Essential Services for Health in Ethiopia Is Implemented by John Snow, Inc

?ll^gmbZe M^kob\^l _hk B ^Zema bg ?mabhibZ

?g]+ebg^ B hnl^ahe] Mnko^r L^ihkm

; f aZkZ L^`bhg

=hgmkZ\m 441+=+..+.2+..2.1+..

M^im^f [^k 0..6 ; ]]bl ; [Z[Z

Essential Services for Health in Ethiopia is implemented by John Snow, Inc. In collaboration with Abt Associates, Academy for Educational Development, and Initiatives, Inc.

This report was made possible by the support of the American people through the United States Agency for International Development (USAID) under Contract 663-C-00-00403-00. The contents are the sole responsibility of John Snow, Inc. and do not necessarily reflect the views of USAID or the United States Government.

ACKNOWLEDGMENT

Essential Services for Health in Ethiopia was able to contribute to long term improvements in child survival in Oromia, Amhara and Southern Nations, Nationalities and Peoples Regional States, thanks to the leadership of the Regional Health Bureaus in mobilizing and coordinating partners in supporting the different woredas and their communities in the three regions.

This end line survey could not have been conducted without the collaboration and support of Regional Health Bureaus, Zonal Health Offices and Woreda Health Offices, and this support is greatly appreciated. We also like to express our sincere thanks to the end line survey team members: the principal coordinator of the survey and the assistant coordinator, the technical advisors in the Central Office, the regional project officers and the field supervisors, the interviewers, the data entry clerks, the many drivers who accompanied the teams, the senior advisors in headquarters of JSI and AED respectively, the logistics staff in the project, and program officers who contribute their share to the final production. Without this superb teamwork and continuous dedication, the end line surveys could not have provided the valuable information for evaluation and future planning.

In addition, we recognize the efforts that communities, voluntary community health workers, health extension workers and other health workers make on a daily basis in order to improve health of households and communities. The survey results show how much they have accomplished.

Finally we like to recognize the different partners with whom ESHE works on a continuous basis in the three regions: projects of multilateral and bilateral cooperation agencies, projects of non- governmental organizations and initiatives of training institutions. The end line surveys measure progress of child survival indicators at regional level and at the level of two strata: project areas and non project areas. Since ESHE is not the only intervention partner in the project areas, some results represent outcomes of direct support, and some results represent effective synergy with other projects.

Special thanks also goes to the USAID-Health, Population, AIDS and Nutrition Office team in Addis, for their continuous support to Essential Health Services in Ethiopia.

Table of Contents ACKNOWLEDGMENT ...... i ABBREVIATIONS AND ACRONYMS ...... vii EXECUTIVE SUMMARY ...... 1 1. INTRODUCTION ...... 8 1.1. The Context of the Amhara Region ...... 8 1.2. The Three Pillars of ESHE’s Intervention ...... 8 1.3. The ESHE Community-Based Intervention ...... 9 2. METHODOLOGY ...... 10 2.1. Study Design ...... 10 2.2. Sample Area ...... 11 2.3. Sample Size ...... 11 2.4. Survey Questionnaires ...... 12 2.5. Anthropometry ...... 13 2.6. Recruitment, Training, and Fieldwork ...... 13 2.7. Data Processing and Analysis ...... 13 2.8. Study Limitations ...... 14 3. INDIVIDUAL AND HOUSEHOLD CHARACTERISTICS ...... 14 3.1. Socio-demographic Characteristics of Respondents ...... 14 3.2. Household Safe Water Supply and Sanitation ...... 14 3.3. Access to Health Facility ...... 15 3.4. Possession of Insecticide Treated Nets ...... 16 4. PROGRAM REACH ...... 16 4.1. Volunteer Community Health Workers ...... 16 4.2. Health Extension Workers and Other Community Health Workers ...... 17 4.3. Awareness of the Family Health Card ...... 18 4.4. Possession of the Family Health Card ...... 19 5. IMMUNIZATION ...... 20 5.1. Vaccination Coverage and Trend ...... 20 5.2. Source of Information on Immunization ...... 22 5.3. Reason for Never or Incompletely Vaccinated ...... 23 5.4. Summary and Discussions ...... 24 6. ESSENTIAL NUTRITION ACTIONS ...... 25 Breastfeeding of Children 0-5 Months ...... 25 6.2. Complementary Feeding with Breastfeeding (6-23 months) ...... 27 6.3. Nutritional Care of the Sick Child ...... 32 6.4. Control of Vitamin A Deficiency ...... 33 6.6. Control of Anemia ...... 34 6.7. Children Sleeping under an Insecticide Treated Net (0 to 23 months) ...... 36 6.8. Women’s Nutrition ...... 36 6.9. Source of Nutrition Related Information ...... 36 6.10. Information to Women During Pregnancy and After Delivery ...... 37 6.11. Child Anthropometry ...... 38 6.12. Summary and Discussion ...... 38 7. CHILD MORBIDITY AND TREATMENT PATTERN ...... 41

7.1. Incidence and Trend of Child Morbidity ...... 41 7.2. Treatment Seeking in Health Facilities for Sick Child ...... 42 7.3. Awareness of the Danger Signs of Childhood Illness ...... 43 7.4. Oral Re-hydration Solution and Recommended Fluid to Children with Diarrhea...... 44 7.5. Breastfeeding and Fluid Intake During Illness ...... 45 7.6. Insecticide Treated Net Use among Children ...... 46 7.7. Summary and Discussion ...... 47 8. MATERNAL HEALTH ...... 48 8.1. Antenatal Care Coverage and Trend ...... 48 8.2. Tetanus Toxoid Injection ...... 50 8.3. Delivery Care ...... 51 8.4. Postnatal Care ...... 52 8.5. Information to Women During Pregnancy and After Delivery ...... 52 8.6. Summary and Discussion ...... 53 9. FAMILY PLANNING ...... 54 9.1. Awareness of Family Planning Methods ...... 54 9.2. Contraceptive Use, Level, and Trend ...... 55 9.3. Source of Information on Family Planning ...... 57 9.4. Summary and Discussion ...... 58 10. HIV/AIDS AND CONDOMS ...... 59 10.1. HIV/AIDS Awareness ...... 59 10.2. Awareness about Condoms ...... 60 10.3. Information on HIV/AIDS and Condoms ...... 60 10.4. Summary and Discussion ...... 61 ANNEX 1: TABLE OF INDICATORS ...... 63 ANNEX 2: SAMPLE CLUSTERS ...... 68 ANNEX 3: SURVEY TEAM...... 70

List of Tables Table 1 Number of Interviews Achieved, Number of Respondents and Children Sampled, Household Health Survey, Amhara, April 2008. 12 Table 2 Individual and Household Characteristics of Sampled Respondents, Household Health Survey, Amhara, April 2008. 15 Table 3 Volunteer Community Health Workers in the Sampled Kebeles, Household Health Survey, Amhara, April 2008. 17 Table 4 Immunization Coverage of Children 12-23 Months by Antigen, Household Health Survey, Amhara, April 2008. 20 Table 5 Breastfeeding of Children, Amhara End-line Household Survey, April 2008. 25 Table 6 Complementary Feeding at Age 6 to 9 Months, Amhara Household Health Survey, April 2008. 27 Table 7 Continuation of Breastfeeding at 6 to 23 Months, Amhara Household Health Survey, April 2008. 28 Table 8 Frequency of Feeding at 6 to 23 Months, Amhara Household Health Survey, April 2008. 30 Table 9 Food Diversity for Children Aged 6 to 23 Months, Amhara Household Health Survey, April 2008. 31

iii

Table 10 Types of Food Consumed by Children Aged 6 to 23 Months, Amhara Household Health Survey, April 2008. 31 Table 11 Percentage of Women with Children Aged 0 to 11 Months Having Received Iron/Folic Acid Supplementation, Household Health Survey, Amhara, April 2008. 34 Table 12 Percentage of Women Eating More During Pregnancy and Lactation, Household Health Survey, Amhara, April 2008. 36 Table 13 Percentage of Children Aged 0 to 23 Months Reported to Be Ill with Fever, Diarrhea, Cough, and Difficulty Breathing in the Two Weeks Preceding the Survey, Household Health Survey, Amhara, April 2008. 41 Table 14 Frequently Mentioned Correct Warning Sign That Indicate Treatment for Children under the Aged of Five Years, Household Health Survey, Amhara, April 2008. 43 Table 15 Percentage Distribution of Women with Children Aged 0 to 11 Months According to Receipt of Antenatal Care Services , Household Health Survey, Amhara, April 2008. 49 Table 16 Percentage Distribution of Women According to Receipt of TTI, Household Health Survey, Amhara, April 2008. 51 Table 17 Percentage Distribution of Women with Children Aged 0 to 11 Months According to Place of Delivery, Assistance During Delivery, and the Receipt of Postnatal Care, Household Health Survey, Amhara, April 2008. 52 Table 18 Percentage of Women in the Reproductive Age Who Are Currently Using a Family Planning Method by Type of Method and Source, Household Health Survey, Amhara, April 2008. 55 Table 19 Women’s Awareness of HIV/AIDS, Ways of Avoiding HIV and Knowledge of Places Where to Get Condoms, Household Health Survey, Amhara, April 2008. 59

List of Figures Figure 1 Trend in Proportion of Households with Pit Latrines, Access to Safe Drinking Water, and Residing within Two-hour Walk from Nearby Health Facility (including health post), Amhara Household Survey, and April 2008 15 Figure 2 Household Possession of Insecticide Treated Net, Household Health Survey, Amhara, April 2008. 16 Figure 3 Kebeles Covered with Health Extension Worker, Household Health Survey, Amhara, April 2008. 18 Figure 4 Proportion of Women Heard of the Family Health Card by Source of Information, Amhara Household Health Survey, April 2008. 18 Figure 5 Possession of the Family Health Card According to Child’s Age, Household Health Survey, Amhara, April 2008. 19 Figure 6 Trend in Coverage (%) of BCG, DPT3, Fully Immunized and Possession of Immunization Card, Household Health Survey, Amhara, 2004 and 2008. 21 Figure 7 Trend in Coverage (%) of DPT1, DPT3, Measles and Fully Immunized, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008. 22 Figure 8 Figure 8. Source of Information on Immunization from Volunteer Community Health Workers and Health Workers in the Three Months Preceding the Interview, Household Health Survey, Amhara, April 2008. 23

Figure 9 Most commonly Cited Reasons for Incompletely or Never Having Children Vaccinated, Household Health Survey, Amhara, 2004 and 2008. 23 Figure 10 Figure 10. Breastfeeding Related Practices for Children Aged 0-11 Months, Household Health Survey, Amhara, 2004 and 2008. 26 Figure 11 Breastfeeding Related Practices of Children Aged 0-11 Months, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008. 26 Figure 12 Trend in Complementary Feeding (6 to 9 Months), Household Health Survey, Amhara, 2004 and 2008. 27 Figure 13 Complementary Feeding (Aged 6 to 9 Months), Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008. 28 Figure 14 Feeding Pattern for Children Aged 0 to 23 Months in the Last 24 Hours (breast milk, liquids and foods) in ESHE and non-ESHE Areas, Household Health Survey, Amhara, April 2008. 29 Figure 15 Types of Food Consumed by for Children Aged 6 to 23 Months Compared to ESHE Baseline, Amhara Household Health Survey, April 2008. 32 Figure 16 Percent Distribution of Children Sick in the Two Weeks Preceding the Survey, by Amount of Breastfeeding Offered, Household Health Survey, Amhara, 2003 and 2008. 33 Figure 17 Children Aged 6 to 23 Months Who Received Vitamin A in the Previous Six Months, Household Health Survey, Amhara, 2004 and 2008. 34 Figure 18 Women Who Attended Antenatal Care and Received Iron/Folic, Household Health Survey, Amhara, 2004 and 2008. 35 Figure 19 Source of Information on Child Feeding Practices in the Year Preceding the Survey, Household Health Survey, Amhara, April 2008. 37 Figure 20 Proportion of Women Contacted by Volunteer Community Health Workers During Pregnancy, Household Health Survey, Amhara, April 2008. 38 Figure 21 Trend in the Tow-week Incidence of Fever, Diarrhea, Cough, and Difficulty Breathing, Household Health Survey, Amhara, 2004 and 2008. 41 Figure 22 Trend in the Two-week Incidence of Fever, Diarrhea, Cough, and Difficulty Breathing, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008. 42 Figure 23 Proportion Sick Children (previous two-week) Taken to Health Facility for Treatment, Household Health Survey, Amhara, 2004 and 2008. 43 Figure 24 Trend in Women’s Awareness of Warning Signs That Indicate That a Child under-five Years Should Be Taken to a Health Facility for Treatment, Household Health Survey, Amhara, 2004 and 2008. 44 Figure 25 Proportion Sick Children with Diarrhea in the Two Weeks Preceding the Interview That Received ORS, Household Health Survey, Amhara, 2004 and 2008. 44 Figure 26 Proportion Sick Children with Diarrhea in the Two Weeks Preceding the Interview That Received ORT, Household Health Survey, Amhara, 2008. 45 Figure 27 Percent Distribution of Children Sick in the Two Weeks Preceding the 46

Survey, by Amount of Breastfeeding and Fluid Offered Compared with Normal Practice, Household Health Survey, Amhara, 2004 and 2008. Figure 28 ITN Use among Children Aged 0 to 23 Months (previous night of the interview), Household Health Survey, Amhara, April 2008. 47 Figure 29 Contents of Antenatal Care, as Reported by Women Attending ANC, Household Health Survey, Amhara, 2004 and 2008. 49 Figure 30 Trend in Antenatal Care Coverage and Iron Folate Provision to Pregnant Women, Household Health Survey, Amhara, 2004 and 2008. 50 Figure 31 Trend in Proportion Protected Against TT, Stratified by ESHE Project and Non-project Area, Household Health Survey, Amhara, 2004 and 2008. 51 Figure 32 Trend in Home Delivery, Professionally Assisted Delivery and Postnatal Care, Household Health Survey, Amhara, 2004 and 2008. 52 Figure 33 Proportion of Women Contacted by Volunteer Community Health Workers During Pregnancy and Immediately After Delivery, Household Health Survey, Amhara, April 2008. 53 Figure 34 Figure 34. Percentage of Women in the Reproductive Age Who Know of Any Contraceptive Method, and Places Where to Obtain Method, Stratified by Sample Area, Household Health Survey, Amhara, April 2008. 54 Figure 35 Trend in Contraceptive Use, Household Health Survey, Amhara, 2004 and 2008. 56 Figure 36 Trend in Current Family Planning Use by Method, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008. 56 Figure 37 Source of Information on Family Planning in the Year Preceding the Survey, Household Health Survey, Amhara, April 2008. 57 Figure 38 Figure 38. Trend in the Proportion of Women That Reported Having Been Contacted by Any Volunteer Community Health Worker/Field Worker, Household Health Survey, Amhara, 2004 and 2008. 57 Figure 39 Figure 39. Trend in Proportion Reporting Abstinence, Faithfulness, Condom Use as a Way of Avoiding HIV, Amhara, 2004 and 2008. 59 Figure 40 Figure 40. The proportion of Women That Reported Having Been Contacted by Volunteer Community Health Workers (last 6 months) That Discussed about HIV//AID and Condoms, Household Health Survey, Amhara, April 2008. 60

ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Virus ANC Antenatal Care ARI Acute Respiratory Infection BCC Behavioral Change Communication CBRH Community Based Reproductive Health CBRHA Community Based Reproductive Health Agents CHP Community Health Promoter CPR Contraceptive Prevalence Rate DHS Demographic and Health Survey ENA Essential Nutrition Action EOS Enhanced Outreach Site EPI Expanded Program of Immunization ESHE Essential Health Services in Ethiopia FHC Family Health Card FMoH Federal Ministry of Health FP Family Planning HCF Health Care Financing HEP Health Extension Program HEW Health Extension Worker HF Health Facility HIV Human Immunity Virus HSDP Health Sector Development Program HW Health Worker ID Immunization Diploma IEC Information Education Communication IMCI Integrated Management of Childhood Illnesses IMNCI Integrated Management of Newborn and Childhood Illness IRT Integrated Refresher Training ITN Insecticide Treated Net IYCF Infant and Young Child Feeding LAM Lactational Amenorrhea Method M&E Monitoring and Evaluation MAD Minimum Adequate Diet NGO Non-Governmental Organization ORS Oral Rehydration Salts ORT Oral Rehydration Therapy PA Peasant Association PNC Postnatal Care PPS Probability Proportional to Size RHB Regional Health Bureau STI Sexually Transmitted Infections TT Tetanus Toxoid TTBA Trained Traditional Birth Attendants USAID United States Agency for International Development VAD Vitamin A Deficiency VCHW Voluntary Community Health Workers VHCW Volunteer Community Health Worker*/ WHO World Health Organization

vii

EXECUTIVE SUMMARY

This report presents findings from the impact evaluation of the Essential Services for Health in Ethiopia (EHSE II) Project support to the child survival interventions in Amhara during the period 2004-2008 with primary emphasis on immunization, essential nutrition actions and household behaviors with regard to childhood illnesses. The report also contains findings on other indicators relevant to child health: trends in ITN coverage, household pit latrine possession, maternal health care and family planning services utilization.

