February 2011 Issue 40 ISSN 1743-5080 (print)

Special 40th issue: focus on View of the audience of a drama held during a Productive Safety Net Programme (PSNP) pay day session in Tigray-Hintalo Wajirat, Ethiopia Credit: P Fracassi, Ethiopia, 2010 Credit: P Fracassi,

1 Contents

Tigray Beneshangul Administrative Gumuz Afar Amhara Harari Field Articles Regions and Zones Addis Ababa

7 Enhanced Outreach Strategy/Targeted Supplementary Feeding for of Ethiopia Oromia Somali Child Survival in Ethiopia (EOS/TSF) Gambella SNNPR 11 Can the Nutrition Information System be ‘trusted’ to build on available data sources? 13 Oxfam’s Somaliland-Ethiopia Cross Border Drought Preparedness Project 17 Emergency Food Security and Livelihoods Project in Amhara and Oromia regions 22 The RAIN programme 25 Emergency Food Security and Livelihoods Project in Amhara and Oromia regions 31 Beyond the indicators: Assessing project impact on children’s lives 35 The experience of multi-storey gardens in Ethiopian refugee camps 38 Decentralisation and scale up of outpatient management of SAM in Ethiopia (2008-2010) 43 History of nutritional status and Concern's response in Dessie Zuria woreda, Ethiopia 48 Rapid response and long-term solutions: Christian Aid and food security in Ethiopia 49 Completing the Jigsaw Puzzle: Joint Assessment Missions (JAM) Adapted from graphic produced by UN Emergencies Unit for Ethiopia, March 2000, ©Reliefweb. produced by UN Emergencies Unit for Ethiopia, March 2000, ©Reliefweb. Adapted from graphic 2010. All rights reserved. Programme Food Adapted from ©United Nations World 52 World Vision programme for severe acute malnutrition in SNNPR 56 Market-led Livelihood Recovery and Enhancement Programme and News integrating ENAs 79 Standardised training package on SMART methodology 58 An overview of REST’s implementation of the Productive Safety released by ACF Canada Net Programme 79 Treatment of severe malnutrition now a core competency in 61 Maintaining GOAL’s capacity to support surveillance in Ethiopia health 65 Joint Emergency Operation Plan: NGO response to emergency food 80 Building national capacity in HIV and Nutrition needs in Ethiopia 80 Scale up Nutrition (SUN): a new global movement 68 Integrating OTP into routine health services – CONCERN’s 80 Regional CMAM meeting in Ethiopia 2011 experiences 81 Training and workshop to integrate IYCF in CMAM 75 The Targeted Supplementary Feeding Programme (TSF) 82 Updated HTP resource material for nutrition in emergencies 78 Value chain approach to increase production of RUTF/CSB training Agency Profile Research 21 Profile and overview of the church’s role in emergency response 82 Early stages of a ‘Food by Prescription’ programme for HIV infected adults 45 EHNRI: profile and role in the National Nutrition Programme 84 Emotional Stimulation for acutely and severely malnourished 55 School of Nursing and Midwifery & Pre-Service Training on children in SNNPR Nutrition, Hawassa University, Ethiopia 85 Critical analysis of MICAH programme 74 The Ethiopian Orthodox Church Development and Inter-Church Aid Commission 87 Linking PSNP and NNP: experiences and challenges Programme Profile 89 Post-drought restocking: Can its impact be sustainable? 91 Food insecurity and mental health among community health 32 The Emergency Nutrition Coordination Unit of Ethiopia: roles, volunteers in Ethiopia responsibilities and achievements 64 The Evolution of Ethiopian Government’s Early Warning System 92 Acronyms

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2 Foreword A Simons/FH Ethiopia, 2009

ver twenty five years on from the famine of the 1980s which resulted in many thousands of deaths and devastated livelihoods, Ethiopia today is a country that has placed nutrition and food security concerns at the heart of its development. The launch of the first Ethiopian National Nutrition Strategy and implementation of the National Nutrition Programme are testament to the national drive to Osignificantly improve the population’s nutritional status and to manage the threats to people’s nutrition and food security posed by recurrent emergencies. This special issue of Field Exchange focuses on Ethiopia, 25 years on from the devastating famine of the 1980s. It brings together articles written by many highly experienced Government and non-government actors about the country’s large-scale programmes aimed at preventing and treating acute malnutrition, reducing food insecurity, tackling childhood sickness and improving people’s livelihoods. The wealth of experience contained in these articles reflects the results of many years of lesson learning both within Ethiopia and internationally. Challenges remain with to-scale programming and these are outlined, as are the potential solutions. Smaller scale projects, research initiatives and key national nutrition and coordinating institutions are also profiled in this publication. Overall, this issue of Field Exchange provides a unique and comprehensive picture of Ethiopia’s nutrition and food security programming. It is of value, not only as a resource for those of us in Ethiopia who are working in a complex nutrition and food security environment, but also to others in emergency prone and food insecure countries which are scaling up programmes to address undernutrition. Ethiopia has come a very long way in 25 years. The work being undertaken by Government in partnership with many UN, NGO, church and community based organisations, academic institutions and coordinating bodies as documented here is undoubtedly saving countless lives and, whilst much still needs to be done to tackle food insecurity and undernutrition, these endeavours are providing a better tomorrow for millions of Ethiopians.

H. E Dr Kesetebirhan Admassu, State Minister of Health Dr Ferew Lemma, Senior Nutrition Advisor

From the Editor

thiopia is a diverse country where a signifi- years on from the mid-1980s crisis. It contains six cant proportion of the population live on or agency/programming profiles and twenty field arti- below the poverty line, where food insecurity cles written by national and international actors is widespread and rates of acute malnutrition about nutrition and food security related program- E ming. The profiles and articles provide insights into are often at or above the international threshold that Simon Rolph, Ethiopia Simon Rolph, defines an emergency situation. Levels of chronic some of the key nutrition and food security/liveli- malnutrition are also high. Food and nutrition crises hoods related structures and programmes in arising from the effects of drought, floods, market Ethiopia, covering early warning, response, recovery fluctuations and, at times, political instability are and longer-term programming. frequently faced. The challenges today are enormous Government agencies and structures but over the past 25 years, the Government of The first profile is on the government’s Early Warning Ethiopia (GoE), with the technical support and budg- System (EWS). Written by Kassahun Bedada Beyi, it etary assistance of many donors, UN agencies, plots the EWS evolution from an ad-hoc system in the non-governmental organisations and institutions has 1970s, to a highly centralised, somewhat cumber- developed an impressive array of national nutrition, some system with minimal community involvement food security, livelihoods and health related policies, in the 1980s to the current system which is highly programmes and systems. These are driving nutrition decentralised and takes account of local early warn- and food security improvements and should ensure ing knowledge. Ethiopia’s EWS, as with many that the massive loss of lives and livelihoods seen at emergency prone country experiences, is not with- the height of the famine in the mid-1980s, doesn’t out its problems. It will no doubt continue to evolve arise again. as it manages complex data and strives to strengthen its communication channels and to ensure timely This 40th issue of Field Exchange (FEX) shines a and appropriate responses in areas of the country spotlight on this immense progress in Ethiopia, 25 exposed to acute food and nutrition insecurity.

3 Editorial

Institutionally linked to the government’s EWS is Two profiles reflect the work of two of the largest the well-established Emergency Nutrition church based organisations in Ethiopia – the Coordination Unit (ENCU). Isaack Manyama and Ethiopian Orthodox Church Development and Inter- colleagues describe the unit’s growing mandate Church Aid Commission by Gebreselassie Atsbahha since its inception in 2000, at which time the quality and the Ethiopian Evangelical Church Mekane Yesus, and coordination of nutrition surveys in Ethiopia was by Deed Jaldessa and Debela Kenea. Both highlight severely constrained and links to the EWS were mini- the considerable community reach and resources of mal. The ENCU has seen considerable expansion the Church in mounting emergency responses and in since 2005 and today, it is mandated to coordinate, longer term programming. What is interesting, is how quality assure and disseminate emergency nutrition these Church groups have formed dedicated depart- assessments as well as to coordinate nutrition cluster ments for overseeing their humanitarian and activities, strengthen EWS capacity and related oper- development programming. They are increasingly ational research in Ethiopia. closely aligned to government policies and priorities and are able to help fill gaps in responding to food The ENCU is possibly one of a very few dedicated security crises, largely through food aid distributions. units of its type in sub-Saharan Africa and has a A gap identified by both groups in these articles is considerable wealth of experience and knowledge of their lack of nutrition capacity, which they are aiming coordinating many agencies concerned with nutri- to address in the future. tion assessment and response. Interestingly, since its inception, over 600 nutrition surveys have been Ethiopia’s history of large scale emergencies has carried out in Ethiopia, which, when the logistics and meant that many international agencies have worked Christian Aid/Caroline Waterman related costs are taken into account, raises questions in Ethiopia for 20 to 30 years or more. These agencies circumference (MUAC)), largely due to food sharing about the relative merits of cross-sectional surveys in have therefore been afforded the opportunity to at home and high inclusion error. The programme contrast to a nutrition surveillance system. implement numerous relief and/or development programmes and to refine approaches as lessons also encountered a number of challenges including Another key national structure is the Ethiopian have been learnt. Many of the articles in this issue of logistical problems in more inaccessible areas of the Health and Nutrition Research Institute (EHNRI) Field Exchange therefore reflect lesson learning country, delayed communication of screening results which has considerable experience of working at the amongst agencies over a significant period of time. and weak linkages with other programmes. ‘coal face’ of nutrition related problems in Ethiopia. The second article by Selamawit Negash from With over 450 staff, the EHNRI has (among many Emergency assessments There are three articles on emergency assessment. UNICEF describes the national Enhanced Outreach responsibilities), the mandate to support the govern- Strategy (EOS) programme, which links health exten- ment with implementation of the National Nutrition The first, by Zeine Muzeiyn and Ewnetu Yohannes describes the work undertaken in Goal’s Early sion services and staff (HEW’s) and services with the Programme (NNP) providing analysis of the magni- TSF. The GoE and implementing partners have tude and determinants of malnutrition in Ethiopia, Warning Department involving field based assess- ments in so called ‘hot spot’ woredas (districts) achieved extraordinary coverage with the EOS. capacity mapping for implementing the NNP and During the second round 2009 EOS activity, 11.5 undertaking operational research. It’s most recent identified by the GoE’s ENCU and how this informa- tion fits into decision making and response. Between million children aged 6-59 months were supple- national survey work confirms the need to focus on mented with Vitamin A and 7 million children the determinants of undernutrition in the under 2 August 2005 and June 2010, GOAL Ethiopia conducted 60 nutrition surveys and intervened in between 24-59 months were de-wormed. In addi- year age group, the target group for the NNP, along tion, 3.9 million children and 820,000 pregnant and with women of reproductive age. approximately 95% of woreda’s with an identified need. GOAL’s nutrition survey staff carry out surveys lactating women (PLW) were screened for acute The existence of the EHNRI gives Ethiopia a with government staff at woreda and regional level in malnutrition. Out of these, 318,000 children and unique ‘home grown’ capacity to drive the NNP and, order to build their capacity in planning and conduct- 150,000 PLW were found to be malnourished and arguably, enables government to have a self-deter- ing surveys, analysing data and report writing. referred to TSF and out-patient therapeutic feeding mined dialogue with the myriad of donors and (OTP) respectively A number of factors that have The second article dealing with assessment is by agencies that operate in Ethiopia. This is not to contributed to the high coverage of the EOS are Patrizia Fracassi. This article provides a personal view suggest that Ethiopia has all the nutrition capacity it described: the frequent specialised training of HEW’s of the strengths and weaknesses of the country’s needs to implement its programmes. As the article to strengthen their capacity for social mobilisation, nutrition information system, as well as a vision for written by Aweke Yilma from Hawassa University the participation of a large number of public health the future. highlights, the need for teaching/faculty staff to be institutions and participation of NGOs. Successful trained in nutrition so that they in turn can expand The third article by Alison Oman from UNHCR community mobilisation and demand for EOS serv- the existing nurse and midwifery undergraduate describes the agency’s joint assessment mission ices are partly attributed to the financial incentives training curricula to include nutrition is highlighted (JAM) process with WFP for refugees and how this has (per diems) provided for the local HEWs and volun- as a significant need. The need for pre-service train- evolved since the mid-1990s. This article draws heav- teers. Almost 70% of the total EOS budget is ing on nutrition is likely to be an issue in many of ily on the experiences of implementing JAM’s in expended on per diems Ethiopia’s universities and training institutions and, Ethiopian refugee camps and shows the wide range The third article on SFP’s has been written by where efforts are made to upgrade faculty staff of information gathered in an assessment, e.g. food Sarah Style from Concern Worldwide. In 2008, an knowledge and skills. As described in the article writ- security and coping strategies, logistics, non-food area classified as a ‘hot spot’ due to failure of the short ten by Kate Sadler and Elizabeth N Bontrager from items, market prices, health, nutrition and the envi- belg rains, resulted in Concern Ethiopia initiating a Tufts University, this offers a clear way forward for ronment. The process of consensus building is key as TSF programme which has been continuously opera- building capacity in nutrition among Ethiopia’s key it not only encourages assessment from a multi- tional since then. However, rates of wasting in the graduates. sectoral viewpoint, but also ensures that the woreda have remained relatively un-changed. The recommendations reflect the capacities and expert- TSF programme, although well implemented as Local NGOs and church-based agencies ise of the agencies involved. evidenced by high coverage rates, has poor recovery The article by the REST Team from Ethiopia’s rates and high re-admission rates, (2009 recovery rate largest home-grown NGO, the Relief Society of Tigray Addressing moderate acute malnutrition 27%, non-recovery rate 59%, re-admission rate 57%). (REST) provides an insight into the evolution of a rela- Supplementary feeding programmes (SFPs) are the Investigations suggest that an inadequate general tively small organisation, which started out in the subject of three articles. The first article by Jutta ration, lack of access to the PSNP as well as climatic 1970s working with drought affected Tigrayan’s, to Neitzel from WFP describes the national targeted and topographical constraints, the health environ- the organisation it is today - 700 staff strong, supplementary feeding (TSF) programme imple- ment and poor caring practices, are key factors commanding a multi-million dollar budget and work- mented by the GoE and WFP which is part of the limiting effectiveness. Linkages with the general food ing in both emergency and long-term programming. government’s Extended Outreach Strategy (EOS). distribution (GFD) is limited and the impossibility of This article describes REST’s approach to the imple- Initially, the TSF covered 325 woredas when estab- registering the whole population for the PSNP and mentation of the large-scale Productive Safety Nets lished in 2004, but due to soaring food prices as well GFD means that sharing of the supplementary food Programme (PSNP) and the impact of the PSNP on as diminished donor support in early 2008, the amongst non-beneficiary children is commonplace. levels of wasting and stunting, on dietary diversity programme had to be downscaled so that today, it The author concludes that improvements in rates of and on household food security - all of which report- only covers 168 priority woredas and approximately wasting in this context might be beyond the scope edly showed improvement over a 3 year period. one million children. The TSF has a fairly unique and capacity of nutrition interventions such as SFP’s. Whilst nutrition is not a specific technical compe- design for the TSF in that food distributions only take Such limitations with traditional approaches to the tence of REST staff, it is interesting to note the place every three months and there are no anthropo- prevention and treatment of moderate acute malnu- concerted efforts made to try and capture nutrition metric measurements of children between distributions. A TSF evaluation study conducted in trition are the subject of considerable work impact in their work. 2008 found limited impact (on mid-upper arm internationally.

4 Editorial

community mobilisation mapping and facilitation of enhanced community preparedness capacity, and regular dissemination workshops to facilitate sharing improved integrated natural resource management of experiences. to ensure increased access to and availability of pasture, fodder and water so that households can A number of key factors promoted an enabling preserve their assets. A key lesson from the early environment within which the N-CMAM programme phases of the project is that the focus of pastoralist could achieve its objectives, e.g. continuous and

A Simons/FH Ethiopia, 2010 interventions should be to strengthen the commu- sufficient funding from July 2005, and a strong focus nity and risk reduction strategies, rather than simply on training of the N-CMAM team in how to support fill material gaps through resource provision. partner staff rather than directly implement programmes. Numerous lessons have been learnt Save the Children (UK) has been providing from the experience, e.g. the length of time that the support to pastoral communities in Ethiopia for process of integration requires and the importance of almost 20 years with current programmes in the using both formal and informal channels of commu- Somali and Afar regions. The PILLAR project, which is nication and networking to muster influence. described in the article by Holly Welcome Radice and colleagues, seeks to contribute to community level An article by Play Therapy Action describes early drought risk reduction focusing on the three pillars of findings from a study to explore impact of introduc- pastoralism – people, livestock and natural resources. ing emotional stimulation and good parenting skills, The article focuses on the project’s impact on the Addressing severe acute malnutrition in addition to emergency therapeutic food distribu- lives of children. Children belonging to families There are three articles on the implementation of tion, for SAM children. Investigated in 47 outreach involved in water point construction, small scale irri- programmes to treat severe acute malnutrition therapeutic sites and one hospital in the SNNP gation and income generating activity (SAM), a research piece sharing work on the impact of Region, preliminary results found faster weight gain, micro-projects reported that they had more time for emotional stimulation on SAM outcomes, and a less developmental damage of the acute malnutri- leisure and more time with their parents. They also further article on the challenges of securing afford- tion ‘event’, and positive ‘knock on’ effects of the spent less time on chores and attended school more able ready to use therapeutic foods (RUTF). Sylvie interventions on care of other children, on the regularly. Chamois from UNICEF Ethiopia describes the impres- mother’s mental well-being and her empowerment, sive scale up of the GoE OTP to over 6,400 health and on family life. There are five articles written about programmes aimed at supporting the livelihoods of farmers in posts (at the time of writing) in 691 woredas. The arti- An article by Yuki Isogai from the World Bank (WB) Ethiopia, which include market based analyses for cle describes how scale up was achieved and key outlines how the cost of treating the severely and high value commodities. The first of these is by challenges faced. The enabling factors identified for moderately malnourished in Ethiopia is ‘too high’ as a Andrew Simmons who writes about the Food for the scale up included advocacy and coordination, donor large share of the feeding products, i.e. RUTF and Hungry (FFH) Market-led Livelihood Recovery and support, development of regional action plans, tech- CSB, have to be imported from abroad. She poses the Enhancement Programme (MLREP). This programme nical assistance for training and follow up, provision question-‘why hasn’t the private sector stepped in to aims to improve the food and livelihood security of supply and logistics support and enhanced fill the local supply gap’? The WB Ethiopian Nutrition status of smallholders in SNNP region. The programme monitoring and quality assurance. Team conducted a thorough review of this question programme targets PSNP beneficiaries to help them Ensuring good programme monitoring and quality and identified three major issues, which are inter- build assets and graduate from the PSNP proved to be particularly challenging with the rapid linked with each other: lack of market information, programme. The approach involves building upon multiplication of OTP sites. low access to finance; and weak value chain. The and integrating livelihood components identified The vast majority of OTP sites are achieving author argues that the problems affecting the whole following the results of a value chain analysis (VCA) SPHERE standards and UNICEF considers that there value chain need to be tackled simultaneously if a study. The analysis provides the answer to the ques- have been a number of important contributory solution is to be found. To do this will requires a tion, ‘which commodity should be pushed further in factors to the success of this programme. Particularly strong public private partnership involving private terms of ease of access to input and output markets? noteworthy are the GoE’s commitment to develop companies, commercial banks, farms, NGOs, UN After the completion of the first year of the MLREP, policies and guidelines on decentralised treatment of agencies and donors. initial benefits were seen at the household level in SAM and to integrate services into the wider decen- Reaching pastoralists and livelihood programmes terms of income generation. However, there was no tralised health programme, advocacy by agencies Two field articles specifically focus on pastoralists, obvious evidence that this increased income was such as UNICEF, high educational levels, technical who represent a significant minority in Ethiopia. Dr being put to use to improve the nutrition and health skills and commitment amongst programme staff Abay Bekele writes about Oxfam UK’s Somaliland- outcomes of the most vulnerable members of the working within the health sector and enhanced coor- Ethiopia cross-border programme. At the heart of family. dination between the key actors. the programme is a concern to build strong, repre- An article by Todd Flower from Mercy Corps Another article written by Sisay Sinamo describes sentative pastoral organisations, through which describes the Revitalising Agricultural/pastoral the World Vision Ethiopia (WVE) programme for treat- pastoralists can better understand and claim their Incomes and New markets (RAIN) programme - a ment of SAM (called Community Therapeutic Care rights and manage the development services they multimillion dollar OFDA/USAID funded programme (CTC) at the time), between 2005 and 2007. Lessons need. Principle aims include improved institutional being implemented for three years (2009 to 2012) in learnt were then used to inform the design of a capacity for drought preparedness linked to zones in the Oromia Region with four bordering subsequent programme in 2009 with h had a more zones of the . RAIN seeks to protect, ‘hands-off’ approach. In the 2009 programme, WVE Aldei Yimam (male, 20 promote, and diversify livelihoods as a means of staff focused on capacity building of partners rather months) has been in increasing households’ resilience to shocks. The RAIN than direct implementation. This was described as a and out of SFP and programme focuses on market systems and provides ‘minimum support’ approach. In addition, WVE OTP on five occasions support by creating linkages between various market supplied a protection ration for children discharged (Gelsha kebele) participants. In the first year of the programme, from the OTP, as it could not be assumed that these several value chains were identified and evaluated children would be enrolled on the TSF programme. including live animals, hides and skins, milk, fruits and vegetables, and peanuts. The RAIN programme Emily Mates from Concern Worldwide describes works to improve access to agricultural input the history of Concern’s programme that evolved supplies to assist producers in meeting available from an innovative emergency intervention, into a market demand. longer-term initiative aimed at supporting the Ministry of Health (MoH) to integrate treatment serv- Another article by Shekar Arnand from Oxfam ices for SAM within the routine health system – the describes the emergency and food security liveli- National CMAM (N-CMAM) programme. The N-CMAM hoods (EFSL) project which is part of the Global team assisted the MoH in selected areas of four Agricultural Scale up (GASU) initiative started by regions (Oromia, Tigray, SNNP and Amhara). The Oxfam four years ago. The GSAU programme in approach used a process of incremental capacity Ethiopia has worked with farmers on many crops. It building from the outset to ensure that the owner- has now been decided to use a scalable model for ship of the programme was always firmly in the three commodities, honey, coffee and sesame. These hands of the MoH. Concern provided a minimal have also been identified by the GoE as high value support package of theoretical and practical training export crops. in OTP and in-patient SAM case management, as well The EFSL component arose out of Oxfam’s aware- as joint supportive supervision and follow-up,

