Leadership in Action: How Ethiopia Embraced the Nurturing Care Agenda

Leadership in action: how Ethiopia embraced the nurturing care agenda

Clear and consistent government leadership at all levels, starting with executive leadership at the highest level, facilitates implementation of the nurturing care agenda. Ethiopia’s vision for an inclusive and prosperous nation has encouraged all ministries and sectors to play their part and created an enabling environment for new ways of working: this opened the door for greater attention to ensuring that all children in Ethiopia aged under 5 years receive nurturing care. Photo credit: © UNICEF/UN0157429/Ayene

Since 1990, Ethiopia has made This case study describes how the steady progress in improving child MOH has been collaborating with survival, with under-5 mortality other ministries to elevate attention “Our fear is that a dropping from 205 per 1,000 live to and investment in early childhood whole generation will births in 1990 to 55 per 1,000 live development (ECD) and leading a not be equipped to births in 2019.1 While more and more multisectoral effort to operationalize children are surviving, the Ministry the nurturing care agenda. The reach its full potential of Health (MOH) is cognizant that case study sets out the process and compete in the not all are able to reach their full followed in developing a vision economy of the future.” developmental potential. The new shared by different sectors and enabling environment made it stakeholders, assigning roles and Dr Abiy Ahmed, possible for the MOH, under the responsibilities, developing strategic Prime Minister of Ethiopia direction of the Directorate of and operational plans, and building Maternal, Child Health and Nutrition, capacity to implement effective to expand its focus beyond surviving interventions at national and to include thriving and transforming regional (i.e. subnational) levels. children’s lives. It also served to reinforce collaborations with the Ministries of Education, Labour and Social Affairs, and Women, Children and Youth Affairs, as well as a range of development partners and stakeholders across diverse sectors.

1 Ethiopia demographic and health survey 2016: key indicators report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: Central Statistical Agency [Ethiopia] and ICF International; 2016. LEAD AND INVEST

Advocacy and sectors and diverse stakeholders to work together at different levels to leadership actions promote nurturing care. This section captures the five key building blocks Within three years, the MOH, of Ethiopia’s collective dedication together with other key ministries and commitment to advancing and partners, has created a vibrant nurturing care (see Figure). environment which enables multiple

Figure. Advocacy and leadership actions to advance nurturing care in Ethiopia

Lancet Early Childhood Development Missing (ECD) series responsive published caregiving and early learning content Establishment Learning Regional National included in National Launch of Finalization of ECD visit to Nurturing Care Sensitization refresher training on Addis Ababa of National Technical China Framework Workshop training the global demonstration Health Working Stakeholder on Nurturing for Health Care for Child project Strategic Group Consultation, Care Extension Development Plan for ECD Kenya Workers (CCD) package

OCT 2016 APR 2018 MAY 2018 SEP 2018 OCT 2018 NOV 2018 DEC 2018 JAN 2019 FEB 2019 MAR 2019 MAY 2019 AUG 2019 JAN 2020 APR 2020 SEP 2020

UNICEF/ Launch of High-level Revitalization Establishment Situational Finalization of Adaptation Ethiopia Nurturing Care debrief of of coordination of ECD analysis Early Childhood of CCD presentation Framework at learning visits among Research concluded Development package of Lancet ECD seventy-first relevant Advisory and Education to the series findings World Health ministries Council Policy Ethiopian Assembly Framework context

Learning visit to Training Opportunistic Mozambique of service integration providers of missing at select responsive Transform caregiving and Primary early learning Health Care content in Project sites strategies, tools and guidelines

Learning about nurturing care and participated in multiple learning Ethiopian delegation attended a the power of investing in ECD. The events that provided the essential regional consultation in Nairobi, Lancet’s ECD series2 (2016) and the underpinnings for the design of Kenya3 to discuss operationalization Nurturing Care Framework (2018) Ethiopia’s nurturing care roadmap. of the Nurturing Care Framework provided the global foundation These included: a presentation on within the health sector, resulting for the promotion of nurturing The Lancet’s ECD series for partners in the development of a national care generally, and particularly in Ethiopia; a learning visit to China action plan. Participants in responsive caregiving and early to see ECD programmes and learning exchanges debriefed learning through routine services. multisectoral collaboration in action; their colleagues and jointly agreed Throughout 2018, representatives and a visit to see how responsive on next steps. In 2019, additional from the MOH, together with caregiving and early learning learning visits to Brazil and Denmark other ministries and development (in the form of developmental were organized for the Minister partners including PATH, USAID, counselling and monitoring) of Health and delegates from the the World Bank, the World Health were being integrated into health Prime Minister’s Office and the Organization (WHO) and UNICEF, services in Mozambique. A large Addis Ababa City Administration.

