EVALUATION OF THE FOOD AND NUTRITION TECHNICAL ASSISTANCE (FANTA) PROJECT JULY 2007 This publication was produced for review by the United States Agency for International Development. It was prepared by Mary Ann Anderson, Team Leader, Claudia Parvanta, and Elizabeth Berard through the Global Health Technical Assistance Project. EVALUATION OF THE FOOD AND NUTRITION TECHNICAL ASSISTANCE (FANTA) PROJECT DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project This document (Report No. 07-001-020) is available in printed or online versions. Online documents can be located in the GH Tech website library at www.ghtechproject.com/library/. Documents are also made available through the Development Experience Clearing House (http://dec.usaid.gov). Additional information can be obtained from The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 info@ghtechproject.com ii Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project ACKNOWLEDGMENTS The FANTA Evaluation Team thanks the United States Agency for International Development (USAID) for commissioning this evaluation of the Food and Nutrition Technical Assistance Project (FANTA) and for selecting us to undertake this large task. We owe a debt of gratitude to the many persons we have interviewed from USAID, private voluntary organizations, and international organizations, and to the staff of FANTA and its partner organizations for their responsiveness to our many questions. We also thank them for their openness to constructively discuss lessons learned and to make recommendations for the future. The evaluation team was truly impressed with the superlatives used to describe the high quality of FANTA’s assistance and to express gratitude for the invaluable technical support FANTA has provided to so many to improve nutrition and food security programs around the world. To this we add our heartfelt congratulations to FANTA on a job extremely well done. The FANTA team has greatly enriched the evidence base on effective food and nutrition programs and policies. Reviewing FANTA’s products and publications has added substantially to our own professional knowledge and brought us up to date on the state-of-the-art. For this opportunity, we are thankful. FANTA’s excellent work in improving food and nutrition programming and policies for more than eight years has no doubt done much to reduce suffering due to food insecurity and malnutrition around the world. Nevertheless, hunger in the developing world remains a serious problem. Therefore, we urge USAID to continue to support such important nutrition and food security technical assistance projects. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project i ACRONYMS ACCESS Access to Clinical and Community Maternal, Neonatal, and Women’s Health Services Project, JHPIEGO/USAID ADRA Adventist Development and Relief Agency AED Academy for Educational Development AFR USAID Africa Bureau ART Antiretroviral Therapy A2Z A2Z Micronutrient and Child Blindness Project, AED USAID CA Cooperating Agency CDC Centers for Disease Control CMAM Community-based Management for Severe Acute Malnutrition CORE Child Survival Collaboration and Resources Group CRED Centre for Research on the Epidemiology of Disasters CRS Catholic Relief Services CS Cooperating Sponsor (includes Private Voluntary Organizations) CSB Corn-Soy Blend CSH Child Survival and other Health Funds CSHGP Child Survival and Health Grant Program CSTS Child Survival Technical Support Project CTC Community-Based Therapeutic Care CTO Cognizant Technical Officer, USAID DA Development Assistance DAP Development Assistance Programs DCHA USAID Bureau for Democracy, Conflict, and Humanitarian Assistance DD Dietary Diversity DFID Department for International Development, United Kingdom DHS Demographic and Health Surveys DIP Detailed Implementation Plans EGAT USAID Economic Growth, Agriculture, and Trade Bureau ESF Economic Support Funds F U.S. Department of State, Office of the Director of U.S. Foreign Assistance FAM Food Aid Management Consortium of Cooperating Sponsor PVOs FANTA Food and Nutrition Technical Assistance Project FAO Food and Agriculture Organization FEWS NET Famine Early Warning System Network FFP Office of Food for Peace, USAID DCHA Bureau FH Food for the Hungry GAO United States Government Accountability Office GFATM Global Fund for AIDS, Tuberculosis, and Malaria GH USAID Bureau for Global Health HDDS Household Dietary Diversity Score HFIAS Household Food Insecurity Access Scale ii Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project HIDN Office of Health, Infectious Diseases, and Nutrition, USAID, GH Bureau HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HPN Health, Population, and Nutrition ICB Institutional Capacity Building IDFA International Disaster and Famine Assistance Funds IFPRI International Food Policy Research Institute IR Intermediate Result IRD Institute of Research for Development, France (formerly ORSTROM) IYCF Infant and Young Child Feeding JHPIEGO Johns Hopkins International Program in Obstetrics and Gynecology KEMRI Kenya Medical Research Institute KPC Knowledge, Practice, and Coverage Survey LQAS Lot Quality Assurance Sampling LSHTM London School of Tropical Hygiene and Medicine M&E Monitoring and Evaluation MCHN Maternal and Child Health and Nutrition MOA Ministry of Agriculture MOH Ministry of Health MUAC Mid-upper Arm Circumference MYAP Multi-Year Assistance Program NGO Non-governmental Organization OGAC Office of Global AIDS Coordinator, State Department OFDA Office of U.S. Foreign Disaster Assistance, USAID DCHA Bureau OHA Office of HIV/AIDS, USAID GH Bureau OICI Opportunities Industrialization Centers International PART Program Assessment Rating Tool PDA Personal Data Assistant PEPFAR President’s Emergency Plan for HIV/AIDS Relief PLHIV Persons Living with HIV PLWHA People Living with HIV/AIDS PL 480 Public Law 480 Title II Food Aid Programs PPC Bureau for Policy and Program Coordination, USAID PRH Office of Population and Reproductive Health, USAID, GH Bureau PROFILES A Process for Nutrition Policy Analysis and Advocacy PVO Private Voluntary Organization (also used for Cooperating Sponsor) PY Program Year of FANTA Agreement RCQHC Regional Centre for Quality of Health Care, Uganda RFA Request for Application RUTF Ready-to-Use Therapeutic Foods SAM Severe Acute Malnutrition SCN United Nations Standing Committee on Nutrition SO Strategic Objective SYAP Single-Year Assistance Program Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project iii TALC Teaching Aids at Low Cost TAG Technical Advisory Group TANGO Technical Assistance to NGOs International TII Title II TRM Technical Reference Materials UN United Nations UNDP United Nations Development Program UNICEF United Nations Children’s Fund USAID United States Agency for International Development USAID/EA USAID/East Africa Regional Office USAID/W USAID/Washington, DC, Office USDA United States Department of Agriculture USG United States Government VAM Vulnerability Analysis and Mapping WAGGGS World Association of Girl Guides and Girl Scouts WFP World Food Programme WHO World Health Organization WV World Vision iv Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project CONTENTS ACKNOWLEDGMENTS .................................................................................................................. I ACRONYMS.................................................................................................................................... II EXECUTIVE SUMMARY................................................................................................................. 1 I. INTRODUCTION .......................................................................................................................... 7 A. Background and Evolution of the FANTA Project and its Operating Environment...... 7 B. Evaluation Scope of Work ................................................................................................ 11 C. Methodology....................................................................................................................... 11 II. FINDINGS OF THE EVALUATION........................................................................................... 13 A. Overall Achievement of Strategic Objective: “Improved Food and Nutrition Policy, Strategy, and Program Development”............................................................................. 13 B. Support to Improve Nutrition and Food Security Program Development, Analysis, Monitoring, and Evaluation by USAID and Cooperating Sponsors (Intermediate Result IR1) .......................................................................................................................... 14 C. Support to Improve Integrated Nutrition and Food Security Strategies and Policies of USAID, Host Governments and Cooperating Sponsors (Intermediate Result IR2) .......................................................................................................................... 24 D. Promotion of Promising Practices and Acceptable Standards for Nutrition and Food Security Policy and Programs to USAID, Cooperating Sponsors, and other Key Stakeholders, and their Adoption (Intermediate Result IR3)................................. 29 E. Program Management ....................................................................................................... 43 III. FUTURE NEEDS...................................................................................................................... 47 IV. RECOMMENDATIONS............................................................................................................ 51 V. APPENDICES......................................................................................................................... 53 Appendix A: Expanded Conceptual Framework for Understanding Food Insecurity..... 55 Appendix B: Scope of Work.................................................................................................. 57 Appendix C: FANTA Products by Intermediate Result....................................................... 62 Appendix D: References........................................................................................................ 86 Appendix E: Persons Interviewed ........................................................................................ 87 Appendix F: Fanta Interview Guide ...................................................................................... 90 Appendix G: Top Ten PDF Document Downloads.............................................................. 91 Appendix H: USAID Pathway from Research to Field Implementation and Use ............. 93 Appendix I: FANTA Funding Data......................................................................................... 94 Appendix J: FANTA Project TAG Meetings: 1998−Present ............................................... 97 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project v FIGURES Figure 1.: FANTA Results Framework and Performance Indicators........................................ 9 Figure I-1: Total Funding Obligations ....................................................................................... 94 Figure I-2: GH−Non-GH Funding................................................................................................ 94 Figure I-3: GH/Non-GH Funding................................................................................................. 95 Figure I-4: GH Funds by Strategic Objective ............................................................................ 95 Figure I-5: Support to Title II and HIV Programming................................................................ 96 Figure I-6: Non-GH Funds by Source ........................................................................................ 96 TABLES Table 1. Number of People Interviewed for FANTA Evaluation by Organization.................. 12 Table 2. Number of Promising Ppractices and Acceptable Standards Disseminated ................................................................................................................ 29 Table 3. Areas of FANTA’s Contribution along Pathway from Research to Field Implementation and Use, as of June 2007 ................................................................. 33 vi Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project EXECUTIVE SUMMARY The purpose (Strategic Objective) of the U.S. Agency for International Development’s (USAID) ten-year, $45 million Food and Nutrition Technical Assistance (FANTA) Project is improved food and nutrition policy, strategy, and program development. USAID’s Bureau for Global Health (GH)/Office of Health, Infectious Diseases and Nutrition (HIDN) manages the FANTA Project and the Academy for Educational Development (AED) implements it through a cooperative agreement that covers the period September 1998 – September 2008. The program has received $38.2 million in USAID funding to date. Technical support from FANTA has been provided throughout the developing world, long-term in eleven countries and short-term in seven countries. The FANTA Project has been a major source of technical support to USAID/W (Washington), most notably in working with the Bureau for Democracy, Conflict and Humanitarian Assistance (DCHA) on the Title II food assistance program of the Office of Food for Peace (FFP) and on emergency nutrition programs of the Office of Foreign Disaster Assistance (OFDA), as well as supporting GH/HIDN programs and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) programs of the GH/Office of HIV/AIDS (OHA) and the Africa (AFR) Bureau. The FANTA Project provides technical support to private voluntary organizations (PVO) that implement Title II programs, known as Cooperating Sponsors (CS), and to other PVOs, host governments, and stakeholders. In summary, the expected results of the FANTA project’s technical support are as follows: Intermediate Result IR1 – improved nutrition and food security program development, analysis, monitoring, and evaluation; Intermediate Result IR2 – improved integrated nutrition and food security strategies and policies; and Intermediate Result IR3 – adoption of promising practices and acceptable standards for nutrition and food security policy and programs. An external evaluation of the FANTA cooperative agreement was conducted in May–June, 2007 to assess and make recommendations concerning: A. Progress to date in achieving FANTA’s three Intermediate Results (IR) for nutrition and food security. B. Appropriateness and effectiveness of FANTA’s approaches or strategies, and activities in achieving its Strategic Objective (SO), including program operations/management, resource utilization, staffing, communications, and collaborative relations. If needed, changes in FANTA program priority areas that can be implemented within the remaining project period. C. FANTA’s roles and contributions toward the overall objective of the USAID Nutrition Results Package and in improving USAID and its partners’ food security and nutrition programs, particularly progress in assessment, monitoring and evaluation. D. Future needs for a project like FANTA, considering the overall success of FANTA in achieving its Strategic Objective through its current approaches and strategies, and its emerging, future needs relevant to the current policy and programming environments, namely the recent USG (United States Government) Foreign Assistance Reform. SUMMARY FINDINGS ON FANTA’S OVERALL ACHIEVEMENT The evaluation team concludes that FANTA has achieved its SO of “improved food and nutrition policy, strategy, and program development,” and has contributed greatly to the objective of USAID’s Nutrition Results Package: “Increased use of nutrition interventions to promote health and survival among women and children.” Numerous examples in the evaluation findings detailed in this report substantiate this conclusion. FANTA has provided a unique mechanism for very effective cross-bureau support to USAID, leading to greater attention to nutrition and food Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 1 security issues in a number of programs, including Title II food aid, HIV/AIDS care and support, Child Survival and Health Grants (CSHGP), and emergencies. The FANTA Project has influenced strategies and policies for these programs in a very positive and far reaching way. FANTA has made major operations research contributions to the evidence base on promising practices that are effective for monitoring and evaluation of food security, providing nutritional care and support for HIV/AIDS, and doing community-based therapeutic care (CTC) to manage severe acute malnutrition. This research has progressed far along the pathway to field implementation and use on a very large scale. The extraordinary synergies created across bureaus and FANTA’s high productivity and responsiveness to urgent needs would not exist without the initiative, exemplary vision, outreach, and excellent management by GH/HIDN. Continuity of purpose and staff has been key to the success of the project. There is as much need or more today for a project like FANTA as there was in 1998. A summary of the additional needs or gaps through the end of the FANTA Project, and the key findings are presented for each of the intermediate results and for program management. Support to Improve Nutrition and Food Security Program Development, Analysis, Monitoring, and Evaluation by USAID and Cooperating Sponsors (Intermediate Result IR1). Additional needs or gaps to address before FANTA ends, if time and funds permit, or as a top priority during the first year of a new nutrition and food security global project: • Proactively work with the network organization of PVOs that implement child survival and health grants known as CORE, or the Child Survival Collaboration and Resources Group, to further address Title II PVO nutrition issues in CORE Nutrition working group activities. • Document lessons learned in real Title II program phase outs to prepare more guidance on effective graduation and exit strategies for sustainability of food security and nutrition programs, especially in Honduras and Nicaragua where FANTA is working. Assess the needs of CSs with phase out programs and whether they are using and finding useful the two technical publications on this topic by FANTA. • Assist FFP and CSs to define and test trigger indicators derived from real programs to determine the threshold at which Title II programs need to shift along the development￾relief continuum, or require additional resources in response to shocks, per the new FFP strategy, including how to measure these. Coordinate this work with FFP’s Famine Early Warning System Network (FEWS NET) program. • Write a history of the process of improving the food security and nutrition focus of Title II programs and key reforms since 1995, with IMPACT (FANTA predecessor project) and FANTA technical assistance, especially by FANTA Project Director. Document this success story to contribute to FFP’s institutional memory. Summary of Key Findings: • FANTA has provided extremely effective and responsive technical support to improve Title II programming, contributing significantly to better design, monitoring, and evaluation, primarily by direct assistance to USAID DCHA/FFP and priority country activities. Cooperating Sponsors have benefited from FANTA’s technical assistance, collaboration, and tools, especially for monitoring and evaluation. However, such support has declined over the life of the project. • FANTA has offered critical and ranging support to improve nutrition programming in the CSHGP, including active participation in CORE working groups, collaboration with and 2 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project ongoing support to PVOs, and sharing updates and technical expertise in food security and nutrition. Support to Improve Integrated Nutrition and Food Security Strategies and Policies of USAID, Host Governments and Cooperating Sponsors (Intermediate Result IR2) Summary of Key Findings: • FANTA has had a major impact on establishing improved nutrition and food security strategies and policies, with the most significant examples being its work in shaping the FFP Strategic Plan, drafting and launching national guidelines for nutritional care and support for HIV/AIDS in Africa, and achieving UN (United Nations) endorsement of the use of CTC for the management of severe acute malnutrition. • Leadership on women’s nutrition and on improved agriculture, food consumption and nutrition linkages have received less of FANTA’s attention than originally proposed, compared to other project areas, and deserve greater priority in the future. The work FANTA has done on anemia in women, however, has been useful and merits additional advocacy for gaining commitment to action by stakeholders. Promotion of Promising Practices and Acceptable Standards for Nutrition and Food Security Policy and Programs to USAID, Cooperating Sponsors, and other Key Stakeholders, and their Adoption (Intermediate Result IR3). Additional needs or gaps to address before FANTA ends, if time and funds permit, or as a top priority during the first year of a new nutrition and food security global project: • Develop several teaching or training modules on basic applications of “Layers” that could be broadly disseminated without customized technical assistance. • Present lessons learned and major products (manuals/guides, etc.) on promising practices and acceptable standards in form of final training workshop(s)/conference(s) for CSs, PVOs, and other stakeholders. Maximize dissemination opportunities. • Once clinical trials are completed of food supplementation for HIV/AIDS patients on antiretroviral therapy, present all of FANTA’s work on guidelines, training and counseling materials, and food supplementation to appropriate cooperating agencies (CA) of GH/OHA, and to the State Department’s Office of the Global AIDS Coordinator, either in a conference organized by FANTA or taking advantage of events by others. The goal is to mainstream this work and get other CAs to adopt and expand it. • Because the GH/Office of Population and Reproductive Health (GH/PRH) has the USAID mandate for working on adolescent reproductive health, in order to gain additional support for anemia prevention and control for adolescent girls, if it proves effective, FANTA should present its work on the Girl Guides Project jointly to GH/PRH and GH/HIDN and to the A2Z Micronutrient and Child Blindness Project (A2Z). Summary of Key Findings: • A unique feature of FANTA that everyone we interviewed said should be preserved in future efforts are the bridges it has built among GH, FFP and its Cooperating Sponsors, Missions, regional institutions, host country governments, implementing agencies, and the academic community. Quoting from interviews: “FANTA added value—from academic rigor to grassroots field methods, and from realism and simplicity to academic protocols—on every transaction between academia and the field, in both directions.” “Having a team or project available to step back from the day-to-day operations in these Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 3 highly charged areas—HIV, emergency response, Title II programs—and reflect on whether these things really work and how we know it is beneficial to us all.” • FANTA has designed more effective and efficient measures at all stages of Title II monitoring and evaluation. These are greatly appreciated and widely used. They include new and improved indicators, performance monitoring systems, impact survey design, data collection, and analysis. • FANTA’s ability to assess the need for technical materials and to fill these gaps rapidly and solidly has been one of the most appreciated aspects of the program. • Through FANTA, USAID has been a global leader in effectiveness research on new approaches for nutrition and food security policy and programs. FANTA’s most significant contributions are demonstrating that CTC works extremely well for managing severe acute malnutrition, and that a preventive approach to child malnutrition is more cost-effective than a recuperative one. Through ongoing trials FANTA is also defining appropriate nutritional care and support for HIV/AIDS. Program Management Additional needs or gaps through end of FANTA: • FANTA Director, Deputy Director, and other senior staff responsibilities leading up to and through close out should be re-assessed, sooner rather than later, to allow time for full documentation of the project’s work and a smooth close out. Summary of Key Findings: • The FANTA Project has been well managed by AED and USAID. FANTA staff and consultants are leaders in the food security and nutrition fields and are noted for their responsiveness and collaboration. FANTA has adjusted its staffing and use of consultants to meet the demand; further adjustments may be required to complete ongoing activities and proceed smoothly through project close out. FUTURE NEEDS The evaluation team was asked to give advice on the need for a future project after FANTA ends. A new nutrition and food security global project is definitely needed to continue to provide multi￾sectoral, state-of-the-art technical assistance to USAID-assisted programs. This is the broad consensus of the evaluation team, staff of Title II CSs and other PVOs, USAID/W (GH/HIDN, GH/OHA, DCHA/FFP, DCHA/OFDA, AFR), and USAID Missions where FANTA is currently providing technical support. The main, but not exclusive, focus should be on continuing technical support to improve programming, strategies, and policies for optimizing Title II resources to reduce food insecurity and malnutrition in the 18 FFP priority countries. The large Title II program needs this support and offers the greatest potential for significant positive impact on nutrition. Assistance to Title II should be provided equally to USAID and to CSs that implement the program, and to both headquarters level and the 18 priority countries. Opportunities for integrating or improving nutrition interventions in additional USAID programs, e.g., continued assistance to the CSHGP and to advance nutritional care and support for HIV/AIDS in PEPFAR programs, should be actively pursued, while assuring adequate support to the Title II program. Global leadership is a critical component of a new project. This means that applied research to evaluate effectiveness and cost of nutrition and food security tools, approaches and interventions, and activities to promote their use must continue. 4 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project It is urgent in Title II programs that the new nutrition and food security global project be in place by September 30, 2008, when FANTA ends. All of the current FANTA clients are counting on this seamless, continuing support. They have major new tasks coming up in that timeframe, that are critical to implementing FFP’s 2006-2010 strategy and new MYAPs, which will be seriously impaired if no assistance is available. Technical Content of a New Project The current program description and types of technical support FANTA provided are appropriate and should be carried forward; however, certain areas need more attention than received under FANTA, and there are some new needs to address as follows: • Capacity building for CSs, especially in monitoring and evaluation • Effective graduation and exit strategies for Title II programs • Effective interventions for nutrition and HIV/AIDS • Maternal and child malnutrition prevention and behavior change interventions • Performance quality improvement for nutrition interventions • Agriculture and livelihood security to increase food consumption/access • Development relief Title II program design • Emergency and crisis food aid programming What to do differently in a new project: • Create a central technical assistance fund to engage with and assist Title II CSs, and encourage more FFP priority countries to improve Title II programs. • Establish regional field offices with local advisors. RECOMMENDATIONS FANTA Should: 1. Increase FANTA’s outreach to, support of, and collaboration with Title II Cooperating Sponsors. 2. Adapt to simplify a collection of key FANTA “how to” documents for more basic field application, with highest priority given to creating Title II Technical Reference Materials for Cooperating Sponsors. 3. Address additional needs or gaps through the end of FANTA as identified in this evaluation, as feasible within time and funding remaining. 4. To assure public access to essential technical references produced for USAID, leave in place the means to maintain the FANTA Web site after the project ends. USAID Should: 1. Continue USAID technical support to improve food security and nutrition programming in Title II, CSHGP, PEPFAR, and other programs, and assure that a new nutrition and food security project is in place when FANTA ends. Include dedicated central funds for Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 5 more technical assistance to for Title II CSs and country programs than has been possible relying only on Mission field support. 2. Give high priority to seeking and securing additional resources to advance the strategic vision of FFP for implementation of its 2006–2010 strategic plan by supporting the applied research and other important tasks proposed by FANTA, both in the time remaining in the FANTA agreement and in a future similar project. 3. Contact USAID Mission Directors in 18 priority FFP countries to urge Mission financial support for FANTA and a future central project for critical food security and nutrition technical assistance to improve effectiveness of Title II programs. 4. Assure that a future project for technical support to improve food security and nutrition strategies and policies works more closely with host country governments to achieve sustainability, especially in an era of phase out of many Title II programs. 5. Use the excellent food access/consumption and nutritional status indicators, proven useful and feasible to collect by FANTA, as outcome indicators of Title II and other nutrition programs in the operational planning or F process. 6. Facilitate a major final year push by FANTA to share its nutritional care and support for HIV/AIDS guidelines, training and counseling materials, and food supplementation trial findings with other GH and AFR CAs to mainstream in their HIV/AIDS activities. . USAID should ensure that this important work continues in a new nutrition and food security global project. 7. Work with FANTA to prioritize addressing the additional needs or gaps identified in this evaluation before the project ends, including adapting and simplifying “how to” materials. Include, as priority tasks for the first year of a new nutrition and food security global project, any of these needs or gaps that cannot be addressed now. 6 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project I. INTRODUCTION A. BACKGROUND AND EVOLUTION OF THE FANTA PROJECT AND ITS OPERATING ENVIRONMENT In 1998, the Bureau for Global Health (GH) of USAID authorized its ten-year program framework, the Nutrition Results Package. It was amended in 2004 to extend through 2013 (Appendix D.1). The objective is “increased use of nutrition interventions to promote health and survival among women and children.” Under this authorization, on September 28, 1998, USAID competitively awarded a $29,996,977, five-year, Cooperative agreement for the Food and Nutrition Technical Assistance (FANTA) project to the Academy for Educational Development (AED). Cornell University and Tufts University were partners for FANTA under sub-agreements with AED. Food Aid Management (FAM), a consortium of private voluntary organizations (PVO) that implement Title II programs (referred to as Cooperating Sponsors (CS)) joined the FANTA partnership through a Memorandum of Understanding with AED. USAID conducted an external assessment of the FANTA Project in 2002 (2). Based on satisfactory performance and continued importance to achieving USAID’s nutrition results, GH extended the FANTA Cooperative agreement through September 30, 2008, and increased the Total Estimated Amount by $15 million to a new total of $44,996,977.1 As demands for FANTA’s support have grown and additional needs have been identified, the following partners have joined the team under sub-agreements with AED: International Food Policy Research Institute (IFPRI), Freedom from Hunger, Helen Keller International, Kenya Medical Research Institute (KEMRI), NicaSalud, Regional Centre for Quality of Health Care, Uganda (RCQHC), Technical Assistance to NGOs International (TANGO), Valid International, and the World Health Organization (WHO). The purpose (Strategic Objective or SO) of the FANTA Project is “improved food and nutrition policy, strategy, and program development”. See Figure 1 (page 9) for the Results Framework, which includes three Intermediate Results (IRs) to be achieved through FANTA’s technical support to USAID, Cooperating Sponsors, host governments, and other Stakeholders. In summary, these expected results are: IR1—improved nutrition and food security program development, analysis, monitoring, and evaluation; IR2—improved integrated nutrition and food security strategies and policies; and IR3—promotion and adoption of promising practices and acceptable standards for nutrition and food security policy and programs. The project provides technical leadership in nutrition and food security policy and programming with a focus on improving food consumption and nutrition outcomes. According to the FANTA Project’s Web site (www.fantaproject.org), “the project helps to integrate nutrition into the strategic planning process; provides analyses for food security and nutrition policy development; and shares information and knowledge with partners. Technical assistance is provided to USAID Missions, host governments, PVOs, and non￾governmental organizations (NGOs) to improve program design, monitoring and evaluation.” One of the main roles of the FANTA Project when it started was to provide technical support to USAID’s P.L. 480 Title II food assistance programs to enhance their impact on food security and nutrition. This continues to be an important part of the project’s work, but FANTA’s scope has expanded to respond to new opportunities and increasing demand for its support to meet food and nutrition challenges over its more than eight years of operation. In USAID/Washington, FANTA provides technical support primarily to the Bureau for Global Health (GH)/Office of Health, Infectious Diseases and Nutrition (HIDN), GH/Office of HIV/ AIDS (OHA), the Bureau for Democracy, Conflict and Humanitarian Assistance (DCHA)/Office of Food for Peace (FFP), and DCHA/Office of Foreign Disaster Assistance (OFDA). FANTA works to support USAID programs in a number of focus countries and regions including: the East Africa 1 Modification #15 with effective date of July 8, 2003. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 7 Region, Ethiopia, Kenya, Madagascar, Rwanda, Zambia, Malawi, Mozambique, Namibia, India, Guatemala, Haiti, Honduras, and Nicaragua. Other countries have received assistance from the project for smaller scale, discrete activities, including: Bangladesh, Indonesia, Benin, Uganda, and Bolivia. The GH/HIDN office in USAID/Washington manages FANTA. Operating Environment: One of the challenges that led GH/HIDN to design the FANTA Project was the ongoing need to promote more widespread integration of effective interventions to reduce malnutrition and improve food security into related USAID programs. There was clear evidence that mild and moderate malnutrition was an underlying cause of most child deaths and that, if infant and child mortality reduction goals were to be achieved, nutrition interventions had to accompany other USAID child survival and health and food aid programs. Food insecurity is a daunting problem. According to the United Nations Food and Agriculture Organization (FAO) an estimated 850 million people in the world are currently undernourished (Appendix D.3). The greatest U.S. government resource for addressing food insecurity and malnutrition is food aid, and the U.S. is the largest provider of food aid in the world (Appendix D.3). Thus, GH/HIDN recognized that the greatest target of opportunity for improving nutrition and food security in USAID programs was to provide technical support to improve the outcomes and impact of the Title II food aid program, which accounts for the largest share of U.S. food aid. The USAID Office of Food for Peace (FFP) DCHA Bureau and USAID Missions administer the Title II program in partnership with Cooperating Sponsors in developing countries around the world. In FY 2006, 23 Cooperating Sponsors in 55 countries implemented the Title II program, benefiting 48 million people with approximately $1.8 billion worth (or 2.3 million metric tons) of commodities (4). The first GH/HIDN project designed to provide food and nutrition technical support to the Title II program was the IMPACT Project, the smaller predecessor to the FANTA Project implemented by the International Science and Technology Institute from 1993-98, with a focus on monitoring and evaluation. To respond to growing demand and need, GH/HIDN launched FANTA in 1998 to expand the technical support bridge that had earlier been built by IMPACT to maximize synergy, technical exchange, and collaboration between the GH/HIDN health, population, and nutrition (HPN) program and the DCHA/FFP Title II food aid program. The U.S. 1990 Farm Bill and the USAID 1995 policy on “Food Aid and Food Security,” greatly stimulated the use of the FANTA bridge between GH and DCHA/FFP and the uptake of this exemplary and uncommon offer of technical support to the Title II program. The 1990 Farm Bill made major changes in the (public law) PL 480 food assistance program by designating “enhancing food security in the developing world” as the overriding objective. In response, USAID’s 1995 policy called for major changes in the Title II program to comply with the law and enhance its food security impact (5). Re-designing programs and making major changes take time. Thus, there has been great receptivity to technical assistance from FANTA to help accelerate this process. Food security remains the cornerstone of the new FFP Strategic Plan for 2006-2010, which focuses Title II resources on reducing risk and vulnerability to achieve the Strategic Objective of “Food insecurity in vulnerable populations reduced”(5). See the Expanded Conceptual Framework for Understanding Food Insecurity, which FANTA helped FFP develop for its current strategy in Appendix A. Reducing food insecurity is now the goal, rather than increasing food security. “The strategy targets communities and households that are already food insecure or in imminent risk of becoming food insecure” (5). Title II resources for development-oriented, Multi-year Assistance Programs (MYAPs) are now focused on the most food-insecure countries. Eighteen countries, deemed most vulnerable by objective criteria, are now the FFP priority countries, and Title II non￾emergency programs are being phased out between FY 2006–2009 in 14 countries deemed less vulnerable.2 2 The 18 priority FFP countries are Afghanistan, Bangladesh, Burkina Faso, Burundi, Chad, Democratic Republic of Congo, Ethiopia, Guatemala, Haiti, Liberia, Madagascar, Malawi, Mauritania, Mozambique, Niger, Sierra Leone, Uganda, and Zambia. 8 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Figure 1. FANTA Results Framework and Performance Indicators Strategic Objective Improved food and nutrition policy, strategy, and program development Impact Indicator 1 Enhanced nutritional impact of FANTA-assisted nutrition and food security-related programs as demonstrated by decreased prevalence in stunting in the target populations in priority countries over the life of activities Monitoring Indicator 1 Percentage of programs in the priority countries reporting improvements in nutritional status among direct beneficiaries in a given year INTERMEDIATE RESULT ONE USAID’s and CS’s nutrition and food security-related program development, analysis, monitoring and evaluation improved INTERMEDIATE RESULT TWO USAID, host country governments & CSs establish improved, integrated nutrition and food security-related strategies and policies INTERMEDIATE RESULT THREE Promising practices and acceptable standards in nutrition and food security-related policy and programming adopted by USAID, CSs, and other key stakeholders Monitoring Indicator 1.1 Percentage of CS food aid proposals assessed to satisfy agency review criteria in problem assessment, performance indicators, intervention design, and monitoring & evaluation plan Monitoring Indicator 1.2 Percentage of development food aid CS programs able to meet USAID’s reporting requirements including annual submissions, baselines and evaluations Monitoring Indicator 1.3 Percentage of FFP/ER programs reporting positive change or maintenance of nutritional status Monitoring Indicator 1.4 Percentage of CSs able to meet FFP/ER reporting requirements Monitoring Indicator 2.1 Percentage of recommendations adopted by priority country CS programs Monitoring Indicator 2.2 Percentage of recommendations adopted by priority country USAID missions Monitoring Indicator 2.3 Number of recommended policies or strategies adopted by priority country host governments. Monitoring Indicator 3.1 Percentage of funding from other than G/PHN Monitoring Indicator 3.2 Number of promising practices and acceptable standards identified, produced, and disseminated by FANTA Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 9 The Inspector General’s findings in audits in two country programs have spurred demand for FANTA’s assistance to improve monitoring and evaluation of Title II programs. Furthermore, the U.S. Government Accountability Office’s (GAO) 2007 study done on the efficiency and effectiveness of U.S. food aid programs makes specific recommendations for enhancing the reliability and use of needs assessments and for improving monitoring to ensure proper management and implementation. Assessment, monitoring, and evaluation are areas in which FANTA has developed tools and has offered its expertise (3). The GAO study was done to inform Congress in its deliberations on reauthorizing the food aid provisions of the Farm Bill in 2007. Past changes in the Farm Bill have had a major impact on Title II, such as the food security focus introduced in 1990. How food aid fares in the 2007 Farm Bill could well affect FFP’s agenda for FANTA’s technical support to the Title II program through the end of the agreement in September 2008. The second half of the FANTA agreement coincided with the launching of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, which significantly increased resources available to USAID and other U.S. government agencies for prevention, care and treatment of HIV/AIDS in 15 focus countries. Nutritional care and support for People Living with HIV/AIDS (PLWHA) were not initially a major focus of PEPFAR, nor were they well understood. FANTA was proactive in pioneering guidelines in this field and in designing food security and food aid strategies to mitigate the impact of HIV/AIDS for use in Title II programs. Demand for FANTA’s technical support to HIV/AIDS programs has grown greatly in the second half of the project, in a way never anticipated in the original design. Similarly, with the increased frequency and severity of natural and manmade disasters and chronic emergencies, bringing with them nutritional emergencies, the need for an effective way to treat severe acute malnutrition (SAM: very low weight for height or severe wasting)3 at home and at the community level has grown. In response to the needs of OFDA and others, FANTA facilitated and provided technical oversight in the development of guidelines for community-based therapeutic care (CTC) to manage SAM. FANTA also developed and validated Lot Quality Assurance Sampling (LQAS) methods for assessment of the prevalence of acute malnutrition in emergency settings. Another example of FANTA’s technical assistance to improve food security and nutrition outcomes in other USAID programs is its continuing role, from FY 2001 to date, in working with the GH/HIDN Child Survival and Health Grants Program (CSHGP) to improve implementation of PVO recipients programs with a nutrition focus. In FY 2007, under the leadership of the U.S. Department of State, Office of the Director of U.S. Foreign Assistance and the USAID Administrator (F), a new foreign assistance framework was adopted to guide all USAID and other U.S government agencies’ foreign assistance programs. Use of the framework was put into effect with standardized operational planning and budgeting procedures, which quantified common output indicators to be achieved with planned budget inputs by program areas, elements, and sub-elements under each of the five overarching objectives of the framework. This is known in short as the F Process and is mentioned as part of the evolution of FANTA’s operating environment because FANTA’s work is broad and contributes to three of the five objectives of the Foreign Assistance Framework. FANTA contributes to the “Investing in People” objective and, under that objective, to the Health Program Area elements of: 1) HIV/AIDS and 2) Maternal and Child Health. FANTA also contributes to the Social Services and Protection for Especially Vulnerable Populations Program Area elements of: 1) Policies, Regulations and Systems and 2) Social Assistance. Under the “Economic Growth” objective, FANTA assists the Agriculture Program Area elements of: 1) Agricultural Sector Productivity and 2) Program Support. FANTA also contributes to the “Humanitarian Assistance” objective and, under that objective, to the Protection, Assistance, and Solutions Program Area elements of: 1) Assistance and 3 Severe acute malnutrition or SAM is weight for height <-3 Z scores or <70% of the reference median and/or bipedal edema. 10 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Recovery, and 2) Program Support, and to the Disaster Readiness Program Area elements of: 1) Capacity Building, Preparedness, and Planning and 2) Program Support. B. EVALUATION SCOPE OF WORK USAID’s GH/HIDN requested the GH Tech Project to conduct an external evaluation of the FANTA cooperative agreement in May–June 2007. Appendix B contains the scope of work for the evaluation. The objectives of the evaluation were to assess and make recommendations concerning the following aspects: 1. Progress made to date in achieving FANTA’s three Intermediate Results (IR) for nutrition and food security, per Figure 1, namely IR1 – improved programs; IR2 –improved strategies and policies; and IR3 – promotion and adoption of promising practices and acceptable standards 2. Appropriateness and effectiveness of FANTA’s approaches, strategies, and activities in achieving its Strategic Objective, including program operations, management, resource utilization, staffing, communications, and collaborative relations. If needed, changes in FANTA program priority areas that can be implemented within the remaining project period. 3. FANTA Project roles and contributions toward the overall objective of USAID’s Nutrition Results Package and improving the food security and nutrition programs of USAID and its partners, particularly progress in assessment, monitoring, and evaluation areas. 4. Future needs for a project like FANTA, considering the overall success of FANTA in achieving its Strategic Objective through its current approaches, strategies, and emerging and future needs relevant to the current policy and programming environments, namely the recent USG Foreign Assistance Reform. The report is organized into four sections: 1) Introduction with background and evolution of the FANTA Project and its operating environment; 2) Findings of the Evaluation, organized according to FANTA’s Results Framework (Figure 1) at the SO level and for each of the three IRs, additional needs or gaps for the remaining project period; and findings and additional needs concerning program management; 3) Future Needs after FANTA ends; and 4) Recommendations. C. METHODOLOGY The three-person FANTA Evaluation team participated in a facilitator-led, Team Planning Meeting (TPM) on May 15–16, 2007, in Washington, D.C. The USAID Cognizant Technical Officer (CTO) for the FANTA Project joined this TPM to brief the team on the FANTA Project and USAID’s working relationship with the project. The FANTA Project staff briefed the team at a presentation that a number of USAID/W staff also attended. The team reviewed FANTA publications, documents (Appendix C), and other references (Appendix D), which provided important information for the evaluation and tangible evidence of the quantity and quality of FANTA’s products. A key reference used extensively in the evaluation was the very well-organized and thorough “FANTA 2007 Assessment Reference Materials,” including CD-ROMs that FANTA prepared for the team, covering its staff, finances, performance reporting, briefs on promising practices, publication list, and products (6). The evaluation team interviewed key USAID, Washington program managers, and senior staff, in person and via telephone interviews, and conducted telephone interviews with USAID Mission staff, key sub-agreement partners, PVO representatives, and staff of the United Nations (UN) and other organizations collaborating with FANTA. One evaluation team member had prior firsthand experience of requesting and receiving FANTA technical assistance while working in two USAID Missions managing Title II and nutrition programs. FANTA staff informed the evaluation through Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 11 Table 1. Number of People Interviewed for FANTA Evaluation by Organization USAID/W CDC and Others Child Survival and Health Grants FANTA Project and AED GH Bureau 9 Reproductive Health 1 CORE 1 Project Staff 10 DCHA Bureau 6 Refugee Health 1 CSTS 2 Other Staff 1 Africa Bureau 3 Gates * Foundation 1 USAID Missions International Organizations Title II PVOs and Others FANTA’s Partners/ Collaborators East Africa 1 UNICEF*** 1 CRS 1 IFPRI 1 Ethiopia 1 WHO 1 World Vision 1 TANGO 1 Guatemala 2 FAO 1 FH 1 Tufts U. 2 Haiti 2 UNDP** 1 Save the Children 2 U. Washington, St. Louis 1 India 1 ADRA 1 Valid 1 Kenya 1 OICI 1 KEMRI 1 Madagascar 1 Concern 1 numerous meetings and interviews. See Appendix E for names of persons interviewed by organization. The evaluation team developed questions for general guidance in conducting interviews (Appendix F). The interviews were open-ended and usually lasted approximately one hour. Two or three team members conducted most of the in-person interviews, while one or two team members conducted most telephone interviews. A total of 52 key informant interviews were conducted. Additionally, 11 individual interviews were conducted with FANTA and AED staff (Table 1). * Formerly with AED, ** Formerly with CARE USA, *** Formerly with FANTA. See Acronyms list at the beginning of the report. 12 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project II. FINDINGS OF THE EVALUATION The findings of the evaluation are presented according to the FANTA Results Framework (Figure 1), starting at the highest level (SO) and proceeding, in turn, to each of the three intermediate results (IR), and finally to program management. There is considerable overlap among the IRs, and many activities contribute to more than one. In the interest of brevity, the findings for these types of activities will be discussed in the IR section to which they contribute the most in the view of the evaluation team, and their contribution cross-referenced briefly in other sections. The quantitative indicators for measuring FANTA’s annual performance shown in Figure 1 are, for the most part, no longer used. Wherever data are still reported for these indicators, they will be included in this evaluation report. Since the 2002 FANTA Assessment, USAID and FANTA management agreed to drop the IR1 and IR2 indicators for annual performance reporting. As the range of project activities steadily expanded, the need for qualitative, results reporting became a greater priority. Furthermore, USAID required information from FANTA on indicators not included in the Results Framework, and the data source for some of the original indicators was no longer available. Moreover, with the new F process, standard indicators are being centrally defined for measuring outputs of USAID-assisted programs in relation to the dollars received. This process is still experimental and in flux, making it hard to use any indicators now that will not be subject to change in the near future. A. OVERALL ACHIEVEMENT OF STRATEGIC OBJECTIVE: “IMPROVED FOOD AND NUTRITION POLICY, STRATEGY, AND PROGRAM DEVELOPMENT” At the SO level, the U.S. Fiscal Year (FY) 2006 results for the two indicators FANTA reports on are as follows: 1) Enhanced nutritional impact of FANTA-assisted nutrition and food security related programs as demonstrated by decreased prevalence in stunting in the target populations in priority countries over the life of activities. Result: In 5 countries (Ethiopia, Madagascar, Guatemala, Honduras, and Nicaragua) stunting was reduced in 85% of CS’ programs (11/13 programs). 2) Percentage of programs in the priority countries reporting improvements to nutritional status among direct beneficiaries in a given year. Result: 100% of 14 CS’ programs in five countries (Haiti, Guatemala, Honduras, Nicaragua, and Madagascar) reported improvements. FANTA’s reported results (6) cannot be attributed directly to FANTA’s technical assistance, because FANTA does not implement Title II programs. FANTA recognizes this, but tracks this information in its focus countries because improving the nutritional status of target populations is the ultimate goal of FANTA. Summary Findings on FANTA’s Overall Achievement The evaluation team concludes that FANTA has achieved its SO of “improved food and nutrition policy, strategy, and program development” and contributed greatly to the objective of USAID’s Nutrition Results Package: “increased use of nutrition interventions to promote health and survival among women and children.” Numerous examples in the evaluation findings detailed in this report substantiate this conclusion. FANTA has provided a unique mechanism for very effective cross￾bureau support to USAID, leading to greater attention to nutrition and food security issues in a number of programs, including Title II food aid, HIV/AIDS care and support, Child Survival and Health Grants, and emergencies. The FANTA Project has influenced strategies and policies for these programs in a very positive and far reaching way. Through FANTA, there have been major operations research contributions to the evidence base on promising practices that are effective for Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 13 monitoring and evaluation of food security, providing nutritional care and support for HIV/AIDS, and doing community-based therapeutic care for severe acute malnutrition. This research has progressed far along the pathway to field implementation and use on a very large scale. The extraordinary synergies created across bureaus, and the high productivity and responsiveness of FANTA to urgent needs would not have happened without the initiative, exemplary vision, outreach, and excellent management of FANTA by GH/HIDN. Continuity of purpose and staff for more than a decade has been key to the success of the project. There is as much need or more today for a project like FANTA as there was when it started in 1998. B. SUPPORT TO IMPROVE NUTRITION AND FOOD SECURITY PROGRAM DEVELOPMENT, ANALYSIS, MONITORING, AND EVALUATION BY USAID AND COOPERATING SPONSORS (INTERMEDIATE RESULT IR1) The primary purpose of IR1 is to improve food security and nutrition programming in USAID’s Title II programs and, from 2001 onwards, in USAID’s Child Survival and Health Grants with a nutrition focus. Specifically, FANTA aims to improve these programs by providing technical support to USAID, its Cooperating Sponsors, and PVO grantees to strengthen nutrition and food security-related program development, analysis, monitoring, and evaluation. According to the FANTA cooperative agreement, the plan was to concentrate efforts and activities on improving the three phases of program development: problem analysis and needs assessment, intervention design, and monitoring and evaluation (7). FANTA would help USAID and its partners strengthen their capacity to analyze problems by providing feedback to improve Title II program proposals and, (more recently) Development Implementation Plans (DIP) for the CSHGP grants, by developing and disseminating practical tools for problem analysis and monitoring and evaluation, and by capacity building with USAID, CSs, and PVOs. 1. Support to improve Title II food aid programming A cornerstone of FANTA’s work since its inception has been its assistance to improve nutrition and food security problem analysis, program design, and performance reporting in the large Title II program. The focus has been on non-emergency, Multi-year Assistance Programs (MYAPs). Over the eight full years that FANTA has been working, approximately one third of all its resources and activities have been in support of the Title II program, and demand/funds received for assistance to Title II have continued steadily from year to year, with only a slight decline of 14% in the second half of the project. Food for Peace officials interviewed were emphatic in stressing that the $1.2 billion average annual Title II program needs specialized technical assistance on food security and nutrition of the type that FANTA has consistently provided. “They have a special skill set that is hard to find, and essential to USAID and CSs.” Interviewees used superlatives to describe the caliber of the technical assistance received from FANTA, which is a collaborative cross-bureau project that breaks down barriers, and increases understanding and collaboration between Food for Peace and other related USAID programs. Food for Peace staff believe that FANTA’s high quality, demand￾driven, needs-based, technical assistance has contributed significantly to increasing the food security and nutritional impact of the Title II program. “They have transformed Title II program effectiveness by putting the program on a solid technical basis.” Food for Peace likes the fact that FANTA is not pushing its own agenda or trying to sell something, yet is proactive in bringing state-of-the-art advances in food security and nutrition to FFP’s attention to keep USAID’s Title II program at the cutting edge. An example is FANTA’s excellent work shaping the new FFP strategy (5). Food for Peace would like to ask FANTA for even more assistance, but they are constrained by their lack of sufficient Development Assistance (DA) funds for this, and perceive that FANTA lacks the staff and time to do more for FFP, given many demands for their services from other parts of USAID. The evaluation team is concerned that FFP may be overly dependent on the FANTA 14 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Project, particularly the support and institutional memory provided by the FANTA Director, who has been an outstanding technical resource for FFP for more than a decade. In reviewing FANTA’s work with Title II programs, the evaluation team noted that they have not provided as much technical support to build the evidence base on what works for emergency food aid programs and have focused more on non-emergency programs. Yet, emergency programs currently receive 75% of all Title II resources. According to FFP, FANTA does not appear to have as strong a technical capacity in emergency food aid programming now as it did earlier in the project. The new Food for Peace strategy stresses programs designed to respond across the development-relief continuum and eliminates the rigid categorization of programs as emergency or non-emergency. Nevertheless, many needs remain for answering technical questions and developing tools to advance the state-of-the-art for emergency food aid programming. The time required to meet these needs exceeds that remaining in the current FANTA agreement. Improving emergency food aid programming to reduce food insecurity and malnutrition should be a priority focus of any future, similar project. We will elaborate on this in the report section on Future Needs. Food for Peace acknowledges that FANTA was instrumental in assisting USAID to define its earlier strategic objective on Title II emergency programs, including measurable and useful performance indicators. Thanks to this support, FFP could report tangible results. FANTA designed the questionnaire, analyzed the data, and helped prepare the annual report. FANTA’s work with OFDA on testing and providing guidelines and training on management of severely acutely malnourished children in CTC programs was also acknowledged as very valuable, but this was done on a small-scale and not in Title II emergency programs. See IR3 section for discussion of FANTA’s work to develop and validate useful LQAS designs to assess the prevalence of acute malnutrition in emergencies in Ethiopia and Sudan. The May 2007 hiring by FANTA of a Senior Emergency Nutrition Specialist strengthened their capacity, but these needs are a tall order for one person. We will now discuss on three levels the evaluation findings on FANTA’s technical support to the Title II program for: 1) USAID/Washington DCHA/FFP; 2) U.S. PVO Cooperating Sponsors (CS) who implement Title II programs; and 3) priority country assistance. This is not a comprehensive, but a brief description of the many ways FANTA has supported FFP for more than eight years. We will feature here FANTA’s work to improve programs (IR1), but discuss in the IR2 findings its important assistance to DCHA/FFP in developing strategies, programming guidelines, and performance monitoring plans, which are more relevant there. a. Technical support to the Office of Food for Peace (DCHA/FFP) and the Program Policy and Coordination Bureau (PPC) Technical Review of Title II Proposals This is a mainstay of FANTA’s assistance, which DCHA/FFP greatly appreciates. Since 2002, FANTA has played an indispensable role reviewing and scoring 92 MYAP proposals from 28 countries. Before FY 2005, these were known as Development Assistance Programs (DAP). For each proposal, FANTA assigns a staff member to follow the review process. FANTA’s technical review provides critical input to FFP, to include in its response to applicants on the strengths and weaknesses of their proposals and areas that need revision. As a result, CSs can more easily revise proposals to improve Title II program design, getting new programs off to a good start. Upon request, FANTA also reviews selected Cooperating Sponsor Results Reports and Single Year Assistance Program proposals (SYAP) written mainly for emergency programs. . One of FANTA’s key contributions was the development of a more transparent and objective scoring system for reviewing Title II MYAPs. In 2006, for the first time, this MYAP review scoring system became a formal part of the official FFP guidelines to applicants for FY 2007 Title II program proposals (8). FANTA worked with FFP to help draft these guidelines. FANTA trained staff of FFP and its institutional contractor, AMEX, and other technical reviewers to use the scoring system. FFP staff said the scoring system and training were very useful and that, given Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 15 turnover in FFP staff, FANTA should repeat the training. The scoring system should result in higher quality programs, with reviewers using it to focus on the key elements of the proposals and to give concrete feedback to applicants for improving program design. Annual Results Reporting is another area where FANTA has greatly helped FFP by aggregating performance data and drafting performance reports that capture highlights and key results from Title II programs around the world. These high quality reports help FFP tell its story and share the important contributions the Title II program makes. The fact that comparable, consistent, meaningful data are available that can be aggregated across many CSs in many countries to monitor the performance of the large Title II program worldwide is a testimony to FANTA’s major contributions in helping FFP define common indicators and draft better data reporting forms. One example is the Standardized Annual Performance Questionnaire that CSs are required to use. Interviewees noted that FANTA’s assistance is also critical in helping FFP meet the reporting requirements of the Office of Management and Budget and the Performance Assessment Rating Tool (PART). Commodities Reference Guide FANTA has assisted FFP to keep this guide up to date with the latest technical developments and international dietary recommendations. It is a valuable reference and helps USAID, CSs, and others involved in food aid programming to understand the food aid commodity list, and to determine the appropriate size and composition of food rations. When FFP receives proposals from food manufacturers for possible new commodities to add to the program, it relies on technical reviews from FANTA. As requested, FANTA also helps FFP resolve problems encountered in the use of Title II commodities, e.g., the recent case of over fortification of Corn Soy Blend (CSB), leading to discoloration upon cooking. Institutional Capacity Building (ICB) Agreements FFP competitively awards ICBs to Title II CSs as the main vehicle for strengthening Title II programs and complementing food aid with 202e and DA dollar resources. FANTA assisted FFP in reviewing proposals that were awarded to the current 15 recipient CSs as 3 to 5-year ICB agreements. There will be a new competition for these agreements in FY 2008 and FANTA is helping FFP think through guidelines for the Request for Application (RFA). Valuable input has come from FANTA’s review and synthesis of the results of and lessons learned from all the mid-term ICB evaluations, which FANTA shared both with FFP and with CSs at a recent workshop presentation. FANTA linked its review of the ICB agreement evaluations to the MYAPs of the same CSs, helping FFP ensure that ICB agreements have the intended impact on strengthening MYAPs. In early 2008, FFP would like FANTA to complete a meta-analysis of the final evaluation findings of all ICB agreements, so that these real experiences can be used to shape the RFA for