In this report, Save the Children UK claims that World Bank efforts to curb childhood malnutrition in Bangladesh, Uganda, and Ethiopia have had no impact. Resources may be being wasted on these large-scale communitynutrition projects, the charity claims. It "found no difference in the rates of malnutrition" in Bangladesh after six years of project implementation. "Growth monitoring charts were poorly understood by mothers and supplementary feeding had limited effectiveness especially for very young children". The report claims that the projects are based on a "widely discredited" approach, which assumes "that the child is malnourished because the mother isn't doing something right".

The report is also critical of what Save the Children UK sees as inadequate monitoring and/or insufficiently transparent communication of evaluation results. It urges the World Bank and donors to stop further scale-up of these projects until objective reviews are completed, as follows:

• "In Bangladesh, a final evaluation of Bangladesh Integrated Nutrition Project (BINP) before proceeding further with the National Nutrition Project.
• In Uganda, the review of the Nutrition and Early Childhood Development project due later this year should be comprehensive, transparent, and widely discussed in order to determine the best approach to the next phase.
• In Ethiopia, the child growth component of the Food Security Project should be reconsidered, or focused on a small-scale pilot. Alternatively, the remaining investment could be shifted to activities that are likely to be more effective."

The report also urges an independent review of the evidence supporting current approaches to addressing poor child growth and explore the cost-effectiveness of alternative approaches. It also calls for increased accountability in the design, monitoring, and evaluation of the projects.

Excerpts from the Executive Summary:

...Thin on the Ground challenges the notion that trying to change the behaviour of poor mothers using growth monitoring and promotion will realise significant impacts on nutritional status. Our evidence suggests that too many mothers are too poor to act on their newly acquired knowledge about nutrition: they live in unhealthy, unsanitary environments lacking adequate and safe water; they have little or no access to health services; they are often illiterate; and they have inadequate time for childcare....[G]rowth monitoring and promotion interventions are bound to fail unless they are explicitly linked to efforts to address the underlying causes of malnutrition and the reasons why caring practices are poor. In practice these links are not made. So while project components aimed at improving food security exist in all three projects and may, if implemented contribute to reductions in nutritional status, the purpose and value of the high level of investment in growth monitoring and promotion are not evident.

In addition to design problems, the projects face a host of implementation constraints. First, the African projects rely on inadequately trained, under-supervised and poorly paid nutrition workers to implement a complex intervention. In addition, project costs are $5-10 per year for each person enrolled on the project, often exceeding the per capita investment in healthservices several times over. The implementation in Uganda and Bangladesh relies on parallel structures (staff, facilities, resources) that for the most part will not last beyond the life of the project, rendering it institutionally unsustainable.

Therefore, before making any further investments of this kind, Save the Children UK asks that the World Bank:

• commissions an independent review of the evidence base behind current approaches to addressing poor child growth, including growth monitoring and promotion, nutrition education and supplementary feeding
• explores the cost-effectiveness of alternative approaches including public health, water and sanitation, as well as food security and livelihoods interventions

Bretton Woods Update 35 (July-August 2003), forwarded to The Communication Initiative on July 31 2003.