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DEVELOPMENT PROJECT LAO PDR NO. 200129ADDRESSING MALNUTRITION THROUGH MATERNAL AND CHILD HEALTH AND NUTRITION ACTIVITIES

Number of beneficiaries1 14,500

Duration of project 18 months (1 July 2010 - 31 December 2011)

Food tonnage 319 mt

Cost (United States dollars)

WFP food cost US $646,050

Total cost to WFP US $1,029,994

EXECUTIVE SUMMARY

Lao PDR is a Least Developed Country (LDC) ranked 133rd out of 182 countries in the UNDP Human Development Index.2 Despite Lao PDRs economic improvement in recent years, about 85 percent3 of the countrys 5.6 million people in rural areas still face food insecurity, poverty and recurring natural disasters. As a result, the nutritional status of the population remains a serious concern, with no significant change in chronic malnutrition rates over the past decade.

The economy is largely subsistence based, with over 80 percent of the population living in rural areas. Agricultural practices are mostly subsistence-oriented, with low input farming systems, weak rural infrastructure, a lack of an educated and skilled work force, and poor access to extension services. Rice production remains low compared to neighbouring countries and local seasonal rice deficits occur each year.

According to the WFPs Comprehensive Food Security and Vulnerability Analysis (CFSVA), it is estimated that approximately two thirds of the rural population are either food insecure or are at risk of becoming food insecure should a shock occur.4Malnutrition rates in Lao PDR are among the highest in the region and contribute significantly to child morbidity. Nearly one out of two children under five are stunted and one out of three children under five under weight. The highest prevalence of chronic malnutrition (stunting) is found in the northern, southern and central highlands with chronic malnutrition among some ethnic groups averaging over 60 percent.5 One third of pregnant and lactating women are undernourished and at higher risk of delivering low-birth weight infants6.

1 Adjusted to avoid overlap between years. 2 UNDP Human Development Report, 2009 report 3 IFAD, Rural Poverty in Lao PDR, 2006 4 WFP Comprehensive Food Security and Vulnerability Analysis (CFSVA) report; 2007 5 WFP Comprehensive Food Security and Vulnerability Analysis (CFSVA) report; 2007 6 Ministry of Health (2006), National Health Survey/MICS3

This Maternal and Child Health and Nutrition (MCHN) development project is a pilot intervention aimed at addressing stunting among children 6-23 months. The project follows the Country Portfolio Evaluation conducted in 2009 which recommended that WFP sharpen its focus on nutrition in the Lao PDR. The objective of the project is to contribute to national efforts to reduce maternal, neonatal and child mortality and maternal and child malnutrition in Lao PDR7 (WFP Strategic Objective 4: Reduce Chronic Hunger and Undernutrition).

WFP will assist the Government of the Lao PDR through an integrated nutrition intervention for women and children comprising two components: i) Provision of a ready-to-use supplementary food (Plumpy Doz) for children 6-23 months; and ii) a nutrition education initiative for pregnant and lactating women.

This development project supports Millennium Development Goal(MDG) 4: Reduced Child Mortality and the Lao MDG 5: Improved Maternal Health and WFPs Gender Policy and Corporate Action Plan (2010-2011). The project is also is line with the priorities of the United Nations Development Assistance Framework (UNDAF) 2007-2011, the Lao Governments National Nutritional Strategy (November 2009) and WFPs partnership on the REACH Initiative.

An expanded phase of this project is expected to be included in the new Lao PDR country programme to commence in 2012.

The Deputy Executive Director and Chief Operating Officer approves, under the Executive Directors delegated authority, the proposed Development Project Lao PDR No.200129, subject to availability of resources.

_____________________________

Signature: Deputy Executive Director and Chief Operating Officer

Dated: ______________________

7 Strategy and Planning Framework for the Integrated Package of Maternal Neonatal and Child Health Services 2009-2015; Ministry of Health, Lao PDR.

PART I SITUATION ANALYSIS 1. Lao PDRs robust economic growth of nearly 10 percent over the last decade has not

translated into an improved nutritional status of a large proportion of the population, with malnutrition rates remaining virtually unchanged over this period. Malnutrition rates in Lao PDR are among the highest in the region and contribute significantly to child morbidity8.

