AMBASEL AND KUTABER WOREDAS (SOUTH WOLLO) BASELINE NUTRITION STUDY
TABLE OF CONTENTS
PAGE
INTRODUCTION 1
1. Background to the Study 1
2. The Survey 2 2.1 The Purpose of the Survey 2 2.2 METHODOLOGY 2 Survey Methodology and Sampling Frame 2 Variables Measured and Recording Information 3 2.3 Organisation and Management of the Survey 3 Organisation 3 Training of the Data Collectors 3 Management of the Survey 4 2.4 Organisation and Management of the Data 4 Data Editing and Input 4 Data Analysis 4 2.5 Other Sources of Information 4 Focus Group Discussion 4 Market Survey 5 Discussions with the Woreda Sector Offices 5
3. Results of the Study and Discussions 5 3.1 Nutritional status 5 3.2 Vaccination and Health Status 6 3.3 Socio-economics and Food Situation of the Households 6 Head of Household and Household Size 6 Staple Foods of the Family 7 Pattern in Acquisition of Staple Foods 7 3.4 Family Health Aspects of the Interviewed Households 8 Health Institutions 8 Health Seeking Practices 8 3.5 Sanitation and Water Requirement Aspects of the Interviewed Households 9 Water Requirement and Source 9 Changes in Water Supplies and Quantity 9 Inadequacy of Water Year Round and the Reason for Shortfall 9 Area of Intervention 9 3.6 Focus Group Discussions 10 Results of Market Surveys 10
4. Further Discussions and Conclusions 11 4.1 Food Security and Related Activities 11 Principal Crops Cultivated 11 The Land 11 Development Schemes 11 4.2 Responses to the Crisis 12 General Ration 12 Supplementary Food Program 12 Other Handouts and Inputs 12 Selection Criteria and the Logistics of Distribution 13 4.3 Malnutrition Level and Related Stresses 13
5. Recommendations 15 EXECUTIVE SUMMARY
This report offers major findings of a baseline nutrition survey that was commissioned by the Ethiopian Red Cross Society and undertaken by the consultant in Kutaber and Ambasel Woredas of the South Wollo Zone.
Ambasel and Kutaber Woredas have a total population of 233,400 organised into 40 Kebele/Peasant Associations. A total of 91,401 Belg farming population is severely affected by drought-induced food shortages.
ERCS distributes general dry ration to 20 Belg Kebeles and the rest are covered by the DPPC. The distribution centres are Kutaber (for Kutaber Woreda) and Wichale (for Ambasel Woreda). The ERCS has also distributed blankets for the poorest of the poor households and select seeds to the needy farmers.
The selection criteria are said to encourage the sale of whatever livestock left including oxen in the household. Therefore, the selection criteria call for revision and improvement.
A total of 36 clusters were studied from 8 K/PAs and an eligible child in a household was included for anthropometric measurement. Mothers were interviewed about family food, health and water using structured questionnaires.
I NUTRITIONAL STATUS AT THE WOREDAS LEVEL
<-2 Z-Score <-3 Z-Score LEVEL
N % N %
Weight-for- 209 31.3 25 3.7 length(WL), n=728 (27.9 – 35.0) (2.5–5.6)
Among the studied children (n=728), Acute Malnutrition or wasting (<-2 Z Scores) affects 31.3% (N=209), 43.6% (317) out of 728 children were ill. The proportion of malnutrition observed is one of the highest recorded.
The main staple diet of more than 53% (N=391) of the households is wheat grain and 97.4%, (N=725) of them have insufficient food items under their possession.
The two Woredas have 9 clinics, 6 health posts and 1 rural hospital. Malaria and stomach ailments are prevalent in the Woredas.
Water is fetched from unprotected springs and 92% of respondent household have to walk (both ways) less than 1 hour to fetch water.
There were few rural development activities witnessed during the study except a reported WFP supported soil conservation work.
II Recommendations
Sensitisation of policy makers at all levels and advocacy for adequate food aid and inputs in health and water sectors development should be the priority task of the ERCS.
The nutritional and health situations should closely be monitored. Follow-up nutritional surveys should be conducted every six months.