2 Black MM, Walker SP, Fernald LCH et al. Early childhood development coming of age: science through the life course. Lancet. 2017, 389(10064):77–90. 3 Participating countries: Ethiopia, Kenya, Malawi, Mozambique, Tanzania, Zambia, Zimbabwe. For the 02 meeting report, see: https://nurturing-care.org/events/stakeholders-consultation-meeting/. LEAD AND INVEST

Following this, the MOH, financially supported by UNICEF, conducted a situational analysis of the extent to which existing health services were promoting nurturing care. The analysis revealed that responsive caregiving and early learning were not generally promoted through the health sector: a critical gap and missed opportunity, because the health sector is often the only way to reach young children and their caregivers consistently during the early years. It also discovered limited multisectoral coordination, insufficient public financing and a lack of national evidence around best practices. A subsequent policy brief and strategy produced by the ECD Research Advisory Council identified promising models Photo credit: ©UNICEF Ethiopia/ 2015/Tesfaye of service delivery approaches and played an instrumental role in shaping the MOH’s vision of Establishing a multisectoral ECD DFID, Christian Children’s Fund of promoting nurturing care. Technical Working Group (TWG) Canada, academia, regional bureaus Building the workforce’s capacity led by the MOH. In May 2018, the representing three sectors5 and to seize opportunities for early Directorate of Maternal, Child Health the media. The workshop raised learning and responsive caregiving and Nutrition established the ECD awareness and fostered a common within existing health platforms. TWG to identify concrete ways understanding of nurturing care, In early 2019, the MOH conducted for the health sector to promote the importance of investing in a training of trainers on the WHO/ nurturing care, and to define key nurturing care, the contribution UNICEF Care for Child Development issues, roles and responsibilities. that each sector could make and the package6 to develop a pool of 42 While this TWG was initially part value of multisectoral coordination. experts at national and regional of the Child Survival TWG, it was Participants developed a joint levels able to build the capacity expanded to increase its diversity action plan with specific tasks of service providers to promote by including representation for the different ministries and responsive caregiving and early from a range of ministries and committed to replicating this learning through existing health stakeholders, such as civil society workshop in five major regions of services. Many of the trainees organizations and private sector Ethiopia. Participants also agreed to had experience as trainers in companies, while continuing to revise the national Early Childhood the Integrated Management be coordinated by the MOH. Development and Education policy of Newborn and Childhood framework to ensure alignment with Organizing a national sensitization Illness (IMNCI) package, which the Nurturing Care Framework. workshop on nurturing care. provided a sound foundation A national sensitization workshop for Gathering and using evidence to for quickly internalizing the relevant ministries and development inform planning. In the Ethiopian content. The training also featured partners convened in late 2018 was context, Research Advisory Councils dedicated sessions on adaptation, the first high-level forum focused established by the MOH gather, contextualization and planning to specifically on nurturing care analyse, synthesize and translate enable immediate introduction of for ECD. The workshop brought international and national evidence the Care for Child Development together over 200 participants to ensure that programmes package into routine health representing national and implement evidence-based services. Following the training, regional representatives from interventions. In 2019, a Research four regional health bureaus rapidly four ministries,4 UNICEF, WHO, Advisory Council thematic group started building local capacity for the World Bank, PATH, USAID, was specifically established for ECD. its implementation.