The ESHE II project is the USAID/Ethiopia five-year bilateral initiative for child health and health sector reform with the Ethiopian Government. The project contributes to achieving USAID/Ethiopia’s Strategic Objective 14: “Human Capacity and Social Resilience Increased by increasing the effective use of high-impact child health, family planning, and nutrition services, products and practices”. Over 5 million people (25% of the region’s population) have benefited from ESHE II project intervention in 20 woredas (districts) of the Amhara Region since 2004.

A quasi-experimental design was used, in which coverage indicators concerning key child survival interventions were compared between the baseline (2004) and end-line (2008) for the entire region, as well as for ESHE project focus area and the non-project area separately. Data were obtained from interviewing three groups of respondents, namely (1) women age 15-49 years (2) women with children age 0-11 months and (3) women with children 12-23 months. The surveys divide the region into two sampling frames (domains), as ESHE-project focus woredas and non- project woredas that contain the clusters (kebeles) from which will be sampled. From each area, 30 clusters or kebeles (A kebele is the smallest administrative unit) were selected using probability proportional to size (PPS), which results in a total of 60 clusters. A woman can respond to one or more of the questionnaires depending upon whether she has a child under 2- year of age. Overall, 1518 women were interviewed, resulting in 1800 interviews.

Community/Cluster level information was collected at end-line. The community questionnaire asks community key informants, mostly Health Extension Workers, or kebele chairpersons concerning availability of community health workers, their types and numbers, the type and numbers of health facilities in the kebele, among others. Information on the whether or not the kebele is endemic to malaria was also collected.

Since an equal number of clusters were taken from the two domains, irrespective of their population size, sample weights are introduced (that reflect the total population in each domain) in order to get the regional estimates.

In the Amhara region, this study documented notable region wide progresses in the areas of child immunization, ENA, family planning, pit latrines and ITN coverage. Unlike findings from the SNNP and Oromia regions, this study failed to document significant differences due to ESHE’s project intervention in the region. ESHE’s intervention in Amhara was relatively short in duration compared to the other regions with the CHPs serving for a median of 16 months. This is significantly shorter than the 24 months median reported from SNNP and Oromia regions. Furthermore, the higher coverage of non-project kebeles with health posts as opposed to the ESHE project focus kebeles might have improved access to services in the non-project area, and thereby offsets the likely impact of the ESHE’s project intervention. At the same time the ESHE project focus areas and the non-project cannot be considered mutually exclusive in terms of exposure to the ESHE’s community-based interventions. Indeed, it has also been ascertained

that the ESHE intervention has a spillover effect beyond its target areas to the other parts of the region.

While the main text provides the findings in greater detail, the salient findings can be summarized as follows.

Immunization

Key Findings

− Access (DPT1) to and continuation (DPT3) of EPI improved significantly in the region with DPT1 increasing from 65% to 83% (p<0.001) and DPT3 increasing from 51% to 66% (p<0.0001). Measles coverage increased significantly from 50% to 63% (p<0.001).

− No significant difference in vaccination coverage between the ESHE project and non-project areas both at baseline and end-line. Furthermore, similar positive trends in DPT1, DPT3 and Measles coverage were documented both in the project and non-project areas.

− Dropout rate from DPT1 to DPT3 is estimated at 20% which is almost similar to the 21% documented at baseline.

Recommendations

− Continue to empower HEWs and VCHW to provide information to care takers on the importance of immunization and to encourage individual caretakers to follow schedule until full immunization.

− Encourage HEWs and other health workers to use volunteers for defaulters tracing and minimize the drop outs.

− Efforts should be made to strengthen the logistics management system that includes vaccines and supplies and ensuring cold chain management and maintenance.

Essential Nutrition Actions

Key Findings

− In Amhara, improvements in selected Essential Nutrition Actions have been recorded in the region, and some improvements are higher in ESHE area.

− There is no significant change since the baseline in the initiation of breastfeeding within 1 hour after birth (from 31% to 34%), whereas exclusive breastfeeding (0-5 months) significantly increased from 75% to 87% (p<0.001). The initiation of breastfeeding within 1 hour increased from the baseline only in the ESHE project area (from 31% to 52%, p<0.001) and remained the same in the non-ESHE. Both in the ESHE project and non-project areas the proportion of exclusively breastfeeding 0-5 months increased – from 75% to 81% in the ESHE project area and from 76% to 88% in the non-project area.

− Timely introduction of complementary feeding (6-9 months) increased significantly from the baseline 43% to 61% at end-line (p<0.0001) in the region. Trend appeared comparable

between the ESHE project and non-project areas. For children 6-23 months, continuation of breastfeeding remained high at 96% and more than half of the children had adequate frequency of feeding at 69%. The dietary diversity remained as 27% of children ate between 3-4 different types of food.

− Breastfeeding during illness increased from 2% to 14% (p<0.05) in the region, increase being significantly higher in ESHE area from 4% at baseline to 27%.

− The supplementation coverage of vitamin A for children age 6-23 months reached 61% in the region. This is a significant increase from 17% at baseline (p<0.0001). In both areas, significant and comparable improvement in vitamin A coverage was also documented. The post partum supplementation in Vitamin A remained low at 9%.

− The supplementation of Iron/folic Folic was given to 34% of the pregnant women attending ANC in 2008, which is not significantly different from the 38% documented in 2004.

Recommendations

− Continue to support the Amhara Regional Health Bureau and partners to expand the ENA approach to the entire region replicating successes on optimal breastfeeding practices.

− Expand beyond the success of breastfeeding and vitamin A supplementation to ensure adequate complementary feeding practices (including feeding during and after illness) and adequate nutritional care for pregnant and lactating women. Programmatic efforts that support advocacy, training, promotion and counseling (using negotiation skills) will help achieve success.

− Carry out formative research on IYCF to assess 1) how current messages are delivered, 2) how parents perceived them and what are the facilitators and obstacles (including access and utilization of food), and 3) how to strengthen the program to replicate success.

Child Morbidity, Treatment, and Awareness

Key Findings

− The reported previous two-week incidence of illness have declined significantly since the baseline - Fever (from 18.4% to 8.9%, p<0.001), Diarrhea (from 18.1% to 12.6%), Cough (from 12.2% to 7%) and difficult breathing (from 7.3% to 3.5%).

− Half of the mothers with sick children in the 2-week preceding the survey reported that they had taken their children to health facility for treatment. This is significantly higher than the 34% reported at baseline (p<0.001). Of note, the proportion of sick children taken to health facility for treatment increased significantly from 31% to 50.4% (p<0.05) in the non- project area. There was however a slight and statistically insignificant increase from 42.5% to 52% in the ESHE project area.

− ORS was reported to be given to about 24% of the children suffering from diarrhea in the 2- week preceding the survey, which is not significantly higher than the 17% reported at baseline. The provision of ORS to children with Diarrhea did not increase significantly both in the ESHE project and non-project area.

− Sick children with diarrhea that received ORS and/or any recommended homemade fluid are considered as having Oral Re-hydration Therapy (ORT). The end-line data revealed that almost equal percentage of the children (48%) with diarrhea in the ESHE and non-ESHE areas were given ORT.

− Temporal positive trend was noted both in the provision of increased breastfeeding to any sick child (from 2% to 14%, p<0.05) and increased fluids to sick children with diarrhea (from 5% to 7%) in the 2-week preceding the surveys. In the ESHE area, the proportion of sick children that received increased breastfeeding during illness increased significantly from the baseline 4% to 27% (p<0.05) only in the ESHE project area. This noted trend in the non- project area was not statically significant (from 2% to 9%).

Recommendations

− Strengthen the awareness of caretakers on the danger signs of illnesses that need immediate action from a trained health care provider or health facility.

− Further improve the caretaker’s appropriate home management practices for sick children through training and support of HEWs, VCHWs

− Improve access to treatment, for sick children by strengthening health facilities with skilled personnel, essential drugs .and supplies.

− Scale up IMNCI training and follow up for health workers and HEWs to improve their case management skills as well as referral.

− Further strengthen the preventive and promotive services and practices such as immunization, appropriate infant and young child feeding, use of ITN, latrine and safe water as well as hand washing to reduce most of the burden of childhood illnesses.

Insecticide Treated Net Coverage

Key Findings

− Overall, 69% of the households in the malarious areas owned at least one ITN, this is remarkably higher than the tiny percentage (4%) reported at baseline. In terms of the type of ITN, it was reported that 62% of the households owned long-lasting treated nets. This means among all the ITNs reported, the vast majority (90%) was long-lasting nets.

− Thirty seven percent (37%) of the children age 0-23 months residing in the malarious areas reported to have slept under ITN the night before the interview. Compared to the less than 4% reported at baseline, this represents a remarkable improvement in the use of ITN in the region.

− Higher trends in correct usage of ITN for their under-five children in households possessing ITN in ESHE supported areas compared to non-ESHE areas: 67% vs 58%.

Recommendations

− Continue increasing awareness of use of ITN by children under 5 years and pregnant women

Water and Sanitation

Key Findings

− Access to safe drinking water has improved remarkably from the baseline 26.3% to 60.6% at end-line (p<0.0001), with data for intervention areas higher than non-project areas (73% vs 57%).

− Household ownership of pit latrines reached 44% in the region, which is significantly higher than the baseline 28% (p<0.0001), no difference exists between project and non-project areas.

Recommendations

− Promote safe handling of water and hand washing practices

− While the recent improved pit latrine coverage is encouraging, HEWs and voluntary community workers need to encourage toilet use by families. Increasing pit latrines coverage while insuring functionality of the already constructed pit latrines should constitute among the priority focus interventions.

Maternal Health

Key Findings

− The receipt of ANC by pregnant women reached 50% for the whole region at end-line, which is not significantly higher than the 44% reported at baseline. Baseline to end-line comparison revealed significant positive temporal trend in the uptake of ANC among women from the ESHE project area (from 45% to 54%, p<0.05). The observed trend was not statistically significant in the non-project area (from 43% to 48%)

− Based on the definition for life long protection against neonatal tetanus, 54% of the women in the region can be considered protected against tetanus. This is significantly higher than the baseline 36% (p<0.001). Trend data revealed comparable temporal change both in the project and non-project areas.

− Home delivery is high in the region with about 90% of the children age 0-11 born at home last year. Baseline data documented almost similar proportion of women having had home delivery as that of the end-line.

− About 10% of the deliveries that happened last year (2007) were assisted by health professionals either in the health institutions or at home, which is almost comparable to the baseline finding at 11%. The Health Extension Workers reported to have assisted only about 2% of the mothers during delivery last year. Trained Traditional Birth Attendants (TTBAs) assisted 8% of the women last year, which is almost similar to the 6% reported at baseline.

− Only few (4%) women with children age 0-11 months were examined by trained health professional within 45 days after delivery (postnatal care). At baseline this was reported at 5%. There is no significant difference in the receipt of postnatal care between the ESHE project and non-project areas (5% vs. 3%).

Recommendations

− Promote focused ANC/Birth preparedness at all levels.

− Promote the provision of TT and iron Folate by strengthening HW skill and knowledge and by improving the logistics management system.

− Support the region and facilitate the development of a strategy to address the very low skilled delivery care coverage.

− Provide in-service training and mentor HEWs to strengthen their midwifery skill including administration of misoprostol implement the principles of infection prevention and provide essential care for the mother and the baby.

− Accelerate the expansion of health centers with emergency obstetric care services

Family Planning

Key Findings

− The contraceptive prevalence rate (CPR) among women age 15-49 years is found to be 23%, which is significantly higher than the baseline 16% (p<0.001). When the analysis is restricted to currently married women (87% of the women interviewed were currently married), the end- line contraceptive prevalence rate estimated at 25%.

− Data from the end-line survey also confirmed the dominant emphasis on the Injectables in the region. Injectables appeared by far the predominant contraceptive method reported by women (Injectables prevalence, 20%). This means that about 90% of contraceptive prevalence is accounted for by the Injectables. Furthermore, Injectables is responsible for the apparent and significant temporal trend in contraceptive use during the period, with its prevalence increasing from 11.3% to 20.4% during the period.

− The prevalence of Pills is estimated at only 1%, which is lower than the 4% estimated at baseline.

− Heath post reported the predominant source (56%), followed by health center (34%) and the remaining 11% attributed to other sources including CBRHAs. Of note, the proportion that obtained their current method from a health post was 35% at baseline, which is significantly lower (p<0.05) than the 56% reported at end-line.

Recommendations

− Develop and harmonize FP messages and train HEWs and VCHW to facilitate the dissemination of appropriate information to house holds at scale.

− Promote healthy timing and spacing of pregnancies through household BCC and youth clubs.

− Strengthen the capacity of HPs to provide short acting contraceptive methods and refer eligible clients for the long acting methods.

− Strengthen the capacity of Health Centers to provide comprehensive services that include long acting methods.

HIV/AIDS Awareness

Key Findings

Awareness of HIV/AIDS is nearly universal with 94.5% of the women age 15-49 years reporting that they had heard of HIV/AIDS. Despite this, women’s awareness of the “programmatically important“ ways (ABC) of avoiding HIV/AIDS appeared limited- with 41.3%, 69.7% and 21.3%, respectively, identified abstinence, faithfulness to ones partners and condom use as the most important ways of avoiding HIV. No significant change noted in awareness of ABC among women since the baseline.

Recommendations

− Include HIV prevention and control messages in the training of VCHWs and develop BCC tools to be promoted in the community.

− Strengthen integrated community conversation activities that includes HIV/AIDS issues

1. INTRODUCTION

This study presents findings from the outcome evaluation of the Essential Services for Health in Ethiopia (EHSE) II Project support to the child survival interventions in Amhara region. The ESHE II project is the USAID/Ethiopia five-year bilateral initiative for child health and health sector reform with the Ethiopian Government. The project contributes to achieving USAID/Ethiopia’s Strategic Objective 14: “Human Capacity and Social Resilience Increased by increasing the effective use of high-impact child health, family planning, and nutrition services, products and practices”.

ESHE II was launched in 2004 in Amhara, and supported child health activities in 20 selected woredas in the region. Over 5 million people (i.e. 25% of the region’s population) have been benefiting from the project intervention. The key child survival interventions ESHE promoted include Immunization, Essential Nutrition Actions (ENA), and Integrated Management of Newborns and Childhood Illnesses (IMNCI).

1.1. The Context of the Amhara Region

Amhara Region is located in the northwestern part of Ethiopia covering a total area of about 170152 km2. The Region shares boundaries with Tigray in the North, Afar in the East, Oromia in the South, Benishangul-Gumuz Region in the Southwest and the country Sudan in the west. The region is administratively divided into 11 zones, 113 Woredas (districts) and about 3232 Kebeles. According to the Central Statistical Authority (CSA), the population of the region was estimated at 18.1 million in 2004, representing about 26% of the total population of Ethiopia. Nearly 90% of the region’s population resides in the rural area and is predominantly engaged in agricultural activities. The region has a population density ranging between 5 and 281 persons per square kilometer, with an average of 109 persons per square kilometer.

1.2. The Three Pillars of ESHE’s Intervention

The ESHE child survival intervention strategic framework rests on the following three pillars: (1) Strengthen Health Worker Skills, (2) Improve Community Household Practices and (3) Improve Health Systems.

Pillar I: Strengthening Health Worker Skills The ESHE intervention project has been working to build health worker skills and capacity in the areas of IMCI, ENA and EPI. Consultations with the FMOH and health partners have led to the development of training courses and materials that have been utilized at Regional/ Zonal/ Woreda/ facility and community levels throughout both ESHE and non-ESHE focus areas. To sustain performance post-training, ESHE has also implemented supportive supervision and HMIS monitoring. At national level, the project has also provided valuable input to development of IEC and M&E components of the Integrated Refresher Training (IRT) for the Health Extension Program.

Pillar II: Improve Community Household Practices In Ethiopia, there is a strong recognition that improvements in facility-based services alone cannot contribute significantly to reductions in child mortality. Access to qualified health providers or facilities is limited and many children die at home due to delays or lack of knowledge in seeking appropriate care. Pillar II aims to “strengthen positive health behaviors at

household and community levels.” Activities focus on changing these behaviors through a variety of outlets. Through community mobilization, individuals are encouraged to become Community Health Promoters (CHP). As CHPs, individuals are empowered by Health Extension Workers (HEW) to adopt healthy behaviors as well as serve as models for their neighbors. These efforts are supported by messages shared through mass media as well as in print (Family Health Card and Immunization Diploma).

