Results of midline evaluation after the first two distributionrounds will be presented at a midterm review meeting timed to support commitments by the Government to assume 25% financing for the expanded order of vitamin A capsules and mebendazole tablets scheduled for rounds 3 and 5.

The PIU will contract an independent institution to conduct a cost-benefit study during the final months of the Project. This will be informed by documented costs of the program as well as results of the biological and nutrition evaluations.

Throughout the project, an international program development consultant will work with NIN on a regular basis to ensure the Project is integrated with, and supported by, other ongoing initiatives to address micronutrient deficiencies (e.g., iron fortification of fish sauce and flour, iron supplementation programs for at-risk populations and fortified complementary foods for young children). This is consistent with the established international best practice that a multipronged approach is needed to ensure all target groups are reached for all nutrients requiring programmatic attention.

Based on the expected results of these impact evaluations and added analysis, a national advocacy meeting will be held during the

5 The University of Melbourne (Australia) is currently a technical partner to NIMPE for deworming activities focused

on women of reproductive age. The team members have indicated their willingness to support NIMPE’s project activities as part of this ongoing technical support. There will be no contractual arrangement with the University of Melbourne or WHO.

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final months of the Project with the following objectives: Confirm commitments for sustained financing in the 18 JFPR

project provinces; Advocate for the expansion of integrated deworming

programs on a national basis to all rural and peri-urban areas where high prevalence of worm infections threatensvitamin A and anemia status as well as the overall health and nutrition situation.

Advocate for the expansion of integrated nutrition and deworming programs to other at-risk groups including pregnant women, women of child-bearing age and school children.

Monitorable Deliverables/Outputs (i) Baseline survey with comprehensive indicator set (serum retinol, hemoglobin (Hb), parasite and growth)

(ii) Midline survey with field indicator set (Hb and worm infection) (iii) Report and commitment of midterm workshop (iv) Final impact survey with comprehensive indicator set (v) Cost-benefit analysis report (vi) Proposals for full integration of enhanced vitamin A-deworming

campaigns with other NIN nutrition activities (vii) Report and commitments from national advocacy meeting


7 months of grant-financed activities including: (i) Month 5: baseline biological and nutrition survey (ii) Months 7, 13, 19, and 25: reports of process evaluation team (iii) Month 13: report of midline evaluation (iv) Month 13: midterm evaluation meeting (v) Month 28: report of final biological and nutrition evaluation (vi) Month 28: report of cost-benefit analysis (vii) Month 29: report of national advocacy meeting

2. Financing Plan for Proposed Grant To Be Supported by JFPR

Funding Source Amount ($)

JFPR $1,000,000 Government $185,709 (2/3rd in kind) Other Sources (Please identify) $30,170 (WHO) Total $1,215,879 3. Background Reducing the prevalence of anemia and vitamin A deficiency (VAD) is critical for achievement of the MDGs and Viet Nam Development Goals (VDGs).6 Programs distributing high-dose vitamin A capsules have been shown to reduce mortality of children less than 5 years of age by at least 23%7 and will be key to achieving VDG 4 Target 1, to reduce the under-5 mortality rate to 36 per 1,000 live births by 2005 and 32 by 2010. In addition to VAD, anemia caused by iron deficiency or other causes in young children is associated with poor physical and mental development, poor school performance, and reduced work performance and productivity

6 World Bank. 2005. Economic Growth Improved Nutrition. Washington D.C. 7 Beaton et al. 1993. Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and

Mortality in Developing Countries. Nutrition Policy Discussion Paper No. 13. Geneva: United Nations.

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in adult life. However, the Government has had mixed success in implementing programs to reduce the burden of VAD and anemia, particularly from iron deficiency. Despite more than a decade of high reported coverage (>90%) with high-dose vitamin A capsules, the prevalence of VAD remains a significant public health problem among children less than 5 years of age, ranging from 17% to 62% across the nation’s five ecological zones.8 One reason for this high prevalence is that the Government program currently only distributes vitamin A capsules to children 6–36 months of age and does not cover children up to 60 months as suggested in deficiency reports and as recommended by WHO. While a number of programs to improve iron status and reduce anemia among young children in Viet Nam continue to develop and expand, including interventions such as fortifying fish sauce, pharmaceutical supplementation, and low-cost complementary food programs, anemia remains a severe public health threat to children under 5 years of age, with prevalence ranging from 17% to 74% across the five ecological zones (footnote 8). A particular issue for Viet Nam is the high rate of parasitic worm infection among children. These heavy worm burdens limit the success of Government investments in programs to control vitamin A and anemia and are additional assaults on the health and development of young children. Nationally, nearly half of all children under 5 years of age are infected with helminths such as roundworm.9 In addition to a well-known association with morbidity and mortality, as well as depressed growth and cognitive development, worm infections are closely associated with VAD and anemia. Deworming treatment improves the absorption of vitamin A up to 250%,10 underscoring the WHO assertion that “worm-free children will have better vitamin A status.”11 Evidence consistently indicates deworming treatment lowers the prevalence of anemia in children by between 60% and 77%. In addition, even a single deworming treatment can improve a range of nutrition indicators in children, including weight and height as well as fitness scores such as heart rate.12

With the support of ADB, WHO, and other NGOs, more than 2 million schoolchildren are dewormed biannually in Viet Nam.13 While schoolchildren suffer higher infection rates and heavy worm burdens, almost half of preschool-age children are also infected with parasites and are not currently reached by any government treatment programs (footnote 10). Preschool children are in an intense period of physical and mental development and therefore have a greater need for the vitamins and minerals lost through worm infections.14 The associated risks of disease and death malnutrition along with the irreversible damage to physical and cognitive growth are more severe among these younger children.15

8 National Institute of Nutrition. 2006. Vitamin A and Iron Deficiency Survey. Hanoi. 9 Der Hoek et al. 2003. Current Status of Soil Transmitted Helminths in Viet Nam. Southeast Asian J Trop Med

Public Health. Vol 34. 10 Mahalanabis et al. 1976. Vitamin A absorption in ascariasis Am J Clin Nut 29: 1372–1375. 11 WHO. 2004. Deworming for Health and Development. Geneva. 12 Stephenson, L.S. et al. 1993. Physical fitness, growth and appetite of Kenyan school boys with hookworm,

Trichuris trichiura and Ascaris lumbricoides infections are improved four months after a single dose of albendazole. Journal of Nutrition, 123:1036–1046.