4 Ministry of Health, Ministry of Education, Ministry of Labour and Social Affairs and Ministry of Women, Children and Youth. 5 Ministry of Health, Ministry of Education and Ministry of Women, Children and Youth. 6 Care for Child Development is a toolkit that equips front-line workers, such as health and social workers, with the knowledge and skills to counsel and empower caregivers to communicate and play with their children. See: https://www.who.int/maternal_child_adolescent/documents/care_child_ 03 development/en/. LEAD AND INVEST

Achievements Integration of early learning and responsive caregiving into maternal ለልጅ ሁለንተናዊ እድገት የሚደረግ Together, these advocacy and and child health training packages. እንክብካቤን በተመለከተ ምክር ይስጡ Following extensive consultation, leadership actions created ከ 1 እስከ 6 ወር ከ 6 እስከ 9 ወር ከ 9 እስከ 12 ወር ከ 12 ወር እስከ 2 ዓመት 2 ዓመትና ከዛ በላይ

በደነንብ እየጠባሽ ነው ይሳቅ የአባን ቢጫ ሼሚዝ ገንፎ ትወዳለህ አይደል ኪያ? ይህ በግ ይባላል አዎ እሱ አፍንጫህ ነው conditions in which Ethiopia the Care for Child Development አይደል ሃና? ርቦሽ ነበር… ማግኘት ትችላለህ? was able to rapidly translate the package was contextualized and Nurturing Care Framework into adapted to include developmental

አሃ! ልብሴ ላይ ያለውን አበባ አንድ፤ሁለት! በጣም ጥሩ! well conceived and coordinated monitoring and maternal mental ኳሷን አየህ ኢብሳ? ለእማና አባ አጨብጭብ ወደድከው! ሰማያዊውን ከተትከው ጎበዝ! action which is already beginning health screening and counselling to bear fruit through development content, and was made more

እማ የታለች? ጎበዝ! የኔ ልጅ ወደ እማ ተረት ተረት አንድ ወፍ of enhanced policies, strategies conducive to participatory adult እየተራመድሽ ነው ነበረች… and programmes for young learning. Content on responsive children and their families. caregiving and early learning was ታደለ የሽንት ጨርቅህን አሁን ጫሊ ይሄ ጣራወ ነው? integrated into the Integrated ድምጹን ወደድከው? ልቀይልህ ነው? Enabling a multisectoral policy Refresher Training for Health environment. The national Extension Workers (HEWs), the ለወላጅ/አሳዳጊ ሰላምታ ወላጅ/አሳዳጊ ለልጃቸው ተገቢ ወላጅ/አሳዳጊ ልጅን ማጫወት sensitization workshop revitalized 1 ይስጡ 4 ምላሽ ሲሰጡ ያበረታቱ 7 አና ማዋራትን በተመለከተ የሚያነስዋቸውን ችግሮች HEW pre-service curriculum, ወላጅ/አሳዳጊ ልጃቸውን ወላጅ/አሳዳጊ ከልጃቸው እንዴት በቀላሉ መፍታት እንዴት እንደሚያጫውቱ እና ጋር አዳዲስ ጫወታዎችን 2 5 እንደሚችሉ በማስረዳት commitment to multisectoral እንደሚያዋሩ እንድያሳይዎት እንዲጫወቱ ያበረታቱ በቤት የሚተገብሩትን ዕቅድ new job aids for HEWs and social ይጠይቁ ልጆችን ማጫወት እና ማዋራት እንዲያቅዱ ያድርጉ እንደሚችሉ collaboration at national and ወላጅ/አሳዳጊ ለልጃቸው ተገቢ 6 ለምን እንደሚጠቅም ያስረዱ workers, the BabyWASH manual, 3 ምላሽ ሰጪ መሆናቸውን ይመልከቱ regional levels and positioned the and COVID-19 guidelines. Work is nurturing care agenda as a collective currently underway to integrate responsibility. Coordinated efforts responsive caregiving and early Adapted and contextualized Care for Child by ministries and development learning content into packages Development counselling card (in Amharic). partners led to revision of the Early used by health facility workers (e.g. Child Care and Education policy IMNCI and neonatal intensive care in four major regions, as well as framework. The newly named unit training manuals). In addition, to disseminate job aids and build Early Childhood Development key messages were introduced into service providers’ capacity. The and Education (ECDE) framework, the existing mHealth platform to Addis Ababa City Administration, adopted in 2019, emphasizes support uptake of and demand for Big Win Philanthropies and the the importance of responsive reproductive, maternal, newborn Bernard van Leer Foundation are co- caregiving and recognizes the and child health services by parents financing a national demonstration need to leverage all touch-points and caregivers and to promote project to promote nurturing care (including in health facilities). Most healthy behaviours. importantly, it specifies the roles through health facilities, home and responsibilities of each sector visits and ECD centres. This project in advancing the nurturing care has obtained additional technical agenda. By the end of 2020, four assistance through a grant to PATH regional health bureaus had already The Early Childhood from the Bainum Family Foundation integrated activities promoting Development and to support integrating health sector work within the larger multisectoral nurturing care into their annual Education (ECDE) work plans and budgets. initiative. Results and lessons framework, adopted in learned from these initiatives will A clearly defined way forward for 2019, emphasizes the inform the finalization of health the MOH. The enabling national sector packages, encompassing the environment, and lessons learned importance of responsive nurturing care components for use from the various workshops and caregiving and in routine health services nationally. country exchange visits, enabled the MOH to reinforce support for recognizes the need to nurturing care in influential guiding leverage all touch-points. documents. Examples include the National Mental Health Strategy (2020–2025), the Health Sector Transformation Plan (2020–2030) Financing at national and regional and the National Health Strategic levels to promote nurturing care Plan (NHSP) for ECD (2021–2025). within health services. The MOH The NHSP is aligned with the revised has successfully leveraged financing ECDE policy framework and the from the USAID-funded Transform Nurturing Care Framework and is Primary Health Care Project to complemented by a monitoring and reinforce missing responsive evaluation framework developed by caregiving and early learning the ECD Research Advisory Council. content in routine health services