Pillar III: Improve Health Systems Recognizing the chronic under-funding of the health care system, the MOH, through the HSDP III, has focused on increasing resources to the health sector, improving efficiency in resource allocation and utilization, ensuring sustainability of financing, and improving the quality and equity in delivery of health care services. ESHE has provided technical assistance to the MOH by conducting studies and developing concept papers towards the development of a legal framework to support health care financing strategy for the country.

Skills in the use of data for decision making and supportive supervision were also strengthened at all levels of the health care system. Management and service delivery standards were developed and utilized for quality improvement in the project woredas. Regular review of performance at regional, zonal and woreda levels were encouraged and supported technically and financially.

1.3. The ESHE Community-Based Intervention

The community based intervention strategies primarily revolve around behavioral change communication (BCC) activities. ESHE’s BCC and Community Mobilization interventions focus on building capacity of communities to improve the health of their families and to advocate for increased use of health services using multi-channeled approaches to reach multiple audiences to influence positive sustainable health behaviors. The BCC addresses families, caretakers, and service providers. It is integrated into pre-service and in-service training for health workers and both pre-and in-service faculty for Health Extension Workers (HEWs) as well as community trainings of Community Health Promoters (CHPs) to strengthen communication skills and harmonize messages.

Community Health Promoters’ Initiative The Community Health Promoters’ Initiative (CHPI) builds capacity of communities to improve child and family health through promotion of small doable actions that lead to improved health for children and families. The main engines of this initiative are the community volunteers that are selected by the community – known as, community health promoters (CHPs) - who received short trainings on key health issues. The trainings to the CHPs emphasized action- based messages that help induce positive changes in health behaviors of the population, especially women. The CHPs are encouraged to first take action in their own home, and then move on to promote messages among friends and neighbors. To promote healthy actions, the CHPI encourages use of everyday opportunities, such as coffee ceremonies, visits to neighbors (new births and sick children), social events, at the well or spring, at markets. Over 16,000 CHPs are actively serving their communities in Amhara since 2004.

CHPI support to the Health Extension Program The CHPI is not intending to replace existing or upcoming categories of community health workers or activities. Rather, the CHPs add impetus to existing services and programs of the Health Extension Program. With one CHP to 50 households, CHPs greatly enhanced the ability

of the health extension workers (HEWs), who are responsible for 500 households, to reach the community. Several woredas have undertaken expansion of CHPI using their own resources. Furthermore, the CHPI is part of the Health Sector Development Program (HSDP III) of the country. The Federal Ministry of Health (FMoH) and regional health bureaus have recognized the need to make the Health Extension Program effective by engaging communities.

ESHE focuses on building HEWs capacity to train and support CHPs in a fashion that helps complement HEWs’ routine activities. Given the increased coverage of deployed HEWs and their responsibility for managing community health workers, HEWs are ideally placed to provide CHPs regular mentoring and encouragement. An integral CHPI component is provision of support and encouragement to CHPs by HEWs. One way is through monthly CHP and HEW experience sharing, where CHPs have opportunities to share activities and experiences, learn from one another, and identify as a group common problems and solutions. ESHE has developed a handbook for HEWs to help them conduct short trainings with small groups of CHPs in their own village. This approach builds upon the strong collaboration that has been witnessed between HEWs and CHPs in communities.

Behavioral Change Communication Tools The CHPI is supplemented by key BCC tools mainly the Family Health Card (FHC) and the Immunization Diploma (ID).

The Family Health Card (FHC) is given to families to help them carry out small doable health actions in households and encourage them to seek services from the nearby health facility. The FHC illustrations and messages help caretakers follow their child’s growth from birth to two years of age for their child’s proper growth and development. The FHC also focuses on health of mothers and pregnant women. CHPs use the FHC to help and encourage parents to understand messages and negotiate to carry out health actions. ESHE recently collaborates with partners to widely distribute the FHC beyond its project focus areas.

The Immunization Diploma (ID) is a motivational tool that encourages parents to get their child fully immunized by their child’s first birthday. Health workers award the ID to parents of children who completed the full series of vaccines before one year of age. Proud parents post the ID in their home to show neighbors, relatives, and friends, thereby becoming role models and promoters for immunizations.

2. METHODOLOGY

2.1. Study Design

A quasi-experimental design was used, in which several indicators concerning key intervention on child survival were compared between the baseline and end-line for the entire region, as well as for ESHE project focus area and the non-project area separately. The indicators emerged from interviewing the following groups both at baseline and end-line:

− women in the reproductive age (15-49 years),

− women with children age 0-11 months

− women with children age 12-23 months

A community questionnaire that collected kebele/cluster profiles with reference to availability of community health workers, health facility availability, whether or not the Kebele is endemic to malaria, among others, was also administered at end-line. Respondents to this questionnaire were either HEWs or the Kebele chairpersons (i.e. only one interview per Kebele, totaling 60 interviewees for the whole survey). Of note, this information was not collected at baseline.

2.2. Sample Area

The end-line survey divides the Amhara region into two study areas or sampling frames (domains), as ESHE-project focus Woredas and non-project Woredas. From each area, 30 clusters were selected using probability proportional to size (PPS), which results in a total of 60 clusters for the whole region. The population size for each Kebele is obtained from the 1994 census list of the Amhara. By definition a cluster is a Kebele, which is the smallest administrative unit. All the Kebeles in each sample area were included in their respective sampling frame for selection. Since an equal number of clusters were taken from the ESHE project focus-area and non-project area irrespective of their population size, sample weights are introduced to reflect the total population in each domain in order to get regional estimate. The baseline survey, conducted in 2004, followed similar methodology and the sample size implemented was also the same. Details about the baseline methodology and sampling can be found elsewhere2.

2.3. Sample Size

The end-line survey sample size for each target group is 10 respondents per cluster. Overall, there are 600 respondent women age 15-49 years; 600 respondent women with children age 0- 11 months and another 600 respondent women with children 12-23 months, for the whole region. Table 1 presents the number of interviewees achieved, number of women respondents, children whose lengths and weights measured, and the number of community level respondents.

2 Amhara Baseline Household Health Survey Report: 2004

Table 1. Number of Interviews Achieved, Number of Respondents and Children Sampled, Household Health Survey, Amhara, April 2008. ESHE Project Non-ESHE Amhara Areas ‘08 Areas ‘08 ‘ 08 Interviewees: Total number of Interviewees 900 900 1800

• Number of interviewees using the questionnaire for women 300 300 600 15-49 • Number of interviewees using the questionnaire for women 300 300 600 with children 0-11 months • Number of interviewees using the questionnaire for women 300 300 600 children 12-23 months Women Respondents: Total number of Respondents 763 755 1518

• Number of respondents of the questionnaire for women 15- 154 144 298 49 but not for the other questionnaires • Number of respondents of at least 2 of the 3 questionnaires 146 158 304 • Number of respondents of the questionnaire targeting either children age 0-11 or 12-23 but not the questionnaire for 463 453 916 women age 15-49 years Children sampled (0-23 months): 600 600 1200

Age 0-5 165 145 310 6-11 135 155 290 12-23 300 300 600 Sex: Male 294 276 570 Female 306 324 630

Weight & length measurements used in the analysis (for age 6-23 434 454 888 months) Community Respondents:

Number of HEWs/Kebele Chairpersons responding to the community 30 30 60 questionnaire

2.4. Survey Questionnaires

Three household-level and one community or cluster-level questionnaires were employed in accordance with the target respondent. The household questionnaires at end-line are almost similar to those at baseline although this time more information on exposure to program intervention, including few others on new born care were included. 1) Questionnaire for Women in the Reproductive Aged15-49 Years This questionnaire contains information on household and demographic characteristics; utilization of health services, bed nets, exposure to radio, family planning, HIV/AIDS, condoms, etc.

2) Questionnaire for Women with Children Aged 0-11 Months This questionnaire contains information on utilization of maternal health care services, childhood morbidity and treatment pattern, use of bed nets, breastfeeding, supplementation, nutritional status of children, etc. Questions capturing respondents’ exposure to key messages and ownership of BCC materials, especially the FHC were included.

3) Questionnaire for Women with Children Aged12-23 Months

This questionnaire contains information on child immunization, childhood morbidity and treatment pattern, use of bed nets, breastfeeding, supplementation, and nutritional status of children, etc. Questions capturing respondents’ exposure to key messages and ownership of BCC materials, including the FHC and immunization diploma were included.

4) Community Questionnaire This questionnaire asks community key informants, mostly Health Extension Workers, or kebele chairpersons concerning availability of community health workers, their types and numbers, the type and numbers of health facilities in the kebele, among others. Information on the whether or not the kebele is endemic to malaria was also collected.

The questionnaires are largely pre-coded, with fixed response categories. They were translated into Amharic for easy administration. Amharic is the official language of Ethiopia as well as that of the Amhara.

2.5. Anthropometry

Length and weight measurements were taken from children age 6-23 months. The weight of each child was measured using a Salter scale, which is a hanging spring balance. For the measurement of length, children were measured lying down on an adjustable measuring board.

2.6. Recruitment, Training, and Fieldwork

A total of six survey teams were involved - five made up of one field supervisor and four interviewers, while one team consisted of a supervisor and 2 interviews. An intensive and detailed 5-day training that consisted item-by-item review of the questionnaires, practice in weighing and measuring of children, role-plays and field practice were given to survey staffs. Close monitoring of data collection was made by the supervisors as well as regional ESHE office staffs that had undergone through the 5-day training themselves. Data collection took about 4 weeks.

Each data collection team was provided with a four-wheel drive vehicle. Data collection was not without problems. In most cases teams had to travel on foot for at least 2-3 hours to get to the target Kebeles. There were situations whereby survey teams had to travel on foot for over 4 hours to get to the selected Kebeles due to inaccessibility of the Kebeles by car. Out of the 60 originally selected clusters, 3 were replaced due to varying reasons. The replacement of these clusters followed scientific procedures and done at central level.

2.7. Data Processing and Analysis

Data from the field were simultaneously entered into microcomputers at the ESHE office in Addis Ababa. Two highly-experienced data entry clerks computerized the survey data using EPI- INFO 6.04. A brief training about the questionnaires, variables and the organization of the database was given to the data entry clerks. Data analysis was performed using STATA 7.0.

The analyses were made in the following way:

− A comparison between baseline and end-line weighted indicators for the entire region

− A comparison between baseline and end-line indicators, separately, for the ESHE project focus area and non-project area

− A post-test only comparison of indicators between the ESHE project focus area and non- project area at end-line

Analyses are limited to Univariate level. Chi-square Test for Trend was carried out to estimate the significance of the differences observed between baseline and end-line dichotomous outcome indicators using the 95 percent level of significance. Post-test only comparison of indicators between the ESHE project-focus areas and the non-project were made using the Chi- square Test for Independence.

2.8. Study Limitations

The ESHE project focus areas and the non-project cannot be considered mutually exclusive in terms of exposure to the ESHE’s community-based interventions. Indeed, we have ascertained that the ESHE intervention has a spillover effect beyond its target areas to the other parts of the region. Some of the indications for this, among others, include the deployment of the CHPs in the non-project areas (43% of the non-project Kebeles included in this study covered by CHPs) as well as the distribution of the FHC to families residing in the non-project area. ESHE also provided training, technical support and other capacity building activities beyond its focus Woredas. As a result, the maximum possible effect of the ESHE intervention may not be documented by this study.

3. INDIVIDUAL AND HOUSEHOLD CHARACTERISTICS

3.1. Socio-demographic Characteristics of Respondents

A total of 1518 women were interviewed using one or more of the three types of questionnaires. Their overall mean age 27 years was comparable between the two areas (Table 2). Over a fifth of the respondents (22%) can read or write. The proportion who can read/write appeared a bit higher in the ESHE project area (26.3%) than in the non-project (22.8%) though not significantly. About 81% of the women were married, 81.7% from the project and 80.8% from the non-project.

3.2. Household Safe Water Supply and Sanitation

Pit latrine is reported to be owned by 44% of the households in the region (Table 2). There is no significant difference in pit latrine ownership between the ESHE project area and the non- project (46% vs. 43.3%). Overall, trend data (Figure 1) indicated significant increase in pit latrine coverage in the region from 27.7% at baseline to 44% at end line (p<0.001).

Household access to safe drinking water reached 60.6% in the region. It appears that access to safe drinking water is significantly better in the ESHE project area than in the non-project (73% vs. 56.7%, p<0.000). Compared to the baseline, access to safe drinking has improved remarkably at end-line – from 26.3% to 60.6% (p<0.0001).

3.3. Access to Health Facility

Health services access (including Health Post), as measured by the proportion residing within less than a 2-hour walk from the nearby health facility (i.e. within 10 km) improved significantly since the baseline (Figure 1) – from 64.9% to 91.4% (p<0.0001). Health post coverage of Kebeles at regional level reached 91%. This has contributed to the improved access in health service in the region. Of note, coverage with health post is found to be significantly lower in the ESHE project area (73.3%) than in the non-project (96.7%).

Table 2. Individual and Household Characteristics of Sampled Respondents, Household Health Survey, Amhara, April 2008. ESHE Non-project Amhara2008 Project Area (weighted) Area Women’s characteristics: N=763 N=755 N=1518

Mean age of respondents 27.1 27.3 27.2 % women literate (can read or write) 26.3 20.8 22.2 % women currently married 81.7 80.8 80.9

Household characteristics: N=300 N=300 N=600

% households with Pit latrine 46.0 43.3 44.0 % household with safe water supply1 73.0*** 56.7 60.6 % households within a 2-hour walk from a health facility2 95.7** 90.0 91.4 % Kebeles with health post 73.3 96.7* 91.0 *p<0.05 **p<0.001 ***p<0.0001 (ESHE Vs. non-ESHE) 1Piped water or protected/covered well or spring 2Health post included

Figure 1, Trend in Proportion of Households with Pit Latrines, Access to Safe Drinking Water, and Residing within Two-hour Walk from Nearby Health Facility (including health post), Amhara Household Survey, and April 2008.

91.4

64.9 60.6

% 44

27.7 26.3

Pitlatrines Safe Drinking Water With in 2-hour Walk from a Health Facility

2004 2008

3.4. Possession of Insecticide Treated Nets

Findings from the community level data indicated that about 20% of the sampled clusters (Kebeles) are completely malarious, 58% partially while the remaining 22% are not malarious at all (Data not shown). Analysis on ITN coverage is restricted to only those areas either completely or partially malarious. Accordingly, 69% of the households in the malarious areas owned at least one ITN, as confirmed by the interviewers (Figure 2). The ITN coverage documented by this study is remarkably higher than the tiny percentage (4%) reported at baseline (Data not shown). In terms of the type of ITN, it was reported that 62% of the households owned long-lasting treated nets. This means among all the ITNs reported, the vast majority (90%) was long-lasting nets. The end-line data also found similar household coverage with in the ESHE project and non-project areas (71% vs. 68.4%).

Figure 2. Household Possession of Insecticide Treated Net, Household Health Survey, Amhara, April 2008.

69.1 71 68.4 61.6 62.1 61.5

ITNs (any type) Long-lasting treated Nets

Amhara '08 ESHE '08 Non-ESHE '08

4. PROGRAM REACH

4.1. Volunteer Community Health Workers

Volunteer community health workers (VCHWs) are the main actors of ESHE’s Behavioral Change Communication (BCC) intervention. Findings show 90% the Kebels in the ESHE project areas are currently served with VCHWs. The number of VCHWs per Kebels ranged between 2 and 65 in the ESHE project area, averaging at 27 (Table 3).

A substantial proportion of Kebeles (43.3%) from the non-project areas also reported to be served with CHPs. In these Kebeles an average of 20 VCHWs are reported to be operating per Kebele, ranging between 2 and 38. In the entire region, 54.5% of the Kebeles are estimated to be served by a good number CHPs (median: 21; range: 2-28). With regards to the duration in-service, VCHWs both in the project and non-project areas reported to have been deployed for average of 16 months. In some of the ESHE project area Kebeles they have been there for 48 months while in others they have been in operation for less than 6 months.

In terms of the provision of training to VCHWs, 26% of the ESHE project Kebeles and 61.5% of the non-project reported to have their VCHWs trained via the community health promoters’ initiatives (CHPI). Likewise, 77.8% and 53.9%, respectively, were trained by the HEWs. The vast majority (over 90%) of the Kebeles both from the project and non-project areas reported that their CHWs were trained both via the CHPI as well as by the HEWs in different occasions.