13 Deworming programs for schoolchildren will be further strengthened through ADB. 2005. Report and Recommendation of the President to the Board of Directors on a Proposed Grant to the Greater Mekong Subregion Regional Communicable Diseases Control Project (Cambodia, Lao People’s Democratic Republic, and Viet Nam). Manila (Grant 0025-27, approved on 21 November 2005).

14 Stoltzfus, R. et al. 1996. Hemoquant determination of hookworm-related blood loss and its role in iron deficiency in African children. American Journal of Tropical Medicine and Hygiene 55:339–404.

15 Kvalsvig, J.D. et al. 1991. The effects of parasite infections on cognitive processes in children. Annals of Tropical Medicine and Parasitology 85:551–568.

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To address this overwhelming need, NIN and NIMPE ,with the close involvement of WHO, UNICEF, and ADB, have worked closely to develop the proposed Project to reach all children 6–60 months in 18 high-risk provinces (see Appendix 6 for description of selection method) with simultaneous doses of vitamin A and deworming tablets. The vitamin A capsule distribution program administered by MOH-PEMCP offers an existing well-functioning infrastructure that cost-effectively reaches more than 90% of children 6–36 months old on a biannual basis. The proposed Project will build on the growing experience within ADB for JFPR-financed nutrition projects especially targeting micronutrient deficiencies, in particular the regional project in Central Asia and projects in Indonesia and Pakistan. 4. Innovation The key innovation in the proposed JFPR-funded Project is to create a cost-effective and integrated approach to address the multifactorial causes of malnutrition among poor and vulnerable children. The Project capitalizes on

(i) the synergistic health and nutritional benefits of simultaneously providing vitamin

A capsules and deworming tablets, (ii) the preexisting system for the biannual delivery of vitamin A capsules to children

of low-income families and in remote areas, and (iii) a wide awareness and trust built by multisectoral partnerships supporting vitamin

A campaigns. Due to poor diet, sanitation, and other factors, parasite infections and VAD co-exist and from low-income families suffer a disproportionate burden. The predominantly rural provinces proposed for this Project (x18) are characterized by poverty and under-five mortality rates well above the national average. Of approximately 1.8 million children 6–60 months old in the project provinces, about half are estimated to be both vitamin A-deficient, anemic, and worm infected. The entire population of 6–60 months old essentially remains at high risk from preventable morbidity and mortality along with depressed growth and cognitive development. Since more than 90% of these poor and at-risk children aged 6–36 months are currently served with community-based vitamin A distribution, the integration of deworming tablets with vitamin A distribution offers an innovative and low-cost strategy to significantly improve their health, nutrition and growth for these reasons:

(i) vitamin A capsules and deworming tablets are inexpensive, safe, and simple to administer;

(ii) both treatments are optimally delivered at 6-month intervals; (iii) VAD and worm infection have overlapping geographic occurrence; (iv) the target age groups for vitamin A capsule distribution are very similar; (v) the training of commune health workers and village health volunteers is simple

and can be easily integrated into existing training for vitamin A distribution; (vi) the requirements for procurement, delivery, reporting, and monitoring of vitamin

A capsules and deworming tablets distribution overlap and can be easily integrated; and

(vii) adding deworming to vitamin A distribution is not a burden or disruptive to the vitamin A campaigns. In fact, in the experience of other countries, the addition of a deworming tablet to the campaign has been found to be very popular among mothers, adding a visible benefit for participation in the biannual distribution (mothers are generally very happy to see their children rid of the worms they know the children are infected with).