Concern Ethiopia ness that their target farmers are often exposed to

5 Editorial

An article on the PSNP by Matt Hobson and Sarah The GoE has also proven itself over many years to Coll-Black from the World Bank describes how the be ‘fiercely independent’ of international agencies. Its PSNP has developed over the last 5 years, its achieve- emergency and development philosophy with ments and major challenges. respect to external actors is very much along the Concern Ethiopia lines of ‘work with us, help us to develop the capacity By 2009, the PSNP supported 7.6 million people in to implement programming and then leave us alone 290 chronically food insecure woredas in eight of the to do it’. Most international agencies working in country’s 10 regions. This demonstrates that large Ethiopia have embraced this and invest considerable scale cash and/or food transfers are operationally and resources in building national capacity. This can only logistically possible in resource-poor, low-income bode well for Ethiopia and its capacity to prepare, rural settings. However, between 2007 and 2009, respond and recover from emergencies in the future. only around 280,000 individuals graduated from the There are, however, as highlighted in some the arti- PSNP, which although not insignificant (especially cles in this issue, risks associated with rapid scale up given the adverse events of 2008), falls well short of where the demands for implementing ‘best-practice’ the national goal. Deficiencies in implementation, and high quality programmes can outstrip capacity due to limited human and physical capacity, under- for delivery. This is a challenge facing many countries, mine the potential impact of the PSNP, while Hayat Seid, female, 29 months, has been not only Ethiopia, and will be the subject of interna- in and out of OTP and SFP five times ensuring quality implementation in all programme tional focus as the international Scaling up Nutrition areas remains a significant challenge for the future. (SUN) initiative gets underway. An article by Alix Carter from CARE Ethiopia The extent to which programmes are joined up, emergencies caused by drought, flood, market describes the Joint Emergency Operation Plan (JEOP) coherent and integrated to maximise nutritional turbulence and climate change. The idea is therefore which has existed in different iterations since 1984. objectives is a challenge. For example, SFPs will not to embed a humanitarian response programme JEOP targets food insecure households who are not be effective if general rations or basic food security is within the programme to prevent farmers from covered though the PSNP. It thus provides a comple- inadequate and integrating the TSF with OTP, or PSNP falling into ‘the poverty trap’. The EFSL project aims mentary intervention to prevent acute food with TSF/OTP households, need to be fully grasped. ’to protect those farmers that are vulnerable to shortages from depleting overall community There are also a number of specific challenges for impact of drought and other shocks’. Key lessons progress gained through PSNP.The JEOP is activated GoE and its implementing partners. For example, learnt so far from the EFSL include the understanding in close collaboration with the GoE when chronic scale up of local production of RUTF for the treatment that asset poor households are less able to apply food insecurity is exacerbated by emergency shocks, of SAM and the need to bring prices down so that the resource management practices and that the onset requiring additional coverage of emergency food current roll out of OTP and TFP can be sustained. of natural disasters presents new business opportu- relief. The partnership was re-activated in 2000 under Another challenge relates to the large case load of nities for microfinance institutions (MFI) especially in its current form with five member international MAM in Ethiopia. It is widely acknowledged both rural areas. NGOs. More recently, REST and SC-UK have joined. As within and outside of Ethiopia that the current TSF is An article by Antoinette Powell describes a result of recurrent shocks, JEOP has been opera- not a panacea and that much work needs to be done Christian Aids (CA’s) response to a series of emergen- tional in seven of the last ten years, providing one to develop an evidenced MAM strategy, underpinned cies and subsequent work with implementing third of all emergency food relief in Ethiopia to an by a clear implementation plan to reach the large partners to rebuild lives and livelihoods and average of 1.8 million beneficiaries at each round. number of MAM population affected. strengthen disaster preparedness. Christian Aid A major challenge for the JEOP is delays and Despite these challenges, Ethiopia appears, with works through a range of implementing partners changes in allocation of food aid figures to partner minimal publicity and fuss, to have manoeuvred itself with some of the most marginalised communities in agencies’ caused, in large measure, by communica- away from being the country which, in many previ- Ethiopia, including pastoralist communities in the tion and capacity gaps between or at different levels ous years grabbed the international humanitarian country’s south and farmers in SNNP region. Concern of Government. Another difficulty is the arrival of spotlight as a result of drought and famine. Sadly, about the effects of climate change has recently huge shipments of commodities to ports and ware- other countries have taken its place. The good news prompted Christian Aid to fund one of its partners, houses, creating congestion and difficulty for is that famine early warning and response systems in Citizens Solidarity for the Campaign Against Famine partners to secure enough space for their commodity Ethiopia have been considerably strengthened in Ethiopia (CS-CAFÉ),to carry out a study on climate storage. In addition, secondary transport to distribu- through many years of programme implementation change. tion sites has proven difficult for some JEOP partners and learning. The article written by Mulugeta Wtsadik from and different strategies have been used to overcome This issue of Field Exchange has tried to capture the UNHCR describes a multi-story gardens (MSG) these problems. In the Extended JEOP, partner agen- array of national and international policies, programme in refugee camps for Eritreans and cies are considering options for a pooled transport programmes and systems that have been put in place . Mulugeta outlines how a pilot MSG system that could circumvent these logistical issues to drive nutrition and food security developments in programme was established in three camps to in the future. Ethiopia. Many of these developments have been address problems of anaemia and to compensate for adapted from international policies and evidence- Concluding remarks a WFP ration considered inadequate in terms of based good practice in key areas of nutrition, as well as The articles in this special issue of Field Exchange micronutrients like iron and zinc. The pilot project from lessons learnt from within Ethiopia on what does show clearly how a range of actors are playing a vital began in April 2008 and has had a significant impact and doesn’t work within the country’s specific political, role in testing and developing new and more effec- on the diversity of foods available to beneficiary socio-economic and cultural context. There is much to tive programming approaches, disseminating households – particularly in terms of fruits and learn from this experience and we hope that this findings and then advocating for adoption and scale vegetables. Water shortages have been the main special issue of Field Exchange plays some small part in up of evidence based programming to address acute problem with the programme, although various disseminating the many lessons learned by the GoE malnutrition, food insecurity and support more methods have been employed to conserve scarce and the myriad of national and international actors sustainable livelihoods in Ethiopia. There is a strong water in the more arid camps. involved in humanitarian work in Ethiopia. commitment by GoE to invest in scaled up program- Large-scale safety net programming ming. The two best examples are the scale up of the Jeremy Shoham, Editor After many years of implementing food relief OTP and the PSNP. Carmel Dolan, Guest editor programmes through the old Employment Generation Scheme (EGS), implementing partners reached a view that there had to be a better way of meeting transient emergency needs. The EGS activi- ties were poorly managed and ultimately unproductive so that recipients rarely graduated to any level of food security and remained dependent on annual food relief packages. The advent of the A Simons/FH Ethiopia, 2009 PSNP in 2005 was a reflection of this learning. The vision for the PSNP, which uses food and/or cash as a resource transfer, was to use resources more imagina- tively to help build up productive assets and so enable beneficiaries to graduate out of structural poverty and chronic food insecurity. The multi- annual and multi-donor commitment to this programme reflects this vision. Women work in tree and fodder nurseries as part of the cash for work scheme By Selamawit Negash, Nutrition Specialist, UNICEF Ethiopia Selamawit Negash (MPH) has been A child receiving vitamin A supplements during EOS in working as a Nutrition Specialist with , Adwa District UNICEF Ethiopia since April 2007. From December 2005 to March 2007 she worked with WHO Ethiopia as a Supplemental Immunisation Enhanced Outreach Activities (SIA) officer. She was a

Indrias Getachew, UNICEF Ethiopia, 2009 Indrias Getachew, Nutrition Team Leader in Federal Ministry of Health, Strategy/ Targeted Ethiopia from January 2002 to November 2005. The author would like to acknowledge Sylvie Chamois Supplementary and Orla O’Neill for their valuable inputs for this article. The author would also like to acknowledge all others Feeding for Child who have kindly commented on the draft article. Disclaimer: the findings, interpretations, and conclusions in Survival in Ethiopia this article are those of the author. They do not necessarily represent the views of UNICEF, its Executive Directors, or the countries that they represent and should not be (EOS/ TSF) attributed to them.

thiopia has one of the highest under primary objective of EOS was to increase Initially, the EOS/TSF target was to cover five mortality rates of all developing twice yearly VAS coverage that was more than 90% of the 6.8 million children countries, due largely to the extremely low. The opportunity was also aged 6-59 months old and 1.5 million preg- combined effect of a high incidence taken to include deworming to promote nant and lactating women (PLW) living in 325 Eof infectious diseases and inadequate infant normal growth and prevent malnutrition drought prone districts. However, there and young child nutrition. Results from the among children under the age of five. Before remained an additional 6.4 million children in 2005 Demographic & Health Survey (DHS) 2003, moderate acute malnutrition (MAM) 299 ‘non-EOS districts’. These were not reported the chronic malnutrition rate among was addressed only through blanket supple- covered by EOS/TSF interventions because children under 5 years (stunting) to be 46% mentary feeding distributed together with the districts were not considered as the most Field Article and acute malnutrition (wasting) 11%1. About food aid in drought affected districts. The vulnerable and ‘drought prone’. In 2005, the 27% of women are malnourished (Body Mass introduction of the EOS was seen as an MOH and partners decided to extend its Index (BMI) < 18.52). Vitamin A deficiency opportunity to target MAM for TSF in a much cover to reach these additional 6.4 million (VAD) is a severe public health problem wider coverage than seen before. However, children in the 299 ‘non-EOS’ districts with a affecting 30-95% of children 6-59 months of due to capacity/resources issues, screening package of biannual vitamin A supplementa- age in all 11 regions of the country3. In addi- for acute malnutrition and TSF were started tion and deworming only. Nutritional tion, food insecurity and poverty remains a in 325 drought prone districts only5. screening and TSF were not included due to resource limitations. threat, as Ethiopia has been exposed to Partnership was developed between repeated droughts, resulting in chronic food UNICEF, WFP and the Government of Objectives insecurity for the last four decades. Periodic Ethiopia (GoE) under the United Nations The overall objective of the EOS is to reduce episodes of acute food shortage still occur in Development Assistance Framework mortality and morbidity in children under many parts of the country and continue to (UNDAF, 2007-2011). A memorandum of five by providing low cost, high impact child jeopardise the nutritional status of the most understanding, signed by Disaster Risk survival interventions at community level. vulnerable, especially children. The situation Management and Food Security Sector The specific objectives are: has been described as a constant state of (DRMFSS), MOH, UNICEF and WFP, chronic emergency and therefore effective outlined the roles and responsibilities of each health and nutrition interventions need to party. Whilst UNICEF and WFP provide address the long-term and periodic emer- 1 Ethiopia Demographic and Health Survey, 2005 financial resources and technical support, 2 ibid gency needs underlying this complex coordination, implementation and manage- 3 National Vitamin A Deficiency Survey Report, Ethiopian situation. Health and Nutrition Research Institute, 2006 ment of the EOS/TSF were and remain under 4 Mission Report, Enhanced Outreach Strategy/Targeted Rationale and programme design the responsibility of the MOH and DRMFSS Supplementary Food for Child Survival Interventions, both at federal and regional levels. See Figure Ethiopia, Andrew Hall and Tanya Khara, November- The Enhanced Outreach Strategy/Targeted December 2006 Supplementary Feeding (EOS/TSF) is the 1 for an illustration of how the EOS/TSF is 5 In 2008, the number of TSF districts reduced from 325 first national programme in Ethiopia to link organised. to 167 due to resource constraints. community-based preventive health services with a ration of supplementary food for Figure 1: Illustration of how EOS/TSF is organised women and children who are identified as 4 malnourished . It is one of the leading MOH/ UNICEF Children, DRMFSS/ WFP approaches to address child survival and pregnant and EOS (every 6 months) at kebele level: TSF (every 3 months) at kebele lactating malnutrition and yet its establishment in 2004 • Vitamin A supp. (6-59 months old) level: women was triggered as a response to the acute • De-worming (2-5 years old) • Supplementary Food screened with famine that affected many parts of the coun- • Screening for acute malnutrition (children 6-59 Distribution (treatment of months, pregnant and lactating women) malnutrition try in 2003. It was also introduced as a moderate malnutrition and prevention of severe transition strategy towards the establishment malnutrition) of the Ministry of Health (MOH)’s Health Children and women Extension Programme (HEP), which aims to with severe acute DRMFSS/ UNICEF extend primary health care services to meet malnutrition ENCU at regional and federal the population’s long term health and nutri- Screening data level: tion needs at community level. • compilation of EOS data, At health facility level (hospital, health centre data quality check, nutrition In 2001/2002, progress had been made to and health post): situation analysis, • Therapeutic Feeding Programme (In and Out- coordination of emergency increase the Vitamin A supplementation patient treatment of severe malnutrition) nutrition response (VAS) coverage using the opportunity of polio and measles National Immunisation Source: UNICEF Ethiopia. Days. However, coverage was not more than ENCU: Emergency Nutrition Coordination Unit; EOS/TSF: Enhanced Outreach Strategy Targeted Supplementary Feeding; MOH: 64% and it included only one dose. The Ministry of Health; DRMFSS: Disaster Risk Managment and Food Security Sector

7 Field Article

• In all districts of Ethiopia except Addis Figure 2: Children (6-59m) reached by EOS Figure 3: Survey VAS Coverage and Ababa and every 6 months: services per year (2004-2009) Administrative VAS Coverage by region, Post - > 90% of children 6-59 months old are Campaign Coverage Evaluation survey, June- supplemented with high dose vitamin A. 12,000,000 September 2008 - > 90% of children 2-5 years old are 10,000,000 100% 11,812,673

8,000,000 11,490,616 94%

dewormed. 94% 11,179,017 98.9% 98.9% 11,179,017 11,156,698 96%

10,937,894 80% 10,760,198 93.7% 88% 92.7% 92.3% 92.1% 93.2% 92.9% 90.4% 10,154,375 89.1% 86.3% 86.1% • In all districts of Ethiopia except Addis 6,000,000 85.1% 60% Ababa and once a year: 4,000,000 8,269,753 - > 90% of children 9-23 months old are 40% 56.5%

2,000,000 4,946,811 vaccinated against measles if they have

1,389,438 2,576,620 20% missed routine vaccination. 0 0% • In TSF selected districts: Afar

-> 90% of children 6-59 months old and Tigray SNNPR Somali Gumuz Oromia Amhara

PLW are screened for malnutrition and Dawa Dire Benshangul

referred to TSF when acutely - 1st Round 2004 2004 - 2nd Round 2005 - 1st Round 2005 - 2nd Round 2006 - 1st Round 2006 - 2nd Round 2007 - 1st Round 2007 - 2nd Round 2008 - 1st Round 2008 - 2nd Round 2009 - 1st Round 2009 - 2nd Round Survey Vitamin A supplementation (VAS) coverage malnourished. Achievements: # of children covered National target children in Child Survival EOS is also used as an opportunity to integrate other interventions, such as measles catch up prepared. Training of trainers and micro-plans and follow-up campaigns, tetanus toxoid and instances, the Regional Health Bureaus take the are completed once every year. Two standard polio supplemental immunisation activities, opportunity to deliver other essential services, formats are provided for easy calculation of the long-lasting insecticide treated nets (ITN) such as measles vaccination, tetanus vaccina- needs, both in terms of operational costs and distribution and iodine supplementation. Some tion, mosquito net distribution, HIV/AIDS supplies. One to two weeks before the imple- of the districts are also using the opportunity to prevention, iodine capsules distribution, etc. mentation, service providers (supervisors, conduct routine Expanded Programme of health workers, HEWs and support staff) are Immunisation (EPI) outreaches. In TSF districts, the EOS team is expanded trained for two days by the district trainers. with an additional two health staff, generally Training of service providers is given on every EOS activities are part of the Ethiopian one HEW and one support staff, to undertake round, i.e. every six months. The training is government Health Sector Development Plan the screening of children and PLW. Screeners based on the national guideline8. and one of the sub components in the National measure the mid-upper arm circumference Nutrition Programme (NNP)6. UNICEF is (MUAC) and check for bilateral oedema. Results supporting EOS as per its Country Programme Children and women eligible for TSF are regis- After the introduction of EOS, the service cover- Action Plan (2007-2011) under the output tered in a book and given a TSF ration card. In age has consistently increased, providing key “eighty percent of children and mothers in addition to receiving the TSF ration, children proven child survival interventions (low cost, drought-prone districts receiving high-impact, identified with severe acute malnutrition7 are high impact interventions) to children and PLW community health and nutrition services every also referred to the nearest Therapeutic Feeding every 6 months. Since the start of the six months through the EOS”. It is also part of Programme (TFP). programme, the number of children reached by the UNDAF Humanitarian Response and EOS services has progressively increased (see Recovery and Food Security sub-component for Comprehensive social mobilisation is Figure 2 and Table 1). The EOS programme “improved health and nutrition status of 90% of conducted to ensure all eligible children and children and PLW in chronically food-insecure mothers come to the health post. One team supervisor is assigned to support 3-6 teams. 6 The NNP is a long-term programme that will be imple areas through outreach activities”. mented in two phases for the next 10 years, each phase The team supervisors provide all-round lasting five years. The current NNP phase I spanning from Modalities of EOS service delivery support, including management and logistic July 2008 to June 2013. The NNP targets the most vulner- Every six months and with UNICEF support, support, technical support and identify prob- able i.e. under 5 year children, particularly those under 2 years, PLW, and adolescents. The objective of the NNP is to Regional Health Bureaus organise the EOS. Each lems and constraints and plan for better halve malnutrition from 1990 levels (underweight in children district that is not a TSF district has one EOS performance of next the day. under 5y) by 2015 that constitutes the non-income target team per sub-district, composed of one health of the MDG 1. It also explicitly aims to reduce child stunting, Two months before the implementation of wasting, and low birth weight rates by half by 2010, to worker and one HEW. These staff mobilise the which the NNP will contribute as an integral part of the HEP. EOS, training of trainers is given to district/ 7 community to come to the nearest health post Eligibility for TFP: children with MUAC < 11 cm and/or zonal health managers (coordinators and bilateral oedema. on a specific day, the EOS day. On EOS day, the 8 supervisors) by regional and central facilitators. Guidelines, Enhanced Outreach Strategy for Child Survival EOS team deworms and supplements with Interventions, Ethiopia, Federal Ministry of Health, March At the same time, district level micro-plans are vitamin A all children under five years. In many 2006

Table 1: EOS results per year and per round (2004-2009) 2004 2005 2006 2007 2008 2009 R1 R2 R1 R2 R1 R2 R1 R2 R1 R2 R1 R2 Vitamin A supplementation (6-59 months old) No. of children targeted 1,521,204 2,879,374 5,431,811 9,427,048 11,071,190 11,567,721 11,744,360 11,926,235 11,917,323 12,583,034 12,028,833 11,397,948 No. of children supplemented 1,389,438 2,576,620 4,946,811 8,269,753 10,154,375 10,760,198 10,937,894 11,156,698 11,179,017 11,812,673 11,490,616 10,707,244 VAS coverage 92.6% 89.5% 91.1% 87.7% 91.7% 93% 93.1% 93.5% 93.8% 94.1% 95.5% 93.9% Deworming (2-5 years old) No of children targeted 1,306,162 2,553,918 4,557,592 9,427,048 9,804,259 10,265,133 7,869,237 7,990,586 8,061,722 8,449,184 8,323,036 7,352,881 No of children dewormed 855,482 2,265,321 4,152,385 8,269,753 9,013,888 9,456,451 7,746,443 8,174,227 7,999,734 8,282,718 8,059,861 7,092,712 Deworming coverage (%) 65.6% 88.7% 91.1% 86.6% 91.9% 92.1% 98.4% 102% 99.2% 98% 96.8% 96.5% Screening for acute malnutrition (6-59 months old) No of children targeted 1,522,760 2,907,581 5,104,418 5,574,715 5,795,379 6,555,634 6,352,271 6,352,271 3,687,509 4,844,574 3,952,015 4,309,853 No of children screened 1,304,429 2,636,501 4,641,860 4,939,404 5,249,589 6,145,624 6,049,750 6,082,610 3,467,356 4,525,101 3,869,890 3,941,853 Screening coverage (%) 85.7% 90.7% 90.9% 88.6% 90.6% 93.7% 95.2% 94.1% 94% 93.4% 97.9% 91.5% No and % of children identified with acute 85,522 211,445 302,030 247,870 425,199 528,766 479,030 351,232 416,269 438,862 498,833 318,353 malnutrition and referred to TSF (6.6%) (8%) (6.5%) (5%) (8.1%) (8.6%) (8%) (7.2%) (12%) (10.2%) (12.8%) (8.1%) Screening for acute malnutrition (pregnant and lactating women (PLW)) No of PLW targeted 333,106 680,865 1,118,022 1,211,409 1,266,126 1,416,739 1,380,005 1,406,681 814,014 1,053,370 895,645 961,173 No of PLW screened 158,928 343,602 584,363 643,751 834,773 1,416,739 1,072,234 1,125,284 707,730 830,953 788,392 829,813 Screening coverage (%) 47.7% 50.5% 52.3% 53.1% 65.9% 74% 77.7% 80% 86.9% 78.9% 88% 86.3% No and % of PLW identified with acute 33,010 79,033 150,472 117,508 165,386 216,461 236,450 228,715 175,358 178,445 171,433 150,046 malnutrition and referred to TSF (20.8%) (23%) (25.7%) (18.3%) (19.8%) (20.6%) (22.1%) (20.3%) (24%) (24.8%) (21.7%) (18.1%) Source: Federal Ministry of Health, EOS data base, 2010

8 Field Article

Table 2: EOS and measles, vitamin A and deworming coverage by region, 2006 Region Measles Vitamin A Deworming Survey Admin. Survey Admin. Survey Admin. coverage coverage coverage coverage coverage coverage Oromia 91% 97% 95.8% 96.6% 85% 95.6% Amhara 97.6% 88.6% 98.3% 79.6% 93.8% 87% SNNPR 90.2% 87% 91% 91% 77.3% 87% Indrias Getachew, UNICEF Ethiopia, 2009 Indrias Getachew, Tigray 95.2% 82.8% 98.7% 83.9% 86.6% 86% Health extension worker assessing the nutritional B.Gumuz 90.2% 101% 89.6% 71% 67.1% 71% status of a child using MUAC measurement during Somali 85% 91% 84.4% 89% 83% 88% EOS in Tigray region, Adwa Distric reached its peak activity level in 2006/2007. tions including measles. In conclusion, the • The EOS programme benefits from the Using the EOS approach the programme is now study found that EOS interventions are participation of a large number of public covering the entire country, except Addis extremely cost-effective and a good investment health institutions at all administrative Ababa city administration, reaching more than for Ethiopia13. levels and of non-governmental organisations 11 million children every six months. (NGOs). Despite the favourable unit costs of deliver- • Its cost effectiveness is proven and a ing life saving interventions such as VAS and Based on routine administrative reports, the number of donors have been supporting the deworming, there is no direct evidence that the EOS coverage has exceeded the planned target programme since the start. EOS/TSF is having a positive impact on mortal- for each round for vitamin A supplementation, • Added EOS services like measles ity reduction and improving the nutritional deworming and nutritional screening. During vaccination, ITN distribution and iodine status of children enrolled in the programme. A the second round of the 2009 EOS, 11.5 million supplementation have contributed to lowering meta-analysis of the effectiveness of VAS to children aged 6-59 months were supplemented the average cost per person served. control young child morbidity and mortality in with vitamin A and 7 million children aged 24- • Successful community mobilisation and developing countries showed that improving 59 months were dewormed. In addition, 3.9 demand for the service is attributable to the the vitamin A status reduces mortality rates by million children and 820,000 PLW were financial incentives (outreach allowances) some 23%14. However, in Ethiopia it is not possi- screened for acute malnutrition. From these, provided for the local HEWs and volunteers. ble to quantify the impact of EOS because there 318,000 children and 150,000 PLW were found to About 68% of the total costs of EOS are for is no baseline data or case-control study for be malnourished and referred to the TSF/TFP. outreach allowances17. comparison. A formula developed by Pelletier Monitoring and evaluation et al15 was used to estimate the life saving Challenges Between March and May 2006, a measles follow impact of EOS. Based on this method, it is esti- During the course of its implementation, EOS has up campaign was conducted in Oromia, mated that 171,000 under five children’s death also encountered some significant challenges: Amhara, Tigray, Somali, SNNP and Benishangul are prevented through the EOS/TSF every year. Gumuz regions9. The campaign was integrated Poor nutritional screening data quality has with the EOS interventions. Following the Factors contributing to high coverage in been an issue. The Outcome Evaluation Study 18 campaign, a coverage evaluation survey was the EOS programme of the TSF programme in Ethiopia conducted conducted between June and Sept 2006 to vali- Factors contributing to high coverage in the by WFP in 2008 highlighted a very high inclu- date the administrative coverage report10. The EOS programme include: sion error of the TSF beneficiaries screened EPI cluster methodology was used to design and • The specialised training conducted before during the EOS (46% mistakenly admitted into conduct the survey. A total of 8,116 households every round of EOS for health service the TSF). Efforts made since to improve the were assessed. The survey identified that inte- providers to strengthen capacity. This helps quality of nutrition screening measurements grated child survival interventions coverage was to overcome the high staff turnover in the include providing training before every round high and very close to administrative reports, health system. of EOS, simplification of the screening method- with little variation between each study area (see • Social mobilisation has been the key effort to ology to reduce risks of error (from a two-stage Table 2). get people to attend the EOS centres, and it screening comprising of MUAC and weight- was central to achieving 90% coverage16. for-height to MUAC only), wide-spread Another coverage survey was conducted in High community participation, created by dissemination of posters in local languages, and 2008 to validate EOS coverage data collected public announcement and mobilisation use of a new MUAC tape with a colour code to through routine administrative systems. This during the screening time, promoted EOS both help HEWs understand screening proce- involve gathering household level data on service uptake, which has a knock-on effect in dures and to increase the beneficiary’s selected indicators such as VAS, deworming promoting general health service uptake at awareness of their entitlement. While noting the and nutritional screening11. It was a cross sub-district level. continuous improvement of screening data sectional survey conducted in 42 districts in • It creates community demand whereby quality19, the Emergency Nutrition Coordination Oromia, Amhara, SNNPR, Tigray, Somali, Afar mothers/caregivers appreciate deworming Unit20 still encounters problems with the data and Benishangul Gumuz regions. Six districts because of a visible immediate effect. retrieved from systematic checks. from each region were randomly selected and in each district, nine sub-districts were assessed 9 Bale, Borena, Guji, East Showa and Arsi zones of Oromia 15 Pelletier, DL, E.A. Fongillo, Jr., D.G. Schroeder, and J.P. using a 30 by 30 cluster methodology. A total of region, North Wollo, SouthWollo and Waghimra zones of Habitch. 1994. A methodology for estimating the contribution 900 households with children under five years , all districts of Tigray region, all districts of of malnutrition to child mortality in developing countries. B. Gumuz region, all districts of Somali region and Gurage, Journal of Nutrition 124 (10 SUPPL.): 2106s-2122s were assessed. Wolayita, Dauro, Siltie, Hadiya, Kembata Tembaro zones 16 Mission Report, Enhanced Outreach Strategy/Targeted and Konta, Alaba districts, and Awassa, SNNPR. Supplementary Food for Child Survival Interventions, The results showed that the overall coverage 10 Coverage Survey Report on Integrated Child Survival Ethiopia, Andrew Hall and Tanya Khara, November- Interventions In Oromia, Amhara, SNNPR, Tigray, Somali December 2006 of the EOS campaign was very high and above 17 and Benishangul Gumuz National Regional States of Feedler, J. and Chuko, T. 2006. Costing Study. Enhanced 80%. It also confirmed that the post-campaign Ethiopia, UNICEF Addis Ababa, December 2006 Outreach Strategy, Micronutrient Initiative, A2Z, World coverage estimates for VAS, deworming, and 11 Post campaign Evaluation Survey of round 1 2008 Bank, UNICEF Enhanced Outreach Strategy in Ethiopia, Addis .Continental 18 Outcome evaluation study of the Targeted Supplementary nutritional screening were not necessarily the Institute of Public Health, October 2008 Food (TSF) programme in Ethiopia; World Food Programme; same as those found in routine administrative 12 Feedler, J. and Chuko, T. 2006. Enhanced Outreach Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MD Strategy Costing Study. Micronutrient Initiative, A2Z, World MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH. EOS reports (Figure 3). Bank, UNICEF 19 The ENCU checks show regular decreases in the proportion 13 The Macroeconomic Commission on Health classifies all of districts with unreliable screening data. Those with unreli- In addition to achieving high coverage, EOS health interventions that have a cost per life saved that is able data amounted to 48% in 2008 Round 1, 44% in 2008 has been found to be a cost effective strategy for the equivalent of less than per capita GDP as “highly cost- Round 2, and 47% in 2009 Round 1, 27 % in 2009 Round 2. 20 The Emergency Nutrition Coordination Unit (ENCU), which 12 effective”. child survival . The ‘EOS costing study’ 14 Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe is the technical arm of Disaster Management and Food conducted in 2006 has estimated that the cost G, Ross AC, and Harvey B - Effectiveness of Vitamin A Security Sector (DMFSS), with the support of UNICEF, was per life saved is equivalent to only $58 for Supplementation in the Control of Young Child Morbidity established in 2000 to coordinate emergency nutrition and Mortality in Developing Countries; ACC/SCN State-of- assessments and interventions. ENCU is doing quality Vitamin A, and $228 for integrated interven- the-Art Series, Nutrition Policy Discussion Paper No.13, 1993 check for EOS nutritional screening data.