Improving the selection criteria of beneficiaries and distribution systems should strengthen the rehabilitation program.
Free or subsidised distribution of early-maturing crop seeds and introduction of root crops be encouraged.
Water should be developed for sanitation and micro-irrigation schemes. Some of the hillside springs appear to be feasible for use in backyard gardening and the like. Related development activities or schemes like roads, forestry and soil sectors are indispensable.
The ERCS should further strengthen its branch and sub-branch offices in South Wollo and extensively use its strong Youth Club bases to execute the rehabilitation and development schemes including nutrition and food diversification education.
The use of baseline information for future projects appraisals, implementation, monitoring and impact evaluation is highly recommended.
III 1. Background to the Study
This report offers major findings of a baseline nutrition survey which was commissioned by the Ethiopian Red Cross Society and undertaken by the consultant in Kutaber and Ambasel Woredas of the South Wollo Zone (the TOR and map of the area are attached in the in as annexes).
These two Woredas are situated in one of the areas highly vulnerable to food insecurity and related disasters and has been affected by four years consecutive drought-induced crop failures and the resulting food shortages.
The two Woredas have a total population of 233,400 (Kutaber, 107,830 and Ambasel, 125,569) organised into 40 (Kutaber, 16 and Ambasel, 24) Kebele/Peasant Associations (K/PAs). According to the authorities of the two Woredas, 91,401 (31, 907 in Kutaber and 59,404 in Ambasel) Belg farming population are reported to have been severely affected by the current drought-induced food shortages.
The Ethiopian Red Cross Society (ERCS) has been involved in these Woredas in terms of distribution of relief foods and other items (select seeds and blankets) and is well-established in the region in terms of understanding the situation and mobilisation of resources to contribute towards containing the crisis.
In this context, a need was felt by the society to undertake baseline nutrition surveys in the Woredas to fine-tune the ERCS’s assistance as well as for further advocacy for resources and planning of health and nutrition-related interventions. This report, therefore, highlights the findings of the survey in the context of current food, nutrition and health insecurity the area is facing. Detailed results of the study are presented in appendices and annexes.
1 The report is presented in four parts. The first part deals with brief background and description of the study site while the second part highlights the objectives and the methodology. The third part presents discusses the major findings of the study. The fourth part of the report concludes the findings of the study in the context of the current situation in the study areas and the fifth and final part gives suggestions and recommendations for further action.
2. The Survey
· 2.1 The Purpose of the Survey
The first and most immediate purpose of the study is to assess the malnutrition level and generate a baseline information on food, health and water needs of the general population and determine immediate and future nutritional and health inputs for action and advocacy.
2.2 METHODOLOGY
· Survey Methodology and Sampling Frame
The consultant, maintaining WHO’s/FAO’s standards and using DPPC guidelines for such study, has determined the sample size and designed the survey.
A final sample size of 728 children (70-110 cm length) was determined using sample calculation method for a 2-stage cluster sample survey (with 35%-estimated prevalence, 5% precision and 5% error risk). A total of 36 clusters were studied from 8 K/PAs and an eligible child in a household was included for anthropometric measurement.
2 · Variables Measured and Recording Information
Recumbent length was recorded to the nearest 0.5 cm using standard length board. Each child was weighed, using hanging spring scale graduated by 0.1 kg, with minimum clothing (estimated deductions for the clothing were made) and the weight of each child was recorded to the nearest 100 gram. Wherever available, age and vaccination status have been recorded from their EPI card whilst the mothers’ responses were recorded in the absence of such a card. Mothers were interviewed about family food, health and water using structured questionnaires (Annex 2).
2.3 Organisation and Management of the Survey
· Organisation
The survey work was organised into 4 teams consisting of a team leader (a Nutrition Field Worker); two/three trained assistants (ERCS Youth Volunteers) and a guide/interpreter. The assistants help the team leader in measuring the children, recording and filling-in the questionnaires. The guide/interpreter would help each team in locating the selected K/PA introducing the team. The consultant supervised the data collection at random to ensure consistency and qualities were maintained.