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Therefore, for an almost insignificant marginal cost and effort, this innovative integrated strategy can significantly reduce VAD, worm infection, and anemia as well as improve a range of growth and development indicators among the most poor, vulnerable, and nutritionally at-risk population of children in Viet Nam. 5. Sustainability The proposed 30-month Project supports start-up costs for the expansion of the coverage for vitamin A distribution from children 6–36 months old to all children 6–60 months old, as indicated by the prevalence of VAD in Viet Nam and supported by international best practice. The Project will also support initiation of the integration of mebendazole (deworming) tablets into the biannual vitamin A distribution campaigns. During this JFPR-supported start-up phase, the intervention cost is estimated to be about $0.25 per child per year. As activities become fully integrated into the vitamin A campaign structure in years 2 and 3 of the Project, the cost is expected to drop to less than $0.05 per child per year for two distributions. Beside being low cost, thus increasing the prospects of long-term financing by the Government, the deworming treatment is expected to have wide community and consumer support, given its immediate and visible results. The process of transfer to domestic financing is designed into the Project. Throughout the course of the Project, most incremental management, record keeping, storage, and transport costs will be absorbed in the current PEMCP budget. Also, the proposal includes a clear plan for transition of pharmaceutical procurement costs to the Government, with JFPR financing share dropping to 25% by round 5. NIN-PEMCP is committed to full financing in the 18 provinces after the 30-month project is complete. It should also be noted that the proposed Project is closely coordinated with an already existing agreement between the Government and UNICEF, to gradually transfer the full costs of vitamin A capsule procurement to domestic sources by 2011. These added benefits from deworming will support Government plans to build support for sustainable financing of vitamin A campaigns as well as expand the target group from the current 6–36 months old to the recommended international best practice of targeting the 6–60 months old. To ensure the transition to sustained domestic financing, as well as support the expansion of integrated vitamin A and deworming campaigns on a national basis, the project proposal includes resources for independent evaluation, a cost-effectiveness study, and a range of program analysis activities along with resources for a national stakeholder meeting, a mid-term evaluation meeting, and a national advocacy meeting. These are all designed to develop the evidence base and support the advocacy for supportive policy and sustained financing. 6. Participatory Approach Over the past decade, the sustained high coverage of Viet Nam’s vitamin A capsule distribution campaigns was made possible by a collaborative and participatory approach reaching the community level. It should be noted that unlike a number of national Government MOH programs, decisions regarding more than 90% of the PEMCP budget are made at provincial, district, and local levels with the central office at NIN in Hanoi focusing on coordination and value-added activities such as centralized capacity building or procurement of supplies and pharmaceuticals. The proposed Project is integrated into the structure of PEMCP’s established vitamin A distribution campaign, which includes multisectoral steering committees at the national, provincial, and district levels to ensure stakeholder oversight, participation, and support. Commune-level steering committees ensure the participation of village volunteers, local NGOs, day-care centers, and other grass-roots structures. On campaign days, vitamin A distribution activities mobilize approximately 100,000 local volunteers at the community level.

13

Primary Beneficiaries and Other Affected

Groups and Relevant Description Other Key Stakeholders and Brief

Description Approximately 1.8 million children aged 6–60 months, across 18 provinces, that are currently affected by heavy worm burdens and widespread VAD that affects long-term growth and development. As malnutrition rates are highly correlated with poverty rates which are highly correlated with ethnic minority populations, the Project will have a disproportionately beneficial effect on ethnic minority populations in the targeted provinces.

The Project will strengthen cooperation among key national stakeholders including MOH, NIN, and NIMPE along with the international technical agencies of UNICEF and WHO. WHO will provide technical support for the deworming program and policy; UNICEF will provide the ongoing technical support for vitamin A programs. At provincial and district levels, the Project calls on the health services to continue their effective vitamin A distribution and, with minimal additional effort, to add the deworming tablet to the distribution. Mothers and their children, as the target beneficiaries of the vitamin A programs, are the community-level stakeholders.

7. Coordination MOH, NIN, and NIMPE are the key agencies to collaborate with ADB in project implementation. Universities or research institutes will be engaged to assist with the tracking of changes in vitamin A status and worm infection rates. Japanese aid agencies and the World Bank are not currently involved in nutrition activities of this kind in Viet Nam. Mr. Rynia Yutani, second secretary, Japanese Embassy (Hanoi), was consulted on Wednesday 23 August. Mr. Yutani requested that ADB and NIN confirm that there was no overlap in the financing support from other sources. This was confirmed by the project leader and by the director of NIN, the Implementing Agency. 8. Detailed Cost Table Please refer to Appendix 1 for summary cost matrix, Appendix 2 for the detailed cost estimates, and Appendix 3 for the fund flow arrangement. C. Linkage to ADB Strategy and ADB-Financed Operations 1. Linkage to ADB Strategy

Document Document Number

Date of Last Discussion

Objective(s)

ADB Policy for the Health Sector

1999 Food fortification is a key priority health intervention with proven cost-effectiveness.

Viet Nam Country Strategy and Program (CSP) 2004–2006

2005 (CSP Update)

Identified “inclusive social development, with emphasis on health and education” as a priority area for ADB’s country program; target areas to be continued in CSP for 2006–2010.

2. Linkage to Specific ADB-Financed Operation

Project Name Preventive Health System Support Project Project Number 34348 Date of Board Approval 25 August 2005 Loan Amount ($ million) 37.9 including 10.0 ADF Grant.

14

3. Development Objective of the Associated ADB-Financed Operation The Preventive Health System Support Project has the goal of improving the health status of the targeted populations and aims to assist in achieving the health-related VDGs, specifically, to substantially reduce communicable diseases and reduce child mortality rates. Specific communicable diseases of concern include: gastrointestinal diseases (especially those causing diarrhea); tuberculosis, malaria, and leprosy. The Preventive Health System Support Project targets similar poor and vulnerable populations while the proposed JFPR Project has a similar target group. The proposed JFPR Project focuses on developing an intervention for the most at-risk segment of this poor rural population, 6–60 months old rural children and will seek to address one of the key underlying causes of disease and mortality in this group (malnutrition). The Project will build on the community MOH infrastructure by integrating additional activities for Viet Nam Women’s Union and other local government organizations and NGOs. Lessons learned from the Project can be integrated into ongoing reform and the health care system. 4. List the Main Components of the Associated ADB-Financed Operation:

No. Component Name Brief Description 1. Strengthening the surveillance

system and priority health issues Expand the existing provincial surveillance system, establish training programs, and enhance the capacity for utilizing information. Also, develop province-specific priority action plans for disease control.

2. Strengthening the preventive health system

Provide basic equipment needs for provincial preventive health centers and national public health institutions.

3. Human resource development Develop and deliver training programs for national, provincial and district health personnel for community-focused preventive health and waste management as well as for field epidemiology.