the next round of applications. FANTA also played a similar role, assisting FFP with the previous cycle of these grants (formerly Institutional Strengthening Agreements). Food Aid Managers’ Course FANTA has been proactive at making technical presentations at these courses that FFP organizes periodically to train Mission staff on the latest policy and programming guidelines and state-of-the-art approaches to using food aid. b. Technical support to Cooperating Sponsors Cooperating Sponsors are the frontline implementers of Title II programs and, therefore, as a result of FANTA’s technical support, are featured in each of FANTA’s intermediate results as one of the key groups expected to improve their programs, strategies, and policies, and to adopt promising practices for nutrition and food security. As discussed above, many FFP technical requirements for CSs for Title II program proposal design, revision and approval, and monitoring and evaluation systems, originated in FANTA’s technical support to FFP. These FFP requirements have raised the bar for the technical quality of Title II programs and, in compliance, CS’ program design, monitoring, and evaluation have improved. However, since country specific activities will be discussed in the subsequent section, this section of the report will focus on evaluation findings relevant to FANTA’s direct support to the CSs, especially at the CS’ headquarters or organization￾16 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project wide level. According to FANTA, funding from FFP is a central constraint to the technical support they provide directly to CSs, such that it is not possible to respond to all the demand from individual CSs for technical assistance. Given scarce resources and the project’s mandate, FANTA’s approach has been to provide direct support to CSs only in cases where the results are likely to benefit the larger food aid programming community, not in cases where the main benefit is to improve a single program. Monitoring and Evaluation Guidance and Publications In the views of CSs, this is the area where FANTA has excelled and has provided them the greatest help. They rely on and make extensive use of FANTA’s outstanding publications. PVOs and FFP consider these the gold standard, referencing FANTA’s Web site containing monitoring and evaluation publications. PVO headquarters staff, who have participated in FANTA working groups to define indicators, truly appreciate the experience, especially the working sessions on indicators for FFP’s Performance Monitoring Plan for IR2 (“Title II impact in the field increased”) in the 2006-10 FFP Strategic Plan (9). PVOs use the excellent FANTA “how to” publications to improve monitoring and evaluation of other programs, not just Title II. Some interviewed said that the level of the publications is sometimes too technical and too complicated for use in the field, and that they should be adapted to make them simpler to understand and easier to use. There are more FANTA products and tools on monitoring and evaluation, and fewer for program development. Thus, the improved monitoring and evaluation part of IR1 has been achieved to a greater degree. The majority of CSs interviewed asked that FANTA increase its training of PVO staff on how to use the monitoring and evaluation tools. They welcome the training workshop FANTA is jointly planning with the PVOs and FFP for August 2007 on monitoring and evaluation requirements for the new FFP strategy. CSs desire written guidelines, case studies, and training on Lot Quality Assurance Sampling and the data analysis software (called Layers), which FANTA pioneered to monitor and evaluate Title II programs. One CS suggested that FANTA develop guidelines on what constitutes a good monitoring and evaluation system for a Title II program. This could then be used by PVOs to evaluate their own monitoring and evaluation systems to determine whether standards are being met. Thus, FANTA could share its extensive experience in reviewing the proposed monitoring and evaluation plans in MYAP proposals and real systems in the field, as well as lessons learned on what makes a good system. More technical assistance and training by FANTA to enable CSs to analyze and use data for decision-making would be worthwhile. FANTA has provided valuable technical assistance to USAID Missions and CSs for design and implementation of baseline, mid-term, and final impact evaluation surveys of Title II programs, e.g., baseline surveys in Ethiopia, Madagascar, and Haiti. Program evaluations in India, Bangladesh, Indonesia, Bolivia, Haiti, Honduras, Madagascar, and Ethiopia were assisted by FANTA, including identifying or fielding consultants. The CSs and Missions appreciate this assistance. Spot Technical Assistance Cooperating Sponsors have asked for very short technical consultations, lasting 1-2 hours, to address a technical need in an area of FANTA’s expertise, mostly in program design or monitoring and evaluation. Evaluation results are mixed in this category. Some PVOs have asked FANTA to help and are satisfied with the response, saying that FANTA provides good assistance to CSs from technical, theoretical concepts to on the ground help, and is more accessible than FFP. FANTA helps CSs navigate the FFP world, and their technical assistance is seen as less threatening than USAID directly providing that technical assistance. Other CSs feel that FANTA does not provide this kind of technical assistance because its time is spent in meeting USAID’s needs. Thus, they don’t ask FANTA for help and are disappointed when they can’t get it. To the extent feasible within FANTA’s staff time and budget, the evaluation team believes that providing spot technical assistance when requested should be a high priority for FANTA because an hour of FANTA’s time spent helping a CS technical advisor or program manager at headquarters potentially reaches PVO programs worldwide. However, PVOs need to be more proactive in seeking FANTA’s assistance. If they don’t ask for help, FANTA can’t assist. Furthermore, some Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 17 interviewees noted that PVOs have not taken full advantage of the assistance they do receive from FANTA by broadly sharing lessons learned throughout their organizations. Some CSs want help from FANTA to design specific proposals as they move from DAPs to MYAPs. This would be more time consuming and not “spot” technical assistance. The evaluators believe this design technical assistance is not feasible or advisable because FANTA is also a reviewer of MYAPs for FFP, and should retain its independence to avoid a possible conflict of interest. Furthermore, the demand for such help could far exceed FANTA’s capacity to respond. FANTA has rightly prioritized help to CSs on requests that can contribute to global knowledge and leadership vs. those that only meet specific country needs. FANTA staff stated that lack of staff time is a bigger constraint to their being able to provide technical assistance to PVOs than lack of funds. Capacity-building by FANTA in training sessions for CSs to improve nutrition and food security programming, outside of training in priority country programs, has not been a major emphasis. Per the cooperative agreement, timely and focused FANTA training for PVOs in program design, cost￾effectiveness assessment, data collection and interpretation, indicator selection, and sampling methodologies would be readily available and frequently delivered. In particular, there is demand for FANTA to do Training of Trainers at the headquarters level, which would be similar to the training workshop it is organizing on monitoring and evaluation for August 2007. CSs like the training needs assessment FANTA is collaboratively carrying out with them to plan that workshop, and said that other FANTA training events could have benefited from a similar needs assessment. As planned, FANTA has conducted training in conjunction with ongoing PVO and USAID training efforts, but CSs said that FANTA could have participated more in PVO-organized training events. The CSs definitely want more training to be able to fully use FANTA’s products, and the evaluation team sees such training as necessary to achieve field implementation and use of the many excellent FANTA tools. This should be a high priority for FANTA’s final year. Collaboration with and Engagement of CSs This is an area of FANTA’s performance that CSs rated as weak. The intent in the cooperative agreement was that FANTA would actively solicit participation by the PVO community and involve them in: 1) setting its technical agenda; 2) reviewing and testing its materials, guides, and other tools; and 3) monitoring performance toward results (7). To formalize this participatory process, as part of its proposal to USAID for FANTA, AED signed a Memorandum of Understanding with Food Aid Management (FAM), a consortium of 15 Title II recipient PVOs, funded by an institutional strengthening grant from FFP. Working with FAM enhanced and facilitated FANTA’s collaboration and engagement with CSs until 2003 when FAM ceased to exist because USAID funding for it ended. Some CSs involved in the earlier years with FANTA and FAM said that losing FAM had been detrimental to their collaboration. They believe that, although they do not have a FAM, they should continue to meet and collaborate, and that FANTA should make a greater effort to engage them as technical peers and to organize forums where they could share experiences to inform each other’s work. Two CSs had organized such a forum in late May and invited other CSs with ICB grants to share lessons learned in implementing ICB grants. Everyone found it useful and a FANTA staff person participated. FANTA also participated in an ICB workshop on assessment methods that was organized by Title II CSs in September 2006. At that workshop, FANTA made a presentation of the LQAS designs for assessment of malnutrition in emergencies. The PVOs welcome FANTA co-planning and sponsoring such future events. Recipients of ICB grants are expected to organize events for sharing with other PVOs, but often don’t do so. Organizing such forums should be a high priority for FANTA in its final year. Overall Perceptions Perceptions of CSs who have been involved with FANTA since it inception in 1998 are that, over the more than eight years of its existence, FANTA has increasingly focused on meeting USAID’s needs and not those of the PVOs, with less and less time for collaboration with PVOs. From their perspective, some CSs see FANTA as less responsive to their needs and priorities, noting this as contrary to its design and intent. “PVO support is not what FANTA does 18 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project anymore; their focus has shifted to assisting USAID Missions.” Some wondered if FANTA’s cooperative agreement Program Description had been amended to reduce focus on CSs when it was extended for five more years in 2002. In fact, the FANTA Program Description did not change when the agreement was extended. More likely explanations are the inability of FFP to invest more resources in FANTA for the technical assistance it needs, not having a FAM to facilitate collaboration with CSs, and, to a lesser degree, the near doubling of FANTA’s activities, workload, and resources (especially PEPFAR HIV/AIDS requests) in the period 2003-2006 compared to the earlier years of the project. This CS complaint is rooted in their high regard for FANTA’s technical expertise and in their keen desire to get more of it to improve their programs and share experience as frontline practitioners. Some CSs are also concerned that FFP may be trying to standardize all PVO programs too much through FANTA’s advice, especially in the monitoring and evaluation areas, and not valuing different approaches and the diversity between PVOs. “Each PVO is unique.” From the evaluation team’s perspective, it is logical that, since USAID was funding FANTA, USAID would have first call on its assistance. Nevertheless, not collaborating extensively with or providing sufficient technical support to CSs through proactive outreach and interaction at headquarters level is an opportunity FANTA has missed to have even greater impact on improving Title II nutrition and food security-related programming. Many CSs receive ICB grants from USAID to improve their programs, but lack the specialized technical expertise that FANTA offers, and, unfortunately, CSs cannot pay ICB grant funds to buy the help they need. Interviewees mentioned that some PVOs wanted to give FANTA funds for technical assistance, but the FANTA cooperative agreement was not structured to allow this. We will discuss below the model of the Child Survival and other Health (CSH) Grants Program in which, in addition to grants to PVOs, USAID sets aside additional funds to pay a technical assistance contractor (CSTS) to support the grantees. This model would be worth emulating in a future FANTA-like project, to assure that sufficient funds are dedicated to CS technical assistance needs. c. Country-level assistance for Title II activities From October 2002 through April 2007, FANTA provided long-term technical assistance to 11 countries and short-term technical assistance to seven countries. The focus of this section will be on evaluation findings concerning country-level assistance for Title II activities. Other country and regional-level support for nutrition, HIV, and CTC will be discussed in the section on IR3 promising practices. Which countries receive FANTA’s technical support is driven primarily by which Missions are willing to invest their funds in FANTA to pay for this support. Six long￾standing, focus country, Title II programs have received FANTA technical support from the first half of the project to date, namely Haiti, Ethiopia, Madagascar, India, Honduras, and Nicaragua.4 The commitment of these Missions to support technical assistance from FANTA year after year provides clear evidence of their high level of satisfaction with and need for the support received. Guatemala joined the focus country list in the second half of the project. The most recent countries to receive FANTA assistance are Mozambique and Malawi, FFP priority countries. Bangladesh, Indonesia, and Bolivia have benefited from FANTA’s short-term, technical support. In FY 2006, FANTA provided technical support to 29 non-emergency Title II programs of nine Title II CSs in eight of the 29 countries worldwide with Title II non-emergency programs, paid for by the respective USAID Missions. The Title II resources programmed in these eight countries represented 44% of all non-emergency Title II resources worldwide that year, or approximately $139 million of $313 million (2). Thus, FANTA technical support was being brought to bear at the country level to improve nearly half of the worldwide Title II non-emergency resources in FY 2006. The concern of the evaluation team is that, in 21 other countries with the majority ($174 million) of Title II non-emergency resources in FY 2006, FANTA was not able to directly assist 4 The first 3 countries are FFP priority countries, with the latter 3 scheduled for phase out in 2008-2009. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 19 USAID Missions and CSs to improve nutrition and food security-related programming on the ground. This is because the Missions had not requested or paid for this support. One bureaucratic constraint limiting the number of Missions supporting FANTA technical assistance is the Title II program, which is rich in food, but short on cash to pay for technical support. Mission funding to FANTA for Title II assistance has been mainly Child Survival and Other Health (CSH) funds (76%), while Title II programs are often managed out of other offices in a USAID Mission besides Health, Population, Nutrition (HPN), and Title II programs may not be fully integrated into health strategic objectives. Furthermore, congressional restrictions on the CSH earmark prohibit its use for agricultural productivity, income generation, and many other “access” aspects of food insecurity (non-health) that need to be addressed. Moreover, relatively few Missions have been able to invest DA funds in FANTA to support Title II programs. The evaluation team believes that Title II programs to address major food insecurity and nutrition problems are too important and resources invested in them too great to leave funding for technical assistance to improve them optional and solely at the Mission’s prerogative. This is another example of the need for a central fund for technical assistance to the CSs and USAID Missions for improving Title II programs, which is similar to the need mentioned above for increased technical assistance for CSs at headquarters level. USAID Missions are very satisfied with FANTA’s technical assistance and depend on it. Interviewees noted that FANTA technical assistance is very effective because they understand their role as a facilitator and not a direct implementer, and they work through and build the capacity of CSs and local institutions. Staff interviewed have seen positive impacts on the current Title II programs and are counting on having FANTA support in the next critical phase of rolling out the new FFP strategy on the ground by designing or updating food security strategies, drafting MYAP guidelines, reviewing proposals, and designing monitoring and evaluation systems for new MYAPs. These needs go well beyond the end of FANTA in 2008, and Missions were unanimous in stating their urgent need to continue to receive similar technical support for Title II programs with a seamless transition to a new project once FANTA ends. We will now discuss the evaluation findings on the major types of FANTA county-level, technical support to Title II programs. In the interest of brevity, this is not a comprehensive description of all the many outstanding country-level Title II activities FANTA has supported. Program design including food security assessments, strategies, and MYAP guidelines To design Title II programs well, a critical first step is conducting national food security assessments and using these to design USAID Mission food security strategies, which in turn are used to frame country guidelines for Title II program proposals. FANTA has done an excellent job of assisting Missions to do these in Ethiopia, Madagascar, and, most recently, Mozambique, contributing to IR2 results for improved strategies. In Ethiopia, FANTA succeeded in elevating nutrition as a cross-cutting theme in the Mission’s overall strategy by making strategic use of PROFILES, a Process for Nutrition Policy Analysis and Advocacy that stimulates multi-sectoral team work to analyze and interpret relationships among key factors influencing food security and nutrition. In all three countries, FANTA worked with the Missions to draft clear country guidelines for DAPs and MYAPs to improve Title II programs consistent with the strategies developed. In these and other focus countries, Mission support has made it possible for FANTA to provide very useful guidance to CSs for preparation of their DAP or MYAP proposals, leading to higher quality submissions. Missions are now more involved in reviewing and scoring MYAP proposals, along with FFP in Washington, and they have appreciated FANTA’s thorough and constructive reviews as part of this process. FANTA has also assisted Haiti in the design of early warning systems related to food security. Monitoring and evaluation This is FANTA’s specialty area where country implementers of Title II programs thought they had made the greatest contribution (e.g., in Haiti, Guatemala, Honduras, India, Bangladesh, Indonesia, Ethiopia, and Madagascar). FANTA played a key role in 20 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project harmonizing indicators, baseline design, endline surveys, and monitoring and evaluation systems across multiple CS implementers of Title II programs in these countries. Most Title II countries with non-emergency programs have two or more CSs. For reported performance data to be comparable, it is essential to reach agreement among all implementers. This is very challenging. To achieve consensus among distinct PVOs, real diplomacy, negotiation skills, and technical competence are required, in all of which FANTA excels. In USAID, there are few examples of one program being implemented by many different partners in the same country, e.g., Title II. However, this is the norm in Title II, and this multiplicity greatly complicates achieving high quality monitoring and evaluation. FANTA had considerable success in assisting Missions and CSs to conduct one common baseline survey rather than several. However, there is always the temptation to collect more data than needed in surveys. Missions in Haiti and Ethiopia noted that FANTA had designed baseline surveys that were overly ambitious and that they should streamline them to essential data in the future. Through FANTA’s assistance, Title II indicators were also made more compatible with Missions’ HPN indicators, again greatly contributing to the ease with which performance results could be measured and reported for the entire U.S foreign assistance program in a country. In the process, better coordination between USAID HPN and Title II programs was achieved. Interviewees praised FANTA as a linking project between HPN Projects and Title II programs that creates harmony and synergy between various actors. Another valued FANTA contribution was the introduction of sampling using the LQAS methodology, data collection, entry and analysis with hand-held computers, and Layers software to improve USAID monitoring of food aid logistics and warehouse conditions in Ethiopia, Madagascar, and Haiti. Introduction of this new technology was particularly important to Missions in Haiti and Madagascar where the Inspector General’s audits had criticized USAID for not using representative samples to monitor the Title II Program adequately. Similar criticism of inadequate monitoring of U.S. food aid programs worldwide was made in the 2007 GAO review of these programs (3). Use of the new technology helped the Haiti and Madagascar Missions to close audit recommendations. This improved monitoring has become routine in their programs. However, there were some complaints that FANTA did not yet completely transfer the skills needed for LQAS and Layers to the Missions, so that they continue to depend on FANTA’s technical assistance. The main advisor for this is the FANTA Deputy Director. Because there is much demand for his technical assistance, in addition to his management responsibilities, there have been delays. The methodology has also not been documented to contribute to technology transfer and sustainability, in sharp contrast to other FANTA “how to” products. This will be discussed further in the IR3 promising practices section. CARE appreciated the technical assistance it received from FANTA on LQAS in Haiti, Malawi, and Mozambique. Improved implementation of Maternal and Child Health and Nutrition (MCHN) programs to prevent malnutrition Most of FANTA’s assistance has been directed to improve Title II program design and monitoring and evaluation and less to improve actual implementation. An exception is their excellent work in responding to the regional request of USAID Central America Missions in Guatemala, Honduras, and Nicaragua for assistance to improve Title II MCHN program implementation and specifically community-based growth promotion (CBGP). Missions noted that FANTA has done an excellent job of harmonizing the approaches to CBGP across CSs and assuring that they are consistent with other non-food aid, USAID-supported CBGP programs, Ministry of Health (MOH) norms, and the state-of-the-art in this field. A key focus has been improving CS’ skills in infant and young child feeding behavior change techniques, and, in turn, the counseling skills of village volunteers who implement the Title II program. In the process, FANTA has also been able to improve the skills of MOH staff. Regional sharing across the three countries, planned from the start of this initiative, is still pending and should be a priority in FANTA’s final year. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 21 Additional examples of FANTA’s effective assistance to improve the implementation of Title II programs are the incorporation of promising practices in health and nutrition in the Madagascar and Ethiopia programs. In India, FANTA assessed the effectiveness of program approaches, and tools used to improve health behaviors, feeding practices and nutritional status in the very large CARE Title II program. FANTA is working with CARE to replicate effective practices in the larger national government program. See the IR3 section for a discussion of FANTA’s applied research in Haiti to increase the evidence base on the merits of a preventive approach to addressing malnutrition in children under two years in Title II MCHN programs. Graduation and exit strategies for Title II program phase out Given the 14 countries where Title II non-emergency programs will be phased out in the next two years, the evaluation team was surprised to find that FANTA has provided assistance on designing graduation and exit strategies only for the India program. This is a historic moment when Title II programs of many decades are now facing the uncharted waters of phase out. While there has not been sufficient FFP or Mission demand or support for this assistance, it certainly would seem important in FANTA’s global leadership role to proactively document and share valuable lessons learned for ending these programs well, and sustaining food security and nutrition interventions without Title II. The India Mission had great praise for FANTA’s assistance to them and CARE in developing the exit strategies that are now being implemented to phase out the Title II program by FY 2009 and help with transitioning from Title II food supplements to local foods provided by the government of India. To assist India with transition, FANTA conducted program reviews of phase-down scenarios and supported its partner, IFPRI, to study the transition, which culminated in the report, Food Aid Transition in India’s Integrated Child Development Services Program in CARE-Supported Areas. To assist India with graduation and exit, FANTA produced 1) Phase-Down Strategy for Title II in India, 2) Program Graduation and Exit Strategies: A Focus on Title II Food Aid Development Programs, and 3) Program Graduation and Exit Strategies: Title II Program Experiences and Related Research. The latter two publications have been helpful to other countries and to CSs who now face closing long-standing Title II programs (6). However, these remain somewhat academic and theoretical. There is a great need for case studies to document real experiences and effective alternative approaches across countries and regions, which vary greatly from the unique situation of India with its large domestic food surpluses and government funding for the community-based Integrated Child Development Services program. 2. Support to improve Child Survival and Health Grants programming (CSHGP) Apart from Title II programs, USAID-funded nutrition programs are less common and most often found as components of integrated child survival programs. When USAID/Washington requested that FANTA provide technical assistance to the CSHGP Portfolio in FY 2001, it was seen as a real opportunity to further the influence of the project and achieve its results. FANTA support has continued to date by working with the three main components of the CSHGP that USAID funds: 1) PVOs with cooperative agreements with nutrition components; 2) the CORE Group, a network of 47 international PVOs with eight working groups to support sharing and technical exchange between member PVOs; and 3) the contract staff of ORC/Macro International for the Child Survival Technical Support Plus Project (CSTS) that provides technical assistance, monitoring, evaluation, and management support to the CSHGP and PVO grantees. FANTA has been actively involved in a range of activities. They have led annual updates of the Nutrition Module of the Technical Reference Materials (TRM) for PVOs. The Nutrition TRM has served as a useful mechanism for disseminating promising nutrition practices that PVOs can adopt. FANTA has also 22 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project been a considerable help to the CSHGP by technically reviewing and working to improve the Detailed Implementation Plans (DIP) of agreements with nutrition content, that recipient PVOs prepare within seven months of signing their agreements. From 2002–2007, FANTA reviewed 22 DIPs from 16 countries. According to CSTS, it was more willing and proactive in offering to do these reviews than other cooperating agencies. FANTA listens to PVOs and meets their needs, rather than pushing its own agenda. Given FANTA’s extensive expertise in nutrition monitoring and evaluation, it has provided technical feedback and written guidance materials for the Knowledge, Practice, and Coverage (KPC) 2000+ Survey that the CSHGP recipients are required to use to conduct baseline, mid-term and final impact evaluations surveys. Specifically FANTA prepared the KPC 2000+ Module 2 on Breastfeeding and Infant and Young Child Feeding (IYCF) Practices, and guidance on analysis and use of the new IYCF indicators. FANTA also worked to get these incorporated in the analysis of data from Demographic and Health Surveys (DHS) (10). The IYCF indicators are derived by more meaningful analysis of data already collected and do not require additional data collection. Interviewees noted that while the incorporation of analysis and use of IYCF indicators into the KPC Module has been confusing to some PVOs, FANTA has always been willing to listen to PVO views and frustrations, and provide guidance, training, and support to resolve these issues. Additionally, those interviewed in the CSHGP stated that FANTA has played an active and helpful role by participating in CORE Nutrition and Monitoring and Evaluation working groups and by presenting promising practices and technical updates to build PVOs’ capacity in nutrition: 1) at various CSHGP forums, 2) in training sessions at the CSTS Mini-Universities, 3) at CORE meetings and working group sessions, and 4) by using CORE’s on-line medium called Elluminate. Examples include FANTA’s updating PVOs on the 2006 WHO Child Growth Standards, the IYCF Indicators in the KPC 2000+ Module 2, and CTC and Positive Deviance/Hearth approaches to recuperating children with severe acute malnutrition. In 2005, FANTA led the reorganization and update of the Nutrition Module of the TRM. Since most PVO participants in these activities are the lead, senior health and nutrition technical advisors for their organizations worldwide, the evaluation team believes that FANTA’s investment of time in capacity building to update their nutrition skills has been very cost effective and well worth the effort. It has the potential for a large multiplier effect, to the extent that these PVO technical advisors share their new nutrition knowledge and skills within their organizations. With the ending of the FAM consortium in 2003, FANTA and the PVOs lost a crucial forum for information sharing around nutrition and food security issues in Title II programs. Thus, FANTA’s efforts to explore the possibility of using the CORE Nutrition working group to also reach Title II PVOs with food security and nutrition updates and information sharing make good sense. Nearly all Title II Cooperating Sponsor (CS) organizations are members of CORE and share many common interests with other PVOs working on child survival/ nutrition programs without food aid. Although CORE participants tend to be child survival and health staff of PVOs, not food security and food aid staff, they work at the same PVOs. Unfortunately, to date, FANTA’s action plan to more fully involve Title II CSs in CORE Nutrition working group activities has not yet caught on. Interviewees noted that there has been limited success in expanding the reach of CORE’s Nutrition working group to include Title II program interest areas. 3. Additional needs or gaps to address before FANTA ends, if time and funds permit, or as a top priority during the first year of a new nutrition and food security global project: • Proactively work with CORE to further address Title II PVO nutrition issues in CORE Nutrition working group activities. • Document lessons learned in real Title II program phase-outs to prepare more guidance on effective graduation and exit strategies for sustainability of food security and nutrition Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 23 programs, especially in Honduras and Nicaragua where FANTA is working. Assess the needs of CSs with phase out programs and whether they are using and finding useful two technical publications on this topic by FANTA. • Assist FFP and CSs to define and test trigger indicators derived from real programs to determine the threshold at which Title II programs need to shift along the development￾relief continuum, or require additional resources in response to shocks, per the new FFP strategy, including how to measure these. Coordinate this work with FFP’s FEWS NET program. • Write a history of the process of improving the food security and nutrition focus of Title II programs and key reforms since 1995, with IMPACT and FANTA technical assistance, especially by Project Director. Document this success story to contribute to FFP’s institutional memory. 