Table 3. Volunteer Community Health Workers in the Sampled Kebeles, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 N=60 N=30 N=30 CHP coverage

% Kebeles with CHPs 90.0 43.3 54.5

Number of CHPs per Kebeles: Median (range) 27 (2-65) 20 (2-28) 21 (2-83)

Duration in service of CHPs (in month): Median (range) 16Mo (2-48) 16Mo(2-36) 16Mo(2-48)

Training to CHPs

% CHPs trained via the CHPI 25.9 61.5 47.3

% CHPs trained by HEWs 77.8 53.9 63.4

% CHPs trained BOTH via the CHPI and by the HEWs 96.7 90.0 91.6

4.2. Health Extension Workers and Other Community Health Workers

As shown in Figure 3, coverage with the HEW is nearly universal in the region, with 96.7% of the Kebeles currently served by two HEWs. While all non-project Kebeles sampled for this study reported to have HEWs, this is reported to be 90% in the ESHE project area. Coverage with at least one Community-Based Reproductive Health Agents3 (CBRHAs) was reported from 83% of the Kebeles sampled, 80% in the ESHE project and 88% in the non-project (Data not shown). The average number of CBRHAs per Kebele reported to be 2 (range: 1-8).

3 CBRHAs are community volunteers primarily in charge family planning promotion and provision of pills and condoms as well as referring clients in need of clinical methods. They are providing the service via house-to-house visit. CBRHAs are also participating in the promotion of other reproductive health information to the needy.

Figure 3. Kebeles Covered with Health Extension Worker, Household Health Survey, Amhara, April 2008.

97.6 100 95 96.7 90 90

At least one HEW Two HEWs

Amhara '08 ESHE '08 Non-ESHE '08

4.3. Awareness of the Family Health Card

As discussed above, the FHC is given to families to help them carry out small doable health actions in households and encourage them to seek services from the nearby health facility. FHC illustrations and messages help caretakers follow their child’s growth from birth to two years of age for their child’s proper growth and development. The FHC also provides important information that are relevant to the health of mothers and pregnant women. CHPs use the FHC to help and encourage parents to understand messages and negotiate to carry out health actions.

As shown in Figure 4, 19.2% of the women (with children 0-23 months) in the region reported that they heard of the FHC. Awareness of the FHC is significantly higher among women in the ESHE project areas than those in the non-project (54.5% vs. 8%, p<0.0001). In terms of the source of information on the FHC, 24.5% and 35% of the women from the ESHE project area, respectively, reported to have heard of FHC from CHPs and HEWs. The corresponding figures for the whole region were 6% and 13.8%, respectively.

Figure 4. Proportion of Women Heard of the Family Health Card by Source of Information, Amhara Household Health Survey, April 2008.

54.4

% 24.5 19.2 13.8 8 6 7 0.2

Heard of FHC Heard of FHC from CHPs Heard of FHC from HEWs

Amhara '08 ESHE '08 Non-ESHE '08 18

4.4. Possession of the Family Health Card

Possession of the FHC was assessed by asking woman if they owned the FHC for the target children. If a woman responded affirmatively to the question, she was further asked to show the card. Thus, a child is considered owning a FHC only if the alleged card is seen and confirmed by the interviewer. Accordingly, 34.6% of the children age 0-23 months residing in the ESHE project areas owned a FHC, this is significantly higher than the tiny percentage (1.5%) reported from the non-project (p<0.0001). On the whole, about 10% of the children age 0-23 in the region owned a FHC (Figure 5). As an indicator of families’ access to the FHC, the proportion of newborns (0-1 months) that owned a FHC was computed. Accordingly, a quarter of the newborns in the ESHE project area had a FHC. The age pattern of ownership of a FHC in the ESHE project area indicated that although access to the FHC appeared to be limited to about a quarter of the newborns, it improved notably afterwards; and that by the age of 6-11 months 42% owned the FHC. At the later ages (i.e. after 12 months) about a third of the children reported to own the FHC.

Figure 5. Possession of the Family Health Card According to Child’s Age, Household Health Survey, Amhara, April 2008.

41.9

35.6 34.6 31.4

25 %

11.9 10 9.1 9.5 5 1.7 2 0 0.8 1.5

0-1 month 0-5 months 6-11 months 12-23 months 0-23 months

Amhara '08 ESHE '08 Non-ESHE '08

Conclusions

The expansion of coverage with HEWs is nearly universal in the region with 95% of the Kebeles having had 2 HEWs. Improvements in the access to important and new community level initiatives which include use of community health promoters and family health card have been encouraging. The expansion of these same initiatives to non-project areas has also shown progress.

Recommendations

− Continue support to the region in the introduction of the new initiatives i.e. the use of CHP and FHC through the in-service trainings provided to HEWs.

− Encourage use of volunteers to identify eligible households and provide all with FHC

5. IMMUNIZATION

5.1. Vaccination Coverage and Trend

The percentage of children age 12-23 months who have received vaccinations is shown in Table 4 & Figure 6. At end-line, vaccination cards were seen by the interviewers for 43.7% of the sampled children in the region, this is has shown a modest increase from the 37.1% noted at baseline.

By combining information obtained either from cards or reported by the mothers about 48% of the children in the region are fully vaccinated, which is slightly higher, though not significantly, than the 44% documented at baseline. The end-line data also revealed that 41% of the children age 12-23 months can be considered fully immunized by their first birthday.

Coverage rates of individual vaccines have shown notable and significant improvement since the baseline. DPT1 coverage reached 83% from the baseline 65% (p<0.001). The proportion that received DPT3 significantly increased from 51% to 66% (p<0.001). Dropout rate from DPT1 to DPT3 (20.3%) is not different from the 21% documented at baseline. Measles increased from 50% to 63% (p<0.001) during the period (Figure 5).

Table 4. Immunization Coverage of Children 12-23 Months by Antigen, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) N=300 N=300 N=600 % With vaccination card 39.7 45.0 43.7 BCG 81.7 81.8 81.8 POLIO0 6.7 9.3 8.6 POLIO1 92.0 87.4 88.5 POLIO2 81.0 81.5 81.4 POLIO3 68.7 67.6 67.8 DPT1 82.7 82.8 82.8 DPT2 76.0 74.8 75.1 DPT3 65.3 66.2 66.0 Measles 63.0 63.6 63.4 Fully immunized1 48.0 47.7 47.8 Fully immunized before 1st birthday4 40.7 40.4 40.5 Drop-out rate: DPT1 to DPT3 21.4 20.0 20.3

1Children who are fully vaccinated are those who have received BCG, measles, and three doses of DPT and polio vaccines (excluding polio vaccine given at birth)

4For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination

Figure 6. Trend in Coverage (%) of BCG, DPT3, Fully Immunized and Possession of Immunization Card, Household Health Survey, Amhara, 2004 and 2008.

82.8

66 64.8 63.4

51 50.3 47.8 43.7 44.2 % 37.1

21.3 20.3

Immunization DPT1 DPT3 Measles Fully Dropout DP1- Diploma Immunized DPT3

2004 2008

ESHE Project Areas versus Non-project Areas In general, there was no significant difference in vaccination coverage between the ESHE project and non-project areas both at baseline and end-line (Table 4). Furthermore, similar trends in vaccination coverage were also noted in the project and non-project areas (Figure 7 a-d).

Figure 7. Trend in Coverage (%) of DPT1, DPT3, Measles and Fully Immunized, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008.

DPT 1 DPT 3

83 83 63 65 65 66 49 52 % %

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

Measles Fully immunized

63 64 52 45 48 46 48

% % 40

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

5.2. Source of Information on Immunization

Women with children 0-23 months were asked whether they had heard of or received information on immunization from health workers or community health workers in the 3 months preceding the survey. Figure 8 shows that 49% of the surveyed women reported that they had heard of immunization from community health worker in the last 3 months, 46% from HEWs and 12% from CHPs. Compared to the baseline, the receipt of immunization information from community health workers has increased significantly from only 10% at baseline (Data not shown) to 49% at end-line.

Women’s exposure to immunization information was compared between the ESHE Project area and the non-project. Taken together, there was no significant difference in the receipt of immunization from community health workers by women between the ESHE project and non- project areas (50.2% vs. 48.5%). Whilst there was no significant difference in women’s access to immunization information from the HEWs in the ESHE project and non-project areas (44.3% vs. 46.2%), women from the ESHE project area appeared more likely than those from the non- project to have heard of immunization from CHPs in the 3 months preceding the survey (28.8% vs. 6.5%m, p<0.0001).

Figure 8. Source of Information on Immunization from Volunteer Community Health Workers and Health Workers in the Three Months Preceding the Interview, Household Health Survey, Amhara, April 2008.

48.9 50.2 48.5 45.7 44.3 46.2

28.8 % 25

19.3 17.4 11.9 6.5

Health Worker Any community HEW CHP w orker

Amhara '08 ESHE '08 Non-ESHE '08

5.3. Reason for Never or Incompletely Vaccinated

Mothers whose children did not receive immunization at all or failed to complete vaccination were asked to mention the reason(s) for that (Figure 9). At end-line, a number of reasons were cited for not completing vaccination or never having children vaccinated, which include unaware of need of immunization (16.4%), place and/or time of immunization unknown (11.3%), mother too busy (10.4%), fear of side effect (9.9%), vaccination absent (8.9%), unaware of need to return for a 2nd or third time (7.5%), and place too far (2.1%). Although these sets of reasons were also reported at baseline, their magnitude has declined notably since then. For instance, the proportion that reported lack of time declined from 33.8% at baseline to 10.4% at end-line, place too far from 12% to 2%, and place/time immunization unknown from 22% to 11%.

Figure 9. Most commonly Cited Reasons for Incompletely or Never Having Children Vaccinated, Household Health Survey, Amhara, 2004 and 2008.

33.8

21.9 20.6 % 16.4 12.1 12.4 11.3 10.4 10.9 10 8.9 9.9 7.5

2.1

Unaw are of Unaw are of Place and/or Mother Too Vaccination Place Too Far Fear of Side Need for Need to Return Time of Busy Abscent Effect Immunization for 2nd or 3rd Immunization Round Unknow n

2004 2008

5.4. Summary and Discussions

Child immunization coverage for the entire region is estimated at 48%, which is higher than the 44% documented at baseline. By their first birthday 40.5% of the children were fully immunized in the region. Although the fully vaccination coverage showed a modest improvement during the period, coverage trends for individual vaccines appeared quite remarkable, as DPT3 increased from 51% to 66% and Measles from 50.3% to 63.4% during the period. The noted improvement in Measles coverage should be emphasized, as it is one of the indicators for MDG-4 to track progress on child survival.

Immunization coverage and trends did not vary between the ESHE project and non-project areas despite intervention efforts to improve immunization uptake in the ESHE focus areas. Some plausible explanations can be anticipated for the observed lack of differences in immunization coverage between the two areas. First and foremost, it should be underscored that ESHE’s BCC intervention can be considered of short duration in the region, as the CHPs were in operation in the target woredas/kebeles only for an average of 16 months (range: 2-48 months). This means a considerable portion of the children currently age 12-23 months were not exposed to ESHE’s BCC intervention during their infancy because of the then limited number of kebeles served by the CHPs. Promotion of child immunization would be more successful when it is initiated during pregnancy and/or from few days or weeks after delivery. Secondly, this study found considerably high and comparable exposure to immunization information by women both in the ESHE project (50.2%) and non-project (48.5%) areas via the HEWs. Thirdly, the higher coverage of non-project kebeles with health posts as opposed to the ESHE project focus kebeles (96.7% vs. 73.3%) might have improved access to immunization of children in the non-project area, and as a result might offset the possible coverage differences that could have arisen as a result of the ESHE’s intervention.

Despite recent improved access to immunization information, women in the region are yet to be well aware of the benefits of immunization and place where to obtain the service. For instance, dropout rate from DPT1 to DPT3 remained at around 20% during the period. This is much higher than the 10% universal target. The end-line finding also revealed 16% and 11%, respectively, reported unaware of the need of immunization and unaware places where to get the service, among the main reasons for never having their children immunized or failing to complete vaccination. Though declined substantially since the baseline, about a tenth of the mothers still blamed lack of time for not having children immunized. Another 10% avoided having their children vaccinated due to fear of side effects.

Intervention in the region needs to continue promoting the benefits of immunization as well as dispel some of the unfounded rumors concerning vaccination side effects with a parallel effort to bring the service closer to the community. Expansion of health posts to reach out to those kebeles with limited access to health facilities would improve access to immunization services, thereby utilization.

Recommendations

− Continue to empower HEWs and VCHW to provide information to care takers on the importance of immunization and to encourage individual caretakers to follow schedule until full immunization.

− Encourage HEWs and other HWs to use volunteers for defaulters tracing and minimize the drop outs.

− Efforts should be made to strengthen the logistics management system that includes vaccines and supplies and ensuring cold chain management and maintenance.

6. ESSENTIAL NUTRITION ACTIONS

Breastfeeding of Children 0-5 Months

Optimal Breastfeeding Practices Early and exclusive breastfeeding practices are recognized by international health experts as key child survival interventions. With near to universal coverage, global estimates show that optimal breastfeeding could avert upwards to 13 to 15 percent of all under-five deaths. Early and exclusive breastfeeding has also been identified as one of the key interventions to save newborn lives.

Table 5. Breastfeeding of Children, Amhara End-line Household Survey, April 2008. ESHE Project Non-project Amhara ‘08 Areas ‘08 Areas ‘08 (weighted) %children 0-11 months who initiated 52*** 28 34 breastfeeding within 1 hour after birth (n=300) (n=300) (n=600)

%children 0-5 months exclusively breastfed 81 88 87 (n=145) (n=145) (n=310) %women with children 0-11 months who gave first colostrums 48** 36 39 (n=300) (n=300) (n=600) *p<0.05 **p<0.001 ***p<0.0001(ESHE Vs. non-ESHE)

About 34% of the women with children age 0-11 months reported that they had put their children on the breast within 1 hour after birth. Colostrum feeding reported to be given to children by 39% of the mothers. Since baseline, there is no change in the proportion of mothers initiating breastfeed within 1 hour. The proportion feeding colostrum decreased significantly from 54% to 39% (p<0.001) during the period.

For children 0-5 months currently being breastfed, mothers were asked if the child had been given other liquids or solid foods at any time during 24 hours prior the interview and children who received nothing but breast milk are defined as being exclusively breastfed. The end-line data found exclusive breastfeeding rate at 87%, which is significantly higher than the 75% reported at baseline (p<0.001).

Figure 10. Breastfeeding Related Practices for Children Aged 0-11 Months, Household Health Survey, Amhara, 2004 and 2008.

87 75

% 39 34 31

BF w ithin 1hr Colostum given Exclusive BF (0-5 mo)

2004 2008

In ESHE project area vs. non-project area, the initiation of breastfeeding within 1 hour increased from the baseline only in the ESHE project area (from 31% to 52%, p<0.001) and remained the same in non ESHE area. Colostrum feeding declined notably both in the ESHE project and non- project areas, to a less extend in the ESHE area. Both in the ESHE project and non-project areas the proportion exclusively breastfed children 0-5 months increased – from 75% to 82% in the ESHE project area and from 76% to 88% in the non-project area.

Figure 11. Breastfeeding Related Practices of Children Aged 0-11 Months, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008.

A: BF within 1 hour B: Colostrum given

57 54 52 48 36 31 30 28

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

C: Exclusive BF (0-5 Months)

88 81

75 76

ESHE non-ESHE

2004 2008

Frequency of Breastfeeding The frequency of breastfeeding at least 8 times a day was reported to be respectively 78%, 75%, and 80% for the region, ESHE, and non ESHE areas. The frequency of breastfeeding was found to be lower then the region’s baseline of 91%. The baseline of 76% in the ESHE area remained similar in 2008.

Bottle Feeding (0-5 months) The use of bottles to feed babies less than 6 months old is low at 4% in the region, in ESHE and non-ESHE area and is the same as the baseline.

6.2. Complementary Feeding with Breastfeeding (6-23 months)

Timely Complementary Feeding Rate It is recommended that complementary foods be introduced starting at 6 months of age as this is an age when nutrients from breast milk are not sufficient to support healthy growth. The ‘timely complementary feeding rate’ is defined as the percentage of children age 6–9 months who were fed solid or semi-solid complementary foods in addition to breast milk in the 24-hour prior to the interview.

Table 6. Complementary Feeding at Age 6 to 9 Months, Amhara Household Health Survey, April 2008. ESHE Project Non-project Amhara Areas ‘08 Areas ‘08 ‘08 (Weighted)

% children 6-9 months who receive Semi-solid 67 59 61 food (n=96) (n= 81) (n=177)

*p<0.05 **p<0.001 ***p<0.0001(ESHE-non-ESHE)

About 61% of the children age 6-9 months reported to have semi-solid food the day before. This represents a significant (p<0.0001) increase from the 43% reported at baseline.

Figure 12. Trend in Complementary Feeding (6 to 9 Months), Household Health Survey, Amhara, 2004 and 2008.