5. Rationale for Grant Funding versus ADB Lending The Preventive Health System Support Project will build capacity aimed at assisting Viet Nam adapt to changing epidemiological patterns. The scope and activities of the project are however not specifically aimed at the very specific micronutrient deficiencies and infections such as worms that affect poor children between the ages of 6 months and 5 years. International experience has shown that the specific interventions of vitamin A capsule and deworming medicine distribution on a biannual basis will continue to be required until the persistent conditions of poverty are addressed. In the meantime, the growth and development of a whole generation is at risk, but the problem can be readily addressed through this simple intervention. However, the Government is unlikely to borrow for such a specific and targeted intervention although Government financing is likely in the medium term when appropriate distribution and financing mechanisms are established. D. Implementation of the Proposed Grant

1. Provide the Name of the Implementing Agency National Institute of Nutrition of the Ministry of Health 48 B Tang Bat Ho St. Hanoi Viet Nam Tel.: 844 971 6058 Fax: 844 971 7090

15

2. Risks Affecting Grant Implementation

Type of Risk Brief Description Measure to Mitigate the Risk MOH regulation Potential resistance to amending

protocols for mebendazole (deworming) administration to children 12–24 months

Pilot trials and scientific workshop as well as communication of WHO “best practices” prior to project inception and during the initial months of the project will address scientific and regulatory issues.

Inadequate supplies of treatment or procurement and/or distribution is delayed.

Delays in distribution―from source of procurement to country; and from port of arrival through to distribution point―would disrupt the effectiveness and integrity of the biannual distribution program.

Indications from the international agencies experienced with these programs (WHO and UNICEF) are that the planning times allowed for procurement should be sufficient. Also, the proposed project uses a system that is well established and by all accounts well functioning on a regular basis with various mechanisms for self-correction.

Side effects of treatment

Long experience with vitamin A distribution and deworming tablets has shown the side effects to be minimal or nonexistent. However, in children with high worm loads, deworming may result in some discomfort and stomach ache as children expel worms. Moreover, there is a risk with any population-based treatment for children that side effects will be perceived or incorrectly associated with the treatment.

Training of commune and village health workers along with carefully designed, targeted communication to mothers on the risks (nonexistent) and possible side effects (minimal).

Sustainable financing Resistance to transferring the costs of deworming medications from the project to the Government.

Midterm evaluation and advocacy meeting along with final evaluation and cost-effectiveness study to provide platform for continuous and effective programs.

3. Incremental ADB Costs

Component Incremental ADB Cost Amount requested $50,000

Justification

Intermittent staff consultant inputs needed to assist with project initiation, to ensure smooth integration and a rapid start-up, as well as to assist, at midterm with documenting experiences and knowledge learned to ensure international dissemination and appropriate sharing with national and international policy development processes.

Type of work to be rendered by ADB Initiation workshop, midterm review and biannual reviews

16

4. Monitoring and Evaluation

Key Performance Indicator Reporting Mechanism Plan and Timetable for M&E

NIN reports of two training sessions for 18 provinces

Month 3

Reports from provinces and NIN trainers on training for 18 districts

Months 5 and 11

Reports from districts of 173 commune training

Months 6 and 12

Reports from commune health station of 2,676 village training

Months 6 and 12

1. Build capacity of national, provincial, and local government along with village volunteers and NGOs for sustained community- based delivery of vitamin A and deworming tablets twice annually

Receipt by NIN of training and information, education and communication materials and reports of distribution from appropriate field level.

Month 5

NIN report of receipt of pharmaceuticals at port or airport.

Months 4, 10, 16, 22, and 28

Inventory and delivery reports by regional institutes, provincial PHC, district and commune (parallel with current vitamin A reporting system)

(i) Regional institutes: months 4, 10, 16, 22, and 28 (ii) Province PHC: months 5, 11, 17, 23, 29 (iii) District/commune HS: months 6, 12, 18, 24, and 30

Distribution reports of districts and communes (parallel with current vitamin A reporting system)

Months 6, 12, 18, 24, and 30

2. Implement 5 biannual community-based distributions integrating deworming tablets with ongoing vitamin A capsule campaigns reaching 1.8 million children in 18 high-risk poor provinces, including expanding vitamin A distribution from the current target group of children 6–36 months to all children 6–60 months.

Independent verification of village/commune health worker knowledge, coverage of children during campaign distributions, and community perceptions by WHO-led team campaign.

Months 7, 13, 19, and 25

3. Reduce prevalence of VAD, anemia, and worm infection

Reports from NIMPE independent evaluation for worm load and prevalence; anemia (Hb) and VAD.

Baseline: month 5 Midline survey: month 14 Final report: month 27

Consensus report of scientific meeting

Month 1

Report of inception meeting Month 2

Report of midterm evaluation Month 13

4. Establish a national MOH support, including sustained financing, for integrated biannual distribution of vitamin A capsules to all children aged 6–60 months and deworming tablets to all children 12–60 months. National advocacy meeting report. Month 29

Develop additional integrated innovative approaches to improve nutrition of children aged 6–60 months, pregnant women, and women of reproductive age by more effectively coordinating PEMCP activities including supplementation, deworming and food-based interventions.

Consultant reports and PEMCP team reports, presentations to advocacy meetings and proposals to the Government, ADB, and other potential sources of financing.