04 LEAD AND INVEST

Success factors All-of-government approach to multiple sectors, making it easier nurturing care action. Government for all actors to own the revision of Cultivating champions at the leaders set the vision, provide the ECDE policy framework. These highest level of government and overall directives, call upon the deliberate multisectoral actions, across key ministries. Nurturing whole of government, facilitate driven not by external partners care in Ethiopia has benefited multisectoral responses and commit or funders but by champions from consistent leadership and a to investment. National programme within government, facilitated the harmonized vision at all levels of staff orient stakeholders at all levels, contextualization of the nurturing government. The Prime Minister’s conduct planning meetings, set care agenda and ensured its encouragement to ministries to priorities, build multistakeholder alignment with national priorities. partnership, plan together, expand their mandate to ensure all-round development of Ethiopians implement by sector, monitor has opened the door for individual together, facilitate local adaptation, ministries to promote the nurturing build national and regional capacity Consistent leadership for implementation, agree on care agenda. Focal persons have and a harmonized been appointed in each ministry indicators, monitor implementation and empowered (including with and mobilize resources. Regional vision at all levels of financial resources) to work on health bureaus, in collaboration government have seeded this agenda. Within the MOH, with stakeholders, develop plans in the Minister of Health, the State line with national priorities, make nurturing care minister, the Maternal and Child local adaptations, build capacity of in Ethiopia. Health Director and the Child Health managers, supervisors and front-line Case Team Coordinator frequently providers, mobilize communities, check on progress and motivate create demand, and monitor, ECD TWG members and the MOH review, revise and act. Harnessing partnerships to drive ECD Focal Person by recognizing the agenda. Strong collaboration Opportunities for learning and between the key ministries, coupled their contributions. The dedication, exchange at all levels. The multiple passion and continued leadership with commitments by several UN learning opportunities and effective and nongovernmental partners of the ECD Focal Person, Mrs. Tina dissemination approaches were Asnake, have been critical for the to help the government advance instrumental in garnering and its vision and priorities, helped to MOH’s embracing of the nurturing maintaining enthusiasm. For care agenda, for collaboration catalyse and sustain momentum for example, the Deputy Mayor of Addis the nurturing care agenda. Financial with other sectors and for seeding Ababa’s visits to Brazil and Denmark nurturing care across Ethiopia. contributions and technical influenced his decision to establish assistance from UNICEF, WHO, and co-finance the demonstration Transform Primary Health Care, the project in Addis Ababa. The ECD World Bank and PATH helped the Focal Person participated in a government to achieve key activities technical meeting of global experts and processes (e.g. ECD situational 7 in Geneva , which took stock of analysis, learning visits, capacity actions across countries to advance building of service providers, nurturing care and provided contextualization of the Care for further guidance on how to Child Development package elaborate activities. and printing of job aids and Collaborative engagement from the counselling materials). very beginning. The composition Taking the time to reflect and be of the ECD TWG and the various evidence-driven. The learning visits learning events were deliberately not only sensitized key Ethiopian structured to include representation stakeholders to best practices and from multiple institutions and the latest evidence for nurturing sectors. This approach recognized care, but also served as forums and appreciated the contributions for reflection on what is currently of each sector, with dialogue and happening and how existing collaboration forming the basis of interventions can be reinforced joint action plans. For example, the to promote all aspects of national sensitization workshop on nurturing care. nurturing care brought together Photo credit: ©UNICEF Ethiopia/2012/Getachew a range of stakeholders from