43 %

2004 2008

In ESHE project area vs. non-project area, end-line data revealed that there is no difference between the ESHE project and the non-project area, respectively 67% and 59%. However, this

represents a higher rate as compared to the baseline when ESHE was at 38% and non-ESHE at 44% (for both p< 0.0001).

Figure 13. Complementary Feeding (Aged 6 to 9 Months), Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008.

67 59

44 38 %

ESHE non-ESHE

2004 2008 Continuation of Breastfeeding It is recommended to continue breastfeeding until the child is two years of age, as breast milk is still an important source of nutrients and vitamins.

Table 7. Continuation of Breastfeeding at 6 to 23 Months, Amhara Household Health Survey, April 2008. ESHE Project Non-project Amhara Areas ‘08 Areas ‘08 ‘08 (Weighted) 6-11 months 100 99 99.5 (n=155) (n=135) (n=290) 12-17 months 96 99 98 (n=164) (n=150) (n=314) 18-23 months 96* 87 89 (n=135) (n=150) (n=285) 6-23 months 97 95 96 (n=454) (n=435) (n=889) *p<0.05 **p<0.001 ***p<0.0001(ESHE-non-ESHE)

The continuation of breastfeeding of children 6-23 months old is high at 96%. The continuation during the critical age group 18-23 months is 89%, similar to the baseline.

In ESHE project area vs. non-project area the continuation of breastfeeding remains high in both ESHE and non-ESHE areas, and it is significantly higher for children 18-23 months.

Figure 13. Feeding Pattern for Children Aged 0 to 23 Months in the Last 24 Hours (breast milk, liquids and foods) in ESHE and non-ESHE Areas, Household Health Survey, Amhara, April 2008.

Amhara – ESHE

100

75 Not breastfed Breastmilk & solids t

n Breastmilk & other milk e c

r 50 Breastmilk & other liquid e

P Breastmilk & water Breastfed & no food/liquid reported Breastmilk reported & no food/liquid 25

0 0-1m 2-3m 4-5m 6-7m 8-9m 10- 12- 14- 16- 18- 20- 22- 11m 13m 15m 17m 19m 21m 23m Current age

Amhara – non-ESHE

100

75 Not breastfed Breastmilk & solids t

n Breastmilk & other milk e c

r 50 Breastmilk & other liquid e

P Breastmilk & water Breastfed no food/liquid reported Breastmilk reported & no food/liquid 25

0 0-1m 2-3m 4-5m 6-7m 8-9m 10- 12- 14- 16- 18- 20- 22- 11m 13m 15m 17m 19m 21m 23m Current age

Feeding Frequency of Complementary Foods In Ethiopia, as in many other countries, it is problematic to determine feeding frequency especially in terms of what constitutes a ‘meal’ and what constitutes a ‘snack’ (mekses). In Amhara baseline, the way in which data on meals and snacks were collected survey is different that the current recommended questions on soft, semi-solid, and solid foods. Thus in the present analysis, 24 hour recall data on the frequency of meals only, not snacks, was used.

Table 8. Frequency of Feeding at 6 to 23 Months, Amhara Household Health Survey, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) 6-11 months 60 66 64 (Minimum 2 times) (n=155) (n=135) (n=290) 12-23 months 72 72 72 (Minimum 3 times) (n=300) (n=299) (n=599) 6-23 months 68 70 69 (n=454) (n=435) (n=889) *p<0.05 **p<0.001 ***p<0.0001(ESHE-non-ESHE)

In Amhara Region, the frequency of feeding (minimum 2 times) is found at 64% for children 6- 11 months, 72% for children 12-23 months (minimum 3 times), and 69% among children 6-23 months.

In ESHE project area vs. non-project area, there are similar findings in ESHE and non ESHE areas in 2008. For ESHE children 6-11 months who were feed a minimum of 2 times a day, there is an undesired decrease from 77% at baseline to 60%; there is no change for children 11- 23 months who are fed more than 3 times a day.

Dietary Diversity The ENA messages on dietary diversity recommend that in addition to the baby’s staple porridge, at a minimum at least 2 to 3 additional food groups should be eaten. Thus on a daily basis a young child should be eating 3 to 4 different types of foods each day. During the baseline surveys, 24 hour recall data were collected which focused on seven major food categories. The seven food groups are as follows:

− Grains, roots & tubers

− Animal milk (primarily cow milk)

− Vitamin A rich foods (fruit & vegetable sources)

− Other fruits & vegetables

− Meat, poultry, fish, eggs, cheese and yoghurt

− Legumes or nuts

− Oil, fat & butter

For children 6-23 months, dietary diversity in the 24 hours recall was defined as ‘low’ for children who only ate foods from 0 to 2 food groups in the previous 24 hours, ‘medium’ for children who ate from 3 to 4 groups, and ‘high’ for children who ate more than from 5 groups. The minimum recommended diet diversity was set as 3-4 different types of food per day.

Table 9. Food Diversity for Children Aged 6 to 23 Months, Amhara Household Health Survey, April 2008. Out of 7 food groups ESHE Project Non-project Amhara ‘08 Areas ‘08 Areas ‘08 (Weighted) (n=454) (n=435) (n=889) 0-2 food groups 66*** 74 72

3-4 food groups 33*** 26 27

More than 5 food groups 1 0 0

*p<0.05 **p<0.001 ***p<0.0001(ESHE-non-ESHE)

Compared to the ESHE baseline, dietary diversity for children 6-23 months remains the same. At the baseline dietary diversity was similar with 72% of children having an inadequate diet with 2 food groups or less (low diversity), 25% ate 3 to 4 food groups (medium diversity), and 3% of children ate 5 or more food groups (high diversity).

Children in ESHE area have a significantly more diverse diet with 66% of children having less than two types of food compared to 74% in non ESHE area, and more children having three types or more (33 vs 26%)

Looking at the variation in the foods consumed by the children during the 24 hours preceding the 2008 survey, there is no difference between ESHE and non-ESHE area.

Table 10. Types of Food Consumed by Children Aged 6 to 23 Months, Amhara Household Health Survey, April 2008. Of Seven Food Groups ESHE Project Non-project Amhara Areas ‘08 Areas ‘08 ‘08 (Weighted) (n=454) (n=435) (n=889) Foods made from grains, roots or tubers 80 83 83 Milk other than breast milk, formula 12 10 11 Vitamin A rich vegetables or fruits 8 8 8 Other fruits/vegetables 2 2 2 Meat, fish, eggs, yoghurt/cheese 16 12 13 Foods made from legumes 52 48 49 Food made with oil/fat/butter 32 25 27

Compared to the ESHE baseline (regional and non-ESHE baseline are not available), there is an increase of consumption of grains, roots and tubers and oil/fat/butter with a decrease of dairy and animal proteins.

Figure 14 . Types of Food Consumed by for Children Aged 6 to 23 Months Compared to ESHE Baseline, Amhara Household Health Survey, April 2008.

83 80

52 47 48 48

% 32 28 25 21 16 12 11 11 12 11 10 8 8 2 2

Dairy Vitamin A rich Other fruits & Animal Legumes Oil, fat & butter Grains, roots & fruits & vegetables proteins tubers vegetables

ESHE 04 ESHE 08 non-ESHE 08

Bottle Feeding (6 to 23 months) The use of bottles to feed young children 6-23 months is found to be the same in the region, ESHE and non ESHE areas at 4%, and similar to the baseline.

Hand Washing Hand washing is recommended as one means by which to improve the nutrition of young children through its effects on decreasing illness, particularly diarrhea.

The proportion of women reporting washing hands before feeding the children is at 90% for children 6-23 months, 93% in ESHE area and 90% in non ESHE area. The findings are similar to ESHE baseline at 66%.

6.3. Nutritional Care of the Sick Child

Recommendations encourage mothers to increase the frequency of breastfeeding and/or feeding during and after each illness. Mothers were asked if their children had experienced any illness in the two weeks prior to the baseline surveys.

At end-line, 14% of the mothers reported having breastfed their sick children more often than usual during illness, that shows an improvement compared to baseline at 2% (p<0.05)

Figure 15: Percent Distribution of Children Sick in the Two Weeks Preceding the Survey, by Amount of Breastfeeding Offered, Household Health Survey, Amhara, 2003 and 2008.

% 27

14 9 2 4 2

Amhara ESHE non-ESHE

2004 2008

In ESHE project area vs. non-project area, increased the frequency of breastfeeding sick children significantly increased from 4% at baseline to 27% at end-line (p<0.05) in the ESHE project area.

6.4. Control of Vitamin A Deficiency

Vitamin A Deficiency (VAD) is widespread in Ethiopia. It is recommended that children receive adequate amounts of vitamin A, among others, either in their diet or through supplementation.

Consumption of Vitamin A Rich Foods The consumption of vitamin A rich foods (e.g. pumpkins, carrots, red sweet potatoes, green leafy vegetables, mangos, papaya and liver) in the diet is promoted to improve the vitamin A status. In Amhara, only 8% of children 6-23 months consumed such foods in the 24 hours preceding the survey; results are similar to baseline.

Post partum Vitamin A Supplementation for Women Supplementation of Vitamin A within 45 days after delivery is recommended to increase Vitamin A through breast milk intake. In Amhara region, in ESHE area and non-ESHE, 9% of women post partum received Vitamin A capsules, compared to 3% at regional and ESHE baselines.

Vitamin A Supplementation for Children Six Months and Older The coverage of vitamin A for children age 6-23 months reached 61% in the region. This is a significant increase from 17% at baseline (p<0.0001). In both areas, significant and comparable improvement in vitamin A coverage was also documented.

Figure 16. Children Aged 6 to 23 Months Who Received Vitamin A in the Previous Six Months, Household Health Survey, Amhara, 2004 and 2008.

61 62 57

17 18 14

Amhara ESHE non-ESHE

2004 2008

6.6. Control of Anemia

Antenatal Care: Supplementation in Iron/Folic Acid During Pregnancy During ante-natal consultations, pregnant women need to receive iron/acid folic supplementation as an intervention to prevent anemia. Women with children age 0-11 months were asked if their have received these services during the ANC.

Table 11. Percentage of Women with Children Aged 0 to 11 Months Having Received Iron/Folic Acid Supplementation, Household Health Survey, Amhara, April 2008. ESHE Project Non-ESHE Project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Received ANC in Health Facility 54 48 50 n=300 n=300 n=600

Received Iron Tablet 40* 32 34 Among Antenatal Care Users n=162 n=144 n=300

Among the Total Number of Women 22% 15% 17% n=300 n=300 n=600 *p<0.05 **p<0.001 ***p<0.0001(ESHE Vs. non-ESHE)

Results revealed that attendance at ANC has remained the same as baseline with half pregnant women attending ANC (see chapter 8), but only one out of three women attending ANC has received iron/acid folic supplementation; this is also similar to the baseline at 38%.

Only 17% of all pregnant women included in the survey received iron/acid folic which is the same as the baseline.

In ESHE project area vs. non-project area, the supplementation of iron/acid folic in women that attend ANC is significantly higher in ESHE area compared to the non-ESHE area, 40% vs 32%. However, the rate found in ESHE area is the similar to the baseline (38%).

Figure 17. Women Who Attended Antenatal Care and Received Iron/Folic, Household Health Survey, Amhara, 2004 and 2008.

38 38 40 38 % 34 32

Amhara ESHE non-ESHE

2004 2008

In Ethiopia malnutrition begins early on in life and continues to increase progressively up through two years. Much of the onset of malnutrition stems from inappropriate infant feeding practices during the first year of life in combination with infections such as diarrhea brought about by unhygienic food handling. Therefore, improving infant and young child feeding practices from 0-23 months of age and women’s nutrition is essential to reduce the high levels of child malnutrition found in the country. In addition, the control of micronutrient deficiencies has been shown to have impacts on children and women mortality and morbidity. Therefore the government of Ethiopia has adopted the Essential Nutrition Actions approach to achieve at scale the MDGs on mortality and malnutrition reduction.

Optimal breastfeeding and complementary feeding practices have been promoted by the ESHE project and supported through training of health workers, health extension workers, and community health promoters and by providing counseling guides for health providers and reminder materials for the target audiences. Similar activities were also carried out outside the ESHE project area although mainly by health workers and health extensions workers. The family health card (FHC) was widely available in ESHE area compared to the non ESHE area.

Optimal breastfeeding practices for children 0-6 months, introduction of complementary food and control of Vitamin A deficiency were carried out since the beginning of the ESHE project in 2003 in the phase 1 in SNNP. Other nutrition practices were introduced in all ESHE regions in late 2006. The ESHE team has strengthened their community and health facilities interventions to address the inadequate feeding practices of children 6-23 months that were reported in the baseline survey. Counselling tools on complementary feeding were developed for community providers in 2005. Training of community providers (HEW and CHP) was scaled up from 2006 as requested by the Regional Health Bureaus

The newly accepted IYCF indicators, particularly the ‘Minimum Adequate Diet’ has been calculated using the end line data and is annexed in this report. These indicators reveal more precisely the diet of children 6-23 months.

During the same timeframe of the ESHE implementation, the government started to implement bi-annual mass campaign providing Vitamin A for children 6-59 months, de-worming for children

24 to 59 months, and more recently ITN distribution for pregnant women and children under- five years of age.

Baseline and end line information are compared to determine if improvements were achieved in regard to each of the essential nutrition actions.

6.7. Children Sleeping under an Insecticide Treated Net (0 to 23 months)

Sleeping under insecticide treated nets (ITN) is part of the strategy to prevent malaria and also to control anemia in children as well as pregnant and lactating women. The end line survey shows a significant improvement with 70% of the household owning ITNs. A smaller proportion of children under 5 sleep under an ITN in the region, ESHE area, and non ESHE area, 38%, 39%, 36% respectively. Similar numbers are found regarding women.

6.8. Women’s Nutrition

Improving women’s nutrition is a key intervention at medium and long term to improve children and women’s health. However, the program focused on women’s nutritional needs during pregnancy or lactation.

Table 12. Percentage of Women Eating More During Pregnancy and Lactation, Household Health Survey, Amhara, April 2008. ESHE Project Non-ESHE Project Amhara Areas ‘08 Areas ‘08 ‘08 (Weighted) Eating more during pregnancy 24*** 8 12 (children 0-11 months) (n=300) (n=300) (n=600)

Eating more during lactation (children 0-23 61** 38 48 months) (n=600) (n=600) (n=1200) *p<0.05 **p<0.001 ***p<0.0001(ESHE Vs. non-ESHE)

In Amhara, one women out of eight reported to have eaten more because she was pregnant. Findings are significantly higher in ESHE than non-ESHE area, but similar to the ESHE baseline survey.

Findings show almost half the women in the region, 48%, eating more during lactation. Nutritional improvements are significantly higher in ESHE area as compared to the non-ESHE area (61% vs 38%). 2008 findings related to diet during lactation are higher that the 2004 baseline for the region and ESHE respectively 36% and 34%.

6.9. Source of Nutrition Related Information

Source of Information about Feeding Practices Women were asked whether community health workers contacted them in the 12 months preceding the survey to discuss feeding of children age 0-23 months.

Women reported to have been contacted by at least one community health worker (19%), 15% by HEWs and 5% by CHPs.

ESHE project area vs. non-project area, about 38% of the women from the ESHE project area as opposed to only 13 from the non-project (p<0.0001) reported having been contacted by at least one community health workers.

Figure 18. Source of Information on Child Feeding Practices in the Year Preceding the Survey, Household Health Survey, Amhara, April 2008.

38 % 26 19 19 15 13 12 5 1

Any community health worker HEW CHP

Amhara '08 ESHE '08 Non-ESHE '08 Women were asked to spontaneously mention any messages they heard on children feeding practices, the main messages recalled are:

− to take extra amount of foods (81%),

− to exclusively breastfeed their child up to six months (47%),

− to begin complementary feeding at 6 months (45%)

− to use different food to enrich porridge for their children (31%), and

− about breastfeeding frequency (39%).

6.10. Information to Women During Pregnancy and After Delivery

Women with children age 0-11 months were asked if they were contacted by community health workers to discuss about their health and that of their child during pregnancy or immediately after delivery.

Figure 19. Proportion of Women Contacted by Volunteer Community Health Workers During Pregnancy, Household Health Survey, Amhara, April 2008.

16 % 14 13

4 0

HEW CHP

Amhara '08 ESHE '08 non-ESHE '08

In terms of the type of community health workers contacted during pregnancy, 16% of the women in the region were contacted by HEW and 4% by CHP. It is higher in ESHE area.

In terms of the type of community health worker contacted during pregnancy, 23% and 14% (p<0.001) of the women from the project and non-project area, respectively, reported HEWs. The corresponding proportion of women reported to be contacted by CHPs was 13% and 1% (p<0.0001), respectively.

There is no difference in the proportion of women that received information from community health workers few days after delivery between the ESHE project (1%) and non-project areas (almost none).