Months 5, 14, and 26

17

5. Estimated Disbursement Schedule

Fiscal Year (FY) Amount ($) FY 1 Estimate includes contingency $375,000 FY 2 Estimate includes contingency $300,000 FY 3 Estimate includes contingency $325,000 Total Disbursements $1,000,000 ----------------------------------------------------------------------------- Appendixes

1. Cost Matrix 2. Detailed Cost Estimates 3. Fund Flow Arrangement 4. Implementation Arrangements 5. Project 36-Month Timetable 6. Project Locations and Province Selection Criteria

18 Appendix 1

Component A Communications and Program Coordination

Component B Integrated Procurement,

Distribution, and Delivery of Vitamin A

and Capsules and Deworming Tablets

Component C Community Mobilization, Capacity Building, and

Integrated Vitamin A and Deworming Tablet/IEC

Distribution

Component D Monitoring, Evaluation, and

Policy Development

Total (Input) Percent

1. Civil Works:

2. Equipment and Supplies: 118,925 184,344 17,400 4,200 324,869 32.5

3. Training, Workshops, Seminars, and Public Campaigns: 102,000 15,000 127,524 28,075 272,599 27.3

4. Consulting Services: 45,000 0 50,000 25,000 120,000 12.0

5. Grant Management: 40,000 15,000 16,000 21,000 92,000 9.2

6. Other Inputs: 150,000 150,000 15.0

7. Contingencies (0–10% of total estimated grant fund): 12,923 9,055 8,910 9,643 40,532 4.1

Subtotal JFPR Grant Financed 318,848 223,400 219,834 237,918 1,000,000 82.2

Government Contribution 5,560 77,391 95,898 6,860 185,709 15.3

Other Donor(s) Contributions 10,170 20,000 30,170 2.5

Community's Contributions (mostly in kind):

Total Estimated Costs 334,578 300,791 315,732 264,778 1,215,879 100.0

Incremental Costs

Inputs / Expenditure Category

Grant Components

COST MATRIX ($)

IEC = information, education, and communication. Source: Asian Development Bank estimates.

Appendix 2 19

DETAILED COST ESTIMATES ($)

Code Supplies and Services Rendered Unit Quantity Cost TotalUnits Per Unit $

Amount Method of Procure-ment

Component A. Communications and Program Coordination 6 months Subtotal 321,655 305,925 5,560 10,1701.1 Civil Works1.2 Equipment and Supplies shopping

1.2.1 Pilot Distribution Albendezole tablets 10,000 0.017 170 1701.2.2 Design and Pretest of Training & IEC Materials drafts and mock-ups 1 5,000 5,000 5,0001.2.3 Provinicial & District Training and Informational Materials booklet 250 2.50 625 6251.2.4 Commune Training Inserts leaflet 4000 1.50 6,000 6,0001.2.5 Production Commune Loudspeaker Tapes tape master 18 250 4,500 4,5001.2.6 Duplication of Tapes tapes 4000 0.25 1,000 1,0001.2.7 Community Education Leaflets for VAD, Deworming etc leaflet 1,800,000 0.05 90,000 90,0001.2.8 Project Office Space at NIN rent 10 400 4,000 4,0001.2.9 Office Equipment equipment 1 10,000 10,000 10,000

1.2.10 Office Suppliers and Recurring Expense (tel, ect) monthly recurring 6 300 1,800 1,800

1.3 Training, Workshops, Seminars, and Public Campaigns1.3.1 Scientific Workshop: Review of Pilot Distribution Learnings 1 day workshop 1 6,000 6,000 6,0001.3.2 National Stakeholder Workshop: 1 day workshop 1 10,000 10,000 10,0001.3.3 Provinical Introductory Trainings regional workshop for 18 provinces 2 4,000 8,000 8,0001.3.4 NIN Training and supervision support monthly travel allowance 6 500 3,000 3,0001.3.5 NIMPE Training and supervision support monthly travel allowance 6 500 3,000 3,0001.3.6 Community Advocacy and Participatory Consultations 18 provincial sessions 18 3,000 54,000 54,0001.3.7 Mid-term review community consultations meetings, travel, per-diem 6 3,000 18,000 18,000

1.4 Consulting Services1.4.1 Communications & Education Consultant month 1 20,000 20,000 20,0001.4.2 Technical Consultant on Deworming Protocol est expense 1 10,000 10,000 10,0001.4.3 International Program Development Consultant months 1 25,000 25,000 25,000

1.5 Management and Coordination 1.5.1 NIN PEM Control Program Director monthly salary @ 20% 1.2 500 600 6001.5.2 NIN PEM Control Program Coordinator monthly salary @ 20% 1.2 400 480 4801.5.3 NIMPE Trainer monthly salary @ 20% 1.2 400 480 4801.5.3 NIN JFPR Project Coordinator (consultant) monthly consulant stipend 6 700 4,200 4,2001.5.4 Project Administrative Assitant (consultant) monthly consulant stipend 6 300 1,800 1,8001.5.5 Project Accountant (consultant) monthly consulant stipend 6 500 3,000 3,0001.5.6 Recurit of Project Staff 1 time expense 1 1,000 1,000 1,0001.5.7 External Audit annual 3 10,000 30,000 30,000

Component B. Integrated Procurement, Distribution, and Delivery of Vitamin A Capules and Deworming Tablets 8 months Subtotal 291,735 214,344 0 77,391 0

2.1 Civil Works

2.2 Equipment and Supplies direct 2.2.1 Mebendazole (deworming) Year 1: Two Rounds tablet (100% JFPR) 4,000,000 0.0170 68,000 68,000 contracting2.2.2 Mebendazole (deworming) Year 2: Two Rounds tablet (75% JFPR) 4,000,000 0.0170 68,000 51,000 17,0002.2.3 Mebendazole (deworming) Year 3: 1 Round tablet (25% JFPR) 2,000,000 0.0170 34,000 8,500 25,5002.2.4 Vitamin A Capsules Year 1: Two Rounds tablet 1,760,000 0.0158 27,773 27,7732.2.5 Vitamin A Capsules Year 2:Two Rounds including tablet 1,760,000 0.0158 27,773 20,830 6,9432.2.6 Vitamin A Capsules Year 3: 1 Round tablet 880,000 0.0158 13,886 3,472 10,4152.2.7 Incremental Transport & Storage Costs 3% tablet costs 7,183 2,370 4,8132.2.8 Office Space monthly rent 8 400 3,200 3,2002.2.9 Office Suppliers and Expense monthly expenses 8 300 2,400 2,400