9 Field Article

Due to poor quality, the EOS screening data Lessons programme through establishing appropriate cannot be used for trend analysis in the context EOS in conjunction with TSF seems to be a safeguard mechanisms. Re-design should also of nutrition surveillance. While reporting is highly relevant action for the local environ- look to secure wider coverage and use of alter- part of every six monthly EOS refresher train- ment. This is partly due to the prevailing critical native products for management of MAM. ing, late data compilation and reporting still nutrition and health situation in large areas of Ethiopia has achieved encouraging progress occurs. the country, where on average 47% of children in recent years in detecting and managing acute MOH leadership to manage the logistics suffer from chronic malnutrition. For sustain- malnutrition through EOS and the expansion of need and programme information/data ability, the GOE has prepared a plan for EOS the national TFP. At the same time, there is a management has been limited. Supply and transition in HEP with phase by phase exit growing understanding that it is time to invest distribution of resources at national scale is a strategy for EOS. The plan is to be implemented in a more comprehensive approach at house- challenge for all programmes without a MOH within the MOH’s Health Sector Development hold and community level to prevent and National Logistics Master Plan that is still not Plan IV (period 2010-2014). It is important to manage all causes of malnutrition. The fully functional. make sure that the transition is smooth and that Community Based Nutrition programme the HEP will be able to maintain the current (CBN) is the first compressive nutrition Except for staff salary and overhead cost, gain in EOS. there is no budget allocation from government programme to address some of the immediate, for EOS programme. The programme is Availability of financial incentives associated underlining and basic cause of malnutrition in supported by international donors through in with EOS has played an important role in the Ethiopia. Started at the end of 2008, CBN is kind assistance (vitamin A capsules from the success of EOS. However, there are also being implemented in 170 districts so far. CBN Canadian International Development Agency concerns regarding the sustainability of its high activities are centred on the Triple-A (assess, (CIDA) and the Micronutrient Initiative (MI)), coverage when the financial incentives are with- analyse, act) approach, which helps and financial contributions for supplies and drawn. For example, it will be difficult to parents/caregivers and community members operational costs (CIDA, MI, Spanish maintain the high level of engagement of to assess the situation of children and women, Government, Australian Aid, UNOCHA, Community Health Workers (that are volun- analyse causes of the problems and take feasi- USAID, different national committees for teers) if financial incentives are removed. This ble actions at family and community level. UNICEF, etc.). Donor’s funding commitment is will have a negative impact on programme Monthly growth monitoring and promotion is usually for one or two rounds so that it is diffi- coverage. The reliance on pure volunteerism to conducted for children under two years, which cult to plan for the longer-term. support community mobilisation remains a is the most vulnerable period and when the challenge to any community-based programme. impact of early childhood malnutrition can be Future Direction: EOS transition into the HEP reversed. In all of the CBN districts, services The process of screening children using The Health Extension Programme (HEP) is the under the EOS package are being delivered as MUAC instead of weight-for-height has helped long term and sustainable strategy for deliver- quarterly CHDs. The CBN has established to identify more severely malnourished chil- ing the child survival and maternal packages effective referral linkages to the management of dren who are at risk of death. In addition, it under EOS. While the EOS will continue to be acute malnutrition. implemented, its pilot transition to the HEP makes the task much simpler for the HEWs and was started in 39 selected districts from reduces risks of error attached to conducting In many countries, social security has Amhara, Oromia, Tigray and SNNPR. two stage screening (i.e. using both MUAC and reduced poverty and inequality by half and weight for height). more26. There is evidence that social protection Two modalities are envisaged to provide in a form of cash transfer has improved the The EOS screening should ensure that only EOS services in the HEP package: nutritional status of children27,28,29. While most of acutely malnourished children get access to • The first and main mode is the Community the EOS/TSF districts are chronically food inse- supplementary feeding. However, the current Health Days (CHDs) that will be organised cure, the current management of MAM is not safeguard mechanisms in EOS/TSF are not by the HEWs on a quarterly basis to allow adequately linked with existing food assis- enough to adequately prevent distortion23. In more frequent identification and early treat- tance/ food security programmes. Food addition, there is no formal appeal process for ment of the malnourished cases. The vitamin sharing has been noted in TSF outcome evalua- individuals if they feel that they have been A and deworming will continue to be deliv- tion study conducted by WFP30. It is one of the unfairly excluded24. EOS/TSF partners are ered every six months. The CHDs are cultural mechanisms to cope with food insecu- currently working on improving supervision underway since the end of 2008. rity. Therefore, targeting a malnourished child and monitoring during EOS/CHD screening • The second mode would be part of the in poor family will not be enough to get the and conducting intensive community aware- routine activity at the health post and required programme effectiveness. Poor fami- ness and social mobilisation before, during and during home visits by the HEWs, in order lies/communities need to be targeted for social after the EOS/CHD screening to mitigate the to maximise the current ‘missed’ security programming. One possible way to problem in the short-term. Dialogue is ongoing opportunity and enhance coverage (this has improve programme effectiveness lies with the with Ministry officials and donors to discuss not yet started). possibility of changing the targeting mecha- the actions necessary to improve the overall nism to include not just anthropometry, but also The main rationales for the transition are: management of MAM in the country. A re- targeting families of vulnerable children for • Creating a mechanism for the sustainable design of nutritional screening and basic social protection. delivery of child survival service packages management of MAM is required, both to as part of the HEP by maintaining the respond to the immediate need to overcome the For more information, contact: Selamawit current EOS coverage of 90%. high inclusion error25 and to strengthen the Negash, email: [email protected] • Giving responsibility to the local distric and sub-district to plan, implement and monitor programmes. 21 1,391 children sampled in 1,103 households in Tigray, 2009 Round 1 and 27 per cent in 2009 Round 2. Oromia and SNNPR less than 2 weeks after the CHD 26 International Labour Office, ‘Can Low income countries • To help the HEWs to organise and execute 22 The proportion of VA supplementation was 73.3% in SNNP afford Basic Social Security?’, Social Security Policy Briefing, the services as part of their regular work 51.9% in Tigray 62.9% in Oromia Regions. The proportion no.3 ILO, Social Security Department, Geneva, 2008. and ultimately to increase local ownership of children de-wormed was 65.8% in SNNP, 35.4% Tigray 27 Rutstein S. O, Effects of preceding birth Intervals on and 52.4% in Oromia regions. The proportion of screened neonatal, infants and under five years mortality and and service delivery capacity. children was higher 89.4% in Tigray, 73.5% in Oromia and nutritional status in developing countries: evidence from 66.6% in SNNP Regions the demographic and health surveys. International Journal As of now, 170 districts have started imple- 23 Aid, Accountabilities and Distortion, An exploratory study of Gynecology anad Obstetrics, Vol.89, Supplement 1, April menting CHDs. In 2009, more than 1.3 million into possible distortion in donor-supported development 2005, PP S7-S24. programmes in Ethiopia, Productive Safety Nets Programme; 28 Erhlich, Isaac and Jinyoung Kim, ‘Has Social security children 6-59 months have received VAS and Protection of Basic Services Grant; Humanitarian Relief Influenced Family Formation and fertility in OECD about 800,000 children 24-59 months were Programme; Enhanced Outreach Strategy – Targeted Countries? An Economic and Econometric analysis’’, NBER Supplementary Feeding Programme, Report prepared by Working Paper no. 12869, National Bureau of Economic dewormed through the CHD modality. In addi- DFID on behalf of, and for the consideration of, the Research, Cambridge, MA, January 2007 tion, 1.3 million children 6-59 months were Development Assistance Group, Ethiopia, 23rd March 2010 29 Boldrin Michele, Mariacristina De nardi and Larry Jones, 24 ibid ‘Fertility and Social Security’, NBER Working Paper no. screened for acute malnutrition. Post-CHD 25 Outcome evaluation study of the Targeted Supplementary 11146, National Bureau of Economic Research, Cambridge, coverage surveys were conducted in October Food (TSF) programme in Ethiopia; World Food Programme; MA, February 2005. 30 2009 in three regions21. The preliminary report is Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MD Outcome evaluation study of the Targeted Supplementary MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH. The Food (TSF) programme in Ethiopia; World Food Programme; showing coverage is ranging from 58% to 73% ENCU checks show regular decreases in the proportion of Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, for VAS22. districts with unreliable screening data: it was 48 per cent in MD MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH. 2008 Round 1; 44 per cent in 2008 Round 2; 47 per cent in

10 Field Article

n Ethiopia, the role of the national Nutrition Information System (NIS) has been clearly stated in the Ethiopian National Nutrition Programme (NNP). IThere are three constituent parts to this role. P Fracassi, Ethiopia, 2008 P Fracassi, These provide a ‘comprehensive’ and holistic Ethiopia, 2008 P Fracassi, structure to NIS design: to support timely warn- ing and adequate interventions at woreda and higher levels, to develop, manage and evaluate the NNP at all levels, and to inform other sectors like agriculture, water/sanitation and Children with their caregivers on OTP day economic development. This comprehensive in Chalenqo Health Centre, Fedis woreda vision for the NIS is to inform understanding of the nutritional situation with respect to chronic Nutrition data management and newly occurring problems, as well as the While there are ‘trust’ issues on data quality and causes of these problems, and how these change credibility, the administrative decentralisation over time in order to help in decision-making at and existence of a widespread health network, Child screening in Fedis woreda during all levels. However, while the NIS can effec- Community Health Day creates the rare opportunity to build capacities, tively accommodate and be ‘open’ to an accountability and transparency at lower levels unlimited amount of data, the ability to trigger like the woreda and the kebele. an effective and appropriate response requires Can the that the information is timely, reliable and Initial data collectors are volunteers and consistent. These conditions ultimately deter- frontline health practitioners. Many report that mine the basic parameters upon which the data collection is an additional burden to their Nutrition initial choice of information for the NIS is made. already crowded agenda. After the initial collec- Put simply, all data should be trusted and tion, data flows up through various levels via Information continuously available, data should be triangu- supervisors and health officials. However, little lated to generate ‘context-specific’ and feedback is given through the system so that evidence-based information and there should people directly involved have a limited sense of System be be a clear process, agreed by all actors, to feed what is actually done with the information information into decision-making. provided. The sheer volume of reports stored ‘trusted’ to testifies to the regularity of data collection Unique data situation in Ethiopia undertaken and the immediate priority that Ethiopia is in quite a unique position because, should be given to improve the ‘efficiency’ of build on over the last thirty years, large amounts of data the process. Currently, asking for nutrition have been collected by the Early Warning information from a woreda official leads to a available System (EWS), including health and nutrition paper-chase given the amount of report forms information. However, the nutrition informa- collated. Where officials have been provided tion collected by the EWS (see Box 1) provides with a computer, data appears to have been data sources? only scattered data - mostly alert signals based regularly updated. Given the increased require- upon ‘observable’ degeneration. Data is ments for information management, it seems By Patrizia Fracassi collected directly from health workers at ‘criti- inevitable that woreda Health Offices will move cal times’ and without systematic comparison from a paper-based system to a computerised Patrizia holds an M.Sc. in with what would be ‘normal’ for a given time of Development Management. one, allowing them to perform data quality Over the past two years, she year. Nutritional assessments are required checks that otherwise are time consuming and has consulted in Ethiopia for during these critical times to confirm ‘emergen- prone to mistakes if done manually. The impli- UNICEF and the World Bank. cies’ but the seasonality of these critical times cation here is that woreda level officials are She previously worked for creates a widespread, simultaneous demand for mostly young, often computer-literate, profes- UNICEF Uganda as a assessments, which rarely can be adequately sionals with degrees. Provision of adequate Nutrition Specialist and for met. tools/software to practically manage informa- Italian NGOs, CESVI (Cooperazione e Sviluppo) tion can help build their capacity to implement In recent years, targeting of surveys has been and Ucodep (Unity and Cooperation for the system. If information is not properly improved through increased use of routine data Development of Peoples, now Oxfam Italia) in valued at woreda level, where most data are Vietnam as Country Representative and sources, at least to indicate where an assessment collated and ‘checked’, then the task of quality Programme Manager. She also developed and is most urgently needed. Nutrition data are now assurance at higher levels is nigh-on impossible. manages the technical content for the available and accessible on a monthly and quar- website: www.motherchildnutrition.org. terly basis at the lowest levels due in large Added value of NIS: triangulation of data Patrizia would like to acknowledge team- measure to three programmes: The Community What is ‘new’ in the NIS paradigm is the members from the federal and regional Based Nutrition programme (CBN), the requirement for ‘triangulation’ to provide Emergency Nutrition Coordination Units and Therapeutic Feeding Programme (TFP) and evidence-based information for decision- from UNICEF Nutrition and Food Security Community Health Days (CHD) (See Box 1). making. This implies that collected data are not Section for their continuous support, and These routine systems are the monitoring back- interpreted in isolation but are brought together especially government representatives at all bone of the NNP, which - at least theoretically - levels for their willingness to share information from different sources. The strength of triangu- can be combined to inform timely warning and and give their valuable insights. lation is the ‘contextualisation’ of the data, be shared with other sectors. Similarly, a meaning numbers and/or standardised obser- number of diseases are also currently being vations are grounded in ‘local knowledge’. tracked on a weekly basis through the Public Frontline practitioners in health-posts have Health Emergency Management (PHEM) access to nutrition and health information system (see Box 1). Thus, there is a very real through regular contact with patients. With potential for the EWS to systematically tap into nutrition, for example, they are in the best posi- specific data from existing health information tion to judge if the deteriorating weight of a sources and vice-versa. This will be most effec- child during monthly growth monitoring or tive if a consensus is reached on key indicators, his/her admission in the Outpatient in particular for timely warning. The key ques- Therapeutic Programme (OTP) is linked to lack The findings, interpretations and conclusions in tion, ultimately, is whether decision-makers of food in the family or to other causes like this article are those of the author. They do not from all sectors are willing to exchange and use illness, inappropriate feeding practices, etc. It is necessarily represent the views of UNICEF, its available routine data to inform their decisions Executive Directors or the countries that they this ‘proximity’ that allows for the triangulation represent and should not be attributed to them. and response. to be most helpful at community level whereby

11 Field Article root causes of malnutrition can be identified. An exam- ple where this could be used is in chronically food insecure areas supported by the Productive Safety Net Programme (PSNP) where risk financing mechanisms exist to address new chronic or temporary food insecu- rity. By monitoring increases in underweight (as an P Fracassi, Ethiopia, 2008 P Fracassi, early indicator) and OTP admissions (as a late indica- tor), frontline health practitioners, who are members of Queuing during HD in Fedis Woreda the Food Security Task Forces (FSTF), can play a crucial role in providing information for appeal processes. Box 1: A guide to key systems and programmes in Ethiopia implemented by the Government However, the credibility of their information will depend on their full understanding that risk financing The Early Warning System (EWS) is imple- underweight, number of trained and report- mechanisms are only accessible when malnutrition is mented nationally under the Disaster Risk ing vCHWs, number of implemented CC linked to food insecurity. Thus, triangulation of data at Management Food Security Sector sessions and participants. Indicators are (DRMFSS). Information are collected at disaggregated by gender. source is a kind of check by key people before informa- kebele level by Development Agents and The Community Health Days (CHD) are tion is fed into the decision-making processes or passed to the Woreda Early Warning Food implemented every three-months and reported to higher levels. Security Task Force. The Task Force analyses expected to cover all 150 CBN woredas. and interprets data and submits reports to Trust, accountability and transparency MUAC screening is conducted for all children the regional level and to the Woreda Council. 6-59 months and for PLW. Those identified as In Ethiopia, in line with governmental decentralisation, Collected information include: rainfall condi- malnourished are referred to therapeutic woreda and kebele level administrations have been tion, crop condition, migratory pests, input feeding programmes or supplementary given increased power to analyse, assess and act on their supply, livestock condition; human health feeding, where available. Every six months, own changing situation. They are therefore more condition, water access and availability, children are additionally provided with responsible and accountable for both development and education related information, fast on-set Vitamin A and deworming. Collected infor- emergency response. Addressing the challenges of how disasters (flash and seasonal river floods, mation includes: targeted population landslides, conflict, forest fire outbreak and information can feed into decision-making will ensure (children 6-59 months), coverage of child livestock diseases outbreak and human the credibility and sustainability of the NIS. At the and PLW MUAC screening, coverage of epidemics), grain, livestock and other moment, available data from routine sources are not Vitamin A and deworming supplementation. commodities prices, coping mechanisms, adequately linked to information use. The main chal- Children and PLW are grouped on the basis emergency relief responses. Information is lenge for data utilisation at higher levels is that sources of MUAC as follows: MUAC >12 cm, MUAC fed into decision-making processes for clas- are not fully trusted while at lower levels there are limi- between 11-11.9 cm and MUAC <11 cm, PLW sification of emergency affected tations over capacities and mandate. While data quality with MUAC <21 cm. Data are collected by the areas/woredas and relief allocation. In Health Extension Workers and volunteers assurance can be built into the system, especially by Productive-Safety-Net Program woredas, EW and sent to the Woreda Health Office for improving lower-level capacity, more emphasis needs to information is used to help programme the further transmission to the zonal, regional be given to the human aspect. ‘Trust’ cannot be built newly established Contingency Funds. In and federal level. Where supplementary without attention to the role played by each stakeholder, addition, the DRMFSS is responsible for the feeding is available, screening results are starting with frontline practitioners. ‘Accountability’ implementation of bi-annual seasonal (belg shared with the DRMFSS to establish the cannot be acquired if there is no hand over of responsi- and mehr) multi-sectoral assessments. number of beneficiaries. bility. ‘Transparency’ cannot be promoted without Information is used to identify acutely food making response and feedback more visible. insecure woredas and estimate the number The Outpatient Therapeutic Feeding of affected population in need of relief. Programme (OTP), as part of the manage- The NIS in Ethiopia can be built upon coupling avail- ment of severe malnutrition, is now covering able data sources with adequate technical support The emergency nutrition surveys are coordinated by the regional and federal more than 6,000 sites (health centres and provided throughout the health system. However, Emergency Nutrition Coordination Units health posts). Collected information technical inputs are not enough to ensure its sustainabil- (ENCU) under the DRMFSS. Surveys are includes: number of in-charge beneficiaries, ity. A sense of ‘value’ is what motivates people and conducted by non-governmental organisa- number of admitted beneficiaries (severely without it, the simple transmission of data to higher tions (NGOs) and/or government wasted, with oedema, transferred, etc.), levels will not provide incentive to stakeholders for their multi-sectoral teams using the SMART number of discharged beneficiaries and input. ‘Triangulation’ is most effective at community methodology. ENCU is responsible for the performance indicators (cured, death, level where individual data sets can be compared at technical quality through an approval defaulter, etc.). Data are collected by the Health Extension Workers and health work- source and understood within a given context. process of the initial proposal and final find- ers and sent to the Woreda Health Office Frontline practitioners play a crucial role in building the ings. Request for an emergency nutrition survey should come or be endorsed by the (WorHO) for further transmission to the credibility of the NIS but this can only come about with zonal, regional and federal level. increased recognition of the role they play in informing woreda/regional authority based on EW decision-making. As the process of decentralisation information and/or results from the bi- The Public Health Emergency continues within Ethiopia, important decisions to be annual assessments. Information is used to Management (PHEM) system, coordinated confirm ‘emergencies’ and mobilize response taken at the lowest levels, risk financing mechanisms by the Ethiopian Health and Nutrition for relief and selective feeding programmes. Research Institute (EHNRI), is expected to be being an example, will require bringing together avail- The Community Based Nutrition implemented on a nation-wide scale. able data from different sources. This, in turn, will rely Immediately reportable diseases include increasingly on key people accountable for informing Programme (CBN), started in 2007, is now expanding in 150 woredas covering all kebe- polio, anthrax, avian human influenza, this process at the frontline. Before trusting the cholera, guinea worm, measles, neonatal Nutrition Information ‘System’, a vote of confidence les. The programme is implemented by Volunteer Community Health Workers tetanus, pandemic influenza, rabies, severe should be given to empowering the information (vCHWs) under the supervision of the Health acute respiratory syndrome, smallpox, viral ‘Source’. Credibility, after all, should always start with Extension Workers. It includes monthly hemorrhagic fever and yellow fever. Weekly the people. Growth Monitoring and Promotion (GMP) of reportable diseases are dysentery, malaria, children under two years with referral of relapsing fever, typhoid fever, typhus and For more information, contact: Patrizia Fracassi, email: severe acute malnutrition. The latter has [email protected] those who are severely underweight, not gaining weight for two months or with other been only recently added among the weekly health problems. Pregnant and Lactating reportable diseases. Health facilities have to Talking about data with Development Women (PLW) receive folic acid supplemen- inform the WorHO within thirty minutes after Agents in Checheho kebele, Lay Gayint tation and are mobilised for antenatal care, they see an immediately reportable disease. safe delivery and other maternal services. Further data transmission from woreda to Community Conversation (CC) is conducted zone/regions and from zone/region to EHNRI monthly to assess child malnutrition, analyse is expected to take place within an hour causes and plan for action (Triple A Cycle using any available communication mecha- Approach). Collected information includes: nism. Health facilities (including health number of children under two years, posts) report data from Monday to Sunday number of weighed children, children with every Monday to WorHO. Data are expected normal weight, underweight and severe to arrive at EHNRI every Thursday. P Fracassi, Ethiopia, 2010 P Fracassi, 12 Field Article

The ECHO RDD support for the second phase from July 2009 to June 2010 was seen as the time to consolidate the activities, learning and outcomes of the first phase. Background to the project Million Ali, Ethiopia, 2008 The pastoralist populations in Ethiopia and Somaliland are exposed to multiple hazards. Continued and increasing frequency of drought Oxfam’s combined with a weakened asset base and coping mechanisms has resulted in high levels of risk. Frequent droughts lead to inadequate Somaliland-Ethiopia access to and availability of both water and pasture. Rapid population growth and a declin- ing natural resource base have exacerbated the Cross Border Drought negative impact of the recurrent droughts. The major water source for pastoralists and Preparedness Project their livestock is surface water collected in water catchments (birkads) during the rainy A community birkad in the season. There is also an increasing trend of Harshin-Somali region expanding underground cement water tanks. Some of the water facilities in pastoral commu- nities are privately owned although a large By Abay Bekele number are communally owned, particularly Abay Bekele works for Oxfam GB as Senior Pastoral Programme Manager. He has water pans/catchments. Though communally over nine years of technical and managerial experience in pastoral development managed water facilities offer good coverage and humanitarian programming. He has also managed programmes in to various social groups within pastoral ACDI/VOCA, SC US and CARE International in Ethiopia. He holds a Doctor of communities, there are increasing concerns in Veterinary Medicine from Addis Ababa University. terms of their maintenance. Overall, the exist- The author would like to thank the staff of Oxfam GB Somaliland and Ethiopia and ing water sources are inadequate to provide Horn of Africa, east and Central Africa, that designed and implemented RDD I and II projects, partic- water for human and livestock needs, even ularly Helen Bushell, Abdirahim Salah, Mustapha Mohammud, Million Ali, and Elias Kebede. Special during normal times. The situation worsens thanks go to Jeremy Shoham for his invaluable support in putting documents and materials usually during periods of water stress. During together and revisions of drafts. this time, competition over water and pasture often results in conflict and forces pastoralists The author is particularly grateful to the many pastoralist communities, partners with whom Oxfam has been working to end poverty and suffering in Ethiopia. to travel for longer distances with weakened livestock to find water. The stress induced by long-distance migrations leads to an erosion of the social capital and social support networks amongst the pastoralists, Access to basic social services such as education and health facilities is also disrupted, rendering this group less xfam’s Somaliland-Ethiopia Cross Border Drought Preparedness resilient to the increased incidence of drought. Project is implemented as a component of Oxfam GB’s 15-year regional pastoral initiative that covers six countries in the Horn and At the same time, the stress-induced migra- East Africa1. This initiative is divided into 3-year phases. In the tions negatively affect the health and OSomali region of Ethiopia, implementation started in 2002 and is now in the productivity of livestock, leading to a signifi- second phase, whilst in Somaliland the first phase started in 2005. The first cant increase in livestock mortality during phase of Oxfam’s Ethiopia-Somaliland Cross Border Drought Preparedness drought periods. As the health of the livestock Project (see map) ran from January 2008 – June 2009. The second phase, which deteriorates, pastoralists resort to selling was funded under the European Commission Humanitarian Office (ECHO) animals, thus crowding the market and lead- Field Article Regional Drought Decision (RDD), was a 12-month project implemented in ing to a drop in prices. This reduces the income partnership with HAVOYOCO (Horn of Africa Voluntary Youth Committee) of the pastoral households at a time when and ended in June 2010. prices of all other consumables tend to go up, hence weakening the purchasing power of the The regional pastoral initiative is based on the idea that the key issue in pastoralists. The end results are loss of assets, reducing poverty and marginalisation in pastoral communities is increasing destitution and, finally, dropping out from the level and quality of pastoralists’ participation and representation. At the pastoralism. ‘Drop out’ pastoralists tend to heart of the programme is a concern to build strong, representative pastoral migrate to urban settlements to access human- organisations, through which pastoralists can better understand and claim itarian relief and other basic social services. their rights and manage the development services they need. Strengthening These situations create a sub-group of the drought management capacity (at technical, organisational and institutional population around large towns and villages levels) and working to reduce vulnerability to drought is a central aspect of the who lack the skills to take part in economic pastoral development programme. activities in their new settings. Communities living in adjacent border Figure 1: Location of Ethiopia-Somaliland Cross Border Drought Preparedness Project areas are often inter-dependent (in terms of culture and ethnicity, language, sharing common resources, trade and marketing Galbeed and Toghdeer routes), and the causes of their poverty are in Somaliland inter-linked. This is particularly the case in pastoral areas where pasture and water need to be accessed by resource users on both sides of the border. Furthermore, communities shar- Harshin Woreda, Somali ing a common border are faced with similar Region, Ethiopia environmental conditions, socio-economic constraints and risk profiles. Effective natural