6.11. Child Anthropometry

The anthropometric data, once analyzed and validated will be the subject of a separate report.

6.12. Summary and Discussion

ESHE project area although mainly by health workers and health extensions workers. The family health card (FHC) was widely available in ESHE area compared to the non ESHE area.

During the same timeframe of the ESHE implementation, the government started to implement bi-annual mass campaign providing Vitamin A for children 6-59 months, de-worming for children 24 to 59 months, and more recently ITN distribution for pregnant women and children under- five years of age.

Baseline and end line information are compared to determine if improvements were achieved in regard to each of the essential nutrition actions.

In the ESHE area, advocacy, training, promotion and counseling (through negotiation skills) of improved feeding practices were carried since the start of the project, in the phase 1 of ESHE implementation (2003-2006), and were parts of two of the three pillars (Training and supervision of health workers, and strengthening community health promoters, and health extensions workers). The ‘family health card’ (FHC) promotes ENA small do-able and actions oriented messages, was widely used by community health workers to encourage family members and caregivers to adopt adequate improved feeding practices.

In non-ESHE area, similar interventions, with less intensity (less training, fewer kebeles with community promoters, and fewer FHC distributed), were also implemented.

In Amhara region, the infant and young child feeding practices, exclusive breastfeeding and introduction of complementary foods have significantly improved from 2004 to 2008. Achievements are similar in ESHE and non-ESHE areas. Compared to the baseline, early initiation of breastfeeding is higher in the ESHE area than non-ESHE area.

The post-partum vitamin A supplementation to improve the Vitamin A content of the breast milk remains very low but has slightly improved since the baseline.

The vitamin A supplementation for children 6-23 months has improved in the region and reflects the success of the EOS strategy which has increased access to such a service. Achievements are still below the national target of 80% coverage. However, the presence of community health promoters does not seem to affect the coverage of Vitamin A supplementation as there is no difference between ESHE and non-ESHE area in 2008.

In the second phase (2006) of ESHE project implementation, promotion of feeding practices such as ‘frequency of feeding’ and ‘dietary diversity’ was introduced. There is an unexpected decrease of feeding frequency for children 6-11 months in ESHE area since the baseline. There is also no improvement in the overall diversity, number of food groups consumed compared to the ESHE baseline. In 2008 , the analysis of the consumption of specific food groups in ESHE area as compared to the non-ESHE area showed staple foods and high-fat containing food intake increased but in both areas, animal products and dairy decreased. There no improvement if breastfeeding practices during illness, and in the consumption of Vitamin A rich foods. Unfortunately it is not possible from the existing data to determine the relative importance of possible contributing factors such as cultural food habits leading to food aversions, lack of awareness of the importance of feeding a diverse diet, or limited family access to different foods groups due to high cost or lack of availability. Field experience suggests a mixture of all these factors. In addition, the current food crisis further jeopardizes the diversity of children’s diet.

The ‘continuation of breastfeeding to 24 months and beyond’ and ‘the hand washing before feeding the child’ were high in baseline and remain high.

The current survey also represented an opportunity to assess feeding practices using the newly development Minimum Adequate Diet’ indicator. This indicator reveals more adequately the diet of children 6-23 months.

There is no increase of ANC attendance in the Amhara region, the supplementation of iron/folic acid during pregnancy is similar than in the baseline, but in 2008 it is higher in the ESHE area than the non-ESHE areas. There is no improvement of in women’s diet during pregnancy, but lactating women have a better diet compared to baseline, and this is higher in ESHE areas. Data presented show that community health workers focus on child health issues slighlty more than maternal issues.

Women in ESHE area have been contacted more frequently by community providers, including HEW and CHP to discuss IYCF practices, and during their pregnancy and too less extend just after delivery. The messages recalled by women often reflect the improvement in feeding practices shown in the survey.

Since 2004, many targeted essential nutrition actions have shown improvements, some as a result of intensive training and a strong behavior change communication strategy (early and exclusive breastfeeding and introduction of complementary food) and others through an improvement of the delivery systems such as EOS. Breastfeeding and vitamin A supplementation are the two lead nutrition interventions to decrease under-five mortality.

Other practices, mostly related maternal nutrition have shown limited improvement such as receipt of Vitamin A post partum, iron/folic acid supplementation during pregnancy, and improved diet during pregnancy and lactation. Less program emphasis and less community health worker contact may contribute to these findings.

Recommendations

− Continue to support the Amhara Regional Health Bureau and partners to expand the ENA approach to the entire region replicating successes on optimal breastfeeding practices.

7.1. Incidence and Trend of Child Morbidity

Information on child morbidity (age 0-23 months) was collected by asking mothers of the incidence of cough, fever, difficult in breathing and diarrhea in the 2 weeks preceding the interview. Findings show that 8.9%, 12.6%, 7% and 3.5% of the children age 0-23 months, respectively, were reported to be ill with fever, diarrhea, cough and difficult breathing in the two weeks preceding the survey (Table 13).

Although comparing trend in incidence of childhood illnesses between two surveys may be confounded by the seasonal diversity of the time of the surveys fielded, yet some interesting patterns have emerged when data compared between the baseline and the end-line. As shown in Figure 20, the reported previous two-week incidence illness have declined significantly since the baseline – Fever (from 18.4% to 8.9%, p<0.001), Diarrhea (from 18.1% to 12.6%), Cough (from 12.2% to 7%) and difficult breathing (from 7.3% to 3.5%).

Table 13. Percentage of Children Aged 0 to 23 Months Reported to Be Ill with Fever, Diarrhea, Cough, and Difficulty Breathing in the Two Weeks Preceding the Survey, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted)

Fever 11.0* 7.8 8.9 Diarrhea 14.2 12.1 12.6 Cough 8.7 6.5 7.0 Difficult breathing 5.7 2.8 3.5 *p<0.05(ESHE Vs. non-ESHE)

Figure 20. Trend in the Tow-week Incidence of Fever, Diarrhea, Cough, and Difficulty Breathing, Household Health Survey, Amhara, 2004 and 2008.

18.4 18.1

12.6 12.2 % 8.9 7 7.3

3.5

Fever Diarrhea Cough Difficult breathing

2004 2008 41

ESHE Project Areas versus Non-project Areas Taken together, the 2-week incidence of illness declined notably irrespective of the study area. The baseline data revealed that the two-week incidence of fever and diarrhea among children age 0-23 months were higher in the ESHE project area than in the non-project – Fever, 22.2% vs. 17.2% and Diarrhea, 24.2% vs. 16.2%. Although higher incidence of illness among children from the ESHE project area was still seen at end-line, baseline to end-line comparison of the 2-week incidence of childhood illnesses revealed parallel and comparable decline in both areas (Figure 21).

Figure 21. Trend in the Two-week Incidence of Fever, Diarrhea, Cough, and Difficulty Breathing, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008.

Fever Diarrhea

24 22 17 18 14

% 11 % 12 8

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

Cough Difficulty breathing

% 12 12 % 9 7 7 6 7 3

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

7.2. Treatment Seeking in Health Facilities for Sick Child

Half of the mothers with sick children in the 2-week preceding the survey reported that they had taken their children to health facility for treatment (Figure 22). This is significantly higher than the 34% reported at baseline (p<0.001). Of note, the proportion sick children taken to health facility for treatment increased significantly from 31% to 50.4% (p<0.05) in the non- project area. There was however a slight and statistically insignificant increase from 42.5% to 52% in the ESHE project area.

Figure 22. Proportion Sick Children (previous two-week) Taken to Health Facility for Treatment, Household Health Survey, Amhara, 2004 and 2008.

51.9 50.1 50.4 42.5

34 31

Amhara '08 ESHE '08 Non-ESHE '08

2004 2008

7.3. Awareness of the Danger Signs of Childhood Illness

Women with children age 0-23 months were asked to spontaneously mention those warning signs that indicate a child under the age of 5 years should be taken to a health facility (Table 14). The vast majority (82.6%) reported fever, followed by repeated water stool (67.2%), repeated vomiting (50.6%), cough (27.9%), not eating/drinking well (14.3%), convulsion (12.8%) among few others. Overall, women’s reporting of the warning signs of childhood illnesses remained nearly unchanged since the baseline with the exception of the reporting of repeated watery stool (from 38.1% to 67.2%, p<0.0001) and repeated vomiting (from 38.6% to 50.6%, p<0.001) that have shown improvement significantly since the baseline (Figure 23).

Table 14. Frequently Mentioned Correct Warning Sign That Indicate Treatment for Children under the Aged of Five Years, Household Health Survey, Amhara, April 2008. ESHE Project Non-ESHE Project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Fever 85.2 81.7 82.6 Repeated watery stool 62.2 68.8 67.2 Blood in stool 5.5 2.2 2.9 Sunken eye 2.0 2.5 2.4 Cough 22.7 29.6 27.9 Fast breathing 10.0 5.8 6.8 Difficult breathing 5.7 2.8 3.5 Noisy breathing 2.0 2.3 2.3 Convulsion 11.8 13.1 12.8 Not eating/drinking well 14.3 14.3 14.3 Repeated vomiting 48.2 51.3 50.6

Figure 23. Trend in Women’s Awareness of Warning Signs That Indicate That a Child under-five Years Should Be Taken to a Health Facility for Treatment, Household Health Survey, Amhara, 2004 and 2008.

83.882.5 67.2

50.6 % 38.1 38.6 27.327.9 18.2 12 12.8 11.914.3 6.8 7.2 9.2 2.9 3.5

r l l e o o h g g n ll g v o o g in in io e in e t t u h h s w it F s s o t t l y n C a a u k m r i re re v in o te d b b n g v a o t o n d o st l C ri e W l a u d t d B F fic / a e if g e t tin p a D a e e e R p t e o R N

2004 2008

7.4. Oral Re-hydration Solution and Recommended Fluid to Children with Diarrhea

Oral Rehydration Salt (ORS) is highly recommended for children with diarrhea. At end-line, ORS was reported to be given to 23.6% of the children suffering from diarrhea in the 2-week preceding the survey, which is slightly higher (not significantly) than the 17.1% reported at baseline (Figure 24). The provision of ORS to children with Diarrhea did not increase significantly both in the ESHE project and non-project area.

Figure 24. Proportion Sick Children with Diarrhea in the Two Weeks Preceding the Interview That Received ORS, Household Health Survey, Amhara, 2004 and 2008.

28 25 24 22

17 % 13

Amhara ESHE non-ESHE

2004 2008 44

Sick children with diarrhea that received ORS and/or any recommended homemade fluid are considered as having Oral Rehydration Therapy (ORT). The end-line data revealed that almost equal percentage of the children (48%) with diarrhea in the ESHE and non-ESHE areas were given ORT (Figure 25).

Figure 25. Proportion Sick Children with Diarrhea in the Two Weeks Preceding the Interview That Received ORT, Household Health Survey, Amhara, 2008.

48 48 48

Amhara 08 ESHE 08 non-ESHE 08

7.5. Breastfeeding and Fluid Intake During Illness

It is recommended to continue breastfeeding and increase the amount of fluid to children during illness. Mothers were asked about changes in feeding practices for those children ill during the 2- week prior to the interview. Figure 26 presents the feeding practices of children under 2-year of age during illness with emphasis to breastfeeding and fluid intake. At end-line, 14% of the mothers reported having breastfed their sick children in the 2-week preceding the survey more often than usual during illness. Only 7.2% of the mothers reported that they had offered increased fluid to children with diarrhea. Temporal positive trend was noted both in the provison of increased breastfeeding to all sick children (from 2.3% to 14.1%, p<0.05) and increased fluids to sick children with diarrhea (from 4.6% to 7.2%) in the 2-week preceeding the surveys. Of note, the reporting of increased breastfeeding to all sick children significantly increased from 4.4% at basleine to 26.9% at end-line (p<0.05) only in the ESHE project area (Figure 26). This was not however exhibited in the non-project (from 1.5% to 8.9%, p>0.05).

Figure 26. Percent Distribution of Children Sick in the Two Weeks Preceding the Survey, by Amount of Breastfeeding and Fluid Offered Compared with Normal Practice, Household Health Survey, Amhara, 2004 and 2008.

Increased BF during Illness Increased Fluid during illness to children with diarrhea % % 27 15 14 9 2 4 2 5 7 8 3 4

Amhara ESHE non-ESHE Amhara ESHE non-ESHE

2004 2008 2004 2008

7.6. Insecticide Treated Net Use among Children

Mothers of children age 0-23 were asked if the target child slept under an ITN the night before the interview. This analysis is restricted to children residing in malarious areas. Overall, 37.4% of the children age 0-23 months residing in the malarious areas reported to have slept under ITN the night before the interview (Figure 27). Compared to the less than 4% reported at baseline, this suggests a remarkable improvement in the use of ITN in the entire region.

It is also important to note that not all families that owned ITN had their under 2 children slept under ITN the night before the survey. The survey revealed that only 54.2% of the children residing in a household that owned at least one ITN slept under ITN the previous night of the interview.

Figure 27. ITN Use among Children Aged 0 to 23 Months (previous night of the interview), Household Health Survey, Amhara, April 2008.

54.2 53.8 54.6

37.4 38.5 36.2

Children (0-23 months) slept under ITN Has ITN & child slept under ITN

Amhara '08 ESHE '08 Non-ESHE '08

7.7. Summary and Discussion

The end-line 2-week child morbidity assessment found a lower incidence of illnesses compared to the baseline. The 2-week incidence of fever declined from 18.4% at baseline to 8.9% at end- line, diarrhea from 18.1% to 12.6%, cough from 12.2% to 7%, and difficult breathing from 7.3% to 3.5%. Several factors, including differences in the seasons the two surveys fielded could confound comparison of incidence of childhood illness between the two periods. Yet some plausible explanations for part of the observed change could be anticipated. For instance, the noted decline in the incidence of fever appears to concur with the recent decrease in the incidence of malaria in most parts of the country, which was primarily realized thorough the widespread use of ITN. This study documented that 37.4% of the children age 0-23 residing in malarious areas reported to have slept under ITN the previous night of the interview. This represents a remarkable increase from less than 4% at baseline. It may well be that the documented improved optimal breastfeeding and timely complementary feeding could also contribute to part of the decline in childhood illnesses in the region. The recent advances in household access to safe drinking water (from 26.3% to 60.6%) and pit latrines (from 27.7% to 44%), as documented by this study, in the region could also play its part. These are all important hypotheses deserving future investigation.

Interventions often promoted positive behavior among mothers to seek care for their sick children with critical symptoms and danger signs. This study found significant improvement in the proportion of sick children taken to health facility for treatment, from a low of 34% at baseline to 50% at end-line. Although there were still half of the children who were sick in the 2-week preceding the end-line survey that were not taken to health facility, the observed improvement since the baseline can be considered quite encouraging. Indeed, a number of barriers could deter treatment seeking for sick child even when the mother is well aware of the danger signs, including, but not limited to, lack of easy access to health facilities, lack of women’s time, limited awareness of the services available in the health facilities, and unbearable indirect costs.

Some notable improvements have also been documented regarding the home management of childhood illness when data compared between the baseline and end-line although the practices can still be considered to be at its rudimentary stage. For instance, increased provision of breastfeeding to sick children rose from a low of 2.3% to 14% during the period. Increased fluid was reported to be offered to children with diarrhea by 4.6% and 7.2% of the mothers, respectively, at baseline and end-line. The provision of ORS to children with diarrhea only slightly improved from 17% at baseline to 23.8% at end-line. Worth mentioning, the home management of sick children varies somehow between the ESHE project and non-project areas. The practice of offering increased breastfeeding to sick children by women improved quite remarkably from the baseline 4.4% to 26.9% at end-line in the ESHE project area. This was reported to rise from 1.5% to 8.9% during the period in the non-project.

On the whole, findings of this study point to the need for continuing to strengthen the BCC campaigns to improve women’s awareness of the home management of childhood illnesses as well as the applications in the house premises. As well, encouraging treatment seeking behavior of the community for children with known danger signs should constitute a priority. Similarly, the health facilities need to be equipped with the necessary facilities, manpower and skills to properly manage and treat childhood illnesses.

Recommendations

− Strengthen the awareness of caretakers on the danger signs of illnesses that need immediate action from a trained health care provider or health facility.

− Further improve the caretaker’s appropriate home management practices for sick children through training and support of HEWs, VCHWs

− Improve access to treatment, for sick children by strengthening health facilities with skilled personnel, essential drugs .and supplies.

− Scale up IMNCI training and follow up for health workers and HEWs to improve their case management skills as well as referral.