2.3 Training, Workshops, Seminars, and Public Campaigns2.3.1 Training and support for delivery monthly travel 10 500 5,000 5,0002.3.2 Monitoring and Evaluation of Delivery travel, materials, reporting costs 10 1,000 10,000 10,000

2.4 Management and Coordination of this Component 2.4.1 NIN PEM Control Program Director monthly salary @ 10% 0.8 500 400 4002.4.2 NIN PEM Control Program Coordinator monthly salary @ 10% 0.8 400 320 3202.4.3 NIN JFPR Project Coordinator (consultant) monthly consulant stipend 10 700 7,000 7,0002.4.4 Project Administrative Assistant (consultant) monthly consulant stipend 10 300 3,000 3,0002.4.5 Project Accountant (consultant) monthly consulant stipend 10 500 5,000 5,0002.4.6 Incremental Record Keeping & Supervision 4 Institutes Storing Tablets 10 months x 4 institutes 2 persons 5% 4 400 1,600 1,6002.4.7 Incremental Record Keeping & Supervision for 2 Staff in 18 Provincial PHS 10 months x18 provinces 2 person 5% 18 400 7,200 7,200

Costs Contributions

CommunitiesGovernment Other DonorsJFPR

20 Appendix 2

Code Supplies and Services Rendered Unit Quantity Cost TotalUnits Per Unit $

Amount Method of Procure-ment

Component C Community Moblization, Capacity Building, and Integrated Vitamin A and 8 months Subtotal 306,822 210,924 95,898Deworming Tablet/IEC Distribution

3.1 Civil Works

3.2 Equipment and Supplies shopping3.2.3 Record Keeping Supplies (Village, Commune, District, Province) villages, communces, districts, provinces 30,000 $0.50 15,000 15,0003.2.3 Office Space months 8 $400 3,200 3,2003.2.4 Office Suppliers and Recurring Expense (tel, ect) months 8 $300 2,400 2,400

3.3 Training, Workshops, Seminars, and Public Campaigns

3.3.1District Introductory Trainings: Expenses

added 1 day provincial workshop for 173 districts for 2 rounds 36 2,000 72,000 72,000

3.3.2 District Training: Provincial & District Personnel Incremental Timeadded 1 day for 173 district and 18

province @ $400/month for 2 rounds 382 18 6,945 6,945

3.3.3 District Training: District Personnel Per Diem added 1 day for 173 district at $20/day 346 20 6,920 6,9203.3.4 Commune Distribution & Training: District Personnel Incremental Time day for district personnel at $400/month for 346 18 6,291 6,2913.3.5 District Peronnel IncrementalTravel Expense y in filed for district health personnel @ $20 f 346 20 6,920 6,9203.3.6 Commune Travel Alliance 1 day @ $2 x 2 rouns 5352 1 5,352 5,3523.3.7 Village Training: Commune Personnel Incremental Time day for commune personnel at $300/month 5352 14 72,982 72,9823.3.8 Village Volunteer Incremental Time and Training Allowance 2500 VND 2 volunteers per village for 2 rounds 109992 0.167 18,332 18,3323.3.9 Campaign supervision for Initial 3 Rounds 18 provinces x 8 month @ 10% added time 14.4 $400 5,760 5,760

3.3.10 Travel & Per Diem for Campaign Supervision, 3 rounds lump sum $200 plus 20 days in field @ $20 18 $1,000 18,000 18,000

3.4 Consulting Services 3.4.1 International Program Development Consultant months 2 25,000 50,000 50,000

3.5 Management and Coordination of this Component 3.5.1 NIN PEM Control Program Director monthly salary @ 10% 0.8 $500 400 4003.5.2 NIN PEM Control Program Coordinator monthly salary @ 10% 0.8 $400 320 3203.5.3 NIN JFPR Project Coordinator (consultant) monthly consultant stipend 8 $700 5,600 5,6003.5.4 Project Administrative Assistance (consultant) monthly consultant stipend 8 $300 2,400 2,4003.5.5 Project Accountant (consultant) monthly consultant stipend 8 $500 4,000 4,0003.5.6 Travel allowance for Project Coordinator allowance 8 $500 4,000 4,000

Component D - Monitoring, Evaluation, and Policy Development 8 Months Subtotal 255,135 228,275 6,860 20,000 0

4.1 Equipment and Supplies shopping4.1.1 Office Space months 14 $400 5,600 5,6004.1.2 Office Suppliers and Recurring Expense (tel, ect) months 14 $300 4,200 4,200

4.2 Training, Workshops, Seminars, and Public Campaigns4.2.1 Mid-Term Review Meeting meeting 1 10,000 10,000 10,0004.2.2 Advocacy Policy Meeting meeting 1 15,000 15,000 15,000

4.2.3 Travel and Per Diem for Post Distribution Coverage Surveys 5 surveys @ 3 days w/ 3 person @ $35/day plus $100 travel 3075 3,075

4.3 Consulting Services 4.3.4 WHO Advisor for Coverage Surveys months 2 10,000 20000 20,0004.3.5 International Program Develolpment Consultant months 1 25,000 25,000 25,000

4.4 Management and Coordination of this Component 4.4.1 NIN PEM Control Program Director salary @ 10% 1.4 500 700 7004.4.2 NIN PEM Control Program Coordinator salary @ 10% 1.4 400 560 5604.4.3 NIN Deworming Project Coordinator monthly consulant stipend 14 700 9,800 9,8004.4.4 Project Administrative Assistant monthly consulant stipend 14 300 4,200 4,2004.4.5 Project Accountant monthly consulant stipend 14 500 7,000 7,000