2. Nearly 40 percent of children under five are stunted, 37 percent underweight, and about 7 percent are wasted9. More than 30 percent of pregnant and lactating women are undernourished and thus are at higher risk of delivering low-birth weight babies. While the national average of low-birth weight babies is 11 percent10, in remote areas this figure is much higher. Micronutrient deficiencies such as that of iron, iodine and of vitamin A continue to be a public health concern in Laos PDR. 45 percent of children under five (CU5) suffer from Vitamin A deficiency and 23 percent11 of women between 12 and 49 years of age suffer from sub-clinical Vitamin A deficiency. Iron deficiency in women of reproductive age is approximately 22 percent. The 2006 National Nutrition Survey showed that 64 percent of children under two (CU2), 41 percent12 of CU5, and 36 percent13 of women of reproductive age (WRA) suffered from anaemia.

3. The Comprehensive Food Security and Vulnerability Assessment (CFSVA) found

that the most food insecure provinces are located in the northern, central and southern highlands of Lao PDR. Farmers engaging in upland rice production form the majority of food-insecure households, with 42 percent reported to have poor food consumption. Limited access to land for cultivation due to mountainous terrain also affects food availability in these areas. Levels of food insecurity are also found to be higher among ethnic communities. The CFSVA found that the Hmong-Mien ethnic group had some of the highest levels of food insecurity at 28 percent.

4. Poor maternal and child health is the result of many factors, including poor consumption of nutritious foods, unfavourable complementary feeding practices such as the early introduction of nutritionally poor foods, the unsafe preparation of foods and poor childcare practices. Additionally, limited knowledge of the appropriate utilisation of foods from the local environment is a strong contributing factor to poor diets, despite the availability of diverse food sources in some areas.

5. The causes of malnutrition also include poor access to health care and sanitation

facilities. The LECS 314 survey showed that in rural upland areas, it takes an average of three hours to reach a health facility. The 2009 Emergency Food Security Assessment (EFSA) conducted in northern Laos found that 40 percent of households interviewed had no latrines and used open fields. Women continue to have fewer

8 Ministry of Health (2006), National Health Survey/MICS3 9 Ministry of Health (2009), National Nutritional Strategy and Plan of Action 2010-2015. 10 Ministry of Health (2009) Strategy and Planning Framework for the Integrated package of Maternal Neonatal and Child Health Services 2009-2010, Lao PDR. 11 WHO 2000. Serum/plasma retinol concentration < 0.7 mol/l. 12 National Nutrition Survey 2006. Proportion of children < 5 with Haemaglobin(HB) < 110 g / L. 13 National Nutrition Survey 2006. Proportion of WRA with HB < 120 g / L. 14 Lao Expenditure and Consumption Survey (LECS3) (2004), National Statistics Centre, Lao PDR.

rights, lower education and health status, less income and lower access to resources and decision making than men.

6. The Lao diet is based largely on staple foods. The CFSVA shows that rice is

consumed on average 6.4 days per week whereas meat (small wildlife, poultry, pigs) is consumed one or less days per week. Green leafy vegetables are consumed on average 4.7 days per week but oil or lard is consumed only 2 days per week. Traditionally, sources of fat and protein are largely derived from wild animals and forest products. Access to these food sources is increasingly limited due to the expansion of commercial farming, deforestation, over-harvesting of non-timber forest products and resettlement of the population. Vegetable oil has not become part of peoples diet and pulses are used in small quantities in only sweet dishes15.

7. The United Nations is working with the Government of the Lao PDR (GoL) to achieve the Millennium Development Goals (MDGs), including MDG 1: to halve the proportion of people who suffer from hunger; MDG 4: to reduce child mortality; and MDG 5: to improve maternal health. The MDG progress report, prepared in 2008 by the Government and the UN, identifies malnutrition as the biggest obstacle to achieving the MDGs. While GDP doubled in the Lao PDR between 2000 and 2007, rates of child malnutrition remained constant16.

8. Despite some progress in the decline of infant mortality rates from 104 per 1,000 live births to 70 per 1,000 live births between 1995 and 200517, and the decline of the Maternal Mortality Rate (MMR) from 656 per 100,000 live births to 405 per 100,000 live births18 during the same period, Lao PDR is unlikely to achieve relevant MDGs by 2015, especially MDGs 1 and 519. The Government concurs that the targets of reducing maternal mortality by three-quarters and achieving universal access to reproductive health care 20 will not be achieved by 2015.