8. MATERNAL HEALTH

8.1. Antenatal Care Coverage and Trend

Women of children age 0-11 months were asked whether they had gone for ANC check-up to a health institution during pregnancy (Table 15). The end-line data show half of the women (49.8%) received ANC during their most recent pregnancy last year, which is slightly higher (not significantly) than the 43.8% reported at baseline (Figure 28). The content of antenatal care is vital in evaluating its value. The end-line data revealed that among those who received ANC, 66.3% reported their weight measured, 75% blood pressure measured, 42.1% height measured, 34.2% received iron tablets, 14.6% gave blood sample, among others. Taken together, the contents ANC, as reported by women, have not changed since the baseline (Figure 28).

Table 15. Percentage Distribution of Women with Children Aged 0 to 11 Months According to Receipt of Antenatal Care Services , Household Health Survey, Amhara, April 2008. ESHE Project Non-ESHE Project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Received ANC in health facility 54.3 48.3 49.8

Antenatal care Contents (Among antenatal care users)

Weight measured 72.4 64.1 66.3 Height measured 42.3 42.1 42.1 Blood pressure measured 65.0 78.6* 75.0 Urine sample given 14.1* 6.9 8.8 Blood sample given 14.7 14.5 14.6 Received anti-malarial 6.1 2.1 3.1 Received Iron tablet 39.3 32.4 34.2

*p<0.05 (ESHE Vs. non-ESHE)

Figure 28. Contents of Antenatal Care, as Reported by Women Attending ANC, Household Health Survey, Amhara, 2004 and 2008.

76 75 65 66

42 38 38 % 34

13 15 9 10 11 3

Weight Height Blood Urine Blood Received Received measured measured pressure sample sample anti-malarial Iron tablet measured given given

2004 2008

ESHE Project Areas versus Non-project Areas The receipt of ANC found slightly higher in the ESHE project area than in the non-project although the difference was not statistically significant (54.3% vs. 48.3%, p>0.05). However, baseline to end-line comparison (Figure 29) revealed significant positive temporal trend in the uptake of ANC among women from the ESHE project area (from 45.3% to 54.3%, p<0.05). The observed trend was not statistically significant in the non-project area (from 43.3% to 48.3%, p>0.05)

At end-line 34.2% of the women reported to receive Iron Folate during their most recent pregnancy last year. There was no significant difference in the receipt of Iron Folate between the project and non-project areas (39.3% vs. 32.4%). Furthermore, baseline to end-line comparison found nearly stable trend in the uptake of Iron Folate since the baseline in both areas (Figure 29).

Figure 29. Trend in Antenatal Care Coverage and Iron Folate Provision to Pregnant Women, Household Health Survey, Amhara, 2004 and 2008.

Antenatal Care (ANC) Iron Tablets given during ANC

50 54 44 45 43 48

% % 39 38 34 38 38 32

Amhara ESHE non-ESHE Amhara ESHE non-ESHE

2004 2008 2004 2008

8.2. Tetanus Toxoid Injection

Pregnant women who are up to date on tetanus Toxoid during pregnancy are nearly 100 % protected against tetanus for their newborn and themselves. Two doses of Tetanus Toxoid during a first pregnancy offer full protection. However, if a woman was vaccinated during a previous pregnancy, she may only need a booster to give full protection. Five doses at the appropriate intervals provide lifetime protection. If a mother reports receiving at least two tetanus Toxoid injections during her lifetime, the last of which occurred less than 3 years ago, OR if she received at least 3 tetanus Toxoid injections during her lifetime, the last of which occurred in the last 10 years OR if she has received at least 5 tetanus Toxoid injections during her lifetime, then she is considered protected against tetanus for herself (maternal tetanus) and her newborn (neonatal tetanus).

Women with children age 0-11 months were asked if she received TTI during her most recent pregnancy or any time during her previous pregnancies and, if so, she was further asked the number of injections and when was the last injection given. Overall, 41.2% the women received at least 2 TTI during pregnancy of the child age 0-11 months. This is not significantly higher than the baseline 33.7% (Data not shown). Based on the definition for life long protection against neonatal tetanus, 54.4% of the women at end-line can be considered protected against tetanus, which is significantly higher than the 36.4% (p<0.001) documented at end-line (Figure 30).

ESHE Project Areas Versus Non-project Areas Both in the ESHE project and non-project areas the proportion of women protected against TT increased significantly since the baseline – from 29.3% to 59.7 (p<0.0001) in the ESHE project area and from 43.4% to 52.7% (p<0.0001) in the non-project. Of note the noted temporal change is much more pronounced in the ESHE project area than in the non-project (Figure 30).

Table 16. Percentage Distribution of Women According to Receipt of TTI, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted)

TTI during the pregnancy the most recent live birth last year None 39.7 41.7 41.2 1 13.7 23.7 21.2 2+ 46.6 34.6 37.6 Protection against Tetanus: Received 2+ doses, last within 3 yrs 47.0 35.0 37.9 Received 3+ doses, last within 10 yrs 10.7 14.3 13.4 Received 5+ doses during lifetime 2.0 3.3 3.0 Protected against TT 59.7 52.7 54.4

Figure 30. Trend in Proportion Protected Against TT, Stratified by ESHE Project and Non- project Area, Household Health Survey, Amhara, 2004 and 2008.

60 55 53

43 36 % 29

Amhara ESHE non-ESHE

2004 2008 8.3. Delivery Care

Home delivery is high in the region with about 90% of the children age 0-11 born at home last year (Table 17). Baseline data documented almost similar proportion of women having had home delivery as that of the end-line. About 10% of the deliveries that happened last year were assisted by health professionals either in the health institutions or at home, which is almost comparable to the baseline finding at 10.5%. The Health Extension Workers reported to have assisted only about 2% of the mothers during delivery last year. Trained Traditional Birth Attendants (TTBAs) assisted 7.7% of the women last year, which is almost similar to the 6.4% reported at baseline (Figure 31).

8.4. Postnatal Care

Only few (3.6%) women with children age 0-11 months were examined by trained health professional within 45 days after delivery (postnatal care). At baseline this was reported at 4.8%. There is no significant difference in the receipt of postnatal care between the ESHE project and non-project areas (5.3% vs. 3%).

Table 17. Percentage Distribution of Women with Children Aged 0 to 11 Months According to Place of Delivery, Assistance During Delivery, and the Receipt of Postnatal Care, Household Health Survey, Amhara, April 2008. ESHEProject Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Home delivery 86.3 91.0 89.7

Assistance during delivery Health professional 12.7 8.7 9.6 Health Extension Workers 1.0 2.0 1.8 Trained traditional birth attendant 5.7 8.3 7.7 Untrained traditional birth attendant 42.7* 31.7 34.3

Examined by trained health professional within 45 5.3 3.0 3.6 days after delivery **p<0.05 (ESHE Vs. non-ESHE)

Figure 31. Trend in Home Delivery, Professionally Assisted Delivery and Postnatal Care, Household Health Survey, Amhara, 2004 and 2008.

90 90

11 10 8 6 5 4

Home Delivery Assisted by Health Assisted by TTBA Postnatal Care (<45 Professionals Days)

2004 2008

8.5. Information to Women During Pregnancy and After Delivery

Women with children age 0-11 months were asked if they were contacted by community health workers who talked about their health and that of their child during pregnancy or immediately after delivery. As shown in Figure 29 A, 15.8% and 3.5% of the mothers in the region, respectively, reported that they were contacted by HEWs and CHPs during pregnancy last year. Only 1.6% and 0.2% of the mothers in the region reported that they were visited by HEWs and CHPs, respectively, within few days or weeks after delivery at their homes (Figure 32).

The receipt of information from community health worker (either from HEWs or CHPs) by women during pregnancy found significantly higher in the ESHE project area than in the non- project (Figure 32). In terms of the type of community health worker contacted during pregnancy, 22.7% and 13.7% (p<0.001) of the women from the project and non-project area, respectively, reported HEWs. The corresponding proportion of women reported to be contacted by CHPs was 13.3% and 0.3% (p<0.0001), respectively. There is however no significant difference in the proportion of women that received information from community health workers few days after delivery between the ESHE project and non-project areas (Figure 32).

Figure 32. Proportion of Women Contacted by Volunteer Community Health Workers During Pregnancy and Immediately After Delivery, Household Health Survey, Amhara, April 2008.

B: contacted by CHW after delivery A: contacted by CHW during pregnancy

22.7

15.8

13.7 13.3 % %

3.5

1.6 1.3 1.7 0.7 0.3 0.2 0

HEW CHP HEW CHP

Amhara '08 ESHE '08 Non-ESHE '08 Amhara '08 ESHE '08 Non-ESHE '08

8.6. Summary and Discussion

This evaluation failed to document significant improvement in the uptake of ANC in the region - from 43.8% at baseline to 49.8% at end-line. While it has shown significantly improvement during the period only in the ESHE project area from 45.3% to 54.3%. Data also showed the lack of positive temporal trend in the uptake of Iron Folate since the baseline (37.8% at baseline vs. 34.2% at end-line). On the other hand, TTI coverage, as measured by the proportion fully protected against TT, increased significantly from the baseline 36.4% to 54.4% at end-line.

Professionally assisted delivery and postnatal care still remained low a staggering at 9.6% and 3.6%, respectively. It should be emphasized that the proportion births attended by skilled health personnel is one of the MDG-5 targets concerning maternal health, and that the still low coverage of this target indicator is an area of concern. The very low coverage for delivery care has often been attributed to the unpredictability of the onset of labor and the difficulty in travel, particularly over long distances, during labor and delivery. Moreover, the lack of easy access to

health facilities and the relatively high cost of delivery care are often blamed for the low use-rate of delivery services.

Taken together, findings signal the limited use of maternal health care services by women in the region. Interventions that promote safe motherhood need to focus on improving women’s awareness of the benefits of ANC, safe and clean delivery as well as other newborn care issues. In parallel, health facilities should be made more accessible and well equipped to attract clients and respond to the likely growing demand for such services.

Recommendations

− Promote focused ANC/Birth preparedness at all levels.

− Promote the provision of TT and iron Folate by strengthening HW skill and knowledge and by improving the logistics management system.

− Support the region and facilitate the development of a strategy to address the very low skilled delivery care coverage.

− Accelerate the expansion of health centers with emergency obstetric care services

9. FAMILY PLANNING

9.1. Awareness of Family Planning Methods

About 89% of the women age 15-49 years heard of family planning in the region with 81.2% reported knowing where to obtain methods (Figure 33). Awareness of family planning methods remained nearly unchanged since the baseline (90.8%) - (Data not shown).

Figure 33. Percentage of Women in the Reproductive Age Who Know of Any Contraceptive Method, and Places Where to Obtain Method, Stratified by Sample Area, Household Health Survey, Amhara, April 2008.

93 88.7 87.3 87 81.2 79.3 %

Heard of Family planning Knew where to obtain method

Amhara '08 ESHE '08 Non-ESHE '08

9.2. Contraceptive Use, Level, and Trend

The contraceptive prevalence rate (CPR) among all women age 15-49 years is found to be 22.9% (Table 18), which is significantly higher than the 15.6% reported at baseline (Figure 34). Temporal trend in contraceptive prevalence rate during the period is statistically significant (p<0.0001). When the analysis is restricted to currently married women (i.e. 87% of the women interviewed were currently married), the contraceptive prevalence rate estimated at 24.8% for the region, 32.2% for married women in the ESHE project area vs. 22.4% in the non-project (p<0.05).

Data from the end-line survey also confirmed the dominant emphasis on the Injectables in the region, as noted in the DHS 2005 and other surveys. Injectables (20.4%) appeared by far the predominant contraceptive method reported by women. It means that about 90% of contraceptive prevalence is accounted for by the Injectables. Furthermore, Injectables is responsible for the apparent and significant temporal trend in contraceptive use during the period, with its prevalence increasing from 11.3% to 20.4% during the period (Figure 34). The prevalence of Pills is estimated at only 1.2%, which is lower than the 3.5% estimated at baseline.

Women were asked the source of family planning they were practicing. Heath post reported the predominant source (55.5%), followed by health center (33.6%) and the remaining 10.9% attributed to other sources including CBRHAs. Of particular interest, the proportion that obtained their current method from a health post was 35.2% at baseline (Data not shown), which is significantly lower (p<0.05) than the 55.5% reported at end-line.

Table 18. Percentage of Women in the Reproductive Age Who Are Currently Using a Family Planning Method by Type of Method and Source, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Current use of contraception a 28.7* 21.1 22.9

Type of current method Injectables 22.7 19.6 20.4 Pill 2.7* 0.5 1.2 Norplant 1.3 1.0 1.1 Any other methods 2.0 0.0 0.2 Source of current method (for the modern methods, n=178) Health post Health center 31.3 65.6* 55.5 Other sources 50.6* 26.6 33.6 18.1* 7.8 10.9 a Pregnant women included in the denominator *p<0.05 (ESHE vs. non-ESHE)

Figure 34. Trend in Contraceptive Use, Household Health Survey, Amhara, 2004 and 2008.

22.9 20.4 % 15.6 11.3

3.5 1.2

Any method Injectables Pills

2004 2008

ESHE Project Areas versus Non-project Areas End-line data revealed significantly higher CPR in the ESHE project area than in the non-project (28.7% vs. 21.1%, p<0.05). As shown in Figure 32a, the contraceptive prevalence rate significantly increased from the baseline only in the ESHE project area, from 14.3% to 28.7% (p<0.001). The observed increase in the non-project area, from 16% to 21.1%, was not statically significant. Of note, Injectables increased significantly in both the project and non-project areas although the apparent temporal trend appeared more pronounced in the ESHE project area (Figure 35). Pills uptake in both area exhibited a reversal trend (Figure 35).

Figure 35. Trend in Current Family Planning Use by Method, Stratified by Sample Area, Household Health Survey, Amhara, 2004 and 2008.

Any method Injectables

29 21 23

% % 20 16 14 11 11

ESHE non-ESHE ESHE non-ESHE

2004 2008 2004 2008

Pills %

4 2 3 0.7

ESHE non-ESHE

2004 2008

9.3. Source of Information on Family Planning

About a quarter of the women reported having been visited by at least one community health worker that discussed about family planning in the 12 months preceding the survey (Figure 36). Health extension workers reported top in the list (20.5%), followed by community health promoters (6%) and community-based reproductive health agents (4.4%).

Women residing in the ESHE project area appeared significantly more likely than those from the non-project to have been contacted by community health workers for information on family planning (33.7% vs. 22.7%, p<0.001). The proportion that reported having been contacted by the HEWs was 26.3% and 18.7%, respectively, in the project and non-project area. The difference was statically significant at p<0.001. Likewise, 10% and 4.7% (p<0.05) of the women from the project and non-project area, respectively, reported that they had been contacted by CHPs for the same.

Figure 36. Source of Information on Family Planning in the Year Preceding the Survey, Household Health Survey, Amhara, April 2008.

33.7

25.3 26.3 % 22.7 20.5 18.7 14 10

6 4.7 4.4 1.3

Any Community Worker HEW CBRHA CHP

Amhara '08 ESHE '08 Non-ESHE '08

Compared to the baseline, the proportion women reporting having been contacted by any community health worker that discussed about family planning (in the year preceding the survey) significantly rose (p<0.05) from 16.5% at baseline to 25.3% at end-line (Figure 37). The apparent temporal trend appeared much pronounced in the ESHE project area than in the non-project (Data not shown).

Figure 37. Trend in the Proportion of Women That Reported Having Been Contacted by Any Volunteer Community Health Worker/Field Worker, Household Health Survey, Amhara, 2004 and 2008.

2004 2008

9.4. Summary and Discussion

Baseline to end-line comparison revealed significant increase in current family planning use from the baseline 15.6% to 22.9% at end-line, representing a mean increase of 1.8% per annum during the period. This is quite an encouraging trend and appeared in agreement with the trend noted by the DHS between the period 2000 and 2005. The DHS found an increasing trend in contraceptive use from 7.5% in 2000 to 16.1% in 2005 for the entire Amhara region (i.e. a 1.7% increase per annum). Of note, findings revealed that trend in current family planning use to be much more pronounced in the ESHE project area (from 14.3% to 28.7%) than in the non-project (from 16% to 21.1%).

The documented increase in contraceptive use appears to have evolved along a parallel track with the recent improved access to family planning information and services in the region. Access to family planning information has been improved recently through the health extension program and also via the active involvement of community volunteers such as CBRHAs and CHPs. From the service side, women’s access to primary health care services, including family planning has been improved remarkably recently mainly through the current expansion of health posts that brings services closer to the community. Indeed, this study confirmed the fact that both access to family planning information and services improved notably since the baseline. The proportion of women reported to be contacted by any community health worker that discussed about family planning increased from 16.5% at baseline to 25.3% at end-line. A closer look at the data also revealed that the HEWs are at the forefront of family planning information provision to the needy in the region. Recently, health posts have become the major sources of family planning method for current family planning users, especially that of Injectables. Baseline to end- line data demonstrated a substantial increase in the proportion of women obtaining their current method from a health post - from 35.2% at baseline to 55% at end-line.