1 , Ethiopia, , Kenya, Uganda, and Tanzania. 13 Field Article resource management, conflict management participate in the decision-making process in border areas of Harshin, Somali region of and development work therefore requires joint respect of matters affecting their welfare. In Ethiopia and in Odwayine, Durqsi, Ballidhiig action. Of particular relevance to the relation to this, women in pastoral societies are (Togdheer Region) and Farawayne, Somaliland-Ethiopia Cross Border Drought highly marginalised and face multiple burdens Allaybadaye and Belligubedle (districts of Preparedness Project are issues of trade, char- in terms of bearing responsibility for most Galbeed province of Somaliland). The border coal production, livestock trekking routes and productive and reproductive tasks, while lack- communities are mainly from Isaac clan shar- water points. For example, poverty reduction in ing comparable authority over productive ing the same ethnic denomination. border areas cannot be achieved without peace- resources and decision making processes. These A total of 76,000 people in 9,500 households building, and most conflicts have a cross-border burdens tend to increase during times of were expected to benefit directly from the inter- dynamic. As well as mitigating risk (conflict, drought stress and conflict. Preparedness plan- vention as shown in Table 1. The beneficiaries disease), cross-border work can also add value, ning and capacity is seen as an urgent need. are pastoral men, women, children, youth and by opening up social/economic opportunities the elderly. Among the general population in (trade, natural resource management (NRM), Phase II objectives and expected Somali region of Ethiopia, 90% are pastoralists education) – this is particularly the case given outcomes while those in Somaliland constitute 60-65% of the trade routes and links between Somaliland The proposal for phase II submitted to ECHO the population. and Ethiopia. states that pastoralist vulnerability to drought will be addressed by focusing upon the natural The activities implemented in phase II in Project strategy resource base and the management of natural order to achieve the three results are The principles of cross border programming as resources, capacity for effective drought summarised in Box 1. Approximately 76,000 applied to the Ethiopia-Somaliland Cross preparedness and response and supporting people (9,500 households) directly benefited Border Drought Preparedness Project have communities to preserve their asset base in from the integrated NRM of water and pasture largely been developed from prior thinking and times of drought stress. The principal objective resources as well as capacity building activities consultations over a period of years. The of the project is to ensure that communities, targeted by the project. Woreda, district and programme strategy is based on Oxfam GB’s local government and civil society organisa- regional authorities, community-based organi- ‘one programme’ approach and Oxfam GB’s tions in Somaliland and the Somali region of sations played a key and predominant role in and HAVOYOCO understanding that the cross Ethiopia are better prepared to manage the the planning, implementation and monitoring border project should be: negative impacts of droughts. of the project. By improving the management of • Proactive in nature and involve high quality Three expected results (outcomes) for Phase II water and pasture resources and reinforcing work with communities are: local capacities, all the Harshin population • Programmatic and strategic, i.e. focused on Result 1: Improved institutional capacity for (80,215 people of whom over 45% are women) strengthening institutions/processes, not drought preparedness linked to enhanced indirectly benefit from the project. Many of just activities community preparedness capacity. these benefit from the technical support • Jointly planned and owned by communities, provided by the implementing team. local partner organisations or by both Greater emphasis was placed on this result governments during the second phase, recognising the Woreda and regional government institu- • Addressing issues that can only be tackled limited achievements during phase I. The focus tions and community-based organisations also by common action and/or coordination on is to improve community access to early warn- benefit from capacity building and technical both sides of the border ing information from national/regional support provided by the project. In • Used to achieve wider impact by influencing authorities, awareness of the drought cycle, and Somaliland, the implementing local partner, policy and practice on a regional basis drought risk management at community level. HAVOYOCO, the community pastoral organi- • Flexible and responsive to changes in an This is supported by the development and zations (POs), the districts/regions authorities operating context improvement of contingency plans with clearly and the national level government departments • Built on shared learning and understanding demarcated roles and responsibilities. including, the national disaster authority and the Ministry of Pastoral Development and Situation analysis Result 2: Improved integrated natural resource Environment of Somaliland, benefit from insti- Assessments carried out in Ethiopia in January management (NRM) to ensure increased access tutional capacity support. On the Ethiopia side, and March 2009 in Harshin Woreda and in to and availability of pasture, fodder and water. the respective woreda and regional government Somaliland during the first week of May 2009 Here the project focuses upon mapping of the institutions of Livestock, Crop and Rural were instrumental in informing the proposal natural resource base as a tool for planning in Development, Water, Energy and Mines, DPP put to ECHO for the second phase of the cross both a humanitarian and development context. border project. The findings revealed that Mapping exercises are built upon by ensuring vulnerable pastoral households were facing the effective management of water points increasing livelihood erosion as droughts (including hygiene practices) and pasture became more frequent and coping capacity management. Based on studies undertaken extremely weakened. Communities identified during phase I, the issue of land enclosure was the effect of drought on vulnerable households to be taken up at a policy and advocacy level. as a core problem, highlighting that lack of Ethiopia, 2010 Bekele, Abay proper, integrated management of natural Result 3: Households better able to preserve resources (water and rangeland) leads to their assets throughout the drought cycle. scarcity of water and pasture, as well as natural The emphasis here is on working to ensure that resource and environmental degradation. The levels of vulnerability to drought do not assessment also identified privatisation of increase amongst pastoral populations by help- communal grazing land, limiting mobility and ing to ensure household assets are preserved availability of resources, poor access to basic during times of stress. This involves reviewing social services, erosion of social capital and and addressing issues of coverage of veterinary resource based conflict as interrelated problems services offered by Community Animal Health associated with the effect of drought. Workers (CAHWs), reviewing livestock Within the current disaster management marketing for effective livestock off-take during system (on the Somaliland side) there is a func- times of drought stress and building the capac- tioning, although often ad hoc, disaster ity amongst livestock marketing cooperatives, management coordination structure and a food Woreda DPPO (Disaster Prevention and security and nutrition information system. Preparedness Office), pharmacists and private However, the absence of government in a vets in drought related livestock diseases and central strong position is a clear limitation in drought response. relation to effectiveness, efficiency and sustain- ability. Furthermore, little attention has been Phase II activities paid to strengthening of the organisational Target population Watering camel from a birkad capacity of community-based institutions to The project was implemented in the cross- in the Harshin-Somali region

14 Field Article

and Health are key beneficiaries from the differ- ent trainings and institutional development support. Amongst target beneficiaries are the POs at

Abay Bekele, Ethiopia, 2010 Bekele, Abay community level and (in Somaliland) district level community development and prepared- Mobility, a key pastoral livelihood ness committees. strategy (Kebribeyah Somali region) Management and coordination Table 1: Profile of intervention targets in Phase II In order to administer and deliver the project, a Project Management Team was formed and led Total population Total number of house- Total direct Total direct benefi- by the Somali Region, Pastoral Programme in target area* holds in target districts** beneficiaries ciary households Manager. The Ethiopia project lead reflected a Somaliland change in approach from phase I which was led Galbeed (project will be working 100,800 12,600 14,729 1,841 by Somaliland. The switch to Ethiopia reflects in 3 of the 10 districts) the larger project on the Ethiopia side of the Togdheer (project working in 3 111,600 13,950 21,271 2,659 border and the greater project management of the 6 districts) capacity correspondingly budgeted within the Total Somaliland 212,400 26,550 36,000 4,500 Ethiopia team. Ethiopia Monitoring, Evaluation and Learning Harshin Woreda 80,215 10,027 40,000 5,000 In Phase I of the project, a Monitoring, Total Somaliand and Ethiopia 292,615 36,577 76,000 9,500 Evaluation and Learning (MEL) guide was *Target area given as districts the project is working in, rather than the region. developed and a project baseline established. In ** Each household has on average 8 people. phase II, the MEL guide and baseline was adapted to incorporate a Logical Framework. Box 1: Phase II activities by anticipated result Project implementing teams conducted Result 1: Improved institutional capacity for disas- • Construction of five community birkads and monthly field monitoring by providing ter risk reduction linked to enhanced community natural resources management training and monthly progress reports. These monitoring preparedness capacity. follow up coaching for five birkad community exercises have been conducted to check the • Awareness raising on disaster risk reduction management committees. progress made against plans and hold discus- (DRR)/drought cycle management topics for • Construction of four rainwater harvesting tanks sions with stakeholders (communities, local pastoral organisations, traditional leaders, in four schools and operations and maintenance authorities and NGOs). The implementing team women groups, traditional meteorologists and training and follow up coaching for four teachers. held monthly coordination meetings to make government (district commissioners, village • Technical vocational skills course for 10 masons decisions based on an analysis of the monitor- head-men and governors (regional and district and carpenters on the construction and main- ing data, and the outcome of the meetings were level)) in Somaliland. tenance of water structures and roof water shared with Oxfam Nairobi Office and FAO • Ten community mapping sessions on drought harvesting system. (flash report). During such reviews, Oxfam GB preparedness including mobility patterns, • Gully erosion control and re-seeding of 6 sq. discussed with beneficiaries the relevance of the water and pasture resources for contingency km of pastureland including provision of tools proposed activities for the next semester and planning in Harshin. to community members. took their comments into account. • Five trainings on DRR and five follow up • Technical and policy level support to the meetings with CAHWs to strengthen a commu- Ministry of Pastoral Development and A final internal evaluation was conducted by nity based early warning information system Environment of Somaliland to advance the a team of Oxfam GB senior staff from Ethiopia using data collected by CAHWs and linked to formulation of the national Land Tenure Policy. and Somaliland, and representatives of NGO the district DPPB office. This includes convening a stakeholder’s review and government bureaus. The baseline survey • District disaster contingency planning work- meeting (to include participants from Ethiopia was repeated and the results compared with the shop, facilitated by DPPB with community by way of joint learning) and incorporating the baseline carried out at the start of the project. participation, to establish a drought contin- findings of the land enclosures study from the gency plan in Harshin District. Also, support to previous phase of the RDD. Lessons learnt during the first two NERAD (National Environment Research and project phases Result 3: Households better able to preserve their Disaster Management) to develop a national Access to and types of rangelands assets throughout the drought cycle. and district contingency planning methodology A key finding of the natural resource study in • A cross border study to investigate the possible for Somaliland as well as a national plan phase II of the project was that communal lands role of Community Animal Health Workers together with six district drought contingency (CAHWs) in drought preparedness and are being increasingly privatised, i.e. they plans. response including tackling drought related become land enclosures. The process seems to • Conduct an early warning system (EWS) user diseases and the overall performance of be influenced by endogenous [erosion of survey and use this as a basis to develop an CAHWS in respect to their given mandate. customary institutions, intra-clan competition, EWS for Somaliland. • Dissemination of study findings to national erosion of communalism and population • Study tour for NERAD, HAVOYOCO and Oxfam bodies via national workshops in Somalilandand growth] and exogenous [weak grass root GB Somaliland to Ethiopia/Kenya to see how Somali Region (government, FAO and agencies government institutions, expansion of settle- these two countries’ disaster risk management engaged with CAHWS working) to help streng- ment and social services, commercialization of agencies (including EWS systems) and mecha- then CAHWS training through the updating of rangeland products and climate change] nisms are set up and function. national and agency training guidelines. factors. This leads to erosion of livelihoods as Result 2: Improved integrated NRM to ensure • Used study findings to develop training guide- livestock numbers decrease, so that more increased access to and availability of pasture, lines on the management of drought related people become involved in selling charcoal as a fodder and water. diseases and trained CAHWS on the same. A means of survival. Charcoal is used domesti- • Cross border integrated natural resource total of 22 CAHWS were trained in Somaliland. cally or sold to the Middle East. management mapping of the project area • Support the Livestock, Crop and Rural focusing on water, pasture resources and Development Bureau in Somali Region of During phase II, Oxfam GB has tried to build possible migration routes in partnership with Ethiopia to roll out the national guideline for community capacity, e.g. through developing the Food and Agriculture Organisation (FAO). the Design and Establishment of CAHWS via water capacity (cement lined wells) and rehabil- • Joint dialogue workshops on findings of natural holding a regional orientation session (target- itating rangelands via the community. resource management (NRM) mapping and ing FAO, Agricultural Bureau DPPB, NGO’s, etc.) A number of negative impacts and chal- land enclosures study from previous phase of and two district orientation sessions (targeting lenges of the programme have emerged. As RDD in partnership with FAO and line bureaus CAHWS, district veterinary technicians, live water points were developed, communities and ministries (proposed formulation of a cross stock marketing cooperatives, private vets and started acquiring their own private birkads. The border NRM technical working group) private pharmacies). number of birkads on the Ethiopian side increased significantly but the amount of graz-

15 Field Article

Table 2: Profile of beneficiaries by result/sector Somaliland side on the basis of assessment, analysis, consultation, and seasonal scenarios. Result /Sector Number of Number of Total number Number of The contingency plan includes linkages with beneficiaries in beneficiaries in of beneficiaries households Somaliland Ethiopia the regional (Ethiopia) and national (Somaliland) early warning system (EWS). It is Result 1: 36,000 40,000 76,000 9,500 Disaster preparedness, local disaster anticipated that these linkages will be strength- management components ened during the forthcoming ECHO Result 2: 4,800 (part of the 25,000 (part of the 29,800 3,725 programme (RDD3). Community based early Disaster preparedness, small-scale 36,000 above) 40,000 above) warning indicators focus on the following key infrastructure and services areas: rainfall, birkad levels, pasture conditions, Result 3: 9,600 (part of above) 0 9,600 1,200 livestock body condition, livestock disease, and Food assistance, short term food migration in/out of the woreda. This informa- security and livelihood support. tion is gathered by CAHWs. Focusing on these indicators would help pilot the process and ing land remained the same, leading to range- need to establish information systems for criti- establish the analytical linkages between land degradation during the dry season in cal knowledge around pastoralist livelihood community based monitoring and the particular. The number of birkads in the area of systems. For example, with regard to livestock regional/national EWs. In Ethiopia, CAHWs the project has now reached more than 5000. diseases, how mobility is influenced by disease information is passed to animal health techni- Livestock come to access the water and graze and how to share information between commu- cians (AHTs) in government. In Harshin there the fields around the water points leading to nities. The congregation of herds at dry season are 13 centres with AHTs. AHTs travel to the rangeland degradation. Wealthy households grazing areas favours disease transmission. district capital each month for payment and can started selling water and natural resource shar- However, this also gives opportunity to access use this opportunity to inform the district of ing mechanisms changed as livelihoods and treat a large population of animals at any developments. The project aims to develop declined. Overall there has been a process of one time, and stands the best chance of break- district contingency plans, which will be acti- commercialisation so that water and grass are ing the chain of transmission. vated by early warning information collected increasingly purchased. Water is now by CAHWs. commonly sold during drought and dry season Cross border livestock trade On the Somaliland side, institutional capac- periods. The structure of the market between communi- ties in the cross border areas of Ethiopia and ity of the government and the technical capacity The total number of water points rehabili- Somaliland conveys livestock to Somaliland of its staff are weaker. Oxfam GB has tried to tated during the two phases has been and brings in consumer goods to Ethiopia. build capacity of DPPO equivalent staff approximately 500 (approx 10%). There are two Oxfam GB will facilitate exchange of informa- although there are not many suitable govern- ways to manage birkads – privately and tion between the two communities. ment staff to train. Thus, the programme is communally. Most of the constructed or reha- stronger on the Harshin side. Marketing activi- bilitated birkads have been constructed for the Cross border mobility ties have not as yet started in this project. community but private birkads tend to be Sharing information on grass and water avail- Oxfam GB recognises that it is important to better managed than communal ones. Another ability and improved management of strategic establish preparedness first but that timely live- lesson from phase II has been that it is impor- water points and grazing lands between the stock marketing will be critical further down tant to support the capacity to manage the two cross-border communities is essential. This the line. water points (financially and institutionally) so will have to be done informally due to the that these resources are sustainable. GoE’s position on cross-border movements. Community vulnerability The Oxfam GB offices in Jijiga and Somaliland The remaining pillar of the Oxfam GB cross- An important finding from this experience plan to exchange information and also dissemi- border project relates to reducing community for Oxfam GB, who are now attempting to nate and share information between the two vulnerability during drought and dry seasons. secure funding from ECHO to continue the communities. The aim in the next project phase Generally, the drought and dry season favours project from July 2010 to December 2011, has will be gradually to institutionalise capacity to the better off but if conditions are very severe, all been that drought related problems cannot be exchange information outlined above. It is also are affected. The most vulnerable are the poor as solved simply by filling gaps, e.g. constructing hoped to take relevant government staff from they lack livestock and natural resources. They birkads. It is far better to build the institutional Ethiopia and Somaliland to West Africa to need alternative income generating sources. capacity of communities so that they can expose them to cross border policy formulation Women are the most vulnerable amongst the manage their own resources more effectively. and implementation in the region (Mali, poor. Women and children remain behind when husbands migrate. If food and money sent by the Another set of key learning points arose in Burkina Faso or Niger) and how information husband diminishes, then they have to send live- relation to types of grazing land (60% sharing can work, i.e. the approach is advocacy stock to their husbands to sell. enclosed/private, 40% communal). Enclosed from above while having an impact at grass- roots level. lands are generally well managed but most of The challenge for the Oxfam GB project is the community are excluded from these lands. Preparedness and livestock disease how to reduce vulnerability of women and chil- Usually, the grass and trees are excellent on Another key issue for the next phase of the proj- dren who remain behind during the dry season. enclosed lands. Communal lands tend to be ect is addressing preparedness. A major The programme is currently attempting to iden- degraded and eroded and poorly managed. In problem for pastoralists is livestock disease, tify business opportunities for women. the next phase of the project, Oxfam GB intends especially drought induced diseases. Five key Conclusion to support the exchange of management experi- livestock diseases for each animal species have In conclusion, a lesson from phases I and II of ence between enclosed and communal lands. been identified as part of this project making it the project is that the focus of pastoralist inter- This will be piloted in three woredas - four possible to strategise disease control measures. ventions should be to strengthen the communities per woreda. The project will use The most important actors with respect to live- community and risk reduction strategies rather households in enclosures to train those commu- stock diseases are CAHWs. Through the than simply fill material gaps through resource nities who use communal lands, in land project, eighty nine have so far been trained on provision. Oxfam GB also realise that informa- management. To reverse the situation, pastoral the Ethiopian side, with others trained on the tion on the interaction of communities with field school will be piloted to train herders and Somali side. These CAHWs move with the neighbouring groups is a pre-requisite for community leaders. Trainees will act as communities to provide animal health service understanding pastoralist societies and plan- resource persons in their local communities to as they are pastoralists themselves. The project ning development initiatives. Furthermore, raise the awareness level of the community on has been building their capacity in disease there is a need to find out about the major rangeland management. surveillance and diagnosis with a view to estab- resources in a community, where these are lishing community early warning and response Another set of issues arising out of the first found, who manages them and perhaps most capacity to drought. This will help facilitate two phases relates to cross-border land areas. important of all, who benefits from them. The GoE does not recognise international vaccination or treatment interventions. For more information, contact: Abay Bekele, movements over the border. Oxfam GB is there- A relevant and appropriate contingency plan tel: +251 11 661 33 44 fax: +251 11 661 35 33, fore looking at issues around mobility and the has been produced both on the Ethiopian and email: [email protected]

16 Field Article

Farmers at work Oxfam’s work has focussed on three domains: • farmer needs - formation of farmer groups, improving governance, development of skills, women’s economic leadership, Oxfam, Ethiopia, 2008 increasing production and linking this to market access and risk reduction • the market - value chain development, assessing market needs and where formal markets exist, food processors, working with the private sector, and • lessons learned - for example, building Oxfam capacity, developing and advocating at policy forums at local, national and regional levels and coordinating with stake- Emergency Food Security and holders. The Agricultural Scale Up programme strategy is about pulling rather than pushing people out Livelihoods Project in Amhara of poverty. The approach builds on the assets and capacities of farmers who are not food inse- cure. The theory is that by focusing on this and Oromia regions stratum of society, it will be possible to make a contribution to the overall economy of the country and resulting GDP. It will create greater wealth and development for the country than a By Shekar Anand, Oxfam strategy which focuses upon the poor and most food insecure. The approach focuses on produc- Shekar is Programme Director for Oxfam GB in Ethiopia. Past experience includes tive areas and productive capacity. working with OXFAM, CARE, CIDA, and Government in Aceh, India, Zimbabawe and Afghanistan. He has a post graduate in Rural Development and Management of NGOs However, Oxfam are aware that their target and twenty-two years of experience in his field. farmers are often exposed to emergencies like The author acknowledges the work of Oxfam GB and the Ethiopia Rift Valley Women drought, flood, market turbulence and climate and Children Development Association, Ethiopia. change. Consequently, Oxfam have endeav- oured to embed a humanitarian response programme within the Agricultural Scale Up programme for pockets of target farmers, to prevent them from falling into the poverty trap. Small holder farmers who become food insecure xfam UK has been working in Ethiopia for close to 30 years. do not have access to the national Productive Oxfam’s flagship coffee programme linked with the interna- Safety Net Programme (PSNP). Furthermore, tional coffee house, Starbucks, has enabled the organisation’s there is very little donor money for supporting unique positioning within agriculture and livelihoods agriculture. Oxfam have therefore come up with Oprogramming in Ethiopia. Oxfam UK is also leading Oxfam an approach called the ‘emergency food security International efforts to establish a single management structure for the and livelihoods (EFSL) project’ to protect those various national Oxfam agencies currently working in Ethiopia. farmers who are vulnerable to impact of drought and other shocks. Oxfam UK currently has three types of programme in Ethiopia: Field Article i) Humanitarian response, e.g. drought or flood response, interventions to address acute outbreaks of watery diarrhoea. ii) Pastoral programmes, e.g. the cross border programme in Somali region.1 iii) Livelihood programming, which includes agricultural development. Agricultural development in Ethiopia The agricultural development programme in Ethiopia is part of the Packed honey ready for Global Agricultural Scale Up (GASU) initiative started by Oxfam four market years ago. This pilot initiative was initially established in three coun- tries, Ethiopia, Honduras and India covering three continents. Tanzania was subsequently included. If successful the programme is to be scaled How the EFSL project started up. The failure of short rains in most parts of The Commercialisation of Agriculture for Smallholders in Ethiopia Ethiopia in 2008 resulted in drought conditions (CASHE) programme (called the Ethiopian Agricultural Scale Up that affected the agricultural scale-up Programme until 2009) targets small farmers with at least half a hectare programme in Amhara and Oromia regions. of land and aims to support these farmers in gaining access to, and Farmers in at least nine woredas required inclusion in, markets. The programme is operating in three regions in immediate EFSL support for a three to five Ethioipa, namely Oromia, Amhara and Benshangul Gumuz Regional month period. Oxfam elected to support the States. Beneficiaries are targeted on the basis of land ownership and farmers to develop agricultural infrastructure market constraints. Farmers are supported in a number of ways, e.g. that would help restore normal food produc- creating an enabling environment, value chain development of select tion levels by the end of the harvest season, i.e. commodities and market service provision. December 2008. The Agricultural Scale Up programme in Ethiopia has worked with The Oxfam EFSL project appeal proposed, farmers on many crops. It has now been decided to use a scalable model first, to provide immediate support to affected for three commodities, honey, coffee and sesame. These have also been communities so that they could withstand the identified by the government as high value crops for export. The project shock till the next harvest season and secondly, ensures that farmers are not dependent upon these crops for their liveli- to stabilise food production in the long run hoods but also grow other crops. through development of agricultural infrastruc- tures and community-managed systems.