05 7 For more information see: https://nurturing-care.org/innovating_for_ecd-2/. LEAD AND INVEST

Barriers Lack of global tools to help the MOH When conducting the situational advance nurturing care. Initially, analysis, for example, the Ethiopia Low technical capacity in the when the MOH was ready to explore team had to develop the tool locally MOH and ECD TWG. Initially, while what it would mean to advance from scratch. Had these materials MOH technical leads and ECD nurturing care through the health already been available it would TWG members were enthusiastic sector alongside other sectors, there have reduced the time and energy about the nurturing care agenda, were no global resources to guide needed at the beginning of the they did not know how to go about implementation of the Nurturing process and ensured that the work strengthening health services Care Framework, (e.g. no global tool was aligned with the global agenda to promote nurturing care. This to conduct a situational analysis from the outset. resulted in a lack of confidence and or implementation guidance). clarity on where to start and what to do. Participation in the national training on the Care for Child to integrate responsive caregiving Development package and the Looking forward and early learning into essential regional stakeholder consultation service delivery platforms at in Nairobi, Kenya provided much Ethiopia has shown that the community and health facility needed clarity and gave the MOH nurturing care agenda can levels. Efforts to build capacity the confidence it needed to own be contextualized and rapidly and ownership at multiple levels, and drive the agenda. scaled up when the following conditions are in place: including among parents and government commitment, communities, will enable all starting from the highest level of stakeholders to work together executive leadership; strong and so that all children survive, participatory coordination and thrive and reach their full collaborative structures; dedicated developmental potential. focal experts in key ministries While there is currently a high level and departments; openness to of interest in and commitment to learn from each other, as well as the nurturing care agenda across from experiences both inside and all key ministries, it cannot be outside the country; and national assumed that this will always be and international partners ready the case. Historically, emergencies to help the government realize or changing priorities at the its vision. highest levels of government have Within three years, Ethiopia’s MOH tended to divert attention and established a solid foundation for resources as is being observed promoting nurturing care in the during the ongoing COVID-19 health sector, and in collaboration pandemic. During such crises, with other sectors. The focus has the focus reverts to child survival, now shifted to sustaining and leaving aside interventions that building on this progress. The support the new thrive agenda, MOH will continue its work with and even risking reversal of recent partners to reinforce missing achievements. Ongoing advocacy nurturing care elements and to efforts are therefore needed at integrate them into key policies, all levels to ensure that decision- strategies, guidelines and tools. makers see nurturing care as a It will also explore opportunities priority, even during times of crisis.

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Tina Asnake, Child Health Program Acknowledgements: Officer/ECD focal person, Directorate The development of this case study of Maternal, Child Health and Nutrition, was led by Tina Asnake (Ministry Photo credit: © UNICEF ETHIOPIA/2016/ Federal Ministry of Health, Ethiopia: of Health, Ethiopia). Debjeet Sen Meklit Mersha [email protected] (PATH) and Sheila Manji (Partnership for Maternal, Newborn & Child Health) Visit https://nurturing-care.org/ facilitated the writing process. country/ethiopia/ for more information Extensive contributions were on the activities and documents provided by Nesibu Agonafir (PATH), mentioned in this case study. Bernadette Daelmans (WHO), nurturing-care.org #NurturingCare Teshome Desta Woldehanna (WHO) 06 @NurturingCare and Matthew Frey (PATH).