Rationale Rapid nutrition surveys can reinforce project formulation or baseline surveys with the objective of establishing benchmarks – specifically to enable estimation of project impact at the Mid-term Review and Final Evaluation. The information generated by these surveys will also facilitate the demonstration of IFAD’s contributions to reaching global targets for poverty alleviation and the elimination of hunger. IFAD’s position on nutrition assessments dates back to 1985. "At the very least, monitoring and evaluation systems should incorporate one or more of the commonly accepted indicators of general nutritional status."

There are three primary indicators of general nutritional status, which are based on anthropometry (physical measurements of young children). Chronic malnutrition (also called "stunting") is calculated in terms of height for age. High levels of chronic malnutrition reflect nutritional deprivation over a period of months or years. It is considered to be one of the best available indicators of the overall wellbeing of a community. The level of chronic malnutrition can respond to changes in food supply, household income, market access, environmental health, maternal education and caring practices. Children who are chronically malnourished may suffer irreversible disability in terms of mental and physical development, causing poor performance in school and reduced physical productivity for the rest of their lives.

Acute malnutrition (or "wasting") is calculated in terms of weight for height. It is associated with temporary shocks, such as famine or episodes of illness. Underweight is calculated in terms of weight for age. It is most often used to monitor the nutrition status of individual children.

All three anthropometric indicators are gender sensitive and are appropriate in multi-cultural contexts. The indicators are determined separately for girls and boys, and there is solid consensus that ethnic/racial differences in growth patterns are not observable among children under the age of five years (although such ethnic/racial differences may begin to appear in later childhood or early adolescence). For these reasons, the indicators are particularly valuable for comparing impacts of different projects across different countries and regions.

Case Examples

Until recently, nutrition indicators have not been regularly included in IFAD projects – due in part to a general absence of quantitative benchmarks at project baseline, and concern regarding the complexity and expense of nutrition surveys. Given the current environment of increased interest in demonstrating project impact, two projects were selected for field-testing the feasibility and relevance of rapid nutrition surveys. This case study draws on the experience gained from those recently completed pilot studies (Morocco in March 2000, and China in October 2000).

Methodology

In each case, a sampling frame was prepared from population data in the project area to ensure a representative sample. Sample sizes were calculated to provide sufficient statistical power using multi-stage sampling methodology (sample sizes are normally in the range of 600-900 children) and corresponding series of villages were randomly selected. (Detailed information on sampling frames, sample sizes and fieldwork plans is available from the IFAD Technical Advisory Division).

Results

Key findings from the Morocco pilot survey are presented below to illustrate the format for benchmark data. Results for the indicators are based on Z-scores (standard deviation units). According to WHO guidelines, any child who has fallen more than two standard deviation units below the reference of the reference median are classified as suffering from malnutrition.

Table 1: Malnutrition Indicators (Z-scores) in the Project Area.

INDICATOR	Girls	Boys	Both Sexes
Chronic Malnutrition (height for age)
Proportion <-2.0	50.8 %	51.6 %	51.2 %
95% Confidence Interval	45.5 – 56.1	45.9 – 57.1	47.4 – 55.0
Acute Malnutrition (weight for height)
Proportion <-2.0	2.9 %	2.4 %	2.6 %
95% Confidence Interval	1.1 – 4.8	1.5 – 5.2	1.6 – 4.2
Underweight (weight for age)
Proportion <-2.0	20.1 %	19.2 %	19.7 %
95% Confidence Interval	16.3 – 24.5	15.3 – 23.9	16.9 – 22.8

[Source: IFAD Formulation Mission, March 2000]

Key Finding: Approximately 51% of children in the project area are chronically malnourished.

Figure 1: Chronic Malnutrition by Project Area and National Data.

[Sources: IFAD Formulation Mission, March 2000

WHO Global Database on Child Growth and Malnutrition]

The levels of chronic malnutrition in the project area were found to be significantly higher than the national average, which includes both urban and rural areas. This finding supports the conclusion that the project location was appropriately selected to serve a population vulnerable to continued food insecurity and malnutrition.

The benchmark data will be complemented by repeat surveys conducted as part of the Mid-term Review and the Final Evaluation. (Note: changes in the level of malnutrition should measured in intervals of 3 years for 6-year projects, and intervals of 5 years for 10-year projects).

Table 2: Estimation of Impact

Indicator: Chronic Malnutrition
Benchmark – 2000			Mid-term Review - 2003				Final evaluation - 2006
Girls	Boys	Both Sexes	Girls	Boys	Both Sexes	% change 2000-2003	Girls	Boys	Both Sexes	% change 2000-2006
50.8%	51.6%	51.2%	x%	x%	x%	x%	y%	y%	y%	y%
45.5-56.1	45.9-57.1	47.4-55.0

Resource Implications

The time required to complete the fieldwork is largely a function of (i) the geography and demographics of the project area, and (ii) the human resources and logistical support available to the survey team. Both of the projects were located in remote mountainous areas.

• In Morocco, the survey team (8 Doctors & Nurses) weighed and measured 750 children during 5 days of fieldwork. Minimal initial training was required, as the MOH staff were already familiar with anthropometric measurements. The weather was not a factor, and there was strong logistical support. Data entry, data analysis and reporting took another 5 working days.

• In China, the survey team (22 project staff & MCH Nurses) completed a sample of 600 children in 6 days of fieldwork. Three ½ day training sessions were conducted to enable project staff to carry out future surveys without external assistance. Also, it should be noted that it was raining steadily during the fieldwork, turning the dirt roads into mud and increasing travel times. Well-planned logistical support mitigated some of these difficulties. Four days were spent on data entry, analysis and reporting.

In terms of expense, neither survey cost more than $ 1,000 in the field. Factoring in the expense of an international consultant (when necessary) and the purchase of measuring equipment, the average cost for a complete survey would be roughly $ 8,000 - $ 10,000. Some savings could be expected when the nutrition assessment is incorporated into a comprehensive baseline survey, which is the recommended procedure.

Value Added to Project Management

Overall, the survey work in Morocco and China was able to demonstrate that anthropometric assessments are feasible, rapid, inexpensive, and can produce relevant benchmark indicators. Project management can then use the benchmark data as anchor indicators for estimating impact in the project area at the Mid-term Review and the Final Evaluation.

14 November 2000