The end-line data also confirmed the widely noted pattern of use of a limited number of family planning methods in the region as well as the dominant emphasis on the Injectables. The Injectables contributes disproportionately to the temporal trend in contraceptive use in the region, as it increased from 11.3% to 20.4% during the period. Also, the relative contribution of Injectables is estimated at 90%. In contrast, long-term methods are rarely practiced by women in the region, as elsewhere in the country. There are a number of deterrents to the uptake of long-term methods in the country. For instance, an assessment of the reasons for the low use of IUD in Ethiopia concluded that inadequate information about the method, lack of access and unfounded rumors about the side effects of the method were the most important barriers to use the method5.

Recommendations

− Develop and harmonize FP messages and train HEWs and VCHW to facilitate the dissemination of appropriate information to house holds at scale.

− Promote healthy timing and spacing of pregnancies through household BCC and youth clubs.

− Strengthen the capacity of HPs to provide short acting contraceptive methods and refer eligible clients for the long acting methods.

− Strengthen the capacity of Health Centers to provide comprehensive services that include long acting methods.

10. HIV/AIDS AND CONDOMS

10.1. HIV/AIDS Awareness

5 Pathfinder International/Ethiopia [PIE]. 2003. Assessment of the c au ses for low u tiliz ation of IU C D s as family planning method in Ethiopia. Addis Ab ab a. Pathfinder

respectively, identified abstinence, faithfulness to ones partners and condom use as the most important ways of avoiding HIV. Trend data revealed a comparable level of awareness of ABC by women between the baseline and end-line (Figure 38).

10.2. Awareness about Condoms

About 65% of the women age 15-49 years heard of condom and 45.6% knew where to get condoms (Table 19). The proportion heard of condom (62.5% vs. 64.6%) and those who knew places where to obtain condoms (44.5% vs. 45.6%) remained nearly unchanged since the baseline (Data not shown).

Table 19. Women’s Awareness of HIV/AIDS, Ways of Avoiding HIV and Knowledge of Places Where to Get Condoms, Household Health Survey, Amhara, April 2008. ESHE Project Non-project Amhara‘08 Areas ‘08 Areas ‘08 (Weighted) Ever heard of HIV/AIDS 95.0 94.3 94.5

Know ways to avoid HIV

Abstinence 40.0 41.7 41.3 Faithfulness 76.0* 67.7 69.7 Using Condoms 21.0 22.3 21.3

Ever heard of condoms 64.0 66.3 64.6

Know places where to obtain condoms 47.7 45.0 45.6 *p<0.05 (ESHE Vs. non-ESHE)

Figure 38. Trend in Proportion Reporting Abstinence, Faithfulness, Condom Use as a Way of Avoiding HIV, Amhara, 2004 and 2008.

74.4 69.7

% 41.3 37.4

21.3 13.5

Abstnence Faithfulness Using condom

2004 2008

10.3. Information on HIV/AIDS and Condoms

Women reported that HEWs (40.7%) and CHPs (10.3%) contacted them in the 6 months preceding the survey that provide them with information on HIV/AIDS (Figure 39). Akin to this,

they also reported receiving information concerning condoms from HEWs (35.9%) and CHPs (11.3%) during the same period. Of note, this study did not ask further questions concerning the issues discussed or the HIV/AIDS/condom related messages received from the community health workers during those contacts. As expected, access to information on HIV/AIDS or condoms from CHPs appeared to be significantly better by women from the ESHE project area than those from the non-project.

Figure 39. The proportion of Women That Reported Having Been Contacted by Volunteer Community Health Workers (last 6 months) That Discussed about HIV//AID and Condoms, Household Health Survey, Amhara, April 2008.

A: Source of HIV/AIDS information (last 6 months) B: Source of Condom information (last 6 months)

43 40.7 40 38.7 35.9 35 % %

21.7 19.7

10.3 11.3 8.7 6.7

HEW CHP HEW CHP

Amhara '08 ESHE '08 Non-ESHE '08 Amhara '08 ESHE '08 Non-ESHE '08

10.4. Summary and Discussion

Since the predominant mode of HIV transmission in Ethiopia as elsewhere in sub-Saharan Africa is through sexual contact, abstinence from sex, limiting the number of partners and using condom have been identified as programmatically important ways to avoid the spread of HIV/AIDS in the country. Over the past two decades, following the advent of HIV, considerable efforts have been made in the country to increase public awareness regarding HIV/AIDS through different channels.

This study confirms that most rural women in the region are yet to be sufficiently aware of HIV/AIDS, as they lack comprehensive knowledge on the programmatically important ways of avoiding HIV infection. On the other hand this study also points to the fact that HEWs and other community volunteers, including CHPs, could play an important role in the fight against HIV/AIDS by reaching out to the vast majority of rural women with key messages on HIV/AIDS and condoms.

Recommendations

− Include HIV prevention and control massages in the training of VCHWs and develop BCC tools to be promoted in the community.

− Strengthen integrated community conversation activities that includes HIV/AIDS issues

− Harmonize message and coordinate HIV/AIDS prevention and control activities among partners to create synergy

ANNEX 1: TABLE OF INDICATORS Annex 1.1. Amhara: Key Household Survey Indicators: 2004-2008 ESHE Area Non-ESHE Area Regional (weighted) Indicators 2004 2008 2004 2008 2004 2008 Household % % % % % % Characteristics Percent of households with access to safe water supply 50 73 61 57 58 61 Safe Water (covered well/spring or Supply piped water) Percent of Households that 29 46 27 43 28 44 Sanitation have latrines Insecticide Treated Nets Percent of households with 8 69 5 71 6 68 (ITN) a bed net Access and Percent of households that utilization of are less than a 2-hour walk 73 96 62 90 65 91 health services to the nearest health facility Immunization Percent of children 12-23 possessing an immunization 31 40 39 45 37 44 card Percent of children 12-23 months old who received 60 82 63 82 62 82 BCG vaccination Percent of children 12-23 months old who received 63 83 65 83 65 83 DPT1 vaccination Percent of children 12-23 months old who received 49 65 52 66 51 66 DPT3 vaccination Percent of children 12-23 months old who received 50 69 52 68 51 68 Polio3 vaccination Percent of children 12-23 months old who received 45 63 52 64 50 63 Measles vaccination Dropout rate (DPT1 - 22 21 20 20 21 20 DPT3) Percent of children 12-23 40 48 46 48 44 48 months old fully immunized Percent of children 0-11 months fully protected from 29 60 43 53 36 54 tetanus at birth Breastfeeding Percent of children 0-11 months who initiated 31 52 30 28 31 34 breastfeeding within 1 hour after birth Percent women with children 0-11 months who 57 48 54 36 54 39 gave colostrums Percent of children 0-5 75 81 76 88 75 87 months exclusively

breastfed Percent of infants 6-9 months who receive Complementary complementary foods in 38 67 44 59 43 61 Feeding addition to breast milk (complementary feeding rate) Percent of children 6-23 Vitamin A months old who received 14 62 18 57 17 61 Supplementation Vitamin A supplementation in the previous 6 months Treatment of Percent of children 0-23 Sick Children months sick in the past two weeks Fever 22 11 17 8 18 9 Diarrhea 24 14 16 12 18 13 Cough 12 9 12 7 12 7 Rapid Breathing 7 6 7 3 7 4 Percent of women with a sick child who sough 43 52 31 50 34 50 treatment Percent of women who offered increased fluids to a 5 7 3 4 5 7 child suffering from diarrhea Percent of women with a sick child in the previous 4 27 2 9 2 4 two weeks who breastfed more after illness Family Planning Percent of women of childbearing age currently 14 29 16 21 16 23 use any family planning methods Injections 11 23 11 20 11 20 Pills 2 3 4 1 4 1 Antenatal, Percent of women with Delivery, & children 0-11 months Postnatal Care attended antenatal care 45 54 43 48 44 50 services during their last pregnancy

Percent of women from 15- 94 95 95 94 95 95 HIV/AIDS 49 years aware of HIV/AIDS Percent of women from 15- 49 years aware of method to avoid HIV/AIDS: Faithfulness to one partner 79 76 73 68 74 70 Abstain 37 40 38 42 37 41 Use condoms 18 21 12 22 14 21 Percent of women from 15- 49 who have heard about 68 64 61 66 63 65 condoms Percent of women from 15- 49 who know where to 48 48 41 45 45 46 obtain condoms

Annex 1.2. Revised IYCF Practices Indicators: Amhara 2008

In 2008, the World Health organization proposed a set of revised IYCF indicators to better describe infant and young child feeding practices:

The breastfeeding indicators remain the same as before (with minor changes in sampling) and include: Early initiation of breastfeeding: Proportion of children 0-23 months of age who were put to the breast within one hour of birth Exclusive breastfeeding under 6 months: Proportion of infants 0-5 months of age who are fed exclusively with breast milk

The indicators related to complementary feeding have been expanded to six indicators. Introduction of solid, semi-solid or soft foods: Proportion of infants 6-8 months of age who receive solid, semi-solid or soft foods (Breastfeeds not including) Continued breastfeeding at 1 year: Proportion of children 12 – 15 months of age who are fed breast milk Continued breastfeeding at 2 years: Proportion of children 20 – 23 months of age who are fed breast milk Minimum meal frequency: Proportion of breastfed and non-breastfed children 6-23 months of age who receive solid, semi-solid, or soft foods (but also including milk feeds for non- breastfed children) the minimum number of times or more. o 6-8 months= minimum 2 times; 9-23 months= minimum of 3 times; non- breastfed=minimum 4 times Minimum dietary diversity: Proportion of children 6-23 months of age who receive foods from 4 or more food groups from the seven groups listed below: o Grains, roots & tubers o Dairy; animal milk, cheese and yoghurt o Vitamin A rich foods (fruit & vegetable sources) o Other fruits & vegetables o Meat, poultry, fish, o Eggs, o Legumes or nuts Minimum adequate diet (MAD); Proportion of children 6-23 months of age who receive a minimum acceptable diet calculated as having the following three indicators: i. Breast milk or other type of milk (formula/other milk); ii. At least the minimum number of meals – 2 meals for breastfed children 6-8 months of age, 3 meals for breastfed children 9-23 months of age, and 4 meals for non-breastfed children 6-23 months of age (for non-breastfed children who received milk or formula this counted as one meal). iii. Minimum 4 or more food groups from seven mentioned above;

Using these indicators, the current IYCF practices were estimated for Amhara region, ESHE project area and the non project area. Except for exclusive breastfeeding practice and continuation of breastfeeding, all other IYCF indicators are sub-optimal, particularly food diversity. The estimated minimum adequate diet is extremely low at 1%, mainly because the dietary diversity being also extremely low at 1%.

Therefore it is critical for IYCF programs to address the low food diversity. Contributing factors such as cultural food habits leading to food aversions, lack of awareness of the importance of

feeding diverse diet, or limited family access to different types of foods due high cost or lack of availability can contribute to poor results in diet diversity and also MAD. However, it is also clear that this complex behavior, given the multitude of factors affecting adherence requires effective counseling tools and trained health providers to address and reinforce the desired behaviors.

Annex 1.2. Amhara: Revised IYCF Practices Indicators, 2008 ESHE Project Non project Region The IYCF indicators area 08 area 08 (weighted) (n=300) (n=300) (n=600) Timely initiation of breastfeeding within one hour after birth 52*** 28 34 (n=145) (n=165) (n=310) Exclusive breastfeeding for children 0-5,9 months 81 88 87 (n=68) (n=56) (n=124) Introduction of soft, solid and semi-solid foods 6-8 months 63 57 59 (n=127) (n=107) (n=234) Continuation of breastfeeding to 24 months 95** 100 99 -12-15 months (n=79) (n=105) (n=184) - 20-23 months 95 85 87 (n=454) (n=435) (n=889) Breastfeeding or for non-breastfed formula/other milk 98 95 96 (n=454) (n=435) (n=889)

Minimum food frequency for 6-23 months 64* 66 66 (n=454) (n=435) (n=889) Minimum dietary diversity 4 out of 7 groups for 6-23 4 1 1 months Grains, roots & tubers 79 83 82 Dairies animal milk, cheese and yoghurt 12 10 11 Vitamin A rich foods (fruit & vegetable) 8 9 8 Other fruits & vegetables 2 2 2 Eggs, 9 6 7 Meats, poultry, fish, 8 6 6 Legumes or nuts 52 48 49 (n=454) (n=435) (n=889) Minimum adequate diet 3 1 1

Linear graph: Feeding practices in the last 24 hours in ESHE area: (i) Mother who mentioned breast milk and not foods or liquids (ii) Solids in last 24 hours

ESHE non-ESHE

100 100

75 75 t t n n e e Breast milk only Breast milk only c c r

r 50 50

e Solids only e Solids only P P

25 25

0 0 0-1m 2-3m 4-5m 6-7m 8-9m 10-11m 12-13m 14-15m 16-17m 18-19m 20-21m 22-23m 0-1m 2-3m 4-5m 6-7m 8-9m 10-11m 12-13m 14-15m 16-17m 18-19m 20-21m 22-23m Current age

The linear graph illustrates the exclusive breastfeeding and introduction of complementary food in ESHE area compared to non project area. In ESHE and non project the exclusive breastfeeding curves are similar. It seems that a slightly higher proportion of younger children received complementary feeding sooner; however, there is a larger drop around one year of age then in non project area.

ANNEX 2: SAMPLE CLUSTERS

Annex 2.1. ESHE Clusters ZONE-1994 WOREDA-1994 PA/KEBELE-1994 DEBUB WELLO DESSIE ZURIA GERADO (009) DESSIE ZURIA ASSOGEDO DESSIE ZURIA ROBIT (011) KUTABER ARSES AMBA (028) DESSIE ZURIA GILBITAE (029) LEGAMBO BUSSO (035) TEHULEDERE TEBISA (016) DESSIE ZURIA BEGIDE TENTA YAMED (01) DEBUB GONDAR DERA METSELE DERA DEWOL DERA WECHET ESTE BELAT AMJAYE ESTE LEBET SLAMAGER ESTE YEDE DEGEMEGN FOGERA KEDEST HANA FOGERA GURANBA KEMEKEM MICHAEL DEBER KEMEKEM BAMBICO SEMEN WELLO DAWUNTA DELANT WEYES DAWUNTA DELANT AMBAT (058) GIDAN DILDY (020) GIDAN KOLAYT (016) GUBA LAFTO TEKLEHAYMANOT MEKET KILLA (05) MEKET DEFERGIE (027) MEKET MESFINA WADLA YENEJA (14) MIRAB GOJAM ADET ADET 002 JABI TEHNAN JIGA 001

Annex 2.2. Non-ESHE Clusters ZONE-1994 WOREDA-1994 PA/KEBELE-1994 ZONE WOREDA PA/KEBELE DEBUB WELLO DEBRESINA SENBO CHILALO (061) LEGEHIDA SHEKETI ARGOBA SPECIAL WOREDA FETEKOMA (035) MEKDELA AMBOFERES (040) SAYINT BEJA (07) WEREBABU EJERSA (020) DEBUB GONDAR FARTA MHADER MARIAM LAY GAYINT K. 16 AMBA MARIAM FARTA LEMADO TACH GAYINT DAJATE MISRAK GOJAM BASO LIBEN ARATU AMBA DEBAY TELATGEN NABRA GEWECHA ENEMAY DIMA GUZAMN YUESABA GUZAMN DASE MIKAILE SEMEN GONDAR ALEFA AHECHA MANGUR BEYEDA MATEBA DABAT DEFEYA DEMBIA WEKERAKO GONDAR ZURIA LAYE TEDA LAY ARMACHEHO JENKRA WEGERA GUNTIR SEMEN SHEWA ANTSOKIYANA GEMZA KEBEKOBE EFRATANA GIDIM ZANBO GERA MIDIRNA KEYA GEBRIEL WEZHEDE TARMABER SARE AMBA MAFUD MEZEZO MOJANA ABEDILAKE MORETNA JIRU BELLO WEREMO WAJETUNA MIDA YIGOBIYA BUGNA SABISA (31)

ANNEX 3: SURVEY TEAM

Name Responsibility Dr. Peter Ernes ESHE/JSI Project Director Dr. Tesfaye Bulto ESHE/JSI Deputy Project Director Frank White ESHE/JSI Deputy Project Director, Finance & Administration Dr. Mary Carnel JSI Child Survival Advisor Dr. Anwar Yibrie Amhara ESHE/JSI regional office head Essete Solomon ESHE/JSI M&E officer Dr. Yared Mekonnen Consultant Dr. Agnes Guyon Nutrition Advisor Betemariam Alemu Amhara Regional HHS coordinators ……………. Amhara Regional HHS coordinators Negussie Amhara Regional HHS coordinators ,,…… Data collectors ……. Data collectors

Birahnu Data entry clerk Shewangizew Data entry clerk