4. Summary of Key Findings • FANTA has provided extremely effective and responsive technical support to improve Title II programming, contributing significantly to better design, monitoring, and evaluation, primarily by direct assistance to USAID DCHA/FFP and priority country activities. Cooperating Sponsors have benefited from FANTA’s technical assistance, collaboration, and tools, especially for monitoring and evaluation. However, such support has declined over the life of the project. • FANTA has offered critical and ranging support to improve nutrition programming in the CSHGP, including active participation in CORE working groups, collaboration with and ongoing support to PVOs, and sharing updates and technical expertise in food security and nutrition. C. SUPPORT TO IMPROVE INTEGRATED NUTRITION AND FOOD SECURITY STRATEGIES AND POLICIES OF USAID, HOST GOVERNMENTS AND COOPERATING SPONSORS (INTERMEDIATE RESULT IR2) Complementing work to improve nutrition and food security-related programs (IR1), the purpose of IR2 is to achieve similar impact at the strategic and policy level through concerted FANTA technical support to USAID, host governments, and CSs. The focus is on improving the conceptual framework for food security, and, more recently, on the expanded conceptual framework for understanding food insecurity, and the use of these frameworks to shape strategies and policies (Appendix A). The FANTA cooperative agreement plan was to provide technical support at agency-wide level and in specific country programs to increase understanding and application of these conceptual frameworks in food-security-related strategies and policies, and to establish and refine technical guidelines (7). A priority for FANTA is integrating food aid programs into Mission’s strategic planning and helping Missions prepare food security strategies for Title II programs. Integration of nutrition concerns into diverse sectors is another thrust. Per the agreement, “Integrated planning at the country level by host governments, which is critically important to food security, is beyond the mandate of FANTA” (7). However, by working to strengthen USAID Mission food security strategies, FANTA hoped to affect host country programs through USAID Missions’ engagement with host governments (to endorse sound policies and strategies) and, to a lesser degree, through CS’ policy dialogue with host governments. Through advocacy and strategic planning, FANTA works to replace entrenched attitudes and opinions about malnutrition and food security with more technically sound and practical views (complemented by IR3 work to expand the evidence base for this). Most of FANTA’s work in IR2 also contributes to IR1 or IR3 and has been described in those sections of this report. Therefore, evaluation findings on FANTA’s achievements to improve integrated nutrition and food security strategies and policies will be 24 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project discussed only briefly here if covered elsewhere. There are a number of very significant IR2 accomplishments are to FANTA’s credit. 1. Food for Peace strategy, policies and food insecurity framework Without a doubt, FANTA’s greatest contribution to improving strategies and policies was the crucial role it played, working hand in hand with FFP, to shape FFP’s Strategic Plan for 2006-2010 (5). By influencing the multi-year, strategic direction of Title II food aid resources worth around $1.2 billion per year to reduce food insecurity in more than 48 million of the most vulnerable people in the world, FANTA’s work has had a far reaching, long-lasting positive impact. According to FFP, FANTA was a huge technical resource to their strategic planning process, assisting them with advice from very broad strategic thinking to the details of drafting the strategy. FANTA brought to bear its extensive prior experience with Title II and its outstanding food security and nutrition expertise to link FFP to the current state-of-the-art. They took into account where the Title II program had been and where it needed to go. According to FFP, they were “exceedingly competent, responsive, and flexible” in meeting FFP’s needs. Early in the process in 2003, FFP commissioned FANTA to prepare two occasional papers on food security that were used as the technical underpinnings for the new strategy, namely Addressing the “In” in Food InSecurity, and Integrating Relief and Development to Accelerate Reductions in Food Insecurity in Shock-Prone Areas (6). These were seminal, think pieces, and the concepts and new approaches proposed in them became the foundation of FFP’s current strategic plan, namely: 1) the new objective of “reducing food insecurity in vulnerable populations” vs. the prior goal of increasing food security, 2) the focus on better targeting Title II to the most vulnerable populations and countries, and 3) the unification of emergency and non-emergency programming into flexible programs able to address needs along the development-relief continuum. Similarly, the basic food security framework that FFP had used was expanded in the new framework “to place emphasis on vulnerability—the risk and consequences of, and resilience to, food security shocks—that impede the achievement of food availability, access, and utilization” (8). See framework in Appendix A. As stated by one FFP staff person interviewed, “It’s been amazing. I don’t think we’d be anywhere close to having the credibility that we do without FANTA’s technical assistance.” A key feature of the new FFP Strategic Plan is to focus non-emergency Title II resources on the most vulnerable people, in the most food insecure countries. In practice, this means phasing out Title II non-emergency programs in 14 less needy countries. Again, FANTA played a lead role in proposing three objective criteria for which data were available from USAID and the World Bank, which FFP ultimately used to derive a weighted average food insecurity ranking for each of 32 countries.5 Without the objective, quantitative criteria used, it would not have been possible to make these painful decisions in a fair, transparent, and scientifically sound manner. This targeting process minimized controversy and FFP was grateful for FANTA’s support. The Farm Bill, up for re-authorization in 2007, is the legislation that governs the strategic direction and implementation of U.S. food assistance (P.L. 480) for the next five years. Successful negotiation for the Farm Bill is a key policy-shaping event for USAID. FANTA greatly informed USAID’s position on what measures would be most useful to see in the new bill. According to FFP, they did this by preparing an excellent and very timely consultant report that recommended specific amendments to the Farm Bill that would allow USAID to implement P.L. 480 programs more effectively and efficiently, and recommended effective approaches to working with Congress to get the proposed changes accepted. If DA or other resources were less constrained, FFP would like to use assistance from advisors of a FANTA-like project even more strategically in the future 5 The criteria are % of children stunted, % of population living on less than $1/day (extreme poverty), and % of population undernourished (average caloric availability), which address the three aspects of food security respectively, i.e. utilization, access, and availability. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 25 by having more counterpart staff assigned to learn from the advisors. The Food for Peace Office would also like such a project to pursue an applied research agenda for demonstrating and evaluating results that would guide more effective food aid programming to reduce food insecurity (consistent with IR3). FANTA has already proposed 18 priority areas to FFP for working together to pursue such a vision that FFP is interested in pursuing and sees as critically important. Unfortunately, financial resources are not available to pursue this vision now, and time is running out in the FANTA agreement. If resources can be found, a high priority in any future project should be to make this strategic vision of more effective, evidence-based, Title II programming a reality by supporting increased technical assistance and applied research. 2. Title II programming and performance management guidelines Being able to measure whether the intended results of the new strategy are achieved requires a well-designed Performance Management Plan (PMP). Following through on its excellent assistance to FFP in strategy design and using its extensive expertise in monitoring and evaluation of food security and nutrition, FANTA worked with FFP to design an excellent PMP for the new FFP strategy. To date, FANTA has helped FFP identify the indicators, in collaboration with CSs, and drafted the Performance Indicator Reference Sheets for the SO and IR2 level (9). Work on IR1 is still being finalized. It is noteworthy that two of the indicators of food access on which FANTA provided guidance, namely household dietary diversity and months of adequate food provisioning, are among indicators to be used to measure achievement of the SO. All CSs with Title II programs designed to increase access to food will be required to measure and report on one or the other of these. FANTA’s compelling technical arguments on the PMP have been helpful to FFP in its efforts to secure approval by the Office of Management and Budget. By zeroing in on how to measure food access and nutritional impact and helping FFP to hold CSs accountable for measuring and achieving these impacts, FANTA has had a huge influence on improving the impact of Title II programs. Their expertise and real commitment to high quality monitoring and evaluation, and their success in getting major monitoring and evaluation improvements adopted as FFP policy have contributed greatly to the evidence-base for what works in Title II programs to improve nutrition and reduce food insecurity. To fully implement the FFP strategy, CSs need to design new Title II programs that put the strategy’s principles into practice. The P.L. 480 Title II Program Policies and Proposal Guidelines that FFP issues annually to guide CSs in preparation and submission of new Title II program proposals are key to assuring sound design. FANTA has played a major role in assisting FFP to draft these guidelines each year. They have shaped the requirements for monitoring and evaluation in Title II programs, including performance indicators and targets and standardized reporting. As discussed elsewhere, FANTA has prepared a series of widely used “how to” guides that are essential references for CSs on monitoring and evaluation. Another key feature now included in the proposal guidelines is the MYAP Review Scoring system developed by FANTA (see IR1). In several of its priority countries, FANTA has had an important impact by designing food security strategies to guide the development of entire Title II programs consistent with the FFP strategy (see IR1). Due to lack of resources and effective demand from Missions, this essential step to solid program design has not been completed in all 18 FFP priority countries. However, it is urgently needed, as many MYAPs in these countries end in FY 2007 and new proposals are expected for FY 2008. This is another example of the need for a central fund for technical assistance to assure that food security strategies are done to guide Title II program design in all priority countries, similar to other needs for such a fund (see IR1). 3. Nutrition programming in emergencies FANTA’s work in demonstrating that CTC is more effective than traditional approaches to managing severe acute malnutrition has had a major influence on changing humanitarian nutrition 26 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project policy. The proof of this is the recently issued joint United Nations Children’s Fund (UNICEF)– World health Organization (WHO)–World Food Programme (WFP) – UN Standing Committee on Nutrition (SCN) statement on community-based management of acute malnutrition, endorsing the CTC approach. Host country governments look to these international bodies for normative guidance. The UN statement should greatly facilitate adoption of CTC in settings where it is urgently needed. Furthermore, the CTC approach is being integrated into protocols of WHO and UNICEF that previously included only facility-based treatment for SAM. The CTC Field Manual that FANTA and its partners prepared, and the accompanying training materials will contribute greatly to shaping national guidelines on CTC. FANTA’s work on CTC has also influenced OFDA policy on nutrition programming in emergencies by increasing the evidence base on its effectiveness and how it can be scaled up by integration into health services. In addition to FANTA’s work on CTC in emergencies, it developed more time and cost-efficient assessment methods using LQAS designs to reliably measure the prevalence of acute malnutrition in emergencies. See the IR3 section for details on what FANTA did to bring about these policy improvements. 4. Nutrition and HIV/AIDS The cutting-edge work of FANTA to find answers and seek solutions to the difficult new challenge of nutrition and HIV/AIDS has had many impacts on improving strategy and policy. Some major examples are presented here and discussed further in the IR3 section. FANTA’s technical input to the PEPFAR 2005 Report to Congress on Food and Nutrition for People Living with HIV/AIDS, and to guidance that FFP and PEPFAR provide about food and nutrition components of HIV/AIDS programs, have increased attention to nutrition and influenced the direction of HIV/AIDS programs in the field. Through its pioneering work in Africa in support of Mission and Regional HIV/AIDS programs, FANTA has adapted global knowledge into country-specific national guidelines that have been produced in twelve countries, five with in-country support from FANTA and seven with indirect technical assistance through regional workshops and a FANTA/RCQHC handbook on national guideline development. FANTA has played a crucial role in integrating nutrition into national HIV responses by working with national AIDS control programs to draft national nutrition and HIV strategies, incorporate nutrition into national HIV strategies, support nutritionists within national AIDS control programs, and develop training and counseling materials in Kenya, Rwanda, Uganda, and Zambia. The manual, Food Assistance Programming in the Context of HIV, that FANTA is producing with its partner, TANGO, in collaboration with WFP, will fill a void and likely have significant strategy and policy impact on how to make food aid an integral component of an effective response. 5. Advocacy and indicators for women’s nutrition FANTA’s work in support of women’s nutrition has been mainly advocacy and indicator development, the first steps toward improving strategies and policies. Although the original FANTA cooperative agreement program description noted that FANTA would promote a life cycle approach to address intergenerational aspects of malnutrition and would “give special attention to…optimal nutrition in girls in childhood and women (a neglected area, with enormous implications for social and economic development),” the evaluation findings are that the nutrition of women and girls has received less focus than various other FANTA Project areas. According to FANTA, this is because of the higher priority that donors, USAID Missions and CSs have placed on other target groups. FANTA’s work on the draft Women’s Nutrition Indicator Guide aims to foster consistent measurement, data collection, analysis, and use of these indicators. This guide, originally begun in Program Year (PY) 4 (FY 2002) and updated to include new indicators, e.g., the Roll Back Malaria indicators for anemia in women, has been delayed in completion. However, it will be useful when finalized in PY 9 (FY 2007). The delays suggest that this guide has been a Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 27 lower priority compared with other FANTA products. See IR3 section for discussion of FANTA’s work to validate a women’s dietary diversity indicator. Another example of FANTA’s work to advance women’s nutrition was its leading the development of the technical brief, Maternal Anemia: A Preventable Killer.6 USAID was happy with FANTA’s collaboration and efforts to bring greater attention to the large and neglected problem of maternal anemia through the technical brief, but wanted FANTA to do more to advocate for action on this and other women’s nutrition needs. 6. Agriculture, food consumption and nutrition linkages FANTA’s role in this area has been a limited, mainly advisory one. It has worked to shape strategic thinking and conceptual frameworks on food security and particularly the “adequate food access” outcome, e.g., its work on assisting FFP with their strategy development and its collaboration with the Africa Bureau and the Partnership to cut Hunger in Africa. The 2002 external assessment of FANTA recommended that, “FANTA needs to increase its support to food security issues that encompass agriculture and other food access measures” (2). FANTA had decided that its role in working on increasing agricultural productivity, purchasing power, and livelihood security would be justified only if the intended outcome of such efforts was to directly increase food consumption or nutritional status. Nevertheless, apart from its extensive and important indicator development for measuring household food access, FANTA did not get very involved in improving programming, strategies and policies for strengthening agriculture, food consumption and nutrition linkages, or evaluating promising practices. It should be noted that to do this, they would have needed to receive DA funds from Missions or from the Economic Growth, Agriculture, and Trade Bureau (EGAT), which had suffered serious cuts in recent years. Few Missions contributed DA funds to FANTA; DA represented only 7% of Regional Bureau, Regional Mission, and Mission field support, with no funding from EGAT. The principal source of DA funds that FANTA received was FFP; however, these were more than fully subscribed by all the support that FANTA provided FFP. Several people interviewed from CSs, FFP, and USAID Missions wished that FANTA could have done more to assist in this area of Title II and food security programming and policy, noting that this is a real need that no one else is filling and one in which FANTA and its partners have expertise. 7. Nutritional advocacy using PROFILES FANTA supported the use of PROFILES in Rwanda, Benin, and Ethiopia, and the development of new models for policy analysis, planning, and advocacy on women's nutrition. After PROFILES was presented in Ethiopia, examples of its impact are: 1) the opening of a new Nutrition Office in the Ministry of Health, 2) stronger nutrition components in Title II DAPs, and 3) the USAID Health Office’s adoption of the Essential Nutrition Actions approach. 8. Summary of Key Findings • FANTA has had a major impact on establishing improved nutrition and food security strategies and policies, with the most significant examples being its work shaping the FFP Strategic Plan, drafting and launching national guidelines for nutritional care and support for HIV/AIDS in Africa, and achieving UN endorsement of the use of CTC for the management of severe acute malnutrition. • Leadership on women’s nutrition and on improved agriculture, food consumption, and nutrition linkages have received less of FANTA’s attention than originally proposed, 6 Done in collaboration with USAID staff, and the A2Z and ACCESS Projects (6). 28 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project compared to other project areas, and deserve greater priority in the future. The work FANTA has done on anemia in women, however, has been useful and merits additional advocacy for gaining commitment to action by stakeholders. D. PROMOTION OF PROMISING PRACTICES AND ACCEPTABLE STANDARDS FOR NUTRITION AND FOOD SECURITY POLICY AND PROGRAMS TO USAID, COOPERATING SPONSORS, AND OTHER KEY STAKEHOLDERS, AND THEIR ADOPTION (INTERMEDIATE RESULT IR3) The purpose of IR3 is to advance USAID’s global leadership role through FANTA by promulgating to a wide stakeholder audience the use of evidence-based, promising practices and acceptable standards in nutrition and food security. FANTA’s IR3 approaches include operations research, analysis, documentation, consultation, and dissemination through training and technical assistance. Results for the two IR3 indicators FANTA reports on are as follows: 1) Percentage of funding from sources other than GH. Result: The cumulative non-GH contribution to FANTA through FY 2006 is $22.6 million or 59% of total funding received (6). This is discussed further in Section E.2., Project Management, Resource Utilization. This may not be a complete accounting because it does not include significant in-kind contributions of staff, transportation, material, publication, and other costs associated with collaborating in activities FANTA has initiated; however, it does suggest that other USAID constituents beyond the GH Bureau have taken up promising practices. 2) The number of promising practices and acceptable standards identified, produced, and disseminated by FANTA. Results: FANTA developed numerous methods, indicators, guidelines, and job aids that have been widely disseminated and rapidly adopted. Table 2 shows a very crude accounting of this indicator by year in the second half of the project (6). Table 2. Number of Promising Practices and Acceptable Standards Disseminated PY5 PY6 PY7 PY8 FY 2003 FY 2004 FY 2005 FY 2006 Number of promising practices and acceptable standards identified, produced, and 7 8 8 14 disseminated. 1. Information Dissemination on Promising Practices Program recipients and academic reviewers alike attest to the scientific quality of the information that FANTA has disseminated and its general usefulness for the field. Appendix G shows the Top Ten PDF Document Downloads from FANTA’s Web site for FY 2003–2006, derived from FANTA’s annual reports (6). The Anthropometric Indicators Measurement Guide heads the list all four years. More recently, materials on nutrition for Persons Living with HIV/AIDS (PLWHA) have been extensively downloaded (100,000s in Africa) (6). The Bookmarks from FANTA on Anthropometry Basics and Assessing Nutrition Situations in Emergencies are very popular with PVOs in the field per CSTS (6). Mission suggestions include e-mail or mail delivery of brief technical updates from FANTA. Missions and CSs also need FANTA assistance to give them the skills to write articles themselves for on-line publications, newsletters, and even peer-reviewed Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 29 journals using all of the learning and information that USAID-assisted projects have contributed to the state-of-the-art. This is especially important for documenting Title II program accomplishments as phase out approaches. FANTA’s ability to assess needs for technical materials and to fill these gaps rapidly and solidly has been one of the most appreciated aspects of the project. Through FANTA, USAID has been an important source of effectiveness research to test and validate new approaches and the indicators to measure this effectiveness. Two of the most significant examples are contributing to the evidence base on appropriate nutritional care and support for HIV/AIDS, and advancing the state-of-the-art in community-based management for severe acute malnutrition in children. Over the life of the project, FFP, OFDA, and the PVO community have incorporated information that FANTA has generated on guidelines for preparation and review of proposals and on proposals submitted to USAID and in field implementation of USAID-supported programs. Several UN agencies, led by WHO/UNICEF, have issued a joint statement that all countries should strive to use an integrated approach for the management of SAM, which includes CTC for severely acutely malnourished children per the guidance developed through USAID and FANTA’s work with Valid International, Concern Worldwide and others. Through IR3 activities, FANTA has been very successful in advancing promising practices and acceptable standards for food security and nutrition programming along the structured “Pathway from Research to Field Implementation and Use” as intended in USAID, health-related research and development (11). The USAID health research to implementation pathway—a cycle of assessment, development, pilot testing, and introduction of products and approaches—appears in Appendix H. This approach is similar to that referred to in domestic health as a translation of evidence-based practices into broad applications (14). FANTA’s work in IR3 is mapped along the USAID pathway in Table 3 (next page). It is important to note that OTHERS’ uptake and application of work FANTA initiated is considered an even more powerful accolade than FANTA’s own publications. In the table’s framework, “Assessment” is not represented, as this is an internal USAID activity, and “Global Consensus and Codification” has been added to indicate those practices and standards that FANTA has helped move into international practice. We discuss below by program focus area FANTA’s specific contributions in increasing the evidence base for nutrition and food security policy and programs, and in facilitating their translation into practice. While there is considerable overlap and cross-fertilization among the areas, an attempt is made to discuss each achievement, product, or contribution only once. 2. Tools and indicators for assessment, monitoring, and evaluation FANTA was specifically charged with assisting USAID to use its Title II food aid programs to enhance the effectiveness of child survival, maternal health, nutrition, and food security. In later project years, FANTA also contributed extensively to HIV/AIDS programs implemented through PEPFAR and other sources. Its other key mandate was to strengthen the capacity of Title II program implementers to determine whether they were doing the right things, and if they were doing them correctly (i.e., with total quality management) by improving their ability to measure the impact of programs on household food security, and population-level nutrition and health. a. Measuring food security – Development of new and improved indicators Household Dietary Diversity Score (HDDS) and Months of Adequate Household Food Provisioning Indicators adopted by FFP These two indicators that FANTA developed have been adopted in the Performance Management Plan for FFP’s FY 2006–2010 Strategic Plan for use at the SO level to “capture progress in improving access to food by chronically food insecure households” (9). Furthermore, all new Title II MYAPs, which aim to improve the food access component of food security, are now required to report on one or both of these indicators (8). Both indicators measure improvements in household food consumption and were developed through a consultative process with CSs, researchers, and other technical groups. In order to insure their 30 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project consistent and comparable use, FANTA has developed guides that are available on its Web site, including a standardized questionnaire and analysis instructions. As a breakout issue, FANTA initiated a collaborative project to validate dietary diversity as a measure of the adequacy of women’s diets. This is in its first phase of developing an analytical protocol to address questions on the selection of micronutrients to include in a summary measure of quality; the selection of data sources on food composition; the harmonization of units; and the general analysis approach, using this protocol on one data set. The next phase will use the protocol to analyze several data sets. Household Food Insecurity Access Scale nearly ready for USAID’s full adoption and already in use in broader nutrition and food security community In collaboration with Cornell and Tufts Universities, FANTA has largely completed its work on the Household Food Insecurity Access Scale (HFIAS) and guidance documents. The HFIAS consists of nine questions that have been validated across several countries and cultural contexts and that appear to distinguish food insecure from food secure households in chronically resource poor environments (i.e., not emergency or crisis situations). The HFIAS is an interesting example in which FANTA has built on and adapted for international use a tool that the USDA (U.S. Department of Agriculture) developed to measure food insecurity domestically (The Household Food Security Survey Measure). Hence, the USG domestic investment in the agricultural sector has truly been optimized in the adaptation of this indicator for use internationally, especially in the large Title II program. The HFIAS was developed in response to the need to measure the access component of household food insecurity. An extensive process, including a situation analysis and literature review, followed by field validation studies and years of effort, to collect input from intended users brings the HFIAS development work to its current status. Many of the results have been disseminated through publication in the respected Journal of Nutrition (12). In the last year, FANTA has benefited from close collaboration with FAO to learn from field￾applications of the HFIAS. Many useful insights about the tool and the adaptation process itself have been gained from FAO’s adaptation of the HFIAS in Malawi and two sites in Kenya. In addition, FANTA participates in an Internet discussion forum that FAO organized, in which field experiences with the HFIAS are shared. What remains to be done? Advisory meetings last year resulted in a consensus that the English version of the tool must be refined so that no misunderstandings could occur in any translation7 and that further validation must be conducted across a range of countries and situations. In August 2007, FANTA and FAO will collaborate to test the validity of HFIAS data collected across various countries and contexts. As mentioned above, HFIAS was developed for a chronic food insecurity or development context, and its applicability in emergency settings still needs to be tested. 7 The evaluation team doubts whether this is possible. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 31 32 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Table 3. Areas of FANTA’s Contribution along Pathway from Research to Field Implementation and Use, as of June 2007 Global Consensus Technical area Development Introduction Field Implementation & Codification 1.Tools and Indicators 1.a. Measuring Food Security -HFIAS—Validation studies -HFIAS guide -FAO baseline -J Nutrition Bangladesh, Burkina Faso -FAO adaptation Kenya, Mozambique Supplement Malawi -Semi-annual national -FAO guidelines agricultural survey MOAg, Burkina Faso -HDDS- Validation study—meta -HDDS guide -FFP MYAPs with access -FAO guidelines analysis 10 data sets (2002) components -WFP VAM and Result Management Indicator 1.a. (1) Validating Dietary Diversity to Measure Adequacy of Women’s Diets -Validation study (ongoing) -DHS instrument and tabulation guidelines 1.b. Measuring Infant and Young Child Feeding (IYCF) Practices -Ethiopia DHS analysis -DD, diet quality and child growth analysis—10 data sets -IYCF indicator validation study—10 data sets -DHS instrument and tabulation guidelines -KPC 2000+ Module 2 -IYCF update (ORC Macro) -DHS Country reports -WHO indicator guidance (forthcoming PY09) 1.c. Monitoring Title II Development of LQAS- LQAS for TII program LAYERS approach and monitoring, and closing applications audit recommendations. 1.d. Improving rapid assessment of malnutrition Improving methods to assess the prevalence of acute malnutrition Computer simulations to develop methods. Int. J of Epidemiology article in emergencies Presentation at CRED/LSHTM conference in Belgium - Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 33 Table 3. Areas of FANTA’s Contribution along Pathway from Research to Field Implementation and Use, as of June 2007 Global Consensus Technical area Development Introduction Field Implementation & Codification 2. Nutrition Interventions 2.a. Community Management of Acute Malnutrition (CMAM –CTC) Field study—RUTF for recuperation of moderate acute malnutrition -Monitoring effectiveness study—Ethiopia, Malawi -CTC Field Manual -CTC training modules (on￾going) -CTC Review—Ethiopia, Malawi, Niger (ongoing) -CTC scale up (MOH/Valid/Concern) in Ethiopia, Malawi -CMAM trainings -Joint UNICEF/WHO/ WFP/SCN statement on CMAM in children. -TALC publication of Caring for Children with SAM 2.b. Preventive vs. Recuperative Nutrition Interventions -Field study—Haiti -FFP Guidelines (since 2001) -MYAPs 2.c. Anemia Girl Guides Badge Program Developed set of educational programs and activities w/ RCQHC & WAGGGS Implementation in Swaziland, Rwanda, Uganda. 