· Training of the Data Collectors
The survey team leaders and assistants were assigned by the consultant. Although the team leaders were experienced Nutrition Field Workers (NFWs) who have been conducting such surveys, a refresher orientation, in the context of the current study, was given for 2 days in Addis. A further one-day orientation on the survey and practical training was given to ten assistants selected and provided from the ERCS Youth Volunteers in Dessie town (ERCS Branch Office).
3 · Management of the Survey
Assignment of teams/supervisors and random selection of Kebele/Peasant Associations (K/PA) for each team plus setting of survey dates and times for each cluster were carried out by the consultant.
2.4 Organisation and Management of the Data
· Data Editing and Input
The data collected were coded, edited and cleaned thoroughly before they are keyed into computer using EPI-INFO Version 6. Further cleaning of the data was made before computing and tabulations.
· Data Analysis
The standard deviation scores/indexes (Z-Scores) for anthropometric data were calculated with the help of EPINUT software. Further analysis for associations were performed using and SPSS-PC+ statistical methods.
2.5 Other Sources of Information
· Focus Group Discussion
Focus group discussions (FGD) in non-structured interviews were held with key informants (FA officials) and elders in the Kebeles to substantiate the information collected through formal means. The extracts of the findings from FGDs are summarised and presented in Appendix A.
4 · Market Survey
Market surveys were conducted by the teams and the consultant in markets of the Woredas during the study. In most of the cases, the teams/consultant were able to purchase the items in the smallest unit available. However, for those commodities difficult to buy such as livestock, the team/consultant presented itself as a buyer and collected an average price for each item. Results from Woreda Agriculture Office market surveys are also observed and comparisons have been made. The summary of the findings of these market surveys is presented in Appendix G.
· Discussions with the Woreda Sector Offices
The Woreda Council, Health and Agriculture offices were repeatedly visited starting from the initial stages and during the actual survey. Secondary data and other information pertinent for the study have been collected during these visits and discussions.
3. Results of the Study and Discussions
3.1 Nutritional status
NUTRITIONAL STATUS AT THE WOREDAS LEVEL
<-2 Z-Score <-3 Z-Score LEVEL
N % N %
Weight-for-length(WL), 209 31.3 25 3.7 n=728 (27.9 – 35.0) (2.5–5.6)
The findings of the survey demonstrate that among the studied children (n=728), Global Acute Malnutrition (GAM) or wasting (<-2 Z-Scores) and Severe Acute Malnutrition (SAM) (<-3 Z Score) are 31.3% (N=209) and 3.7% (N=25), respectively.
5 3.2 Vaccination and Health Status
The EPI coverage is grouped into two categories: those households who have reported to have kept EPI card (70.2%, N=511) and who had no card and responded verbally (29.8%, N=217). The results indicate that the combined universal coverage of completion of vaccinations totals to 85.7% (N=623 out of 728 total children) (Table C1).
As regards the health status of the studied children in the last 15 days prior to the survey, the caretakers have reported that 317 (43.6%) out of 728 children were ill. This is a very high level of ill health. Detailed results (Table C2.) show that 55.4% (N=177), 28.5% (N=91) and 15.1% (N=49) were suffering from fever, diarrhoea, and malaria, respectively.
Diarrhoea alone accounted for more than 55% in children indicating a high pattern of malnutrition and related ill health or the visa-versa. In this connection, the predisposition of malnutrition to mass diarrhoea in children has been a common observation during such food shortages and inappropriate infant and child feeding.
3.3 Socio-economics and Food Situation of the Households
· Head of Household and Household Size
Among the interviewed and correctly responded households (n=723), 85.8% (N=620) are headed by men while female-headed households are 14.2% (N=103). The reasons for being female head of a household varied from being widowed 40.2% (N=43), divorced 28.0% (N=30), to migrant husband 27.1% (N=29) (Table D2). Lone mothers or female-headed households tend to be more vulnerable to food shortages and malnutrition.
The mean household size in the survey Woredas is 5.6 and the ranges are given in Table D1 in Appendix D. More than 80% constitute 5-8 people living in the same house. No significant association was observed between household size and malnutrition level in correlation computations. This could be due to some over-reporting by some of the
6 respondents.