4.4 Other Project Inputs (Specify)4.4.1 Biological and Growth Survey, Baseline, Midline and Impact Assessment 120,000 120,0004.4.2 Cost Effectveness Analysis contract 30,000 30,000

Components A to D = Subtotal Subtotal 1,175,347 959,468 0 185,709 30,170 0

Contingency @ 4.05% of JFPR 40,532 40,532

TOTAL Grant Costs Total 1,215,879 1,000,000 185,709 30,170 0

Incremental Cost Details: 50,000 50,000

Costs ContributionsJFPR Government Other

Donors Communities

IEC = information, education, and communication; JFPR = Japan Fund for Poverty Reduction; NIMPE = National Institute Malaria, Parasitology and Entomology; NIN = National Institute of Nutrition; PEM = protein energy malnutrition; VAD = vitamin A deficiency; WHO = World Health Organization; VND = Vietnam dong. Source: Asian Development Bank estimates.

Appendix 3

21

FUND FLOW ARRANGEMENTS

1. The Asian Development Bank (ADB) will channel the Japan Fund for Poverty Reduction (JFPR) funds directly to a JFPR imprest account, which will be opened and maintained by the project implementation unit in the National Institute of Nutrition (NIN) at a bank endorsed by the Executing Agency (EA) and acceptable to ADB, to facilitate day-to-day local expenditures of the JFPR Project. The EA and the Ministry of Finance will be kept informed by the project implementation unit (PIU) about all transactions, and receive copies of all financial statements and audit reports. The JFPR imprest account will be managed by the PIU on the principles of co-signatory arrangement with the NIN of the Ministry of Health, initially based on the first 6-month activity plan and related budget, and afterwards based on the approved annual work plan and budget. 2. ADB will initially channel 10% of the grant amount or 6 months projected expenditure, whichever is less, to the imprest account as an advance for day-to-day project implementation during the inception period, and will replenish funds every 3–6 months to the imprest account, based on the replenishment requests from the PIU through the EA and in accordance with ADB’s statement of expenditures procedure. The statement of expenditures procedure will apply to all payments and transactions under $10,000 to ensure speedy project implementation. Detailed implementation arrangements, such as the flow, replenishment, and administrative procedures will be detailed in the project implementation manual, and be established between ADB and the Government through the JFPR Letter of Agreement. The schematic fund flow for the JFPR Project is shown in Figure A3.

Appendix 3

22

Figure A3: Fund Flow Arrangements for JFPR Project

$305,925

$214,344

$210,924

$228,275

JFPR = Japan Fund for Poverty Reduction.Source: Asian Development Bank estimates.

Grant Imprest Account held at Grant

Implementation Unit (GIU)

Component A

Asian Development Bank

Component D

$1,0

00,0

00

Contingencies: 4%

Component B

Component C

$40,532

Appendix 4

23

IMPLEMENTATION ARRANGEMENTS

1. The Executing Agency for the Project will be the Ministry of Health (MOH). MOH will be supported by the National Nutrition Steering Committee (SC) comprising members from MOH, Ministry of Education and Training, Ministry of Industry, Ministry of Finance and other ministries as appropriate and required. Quarterly reports from the Project will be sent to the SC. 2. The Implementing Agency (IA) will be the National Institute of Nutrition (NIN). Within the NIN, the project implementation unit (PIU) will be established within the office of the Protein Energy Malnutrition Control Program (PEMCP). Pharmaceutical supplies, consultants, and contractors will be managed by the PIU/PEMCP. The PEMCP is overseen by the PEMCP Steering Committee, which will also receive regular project reports. The PIU staff―a project coordinator, a project accountant, and an administrative assistant―will work under the direction of the NIN director and the PEMCP coordinator. 3. Storage, inventory, and delivery to project distribution sites will be integrated with the current systems used to store and deliver vitamin A capsules targeting children 6–36 months― routed via truck and prepositioned at regional nutrition institutes and provincial preventive health centers, and finally delivered to district health centers and commune health stations during the month of distribution campaigns. 4. The Project will engage 18 provincial preventive health centers, 173 district health services, 27,498 commune health stations and the community health workers that work from these health stations. At each level, the PEMCP steering committee will oversee project activities as part of their regular services under this program. 5. The National Institute for Malaria, Parasitology and Entomology (NIMPE) is the national institute with technical capacity for surveillance and testing for worm infections. As such, NIMPE will be ”subcontracted” by NIN to conduct the baseline, midline, and final project survey with the assistance of the World Health Organization and the University of Melbourne, Australia (this University is currently a technical partner to NIMPE for deworming activities focused on women of reproductive age and the team members have indicated their willingness to support NIMPE’s project activities as part of this ongoing technical support). 6. Figure A4 depicts the implementation arrangements in an organo-gram.

Figure A4: Schematic Diagram of Implementation Arrangements

Project Contracts

Distribution and Capacity Building

Capsule and IEC Delivery

Executing/Implementing Agency

Multisector Participation and Oversight

Color Coding Key

NIMPEProject Evaluation Team

Executing Agency: MOH

Grant Implementing Agency: NIN/PEMCP

Project Office (PIU)

Pharmaceutical Suppliers

Regional MOH Institutes

173 DistrictHealth Services

18 Province PHCs

2676 CommuneHealth Services

Provincial Steering Committee

PEM CP Steering Committee

27,498 Village Health Workers, Collaborators, and NGOs

U of Melbourne

WHO

District Steering Committee

Commune Steering Committee

Consultants and Contractors

1,800,000 Children 6–60 Months

National Nutrition Strategy Steering Committee: MOH, MOET, MOI, MOP, MOF, and Others

IEC = information, education, and communication; MOH = Ministry of Health; NGO = nongovernment organization; NIMPE = National Institute Malaria, Parasitology and Entomology; NIN = National Institute of Nutrition; PEMCP = Protein Energy Malnutrition Control Program; PHC = preventive health center; PIU = project implementation unit; U = University; WHO = World Health Organization.Source: Asian Development Bank estimates.