3. Nutrition and HIV/AIDS 3.a. HIV Nutritional Care and Support -Targeted evaluations in Kenya, Malawi- supplementation for -Multiple guides, handbooks, online references and -Multiple countries: National Nutrition Care -WHO Durban consultation pre-ART and ART: RUTF, manuals on nutritional care and Support Guidelines, Statement, CSB, and nutrition counseling & support, as well as curriculum, training and incorporated into alone. development of national counseling materials Report by Secretariat guidelines. -OGAC Food and Nutrition for PLWHA to WHO Executive Board Report to Congress, Guidelines 3.b. Mitigation of Impacts of HIV WFP/FANTA Food Assistance in Context of HIV Guide -HIV Mitigation: Using What we Already Know (forthcoming) Tech Note (2002) -HIV/AIDS and Food Aid Entebbe workshop 34 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project b. Measures and indicators for infant and young child feeding (IYCF) practices incorporated in broader survey tools (e.g., DHS); analyses of DHS and KPC data informed nutrition policy across USAID-sponsored projects FANTA has developed improved methods for the use and interpretation of existing survey data on IYCF practices, as well as new and better indicators for measuring appropriate IYCF practices. Their work includes guidelines for the collection, tabulation, analysis, interpretation, and presentation of feeding data for children from birth through 23 months of age. FANTA has also supported analysis on the relationship between child nutritional status, and infant and young child feeding practices. Results from these activities are survey guidelines now in use for IYCF data collection and analysis in the DHS and in the KPC 2000+ Module 2 used in the CSHGP. The new IYCF indicators were used by ORC Macro in an analysis of results from DHS that it conducted between 1998 and 2004 in 43 countries and published in Infant and Young Child Feeding (IYCF) Update in 2006 (10). On a very fundamental level, FANTA supported the development of a model for use in PROFILES, to quantify the effects of improvements in nutritional status, measured as weight-for-age, on child mortality. This is based on the work of Pelletier and Frongillo, which FANTA broadly disseminated in 2003. What remains to be done? A number of USAID Missions in Latin America and elsewhere use the CDC Division of Reproductive Health, not DHS and ORC Macro, to do their five-year national health surveys. Therefore, FANTA should also share the new guidelines for IYCF indicator use and interpretation with this CDC division and urge that they be used in surveys done by CDC. c. Lot Quality Assurance Sampling-Layers Program developed for and used by USAID to monitor and evaluate Title II programs. LAYERS is a data collection, entry, and analysis system using hand-held computers (or personal data assistants, PDAs) and software that FANTA developed. It is based on principles of Lot Quality Assurance Sampling (LQAS) adapted from industrial quality control. Layers was developed and employed to help USAID Missions in Haiti and Madagascar respond to Inspector General (IG) audit recommendations that Title II program monitoring was weak and needed to be improved. The improvements made by using Layers were considered satisfactory by the IG. Later, Layers was also introduced in Ethiopia. Currently, Layers modules have been developed 1) to: 1) assess the quality of MCHN, Food for Education and Food for Work components of Title II programs; 2) evaluate the management of USAID-supplied commodities (from food aid to vaccines and drugs); 3) verify the correct application of Tiahrt Amendments in USAID-funded family planning activities; and 4) measure HPN program outcome data for USAID/Madagascar. At the GH’s request, FANTA is currently testing Layers as a rapid and relatively inexpensive survey tool to collect population-based, HPN program outcome data between DHS 5-year waves in USAID/Madagascar (building on earlier work) and in USAID/Guatemala. Such HPN program outcome data would be very useful to inform decisions on standard indicators in the F process. What remains to be done? Some “complaints” about FANTA’s implementation of Layers are that the manuals have not yet been published and that FANTA has been programming each application on a custom basis, contributing to delays in implementation, increasing costs, and hindering sustainability. Some applications could be developed as stand-alone modules. This requires FANTA staff or its designees to produce the documentation and software packages necessary and to conduct training for such dissemination and technology transfer. d. Lot Quality Assurance Sampling to assess the prevalence of acute malnutrition FANTA has also used the principles of LQAS to develop new sampling designs for rapid, cost￾effective assessment of the prevalence of acute malnutrition. The designs were developed by computer simulations that tested the limits of LQAS inferences that could be made with small samples about the prevalence of acute malnutrition; they were then field-tested in Ethiopia and Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 35 Sudan. The work was recently published in an article in the International Journal of Epidemiology (13). FANTA made a presentation of the work at the second international conference of the Centre for Research on the Epidemiology of disasters (CRED)/London School of Hygiene and Tropical Medicine (LSHTM), “New Methods for Surveying Health in Complex Situations” in Brussels, Belgium, in June 2007. OFDA recently requested FANTA to train Ministry of Health staff to implement the designs in Burkina Faso. What remains to be done? A technical concern is that rare phenomena, e.g., crude and under five year death rates, require larger samples for precise measures. FANTA acknowledges that some programs will be tempted to use LQAS (because it may be faster and cheaper) when a different sample design may be more appropriate for the purpose of the survey. Therefore, while LQAS methods are relatively cheap and easier to operate and interpret, as with any sampling protocol, sophisticated skills may be required to determine the most appropriate sampling method to use. This is an area where FANTA or future programs need to provide more guidance for decision￾making on appropriate use of sampling tools. 3. Infant, Child and Adolescent Nutrition—Emergency, Transitional and Development Context Interventions Over the life of the project, FANTA has worked in a highly collaborative manner with international organizations to identify, test, and promote promising interventions to reduce child and adolescent malnutrition. Highlights include CTC for severe acute malnutrition (SAM) in emergencies; testing a preventive vs. a recuperative nutrition approach for children under two years in Title II MCHN programs in vulnerable/transitional contexts; and development of a Girl Scout/ Girl Guide merit badge program to prevent anemia in adolescent girls in development contexts. In these areas, USAID, through FANTA, has shown true global leadership as described below. a. Community-based therapeutic care (CTC), now referred to as Community Based Management of Severe Acute Malnutrition, (CMAM) adopted by WHO, UNICEF, WFP and the UN Standing Committee on Nutrition (SCN) The product and the approach in a nutshell: The traditional approach to rehabilitating severely acutely malnourished (SAM) children in emergencies has been in therapeutic feeding centers (TFC), where wasted children first receive therapeutic milk formula F-75 to condition them medically to receive food, and then formula F-100, with a higher nutrient content, allowing for weight gain and overall rehabilitation. In 1998, the French company Nutriset, which also makes F75 and F100, developed “Plumpy’nut,”8 a ready-to-use therapeutic food (RUTF), consisting of peanut paste, milk sugars, fats, and added micronutrients, as a possible, take-home replacement for F100. One advantage of RUTF, and Plumpy’nut in particular, is that they require no added water or mixing, and come in sanitary pre-portioned units. Mothers are instructed that the food contains medicine that their malnourished child requires and that they should not give it generally to their other children—an admonition that they appear to obey (see below). With this product in hand, mothers are able to care for their malnourished children at home, bringing their child back on a weekly basis for a physical examination, and to receive another week’s supply of RUTF. This community-based management frees mothers from spending up to 6 weeks with one child in a feeding center. As vulnerable, malnourished children are not housed in a facility, there is less transmission of infection. Because the mothers are at home, there is less chance of other children becoming sick or dying in their absence. In addition to the product, the approach requires 8 Andre Briend, now at WHO, created Plumpy’nut while at the French Institute of Research for Development (IRD, formerly ORSTROM). 36 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project communication and mobilization: community volunteers go out to a village or camp and using Mid-upper Arm Circumference (MUAC), identify children for the program. When children are weighed at weekly check-ups, mothers are reminded about not sharing the product in the household, if children haven’t made sufficient progress, and other community members are asked to reinforce this reminder. The CTC approach engages the entire community in the care of children, rather than disenfranchising the mothers and the larger community by institutionalizing children. As a result of implementing a community-based approach, one major implementer and FANTA collaborator, Concern Worldwide, reports coverage of 70% of children needing rehabilitation, compared to 10-20% coverage seen in feeding TFCs. It’s important to note that CMAM still includes a triage of children who are anorexic or ill, who are treated at in-patient facilities for up to 7 days, until they can be discharged for CTC. What did FANTA do? According to the main players in this arena, FANTA’s first key contribution was having the vision to see the potential of this approach early on,9 and providing guidance and funding to create the evidence base. In 2003, FANTA (with funding from OFDA) supported Valid International to test the CTC approach in different contexts, to evaluate the program against international standards, and to identify implementation problems. The study compared alternative RUTFs for the severely acutely malnourished, a descriptive study of CTC in the context of the Ethiopia famine, and a comparative study of the Malawi CTC program’s home￾based care versus standard center-based care. These studies showed a range of better outcomes using CTC and the costs appear to be no more per beneficiary than to operate a traditional TFC. (However, there are many more beneficiaries.) With this evidence, FANTA engaged the PVO community in Ethiopia and Malawi to take up the CTC approach and supported the development of publications and training materials. FANTA facilitated the dialogue with WHO, UNICEF, and the broader international community. According to one international respondent, FANTA was “very responsive in engaging with European NGOs. They held one workshop in Dublin in 2003 and a later one in March 2005. The first workshop was almost entirely European NGOs.” FANTA is doing an ongoing review for OFDA of CTC on PVO integration into health services and scale-up by PVOs in Malawi, Ethiopia, and Niger, including development of a cost analysis tool. t. FANTA is also preparing a training manual to accompany the 2006 CTC Field Manual that will be used at a regional training for PVO and MOH personnel in Africa with co-funding from OFDA, the United Kingdom Department for International Development (DFID), and UNICEF. Conclusion: FANTA helped develop the evidence base that CTC works extremely well in emergency contexts. The UN has just issued a joint statement that, going forward, an integrated facility and community-based approach should be used to manage severe acute malnutrition. This is a profound change in humanitarian nutrition policy, and USAID through FANTA is seen as having been a key catalyst. What remains to be done? Operations research and cost effectiveness studies are necessary to determine the role that RUTF and CTC can play in non-emergency (transitional and development) contexts in communities and countries with a high prevalence (>=10%) of moderate and severe acute malnutrition or wasting. In such high prevalence settings, one possibility is to add some aspects of CTC to Integrated Management of Childhood Illness (IMCI) protocols, e.g., routine measurement of MUAC on every visit to a health center, with referral to CTC for those who show signs of moderate to severe acute malnutrition. The community mobilization aspects are challenging. Through Concern and Valid, Malawi, Ethiopia, Rwanda, Zambia, and Haiti are piloting this approach as a precursor to national policy development. The 9 FANTA contacted Nutriset and Valid International in 1999-2000. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 37 potential use of CTC and RUTF for HIV+ adults undergoing antiretroviral therapy (ART) is being assessed (see below under HIV). In addition, FANTA is currently supporting Washington University at St. Louis to compare the effectiveness of milk-peanut RUTF, soy-peanut RUTF, and CSB in supplementary feeding of children with moderate acute malnutrition in Malawi. This study will help answer the question of the role RUTF can play in addressing moderate acute malnutrition, and the relative effectiveness and cost-effectiveness of soy-based and milk￾based RUTF. A major issue is the cost of RUTF and problems associated with importing the product or its components from Europe. At current prices, a course of RUTF for rehabilitating a wasted child is several hundred dollars. In the development context, the “market” for RUTF is about 1% of the children in a country; however, in countries such as Bangladesh or India, this is still a huge number of children and, at $100 per child, the cost would be staggering. There would appear to be some scope for social marketing activities around RUTF, but the results of work to determine whether it has a place in either long-term prevention of SAM or treatment of moderate acute malnutrition remain to be seen. It is far less expensive to prevent SAM than to treat it later, not to mention preventing the immediate and possibly permanent health and cognitive consequences of SAM for the child. It is believed that the price can possibly be cut in half through “local” production (i.e., setting up factories in regional capitals, not at the village level). However, the cost of imported powdered milk has doubled in the past year,10 and the micronutrient mix is still imported from European pharmaceutical companies. Valid and other organizations are now working to develop and test new recipes and formulations. At this time, the best shelf life achieved for locally produced RUTF is six months, compared to two years for Plumpy’nut. For peanut-based products, there is a concern about aflatoxin contamination and control in Africa, as many countries do not have the ability to test for this toxin, which makes peanuts poisonous. In interviews, the evaluation team sensed much excitement about the possibilities for CTC, but also some confused thinking. Given that there is a product associated with CTC, namely RUTF, and that it is “new,” some (not FANTA) see it as a “magic bullet” for solving the malnutrition problem, even in non-emergency settings. Our view is that this is a good public health example of where an ounce of prevention will be worth a pound of cure. In non-emergency contexts, where the prevalence of wasting in children is less than 10%, it is important to put the first priority on preventing malnutrition by improving IYCF practices through programs like community-based growth promotion for all children under two years of age, such as FANTA is supporting in Central America and Haiti. However, lessons learned about the importance of behavior change interventions to improve infant and young child feeding practices and, thus, avoid frequent relapses into malnutrition of children who have recuperated from acute malnutrition must not be forgotten. b. Preventive vs. recuperative child nutrition interventions in transitional, shock-prone contexts FANTA implemented several activities to answer the persistent question, “What should Title II programs do to about undernourished children in non-emergency, but vulnerable, shock-prone or transitional contexts?” FANTA’s publication on Improving the Use of Rations in Title II – Assisted Maternal and Child Health and Nutrition Programs laid out the scientific rationale for targeting food rations and MCHN activities to all children less than 2 years of age in relevant program areas in order to achieve the best nutritional and health impact on the population. In 2001, FFP revised the DAP Guidelines to recommend this approach. However, some PVOs still hesitated, claiming that the evidence was not sufficient that there was a greater impact of the preventive approach on reducing malnutrition than the approach of targeting rations to treat 10 According to Briend at WHO, this is due to China becoming a major importer of the product and driving up demand. 38 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project malnourished children less than five years of age. Through a competitive process among FANTA’s sub-grantees, USAID/Haiti, World Vision (WV)/Haiti and FANTA selected IFPRI and Cornell University to conduct a long-term study of the question. Reports on the findings are available on the IFPRI Web site, including an ethnographic assessment of the community’s perspective on these approaches. Thanks to WV’s willingness, it was possible to randomly assign program villages to the two approaches, which is often not feasible in operations research. Cross￾sectional surveys were conducted to assess the prevalence and severity of malnutrition among children 12–42 months of age at baseline and after three years, and statistical methods for analyzing group randomized designs were applied to evaluate impact. The results are that children in communities receiving the preventive program have a lower prevalence of stunting, underweight, and wasting (23.2%, 22.9%, and 5.2%, respectively) compared to children in the recuperative program communities (28.6%, 30.1%, and 9.2% respectively) after 3 years of program implementation. The study is being readied for publication in a peer-reviewed journal. FANTA is also conducting or providing input to smaller operations research on the impact of the micronutrient supplement, Sprinkles, on child anemia. What remains to be done? As with any study of this nature, critics have raised a number of technical issues (cross-sectional vs. longitudinal designs; the need for concomitant mortality data; Haiti’s unique geopolitical situation; and that “with that much food you would expect any community to do better”). The rate of 5.2% wasting in the preventive communities is indicative of the persisting crisis in Haiti and, therefore, some have suggested that it is difficult to generalize from Haiti. However, it may be considered a worse case scenario, and better results could be expected in more stable settings. Through this research, FANTA has provided additional evidence that supplementing all children 6–24 months with food and preventing malnutrition is more cost￾effective than recuperative feeding of malnourished children less than five years old. Calls for replication of this study should be ignored in favor of other less well understood interventions identified by FANTA, e.g., “food by prescription” for PLWHA, follow-up of children recovering from severe acute malnutrition who received CMAM, building the costs of the preventive approach into food security and food aid interventions, and food supplementation in the context of HIV. c. Prevention in a Development Context: Anemia girl guides badge program Driven by the USAID/East Africa (EA) focus on maternal nutrition, FANTA collaborated with the Regional Center for Quality of Health Care (RCQHC) and the African Regional Office of the World Association of Girl Guides and Girl Scouts (WAGGGS) to implement activities to reduce iron deficiency and anemia. The consortium developed a set of educational programs, community activities, and manuals on anemia control that allow participating Girl Guides (ages 7–18 years) to earn a merit badge. FANTA and RCQHC have trained Girl Guide Leaders and key representatives from Ministries of Education and Health in Swaziland, Rwanda and Uganda, where the program has been enthusiastically embraced. What remains to be done? This is not the first time that a nutrition program has tried to work with WAGGGS, but it might be the most successful result. It would be worthwhile for FANTA to get feedback from the consortium to see what the missing ingredients were that prevented full implementation of earlier ideas compared to FANTA’s success. With a network of approximately 500,000 girls across Africa, and ten million adolescent girls throughout the world, WAGGGS offers a terrific channel for reaching girls with a range of health and nutrition interventions to improve their current and future health as women. Additional modules on folic acid and malaria control could be imagined, if the WAGGGS channel can be kept open and supported through a USAID project. While it makes sense to try to evaluate the impact of this approach on reducing women’s iron deficiency, that seems less important than the role this kind of intervention has in Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 39 sensitizing and educating young women and girls about their own health and nutrition. Such impacts are so long-term and diffuse as to make them virtually impossible to evaluate. 4. Nutrition and HIV/AIDS In response to an overwhelming need for policy guidance and technical assistance in the area of nutrition and HIV, USAID deployed FANTA at all levels during the second half of the project with funding and a scope of work equivalent to a separate project. An estimated 15% of the total FANTA funding through FY 2006 or approximately $5.6 million has been used for HIV/AIDS activities. These funds received from USAID/EA (East Africa Regional Office) and Missions in Kenya, Rwanda, Uganda, Namibia, and Zambia, as well as from the Africa Bureau, and GH/OHA, enabled significant dedication to HIV/AIDS work of core staff and regional positions in East Africa and the placement of a local advisor in Rwanda in 2005-2006. FANTA also collaborates with numerous consultants and institutions at the global, regional, and country levels. Since the commencement of PEPFAR in FY 2004, FANTA has provided continuous consultation, including technical input to PEPFAR’s Report on Food and Nutrition for People Living with HIV/AIDS that was submitted to Congress in 2005, and to guidance that PEPFAR provides to the field about food and nutrition components of HIV programs. FANTA’s primary charges have been to strengthen the evidence base on the role that food and nutrition play in HIV/AIDS care, to develop and disseminate guidelines for programs and policies, and to strengthen the implementation of nutritional care in HIV/AIDS treatment and care services. USAID Mission staff were pleased with FANTA’s assistance and found it extremely effective. They praised the way FANTA worked hand in glove with the MOH and built national capacity and ownership, rather than directly implementing the program itself. Tools developed in one country are being adapted for use in many others, and so there has been a great multiplier effect. Others interviewed found FANTA’s work very pioneering and proactive; they couldn’t say enough good things about them. The highlights are discussed below. a. HIV Nutritional Care and Support Guidance and program tools from an emerging evidence base FANTA first produced HIV/AIDS: A Guide for Nutritional Care and Support (2001) with guidance on nutrition interventions for HIV-affected populations (households, communities and individual patients) (6). The guide was updated in 2004 to incorporate new evidence, WHO recommendations, nutritional implications of antiretroviral therapy for HIV/AIDS (ART), as well as nutritional needs of HIV￾infected pregnant and lactating women. In addition to its wide use by HIV programmers and service providers, the guide has served as the basis for regional and national guidelines throughout Africa. With the RCQHC in Uganda, FANTA supported regional workshops on national guidelines and produced Handbook: Developing and Applying National Guidelines on Nutrition and HIV/AIDS (2003) that provides steps and guidance on developing, applying, and assessing national guidelines (6). Since 2003, this technical support helped twelve countries to produce national guidelines. In order to provide more specific guidance on the emerging area of ART and nutrition, FANTA published Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings (2003, revised 2004) (6). This led to a job aid for ART service providers on managing nutritional implications and informed a 2005 regional forum on ART and nutrition that FANTA and RCQHC facilitated. Within and since publication of these guides, FANTA has assisted countries and programs to produce job aids, training manuals, program operations manuals, and guidelines at all levels. An important emphasis has been the “care” aspects, including management of symptoms, food, and water hygiene, the management of drug-food interactions, and counseling to support improved diets with available resources. FANTA initially produced prototype materials at the regional level that have been used and adapted in multiple countries. For example, with LINKAGES and RCQHC, FANTA developed Nutrition and HIV/AIDS: A Training Manual (2003) to strengthen health care provider capacities in nutrition and HIV (6). The manual has been used and adapted in 40 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project several countries in the east and southern Africa region. At the regional level, FANTA has worked with partners to strengthen the nutrition and HIV capacities of resource persons, conducted reviews of nutrition and HIV programs to identify promising approaches, and reviewed specialized foods targeted to Persons Living with HIV (PLHIV). In Kenya, Rwanda, Uganda, and Zambia FANTA developed national guidelines and counseling materials and provided training to service providers in nutrition and HIV. FANTA has also supported integration of nutrition into national HIV strategies and coordinating bodies, and has provided technical input to the design and monitoring of nutrition and HIV programs. The scope of FANTA’s nutrition and HIV/AIDS work is equivalent to a separate project, and FANTA continues to respond to requests for technical assistance in this vastly underserved area. Effectiveness Trials of Promising Practices Important questions exist about the impacts of providing food supplements to malnourished PLHIV, including: 1) the role of food supplements as an incentive to adhere to HIV treatment; 2) the ability of food supplements to offset lost income and household expenses caused by HIV; and 3) the physiological contribution of food supplements to improve tolerance and effectiveness of ART, survival, nutritional status, functioning, and quality of life. FANTA is contributing to the evidence base in these areas through randomized trials to evaluate the impacts of food supplementation with different food products on malnourished HIV+ adults. A number of programs that host country governments, PEPFAR, the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), and others support provide food supplements to malnourished ART clients and other PLHIV. However, as one researcher said, “We all acknowledge that, when people give ART to wasted adults, they feel compelled to give food supplements. It’s an open question as to whether this is a helpful expense for these programs. Should they invest in specialized foods, or not? The answer is worth millions of dollars.” By evaluating the various impacts of food supplements, FANTA is making a major contribution to answering these questions. The study FANTA is supporting in Kenya with KEMRI compares clinical and nutritional outcomes of malnourished adult ART and pre-ART clients receiving a fortified blended corn-soy flour with those receiving only dietary counseling. The study FANTA is supporting in Malawi with the University of Malawi and Washington University at St. Louis compares clinical and nutritional outcomes of malnourished adult ART clients receiving RUTF with those receiving CSB. These trials will produce results that can inform PEPFAR policy by the State Department’s Office of the Global AIDS Coordinator (OGAC) concerning when (and whether) to provide food supplementation to PLHIV with moderate or severe malnutrition as measured by Body Mass Index (BMI). The results can also inform policies, recommendations, and programs supported by WHO, WFP, GFATM, and other institutions. What remains to be done? Further dissemination and capacity building with the FANTA guidelines and training manuals will be useful. There is an enormous gap in the evidence base on nutritional care and support for HIV/AIDS that goes well beyond the timeframe and role of FANTA or a future similar project. These research questions include among others: 1) whether initial nutritional stabilization before ART results in better outcomes than starting ART in acutely malnourished adults at the same time as (or even in the absence of) nutritional support. (This could be a follow-on to research FANTA is conducting in Kenya and Malawi); 2) whether RUTF contributes to recovery from opportunistic infection in HIV+ persons; 3) testing alternative RUTF recipes for use with PLWHA to cut costs, e.g., reducing milk content and eliminating peanuts; and 4) better defining nutritional requirements in pediatric AIDS. b. Food Security and Food Aid Interventions to mitigate the impact of HIV/AIDS There are many programmatic and operational challenges in this relatively new intervention area. FANTA’s first efforts included collaboration with Cornell University to produce the 1999 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 41 publication Potential Uses of Food Aid to Support HIV/AIDS Mitigation Activities in Sub￾Saharan Africa. Building on this activity, FANTA has continued to support FFP to guide food aid programming to address HIV, including a regional workshop in November 2004, input to guidance and review of Title II proposals, and a recent concept paper on food security and food aid to mitigate the impact of HIV/AIDS, which FFP presented to OGAC. Approximately $45 million worth of Title II commodities per year are directed to mitigating HIV/AIDS. FANTA partnered with Technical Assistance for NGOs (TANGO) to produce a manual, Food Assistance Programming in the Context of HIV, written in collaboration with WFP. According to TANGO, the manual is taking a long time to complete due to the highly participatory nature of its creation. Building on an ever-improving literature base, the manual includes country case studies, results of an NGO workshop on promising practices, and review by scores of program implementers. USAID/EA expressed dismay about the time lag for this product. However, when guidelines are produced through a participatory, consensus-building process they take much longer; nevertheless, they are usually adopted even before publication due to the ownership the intended users feel for them. What remains to be done? The manual and overall guidance on integrating food aid and nutritional support into a comprehensive HIV/AIDS response is still largely at the level of “promising practices” and not evidence-based. This lack of evidence on what works in sector￾based, food-based, or nutrition interventions for HIV/AIDS is hampering CSs and USAID in optimizing Title II resources to respond effectively to food insecurity and malnutrition in the context of HIV/AIDS. Therefore, evaluating the effectiveness of promising PVO practices and programs in this area is a high priority for a future project, followed by updating guidance based on the results. 5. Additional needs or gaps to address before FANTA ends, if time and funds permit, or as a top priority during the first year of a new nutrition and food security global project: • Develop several teaching or training modules on basic applications of “Layers” that could be broadly disseminated without customized technical assistance. • Present lessons learned and major products (manuals/guides, etc.) on promising practices and acceptable standards in form of final training workshop(s)/conference(s) for CSs, PVOs, and other stakeholders. Maximize dissemination opportunities. • Once clinical trials are completed of food supplementation for HIV/AIDS patients on ART, present FANTA’s work on guidelines, training and counseling materials, and food supplementation to appropriate cooperating agencies (CA) of GH/OHA and to OGAC, either in a conference organized by FANTA or by taking advantage of events planned by others. The goal is to mainstream this work and get other CAs to adopt and expand it. • Because the USAID Bureau for Global Health/Office of Population and Reproductive Health (GH/PRH) has the USAID mandate for work on adolescent reproductive health, in order to gain additional support for anemia prevention and control for adolescent girls, if it proves effective, FANTA should present its work on the Girl Guides Project jointly to GH/PRH and GH/HIDN and to the A2Z Micronutrient and Child Blindness Project. 