· Staple Foods of the Family
More than 53% (N=391) of the households have reported foods prepared from wheat grain as their main staple diet. The rest consume barley (19.3%, N=140), sorghum (18.4%, N=134), Tef (5.5%, N=40) and maize [3.0% (N=23] (Table D3).
As regards the source of food, the majority (65.6%, N=476, out of 726) have reported they used to consume from the relief aid. Consumption from their own produce in normal circumstances accounted to 31.1% (N=226). Only 2.8% (N=20) of the respondents used to buy staple foods in normal times. The survey areas have been dependent for years on relief foods such as wheat.
· Pattern in Acquisition of Staple Foods
Regarding the current position of stock of these staple foods in the household, the majority (97.4%, N=725) of them have reported that they have insufficient food items under their possession at present. Currently, nearly all those who used to produce their own staple diet in normal times have turned into aid recipients/purchasers (69.0%, N=500) (Table D6).
Those who currently buy food (58.5%, N=422) get the money from daily labour (42.9%, N=190), sale of firewood (33.6%, N=149) and sale of cattle (17.2%, N=76). Income from labour migration accounted to only 0.9% (N=4). Other sources of income for food purchase ranges from combinations of the above and other petty trades like brewing and distillation of local drinks (Tela and Arakie) and other petty trade. The farmers of the two Woredas have consistently reported that they have exhausted sales of their livestock and other possessions.
In addition, the reported shifting patterns from production to food aid and market-based acquisition of staple foods demonstrate a great deal of loss of entitlement to a household food security (HHFS) and declining positions of other vital assets.
7 3.4 Family Health Aspects of the Interviewed Households
· Health Institutions
The two Woredas have 9 clinics, 6 health posts and 1 rural hospital (3 clinics, 3 health posts and a rural hospital in Kutaber, and 6 clinics and 3 health posts in Ambasel).
According to the records of the health offices and the clinics, diarrhoea has reached an epidemic proportion in April. Malaria is prevalent in Kola (low land) Kebeles of the Woredas. Apparently, marasmic children and anaemic mothers are reported in MCH and Growth Monitoring and Promotion (GM/P) session records in Kutaber Clinic.
In Mariye Clinic, a Health Assistant and Head of the clinic ascertained that diarrhoea (especially bacilliary dysentery) is in an epidemic proportion and the local destitute could not afford to pay for medicine.
Future health intervention components, therefore, should consider the inclusion of essential drugs.
· Health Seeking Practices
In normal times, when a family member fails sick, 67.3% (N=490) of the interviewed households go to a government clinic, 24.4% (N=177) of them go to a hospital (Table E1). The majority of the reporting communities have to walk from 3:00 to 7:00 hours to reach the nearest health institution, in many occasions, carrying the sick on a stretcher or a bed.
8 3.5 Sanitation and Water Requirement Aspects of the Interviewed Households
· Water Requirement and Source
The majority of the survey population (59.0%) interviewed reported daily water requirements of more than 20 litres. More than 44.0% of the water is from unprotected sources (Tables F1 and F2). About 92% of respondent household have to walk (both ways) less than 1 hour to their water sources (Table F3).
· Changes in Water Supplies and Quantity
Only 15.3% (N=111, n=724) of the respondents have changed their normal water sources due to reported insufficient water in their usual source. However, the survey Woredas being highly mountainous, in most villages, natural springs seem to be blessings in disguise for nearby families. Nevertheless, developments of these springs need dire attentions.
· Inadequacy of Water Year Round and the Reason for Shortfall
Only few numbers, (26.4%, N=191) reported that they do not get water year round. Reasons for the shortfalls are drying of the sources part of the year.
· Area of Intervention
The development of free-flowing springs appears to be one of the areas of intervention for water and sanitation. Any excess water that flow from the cupping source can be used for backyard gardening.
9 3.6 Focus Group Discussions
Focus Group Discussions have been held with key informants and elders. The participants of all discussions and all key informants unequivocally expressed that the area has been experiencing a repeated drought (about 6-7 years of gradual crop failures) and 4 years of total Belg crop failures.
The trend in coping strategy was sales of draught animals, sales of small ruminants, sale of vital cattle including plough oxen.