24

Appendix 4

YearMonth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Project ComponentCommunications and ManagementIntegrated Distribution PilotAnalysis and Evaluation of PilotOffice Start-Up Recruitment Scientific and Guidelines WorkshopNational WorkshopTwo Provincial TrainingsCommunication/Training Materials Procurement and DistributionPlace Order (ADB Share) 100 100 75 75 25Delivery to NIN/HanoiDelivery to InstitutesDelivery to Province PHCDelivery to DistrictDelivery to Commune and VillageCommunity Distribution and IEC18 District Training WorkshopsCommune Training Village TrainingDistribution CampaignEvaluation and Policy Process evaluation TeamBaseline SurveyMidline Survey and AnalysisMid-term Review and Advocacy Two Year Impact Survey and AnalysisCost Effectiveness StudyExpanded PEMCP Strategies Advocacy MeetingFinal Report

PROJECT 36–MONTH TIMETABLE

Government

2006 2009

Sustained by the

2007 2008

NIN = National Institute of Nutrition, PEMCP = Protein Energy Malnutrition Control Program, PHC = preventive health center.

Source: Asian Development Bank estimates.

Appendix 5 25

Appendix 6

26

PROJECT LOCATIONS AND PROVINCE SELECTION CRITERIA

1. Provinces have been identified according to national nutrition survey data that provide information on micronutrient deficiency levels (e.g., vitamin A deficiency) and other standard nutrition criteria such as growth figures (height and weight). A selection of these measures is given in Table A6.1. The selection of provinces also considered basic health statistics (mortality), worm infection rates (where known) and the overall poverty measure for the province. Considering all these indicators, the National Institute of Nutrition identified the 18 provinces that clearly have the worst statistics for all these measures. 2. Table A6.2 gives for districts, communes, and villages the basic demographic data and numbers that will be necessary for planning the distribution and communication activities.

Table A6.1: Key Nutrition, Health, and Poverty Indicators for the Selected 18 Provinces

Province Region Estimated Regional VAD Stunting Infant Mortality Rate

Child > 5 Mortality Rate

Child < 5 Prevalence Worm Infection Poverty Rate

Population Child 6–60 months

% per 1,000 per 1,000 per 1,000 % % #Kon Tum Central Highland 41.80 50.0 62.6 17.76 40–60* 46.30 49,963Ha Giang Noth Mountain 61.80 42.7 55.8 46.44 70–80 54.65 79,514Gia Lai Central Highland 41.80 36.0 44.4 8.20 40–60 44.10 142,675Lai Chau North mountainous 61.80 42.1 44.0 >90* 63.57 90,137Cao bang North mountainous 61.80 36.2 42.4 30.00 70–80 47.82 51,262Dien Bien North mountainous 61.80 36.6 41.0 49.10 >90* 44.77 57,396Quang Tri Noth Central 61.80 31.0 37.5 14.30 40–60 29.46 70,803Yen Bai North mountainous 61.80 36.1 35.0 21.37 >90 34.71 68,833Dak Nong Central Highland 41.80 44.0 34.0 2.88 40 42.30 46,071Lao Cai North mountainous 61.80 44.2 30.7 32.10 >90 43.01 80,287Hoa Binh North mountainous 61.80 31.1 27.5 20.30 70–80 37.30 66,569Bac Giang North mountainous 61.80 29.5 27.3 5.45 60–70 31.62 145,082Dak Lak Central Highland 41.80 41.6 27.0 40–50 33.70 245,104Ninh Thuan Noth Central 61.80 32.7 22.6 40 22.90 63,573Quang Binh Noth Central 61.80 42.3 20.8 5.35 70–80 39.20 94,777Dong Thap Mekong river Delta 18.90 33.8 16.1 7.78 40 13.59 137,125Nam Dinh Red River Delta 17.00 28.2 16.0 1.84 >90 14.40 167,063Kien Giang Mekong River Delta 18.90 25.3 16.0 3.90 10–20 15.11 140,778

Total 1,797,012

VAD = vitamin A deficiency. Source: National Institute of Nutrition.

Table A6.2: Numbers of Districts, Communes, Villages, Children, and Pregnant Women for Selected 18 Provinces

Province No. of District No. of Communes No. of Vilages No. of Child U 2 No. of Child U 5

Lai Chau 5 86 860 30,576 90,137 Dien Bien 8 88 880 21,609 57,396 Hoa Binh 11 214 2,140 23,754 66,569 Cao Bang 13 189 1,890 16,065 51,262 Lao Cai 11 180 1,800 28,980 80,287 Yen Bai 9 180 1,800 25,020 68,833 Ha Giang 10 192 1,920 28,268 79,514 Bac Giang 10 229 2,290 49,032 145,082 Nam Dinh 10 225 1,800 55,596 167,063 Quang Binh 7 154 1,232 26,026 94,777 Quang Tri 9 136 1,088 22,168 70,803 Ninh Thuan 5 59 472 19,604 63,573 Gia Lai 14 183 2,745 48,752 142,675 Kon Tum 8 82 1,230 18,486 49,963 Dak Nong 6 52 780 19,328 46,071 Dak Lak 13 165 2,475 88,168 245,104 Dong Thap 11 139 1,112 52,542 137,125 Kien Giang 13 123 984 61,560 140,778 Total 173 2676 27,498 635,534 1,797,012 No. = number, U = under. Source: National Institute of Nutrition.

Improving Vitamin A Nutrition and Deworming for Poor and ...

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