9. The Government has set specific targets for 201021: underweight malnutrition rates to be reduced to 32 percent; maternal mortality to be reduced to 330 per 100,000 live births; infant mortality to be reduced to 55 per 1,000 live births and under 5 mortality to be reduced to 75 per 1,000 live births. It is also committed to further reducing malnutrition rates by 2020. In view of the complex and multi-sectoral nature of food security and nutrition, the combined and coordinated efforts of the Government, UN agencies, non-government entities and civil society are required, working across the relevant sectors as outlined in the Vientiane Declaration on Aid Effectiveness22.

10. WFP has worked with the Ministry of Health on key strategy and policy documents. The MoHs strategy and planning framework for an Integrated Package of Maternal, Neonatal and Child Health Services (2009-2015) guides stakeholders engaged in this sector. The MoH-led National Nutrition Strategy (NNS) and National Plan of Action

15 Comprehensive Food Security and Vulnerability Analysis (CFSVA) (2007), World Food Programme Lao PDR. 16 GDP data World Bank; nutrition from MICS III, 2006. 17 Ministry of Health (2009) Strategy and Planning Framework for the Integrated package of Maternal Neonatal and Child Health Services 2009-2010, Lao PDR. 18 Ibid.19 Ibid. 20 Millennium Development Goals Progress Report: Lao PDR, 2008. 21 Ibid. 22Signed at the Ninth Round Table Meeting on 29 November 2006, in Vientiane, Lao Peoples Democratic Republic.

on Nutrition (NPAN) are key frameworks for addressing malnutrition in the Lao PDR.

11. Additionally, WFP is a leading partner in the REACH Initiative, for which Laos is the first pilot country in Asia. REACH is a Government-led, joint initiative with development partners aimed at accelerating progress on MDG 1, Target 2 (halve the proportion of underweight children under 5) through scaling up proven, cost effective interventions addressing child undernutrition.

PART II PAST COOPERATION AND LESSONS LEARNED

12. WFP food assistance to Lao PDR started in 1975. Between 2005 and 2008, WFP assisted between 300,000 and 500,000 people each year and in 2009, over 800,000 people received WFP support. Currently, three operations are ongoing: two development projects and one protracted relief and recovery operation.

13. The projects and operation have the following objectives: (i) food for relief: to

address emergency needs in times of mostly natural disasters and livelihood transitions; (ii) food for work: to improve livelihoods or reduce long-term food insecurity among food-insecure people, households, and communities; and (iii) school feeding: to contribute to the improvement of school enrolment, attendance rates and reduction of the gender gap in primary schools.

14. A Country Portfolio Evaluation (CPE) undertaken in 2009 found WFPs activities to

be generally well aligned with national policies, systems and processes. In the area of nutrition, WFP has been playing an instrumental role through its analytical and advocacy work by raising awareness and contributing to a process that led to the formulation between 2008 and 2009 of a National Nutrition Policy, Strategy and Plan of Action.

15. WFP participates in Government-led processes in health and education. The school

feeding programme is implemented in collaboration with UNICEFs schools of quality and complements the Asian Development Banks investment in basic education in the same districts and communities.

16. According to the CPE, WFP in Laos performed well by reaching between 75-100

percent of intended beneficiaries, including on average an equal number of men and women. The age distribution of the beneficiaries shows however that WFP did not prioritize groups found to be vulnerable in the comprehensive food security and vulnerability analysis, namely pregnant and lactating women and infants in the age group up to 2 years.

17. A formulation mission conducted in 2009 concluded that a MCHN project was

technically feasible and socially acceptable. This resulting project has been reflected and incorporated into the national health and nutrition development plans of the Government, which supports mobilization and awareness at village and community levels.

18. As supplementary feeding on its own would be insufficient to address the underlying causes of malnutrition in Laos, the components of this development pilot will be integrated into other health and nutrition-related interventions, including WFP-specific (e.g. food for work) and other UN agency-related interventions. Complementary activities by other UN agencies include immunisation and deworming campaigns, exclusive breastfeeding campaigns, capacity building in nutrition and salt iodisation. Coordination with other agencies will be important to achieve the desired impact of WFP assistance. WFP is also present in the target provinces with other activities such as school feeding and food for work. Synergies to improve household level food security will be explored in the target villages.

PART III PROJECT STRATEGY

19. The long-term object...

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