1 See field article in this issue, p27-30. There were three primary objectives: 17 Field Article i) Respond to increasing vulnerability to Box 1: Project activity plan food insecurity faced by smallholder farmers in nine target woredas of Amhara Amhara region • Establishing/strengthening market information and Oromia regions through social • EFSL assessment and planning with communities centres transfer and a public works project. • Construction of 5 grain banks in five malt barley • Capacity and skill building of communities on ii) Strengthen linkages between social growing Woredas maintenance and use of community structures protection and humanitarian response • Construction of 4 honey collection centres in and on the Community Based Resource activities and improve sustainability and each honey Woreda Management (CBRM) approach and mechanisms probability of graduation of beneficiaries. • Construction of access roads- 33 Km • Establishing community-managed revolving This was to be achieved through • Provision of around 150kg bee forage seed and funds for 50,000 birr in two locations in each developing a strategy for collaboration planting on 50 hectares woreda • Capacity and skill building of communities on with PSNP around social protection leading Amhara and Oromia regions maintenance and use of community structures to graduation in target woredas. • Social Security assessments conducted in and CBRM approach and mechanisms iii) Inform long-term agriculture programming targeted woredas • Establishing community-managed revolving on appropriate activities to address the • Consultative review of PSNP and other food funds for 50,000 birr in two locations in each humanitarian context faced by small- security programmes woreda holder farmers as part of an integrated • Consultation and strategy development approach. Oromia region through learning from the response • EFSL assessment and planning with communities • Baseline survey/ assessments Box 1 outlines the activities planned in the • Cleaning and maintaining 22 irrigation schemes • Monitoring of project implementation different regions. • Maintenance of rural roads (100 km) • Documenting lessons learnt and dissemination Management and implementing • Soil and Water conservation structures (25) • Conducting mid term and final evaluation partners • Provision of vegetable seeds to 780 households • Application of learning in development • Provision of farm tools & equipment to 780 programmes and policy advocacy The overall management of the project was households supervised by agricultural scale-up programme managers who were in charge of Amhara and Oromia regions respectively. Partners were enabled households to bridge the hunger gap increased capacity of households to responsible for project implementation on the and deal with food price inflation, improved purchase food items from local markets. ground. The project was implemented over a 16 access to agricultural inputs, particularly those • The provision of farm tools and equipment month period (September 2008 – December that increase the productivity of high value enabled farmers to undertake farm activities 2009). However actual implementation of proj- commodities and enabled households to buy more effectively coupled with the various ect activities was completed in the first 12 productive assets such as livestock. soil and water conservation measures, e.g. month period and the remaining four months Furthermore, almost all households targeted by the construction of check dams, cut off were used for evaluation, documentation of the project now send their children to school. drains, and hill side terraces in areas that lessons learnt and wrap-up. are highly susceptible to erosion and land Data show a clear increasing trend in income The project was implemented by the degradation. These measures have led to an from Oct/Nov 2008 to May and June, 2009, Organisation for Rehabilitation and increase in production and productivity. after which income fluctuated up and down. Development (ORDA) in Amhara region, and • The training and technical support given to Most of the beneficiaries interviewed indicated by Rift Valley Children and Women farmers in improved agronomic practices like that there has been a considerable increase in Development Association (RCWDA) and Rural seed beds preparation, technique of sowing income. Organization for the Betterment of Agro- seeds on the beds, mulching system, shading pastoralists (ROBA) in Oromia region. Relevant Diversification of sources of livelihoods system and improved ways of watering government departments at regional, zonal and Implementing partners and beneficiaries cited seedling in different stages, have all woreda levels were consulted during the course the following as examples of livelihood diversi- contributed to increased production of crops. of implementation. fication due to the project: Access to potable water supply • Increased on-farm and off-farm activities, Access to potable water has improved through Target beneficiaries such as beehive production due to the a number of means (more water points (faucets) In Amhara region, a total of 2,300 households revolving loan scheme and income and construction of pot/calabash stands) lead- (11,500 people) in six woredas were directly generating activities. ing to improved water consumption both involved in and benefited from this project, • Increased number of small holder farmers during the wet and dry seasons. It was also constituting at least 13% of the affected popula- engaged in employment opportunities reported that the use of safe water supply has tion in these woredas. All of the beneficiaries created through cash for work. significantly contributed to improvements in were also the beneficiaries of the Agricultural • Increased production of malt barely crop. Scale Up Programme (1,080 households health status of people, as well as improved targeted on malt barley value chain and around Increased availability of food children’s school enrolment – particularly girls, 1,220 households on honey value chain inter- According to implementing partners and bene- as the time children spend on fetching water ventions). It was estimated that about 88,000 ficiaries this has been achieved through a has decreased. The majority of water collection people in these woredas indirectly benefited number of means: trips used to take 90 minutes but have now from the project interventions. • The transfer of cash resource to vulnerable reduced to 30 minutes. Furthermore, women households through public work has were spending less time queuing. In Oromia region, a total of 3,050 households (15,250 people) in three woredas (Arsi Negelle, Kore and Kofele), in 15 kebeles of Langano Coffee production in Ethiopia Shala locality, were directly involved in and benefited from this project. It is estimated that about 75,000 people in these woredas indirectly benefited from the project interventions. All of the beneficiaries in Oromia region were also beneficiaries of the Agricultural Scale Up Programme. Impact of the programme Changes in household income According to implementing partners and bene- ficiaries, the increase in income as a result of the EFSL project has improved households’ access to food and assisted households to pay back the loans they received from saving and credit groups/institutions. The extra income has also Oxfam, Ethiopia 18 Field Article

Access to local markets staple food such as maize, wheat and sorghum Participation of farmers in the construction The construction and maintenance of feeder in quintals have generally declined over the of the grain banks indicates that there is an roads improved access of particularly margin- year of the intervention. The same pattern was increased knowledge among farmers about the alised communities in the intervention areas to observed in Amhara region for maize and benefits of being organised and working market and also to other social services, such as sorghum, although the price of wheat increased together in grain marketing, as they are now in health. above the normal seasonal patterns. According a better position to influence the market. to WFP, at national level, local prices of major Saving patterns Asset creation and ownership staple foods continued to decrease as a result of Review of the available data indicates that there Most households have created productive and the continued market stabilisation programme is still a low level of household saving. For non productive assets following the project inter- implemented by government and continued instance, the saving and investment of heads of vention. There has also been a marked increase food aid interventions. in holdings of livestock and other productive households in Bugna woreda for the month of assets and a reduction in distress sales of assets. Improved awareness about the benefits of March 2009 show that 100 heads of households organised actions saved/invested a total of 1,657 birr, i.e. 16.57 Prices of cereals in local markets Knowledge and awareness amongst members birr per household. In Arsi Negelle woreda in The situation in Kofele woreda is typical of of self help groups (SHG) on development February 2009, only 160 birr saved/ invested by other woredas where the prices of cereal and related issues has increased. Members explain 189 households, i.e. 0.846 birr per household. livestock have declined or remained more or the importance of organizing into groups by a Changes in gender relations less stable (except for the price of bulls which local saying ‘Jirbiin walitti yaatee arba hiiti’, Interventions in high value crop promotion, have shown exceptional fluctuations in the which means that ‘when threads come together, public works and cash transfers, potable water months of December 2008 and March 2009 as they could tie an elephant’. The group savings supply and the support to off-farm income shown in Figure 1). initiated in each SHG has started to play a role generating activities have all enabled women to in reducing the vulnerability of group members The results of market assessment conducted address both their practical and strategic needs. during production shocks. Currently all the by the World Food Programme (WFP) during Women have been equipped with important life the project year are presented in Table 1. These SHGs have at least a monthly saving scheme skills in areas such as small scale business indicate that in Oromia region, the prices of and regular forums for discussion. development, entrepreneurship, petty trading and the production of vegetables and fruits. Case study: Mohamed Kediro There are clear indications of changes regarding women’s participation in community hill side terraces in areas that are highly level processes, including political participation susceptible to erosion and land degradation. and leadership. Interventions have also started These measures have led to an increase in to change gender based division of labour, with production and productivity.

Oxfam, Ethiopia men and boys now assisting women and girls • The training and technical support given to in household activities such as fetching water. farmers in improved agronomic practices like There has also been a significant shift in deci- seed beds preparation, technique of sowing sion-making. More than half of women now seeds on the beds, mulching system, shading decide whether or not to participate in commu- system and improved ways of watering nity affairs. A considerable number of women seedling in different stages, have all are now members of either committees or lead- contributed to increased production of crops. ers of community organisations, including their Access to potable water supply saving and credit cooperatives, and are free to Access to potable water has improved through a make decisions either to join such community number of means (more water points (faucets) organisations or not. Some of the women Mohamed Kediro is 28 years old and lives in Kore and construction of pot/calabash stands) leading pointed out that because they are now econom- Woreda, Shifa kebele Biftu village/Got/Ganda. He to improved water consumption both during the ically in a better position, they can express has a family of nine (three adults and six children wet and dry seasons. It was also reported that themselves more freely and forcibly. below the age of 18 years). the use of safe water supply has significantly contributed to improvements in health status of Key challenges Mohamed described how after the intervention, people, as well as improved children’s school Due to increasing food prices, the cash household income has increased as he is being enrolment – particularly girls, as the time chil- provided through cash for work programmes is provided with improved seed (malt barley) while dren spend on fetching water has decreased. The the chronic problem of potable water has also becoming inadequate to enable recipients to majority of water collection trips used to take 90 been addressed. Furthermore, availability of purchase foods similar to those provided in a minutes but have now reduced to 30 minutes. household food has increased. Mohamed has food for work programme, thereby discourag- Furthermore, women were spending less time participated in training on crop management. ing participation in the programme. Managing queuing. The project has provided him with financial food price instability is a long standing policy support and improved seed varieties. But he Access to local markets challenge. With mixed experiences of agricul- reported there has been no change in his live- The construction and maintenance of feeder tural price policy reforms, this has re-emerged stock management, as this is not well addressed roads improved access of particularly margin- as a contemporary policy issue. by the project. alised communities in the intervention areas to The project targeted only a portion of the market and also to other social services, such as As a result of his participation in the project, he health. total population in the woredas worst hit by the has now accrued important productive assets – food crisis. There has been an increasing he has bought one sheep, constructed a new Asset creation and ownership demand, particularly for financial support from house and has bought a bed. Most households have created productive and those areas in the woreda that were not targeted non productive assets following the project Increased availability of food by the project. This has led to a situation where intervention. There has also been a marked According to implementing partners and benefi- numbers enrolled in public work activities have increase in holdings of livestock and other ciaries this has been achieved through a number in some cases almost doubled compared to productive assets and a reduction in distress of means: planned number of beneficiaries. This dilutes sales of assets. • The transfer of cash resource to vulnerable financial resources transferred per head. households through public work has Prices of cereals in local markets Stakeholders, government and the commu- increased capacity of households to purchase The situation in Kofele woreda is typical of other nity have limited experience, as well as capacity, food items from local markets. woredas where the prices of cereal and livestock to effectively manage public work activities and • The provision of farm tools and equipment have declined or remained more or less stable enabled farmers to undertake farm activities (except for the price of bulls which have shown cash transfers to vulnerable groups. This has, in more effectively coupled with the various soil exceptional fluctuations in the months of some cases, resulted in the late or untimely and water conservation measures, e.g. the December 2008 and March 2009 as shown in delivery of project inputs to beneficiaries. construction of check dams, cut off drains, and Figure 1). Furthermore, price inflation of important project inputs has forced project expenditures over and above the planned budget.

19 Field Article

Table 1: Prices of cereals in selected regions in April, 2010 Markets Major Current Price change (%) Average Change Commodity Price 1Y 6M 1M 1Y 6M 1M 4. Regional average (BIRR/100KG) Oromia Maize 406 -11.0 -13.6 -4.1 Oxfam, Ethiopia, 2008 Wheat 550 0.6 -17.5 -8.3 Sorghum 403 -22.7 -25.5 -1.6 Tigray Maize 432 -18.9 -29.4 7.3

Wheat 592 0.9 -22.0 -9.9 Making modern bee hives Sorghum 486 -11.4 -26.9 -11.5 Somali Maize 390 -23.5 -1.9 -4.9 Figure 1: Average price of livestock and crops in local markets in Kofele wereda Wheat 375 -39.5 -22.7 -21.1 6000 Sorghum 300 -31.8 -50.8 -15.2 Bull 5000 Cow SNNPR Maize 362 -21.1 10.2 -5.2 Heifer 4000 Wheat 578 -7.5 -2.0 5.6 Sheep/goat Sorghum 385 -6.1 -11.5 0.0 3000 Donkey Amahara Maize 413 -6.4 -11.4 -3.2 2000 Horse/mule Wheat (Quintal) Wheat 578 18.0 10.3 8.9 1000 Quintal of barley Sorghum 450 -13.1 0.0 -16.5 0 Quintal of maize Note: Price increase above normal fluctuation Quintal of beans Normal price fluctuation Quintal of malt barley Jul. 09 Jul. Oct. 09 Oct. Apr. 09 Apr. Jan. 09 Feb. 09 Jun. 09 Sep. 09 Sep. Dec. 08 Nov. 08 Nov. Mar. 09 Mar. Aug. 09 Aug. Price decrease below normal price fluctuation 09 May. Y: year; M: month Source: ROBA, Monthly Market Assessment Data

Lessons learned Implementing this type of project within a Activities undertaken have directly Households who are poorer in terms of owner- short time-frame is a challenge, as there is contributed to improvement in the access of ship of physical assets are less able to apply limited time for community sensitisation, households to local markets. However, the resource management practices (such as land organisation, mobilisation, monitoring and adoption of improved agricultural technologies management, improved farming practices, etc) training. More time should be allocated to in general and the use of improved essential and hence they obtain lower yield and lower ensure effective implementation, follow-up and agricultural inputs- including organic fertilizer, income. support, as well as to assess progress and moni- in particular, is minimal among farmers in the tor impacts. project intervention areas. Facilitating rural credit facilities and provid- ing credit support to poor rural communities Conclusions In order to improve farmers’ access to inputs contributes towards enhancing their involve- The project has made significant contributions in and to markets, future programmes in the area ment in different income generating activities protecting consumption during times of food should build the institutional capacity of local that increase income level. crisis and also saving beneficiaries’ by providing government, community-based organizations cash, credit/loan and other agricultural inputs such as service cooperatives and saving and Farmers’ access to credit should be improved like high value seeds and farm tools. This has credit associations. Efforts should be exerted to through the formation of saving and credit enabled beneficiaries not only to protect their introduce a number of new and improved tech- groups/cooperatives. More saving and credit assets but to go beyond that to create/build nologies to the farming system in the woredas. cooperatives should be established and their additional productive and non-productive assets institutional capacity built up through training, In order for the Agricultural Scale Up in a short period of time. All of the important provision of materials, seed, money or working programme and EFSLP to become the country results and outcomes achieved so far have posi- capital. approach, Oxfam recognise the need to come tively impacted on the capacity of the up with evidence of impact for Government The onset of natural disasters presents new community to prevent, manage and mitigate and donors. Oxfam are no longer alone in advo- opportunities for microfinance institutions vulnerability and shocks. Project interventions cating this approach. The World Bank has (MFI) especially in rural areas. MFIs can act as a have contributed to the gradual stabilisation of recently invested 300 million dollars into an logical mechanism for disaster relief, recon- market prices of major agricultural commodities, agricultural growth programme (AGP) that struction, rehabilitation, and development. which in turn improved the access of households targets food secure districts. Oxfam staff have Disaster-oriented microfinance services may be to food and enabled them to buy goods at been employed as consultants to work on an in the form of new and temporary services reasonable prices. However, the problems of AGP operations manual. developed as a post-disaster response, or as part chronic vulnerability and high level malnutrition of the menu of services already being provided still persist in the project intervention areas. Disseminating lessons to government has by the institution. Microfinance programmes More efforts are required to understand and been slow although Oxfam have convened the that target female clients are likely to have the respond to this chronic vulnerability. first forum on agriculture, which has been greatest impact on household well being. followed by two GoE led national forums. The The project also contributed to the countries’ Oxfam approach converges well with GoE’s Relief and development are not separate awareness of social protection, the ways in PASDEP1 (Poverty Reduction Policy) which entities. They are interdependent and should be which it could be implemented, and the oppor- advocates for agricultural development led considered as such when planning and imple- tunities for poverty reduction that it offers. This industrialisation. menting projects. made the project a welcome support for policy dialogue, demonstrating the possibilities of This programme has managed to integrate Some vulnerable households are labour implementing social protection programmes in humanitarian activities into a development constrained and hence may not be able to the country. project by transferring resources in a different provide the labour required to participate in way. Oxfam are hopeful that the approach will public works. Hence there is likelihood that The added value of the project is that it continue to be emulated by other agencies children under the age of 18 become involved helped maximise opportunities for high-value including Government. in public work programmes. Additional infor- crop production as an alternative source of mation is required to determine whether income by building the capacity of farmers and For more information, contact: Shekhar Anand, children have participated in cash for work farmer-led local institutions. The promotion of email: [email protected] programmes or not. Other data such as school market-oriented agricultural products, such as participation of children and the work loads of high-value crops, is of paramount importance women and girls should also be collected and in the process of quickly changing the lives of analyzed to monitor and mitigate unintended farmers who struggle to get out of extreme 1 Plan for Accelerated and Sustained Development to End outcomes. poverty and vulnerability. Poverty

20 Agency Profile

By Deed Jaldessa and Debela Kenea

Deed Jaldessa has over two decades experience in devel- opment work in rural Ethiopia and currently leads The Ethiopian Evangelical Church Mekane Yesus Development and Social Services Commission (EECMY-DASSC) as a Profile and national Director. He has a BSc in Agriculture and a M.Sc. in overview of Christian Aid / Caroline Waterman Natural Resources management and sustainable agriculture. Debela Kenea is Relief Programme Coordinator with the EECMY-DASSC. Born to a livestock rearing pastoralist family the church’s in a very remote, dry and harsh environment in southern Ethiopia, he is one of the luckiest children born in that area role in to be educated through the work of Norwegian Lutheran Mission and Ethiopian Evangelical Church Mekane.

emergency We acknowledge invaluable support of many organisations and individuals. To mention a few related to current relief and rehabilitation programmes: response UNOCHA/Christian AID, Act alliance, and Finchurchaid. Our words of appreci- ation also go to Mrs. Carmel Dolan for encouraging us to prepare the article and facilitating its publication and for her vital editorial inputs. Our thanks When Dhabe’s pastoralist Borana community lost many of their cattle go to Ms. Marie McGrath for follow-up of the process and important during a drought, EEC-MYs cash–for-work scheme offered them a life- reminders to finalise the work. line, enabling them to buy food and put in place measures to reduce the impact of future disasters.

gency affected people who cannot survive without assistance. Beside the emergency responses to urgent needs, EECMY-DASSC also implements short and long term rehabilitation programmes focusing on capacity building of he Ethiopian Evangelical Church Mekane 1. Socio-economic development (food security, those affected and their local communities, The Yesus (EECMY) was established as a water supply, gender equality, environmental Commission works with Government line Tnational church in Ethiopia in January protection, income generation) departments to secure necessary permissions 1959. As part of the mission of the church, 2. Health and HIV/AIDS prevention and and also to ensure that services are not being EECMY set out to work in the areas of health, control duplicated but well coordinated with other education and community development under 3. Capacity building relief agencies. Most importantly, the its Development Department. This gave birth to 4. Child and Youth Care and Development Commission consult and participate with the a full incorporation of the ‘Holistic Ministry’ 5. Education (formal, informal/literacy, communities to ensure transparency and so concept of the church, developed and commu- vocational and special needs education) that the aid provided helps meet their needs. nicated to the Lutheran Communion (Lutheran 6. Emergency Relief Response, Disaster Risk World Federation (LWF)) in 1972. The Holistic Reduction and Rehabilitation. Targeting and implementation Ministry concept is based on the broad under- The overall national targeting for emergency The EECMY-DASSC works through branch standing of human needs (physical, social and assistance is carried out by the Government’s offices in 21 synods, which are local church spiritual). The EECMY Development and Social Disaster Risk Management and Food Security units geographically located throughout the Services Commission (EECMY-DASSC) is a Sector (DRMFSS) through twice-yearly food country. In total, the EECMY has 5.3 million legally registered1 faith-based development security assessments. Household beneficiaries church members representing around 7 per cent agency that took over the responsibility of the are targeted, screened and registered by the of the total population of Ethiopia. former Development Department of the community based participatory task force in Church in 2000, as required by the national Emergency relief and rehabilitation woredas (districts) in need. The major part of the humanitarian response is usually covered policy of the Ethiopian Government. The Emergency relief is a vital part of EECMY- by the Government. The Church’s response is Commission has robustly continued to work on DASSC’s work to respond to urgent required in situations where the relevant humanitarian emergency response to disaster humanitarian and further rehabilitation needs. affected populations, building on strong experi- The emergency relief response is aimed at ences from the early 1970s and mid 1980s when providing resources either directly or in coordi- 1 In accordance to the Government’s law for non-govern the country faced widespread famine. mental organisation (NGO’s) registration for legal license, nation with other national and international EECMY-DASSC was registered and certified by the Ministry The EECMY-DASSC works in partnership sister churches and NGOs to support emer- of Justice as a development wing of the EECMY in 2000. with sister churches, development and human- itarian agencies in Ethiopia, Europe and North Table 1: Humanitarian assistance by EECMY-DASSC in Ethiopia (October 2010) America. It is a leading member of church Region/District Type of Population Type of response Type of response networks, such as the LWF, Action by Churches emergency targeted Together (ACT) Alliance and other evangelical Oromia region- Gasera & Flood and 17,901 General and supplementary Wabe Batu synod fellowships in the country and abroad. The Madwalbu districts drought food distribution overall budget of the EECMY-DASSC in 2009 SNPP Region- Aleta Wando Drought 20,000 General and supplementary South Central Ethiopia was Ethiopian Birr 200 million (approximately district food distribution Synod USD$ 12 million). These funds are raised from SNPP Region- Yirgachaffee Drought 20,380 General and supplementary South Synod different sister churches, development and food distribution humanitarian agencies operating throughout SNNP Region- Burji special Drought 18,000 General and supplementary Amaro synod the country and worldwide. district food distribution Amhara region- Bati district Drought 32,143 General and supplementary North Central Ethiopia Five year strategy food distribution Synod The following programmes constitute the major Gambella region- Jikawo District Drought 15,894 General and supplementary Western Gambella strategic focus areas of the EECMY-DASSC in its food distribution Bethel Synod current five-year plan. These programme prior- Gambella region Akobo District Tribal 7,020 Non food items Western Gambella ities are closely aligned with the Government‘s conflict Bethel Synod poverty reduction programme and the Gambella region- Itang District Flood 10,500 Disaster Risk Management East Gambella Bethel Millennium Development Goals (MDGs): Synod

21 Field Article

Emma Proud, Ethiopia, 2010 government department, such as the Cash for work beneficiaries DRMFSS, is unable to reach an area or needs digging soil bunds in Gashamo, the support of the Church to mount a Somali Region, to regenerate response. In 2009, the EECMY-DASSC the rangeland responded to emergencies in 10 woredas, reaching a total of 141,838 people with food aid and non food items (NFI) such as blankets, plastic sheets, soap, containers, mosquito nets, seeds and farm tools. At the time of writing (October 2010), humanitarian assistance was being supported by the EECMY-DASSC and implemented by the Commission’s synod offices in six differ- ent regions of the country experiencing emergencies (see Table 1). The Commission’s synod offices are the agents responsible locally for planning, implementation and supervision of humanitarian aid in their respective operational areas. They also ensure community and other stakeholder’s participa- tion in decision making and providing coordinated assistance. The EECMY-DASSC has a responsibility to ensure compliance with the rules, regulations and codes of conduct in the implementation of The RAIN programme programmes. It provides staff training to ensure that they are responsible and qualified for the task. Further training and capacity building supports are also given to local By Miriam Christensen and Todd Flower farmer’s association leaders, to coordination members of the district task force for aid work Miriam Christensen was the Todd Flower is the Chief of and to other local line departments’ staff to Documentation and Information Party of the RAIN programme ensure that they can fulfil their responsibility Officer with the RAIN programme. and has extensive experience She specialises in communications in implementing and managing Challenges and opportunities for the and knowledge management. international agricultural future Miriam now works with the development projects. He Delays in assessment of an emergency often International Labour Organisation specialises in agricultural delay the actions needed to meet critical and is based in Tanzania. market development. needs. EECMY- DASSC will need to The authors acknowledge the support of the U.S. Agency for International strengthen its skilled human power and finan- Development and the Office of Foreign Disaster Assistance. cial capacity for rapid assessment, as well as its capacity to mount even more effective responses in the food and nutrition sector. In many affected woredas, the commu- nity’s normal means of accessing food is ises in global food prices have led to USAID funded programme. The RAIN compromised by both slow and rapid onset of an increase in vulnerability for programme is being implemented for three disasters. Looking back over the past years, areas of the world that are net food years from 2009 to 2012. It is clustered the Churches’ contribution to food security- importers, which includes many around an inter-linked geographic area related emergency response has been Rcountries in Africa. In Ethiopia, pastoralists connecting one zone in the Oromia region considerable. To strengthen EECMY-DASSCs and agro-pastoralist households depend on a with four bordering zones of the Somali response in the future, it is important for the delicate balance of trade to be able to region. RAIN seeks to protect, promote, and EECMY–DASSC to consider increasing its purchase their household food requirements diversify livelihoods in this strategic cluster capacity in a range of response and program- based on the value of their animal herds. If as a means of increasing households’ ming areas based on a clear analysis of risks the prices of animals do not also rise with the resilience to shocks. The RAIN programme and needs. These will include: prices of staple foods, then these households works in the transitional environment from • General food distribution (free) based on can struggle to meet their needs. emergency to development programmes by the level of the food insecurity analysis combining traditional emergency interven- • NFIs provision The United States Agency for tions with longer-term development • Emergency nutrition interventions International Development (USAID) through activities. This seeks to address both the • Seeds, farm tools and restocking of the Office of Foreign Disaster Assistance immediate needs of communities and also to animals (goats, sheep and milk cows, oxen) (OFDA) has been providing support to promote sustainable local economic develop- • Income diversity through self-employment communities in Ethiopia for many years ment and integration. Some of these • Building community capacity in disaster through short-term emergency assistance activities include cash for work, emergency risk reduction and management programmes, such as emergency vaccination animal vaccination campaigns, value chain • Provide assistance for environmental or nutrition campaigns. These programmes analyses, linking producers to markets, and rehabilitation and further rural/ have traditionally lasted from 6 to 12 months. the establishment of a microfinance institu- agricultural development The global food price crisis brought about a tion to increase access to credit. The RAIN change in these programmes, with develop- programme is targeting over 700,000 people Another area in which EECMY-DASSC would ment of a longer term vision of assisting with these activities. like to grow capacity is emergency nutrition people and communities to remove them- and health support in marginal areas and in selves from the cycle of emergency RAIN objectives areas where displacement occurs due to vari- assistance. The programme has two objectives: ous disasters. • To protect the agricultural and pastoral It is in this context that Mercy Corps is productive asset base of food insecure For more information, contact: Deed Jaldessa, implementing the Revitalising Agricultural/ households to prepare them for email: [email protected] pastoral Incomes and New markets (RAIN) participation in more profitable markets programme, a multimillion dollar OFDA/