“The young and the able ones have also left the villages and migrated to other regions to earn a living through sale of daily labour. There are also many cases of ill health and deaths when they come back home. Some of us have lost our children. They come home infected with yellow fever and malaria and die”.
When asked about the current response, they mentioned their appeal, through their associations, to the government bodies. The local authorities have informed them that each vulnerable person would receive 12.5 kg of cereal grain (mainly wheat) but the cut-off number for each household is 5 persons. Those families with more than five members would receive the ration only for five. They have confirmed the commencement of the ration distributions in the surveyed PAs. They all were grateful to the government and the ERCS for the saved lives. According to their account, the quantity they receive has been enough only to sustain life.
· Results of Market Surveys
The market study and other survey results obtained from secondary sources are similar in trends (Appendix G: Tables G1, G2 & G3). The market price trend for food grains show an average 50% to 75% increase from past years during this period. The month to month pattern is similar. The same level of decline in prices of livestock was being observed for the same periods. These types of market phenomenon, if left without interventions, are well-established symptoms of collapsing traditional coping mechanisms and triggers of approaching devastating famine.
10 4. Further Discussions and Conclusions
4.1 Food Security and Related Activities
· Crops
The principal crops cultivated in the area include Tef, wheat, barley, maize, sorghum, beans, peas, lentil, Niger seed, and millets. It was common to witness crops, on the farmers’ plots, are withered for lack of moisture and there is no hope of getting any Belg harvests.
· The Land
The area is mountainous terrain land whose carrying capacity is being totally depleted. Arable land is very limited and an average holding is less than 0.5 ha. /household. On the limited arable land, the traditional agricultural system has concentrated for centuries on cereal and few pulse crops. Cultivation of root crops (potatoes, sweet potatoes, etc) and backyard gardening is non-existent. Soil erosion is rampant and the land is totally deforested. The rural villages are not accessible by land (difficult even on foot and a mule back).
· Development Schemes
There were few rural development activities/schemes (rural accessibility roads, soil conservation, afforestation, etc.) witnessed during the study except a reported WFP supported soil conservation work. According to Woreda Social Sector Heads, a terracing work is in progress in the area. The council pays 3 kg of wheat grain for 7 meter of work.
11 4.2 Responses to the Crisis
· General Ration
In recognition of the relief needs of the population of the area, the ERCS and the Federal DPPC have commenced free distribution of regular monthly rations to the selected 91,401 (current figure) beneficiaries. ERCS distributes general dry ration to 20 (6 Kebeles in Kutaber and 14 in Ambasel) Belg Kebeles and the rest are covered by the DPPC. The type of free distribution being practised currently might be counter- productive in the long-term. In this regard, unless the DPPC has revised its policy (guidelines) for relief activities, 80% of such food aid should be used for development activities. The consultant is of the opinion that at one member of each aid recipient family can perform some type development work.
· Supplementary Food Program
Supplementary Food Program has endorsed 23,379 (9,572 in Kutaber and 13,807 in Ambasel) destitute and each child would receive one kilo per month of either Famix or Faffa/CSB. The volume (1 kg per month) too small for a malnourished child and there is no evidence the child consumes it. Nutrition education is an area neglected by all sectors. Food production in surplus or provision of adequate food for families alone cannot solve nutritional problems in any society.
Therefore, strengthening of nutrition education by health institutions and ERCS youth volunteers during food distribution and other related sessions should part of relief and rehabilitation interventions.
· Other Handouts and Inputs
The ERCS has also distributed blankets for the poorest of the poor households and select seeds (cereals and pulses) to the needy farmers in effort of enabling the families to produce some of the early maturing food crops.
12 · Selection Criteria and the Logistics of Distribution
The general selection criteria include those who have lost harvests all assets including livestock in the household. This is said to encourage the sale of whatever livestock left including oxen in the household. Therefore, the selection criteria call for revision and improvement.
The distribution centres are Kutaber (for Kutaber Woreda) and Wichale (for Ambasel Woreda). The beneficiaries from far away FAs travel for more than 8 hours to receive their shares. It is obvious the beneficiaries face problems to transport all their shares to their places of residences. Some of them, therefore, have to sell part of their shares to local traders for low prices right at the distribution centre. This situation begs for the establishment of satellite distribution centres in accessible areas. The region is also loosing golden opportunities of using some of the food grains which could be channelled towards development activities such as opening up of rural accessible roads to the far away associations. In this regard, the able and strong ones should receive food-work schemes that shall solve problems like accessible roads and soil (and water) conservation.