6. Summary of Key Findings • A unique feature of FANTA that all interviewed felt should be preserved in future efforts, are the bridges it has built between GH, FFP and its CSs, Missions, regional institutions, host country governments, implementing agencies, and the academic community. Quoting from interviews: “FANTA added value—academic rigor to ground up field methods; realism and simplicity to academic protocols—on every transaction between 42 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project academia and the field, in both directions.” “Having a team, or project, available to step back from the day-to-day operations in these highly charged areas, HIV, emergency response, Title II MCHN programs, and reflect on whether these things really work, and how we know it is beneficial to us all.” • FANTA has designed more effective and efficient measures at all stages of Title II monitoring and evaluation. These are greatly appreciated and widely used. They include new and improved indicators, performance monitoring systems, impact survey design, data collection, and analysis. • FANTA’s ability to assess needs for technical materials and to fill these gaps rapidly and solidly has been one of the most appreciated aspects of the program. • Through FANTA, USAID has been a global leader in effectiveness research on new approaches for nutrition and food security policy and programs. FANTA’s most significant contributions are demonstrating that CTC works extremely well for managing severe acute malnutrition and that a preventive approach to child malnutrition is more cost-effective than a recuperative one. Through ongoing trials FANTA is also defining appropriate nutritional care and support for HIV/AIDS. E. PROGRAM MANAGEMENT 1. Program operations/management USAID/Washington GH and DCHA Bureaus, Missions and senior AED staff see FANTA as well managed and exhibiting few problems. The talented and dedicated staff and the continuity of senior management at FANTA and USAID have contributed greatly to the project’s success. The CTO has been a solid manager and a good advocate who has provided good institutional knowledge and technical leadership. FANTA’s many clients throughout USAID appreciate the CTO’s skill at facilitating appropriate collaboration with and use of FANTA. This has enabled FANTA to expand its reach and to build bridges between USAID GH/HIDN, GH/OHA, FFP, OFDA, Africa Bureau, Regional Missions, Missions, implementing agencies, and international donors. Strong technical leadership of FANTA by the Project Director, former Director, and Deputy Director—all top experts in their fields—has been fundamental to the project’s success. However, given many continuing demands for their technical advice, combined with their heavy management responsibilities, the Director and Deputy Director appear to be overextended. Several Missions complained about delays in getting LQAS Layers work done, because only the Deputy Director can help them with it. In preparing for the final year of FANTA close out and even greater management demands on the Director and Deputy Director, it will be important for them to look for further opportunities to delegate work to others. Such delegation is also necessary to afford them time to complete important writing tasks, such as fully documenting the history of assistance to FFP and preparing manuals and lessons learned for the LQAS Layers. FANTA’s standard procedure of clearly defining the concept for activities from the beginning, reaching agreement with all involved in the activity, and adhering to that concept throughout has been very effective and contributed to their responsiveness and high quality products, praised by all clients. Great support from AED general systems and procurement has contributed to smooth management. Some staff from FANTA, USAID/Washington, and USAID Missions think that FANTA could have benefited from having regional offices and greater field presence to facilitate more monitoring and capacity building, especially in countries or regions with large field support. The establishment of FANTA’s regional staff in east Africa in 2007 and AED’s regional east Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 43 Africa Office are seen as very helpful. The placement of regional staff was done in response to FANTA’s receipt of increasing HIV/AIDS funding. The team found FANTA’s annual reports and work plans very well organized and well written. Particularly useful was the convention of consistently numbering the outline for activities by intermediate results, making it easy to track continuity and evolution over more than eight years. 2. Resource utilization See Appendix I for FANTA’s figures that graphically describe the main funding characteristics of the project. The project has received $38.2 million in total funding from USAID from FY 1999 through FY 2006. This was not spread evenly over all 8 years, with funding from 2003–2006, 57% higher than from 1999–2002, mainly due to a doubling in field support funds in the second half of the project. Final obligations are expected in FY 2007. Of the total funds received to date, 72% are from the CSH account (which includes HIV/AIDS), followed by 12% from the DA account, with smaller contributions from International Disaster and Famine Assistance (IDFA), Economic Support Funds (ESF), and other accounts. There are no significant pipeline problems, and FANTA is expected to expend all of its funds by September 30, 2008. About 23% of all funds received have been programmed through sub-agreement partners. FANTA/AED has impressive coding and tracking systems to respond to information requests and report to clients on the status of the many different types of funds received. Based on consistently favorable findings in AED-contracted annual audits, they deem that FANTA has managed the funds well. Of the total funds received, 41% were from the GH Bureau, and 59% were non-GH. This is similar to the level of field support (non-GH funds) anticipated when the project was designed in 1998 and extended in 2003. In the second half of the project, 64% of all funds received have been field support vs. 51% in the first half of the project. To date, 24% of all non-GH funding has come from FFP ($5,515,612), the largest single, non-GH contributor to FANTA.11 Most GH funds have been from the Child Health and Nutrition SO (67%), followed by the Maternal Health and Nutrition SO (26%), and only 7% from the HIV SO. However, a significant portion of field support in the second half of the project was for HIV/AIDS activities. Over the eight years of its operation, 15% of total FANTA funding has been directed to HIV/AIDS; however, this figure was only 9% in the first half of the project and doubled to 18% in the second half of the project. The reverse was seen for the proportion of FANTA’s funding for Title II activities that represented one third of all resources through FY 2006, but fell from 44% of resources and activities in the first half of the project to 24% of resources and activities in the second half of the project. This was mostly because the overall resource pie grew with funds for HIV/AIDS activities, so the proportion dedicated to Title II activities got smaller. This does not represent a significant drop in demand and funds received from FFP and Missions for assistance to Title II programs, which decreased only slightly from an average of $1.6 million per year in the first half of the project to $1.4 million per year in the second half. 3. Staffing and consultants Nearly every individual interviewed for this evaluation recognized FANTA’s outstanding staff and leadership in the field of nutrition and food security. One client noted that FANTA’s partners also include the foremost international nutrition expertise at U.S. universities and research institutions. Continuity of various senior staff through the majority of the project has been an asset. When the original Project Director left FANTA in December 2006, FANTA effectively reorganized management and technical responsibilities. This reorganization allowed for the 11 FFP’s contribution to FANTA was comprised of 65% DA and 35% CSH funds; all CSH funding from FFP was given from 1999-2003. Since 2004, all FFP funding to FANTA was from the DA account. 44 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project promotion of several people within the project and hiring well qualified new people (6 people since November 2006). AED staff noted that while the recruitment process was difficult because the specific technical expertise required is in short supply, they have managed to hire excellent staff. OFDA noted that they were especially happy with the addition of the Senior Emergency Nutrition Specialist, as they had been concerned with some delays in completing CTC tasks before this person arrived. Additionally, FANTA has increased use of short-term consultants to better meet demand. Since 2003, 3,883 consultant days have been billed; 42% of these days were billed by host country national consultants, thus, building developing country professional capacity at the same time. Given FANTA’s extensive work in training, the evaluation team believes they could have benefited from having a training advisor on staff. Overall, FANTA has adjusted its staffing as project demands grew, especially in HIV/AIDS and MCHN. Several FANTA staff noted the richness of the team and the good teamwork that allows people to lend assistance where needed. FANTA staff commented that they learn everyday and enjoy working on this fast-paced project. Staff appreciated the opportunity to “learn by doing,” and felt empowered by working across a range of areas and not being “pigeonholed.” While there is no formal mentoring or shadowing (noted as both advantageous and disadvantageous), FANTA’s work environment is open and supportive. 4. Communications and collaborative relations In interviews, the evaluation team found that FANTA’s communications and collaborative relations had been good with all the many stakeholders and implementers of the project. It had been an effective policy to coordinate all FANTA’s work among USAID clients through the USAID CTO. FANTA’s collaboration with other donors/international organizations, especially in Europe, was a true strength and a great multiplier of their influence. A fair process seemed to have been followed to decide which FANTA partners under sub-agreements would do a particular activity, and there were no complaints. A high degree of collaboration existed between the academics (university partners) and FANTA, with more respect and tolerance of needs and constraints than seen in most projects, i.e., the academics performed well within time limits and did not enlarge research tasks beyond the questions asked, and FANTA went to the academics for specific strengths, using them as arbiters of scientific quality. At the country level, local sub￾grantees, NicaSalud and RCQHC, could have benefited from increased FANTA institutional capacity-building and this would have contributed to sustainability. 5. Role of Technical Advisory Group (TAG) Meetings held by FANTA’s TAG12 served as consultations with its stakeholders, to provide updates on technical advances and project activities and to solicit suggestions and feedback. See Appendix J for the topics and dates of all TAG meetings held to date. No TAG meetings are planned for FY 2007. In contrast to eleven TAG meetings held in the first half of the project through FY 2002, the team was surprised to see that only five had been held from FY 2003–2007. Given complaints by CSs of less FANTA outreach and collaboration with them in the second half of the project, the evaluation team wonders whether more TAG meetings might have been useful. FANTA is in the best position to decide, but should certainly think about an effective use of the TAG in bringing the project to a successful close and sharing its many lessons learned and products. 12TAG members include representatives from the PVO, academic, and research communities. The PVOs are Title II and child survival and health implementing agencies. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 45 6. Additional needs or gaps through end of FANTA • FANTA Director, Deputy Director, and other senior staff responsibilities leading up to and through close out should be re-assessed, sooner rather than later, to allow time for full documentation of the project’s work and smooth close out. 7. Summary of Key Findings • The FANTA Project has been well managed by AED and FANTA. FANTA staff and consultants are leaders in the food security and nutrition fields and are noted for their responsiveness and collaboration. FANTA has adjusted its staffing and use of consultants to meet the demand; further adjustments may be required to complete ongoing activities and proceed smoothly through project close out. 46 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project III. FUTURE NEEDS The evaluation team was asked to “identify changes needed to the FANTA program description for the follow-on agreement that reflect the Project’s overall success in achieving its Strategic Objective through its current approaches/strategies and emerging/future needs relevant in the current policy and programming environments, namely the recent USG Foreign Assistance Reform” (Appendix B). In this section, we share our best judgment on needs in a future project. Our suggestions have been greatly enriched by the input obtained during the evaluation interviews. Broad consensus on need: A new nutrition and food security global project is definitely needed, after FANTA ends, to continue to provide multi-sectoral, state-of-the-art technical assistance to USAID-assisted programs. This is the consensus of the evaluation team, the staff of Title II CSs and other PVOs, USAID/W (GH/HIDN, GH/OHA, DCHA/FFP, DCHA/OFDA, AFR), and USAID Missions where FANTA is currently providing technical support. The main, but not exclusive, focus should be on continuing technical support to improve programming, strategies, and policies for optimizing the use of Title II resources to reduce food insecurity and malnutrition in the 18 FFP priority countries. The large Title II program needs this support and offers the greatest potential for significant positive impact on nutrition. FFP made clear that, as long as there is a Title II program, they would need technical support similar to what they have received from FANTA. Paying for that support is a high priority for whatever DA funds FFP receives. Assistance to Title II should be provided equally to USAID and to CSs that implement the program, and to both headquarters level and to the 18 priority countries. Opportunities for integrating or improving nutrition interventions in additional USAID programs, e.g., continued assistance to the CSHGP and to advance nutritional care and support for HIV/AIDS in PEPFAR programs, should be actively pursued, as FANTA has so well done, while assuring adequate support to the Title II program. Global leadership is a critical component of a new project, as it has been for FANTA. This means that applied research to evaluate the effectiveness and cost of nutrition and food security tools, approaches, and interventions—and activities to promote their use—must continue in a new project. The “translation approach” used elsewhere by the USG to adapt evidence-based interventions to local conditions, measure fidelity to protocols/quality assurance, and track outcomes in the population should be adopted (14). This would include an advisory group for and publication of meta-analyses of evidence-based nutrition research in accessible resources in order to get the evidence accepted and used. It is urgent in Title II programs that the new nutrition and food security global project be in place by September 30, 2008, when FANTA ends. All of the current FANTA clients are counting on this seamless, continuing support. They have major new tasks coming up in that timeframe, that are critical to implementing FFP’s 2006–2010 strategy and new MYAPs, which will be seriously impaired if no assistance is available. Technical content of new project: The current program description and types of technical support FANTA provided are appropriate and should be carried forward; however, certain areas need more attention than received under FANTA and some new needs should be addressed. In reviewing the appropriateness of the current results framework (Figure 1), the evaluation team thinks it might be useful to merge IR1 and IR2 into one result, amended as follows: “improved nutrition and food security programs, strategies and policies.” A further suggestion would be to take this new combined IR and divide it into two IRs, one directed at USAID, and the other directed at CSs, country programs managers, and host country governments. This change would put greater focus on assuring that a new project would provide more assistance to CSs and host Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 47 governments, and would work in more countries than the current project has. Increased support to frontline implementers of Title II programs could be one of the quantifiable results indicators. Keeping flexibility in any new project to respond to new areas not yet identified and to targets of opportunity is a must. Some areas that merit more attention in a new project are as follows: Capacity Building for CSs, especially in monitoring and evaluation should be a focus in a new project in order to scale-up use of tools that FANTA developed for needs assessment, monitoring, and evaluation, and to assist CSs. This would also help USAID better respond to the two recommendations of the 2007 GAO report on improving food aid needs assessment and monitoring (3). The new project should work to strengthen the skills of CSs in using data for decision-making. Capacity building should include assisting PVOs to do case studies on successful PVO programs and to document valuable lessons learned. The new project should learn from the CSs and review and incorporate their firsthand field experiences more when preparing technical guidelines for Title II programming. One possibility could be for the new project to provide small grants to CSs for applied research on adoption and translation of promising practices. Effective graduation and exit strategies for Title II programs and how to monitor and evaluate them, including sustainability of nutrition and food security program services after phase out of Title II, are important technical assistance and applied research areas. Although most of the 14 country phase outs will be completed by 2009, it will be important to document lessons learned to guide future phase outs. Furthermore, such guidance will help ongoing programs incorporate promising practices to assure long-term sustainability. Effective interventions for nutrition and HIV/AIDS need to increase the evidence base and implement effective interventions to respond to the food security impacts of HIV/AIDS, and make best use of food aid for responding to HIV/AIDS. For example, how can Title II, PEPFAR and other resources be systematically linked to support community-based safety nets and long￾term livelihood development for vulnerable groups? FANTA’s manual, Food Assistance Programming in the Context of HIV, which is being prepared in collaboration with TANGO and WFP, is an important first step on which the new project should build. The first priority for advancing this agenda should be given to PEPFAR focus countries that are also FFP priority countries. There is also the need to scale-up the use of guidelines, training curricula, job aids, and counseling materials for proper HIV/AIDS nutritional care and support in countries with generalized HIV/AIDS epidemics, building on FANTA’s pioneering work in a number of African countries. This work should be financed with HIV/AIDS funds and constraints caused by USG account use restrictions need to be overcome. Maternal and child malnutrition prevention and behavior change interventions are well understood through extensive USAID support of them in Latin America, but lessons learned should be shared more widely through technical assistance to Title II MCHN programs in other countries. Several of these programs demonstrate how to improve child nutrition and IYCF practices without food aid, and provide relevant models for sustainability of MCHN services after Title II programs phase out. Greater attention to women’s and adolescent girls’ nutrition is needed, and this should be a focus for the new project. Performance quality improvement for nutrition interventions could be a useful new area for a new project. There is a need to develop guidelines, define performance standards, conduct training, and monitor performance standard compliance in nutrition interventions, as has been done extensively for health interventions by other GH projects in recent years. Definition and monitoring of compliance with local performance standards could be used to accredit providers of MCHN services and to assure that project implementing organizations meet performance standards. This accreditation could be important for sustainability of programs, assuring that they meet basic quality standards when local entities continue them after phase out of Title II and CS 48 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project involvement. The new project would need a greater field presence to be able to facilitate and transfer skills to local implementers for this type of quality assurance. The following are technical content areas for a new project to support successful implementation of the non-health aspects of the FFP Strategic Plan from 2006–2010. Given current restrictions on use of CSH earmark funds, additional DA or other funds are needed for a new project to adequately address the following: Agriculture and livelihood security to increase food consumption/access: Greater priority should be given to improving programming, monitoring, and evaluation for food security “access to food” interventions including agricultural and income generation projects to increase food consumption and improve nutritional status. The new project needs to expand the evidence-base on effective agriculture or livelihood security interventions (poverty alleviation) to reduce food insecurity, increase food consumption, and reduce malnutrition. This work should be financed with DA funds and constraints caused by USAID account use restrictions need to be overcome. Development relief Title II program design: More expertise on staff and more work in a new project are needed to increase the evidence base to inform production of technical programming guidance and tools for implementing this new concept in the FFP 2006–2010 strategy by doing evaluation research in real programs. The CSs are being asked to design flexible Title II programs that integrate emergency response capacity and livelihood provisioning with development interventions that enhance individual capacities, livelihood capabilities, and community resilience. This is a big change from prior development programs and not well understood. Guidance is also needed for monitoring and evaluating such programs. To build the evidence base of what works, it would also be valuable to evaluate the effectiveness of safety net and poverty alleviation programs, like the Ethiopia Productive Safety Net Program. Emergency/crisis food aid programming needs more attention in a new project, as such programs are currently receiving 75% of Title II resources, and the focus on “rebuilding and developing states” in the F process will likely continue. Better guidance is needed on what works best for preparedness and response capacity, contingency plans, and post-emergency/crisis transition and reconstruction programs to restore community food systems and build resilience. Useful early warning and trigger indicators must be defined and how to measure them. Whether to use food aid or not and how to handle disasters when there is no food aid are questions CSs want help on. The answers could also be relevant in countries where Title II programs are being phased out. What to do differently in a new project: The Title II CSs would like to be consulted during the design of a new nutrition and food security global project to make it responsive to their technical assistance needs. One CS suggested that a forum be held to discuss the findings of the FANTA evaluation with CSs and their needs for future assistance. Create a central technical assistance fund to engage with and assist Title II CSs and more FFP priority countries to improve Title II programs. This should be a major focus of a new project. FANTA assisted CSs, but that assistance fell short of demand and need, especially in the second half of the project. They were only able to directly assist Title II programs in about a third of the priority FFP countries, because of lack of Mission support and no core funds for this. The evaluation team believes that in order to adequately support CSs and all Title II FFP priority countries, it will be necessary to dedicate some of the resources in a new project to setting up a central technical assistance fund and a unit of 2–3 full-time project staff devoted only to this. What is proposed is a similar model to the one used for the CSH grants program of GH/HIDN in which the CSTS engages with and assists grant recipient PVOs. Capacity building could be provided to CSs in “mini-universities” as is done by CSTS. USAID could also use such a technical assistance fund for assessments and independent, external evaluations of Title II Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 49 programs that are not now possible, because USAID gives the funds for evaluations directly to the CSs. The fund should also make possible support from the new project to Title II programs in many more of the 18 FFP priority countries than has been possible until now in FANTA, which relied only on Mission field support. It might be worthwhile for FFP to design into the next RFA for ICB grant proposals a provision to institutionalize a link between CSs and FANTA (and a successor project), so the CSs and staff of a new technical assistance project lay out jointly a plan for developing needed technical materials. When we shared the idea for this type of a technical assistance fund with GH, they said that FFP would need to provide most of the support for it, as the CSH budget of GH for the new project would stay at current levels and go to paying core staff costs. When discussed with FFP, they thought the unit to provide greater support to CSs and priority countries was a good idea, but were unsure how to fund it since their DA funds are very limited. They are exploring new options for generating additional dollar resources for the Title II program as part of the Farm Bill, but if approved these could not be used directly for technical assistance, but might free up some other resources. Contributions from PVOS or other private sector partners to pay for some of the assistance should be encouraged by setting up a public-private partnership or alliance component of the new project, so it could co-program and leverage USAID funds with PVO or other private sector contributions (as USAID’s Global Development Alliance does). If additional resources cannot be found to make possible a central technical assistance fund, at a minimum, a certain percentage of core GH and FFP funds should be reserved for providing more assistance to CSs and priority FFP countries. At a high level, FFP should urge Missions in priority countries to contribute to a new nutrition and food security global project to assure that Title II programs receive the technical assistance they need to be effective. It is clear that the new project needs more funds at central level, than the current one has had, and a greater proportion of DA funds. FANTA has been, and the new project should continue to be, a cross-bureau, agency-wide, multi-sectoral project. Therefore, the fact that it is housed in GH/HIDN should not mean that it is financed almost exclusively with CSH funds. The new project should include funds for and should do institutional capacity building for local sub￾grantee partners. Regional presence/offices would be desirable to have and to staff with local advisors. A new project should plan to continue collaboration with other donors/international organizations, especially in Europe, and not just U.S. organizations. This was a huge strength of FANTA. 50 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project IV. RECOMMENDATIONS FANTA SHOULD: 1. Increase FANTA’s outreach to, support of, and collaboration with Title II Cooperating Sponsors. 2. Adapt to simplify a collection of key FANTA “how to” documents for more basic field application, with highest priority given to creating Title II Technical Reference Materials for Cooperating Sponsors. 3. Address additional needs or gaps through the end of FANTA as identified in this evaluation, as feasible within time and funding remaining. 4. To assure public access to essential technical references produced for USAID, leave in place the means to maintain the FANTA Web site after the project ends. USAID SHOULD: 1. Continue USAID technical support to improve food security and nutrition programming in Title II, CSHGP, PEPFAR, and other programs and assure that a new nutrition and food security project is in place when FANTA ends. Include dedicated central funds for more technical assistance to Title II CSs and country programs than has been possible relying only on Mission field support. 2. Give high priority to seeking and securing additional resources to advance the strategic vision of FFP for implementation of its 2006–2010 strategic plan by supporting the applied research and other important tasks proposed by FANTA, both in the time remaining in the FANTA agreement and in a future similar project. 3. Contact USAID Mission Directors in 18 priority FFP countries to urge Mission financial support for FANTA and a future central project for critical food security and nutrition technical assistance to improve effectiveness of Title II programs. 4. Assure that a future project for technical support to improve food security and nutrition strategies and policies works more closely with host country governments to achieve sustainability, especially in an era of phase out of many Title II programs. 5. Use the excellent food access/ consumption and nutritional status indicators, proven useful and feasible to collect by FANTA, as outcome indicators of Title II and other nutrition programs in the operational planning or F process. 6. Facilitate a major FANTA major final year push by FANTA to share its nutritional care and support for HIV/AIDS guidelines, training and counseling materials, and food supplementation trial findings with other GH and AFR CAs to mainstream in their HIV/AIDS activities. USAID should ensure that this important work continues in a new nutrition and food security global project. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 51 7. Work with FANTA to prioritize addressing the additional needs or gaps identified in this evaluation before the project ends, including adapting and simplifying “how to” materials. Include, as priority tasks for the first year of a new nutrition and food security global project, any of these needs or gaps that cannot be addressed now. 52 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Appendices Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 53 54 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project APPENDIX A: EXPANDED CONCEPTUAL FRAMEWORK FOR UNDERSTANDING FOOD INSECURITY Food Security Appropriate Food Utilization Adequate Food Access Adequate Food Availability 1. Resources Natural resource sustainability; Productive assets; Secure livelihoods 2. Productivity Labor productivity; Livelihood stability and diversification 3. Income M arket Integration; Purchasing power; Savings potential; Credit access 4. Equity in intra￾household food distribution; Food quantity, quality, diversity Consumption 5. Human Capital Nutrition; Health and sanitation; M aternal and child care; Dignity; Education; Skills; Political voice; Capacity; Indigenous knowledge Enhanced Community Resiliency Enhanced Livelihood Capacity Enhanced Human Capital Strategic Goal Food Security Outcomes Desired Program Outcomes ‘Natural’ Shocks Climatic shocks; Natural resource mining and degradation; Yield volatility; Asset depletion; Neglect of natural hazard mitigation Economic Risks Income fluctuation; Collapsed terms of trade; Savings depletion; Employment insecurity; Price volatility; High transactions costs; Information asymmetry; Inflation Social and Health Risks Epidemics, HIV/AIDS; Widespread untended undernutrition ; Risk perceptions Corruption; Crime; Social disintegration; Predatory extraction by armed forces; Conflict; Ethnic and social discrimination Food security Risks to be tackled Political Risks: Poor governance (national and local); Lack of legal recourse; Inadequate representation; Lack of accountability; Inadequate provision of services and creation of public goods; Adverse regulations; Lack of recognition of human rights; Political instability; Ineffective institutions. Food Insecurity Source: (5) USAID/ Bureau for Democracy, Conflict and Humanitarian Assistance/Office of Food for Peace. Strategic Plan for 2006–2010. May 2005. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 55 56 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project APPENDIX B: SCOPE OF WORK Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project (GH Tech Revised: 06-08-07) I. Identification of Task The assignment under this scope of work (SOW) is to assist the Bureau for Global Health, Office of Health, Infectious Disease and Nutrition, Division of Nutrition (GH/HIDN/N) in conducting an evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Cooperative Agreement. The evaluation findings will be used to guide future Global Health (GH) program directions. The anticipated period of performance for the assignment is o/a mid-May - June 2007. Activity: Evaluation of Food and Nutrition Technical Assistance Project Cooperative Agreement (HRN-A-00-98-00046-00) Contract: GH Tech Project II. Background The Nutrition Results Package is a ten-year program framework authorized in 1998 and amended in 2004. Under this authorization, GH awarded the FANTA Project competitively in September 1998 to the Academy for Educational Development (AED). Partners for the FANTA Project were Cornell and Tufts Universities as well as Food Aid Management (FAM), a consortium of private voluntary organizations, referred to as Cooperating Sponsors that implement Title II food aid programs. The assessment of the FANTA Project was conducted in 2002. Based on the report of satisfactory performance and continued priority of the FANTA Project in USAID’s work, GH extended FANTA Cooperative Agreement completion date five years from September 2003 to September 2008 and raised the ceiling of the Cooperative Agreement by $15,000,000 from $29,996,977 to $44,996,977. Additional FANTA partners for the second five years included IFPRI, NicaSalud, Valid International, and the Regional Center for Quality Health Care (RCQHC). The overall purpose of FANTA is “Improve food and nutrition policy, strategy and program development.” Three Intermediate Results (IRs) were identified to achieve the above purpose: IR1: USAID and Cooperating Sponsor’s nutrition and food security-related program development, analysis, monitoring and evaluation improved. IR2: USAID, host country governments, and CSs establish improved, integrated nutrition and food security strategies and policies. IR3: Promising practices and acceptable standards in nutrition and food security-related policy and programming adopted by USAID, Cooperating Sponsors, and other key stakeholders. Nine years into the ten-year Cooperative Agreement, as of October 2006, the FANTA project has received $ 15,620,147 from GH Core funds consisting of: Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 57 SO2 (Maternal Health) $ 4,107,000 SO3 (Child Health) $10,388,000 SO4 (HIV/AIDS) $ 1,125,000 And, $22,568,062 Field Support funds from USAID Bureaus (DCHA, Africa and PPC), 14 countries (Bangladesh, Ethiopia, India, Indonesia, Haiti, Honduras, Guatemala, Kenya, Nicaragua, Madagascar, Mozambique, Namibia, Rwanda, Zambia), and USAID/EA, for a total of $ 38,188,209,000. This represents 40% of the total FANTA project allocation from GH CORE and 60% from Field Support to date. III. Evaluation Scope of Work The evaluation should address the following 1. Describe progress made to date in achieving FANTA’s three Intermediate Results areas. 2. Assess the appropriateness and effectiveness of FANTA’s approaches/strategies and activities in achieving its Strategic Objective, including program operations/management, resource utilization, staffing, communications, and collaborative relations. Recommend changes, if any, in FANTA program priority areas that can be implemented within the remaining project period. 3. Describe roles and contributions of the FANTA Project toward the overall objective of USAID Nutrition Results Package and in improving USAID and its partners’ food security/nutrition programs, particularly progress in assessment, monitoring and evaluation areas. 4. Identify changes needed to the FANTA program description for the follow-on agreement that reflect the Project’s overall success in achieving its Strategic Objective through its current approaches/strategies and emerging/future needs relevant in the current policy and programming environments, namely the recent USG Foreign Assistance Reform. IV. Audience The audience for this evaluation includes USAID staff - both field- and Washington-based - involved in food security and nutrition programming. Recommendations made by the evaluation team will be considered in the design of the follow-on agreement as appropriate. V. Methods and Procedures The following steps are proposed: 1. Evaluation: a. Schedule a 1-2 day evaluation team planning meeting to discuss the SOW, agree on each team member’s roles and responsibilities, clarify expectations of USAID, methodologies to be used, and draft a timeline and an outline of the evaluation report. As time allows, begin drafting interview guides and other evaluation tools. 58 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project b. Schedule a meeting with relevant staff from the FANTA Project to obtain a general overview of the project. c. Obtain relevant key project documents from the FANTA Project for the evaluation and complete background reading. d. Develop a questionnaire to conduct interviews with key FANTA stakeholders. USAID will provide the list of suggested key informant names for interview. They include staff from – USAID/Washington (GH and DCHA), Mission staff, and PVO partners (via phone or e-mails). A list will be provided by USAID. e. Conduct interviews. f. Conduct progress debriefing with USAID a/o the third week of the evaluation. 2. Draft report and debriefing: a. Prepare the draft report highlighting key findings, conclusions and recommendations. b. Provide copies of the draft report to USAID and FANTA for review and comments. c. Conduct a debriefing for USAID on the evaluation findings. 3. Final report a. Prepare a final evaluation report by incorporating FANTA and USAID comments on the draft report. VI. Deliverables 1. Draft report not exceeding 40 pages that addresses the areas specified under Section III. Evaluation Scope of Work (Specifically the report outline developed in section (a)). The report will present a clear and concise summary of its findings, conclusions, and recommendations. 2. Final report not exceeding 40 pages that addresses the areas specified under Section III. Evaluation Scope of Work and that has USAID and FANTA comments incorporated. The report will present a clear and concise summary of its findings, conclusions, and recommendations. 3. Debriefing presentation made to USAID/Washington including findings, conclusions, and recommendations. VII. Timeline 1. The evaluation phase should begin on/about May 15, 2007 and be completed on/about July 6, 2007. 2. A debriefing should be scheduled on or before June 29, 2007. 3. The draft report should be provided to USAID and FANTA not later than June 22, 2007 and a debriefing on the findings scheduled shortly thereafter. A one-week period will be given for comments to be submitted by USAID and FANTA to the evaluation team. 4. The final report should be submitted to GH Tech by July 6, 2007. The final report will be edited and delivered to USAID before the end of July 2007. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 59 VIII. Team composition and Level of Effort The evaluation team should be comprised of a team leader and two team members. 1. Team Leader: The team leader will be responsible for providing leadership and coordination and facilitation of all evaluation activities. The team leader, in consultation with other team members will develop tools for the evaluation, a timeline, and a design plan to be shared with USAID for their feedback and comments. S/he will be required to ensure quality of work and provide direction and coordination to the other team members. S/he would be responsible for the evaluation and reporting on areas not covered by other members of the team. The team leader will coordinate the development of the outline for the draft report, present the report and after incorporating the comments, submit the final report the GH Tech Project within the prescribed timeline as presented in Section VII above. The team leader is also expected to be the lead in assessing the overall project management and financial issues. S/he will also lead in providing recommendation for future directions. (Original LOE 20 days; additional 10 days = 30 days new total) Skills/Experience: The team leader will be a senior person having more than 15 years experience working in the field of improved food and nutrition policy, strategy and program development. S/he should have a good understanding of project administration, financing, and management skills, including an understanding of USAID program management. S/he should have excellent writing and communication skills. S/he should have past experience of leading a team for health project evaluations or related assignments. 2. Team Members: The additional two team members will assist in the design of evaluation instruments and will be responsible for reviewing the progress in accomplishing the Project’s planned results and outcomes per their assigned roles and responsibilities. The team members will be responsible for drafting portions of the evaluation report and for preparing the evaluation brief. (Original LOE 15 days + additional 3 days = 18 days new total LOE for Team Member #1; Original LOE 15 days + additional 6 days = 21 days new total LOE for Team Member#2, Assignment Coordinator). Skills/Experience: The team members will have a mixture of the following expertise, qualifications, and experiences: a. Individual(s) with an in-depth understanding of the intricacies of managing USAID Bureau for Global Health-funded technical assistance projects that have a global technical leadership and field support orientation. Knowledge of USAID and its procedures is essential. b. Individual(s) with technical and operational backgrounds and expertise that address food security and nutrition in USAID, especially as they related to PL480 Title II food development and emergency programs and HIV. c. Individual(s) with strategic thinking and planning experience. d. Project monitoring and evaluation experience is desirable. e. Individual(s) should have a first hand understanding of the challenges of working to achieve objectives of GH, USAID Missions, and other partners. One of these team members will fill a dual role of Team Member/Assignment Coordinator. This individual will be responsible for critical information gathering, coordination, and facilitation aspects of this task, ensuring that the work moves forward swiftly and smoothly. This includes coordinating meetings and key interviews, obtaining documents, supporting the development of tools, performing critical follow-up, and supporting the preparation of the final report and briefings/debriefings with USAID. The 60 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Assignment Coordinator will be charged with managing many of the tasks related to bringing the team and information together. IX. Funding and logistical support All logistical support for the FANTA Evaluation will be provided through GH Tech. Activities that will be covered include recruitment of the evaluation team; payment of team members for five-day workweeks; support for all expenses related to the evaluation; logistical support and limited distribution of the draft and final report. Specifically, GH Tech will 1. Carry out the necessary preparatory actions for the FANTA Evaluation, including identifying appropriate consultants for USAID’s review and consent. 2. Organize the evaluation team-planning meeting with the chosen consultants and USAID. 3. Organize a meeting(s)/briefings with FANTA Project staff. 4. Manage and support the evaluation team. 5. Submit a draft of the evaluation report to USAID for comments. 6. Organize a debriefing of the evaluation to USAID. 7. Edit final report before submission to USAID. 8. Submit the completed evaluation report to USAID. This assignment will be funded by GH/HIDN (SO3). X. Relationships and responsibilities. In addition to providing consultants for FANTA Evaluation, GH Tech will provide all administrative and secretary support for the completion of the SOW. GH/HIDN will provide background and reference materials to GH Tech in advance of assignment initiation. Technical direction for the FANTA evaluation will be provided by: Eunyong Chung (CTO for FANTA Project) echung@usaid.gov, Tel: 202 712 47876, GH/HIDN/Nutrition, RRB 3rd floor, 1300 Pennsylvania Ave, NW, Washington, D.C. 20523 -3700 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 61 APPENDIX C: FANTA PRODUCTS BY INTERMEDIATE RESULT October 1998−April 2007 IR 1: USAID’s and Cooperating Sponsors’ nutrition and food security-related program development, analysis, monitoring, and evaluation improved 1A. Technical Support to DCHA and PPC Publications 1. Program Graduation and Exit Strategies: A Focus on Title II Food Aid Development Programs, Technical Note 9, Rogers and Macias (2004) 2. Synthesis Report of the Famine Forum, Sheckler, Shortley, Swindale and Lautze (2004) 3. Program Graduation and Exit Strategies: Title II Program Experiences and Related Research, Rogers and Macias (2004) 4. Program Evaluation Survey Manual for Title II Projects, Dunford, Scheffel and Sheckler (2004) 5. A Review of the Title II Food Aid Program, Technical Note 6, FANTA (2003) 6. Proceedings of the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Workshop, July 23-26, 2002, FANTA (2003) 7. A Study of Emergency Relief Food for Refugees and Displaced Persons, Tanner (2002) 8. Enhancing the Nutritional Quality of Relief Diets: Workshop Proceedings, Washington, DC, April 28-30, 1999, FANTA (1999) Reports, Background Documents and Other Products 1. Paper on Required Changes to Farm Bill to Improve Title II Program Implementation 2. Technical Review of Corn Soy Blend Concerns: Final Report 3. Office of Food for Peace - Bureau for Democracy, Conflict and Humanitarian Assistance (DCHA) - Strategic Plan for 2006-2010 4. Nutritional Status Database Review for USAID Performance and Accountability Reports: Reviews for 2003– 2006 USAID reporting (4 reports) 5. FFP Commodities Reference Guide Updates 6. The Derivation of the Proposed Nutritional Composition of an Emergency Relief Food for Refugees and Displaced Persons 7. Semi-Annual Report of GH/HN SSO4 Activities October 1, 2001 through March 31, 2002 62 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 8. FFP/DP Strategic Objective 2 Results Report Fiscal Year 2001 9. FFP/DP Strategic Objective 2 Results Report Fiscal Year 2000 10. FFP/EP Strategic Objective 1 Results Report Fiscal Year 2000 Trip Reports 1. Belgium July 2004: SMART Initiative 2. Eritrea February 2004: Development relief programming 3. Switzerland April 2003: Sphere Project revisions 1B. Technical Support to Cooperating Sponsors and USAID Missions Publications 1. Tajikistan Food Aid Review, Bonnard, Grobler-Tanner and Mutamba (2003) 2. Report of an Investigation into Recurrent Epidemics of Pellegra in Kuito, Angola, Golden (2002) Reports, Background Documents and Other Products 1. USAID/REDSO/ECA Office of FFP FY 2004 Annual Report 2. Mid-Term Evaluation for the FY 2002-2006 Bolivia Title II Development Assistance Program 3. Field Support for USAID/Bangladesh: Preliminary Performance Management Plan 4. Review of CARE Indonesia Emergency Community Nutrition Program 5. Afghanistan Civil Servant Salary Supplement Program Review 6. Therapeutic and Supplementary Feeding Programs 7. Kenya Drought Emergency Operation-Food Aid and Nutrition: Key Findings and Lessons Learned Trip Reports 1. Indonesia November 2004: M&E workshop and consultations for Title II partners 2. Bolivia October 2004: Title II Mid-term Evaluation 3. Bolivia August 2004: Title II Mid-term Evaluation 4. Bangladesh July 2004: PMP Support to Mission 5. Angola February 2004: Integrate nutrition into Title II CS proposal 6. Indonesia October 2003: Review of CARE’s CTC program 1C. Technical Support to CSHGP Publications Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 63 1. Nutrition Works: Measuring, Understanding and Improving Nutritional Status (Workshop Proceedings), FANTA, CORE, CSTS, FAM (2002) Reports, Background Documents and Other Products 1. Update to CSHGP Technical Reference Materials on Nutrition 2. Revised Knowledge, Practices and Coverage Survey MODULE X: Household Food Access 3. KPC 2000+ TOST Curriculum and Training Materials: Modules Two and Three 4. KPC 2000+ TOST Curriculum and Training Materials: Module One Trip Reports 1. Domestic April 2007: CORE annual meeting 2. Domestic April 2006: CORE annual meeting 3. Domestic April 2005: CORE annual meeting 4. Domestic April 2003: CORE annual meeting 1D. Technical Support to Ethiopia Publications 1. Report on the 2003 Joint Baseline Survey in the Targeted Areas of PL480, Title II Program in Ethiopia, Bergeron, Deitchler and Pender (2004) Reports, Background Documents and Other Products 1. Famine Prevention Discussion Strategy Paper: Draft Trip Reports 1. Ethiopia October 2006: PROFILES workshop, SO-13 indicator, LAYERS, national guidelines for HIV 2. Ethiopia September 2005: Baseline survey, LAYERS, Ethiopia’s National Nutrition Strategy, analyze SO-13 indicator 3. Ethiopia March 2005: PMP indicators, LAYERS, Baseline survey for PSNP 4. Ethiopia October 2004: PMP, LAYERS 5. Ethiopia May 2004 (2): Resettlement site assessment 6. Ethiopia May 2004: PMP, LAYERS, Baseline survey 7. Ethiopia March 2004: Baseline survey, LAYERS, resettlement issues 8. Ethiopia October 2003: Famine prevention framework, PSNP, baseline survey 9. Ethiopia May 2003: M&E support to Title II CSs 10. Ethiopia March 2003: ENA, harmonizing indicators, LAYERS, baseline survey 64 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 11. Ethiopia November 2002: Integration of Mission SO, JBS, Emergency Response Indicators 12. Ethiopia September 2001 13. Ethiopia April 2001 14. Ethiopia October 2000 15. Ethiopia August 2000 16. Ethiopia October 1999 1E. Kenya Publications 1. Kenya Wall Chart: Nutrition Interventions for Common Health Problems among HIV-infected Person in Kenya, Kenya Ministry of Health, UNICEF and FANTA (2006) 2. Kenya Wall Chart: Food Recommendations and Possible Side Effects for Common Medications used by HIV-infected Persons in Kenya, Kenya Ministry of Health, UNICEF and FANTA (2006) 3. Kenya Nutrition Counseling Cards for People Living with HIV/AIDS, Kenya Ministry of Health, UNICEF and FANTA (2006) 4. Kenyan National Guidelines on Nutrition and HIV/AIDS, Kenya Ministry of Health, UNICEF, FANTA, Kenya Medical Research Institute (KEMRI) (2006) 5. Food and Nutrition Implications of ART in Kenya: A Formative Assessment, Faith Mugure Thuita (2005) Reports, Background Documents and Other Products 1. Nutrition and HIV/AIDS: A Toolkit for Service Providers in Comprehensive Care Centres 2. Training materials: Nutrition Management in Care and Treatment of PLWA in Kenya 3. Nutrition and HIV/AIDS: Training Manual for Nutrition Management in the Comprehensive Care Centres in Kenya 4. Training of Kenyan Hospital and Health Facility Staff in Nutrition and HIV/AIDS Comprehensive Care Centers: Feedback Report 5. Training of Kenyan Hospital and Health Facility Staff in Nutrition and HIV/AIDS Comprehensive Care Centers: Training Report 6. Report on the Trainings of Kenya Service Providers in Twelve Districts Trip Reports 1. Kenya June 2004: Development of Kenya national guidelines on nutrition and HIV 2. Kenya April 2004: HIV guidelines and scale up of ART Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 65 1F. Madagascar Products 1. Food Security in Madagascar: A Situation Analysis, Bergeron (2001) Reports, Background Documents and Other Products 1. Quality of Health Services in USAID/ Madagascar target areas: Results from the 2006 data round 2. Madagascar LQAS Simulations 3. Report of the 2004 Joint Baseline Survey in the Targeted Areas of the PL480, Title II Program in Madagascar 4. SantéNet Performance Assessment/Delivering Health Services in Madagascar: Guide de l’Enquete Trip Reports 1. Madagascar November 2005: M&E for HPN, LAYERS 2. Madagascar May 2005: M&E for HPN, LAYERS 3. Madagascar September 2004: LAYERS, baseline survey 4. Madagascar March 2004: LAYERS, baseline survey 5. Madagascar November 2003: Joint baseline survey 6. Madagascar August 2003: Joint baseline survey, LAYERS 7. Madagascar May 2000 8. Madagascar August 1999 1G. Rwanda Publications 1. Rwanda National Protocol on Nutritional Care and Support of People Living with HIV/AIDS, Rwanda Ministry of Health with partners (2006) 2. Rwanda National Guidelines on Nutritional Care and Support of People Living with HIV/AIDS, Rwanda Ministry of Health with partners (2006) 3. Rwanda Wall Chart: Nutrition and Counseling of PLWHA and ART Clients, Rwanda Ministry of Health, TRAC and FANTA (2005) 4. Rwanda Counseling Cards on HIV and Nutrition, Rwanda Ministry of Health, TRAC and FANTA (2005) Reports, Background Documents and Other Products 1. HIV and Nutrition: Annual Report of FANTA Rwanda HIV and Nutrition Program Assistant 66 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 2. Rapport sur le Pretest du Materiel d'IEC dans le Cadre De l'Alimentation et la Nutrition des PVV Trip Reports 1. Rwanda March 2006: HIV nutritional care and support 2. Rwanda July 2005: HIV nutritional care and support 3. Rwanda January 2005: HIV nutritional care and support 4. Rwanda December 2004: ENA curriculum and trainer’s manual 5. Rwanda November 2004: HIV nutritional care and support 6. Rwanda July 2004: HIV nutritional care and support 7. Rwanda February 2004: HIV nutritional care and support workplan 1H. Zambia Publications 1. Zambia Wall Chart: Nutrition and Living Positively with HIV/AIDS, Zambia Central Board of Health with National Food and Nutrition Commission (NFHC) and FANTA (2006) 2. Zambia Wall Chart: Good Nutrition and Keeping Healthy with HIV/AIDS, Zambia Central Board of Health with National Food and Nutrition Commission (NFHC) and FANTA (2006) 3. Zambia Flipchart: Eating and Living Well with HIV/AIDS, Zambia Central Board of Health with National Food and Nutrition Commission (NFHC) and FANTA (2006) 4. Zambia Nutrition Guidelines for Care and Support for PLWHA, Zambia Central Board of Health with National Food and Nutrition Commission (NFHC) and FANTA, Zambia Central Board of Health with National Food and Nutrition Commission (NFHC) and FANTA (2004) Reports, Background Documents and Other Products 1. Specialized Food Products to Address the Nutritional Needs of PLWHA and ART Clients in Zambia: Assessment Report 2. Training Report: Nutrition and HIV/AIDS Counseling Training of Trainers for Facility and Home Based Case Providers 3. Results of Pretest of Nutrition Counseling Materials for PLWHA in Zambia 4. Report on Developing National Guidelines for HIV/AIDS Nutritional Care and Support Workshop, Lusaka, Zambia Trip Reports 1. Zambia May 2006: Africa Forum 2006: PCI Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 67 2. Zambia June 2005: Nutrition counseling materials for PLHIV 3. Zambia September 2004: Zambian national guidelines on HIV and nutrition 4. Zambia March 2004: HIV and food security 1I. India Reports, Background Documents and Other Products 1. Assessment of ICDS Tools and Approaches Developed by CARE/India, Protocol, Draft 3 2. Replication of CARE INHP Approaches in non-CARE Assisted ICDS Programs: Workplan & Strategy Document 3. Needs Assessment for Direct Distribution of Refined Soy Oil: Draft Assessment Tool 4. Food Aid Transition in India's Integrated Child Development Services Program in CARE-Supported Areas 5. India's Integrated Child Development Services (ICDS) Program: A Review of Contemporary Issues 6. Mid-term evaluation of CARE/India 7. A Scenario for Managing Rapid Change and Accelerating Phase-Down of the CRS/India Title II Program: Draft Report and Appendix 8. Social Safety Nets in India: An Assessment of Relevance and Efficacy 9. Review of ICDS Supply Chain Systems in Nine CARE-Assisted States 10. Investigating the Operation and Effectiveness of the Integrated Child Development Services (ICDS) Program in the Context of the Phase-Out of Title II Food: Towards Options for the Strengthening of the Social Safety Net. Detailed Workplan 11. Phase-Down Strategy for Title II In India 12. A Scenario for Managing Rapid Change and Accelerating Phase-Down of the CARE/India Title II Program: Draft Report and Appendix 13. Enhancing Child Survival Impact of PL480 Title II Program in India Trip Reports 1. India November 2005: CARE Title II program transition and replication 2. India August 2005: CARE Title II program transition and replication 3. India February 2004: Title II Program transition review 4. India September 2003: LAYERS 1J. Guatemala Reports, Background Documents and Other Products 1. Final Workshop Report: Monitoring and Evaluation 68 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 2. Final Workshop Report: Process for the Promotion of Child Feeding (ProPAN): Methods and Tools to Develop Behavior Change Strategies in Infant and Young Child Feeding 3. Equipo Nacional para el Fortalecimiento de Promocion del Crecimiento a Nivel Comunitario de Programas de SMI-N en Guatemala: Taller sobre Teoría y Métodos sobre Cambio de Comportamientos para Proyectos de Desarrollo a Nivel Local 4. Informe: Caracterización sobre Aspectos de Convergencia y Divergencia en el Paquete Basico de Servicios de Salud de las ONG Título II y el MSPAS 5. What do Community-Based Growth Monitoring and Promotion Programs in Central America Have to Offer? Desk review of experiences with using data from community-based nutrition surveillance or growth monitoring and promotion programs for famine early warning and/or targeting communities for intervention 6. Sistema Mesoamericano de Alerta Temprana para Seguridad Alimentaria - Inventario de Organizaciones y Bases de Datos para la Identification de un Indicador Nutricional en Guatemala, Honduras y Nicaragua 7. Activity Design Document (First Draft) - Mesoamerican Early Warning System for Food Security (MEWS-FS) 8. Mid-term Evaluation for Project Hope Child Survival Project in Guatemala Trip Reports 1. Guatemala January 2007: Facilitate M&E workshop, meetings with Title II staff 2. Guatemala November 2006: Workshop on Theory and Methods in Behavior Change for Title II Cooperating Sponsors 3. Guatemala March 2006: ProPan workshop, MCH/N working group, IYCF video, MFEWS 4. Guatemala November 2005: Behavior change workshop 5. Domestic March 2005: LAC SOTA Consultative Meeting 6. Guatemala February 2005: Regional IYCF conference, MCHN Working Group 7. Guatemala January 2005 Attachments: Early warning indicators for MFEWS 8. Guatemala January 2005: Early warning indicators for MFEWS 9. Guatemala February 2001 10. Guatemala November 2000 11. Guatemala June 2000 1K. Haiti Publications 1. Report on the 2002 Joint Baseline Survey in the Targeted Areas of PL480, Title II Program in Haiti, Bergeron and Deitchler (2003) Reports, Background Documents and Other Products Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 69 1. Final Evaluation of Title II DAPs in Haiti: Second and Final Inception Report 2. Final Evaluation of Title II DAPs in Haiti: First Inception Report 3. Layers Monitoring System, Findings of the First Round of Data Collection. USAID reports to and responses from Title II CSs: Save the Children, CARE and CRS 4. Design and Development of Early Warning Systems in Haiti: Adapting the NEWS model to Title-II program areas Trip Reports 1. Haiti February 2007: Nutrition and HIV 2. Haiti March 2006: LAYERS, DAP evaluation, MYAP preparation, indicator harmonizing 3. Haiti December 2005: LAYERS, harmonizing indicators 4. Haiti October 2005: DAP evaluation, health indicators 5. Haiti September 2005: DAP evaluation, health indicators, LAYERS 6. Haiti April 2005: Mid-term evaluation, LAYERS, HPN and Title II health indicators 7. Haiti December 2004: CRS Mid-term evaluation 8. Haiti November 2004: LAYERS, MTE for CRS, health indicators, meetings with FEWS NET and Linkages 9. Haiti September 2004: LAYERS, MTE for CRS 10. Haiti November 2003: LAYERS, EWS 11. Haiti September 2003: LAYERS, EWS 12. Haiti June 2003: Baseline reporting, LQAS, EWS 13. Haiti February 2003: Baseline report, LAYERS, NEWS 14. Haiti September 2002: Baseline survey, school feeding, NEWS, preventive vs. recuperative care 15. Haiti June 1999 16. Haiti March 1999 1L. Honduras Publications 1. Food Security Update for the USAID Mission in Honduras, Bonnard and Remancus (2002) Reports, Background Documents and Other Products 1. Final Workshop Report: Strategies for Behavior Change 2. Final Workshop Report: Methods and Tools to Understand Participant Behaviors in Maternal Child Health Nutrition Programs 70 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 3. Informe de Actividades Desarrolladas en la Estrategia de AIN-C Durante la Realización de la Consultaria de FANTA 4. Informe del Taller de Reactivación del Grupo de Trabajo para la Sistematización y Fortalecimiento de los Programs de Salud Materno-Infantil y Nutrition en Honduras Trip Reports 1. Honduras October 2006: Behavior change strategies for Title II CS 2. Honduras September 2006: Title II Program evaluation 3. Honduras July 2006: Behavior change strategies for Title II CS 4. Honduras December 2005: Training on AIN-C implementation, BCC workplan 5. Honduras May 2005: Workplan development workshop for MCHN Title II component working group 6. Honduras March 2005: MCHN Title II working group 7. Honduras December 2004: M&E for Title II programs 10. Honduras June 1999 11. Honduras March 1999 1M. Nicaragua Reports, Background Documents and Other Products 1. NicaSalud Final Report 2. Draft: Validación del Instrumento a Utilizarse en la Aplicación de la Metodología LQAS para la Valorización de la Calidad en la Implementación y el Proceso de Transición al Programa Comunitario de Salud y Nutrición 3. Informe: Primera Ronda de Visitas a la Calidad en la Implementación y el Proceso de Transición al Programa Comunitario de Salud y Nutricion 4. Regional Exchange to Strengthen the Implementation and Expansion of Community-based Growth Promotion in Central America 5. Workshop: Quality Implementation of the Community Health and Nutrition Program 6. NicaSalud Informe Fiscal 2004-2005 7. Youth Health Project: Evaluation Results from León and Matagalpa 8. Final Report of PROSIC: Integrated Community Health Project 9. Informe 2005 Bus Azul Final 10. Bases Conceptuales Grupo de Trabajo 11. Lineamientos Estrategicos en SSR en la Federacion 12. Informe Final Asistencia Tecnica al MINSA 13. Encuesta de Linea de Base. Proyecto de Salud Integral Comunario (PROSIC) 2004­ 2005 14. Taller Nacional Analisis de Datos con Epi Info 3.3. Training Materials. (2004) Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 71 15. Estrategia de Comunicacion. Federacion Red NicaSalud 2005-2009 16. Atencion Comunitaria de la Ninez en Centroamerica, Reflexiones del Equipo de Nicaragua 17. NicaSalud Informe Fiscal 2003-2004 18. Memoria Foro Regional Jovenes 19. Proximos pasos PENA 20. Taller Nacional: Hacia un Plan Estrategico de Adolescentes 21. Evaluación Cualitativa de la Calidad en la prestación de servicios brindados en las sesiones de pesaje de AIN Comunitario 22. Sistematización de la Experiencia AINC 23. Estudio Analisis de Costos AIN 24. Nicaragua Food Security: Post-Mitch TA to USAID Mission in Nicaragua 2000­ 2001 25. Bellmon Report Trip Reports 1. Nicaragua August 2006: Implementation of PROCOSAN 2. Nicaragua November 2005: Evaluation of NicaSalud subgrants, transition to PROCOSAN 3. Nicaragua May 2005: MCHN working group 4. Nicaragua February 2005: MCHN Title II working group 5. Nicaragua July 2004: NicaSalud Sub-Grants Baseline Surveys 6. Nicaragua May 2004: CBGP implementation and conference 7. Nicaragua January 2004: NicaSalud, PROCOSAN 8. Nicaragua September 2003: FANTA-NicaSalud collaboration 9. Nicaragua April 1999 10. Nicaragua March 1999 72 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project IR 2: USAID and its counterparts establish improved, integrated nutrition and food security-related strategies and policies 2A. Implement Strategies for Improving Women’s Nutrition Publications 1. Maternal Anemia: A Preventable Killer, FANTA (2006) 2. Strategies, Policies and Programs to Improve the Nutrition of Women and Girls, Nestel (2000) Reports, Background Documents and Other Products 1. Women’s Nutrition Indicator Guide (Draft) 2. Materials for the West African Nutritional Focal Points Meeting, Accra, Ghana, September 2001 Trip Reports 1. Benin January 2004: PROFILES workshop 2B. Provide Technical Support to GH and USAID Initiatives Support provided through technical revisions of and comments on policies and strategies. 