22 Field Article

Implementation: a market led this tends to lead to low investment in the long approach term because the producers are unaware of The second objective, to strengthen where they can purchase these inputs in the economic recovery and market future. It is also often the case that the emer- systems, is what makes RAIN gency approach leads to ‘dependency dramatically different from tradi- syndrome’ where producers wait for the next

Emma Proud, Ethiopia, 2009 tional OFDA funded projects. distribution to occur. The RAIN programme is Working on market system develop- taking a facilitation approach to ensure sustain- ment focuses on the long-term ability by working with the private sector to approach, rather than immediate, invest in the region. emergency interventions. RAIN in action: the peanut chain Traditional emergency approaches tend to have non-governmental Another example of RAIN programme activi- organisations (NGOs) providing ties in market development is in peanuts. The services directly. A market based RAIN programme is working on supply approach, however, puts the ‘exit through the agricultural input market but also strategy’ first and aims to strengthen on the demand, by connecting farmers to a lead the local market to provide access to firm. Lead firms are identified by size (i.e. goods and services, so that NGOs do number of members of a producer’s coopera- not have to in the future. tive) and their influence (i.e. whether they set the standard for the market). RAIN set a strate- The RAIN programme focuses on gic goal to increase the competitiveness of the market systems and provides regional peanut sector by reducing losses, support by creating linkages increasing production efficiency, upgrading between various market partici- warehousing and storage, strengthening pants. In the first year of the management capability, and facilitating link- programme, several value chains ages to higher value markets. were identified and evaluated including live animals, hides and The RAIN programme is working with the skins, milk, fruits and vegetables, Afran Kallo Union (AKU) and Hilina Enriched Vaccination campaign in and peanuts. These value chains Foods Processing Centre plc to increase income Gashamo, Somali Region were selected for evaluation because for peanut producers in the programme area. they had the highest potential to AKU is a union of peanut suppliers with 68 member cooperatives that represent approxi- • To increase and diversify the asset base of provide benefit for the poor in the programme mately 48,000 individual members. Hilina food insecure households via immediate area. At least one of these commodities is an Enriched Foods is a manufacturer of a ready-to- economic opportunities and the development important income source in all of the communi- use therapeutic food (RUTF)1 used to treat of high impact agriculture and non- ties where the programme is working. severely malnourished children. The relation- agricultural markets, that spurs private The value chain analyses included inter- ship between these producers and the company sector investment and local economic views with government, private sector and was a very typical situation. Hilina could not growth. community members. A common theme to all source enough peanuts on the local market that Implementation: natural resource of these evaluations was that farmers do not met their stringent standards and the AKU was management have access to the inputs they require to invest unaware of the standards and available prices. During the first year and under the mandate of in the production of large quantities of high Low prices on the local market led to low the first objective, projects such as cash for quality products. The RAIN programme is investment by producers in production, work, seasonal and emergency vaccination targeting access to agricultural input supplies harvest, and storage. Considering these needs campaigns and training of community animal to assist producers to be able to meet available gaps and opportunities, the two partners were health workers were implemented. Over 1.5 market demand. Most of the markets in this identified as ideal candidates for support from million animals received vaccinations that area are considered informal, with lots of small the RAIN programme. assisted 160,000 households and so far, more scale transactions in many local markets. There 1 than 9,000 people have been employed under are very few large, formal businesses working Plumpy’nut the cash for work component of the in the area. This has left the RAIN programme programme. While such activities have been to focus on the production side of the value Loading vaccination for livestock campaign in going on in the region for many years as indi- chain for most of these commodities. Demand is considered strong for all of these commodi- Gashamo, Somali vidual projects, it is the first time that such a Region range has been brought together under the ties. This means that any increase in production umbrella of one programme. through intensification and improving access to the means of production, agricultural inputs All cash for work activities have focused on and knowledge, will lead to a cycle of continu- Emma Proud, Ethiopia, 2009 natural resource management to provide imme- ous upgrading for producers. diate assistance for poor households and to ensure that resources are developed for the Producers not only need access to agricul- benefit of the community. Natural resource tural inputs but they also need information management projects include activities like about how to use these inputs effectively and pond rehabilitation or other earth works that information about market demand. The RAIN reduce the threat of flash flooding or drought. programme is working with the private sector All natural resource management activities are because these are the market players who identified by the participating community should offer matching incentives to the produc- through a community action plan. The RAIN ers. If the producer does well, then the input team works together with communities on asset supplier will sell more inputs to that producer. and risk mapping and needs assessment. Cash The RAIN programme is identifying these ‘win- for work is utilised to assist poor households to win’ situations to improve the functionality of rebuild their assets and pay off debts. Poor the market. households are much more likely to be risk The RAIN programme views the producers averse and unable to take chances on new as customers with demands and works to link market opportunities. The cash for work helps private suppliers to the customers. A traditional these households to become more secure so that emergency approach might include the distri- they can participate in profitable markets. bution of needed inputs by an NGO. However,

23 Field Article

One of the goals for the approach is the best method for providing Seed fair beneficiary evaluating remainder of the RAIN benefits to needy people. The RAIN quality of seed before purchasing at programme is to continue programme not only had to demonstrate Midegatola woreda, East Hararghe to focus on market develop- success in the project area to convince people of ment and build on the the approach, but those successes were just as successes to increase the necessary for convincing staff of a new method

Emma Proud, Ethiopia, 2010 impact of the project in the of operation. region. This will leave Agricultural markets in Ethiopia are frag- behind better functioning mented into several regions. The Somali region markets that in turn of Ethiopia tends to do business with contribute to sustainable Somaliland instead of selling commodities livelihoods. internally to the rest of the country. This is due RAIN and microfinance to cultural relationships on both sides of the Providing access to markets border and better access and proximity to those and inputs does not always markets. The RAIN programme is working The RAIN programme facilitated the signing allow producers to invest in these opportuni- with producers to provide better quality of a production contract between Hilina and ties. To complement these activities, the RAIN commodities in these markets but is unable to AKU in June 2010. Hilina and AKU signed a programme is developing the first microfinance work with the end market of commodities, like supply agreement at a 10 to 15 percent market institution in the Somali region to provide livestock and milk, due to funding constraints premium starting July 2010. The RAIN access to credit. The RAIN programme started for working across borders. programme also coordinated a production and with the intent of providing loan guarantees for Like many countries in Africa, the agricul- post-harvest loss prevention training carried producer and income generating groups but it tural input market is highly regulated and in out by Hilina technicians and fully paid for by was quickly realised that there were no microfi- some cases, such as fertiliser, controlled by the AKU and Hilina. By again aligning market nance institutions working in the region. The government. The market place for these prod- RAIN programme began working with the incentives, the RAIN programme has been able ucts becomes a self fulfilling prophecy for the government of the Somali region to establish a to create conditions where participants are will- government. The government believes that the new institution, which was one of the first goals ing to invest in constant upgrading to meet this private sector cannot provide these products at of the new president of the region. The RAIN new market demand. The RAIN programme is a low enough price to the producers so it steps programme has been providing technical providing additional support to this market by into the market to provide the service directly. support by working with the national bank and providing a research grant for improved peanut The private sector is then unable to compete regional government to create all of the docu- production at a local university and by identify- with the government so it remains unable to mentation required, including a business plan ing input suppliers for the cooperative provide services and products to the producers. and memorandum of association. The RAIN members for access to improved seeds. Finally, The RAIN programme is working to identify programme also provided a technical expert to RAIN will supply a management consultant to existing private sector suppliers that offer prod- work directly with the government on making ensure AKU’s management team is proactively ucts that are not in direct competition with the their budget request for the loan capital from able to seek solutions to members’ production government suppliers. The programme will the federal budget. The government has since and post-harvest needs in meeting with market demonstrate that the private sector can compete held a general assembly meeting which voted demand. This consultant will help the AKU and provide benefits to producers with these in favour of all of the documentation required, Board, managers and members establish products. The private sector will then be in a election of the new board of directors, and management structures, responsibilities and better position to demonstrate to the govern- approval of the shares to be distributed to the targets conducive to more proactive and ment that it has the capacity to provide services government and private investors. It is responsive leadership. more efficiently. expected that the new institution will be opera- In short, the RAIN programme seeks to create tional by the end of 2010. The RAIN programme is taking a holistic space and opportunities for market-driven view of the needs of the target region and systems using facilitation techniques to impact Lessons learned providing emergency assistance where needed, the targeted value chains. As the peanut chain The RAIN programme has reached the halfway connecting people to profitable markets, and example illustrates, the programme does this by point of implementation and many lessons assisting people to access capital needs for identifying incentive structures and working to have been learned. It is often difficult to transi- investment. align them to create investment. The programme tion staff into a new approach. When people also works to reduce risks for all participants in have worked for many years on emergency For more information, contact: Todd Flower, the market to stimulate new market transactions. programmes, they are often convinced that email: [email protected]

Seed fair beneficiaries queuing to purchase seed at Midegatola

Emma Proud, Ethiopia, 2010 woreda, East Hararghe.

24 Field Article

By Sarah Coll-Black and Emergency Food Security and Matt Hobson

Livelihoods Project in Amhara Sarah Coll-Black is a Social Protection Specialist working with the World and Oromia regions Bank in Ethiopia and Kenya. She has been involved with Ethiopia’s Productive Safety Net Programme (PSNP) since 2007, initially as a member of the PSNP Donor Coordination Team and then with the World Bank PSNP Task Team. She holds an MPhil from the Institute of Development Studies, University of Sussex.

Matt Hobson is the Donor Coordinator for the PSNP. Previously, he worked for Save the Children as Head of Hunger Reduction in Ethiopia, as well as in Somalia, Sri Lanka, Afghanistan and London. Prior to this, Matt worked as a human rights lawyer in private practice.

PSNP beneficaries in Tigray Fiona Quinn, Ethiopia

This article is based on a longer publication entitled ‘Designing and Implementing a Rural Safety Net in a Low Income Setting: Lessons Learned from Ethiopia’s Productive Safety Net Program 2005-2009’ by Will Wiseman, Julie Van Domelen and Sarah Coll-Black.

or generations, many rural Ethiopians (a) Resettling households from unsustainable chronically ill individuals and female- have experienced significant periods and environmentally degraded lands headed households that are labour poor. (b) Developing a safety net for chronically when they were unable to meet their PSNP stakeholders basic food needs. For over 20 years, the food insecure households The Ministry of Agriculture and Rural Fmain response to this situation was food aid to (c) Supplying agricultural and financial Development (MOARD) is responsible for the ensure basic survival. Ethiopia has received services to food insecure households to management of the PSNP, with the Disaster more emergency support per capita than any promote their graduation out of food Risk Management and Food Security Sector other Sub-Saharan African nation, with appeals insecurity. (DRMFSS) responsible for overall programme rising to 14.5 million people in some years. On Of these three pillars, donors embraced the coordination. average, 700,000 metric tons (MT) of food aid safety net, the subsequent design of whichwas per year have been delivered in Ethiopia since supported by a safety net donor group that The Food Security Co-ordination Directorate 1990. engaged intensely with Government. The is one of two Directorates that report to the DRMFSS and is the main implementing Serious deficiencies with the emergency Productive Safety Net Programme (PSNP) was Directorate for the PSNP. The Early Warning food aid system were increasingly clear by the designed from late 2003 to the end of 2004 and and Response Directorate (EWRD), which is the late 1990s. Despite high levels of food aid, with was launched at scale in February 2005. It was second Directorate under DRMFSS, provides each emergency rural households further not meant immediately to replace the emer- accurate and timely early warning information depleted their assets and found themselves gency appeal system; instead the emergency for the PSNP Risk Financing Mechanism (RF) increasingly vulnerable to even the most appeal system would be gradually reduced and ensures linkages between PSNP RF and marginal livelihood shock. Analyses of these over the course of two years. other humanitarian response activities. The issues revealed that the timeliness of food aid PSNP Operations (2005-2009) Natural Resource Management Directorate deliveries was a serious deficiency in the The objective of the PSNP (2005-2009) was to (NRMD) within MOARD is responsible for system. There was also growing concern of the ensure food consumption and prevention of coordination and oversight of the public works. potentially negative effects of such large asset depletion for rural food insecure house- volumes of food aid on local food markets. The Ministry of Finance and Economic holds in a way that stimulates markets, Development (MOFED) oversees financial By late 2003, a technical group of the New improves access to services and natural management of the programme and disburses Coalition for Food Security1 had developed a resources and rehabilitates and enhances the cash resources to implementing federal proposal to reform the emergency appeal natural environment. ministries and to the regions based on the system in favour of an integrated approach to The PSNP provides cash and/or food trans- annual plan submitted by MOARD. reducing vulnerability and food insecurity. This fers to households through two mechanisms: approach brought together under a single These federal implementation arrangements i) Chronically food insecure households with umbrella a range of initiatives implemented by are replicated by regions and woredas (the able-bodied adults receive a transfer for the Government, donors and non-governmen- Government’s smallest administrative unit). In their participation in public work tal organisations (NGOs). addition to programme implementation, ii) Chronically food insecure households who regional and woreda bodies are responsible for For the Government, the objectives of the cannot provide labour to public works and ensuring sound multi-sectoral coordination of New Coalition for Food Security (which was have no other means of support are provided led by the Prime Minister, Ato Meles Zenawi) an unconditional transfer. Direct support 1 would be largely met through implementation beneficiaries include, but are not limited to, The coalition was established in 2003 to foster partner- ships to take action to lessen the impact of droughts, of the Food Security Programme (FSP). This orphans, pregnant and nursing mothers, improve livelihoods and ensure that communities have consisted of three strategic pillars: people living with disabilities, the elderly, adequate food supplies. Funding support is from UNDP, OFDA and the World Bank.

25 Field Article the public works. Public works planning and Table 1: Examples of the types of Public Works outcomes and activities communities may select selection of PSNP beneficiaries occur within communities and kebeles. Within this framework, non-governmental organisations (NGOs) and the World Food Programme (WFP) play important roles in implementation because of their experience delivering food aid and the institutional requirements of some donor agencies to chan- nel resources through NGOs. In addition, NGOs and WFP provide technical assistance to the programme, and WFP supports the Government in procuring food stocks from abroad. Donor agencies have pooled their financing – both cash and in-kind contributions – and formulated a unified stream of technical advice in support of a single programme led by Government. This has been led by the creation of a Donor Co-ordination Unit, expressly for the purpose of harmonising donor positions, providing technical support to the programme and managing all donor-to-donor and donor- to-Government processes. The rights, obligations and coordination arrangements of the government-donor partnership for the PSNP are articulated in a Memorandum of Understanding (MoU). According to the PIM, households graduate food resources tends to be used in a way that Programme scale and coverage from the PSNP when they are food sufficient, addresses the seasonal rise in food prices lead- In 2009, the PSNP supported 7.6 million people which is defined as “when a household is able ing up to the hungry season. in 290 chronically food insecure woredas in to feed itself for 12 months a year, in the absence Public works are carried out from January to eight of the country’s 10 regions. This is equiv- of programme support, as well as being able to June, during the agricultural slack season, alent to roughly 10% of the national population, withstand modest shocks.” A household’s food which is relatively dry. Transfers are delivered covering over 40% of the country’s woredas. security status is assessed using a set of pre- on a monthly basis. The geographic coverage of the PSNP is shown determined regional “asset-based benchmarks” in Map 1. that are tailored to local conditions. Data are Operating procedures for public works The 2009 annual budget was 2,136,734,460 collected by DAs and verified by kebele and Public works are identified and planned birr in cash and 457,966.21 MT of cereals. This is woreda officials and vetted in community through a participatory process at community equivalent to approximately $360 million – or meetings. level. The Government’s Community-Based about 1.2% of Ethiopia’s GDP. In addition, the Regardless of whether they are PSNP partic- Participatory Watershed Development Government estimates that roughly $54 million ipants, any households that are unhappy with Planning (CBPWDP) approach is the basis for in government staff time is devoted to the the outcome of the targeting and graduation developing a pipeline of sub-projects, many of programme annually. There are at least 1,780 processes are entitled to bring their grievances which have a soil and water conservation focus. regular staff and Technical Assistants working before the PSNP Kebele Appeal Committee The woreda public works plan is integrated on the PSNP full-time, with support from (KAC). into woreda development plans to ensure link- 14,295 Development Agents (DAs). The PSNP ages with other sectoral investments. is integrated into the national budget system in Type, amount and timing of transfers Ethiopia. Transfers are provided to households on a Tailoring the PSNP to specific groups monthly basis for six consecutive months. In The PSNP includes a pastoral programme that Selection of beneficiaries 2009, the daily cash wage rate was 10 EBR and addresses the different risks and vulnerabilities Chronically food insecure households residing the food transfer was 3 kg of cereal. Each Public of pastoral livelihoods in the regions of Afar in PSNP kebeles are eligible to participate in the Works household member is entitled to receive and Somali and pastoral areas of Oromia, and programme. The PSNP Programme a transfer based on five days of work at the Southern Nations, Nationalities and Peoples Implementation Manual (PIM) defines a chron- prevailing cash or food wage rate. Households Region (SNNPR). The programme uses public ically food insecure household as: are provided transfers of cash, food, or a tempo- works and transfer payment mechanisms i) Households that have faced continuous rary mix of both resources. The mix of cash and tailored to the needs of pastoralists. It is also food shortages (usually three months of food gap or more) in the last three years Box 1: Key indicators of the PSNP 2005-2009 Table 1: Examples of the types of Public Works and received food assistance prior to the outcomes and activities communities may select commencement of the PSNP. • 90% of PSNP participants achieve 12 months Outcomes Community Level ii) Households that have suddenly become food access from all sources, including PSNP, sub-projects more vulnerable as a result of a severe loss from December 2008 onwards. Improved land Area closures, soil and of assets and are unable to support • 65% of households report no distress sales of productivity, soil fertility water conservation themselves (last 1-2 years). assets to meet food needs by December 2009. restoration and increased iii) Any household without family support and • 25% increase in volume of locally produced land availability other means of social protection and grain in local markets by December 2009. Improved market Community roads support. • 75% of households in PSNP woredas report infrastructure improved use of health and education services Improved access to Community water projects Based on these criteria, households are selected attributable to PSNP by December 2009. drinking and irrigation such as stream diversion, to participate in the PSNP through a commu- • 75% of households in PSNP woredas report water spring development, nity-based selection process. Once selected to improved availability of clean water and shallow wells participate in the PSNP, households are livestock fodder by December 2009. Increased availability of Area closure incorporating assigned to Public Works or Direct Support • 90% of PSNP participants and non-participants fodder conservation measures depending on the number of able-bodied report improvement in local vegetation High school enrolment Rehabilitating, extending members. coverage of hillsides by December 2009. and improvement health and constructing primary standards schools

26 Field Article

Table 2: Household consumption, assets and million. The PSNP focused on those regions and food insecure households and only evolved land access in PSNP woredas, by PSNP woredas that had received food aid for the into a transitory response instrument in 2007. In beneficiary status, 2008 preceding three years or longer. Woreda admin- 2007, the Government proposed that the Economic Characteristics Household istrators then selected the chronically food regional contingency budgets cover transitory insecure kebeles, assigning the woreda’s ‘PSNP food insecure households in areas where the Direct Public Non- Support Works PSNP quota’ from among these areas. numbers identified by the emergency needs assessment were within this resource envelope. Within targeted woredas, chronic food inse- Total consumption (birr) per 627 1012 1111 An emergency appeal would then be launched curity was widespread but budget constraints month, average only for areas outside the PSNP. required targeting households most in need. Land (hectares), average 1.0 1.1 1.4 Within the food insecure woredas, household Since the start of the PSNP, the relationship Assets (birr), average 2349 4568 6480 eligibility criteria were reinforced by a commu- between the emergency response system and nity-based selection process endorsed through the PSNP has been far from clear. Extensive designed to fit more organically with the insti- community meetings. In addition, the wage rate dialogue between the FSCB, DPPA and donors tutional structures in these areas. for public works sub-projects was set low so that finally led to an agreement in mid-2008 that better-off households would be less tempted to available regional contingency budgets would PSNP responds to the heavy workload of seek employment through the PSNP. be used to respond to emergency needs arising productive and reproductive labour carried by from the failure of the small rains (belg) and The annual retargeting was designed to women in rural Ethiopia by allowing women to food price inflation. The number of people correct for inclusion and exclusion errors and work fewer hours than men for the same pay benefiting from contingency resources from thus responded to changes in the relative posi- and permitting them to switch to Direct 2005 to 2008 is shown in Table 3. These figures tions of households. A contingency budget of Support when pregnant or breastfeeding. suggest that the population covered by the 20% was added to the programme to cover regional contingency budget has grown in PSNP risk financing mechanisms additional households that might become comparison with the regular PSNP programme. The PSNP includes a contingency budget chronically food insecure during the course of equivalent to 20% of the base programme cost the program and to respond to transitory needs Types of transfers and a risk financing facility designed to among PSNP and non-PSNP households. In Implementation experience respond to transitory needs in chronically food 2006, this was augmented by the Risk Financing Starting in 2004, food prices in Ethiopia began insecure woredas. When households are unable Facility. The emergency response system would to rise, spiking in mid-2005 and again in mid- to meet their immediate food needs because of cover any transitory food insecurity beyond the 2006. In both years, the Government and shocks, these households are described as being available contingency and risk financing donors responded by accommodating the transitory food insecure. resources. requests of woredas, which had planned to Of the contingency budget, 15% is held at The emergency response system would also provide cash, to switch to food transfers. Given regional level and 5% at woreda level. The continue to cover food insecurity in non-PSNP this experience with mid-year food price woreda contingency fund is used to address woredas. increases, many regions requested the Federal unexpected needs of chronically food insecure Government shift woredas from cash to food Targeting the PSNP households, such as a successful appeal to the transfers in 2007. The programme accommo- In 2005, the number of households selected to KAC, and transitory food insecurity among dated this by allocating the first two transfers in participate in the PSNP by communities and PSNP and non-PSNP households. The regional cash rather than in food, which freed up food to kebeles was almost always larger than the contingency fund is used to address transitory be used later in the year in other woredas, and quotas assigned by the region and woreda. food insecurity among PSNP and non-PSNP through a local purchase of food resources to Recognising the scale of exclusion in households in PSNP woredas. augment donor pledges. Unlike previous years, programme areas, the Government and donors few mid-year requests to change the cash-food The Government is currently operationalis- agreed that the October 2005 community-based split were accepted. The geographic distribu- ing the Risk Financing Mechanism to address targeting process would identify the actual tion of cash and food transfers by woreda in transitory needs in PSNP woredas. This mecha- number of chronically food insecure individu- early 2007 is shown in Map 2. nism is designed to scale up the PSNP to cover als. The Government and donors were therefore transitory food insecure kebeles as needed, as confident that the programme could handle a In 2008, the cash wage rate was increased for well as to extend the duration of benefits for larger caseload, which was eventually (2009) set the first time from 6 to 8 birr. The trend in 2009 existing PSNP households, if needed. at 8.29 million people. The increase in benefici- was towards greater requests for food transfers ary numbers eased the pressure on the targeting because of continuing increases in food prices. Monitoring and evaluation system significantly. Given the resource mix available to the The PSNP key performance indicators are programme, coupled with budgetary provided in Box 1. Given the flagship nature of Evidence from 2008 shows that the PSNP is constraints, the Government chose to allocate the PSNP, much attention was, and continues to well targeted to the poorest households in cash transfers for three months and then food be, devoted to generating robust evaluations. A PSNP woredas, which have significantly lower transfers for three months to the vast majority set of impact evaluations aims to measure incomes, fewer assets and farm less land than of woredas. The cash wage rate was also further changes for direct and indirect beneficiaries. non-beneficiaries (Table 2). A 2008 survey of increased from 8 to 10 birr. local service delivery in Ethiopia reported that Design issues and trade-offs over 85% of respondents described the PSNP Since 2005, the overall trend has been In 2004, the Government proposed a caseload selection process as being fair. increasing use of cash transfers in the PSNP of 5 million chronically food insecure individu- (Figure 1) and a growing preference amongst als. Donor agencies saw this figure as a Responding to transitory needs beneficiaries for food only transfers (Figure 2). minimum, with the actual number of chroni- In 2005 and 2006, the contingency budget was This move towards cash was, however, less cally food insecure people probably closer to 7.9 mainly used to cover additional chronically than that initially predicted in the programme design and has largely stalled in recent years, due to global food and fuel price rises and Table 3: Use of regional contingency 2005-2008 parity issues between cash and food. In 2009, 2005 2006 2007 2008 roughly 6.65 million people received food No. of % of regular No. of % of regular No. of % of regular No. of % of regular combined with cash transfers. beneficaries programme beneficaries programme beneficaries programme beneficaries programme Amhara 65,522 3% 321,160 13% PSNP public works Oromia 104,015 10% 219,187 16% 331,117 24% 294,859 21% While the PSNP design identified a menu of eligible investments, there was a tendency to SNNP 0% 132,441 10% 292,620 23% 371,457 29% focus on natural resource management projects. Tigray 204,820 22% 373,467 26% 388,427 27% 487,941 34% Dire Dawa 11,580 24% 10,523 20% 10,522 20% 10,525 20% One of the leading causes of previous failure of food for work programmes was the lack of Harari 0 0% 0 0% 0 0% 752 5% appropriate community consultation to ensure TOTAL 320,415 7% 735,618 11% 1,088,208 16% 1,486,694 22% the relevance and ownership of the assets