4.3 Malnutrition Level and Related Stresses
The level of malnutrition observed in Kutaber and Ambassel Woredas is one of the highest recorded from some national and such pocket surveys in the country. The comparative results of some of the nutritional surveys are summarised in Appendix I.
The 1983 and 1992 national surveys found 8.1% and 8.0% of wasting, respectively. The more recent 1995/96 and 1999 Welfare Monitoring Surveys have recorded 10.8% and 7.6% of wasting, respectively. Although it might not be possible to compare national figures with this type of specialised study result, 31% of wasted children in a population of less than quarter of a million could mean the community is on the threshold of total starvation. The past surveys of the present type have recorded comparatively lower figures. These include 22.7 in urban setting (Bahirdar, MEDAC, 1994) 19% in Simada Woreda of South Gonder (Tekabe, 1995), 20.2% in
13 Konso Special Woreda (Tekabe, 1999).
Summary Of Results of Some of the Nutritional Surveys in Ethiopia
Region/ Area Wasting (%) Reference
National (EWS) 7.6 ENI, 1980
National Core Module 8.0 CSA, 1993
Four Towns (FSS) 12.3 MEDAC, 1994
(Bahir Dar) (22.7)
South Gonder (BLS) 13.0 Frew Tekabe, 1995
(Simada) (19.6)
Selected Woredas (FSS) 8.0 CRS, 1997
National (WMS) 10.8 CSA, 1996
Agro-ecological 10-14 AAU, 1994 (PC)
National (WMS) 7.6 CSA, 1999
Konso Special Woreda (BLS) 20.2 Frew Tekabe, 1999
Other important indicators of famine include shifting patterns (as coping strategy) of food consumption (from staple own produced grains in normal times to purchased staples and food aid), sales of assets (the implications of which are declining entitlements to vital possessions of survival like livestock). This trend clearly indicates fast deterioration of food security situation and fast growing nutritional and health stresses. The proportion of acute malnutrition detected in Kutaber and Ambasel Woredas, therefore, is indicative of a prevailing or forthcoming famine situation.
In conclusion, if this condition continues without further interventions and close monitoring the food security system and traditional coping mechanisms will totally collapse and the situation might become unmanageable.
14 5. Recommendations
5.1 Sensitisation of policy makers at the Woreda, Zone and Regional levels and with all those concerned with the welfare of the affected population should be the priority task of the ERCS. The ERCS should strongly advocate for adequate food aid and inputs in health (including essential drugs) and water sectors development.
5.2 The Dessie Branch Office in collaboration with the local health institutions, the Woreda Council, and the Woreda Agricultural Offices should closely monitor the nutritional and health situations. Follow-up nutritional surveys (at least with smaller samples) should be conducted every six months.
5.3 ERCS can use its past expertise to contribute to make the food distribution program to be effective. Improving the selection criteria of beneficiaries and distribution systems should strengthen the rehabilitation program. The implementation should be supervised, closely monitored and the progresses should be evaluated at least every two months.
5.4 The amount of dry ration should be increased with the involvement of food-for-work development activities. Sorghum should be additional alternative grain for general distribution (free and development). Decentralisation of distribution from Kutaber and Wichale is important aspect of food distribution improvement system so that the beneficiaries are not stressed with transporting the food and sell it out of frustration.
5.5 The agriculture based development strategy of the country emphasises on the development of the agricultural sector through the increased utilisation of improved seeds, fertilisers, improved agricultural technologies, farmers access to credit, training, information and
15 extension services. Free or subsidised (plus credit) distribution of early- maturing crop seeds and introduction of root crops be encouraged. The ERCS, in collaboration with the Woreda Council and Woreda Agriculture Office, should look for the sources of these inputs.
5.6 The available water should be developed for sanitation and micro- irrigation schemes. Some of the hillside springs appear to be feasible for use in backyard gardening and the like. The possibility of their extensive utilisation should be assessed.
16