2C. Improve the Food Security Framework Publications 1. Local Capacity Building in Title II Food Security Projects: A Framework, Occasional Paper 3, Gervais (2004) 2. Integrating Relief and Development to Accelerate Reductions in Food Insecurity in Shock-prone Areas, Occasional Paper 2, Haddad and Frankenberger (2003) 3. Addressing the “In” in Food Insecurity, Occasional Paper 1, Webb and Rogers (2003) 4. Report of the Food Aid and Food Security Assessment: A Review of the Title II Development Food Aid Program, Bonnard, Haggerty, and Swindale (2002) Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 73 2D. Improve Health and Nutrition Programming in Emergencies Publications 1. Community-based Therapeutic Care: A Field Manual, Valid International with partners (2006) 2. Proceedings of an Informal Consultation on Community-based Management of Severe Malnutrition in Children, Food and Nutrition Bulletin Volume 27, No. 3, UNU Press (2006) 3. Bookmark on Assessing Nutrition Situations in Emergencies (Yellow), FANTA (2006) 4. Operational Challenges of Implementing Community-based Therapeutic Care (CTC), ENN Report on the Proceedings of an Inter-agency Workshop (2005) 5. Community-based Therapeutic Care, Special Supplement to ENN Field Exchange (2004) 6. Community Therapeutic Care: A New Approach to Managing Acute Malnutrition in Emergencies and Beyond, Technical Note 8, Grobler-Tanner and Collins (2004) 7. Community-based Approaches to Managing Severe Malnutrition, ENN (2003) 8. A Review of the Advances and Challenges in Nutrition in Conflicts and Crises over the Last 20 Years, Mason and Taylor (2003) 9. Caring for Malnourished Children, TALC-UK (2002) 10. Use of Compact Foods in Emergencies, Technical Note 3, Grobler-Tanner (2002) Reports, Background Documents and Other Products 1. Draft Working Document: Training Modules for Community-Based Management of Acutely Malnourished Children (CMAM) 2. Assessment of an Emergency Food Product Report and Executive Summary 3. Integrating Community-based Therapeutic Care (CTC) and HIV/AIDS Support: Research Findings from Malawi 4. HPN Paper: Community-Based Therapeutic Care: A New Paradigm for Selective Feeding in Nutritional Crises 5. Study to examine the Use of Community Therapeutic Care (CTC) to Support HIV/AIDS Infected and Affected Individuals, Households and Communities 6. Community Therapeutic Care (CTC) Monitoring Effectiveness: Summary of results and findings to date (Year 1) 7. CTC Monitoring Effectiveness: Investigating Alternative RUTF Formulations 8. CTC Monitoring Effectiveness: Ethiopia Descriptive Study 9. CTC Monitoring Effectiveness: Malawi Comparison Study 10. Study on CTC to support HIV/AIDS infected and affected individuals, households and communities: Study Tools and Activities 74 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 11. Checklist for Food Aid Managers Setting Up Emergency Food Distributions with References to Useful Resource Materials 12. ACC/SCN Session on Adult Malnutrition Summary Report (Nairobi Conference) Trip Reports 1. Tanzania September 2006: WHO-UNICEF regional training on CTC 2. Malawi August 2004: CTC HIV study and CTC replication and scale up 3. Ethiopia April 2004: CTC replication and scale up 4. Malawi February 2004: CTC HIV study and CTC replication and scale up 5. Ireland October 2003: CTC workshop 6. Ethiopia May 2003 Annex: CTC monitoring effectiveness, annex 7. Ethiopia May 2003: CTC monitoring effectiveness 8. Malawi January 2003: CTC monitoring effectiveness 2E. Support Mission Food Security Strategy Development Reports, Background Documents and Other Products 1. USAID Mozambique - Food Security Programming Strategy, FY 2008-2012 Trip Reports 1. Mozambique October 2006: Mission food security strategy 2F. Support USAID EA Publications 1. Anemia Prevention Award Handbook, Badge Workbook, and Guider's Training Manual, WAGGGS (2007) 2. Counseling Materials on Nutritional Care and Support for PLWHA, RCQHC, FANTA and LINKAGES (2005) 3. Improving the Quality of Life through Nutrition: A Guide for Feeding People Living with HIV/AIDS, RCQHC and FANTA (2004) 4. Nutrition and HIV/AIDS: A Training Manual, RCQHC, FANTA and LINKAGES (2003) 5. Nutritional Care and Support for People Living with HIV/AIDS in Uganda: Guidelines for Service Providers, Uganda Ministry of Health with partners (2003) 6. Handbook: Developing and Applying National Guidelines on Nutrition and HIV/AIDS, RCQHC and FANTA (2003) Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 75 Reports, Background Documents and Other Products 1. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Zambia Report 2. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Uganda Report 3. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Kenya Report 4. Review of Promising Field Practices and Strengthening Resource Person Capacity in HIV/AIDS Nutritional Care and Support: Workshop Report 5. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Tanzania Report 6. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Malawi Report 7. Strengthening Regional Capacity to Address Maternal Anemia: Working with the Girl Guides Association Regional Planning Workshop 8. Review of Promising Field Practices in HIV/AIDS Nutritional Care and Support: Framework and Interview Guidelines for Documenting of Promising Practices 9. Review of Promising Field practices and Strengthening Resource Person Capacity in Implementing Nutrition Care and Support for PLWHA: Orientation Workshop Report 10. Compilation of Specialized Food Products for HIV/AIDS in East and Southern Africa 11. Forum on Integrating Nutrition into HIV/AIDS Care and ART Programs in Africa: Final report 12. Assessment of Nutrition and HIV/AIDS Training Needs of Community Care and Support Providers in the ECSA Countries: With a Focus on Tanzania and Kenya 13. Supporting East Africa National Nutrition Coalitions: Regional Nutrition Congress Meeting Report by Kenya Coalition for Action in Nutrition Society 14. Workshop on Nutrition and HIV: Dissemination of Counseling Materials for PLHA. Workshop Report 15. Workshop on Dissemination of Nutrition and HIV/AIDS: A Training Manual. Workshop Report 16. Development of Uganda Counseling Materials on Nutrition and HIV/AIDS: Uganda Workshop Report 17. Assessment of Nutrition and HIV/AIDS Counseling Services in the ECSA Countries: With a Focus on Uganda 18. Integration of Nutrition and HIV/AIDS into Pre-Service Training in Africa: Workshop Report 19. Household Food Economy Interviews: How Well Do They Monitor Food Security and Food Aid Use in Camps of Persons Displaced by Protracted Emergencies 20. Resources for Emergency Food Aid Managers 76 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 21. Review of Reference Documents and Training Curricula for Emergency Food Aid Managers 22. Reference Documents and Training Curricula for Emergency Food Aid Managers 23. Report on Burundi’s Therapeutic and Supplementary Feeding Programs 24. GHAI Assessment/REDSO Partner meeting, Kenya, Tanzania, and Uganda TDY February 18-28, 2001 Trip Reports 1. Swaziland January 2007: Girl Guides anemia prevention program 2. Uganda August 2006: Girl Guides anemia prevention materials 3. Ethiopia March 2006: ENA 4. Uganda January 2006: Regional planning workshop for Girl Guides anemia prevention 5. Uganda June 2005: Regional forum on nutrition and HIV, KEMRI study planning 6. Uganda May 2004: HIV counseling materials, regional initiatives 7. Tanzania November 2003: HIV pre-service training for nurses workshop 8. Uganda August 2003: RCQHC Partners Planning Meeting 2G. With Host Country Governments Reports, Background Documents and Other Products 1. Strategy and Program Directions & Assessment of the TA Needs for the Government of Brazil Zero Hunger Program Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 77 IR3: Best practices and acceptable standards in nutrition and food security-related policy and programming adopted by USAID, Cooperating Sponsors, and other key stakeholders 3A. Develop Food Security Indicators and Promising Practices Publications 1. Bookmark on Anthropometry Basics (Purple), FANTA (2004) 2. Anthropometric Indicators Measurement Guide, Cogill (2003 available in English and French) 3. Credit with Education and Title II Programs, Technical Note 1, FANTA (2002) 3. Credit with Education: A Promising Title II Microfinance Strategy, Dunford and Denman (2001) 5. Food for Education Indicator Guide, Bergeron and Del Russo (2001) 6. Food Security Indicators and Framework for Use in the Monitoring and Evaluation of Food Aid Programs, Riely, Mock, Cogill, Bailey, and Kenefick (1999) 7. Sampling Guide, Magnani, (1999) (available in English, French and Spanish) 8. Water and Sanitation Indicators Measurement Guide, Billig, Bendahmane, and Swindale (1999) 9. Agricultural Productivity Indicators Measurement Guide, Disken (1999) Reports, Background Documents and Other Products 1. Vitamin A Better Practices Guide Draft 2. Supervision and Support of High-Quality Group-based Nonformal Education Services: The Use of Observation Checklists 3. Listening and Learning from Clients: The Use of Qualitative Methods for Progress Tracking 4. Considering the Applicability of Lot Quality assurance Sampling (LQAS) to Credit with Education 5. Data Pathways: A Guide to Monitoring Systems 6. Evaluation Design Guide (Draft) 7. Assessment of the Vitamin A Status of Lactating Women by Dark Adaptation Testing in a Peri-Urban Area in Petionville Commune, Haiti 8. Materials for the Data Analysis Workshop for Title II Development Program Managers Nairobi, Kenya, November 2000 78 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 3B. Technical Notes on Monitoring and Evaluation Publications 1. Evaluating Title II Development-oriented Multi-year Assistance Projects, Technical Note 11, Bergeron, Swindale, Deitchler and Bilinsky (2006) 2. Monitoring and Evaluation Framework for Title II Development-oriented Projects, Technical Note 10, Bergeron, Deitchler and Bilinsky (2006) 3. Title II Evaluation Scopes of Work, Technical Note 2, Bonnard (2002) 3C. Improve Agriculture, Consumption and Nutrition Linkages All activities accomplished prior to 2002. Publications 1. Improving the Nutrition Impacts of Agriculture Interventions: Strategy and Policy Brief, Bonnard (2001) 2. Increasing the Nutritional Impacts of Agricultural Interventions, Bonnard (2000) 3D. Measuring Improved Food Access Publications 1. Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide, Version 2, Swindale and Bilinsky (2006) 2. Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide (Version 2), Coates, Swindale and Bilinsky (2006) 3. Journal of Nutrition, Advances in Developing Country Food Insecurity Measurement, Journal of Nutrition/6 articles/Multiple authors, May 2006 4. Measuring Household Food Insecurity Workshop II Report, FANTA (2005) 5. Measuring Household Food Consumption: A Technical Guide, Swindale and Ohri-Vachaspati (Revised 2005) 6. Months of Inadequate Household Food Provisioning (MIHFP) for Measurement of Household Food Access Indicator Guide, Bilinsky and Swindale (2005) 7. Development and Validation of an Experience-based Tool to Directly Measure Household Food Insecurity Within and Across Seasons in Northern Burkina Faso, Frongillo and Nanama (2004) 8. Measuring Household Food Insecurity Workshop Report and Appendices, April 15-16 2004, FANTA (2004) 9. Experience and Expression of Food Insecurity Across Cultures: Practical Implications for Valid Measurement, Coates (2004) Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 79 10. Measuring Food Insecurity: Going beyond Indicators of Income and Anthropometry, Coates, Webb and Houser (2003) 11. Food Access Indicator Review, FANTA (2003) 12. Dietary Diversity as a Household Food Security Indicator, Technical Note 4, FANTA (2002) 13. Dietary Diversity as a Household Food Security Indicator, Hoddinott and Yisehac (2002) 14. Building Household Food Security Measurement Tools from the Ground Up, Wolfe and Frongillo (2000) 15. Measuring Household Food Consumption: A Technical Guide (First Edition), Swindale and Ohri-Vachaspati (1999) Reports, Background Documents and Other Products 1. Guidelines for Applying the Food Access Survey Tool (FAST) for Food Security Program Evaluation in Bangladesh 2. Household Food Insecurity Access Scale Data Analysis Plan 3. Report of the Adaptation and Pre-Testing of Household Food Security Monitoring Tools: The Kenya Experience 4. Household Food Insecurity Scale Feedback Form 5. Trajectories of household food insecurity over time in northern Burkina Faso 6. Comparison of Food Insecurity Questionnaires from Burkina Faso and Chad 7. Effects of Development Activities on Households Participating in the Zondoma Food Security Initiative 8. Testing Food-Security Scales for Low-Cost Poverty Assessment: Research Report 9. Proposed Household Food Insecurity Questionnaire for the Africare Chad and Mali Baseline surveys 10. Relations among Wealth, Food Insecurity, Dietary Intake, and Nutritional Status: Analysis of Waves 2 and 3 11. Technical guide to developing a direct, experience-based measurement tool for household food insecurity 12. Development and Results of a Questionnaire-Based Tool to Measure the Food Security of Production Units in Zondoma for Africare’s Baseline Survey 13. Cultural Perspectives for Understanding Food Security among the Mossi 14. Interview Guide for In-depth Understanding of Food Security in Zondoma Province, Burkina Faso 15. Report on the Analysis of the In-depth qualitative data: Revision of the Intial Food Security Measurement Tool 16. Self-reported and Interviewer Assessed Food Security Status Compared with Other Measures of Poverty and Malnutrition in Bangladesh 17. Food Insecurity Measurement and Validation Study: A Report on the Formulation of the Core Food Security Module, and Experiences in its Implementation in Bangladesh 80 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 18. Tufts Food Insecurity Measurement and Validation Study Report on the first round of data collection relating to WVB’s FSEI activities in Bangladesh Trip Reports 1. Kenya March 2007: FAO Workshop on Measuring Household Access to Food 2. Kenya/Malawi July 2006: Field test of HFIAS, HDDS, IDDS 3E. Measuring Infant and Young Child Feeding (IYCF) Practices Publications 1. Developing and Validating Simple Indicators of Complementary Food Intake and Nutrient Density for Breastfed Children in Developing Countries, Dewey, Cohen, Arimond and Ruel (2006) 2. Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in Developing Countries: Summary of Findings from Analysis of 10 Data Sets, Working Group on Young Infant and Child Feeding Indicators (2006) 3. Dietary Diversity, Dietary Quality, and Child Nutritional Status: Evidence from Eleven Demographic and Health Surveys, Arimond and Ruel (2004) 4. Technical Consultation Reports: Nutrition in the DHS November 14, 2003 and Young Child Feeding and the DHS April 16, 2004, FANTA and ORC-Macro (2004) 5. Generating Indicators of Appropriate Feeding of Children 6 through 23 Months from the KPC 2000+, Arimond and Ruel (2003) 6. Recommended Tabulation Guidelines for Complementary Feeding Data from the Demographic and Health Surveys, Arimond and Ruel (2002) 7. Summary Indicators for Infant and Child Feeding Practices: An Example from the Ethiopian Demographic and Health Survey, 2000, Arimond and Ruel (2002) 8. A Multiple-Method Approach to Studying Childcare in an Urban Environment: A Case of Accra, Ghana, Ruel, Arimond, and Klemesu (2002) 9. Assessing Care: Progress Towards the Measurement of Selected Childcare and Feeding Practices, and Implications for Programs, Arimond and Ruel (2002) 10. Infant and Child Feeding Indicators Measurement Guide, Lung’aho (1999; no longer in circulation) Reports, Background Documents and Other Products 1. Infant and Child Feeding Practices in Ethiopia 2. A Positive Deviance Approach to Studying Child Feeding Practices and Care in Accra, Ghana 3. Towards the Development of a Child Feeding Index: Using the Demographic and Health Surveys from Latin America Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 81 Trip Reports 1. Italy October 2004: Dietary diversity and quality for IYCF 3F. Validating Dietary Diversity as a Measure of the Adequacy of Women’s Diets Reports, Background Documents and Other Products 1. Validation of Dietary Diversity as a Measure of the Adequacy of Women’s Diets: Progress Report 3G. HIV Nutritional Care and Support Publications 1. Recommendation for the Nutrient Requirements for People Living with HIV/AIDS 2007, FANTA (2007) 2. HIV/AIDS: A Guide for Nutritional Care and Support (2nd Edition), FANTA (2004) 3. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, Technical Note 7, Castleman, Cogill and Seumo-Fosso (2004) 4. Nutrition and HIV/AIDS: Evidence, Gaps and Priority Actions, SARA and FANTA Projects (2004) 5. Recommendation for the Nutrient Requirements for People Living with HIV/AIDS 2004, FANTA (2004) 6. HIV/AIDS: A Guide for Nutrition, Care and Support (First Edition), FANTA (2001) Reports, Background Documents and Other Products 1. Change in Nutritional Status Following Initiation of ART Among Malnourished HIV/AIDS Patients Attending Selected Health Centres in Uganda 2. Randomized controlled evaluation of the impact of food supplements on malnourished HIV-infected adult ART clients and malnourished, HIV-infected pre￾ART adults in Kenya (tools) 3. Randomized controlled evaluation of the impact of food supplements on malnourished HIV-infected adult ART clients and malnourished, HIV-infected pre￾ART adults in Kenya (protocol) 4. Study of Impacts of Food Supplementation on PLWHA: Training Materials Trip Reports 1. Kenya April 2006: HIV, ART and nutrition regional forum 2. South Africa April 2005: WHO consultation on nutrition and HIV 3. Jamaica May 2003: HIV and ARV regional workshop 82 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 3H. Food Security and Food Aid Interventions to Mitigate the Impact of HIV and AIDS Publications 1. HIV/AIDS and Food Aid: Assessment for Regional Programs and Resource Integration, Assessment Report & Appendices, FANTA (2004) 2. HIV/AIDS Mitigation: Using What We Already Know, Technical Note 5, Bonnard (2002) 3. Potential Uses of Food Aid to Support HIV/AIDS Mitigation Activities in Sub￾Saharan Africa, FANTA (2000) 4. The Potential Role of Food Aid for AIDS Mitigation in East Africa: Stakeholder Views, Kraak, Pelletier, Frongillo, Rajabiun (1999) Reports, Background Documents and Other Products 1. Food Assistance Programming in the Context of HIV [Draft 3] 2. Food Assistance in the Context of HIV Guide: Zambia Country Study 3. Food Assistance in the Context of HIV Guide: Ethiopia Country Study 4. Food Assistance in the Context of HIV Guide: Regional Consultations Synthesis Report 5. Food Assistance in the Context of HIV: Literature Review on Food Programming Trip Reports 1. Kenya August 2005: Food Assistance in the Context of HIV guide 2. Malawi December 2003: Strategies to use food resources for HIV mitigation 3. Mozambique November 2003: Southern Africa PRRO, Food Assistance in the Context of HIV guide 4. Germany September 2003: Food Assistance in the Context of HIV guide 5. Rwanda November 2001 6. Uganda, Kenya and Tanzania November 2001 7. Uganda September 2001 3I. Documenting Improvements in Nutritional Status Publications 1. The Impact of Title II Maternal and Child Health and Nutrition Programs on the Nutritional Status of Children, FFP Occasional Paper 4, Swindale, Deitchler, Cogill and Bilinsky (2004) 2. Changes in Child Survival are Strongly Associated with Changes in Malnutrition in Developing Countries, Pelletier and Frongillo (2002) Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 83 Reports, Background Documents and Other Products 1. Child Survival in Developing Countries: Malnutrition Does Matter 2. Malnutrition and Child Mortality: Findings from Longitudinal and Cross-Sectional Analyses at Population Level 3. Preliminary Review of the Impact of Programs on Child Nutritional Status 3J. Preventative vs. Recuperative Approaches in Nutrition Inventions Publications 1. Childcare, Nutrition and Health in the Central Plateau of Haiti: The Role of Community, Household and Caregiver Resources, Menon, Ruel, Arimond and Ferrus (2003) 2. Improving the use of Food Rations in Title II Maternal/Child Health and Nutrition Programs, FANTA (1999; available in English and Spanish) Reports, Background Documents and Other Products 1. Prevention or Cure? Comparing Preventative and Recuperative Approaches to Targeting Maternal and Child Health and Nutrition Programs in Rural Haiti: Draft Final Report 2. A Qualitative Study of the Patterns of Infant Feeding and Care in the Hinche Area of Plateau Central, Haiti 3. Preventive Versus Recuperative Targeting of Food Aid: Accounting for the Costs, Mid-term Cost Report 4. An Operations Evaluation of World Vision’s Maternal and Child Health and Nutrition Program in Central Plateau, Haiti 5. An Operations Evaluation of World Vision’s Integrated Health and Nutrition Program in Central Plateau, Haiti: Progress Report 6. Process Used to Design an Integrated Health and Nutrition Program to Prevent Child Malnutrition in Rural Haiti 7. Behavior Change Communication to Improve Infant and Young Child Feeding Practices in Rural Haiti: Training and Communication Materials 8. Development of a Behavior Change Communications Program to Prevent Malnutrition in the Central Plateau of Haiti: Results and Challenges from a Formative Research Study 9. Review of Health and Nutrition Education Messages and Delivery System Currently Used in Haiti, and Recommendations for Further Research 10. Selecting Children under 3 Years of Age as Beneficiaries – Summary of findings from a literature review 11. Summary Report: The Use of Food Rations in Maternal and Child Health and Nutrition Title II Programs (Draft) 12. Food Use in Maternal Child Health and Nutrition Programs: Background Report 84 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 3K. Tools to improve the monitoring of Title II programs Reports, Background Documents and Other Products 1. A Field Test of Three LQAS Designs to Assess the Prevalence of Acute Malnutrition. Journal article proof from the International Journal of Epidemiology 2. Using Modified LQAS Designs to Assess Acute Malnutrition: A Validation Study by Computer Simulation 3 files 3. LAYERS 3.0: Data Collection & Analysis User's Guide Trip Reports 1. Italy January 2005: LQAS 3L. Promotion of Information Sharing and Coordination 1. UN Food and Nutrition Library 3.1 2. UN Food and Nutrition Library 3.0 3. Report on the Nutrition Situation of Refugees and Displaced Populations (RNIS) (11 issues) 4. Nutrition Information in Crisis Situations Project (NICS) Reports (11 issues) 5. Standing Committee on Nutrition (SCN) News (5 issues) 6. Severe Malnutrition: Report of a Consultation to Review Current Literature 7. African Journal of Food and Nutritional Sciences, Issues 1 and 2 (2001/2002) 8. Adolescents: Assessment of Nutritional Status in Emergency-affected Populations, Special SCN Supplement, July 2000 9. Adults: Assessment of Nutritional Status in Emergency-affected Populations, July 2000 10. Quarterly Reports on the Nutrition of Refugees and Displaced Person September 1999 –March 2001 11. 1998-1999 Crude Mortality Rate Report 12. 1997-1998 Crude Mortality Rate Report 13. RNIS Emergency Updates Source: The FANTA Project, June 2007. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 85 APPENDIX D: REFERENCES 1. USAID. Nutrition Results Package, 1998 and Action Memorandum to Amend the Nutrition Activity Approval Document, November 2004. 2. Copeland R, Frankenberger T, and Kennedy E. Food and Nutrition Technical Assistance Project Assessment. USAID. March 2002. 3. United States Government Accountability Office (GAO). Foreign Assistance: Various Challenges Impede the Efficiency and Effectiveness of U.S. Food Aid- Report to the Committee on Agriculture, Nutrition, and Forestry, U.S. Senate. April 2007. 4. USAID. U.S. International Food Assistance Report 2006. December 2006. 5. USAID/ Bureau for Democracy, Conflict and Humanitarian Assistance/Office of Food for Peace. Strategic Plan for 2006-2010. May 2005. 6. FANTA Project. FANTA 2007 Evaluation: Reference Materials Briefing Book. May 2007. 7. USAID. The Food and Nutrition Technical Assistance (FANTA) Project, Cooperative Agreement #HRN-A-00-98-00046-00, September 28, 1998. 8. USAID/ Bureau for Democracy, Conflict and Humanitarian Assistance/Office of Food for Peace. P.L. 480 Title II Program Policies and Proposal Guidelines. May 1, 2006. 9. USAID/Bureau for Democracy, Conflict and Humanitarian Assistance/Office of Food for Peace. Performance Management Plan: Office of Food for Peace FY 2006- 2010 Strategic Plan: Food Insecurity in Vulnerable Populations Reduced- DRAFT. August 31, 2006. 10. Mukuria A, Monica K, and Noureddine A. Infant and Young Child Feeding Update. Calverton, MD: ORC Macro. September 2006. 11. Health-Related Research and Development Activities at USAID- Report to Congress. May 2006. 12. Journal of Nutrition. Advances in Developing Country Food Insecurity Measurement, Journal of Nutrition/6 articles/Multiple authors, May 2006. 13. Deitchler M, Valadez J, Egge K, Fernandez S, and Hennigan M. “A Field Test of Three LQAS Designs to Assess the Prevalence of Acute Malnutrition.” International Journal of Epidemiology, Advance Action Published online May 21, 2007. 14. Glasgow R, Lichtenstein E, and Marcus A. “Why Don’t We See More Translation of Health Promotion Research to Practice? Rethinking the Efficacy-to-Effectiveness Transition.” American Journal of Public Health, 93 (8): 1261-1267, August 2003. 86 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project USAID/Washington GH/HIDN Richard Greene GH/HIDN Elizabeth Fox GH/HIDN Michael Zeilinger GH/HIDN/N Eunyong Chung GH/HIDN/N Erin Boyd GH/HIDN/N Namita Agravat GH/HIDN/N Al Bartlett GH/HIDN/MCH Mary Ellen Stanton GH/HIDN/MCH GH/OHA Timothy Quick GH/OHA/TLR DCHA/FFP Carell Laurent DCHA/FFP/GD Dale Skoric DCHA/FFP/PTD Juli Majernik DCHA/FFP/PTD Judy Canahuati DCHA/FFP/PTD Carolyn Mutamba DCHA/FFP/ECA DCHA/OFDA Caroline Abla DCHA/OFDA/TAG AFR Roy Miller AFR/SD Hope Sukin AFR/SD Beth Dunford AFR/EA (Formerly with USAID/Ethiopia and FANTA) APPENDIX E: PERSONS INTERVIEWED FANTA Evaluation List of Persons Interviewed Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 87 USAID Missions Julia Maria Asturias USAID/Guatemala Baudilio Lopez USAID/Guatemala Michelle Jennings USAID/Ethiopia Marie Florence Cadet USAID/Haiti Olbeg Desinor USAID/Haiti Ashi Kohli Kathuria USAID/India Rachel Cintron USAID/Kenya Wendy Benazerga USAID/Madagascar Mary Pat Kieffer USAID/EA Child Survival and Health Grants Program Lynette Walker CORE Jennifer Luna CSTS, ORC Macro Michel Pacque CSTS, ORC Macro PVOs/CSs Carlisle Levine Catholic Relief Services Marco Villela World Vision David Evans Food for the Hungry Bill Fiebig Save the Children Ina Schonberg Save the Children Lynnda Kiess Concern Worldwide Emmanuel Komla Atieku Opportunities Industrialization Centers International (OICI) Nestor Mogollon Adventist Development Relief Agency (ADRA) Centers for Disease Control and Prevention, Brad Woodruff Refugee Health Paul Stupp Reproductive Health 88 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Bill and Melinda Gates Foundation Ellen Piwoz Formerly with AED International Organizations Bruce Cogill UNICEF (Formerly FANTA Project Director until 12/06) Andre Briend WHO Terry Ballard FAO Howard Standen UNDP (Formerly with CARE USA) Academy for Educational Development Margaret Parlato FANTA/AED Project Staff Anne Swindale Gilles Bergeron Irena Barisic Tony Castleman Alain Otarola Sandra Remancus Monica Woldt Joan Whelan Heather Finegan Victoria Michener FANTA Project Partners Marie Ruel IFPRI Tim Frankenburger Technical Assistance to NGOs (TANGO) Beatrice Rogers Tufts University Jennifer Coates Tufts University Mark Manary University of Washington at St. Louis Steve Collins Valid International David L. Mwaniki Kenya Medical Research Institute Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 89 APPENDIX F: FANTA INTERVIEW GUIDE FANTA Evaluation Team What were the circumstances that led you to begin your collaboration with FANTA? Can you describe the nature of your collaboration with FANTA? What did FANTA do to help you respond to that challenge? From your viewpoint, was FANTA’s approach effective in helping you to meet the challenge? What were/are FANTA’s strengths/weaknesses? Would you suggest any changes in FANTA’s approach? What do you consider to be FANTA’s biggest contribution? In the remaining project year, what are the highest priorities for FANTA to focus on? What suggestions do you have for USAID’s consideration in designing a future nutrition and food security assistance activity? 90 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Documents Downloaded from FANTA’s Website Rank Order FY 2003 Rank Order FY 2004 Rank Order FY 2005 Rank Order FY 2006 Anthropometric Indicators Measurement Guide (English, French) 1 1 1 1 The Nutritional Need and Status of Adolescents (English, French) 2 4 5 6 Women’s Nutrition and the Life-Cycle Approach Presentation 3 8 10 10 Sampling Guide (English, French, Spanish)* 4 5 4 2 Women’s Nutrition during Pregnancy and Lactation (English, French) 5 3 7 7 “Understanding Z-scores” from Data Analysis Workshop 2000 6 9 Food Security Indicators and Framework for Use in Monitoring and Evaluation of Food Aid Projects* 7 7 Report of the Food aid and food Security Assessment (FAFSA) 8 Food for Education Indicator Guide 9 HIV/AIDS: A Guide for Nutritional CARE and Support, 2004 10 3 3 Nutrition and HIV/AIDS: A Training Manual 2 “Understanding Weighted Means” from Data Analysis Workshop 2000 6 Nutritional Care and Support for People with HIV/AIDS in Uganda: Guidelines for Service Providers 10 2 5 HIV/AIDS and Food Aid: Assessment for Regional Programs and Resource Integration Workshop Report 6 APPENDIX G: TOP TEN PDF DOCUMENT DOWNLOADS Top Ten PDF Document Downloads from FANTA’s Website for FY 2003-FY 2006 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 91 Measuring Food Insecurity: Going Beyond Indicators of Income and Anthropometry 8 10 Measuring Household Food Consumption: A Technical Guide, 2005 9 9 Ugandan Counseling Materials for Nutritional Care and Support of People Living with HIV/AIDS 4 Operational Challenges of Implementing Community Therapeutic Care: ENN Report on an Interagency Workshop 8 * Initial work done under IMPACT; Finalization done under FANTA I (Fall 98) 92 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project APPENDIX H: USAID PATHWAY FROM RESEARCH TO FIELD IMPLEMENTATION AND USE (11) Health-Related Research and Development Activities at USAID- Report to Congress. May 2006. Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 93 APPENDIX I: FANTA FUNDING DATA Figure I-1: Total Funding Obligations Figure I-2: GH−Non-GH Funding 94 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Figure I-3: GH/Non-GH Funding Figure I-4: GH Funds by Strategic Objective Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 95 Figure I-5: Support to Title II and HIV Programming Figure I-6: Non-GH Funds by Source Source: FANTA Project. May 2007. 96 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project TOPIC DATE Project Year 1 FANTA Work Plan Meeting December 1998 Establishing Priority Thematic and Focus Areas for FANTA and Partners February 1999 Updates on Activities within Focus Areas September 1999 Project Year 2 Estimating Changes in Child Mortality from Changes in Child Malnutrition December 1999 (at RRB) Updates on Activities within Focus Areas with Presentation on Improving February 2000 the Use of Food Rations in Title II Maternal/Child Health Programs and Potential Role of Food Aid for AIDS Mitigation in East Africa Better Practices in Nutrition Care for People Living with HIV/AIDS April 2000 Updates on Activities within Focus Areas July 2000 Project Year 3 Updates on Activities within Focus Areas plus Presentation on Credit with November 2000 Education Field-Based Approaches to Improving Women’s Nutrition July 2001 Project Year 4 Update on Activities within Access Focus Areas and major Guides and December 2001 Better Practices series documents plus Birth Preparedness/ Complications Readiness Update on Activities within Access Focus Areas plus Presentations on May 2002 Measuring Household Food Insecurity Project Year 5 Setting Priority Thematic and Focus Areas for FANTA: Future Directions November 2002 for FANTA II Recuperation vs. Prevention in Nutrition Programs December 2002 Managing the Nutritional Implications of Antiretroviral Therapy June 2003 Project Year 6 LAYERS – A LQAS Application for the Collection, Entry and Analysis of December 2003 Monitoring Data Project Year 8 Food-Assisted Nutrition Programs: Prevention September 2006 or Cure APPENDIX J: FANTA PROJECT TAG MEETINGS: 1998−PRESENT Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project 97 98 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project For more information, please visit http://www.ghtechproject.com/library/ 100 Evaluation of the Food and Nutrition Technical Assistance (FANTA) Project Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 www.ghtechproject.com