27 Field Article created. In order to address this, the design of the PSNP gave Map 2: Geographic Coverage of the PSNP by type of transfer, 2007 the responsibility for the selection of public works sub-projects to communities. To promote this high level of community participation in the public works planning process, in coordina- tion with Government DAs, the Community Food Security Task Forces (CFSTF) were mandated to mobilise communities to identify the public works that would be undertaken on an annual basis. In order to formalise this approach, DAs were provided training on the Community-Based Participatory Watershed Management Guidelines that were developed by Government in coordination with WFP. Implementation experience Since 2005, the PSNP has built a large number of public works sub-projects and evidence suggests that the performance of the public works component has improved over time. The 2008 Public Works Review found that quality had improved overall, with some continued technical deficiencies in roads and need for better operations and maintenance arrangements in water supply and small-scale irrigation projects. Sustainability of public works investments has been a challenge for programmes throughout Ethiopia. In general, sustainability ratings have been favourable, with the lowest ratings on roads, water and irrigation projects. Despite these operational deficiencies, public works outcomes have generally been satisfactory with significant Figure 1: Changing proportion of cash and food in the PSNP, as measured in impact on environmental regeneration, increased access to volume/monthly wage rate water supply, expanded use of small-scale irrigation and improved access to farming training centres. 100% Direct support and tailoring the safety net 80% It was initially anticipated that roughly 80% of PSNP partici- 60% Cash pants would receive aid through Public Works and 20% through Direct Support (unconditional transfers). While the number of 40% Food Direct Support beneficiaries has increased, the Direct Support Overall trend: component as a percentage of programme participants 20% Food for cash remained constant (15%). This proportion varies by region and 0% by year (Figure 3). In 2006, this proportion also varied among Plan Actual Plan Actual Plan Actual Plan Actual woredas, ranging from 3% in , Tigray, to 25% in Boricha, 2005 2006 2007 2008 SNNPR. The light work or community activities for Direct Support beneficiaries that were outlined in the PIM have not been imple- Figure 2: Preference for payments among beneficiaries: cash, food or cash and food mented anywhere in the programme. Some woredas supported payments by NGOs have experimented with crèches or childcare centres. This highlights the lack of priority given to these activities, with 100% 14 90% woredas reporting that there had been no direction to include 28 such activities in their PSNP plans. 36 32 3 80% 46 51 56 4 Fieldwork observed progress in implementing the gender 70% 63 70 66 5 34 provisions of the PIM, although this was uneven across woredas 60% 6 2 29 Food only and in elements of the PIM. Women and women’s organisations 50% tend to be well represented in PSNP decision-making structures 29 14 35 15 40% 7 25 25% cash, 75% food at lower levels, however building alliances with the Women’s 1 8 Affairs Ministry at Federal and regional levels has proven to be 30% 17 22 16 17 50% cash, 50% food more difficult. Although the PIM states that the participation of 12 13 9 20% 14 14 35 10 10 75% cash, 25% food women in public works should be responsive to their regular 10 22 10% 18 10 6 19 work burden, in most cases men and women were found to do 10 5 13 10 4 2 6 Cash only the same work and there seems to be no change in this over time. 0% 2006 2008 2006 2008 2006 2008 2006 2008 2006 2008 In 2006, a separate process to design and implement a pilot All households Tigray Amhara Oromia SNNPR programme that aimed to tailor the PSNP to pastoral livelihoods was launched. The pilot has demonstrated that a safety net is an effective means of supporting chronically food insecure pastoral Figure 3: Annual Direct Support participants as a percent of PSNP population by households, particularly those who are engaged in agro- region pastoralism or have dropped out of the traditional, mobile 30% pastoral livelihood system. Experience from the pilot shows that the targeting mechanism needs to account for differences in 25% social structures and social cohesion among different pastoral groups. With regards to public works, pastoral communities are 20% 2005 easily mobilised to participate in the public works sub-projects 2006 that are relevant to their livelihoods. 15% Currently, the Government is eager to roll out the PSNP 10% 2007 pastoral programme to all pastoral areas, particularly into new 2008 woredas in Somali. 5% Monitoring and evaluation (M&E) 0% The speed with which the programme was launched led to Amhara Oromia SNNP Tigray Dire Dawa Harari TOTAL delays both in monitoring reports and the launch of the evalua-

28 Field Article tion system. There was little information on Importantly, this shows that large scale cash Cost efficiency of the PSNP programme implementation during the first and/or food transfers are operationally and The PSNP compares favourably with interna- months of the PSNP. In response, FSCB and logistically possible in the resource-poor, low- tional experience on public works programmes, donors were forced to establish rapidly an income rural settings in Ethiopia. The direct for its targeting, high wage intensity and a low Information Centre to collect real-time informa- benefits of the programme are summarised in administrative cost due to its use of existing tion on cash and food transfers and grain Table 4. government systems and the programme scale. market prices from a sample of 40% of Key impacts on households Approximately 17.2% of total programme cost programme woredas. These regular reports is dedicated to staff time, administrative costs The 2008 Impact Evaluation found PSNP partic- have proven to be an important source of infor- and capacity building. ipation measurably improved household food mation for programme managers, as the security, as measured by changes in self- monitoring reports have continued to be very Graduation from the PSNP late and of limited use given the inconsistent reported household food gap. This effect was Promoting graduation quality and incomplete data. strongest among those households that To promote graduation, PSNP participants received regular, high value transfers. PSNP were to have access to the OFSP, which was The 2006 FSP M&E Plan reduced the amount households exposed to drought had a 30% financed through a Federal Government of information collected, streamlined the report- higher caloric acquisition growth than non- Specific Purpose Grant to regions and the ing formats and modified reporting procedures. beneficiaries. donor-financed Food Security Project, amount- The focus was on generating basic information ing to roughly $100 million per year. critical to programme management. From 2005/2006 to 2007/2008, negative coping strategies were more prevalent among Households were provided subsidised credit to In 2007, the programme expanded the menu non-PSNP households than they were among rebuild their asset base (in the case of the Food of independent systems reviews, augmenting PSNP households. Security Project which targets the poorest of the the Roving Financial Audit with Roving poor) or to purchase “household packages,” Procurement Audit and Roving Appeal Audit. Participation in PSNP public works which were various combinations of agricul- These audits were designed to generate infor- increased growth in livestock holdings by 0.28 tural inputs sometimes based on a business mation on the functioning of the programme Tropical Livestock Units (TLU) over compara- plan developed with support from the exten- safeguards.2 ble non-PSNP households – equivalent to a sion service. The Government’s Special difference of nearly three sheep. Purpose Grant also financed investments in During the same period, consensus was rural infrastructure, such as roads and water reached on the need for a single logical frame- PSNP beneficiaries have increased their use of social services. Of the 46.1% of PSNP benefi- resource development, and the Resettlement work. A series of joint government-donor Programme. workshops slowly created agreement on what ciary households reporting that they used the programme aimed to achieve and how this health facilities more extensively in 2006 than Recognising the complementary roles of the would be done. The result was a more harmo- the year prior, three quarters (76%) said this PSNP and OFSP to enable households to move nized approach to monitoring progress towards was because of the PSNP. In 2008, one quarter out of food insecurity, starting in 2006 the program objectives. This logical framework (26.7%) of households reported increased use of Government specifically targeted OFSP house- was used in each subsequent JRIS Mission to health facilities over 2007 and nearly half (47%) hold packages to PSNP participants. assess implementation and was the guiding attributed this increase to the PSNP. In 2006, Government targets were set to achieve approx- document for the PSNP review in 2008. half (49.7%) of respondents stated that they imately 30% annual coverage of PSNP kept their children in school longer than in the beneficiaries with the OFSP for three years. One As with other areas of routine monitoring, previous year, and 43% attributed this to the of the main challenges to achieving this coordi- the PSNP was slow to develop a robust public PSNP. nation was that the agricultural extension works monitoring system as part of its manage- system was under-resourced and there were too ment information system. By 2008, apart from The 2008 Impact Assessment measured the few sufficiently skilled DAs. The government- intermittent monitoring through the public combined impacts of the PSNP and the Other initiated reform to upgrade this system was works reviews, there was still no database on Food Security Programme (OFSP, the second seen to be important for the success of the PSNP public works projects and no tracking of public pillar of the FSP focusing on providing credit and OFSP, particularly the move to allocate works standards, performance and effectiveness. services to PSNP households). Households that received high value, regular support from the three DAs to each kebele in the country and to Key PSNP accomplishments PSNP and had access to the OFSP, experienced ensure that posts are filled with people holding Main programme outputs 0.81 months (or 25 days) greater food security a diploma. In 2009, the PSNP provided safety net support from 2006 to 2008 than households receiving Initial experience with the OFSP found that to almost 7.6 million rural Ethiopians. neither the PSNP nor OFSP. Similarly, livestock delivery mechanisms were not always appro- holdings of PSNP households with support priate, which was reflected in low repayment Table 4: Annual direct benefits generated by from the OFSP increased by 0.334 TLUs, while rates and consequently low coverage. PSNP (based on 2009 program parameters) the value of their livestock increased by 14.3% Specifically, there were no guidelines on how Total PSNP as compared to non-beneficiary households. credit or revolving funds should be managed. Total number of programme beneficiaries 7,574,480 While OFSP has only a marginal impact on When guidelines did exist, they were not Total number of households 1,514,896 agricultural productivity when implemented always followed. By 2008, the Food Security Total value of transfer ($) 206,783,304 alone, when combined with the PSNP the Project had collected only 72% of loans that had fallen due and was working with the PSNP Public Works beneficiaries results showed a 38% increase in maize yields. This suggests that by allowing households to Government to transfer revolving funds to Number of households participating in 1,272,513 rural savings and credit cooperatives to ensure public works focus on long-term investments and providing that they were properly managed. Average number of participation days per 150 more regular cash flow, the PSNP is a critical household per year element of a strategy to effectively improve The overall strategy to promote graduation Total number of days of public works 190,876,896 agricultural productivity. has focused on households with available generated per year Key impacts on communities labour and land. Recently, the FSCB has Average value of wages earned per 137 The bulk of investments were concentrated in expanded the scope of support to include non- household ($) per year soil and water conservation (SWC) and rural farm activities to better respond to the needs of Value of wage transfer through public 173,697,975 feeder roads, with selected investments in natu- young people, who generally have no land, in works ($) per year ral resource management and social services. In rural areas. PSNP Direct Support beneficiaries 2008, 92% of households indicated that their Determining graduation Number of households benefiting from 242,383 community had benefited from the construc- In 2007, the Government initiated a process to Direct Support tion of roads, while 88% reported benefiting set graduation criteria for the programme. Value of average annual transfer per 137 from SWC on communal lands. Public works household ($) per year are increasingly perceived to benefit individual 2 The term ‘safeguards’ refers to those mechanisms that aim Total value of transfer through Direct 33,085,329 households as well. Public works are generally to ensure that the programme resources are used for the Support ($) per year evaluated to be of a high technical standard. purposes intended.

29 Field Article

Table 5: Graduation from PSNP: Food Sufficiency and Food Security The next phase of the PSNP will consolidate and strengthen the RF mechanism to provide a Food Sufficiency Food Security predictable response to transitory food insecu- Definition A household can be deemed food sufficient Food security is defined as “access by all people rity in PSNP woredas. when, “in the absence of receiving PSNP [or emer- at all times to sufficient food for an active and gency] transfers it can meet its food needs for 12 healthy life.” Conclusion months and is able to withstand modest shocks.” The PSNP clearly demonstrates the challenge of Application At the point that a household becomes food suffi- The use of the phrase ‘food security’ and its defi- implementing a social protection programme in cient, it no longer needs to receive transfers nition above imply a degree of resilience and a low-income environment. Deficiencies in (except in the event of a major shock). However, suggest that food security is a relatively sustain- implementation resulting from limited human further support in building household assets will able state. Some households will only graduate and physical capacity undermine the potential be needed before households obtain a significant from the PSNP during the programme life and impact of the PSNP in many areas. Ensuring degree of resilience and are able to sustainably will need continued support from the household quality implementation in all programme areas access food and income. asset building component, while other house- remains a significant challenge for the future. holds will graduate completely from the FSP. Nonetheless, Ethiopia’s PSNP has demon- strated the value and potential of a transition Thus, the Federal Government, regions and has reformed the design of the OFSP in ways from addressing food insecurity through the donors developed a set of objective asset-based that should substantially strengthen it. These humanitarian response system to a system that benchmarks tailored to local conditions to reforms have focused on the institutional is development-oriented. measure a household’s food security status. arrangements for financial service delivery, These benchmarks and an accompanying including the development of multiple finan- Most importantly, PSNP has created, for the Graduation Guidance Note clarified that there cial products tailored to the need and capacities first time, a secure entitlement of households to were two levels of graduation: graduation from of different types of households. Reforms also a safety net from the Government. For the more the PSNP upon obtaining food sufficiency and aim to strengthen the extension system and than seven million people who receive PSNP graduation from the FSP upon obtaining food micro enterprise development programme to transfers annually, this enables them to meet security (Table 5). deliver market-led and demand-driven support consumption needs, mitigate risks and avoid to households. selling productive assets during times of crisis. While providing objective criteria against As a result, there is evidence that livelihoods which to assess the assets of households, the Implementing this reformulated OFSP will are stabilising and food insecurity is being overall system to identify households for grad- likely result in higher levels of graduation from reduced among beneficiary households. uation remained weak. Problems with food insecurity within the next five years. Similarly, it is increasingly apparent that the communicating the benchmarks and gradua- While it is likely that the scale of the PSNP will public works investments in soil and water tion process resulted in widespread confusion. reduce as households begin to graduate into conservation can result in significant improve- Additionally, the design of the system placed a food sufficiency, the notion of a ‘floor’ is central ments in the natural environment. This needs to heavy workload on DAs, who were regularly to this model - it suggests that a long-term be consolidated and built on. required to collect detailed household data. social protection system in rural areas is impor- For more information, contact Sarah Coll-Black, Realistic expectations of graduation tant in order to both protect household assets email: [email protected], Approximately 692,002 households (around 3.5 and to create the type of agricultural produc- Matt Hobson, email: [email protected] million people) received credit financed by tion synergies currently witnessed between the and Wolter Soer, email: [email protected] OFSP and an additional 355,279 households PSNP and OFSP. received credit from the donor financed Food Security Project between 2002 and 2007. A Box 2: Key Lessons learned number of independent studies have concluded (a) The PSNP has demonstrated the value of a shift (f) It is possible to combine effectively productive that OFSP coverage was generally insufficient away from a predictable humanitarian response and protective objectives within one safety net to meet the demand for loans among PSNP system to a more development-oriented approach programme, but measures need to be put in beneficiaries. While government reports to addressing food gaps. There is evidence that place to ensure that one objective does not suggest that access to a single household pack- livelihoods are stabilising and food insecurity is usurp the other. The PSNP suggests that it is age should be sufficient to enable graduation, being reduced among beneficiary households. possible to implement a large-scale uncondi- other evidence shows that the process towards tional transfer programme together with a public (b) Large-scale safety nets in low-income settings. graduation is more complex. PSNP beneficiar- works programme when there are sufficient The PSNP had a dramatic start, reaching around 5 ies indicated the need for two or three synergies in terms of target populations and million citizens in the first year of operation. It interventions per household to achieve food geographic coverage. However, attention needs serves as an example of a rural safety net operat- security. to be devoted to carefully reviewing all aspects of ing at scale that reaches a large number of the programme design and implementation to dispersed, low-income rural residents with diverse There has been limited progress towards ensure that the procedures and systems are in livelihoods, targeted on a household basis. graduation to date. Between 2007 and 2009, place to deliver on both objectives. around 280,000 individuals graduated from the (c) Safety nets in drought-prone areas. The PSNP is (g)The strongest implementation comes when PSNP. Although this is perhaps not insignifi- an effective safety net tailored to agrarian contexts key stakeholders have a shared understanding of cant given the adverse events of 2008, it falls while promoting longer-term improvements in programme goals and principles. This, in part, well short of the national goal. rural productivity in areas affected by recurrent accounts for differences in the quality of imple- shocks. Looking Ahead mentation from woreda to woreda. Ensuring The next phase of the PSNP (2010-2014) is (d) Shifting from food aid to cash. Households can ownership and shared understanding with politi- focused on strengthening implementation in all often use cash to respond better to their needs. cal and administrative stakeholders as well as woredas. Measures include strengthening the The PSNP offers lessons learned from one of the technicians is important. Further work in defin- monitoring system to ensure a regular flow of world’s few large-scale efforts to shift from food to ing key principles may better enable the cash-based transfers. data to programme managers, adopting a more development of this shared understanding. strategic approach to capacity building, rein- (e) Productive and pro-growth impacts of social (h) Tailoring a safety net program to respond to forcing accountability and transparency safety nets. The PSNP aims to refocus the interna- specific groups and different vulnerabilities is measures at all levels and expanding these to tional community’s approach to food insecurity by easier when safety net interventions are within the food management system and increasing shifting it away from meeting short-term food the mandate of an implementing ministry. the responsiveness of the program to transitory needs through emergency relief towards address- Building linkages from the PSNP to other depart- shocks. Greater attention to public works is ing the underlying causes of household food ments within MOARD has proven to be easier anticipated to result in more sustainable public insecurity. The goal of the PSNP is to invest in than linkages to other ministries, such as works sub-projects and enhanced programme productive assets in rural communities, as well as Ministries of Health and Women’s Affairs. This impact within communities. provide asset protection for households against suggests that a safety net programme is best shocks as part of a rural growth and poverty positioned to respond to the vulnerabilities For the next phase of the PSNP, and more reduction strategy. under the responsibility of a single Ministry. specifically the broader FSP, the Government

30 A fodder production group has decreased Field Article Sead’s time looking for pasture effect. Immediate results such as better nutri- tion, access to basic needs, access to clean water were valued by the children. Most heartening were the reports of increased school attendance Beyond the and reduction in time spent on chores and even more time to play. These indirect benefits are indicators Mahlet Bezu, Ethiopia, 2009 positive and encouraging for long term community resilience as education is a key component to improving livelihoods. Assessing project impact Children as direct beneficiaries Such an assessment is not scientific by any on children’s lives means, but the value is obvious. It serves as a singular opportunity to ‘ground truth’ the effect of interventions on different groups within a By Holly Welcome Radice, Maria Ruiz-Bascaran, Abebe Zewdu, population. For Save the Children UK’s imple- Oumar Mohamud, Mekdes Asfaw, and Mahlet Bezu mentation team, this exercise was helpful to see the layers of impact that the project has had. Children in the interviewed beneficiary house- holds clearly directly benefited from the interventions on personal, household and community levels. In a project focusing on community Pictures from left to right: Holly is the Head of Livelihoods & Nutrition Information Systems. Maria is the resilience, children may normally be viewed as Senior Programme Manager of the RAIN project and former programme manager for PILLAR II. Abebe is indirect beneficiaries. Additionally, the human- the DRR Coordinatorm Oumar is Project Coordination-Somali and Mekdes is Project Coordinator- Afar. All itarian nature of the project could be mistakenly work for the PILLAR PLUS project and with Save the Children UK Ethiopia. Mahlet was previously interned viewed as only providing short term insurance with Save the Children UK Ethiopia and currently is pursuing a masters at Lund University against shocks. However, this rapid assessment has discounted both of these theories. Children Save the Children UK would like to thank the families in the Afar and Somali Regions that participated in in these communities have received direct, these interviews and ECHO (European Commission Humanitarian Aid Department) for funding this project. immediate benefits. If these benefits identified are maintained, the investment will surely have a profound affect on the future of individual children’s lives and ultimately on community benefits for children had already been revealed n humanitarian work, how do we know resilience. that we are positively reaching distinct in the communities. A local teacher in Afamana members of a community? When we calcu- Tibedha in Afar had mentioned that since the Ultimately, the assessment gave some ideas late beneficiary households, can we be sure construction of a water point in the village, regarding what interventions to build on, better Ithat everyone in the household is really benefit- students were attending classes more regularly to target children in disaster risk management ing? And is it clear to what extent they are and enrolment had increased by 40%. To get a (DRM). The next phase of PILLAR will work benefiting? These are questions that all non- sense of some of PILLAR’s impacts on children, directly with the children in Alternative Basic governmental organisations (NGOs) struggle Save the Children UK conducted a rapid field Education schools. This scheme will pilot chil- with in programme evaluation. Save the assessment in six beneficiary communities and dren-led DRM committees that will look to Children UK Ethiopia recently sought to find case studies of six beneficiary children were build the capacity of children and their care- answers to some of these questions in one of its completed. The case studies were based on givers to be better able to reduce disaster risks projects. focus group discussions and individual inter- within their own communities. views with selected beneficiaries and For nearly 20 years, Save the Children UK discussions held separately with adult benefici- Finally, such an assessment is an opportunity has been providing support to pastoral commu- aries and their children. to listen to and learn from children. Fostering nities in Ethiopia, with current programmes in the practice of voicing opinions and contribut- the Somali and Afar regions. One project is a Children who were interviewed belonged to ing to community matters can be an drought preparedness and risk reduction proj- families that were involved in water point empowering process. In pastoral communities, ect, called PILLAR (Preparedness Improves construction, small scale irrigation and income such as those targeted in PILLAR, being able to Livelihoods and Resilience), funded by ECHO’s generating activity micro-projects. According to speak on behalf of one’s community is an essen- Regional Drought Decision (RDD). The project those children and their caregivers, project tial tool in reduction of vulnerability to was implemented in two phases between April impacts were seen similarly. Broadly the drought. It can encourage a generation to be 2008 and June 2010 in selected drought districts answers of the interviewed children were proactively contributing to their own commu- of the Afar and Somali Regions. PILLAR seeks centred on two categories, household and nity’s involvement in early warning, early to contribute to community level drought risk personal for children, as shown in Table 1. response and community preparedness. reduction through prevention, mitigation, These findings show that the interventions For more information, contact: Holly Welcome preparedness and response through a range of went well beyond what was measured in the Radice, email: [email protected] activities focusing on the three pillars of indicators—availability of water in the dry pastoralism— people, livestock and natural season and protected / diversifying liveli- resources. hoods—and that the interventions had layers of PILLAR has performed well against its objectives and indicators, with some 18,000 Table 1: Project impact as seen by children households reached across two regions. This is good news for the community, the NGO, and Household Personal for children the donor. Being a child focused NGO, Save the • Increased food • More leisure time Children UK wanted to understand and docu- consumption • More time with ment to what extent PILLAR has impacted the • Increased food diversity parents • Increased access to basic • Less time with lives of children. needs (e.g. school supplies, chores medical) • Regular attendance Impact assessment involving children • Increased food and milk at school Internationally, Save the Children UK aims to production • Punctuality at ensure that child participation—informed and • Availability of items for school willing involvement of children—is meaning- purchase • More time for Women targeted by • Access to clean water studies income generation fully incorporated into all its work. Some direct Ethiopia, 2008 Laval, Geraud activities in Fik, Somali region 31 Programme profile

The Emergency Nutrition Coordination Unit of Ethiopia roles, responsibilities and achievements By Isaack B. Manyama, Gugsa Abate and Mathewos Tamiru

Isaack B. Manyama is ENCU Gugsa Abate is Nutrition Mathewos Tamiru is Information Team Leader and Nutrition Specialist at the ENCU Analyst at the ENCU Cluster Coordinator for Ethiopia

The Emergency Nutrition Coordination Unit (ENCU) is located in the Disaster Risk Management and Food Security Sector (DRMFSS), Ministry of Agriculture and Rural Development, Ethiopia.

he history of the Emergency Nutrition Standardisation and harmonisation of emer- The functions of the ENCU are described in Coordination Unit (ENCU) can be gency assessments and response was not among greater detail below. divided into two five-year phases: the major functions of the ENCU at inception. Coordination and quality assurance of Phase One, the inception phase (2000- However the ENCU coordinated the develop- emergency nutrition assessments and T2005) and Phase Two, the expansion phase ment of the National Emergency Nutrition response Assessment guideline in 2002, which aimed to (2005-2010). Analysis of the nutrition situation standardise emergency nutrition assessments in The nutrition situation in Ethiopia is monitored Inception Phase (2000-2005) Ethiopia. In 2004, emergency nutrition interven- by analysing admission trends of new severe tion guidelines were developed to harmonise Recurrent drought has been a key feature of acute malnutrition cases in Therapeutic and standardise implementation and manage- Ethiopian life for several decades leading to Feeding Programme (TFP), analysing nutrition ment of nutrition programmes. widespread crop and pasture failure and peri- related early warning data and information odic severe humanitarian crises. In response, Expansion Phase (2005-2010) systems received from woreda (district), Ethiopia has carried out numerous seasonal By 2005, it was evident amongst partners and regional and national level. Depending on the needs and nutrition assessments and government that ENCU had played a signifi- situation, emergency nutrition surveys (base- programme activities. Initially, the nutrition cant role in coordination of emergency line, monitoring or end-line) are conducted assessments were characterised by a lack of nutrition assessments and response and there- based on the existing national guidelines to national level standardisation and coordina- fore, its mandate and functions at federal level ascertain the situation and recommend appro- tion, leading to duplication and misguided were expanded. In order to fulfil its extended priate responses. The nutrition situation is also allocation of resources. In the year 2000, for role, staffing also increased from one to four monitored through updating the woredas iden- example, a study into the quality of nutrition staff (one team leader, one nutrition specialist, tified as ‘hotspot woredas’ based on pre-agreed 1 surveys in Ethiopia found that only five one information analyst and one administrative criteria. The ’hotspot woreda’ update is under- percent of the 200 nutrition surveys conducted assistant). In the second half of 2006, regional taken as a consultative process carried out at over a 7 year period were of acceptable quality. level ENCUs (R-ENCU) were established in the regional and federal level. A guideline has As a result, the ENCU was established in five drought-prone regions (SNNP, Tigray, been developed to standardise the classifica- November 2000 within the Early Warning Amhara, Oromia and Somali) as part of tion/update process, which enables key actors Department (EWD) of the then DPPA (Disaster strengthening the early warning system and to prioritise areas requiring particular focus. Preparedness and Prevention Agency now coordination of emergency nutrition response. The ENCU plays a key role in provision of Disaster Risk Management and Food Security Each R-ENCU is integrated within the Food nutrition information used during the classifi- Sector (DRMFSS) under the Ministry of Security, Disaster Prevention and Preparedness cation process as well as coordination and Agriculture. At its inception, the ENCU was (FSDPP) of the respective region. All the five R- sharing of the hotspot list with nutrition cluster funded by WFP and later by UNICEF. Since ENCUs are fully operational, with two staff: an partners after approval of the DRMFSS. then, ENCU’s routine activities continue to be information analyst and nutrition expert. The The Government also conducts bi-annual funded by UNICEF, while staff costs have inter- expansion of the ENCU at regional level was food security assessments, and monthly new changeably been funded by both agencies. supported by UNICEF with funding from the TFP admissions are summarised in addition to European Commission until 2009, when At the time of inception, the ENCU was the routine TFP admission trend analysis UNICEF took over. The establishment of a R- charged with fulfilling three major functions: outlined above. Unusual increases in TFP ENCU in Afar region is currently in progress. a) Coordination of emergency nutrition admissions in March to May period informs the assessments, quality assurance and Following the roll out of the Nutrition DRMFSS EWS and partners of a likely worsen- responses. A total of 266 surveys were Cluster approach at national level in 2007, the ing nutrition situation in the forthcoming coordinated by the ENCU during the first ENCU mandate again expanded to include ‘hunger period’ (from June to August in agrarian phase. coordination of Nutrition Cluster activities. In communities2). The DRMFSS/ENCU triangu- b) Establishment of a Multi-Agency Nutrition addition, to its previous roles on coordination lates the TFP data and survey results with other Task Force (MANTF) for coordination, and quality assurance of emergency nutrition food security information and provides an esti- information sharing and discussion of assessments, information management and mate of the anticipated prevalence of technical issues among nutrition partners dissemination, and coordination amongst part- malnutrition in the respective assessment working in Ethiopia. The MANTF forum ners, the ENCU has assumed three new period. This level of prevalence is applied to the was established and is operational to date. functions: estimated total number of rural under-five chil- c) Collection and collation of reports and • Capacity strengthening of early warning results of nutrition surveys conducted system at federal and regional levels

throughout the country and nutrition 1 • Coordination of Nutrition Cluster activities Spiegel et al (2004). Quality of Malnutrition Assessment information database. The Nutrition data • Coordination of operational research on Surveys Conducted During Famine in Ethiopia JAMA. base was established in 2005 and regularly 2004;292:613-618 emergency nutrition assessments. 2 The hungry season is January to February in the pastoralist updated since then. communities.

32 Programme profile

3 dren (usually 14.5% of the rural population) Table 1: Number of nutrition surveys conducted in Ethiopia by region, 2000-2010 from the woredas requiring humanitarian assis- Region 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total tance. Based on this analysis, beneficiaries needing either therapeutic or supplementary SNNPR 9 5 35 30 14 25 20 16 36 26 9 225 feeding are estimated for the period covered by Oromia 3 2 20 27 22 20 14 6 9 13 13 149 the Humanitarian Requirement Document Amhara 5 9 24 17 9 7 6 4 8 13 9 111 (HRD) issued by the Ethiopian Government. Somali 8 5 5 5 8 11 12 2 0 7 1 64 Quality assurance of standard surveys Tigray 0 0 6 7 3 3 0 8 0 4 1 32 All nutrition survey proposals are approved by Afar 0 0 4 5 1 6 4 2 1 1 2 26 the ENCU before they are undertaken. Partners Gambella 0 0 0 0 0 0 0 0 0 0 1 1 planning to conduct emergency nutrition Beneshangul gumuz 0 0 0 0 0 0 0 0 0 1 0 1 assessment are required to prepare a survey Harari 0 0 0 0 0 0 0 1 0 0 0 1 proposal and submit this for review and valida- Total 25 21 94 91 57 72 56 39 54 65 36 610 tion. The proposal is reviewed in terms of objective/rationale, methodology, planned analysis and how the survey will be organised (CHD) and Enhanced Outreach Strategy (EOS) The nutrition information available is regu- in the field. In the process, partners’ capacity is community based bi- annual screening data. larly analysed and shared electronically and assessed and if deemed to be low, consideration ENCU have also developed the EOS screening with nutrition cluster partners through is given for alternative or additional partners to quality checks guideline currently being inte- monthly MANTF meetings. ENCU also dissem- conduct the assessment. After the review is grated into the EOS implementation guideline. inates the information through its emergency nutrition bulletin (available at complete, written feedback is provided to the Table 1 shows the number of nutrition www.dppc.gov.et/pages/ENCU.htm), which respective partner. Since March 2006, all surveys conducted in Ethiopia since the incep- provides detailed analysis and presentation of surveys have been planned, implemented and tion of the ENCU. analyzed using SMART methodology and the survey results and TFP monthly admissions Emergency Nutrition Assessment (ENA) soft- Coordination of Emergency Nutrition and other performance indicators on a quar- ware (2007 version). Responses terly basis. Moreover, monthly nutrition Emergency nutrition responses/interventions situation updates are prepared and shared with Upon completion of the survey, partners are are usually triggered by acute malnutrition key government departments and agencies. In required to submit the raw data to Federal prevalence threshold levels, as per 2004 emer- addition, ENCU hosts many consultation meet- ENCU for quality checks. The data is scruti- gency nutrition intervention guideline. Since it ings with missions, consultants from partners, nised according to agreed criteria along with is not possible to conduct standard assessments and donors inside and outside the country who respective preliminary reports before the report in all hotspots, woredas classified as priority 1 wish to learn how the ENCU works and to is shared with government and partners. A total are given preference for implementation engage in information sharing. There has been of 237 nutrition surveys were carried out based and/or strengthening the existing nutrition also improved analysis, knowledge and utilisa- 4 on the SMART methodology between 2006 and interventions. tion of nutrition information for planning, 2010 and checked by ENCU. So far, only 10 decision making and for monitoring the evolv- The relevant federal and R-ENCU contact surveys have been rejected because of poor data ing nutrition situation at national and regional capable and willing partners to initiate emer- quality. The remaining 227 surveys’ findings levels. have been published in the ENCU quarterly gency nutrition interventions in the identified bulletin of emergency nutrition and posted in woredas, through monthly, ad hoc or bilateral Capacity strengthening the DRMFSS web site: www.dppc.gov.et/ meetings. During the meetings, consensus is The ENCU has focused on four main areas to pages/ENCU.htm. Preliminary reports of the reached with regard to who, what where and support capacity strengthening: respective surveys are reviewed in terms of how (i.e. process to be followed in engagement i) Capacity mapping content and interpretation and are cross-checked of the regional and woreda authorities). This ii) Training on emergency nutrition with recommended reporting format. They are averts duplication of coordination efforts and assessments also checked to ensure that conclusions, recom- overlaps among partners. However, sometimes iii) Database development and information mendations and classification of the nutrition partners engage with the regional authorities management situation are coherent and consistent with infor- directly and therefore the above mentioned iv) Revision/development of guidelines processes are not necessary. mation based on anthropometric and contextual i) Capacity mapping factors (for example, water and sanitation, food Coverage of emergency nutrition interven- The ENCU in collaboration with partners has security and health related indicators). tions in hotspot woredas is monitored on a developed a food and nutrition ‘3W’s’ matrix of Feedback is provided to the respective part- monthly basis based on national and Sphere who is doing what and where. This tool ner on the quality status of their survey. It is standard indictors and shared among partners. contains a wealth of information for each of the important to note that the quality of surveys The ENCU also uses the information to advo- woredas, such as hotspot ranking, survey and the accompanying reports depend very cate for expansion of interventions in hotspot results, and nutrition interventions being much on the existing human resources at that woredas, particularly priority 1 that may not implemented and by respective partners. It also particular point in time within the yet be covered, or in new emerging hotspot provides information on food aid allocation, agency/partner. Where there is high staff areas. Overall, the performance of emergency dispatch information and challenges experi- turnover among partners, sustaining high qual- interventions has been impressive and consis- enced, provided by the WFP country office. ity surveys cannot always be guaranteed. In the tently above national and Sphere standards This tool is updated on a monthly basis. The case of poor quality surveys, bilateral discus- thresholds in recent years. ENCU use the tools to monitor the intervention sions and clarifications are conducted and in coverage in terms of availability of TFP and TSF Information management and services in the hotspot woredas and in woredas most cases, partners accept the ENCU’s feed- dissemination where needs are not being met. The ENCU also back and recommendations. The surveys A nutrition database has been created to store maps the technical capacities of the nutrition classified as ‘acceptable’ are submitted to the survey results as well as other data from large cluster partners in terms of conducting stan- DRMFSS with a note on the data quality and scale programmes such as the EOS and dard assessment and emergency nutrition report for information and approval. After the Productive Safety Net Programme (PSNP). interventions. This matrix is completed through DRMFSS approval, the respective partner is Over the last 10 years, 592 nutrition surveys meetings and bilateral discussions and feed- informed and requested to organise a feedback have been conducted in hotspot woredas and back with respective partners. at regional/woreda level where the assessment the raw data and summary reports of these was conducted, including planning for appro- surveys are posted on the DRMFSS web site ii) Training on emergency nutrition priate response. (see Table 1). The survey results are used for assessments Apart from surveys, quality assurance has information sharing and for triggering nutri- been expanded to cover Community Based tion interventions, which have saved many 3 The 14.5 percent is based on the FMOH estimates lives. 4 Standardised Monitoring and Assessment in relief and Nutrition (CBN), Community Health Day Transition

33 Programme profile

The ENCU focuses on planning and conducting ing high standards of predictable leadership, important issues as per national intervention capacity building sessions to ensure that part- accountability and partnership in emergency guidelines and format. The application is rated ners at national and regional level use the latest response. In Ethiopia, the Government took the on a four point scale of quality. Based on the knowledge and skills in nutrition assessments. cluster lead through sectoral task forces led by level, the proposal is either recommended for For example, a series of SMART trainings were the respective ministries. In view of this, ENCU HRF board review and funding or re-submitted conducted at federal and regional levels to was mandated to coordinate nutrition cluster to the cluster for final consideration for funding enhance skills and knowledge of the staff of activities and the MANTF terms of reference or, it is rejected. In situations where the part- DRMFSS and its partnering NGO agencies. The were revised to align with the IASC and ners are not able to get funds from donors training is aimed at harmonising planning, national level cluster guidance note. It is impor- bilaterally or the cluster faces inadequate fund- implementation, analysis and reporting of tant to understand that the emergency nutrition ing, ENCU communicates with the respective nutrition assessments. As a result, partners’ situation in Ethiopia is characterised as slow donors directly or through UNICEF and advo- capacities for conducting standard emergency onset chronic emergency and therefore, largely cates on the importance of funding the nutrition surveys have significantly improved predictable. This predictability calls for proposed interventions. In most cases the advo- at both regional and national levels. sustained and reliable coordination with capac- cacy has been successful. ities to implement the cluster approach The use of the SMART methodology has One of the limitations of the cluster review integrated within the government structures. revolutionised the execution of the standard process in Ethiopia is that not all emergency UNICEF has created four fixed term positions assessment in Ethiopia. Benefits include nutrition intervention proposals are reviewed at the ENCU in 2010 to ensure stable, improved and shortened planning time for by the nutrition cluster. Partners with adequate predictable, effective coordination and leader- standard surveys, i.e. reduced the challenge of funds or funded bilaterally usually do not ship of the nutrition cluster activities in manual calculation of sample size, number of submit their proposals to the nutrition cluster Ethiopia. he role of the Nutrition Cluster has clusters and assigning clusters based on proba- for review. Despite this, the cluster review been to ensure application of national stan- bility proportion to size of the population. The process has proven to be an important advance dards, guidelines and protocols in emergency inbuilt plausibility check in the ENA software in helping to avert duplication of efforts, assessment and response, advocate partners provides nutritionist and survey teams with the maximise resources and increase coverage of and government for timely assessment and ability to assess the quality of the data collected nutrition interventions in hotspot woredas. response, undertake data and information , and while the survey is in process. Also, as part of quality assurance. ENCU liaises closely with Operational research on emergency quality assurance at the ENCU, the plausibility UNICEF, the nutrition cluster lead agency, on nutrition assessments check guides whether the survey data and all the above responsibilities. It also advocates ENCU/DRMFSS has been collaborating with information is worth using for planning and for donor funding among nutrition cluster part- national and international bodies in conducting decision making. ners. UNICEF, Nutrition Cluster lead agency operational research particularly in the area of iii) Database development and information also has the role of “provider of last resort” emergency nutrition assessment. For example, management when all other options for emergency related in 2006, with funding from the European The ENCU is currently in the process of response are exhausted. Community through UNICEF Ethiopia, ENCU strengthening the R- ENCU’s capacity with the Decentralisation of the Cluster Approach commissioned a study into the relationship aim of decentralising expertise for emergency between weight-for-height, MUAC and body A major development achieved by the ENCU nutrition assessment, quality insurance, and shape in pastoralist, agro pastoralist and agrar- has been the roll out of the nutrition cluster situation analysis and data management. A user ian populations in Ethiopia5. The findings approach to the regions. This has significantly friendly TFP database to be used at woreda helped to shed light on the implications of inter- improved awareness of cluster partners’ level is also in the process of development. This preting nutrition survey results in pastoralist responsibilities, contingency planning/ will facilitate utilisation of nutrition informa- populations and to improve understanding, preparedness, as well as the strengthening of tion for planning, decision making, and both within Ethiopia and at a global level, nutrition information analysis and sharing monitoring/early warning, and enhance and regarding the applicability and appropriateness among partners in the five regions with R- improve reporting at woreda level. of MUAC vs. WHZ indicator use to assess the ENCUs. However, plans are under way to nutrition situation in such communities,. iv) Revision/development of guidelines strengthen the regional nutrition cluster capaci- The ENCU has coordinated the development ties for coordination of emergency assessments In 2009, ENCU/DRMFSS, in collaboration and revision of the national emergency assess- and response where it is weak. with Nutrition Works6, conducted secondary ment and intervention guidelines to ensure that Standardisation of emergency nutrition data analysis of the contextual factors identified partners implement emergency nutrition activ- intervention proposals during emergency nutrition surveys. The result ities based on the latest knowledge, skills and of the study was presented and discussed by In order to standardise the preparation of the best practice in the field. The 2002 emergency nutrition cluster partners in Ethiopia in proposals and assist partners to be focused in assessment guideline, for example, was revised September 20097. There were consensuses that proposal preparation, the ENCU prepared a in 2008 in line with SMART and ENA software. the final emergency nutrition assessment detailed nutrition cluster proposal outline The 2004 emergency intervention guideline is guideline should reflect the report/study based on the Humanitarian Relief Fund (HRF) in the process of being revised to incorporate recommendations and standardise the collec- format. This was intended to shorten the time the 2008 Global Nutrition Cluster intervention tion, analysis and reporting of the contextual for proposal review and facilitate accelerated tool kit. A stand alone moderate acute malnu- factors, as in the case of anthropometric and approval and release of HRF funds to the trition (MAM) guideline will also be developed mortality information collected during the respective partners, with an overall objective of to guide and standardise implementation of surveys. As a result of the recommendation, improving timeliness and coordination of supplementary feeding programmes in the contextual factors are now included in the 2008 emergency nutrition responses. The ENCU country. Also in 2010, ENCU coordinated the revised national emergency guidelines being organises a joint nutrition cluster review by development of new methodology for seasonal funded by UNOCHA-HRF in Ethiopia and the sharing the original proposal with a review assessments and timely response focusing on finalisation of the 2008 draft guideline has committee composed of six members strengthened information and surveillance started. (UNOCHA, UNICEF, WFP, UNFPA (gender) system in line with the Governments Disaster and ENCU) and two members normally from Risk Management (DRM) policy. 5 NGOs who are not related to the proposal ENCU 2007: Report concerning the analysis of data collected for the MUAC/weight for height/body shape Coordination of the Nutrition Cluster application. All members participate equally in research study. Prepared by Mark Myatt, Institute of the review process and decision making. Ophthalmology, University College London. See summary in Alignment of the MANTF with the IASC Field Exchange, Issue No 34 (2008). M Myatt et al. Effect When the nutrition cluster approach was intro- Individual reviewers’ comments are discussed of body shape on weight-for-height and MUAC in Ethiopia. duced globally in 2007, it was not a new during a joint review organised by ENCU and a October 2008. p12. http://fex.ennonline.net/34/effect.aspx joint feedback note is prepared and shared with 6 Nutrition Works (a partnership of international nutritionists approach in Ethiopia. Similar nutrition coordi- based in UK nation mechanisms existed through the HRF based on the consensus from the review 7 Nutrition Works, 2009. Analysis of Nutrition Surveys in MANTF. The main objective of the cluster committee. Ethiopia, Workshop Report September 22-23rd Addis Ababa. See summary in Field Exchange, Issue No 37 approach at global and national level is to During the review process the committee (2009). Contextual data collection in nutrition surveys in strengthen humanitarian response by demand- Ethiopia, November 2009. p14. ensures that the proposal has addressed all the http://fex.ennonline.net/37/contextual.aspx

34 Programme profile Field Article

Future challenges and livelihood and emergency recovery opportunities for the ENCU programmes. Focus is now being Funding placed on articulating alignment of During the mid-term review of the future emergency nutrition interven- The experience UNICEF country programme in 2009, tions with implementation of new it was recommended to incorporate the government policies in relation to ENCU as part of the UNICEF structure DRM and Public Health Emergency of multi-storey from mid 2010, with four fixed term Management (PHEM). This is also positions. This presents an opportunity likely to be addressed by the proposed gardens in for establishing effective leadership guideline revisions. Lack or delayed and in particular, predictable coordina- establishment of a nutrition informa- tion of the nutrition cluster activities as tion/surveillance system, however, Ethiopian part of UNICEF’s Core Commitment will continue to impair the effective- for Children in emergencies, while ness of the envisaged early warning maintaining close coordination with systems, on which preparedness, refugee camps the government. Despite the reinforce- prevention, mitigation and early ment of technical staff, the ENCU’s response components of the DRM roles and mandate continues to expand policy are based. The existence of the and the workload remains a significant R-ENCU presents a unique opportu- An example of gardening challenge. In light of this, UNICEF and nity for improved coordination of in a camp setting DRMFSS have recently agreed to emergency nutrition assessments, recruit additional staff to focus on timely response, monitoring and eval- strengthening of the ENCU nutrition uation, accountability, and quality information systems. assurance of emergency nutrition interventions which is currently weak. Moderate acute malnutrition Over the years, ENCU and cluster part- Information systems ners have faced significant challenges Over the years, ENCU has built a reser- in management, monitoring, evalua- voir of nutrition data and information tion, reporting and coordination of that can be used as a reference for a nutrition interventions addressing future information system that inte- MAM. The 2004 emergency interven- grates emergency and non-emergency tion guideline provides limited nutrition information. Such a system guidance on the implementation of can provide an important input for MAM interventions, reflecting the lack development of nutrition data and of guidance at the global level. There information for disaster risk mitigation are also challenges with the adoption and prevention in line with the govern- of WHO growth standards and the ment’s DRM policy. related implications on the implemen- The ongoing OTP roll out imple- tation of emergency nutrition mented by the federal Ministry of interventions. Moreover, TFP interven- Health (FMOH) provides a unique tions are not always linked with opportunity for integration of manage- supplementary feeding programmes ment of acute malnutrition into longer and other related interventions. term nutrition programmes, such as Recognising these challenges, a CBN and micronutrient deficiency proposal for revision of the 2004 guide- control programmes. lines and development of separate MAM guideline has been accepted by The Government’s National the government and the revision Nutrition Programme (NNP) provides process has started. This provides a considerable opportunities for the inte- unique and timely opportunity for gration of emergency and addressing MAM and other relevant non-emergency nutrition information emergency nutrition interventions systems, as well as integration of the Mulugeta Wtsadik/UNHCR, Ethiopia, 2009 based on recent developments in this ENCU functions into the government technical area. structures. The paradigm shift from By Mulugeta WTsadik crisis management to risk mitigation Assessing pastoral populations and prevention requires strengthened Mulugeta WTsadik is food security and nutrition officer with The lack of international consensus on and improved early warning systems UNHCR Ethiopia since 2004. She has a degree in rural devel- how the nutrition situation in pastoral- of all the sectors including nutrition. opment. Since 1997, she has worked on food security and ist populations should be assessed and The integration of ENCU into the nutrition programmes with a number of organisations. characterised in view of their body government working system includes shape continues to present challenges. preparation and implementation of UNHCR Ethiopia officer, Administration Refugee-Returnee To address this, the ENCU/DRMFSS common DRMFSS-ENCU/UNICEF Affairs (ARRA) and ZOA Refugee Care wish to thank all the has initiated development of pastoral- people directly or indirectly implementing the multi-storey annual work plans supported by ist survey method studies in garden (MSG) and poultry production. We acknowledge the UNICEF. This ensures government collaboration with Action Contre la important contributions of the following individuals without ownership and presents positive signs Faim (ACF) Ethiopia and nutrition whose hard work and support the pilot project could not for future integration within the partners in Ethiopia that may lead to have materialised: Ms Sabine Wahining (UNHCR Ethiopia), government structures. ENCU has also Ms Allison Oman (UNHCR Kenya), Mr Ahmed Fall Baba separate methods for nutrition assess- secured government and partners trust (UNHCR HQ), Mr Tesfaye Bekel (UNHCR Ethiopia), Dr Dejene ments in pastoralist populations in the in the ENCU’s work and strengthened Kebede (UNHCR Ethiopia), Mir Ajit Fernando, Ketyibelu and future. linkages between respective govern- G/Giories (UNHCR Sub-office in Shire), Mir Bekele and Dereje Linking nutrition and food ment institutions, UN agencies, donors Bogale (UNHCR sub-office in Jijiga) and Mr John Bosco and NGOs implementing emergency Kinama (JTZ in Dadaab, Kenya) who conducted field training security/livelihoods programmes for national staff and refugees.. Another significant challenge has been nutrition activities in Ethiopia. the absence of or weak linkages For more information, contact: between emergency nutrition interven- Isaack B. Manyama, tions and long term food security/ email: [email protected]

35 Field Article

thiopia hosts around 112,201 refugees. Table 1: Nutritional status of children 6-23 and 6-59 months of age Approximately 1,564 reside as urban Camp K/Beyah Awbarre Shimelba refugees, while the remainder live in No. of beneficiaries 40 45 43 eight different refugee camps. The (households) surveyed Emajority of refugees are of Somali (K/Beyah, No. (%) who developed MSGs 37 (91%) 39 (93%) 43 (100%) Shedr, Awbarre and Boqolmayo), Sudanese (Fugnido and Sherkole) and Eritrean (Mayani, No. of sacks developed by 1 sack (0%) 1 sack (2%) 1 sack (2%) beneficiary 2 sacks (2%) 2 sacks (11%) 2 sacks (7%) Asayta and Shimelba) nationalities. 3 sacks (5%) 3 sacks (28%) 3 sacks (5%) 4 sacks (7%) 4 sacks (20%) 4 sacks (7%) UNHCR have regularly conducted nutrition 5 sacks (70%) 5 sacks (28%) 5 sacks (70%) surveys amongst this refugee population. Since 6+ sacks (7%) 6+ sacks (4%) 6+ sacks (9%) 2007, the nutrition surveys have also included No. (%) beneficiaries have 30 (75%) 36 (80%) 43 (100%) measurement of haemoglobin using started to harvest vegetables haemocues. These surveys have found alarming No. (%) beneficiaries who 0 (0%) 2 (4%) 6 (14%) levels of anaemia despite the fact that fortified have sold vegetables Average income blended food has been provided since 2007 - 31 Birr/month when corn soya blend (CSB) was introduced to No. (%) beneficiaries eaten Chickens are still small/too Chickens are still small/too 15 (35%) the general ration by the World Food eggs immature to lay eggs and breed immature to lay eggs and breed Average 7.5 eggs Programme (WFP). Slight but insubstantial eaten per week improvements in anaemia rates have been No. (%) beneficiaries who 31 (77%) 28 (62%) 32 (74%) observed since. In 2008 and 2009, data still have recycled water Average 71.2 litres/week Average 79 litres/week Average 146 showed an anaemia prevalence >20%, with up litres/week to 42% prevalence among children under five years. Anaemia prevalence amongst women of Implementation of the project commenced in reproductive age ranged from 6% to 27%. Given January 2009 with ZOA providing the initial this, UNHCR now provides CSB to all children funding. UNHCR funding commenced in April between 6 and 23 months. This complements 2009. One hundred and sixty seven households the WFP ration of wheat, vegetable oil, CSB, were selected in each pilot camp with each pulses, salt and sugar. It is assumed that with household encouraged to construct five MSGs. such high levels of anaemia, there are probably Households were also provided with three other micronutrient deficiencies in the camps, poultry (one cock and two females). Target e.g. zinc. Zinc levels have not been measured as beneficiaries were family members with a case the required methods are too complicated, of anaemia or malnutrition, large female- Mulugeta Wtsadik/UNHCR, Ethiopia, 2009 given the location of the camps and the logisti- headed families and people living with cal infrastructure needed. HIV/AIDS. Some model farmers and other Multi storey gardens and poultry ‘interested’ people were also selected. projects Evaluation of pilot project In order to address this micronutrient problem An evaluation of the pilot was conducted in and more generally improve food security, October 2009 by UNHCR/ZOA and ARRA. The An example of UNHCR undertook a pilot programme of intro- evaluation objectives were to identify lessons multi-storey ducing multi-storey gardens (MSG) and poultry learned and challenges of the project in relation to gardening into three camps (Shimbelba – Eritrean implementation capacity and cost effectiveness, refugees, Awbarre and Kebribeyah – Somali refugees). This initiative was funded through UNHCR regional and HQ funding. Multi-storey gardens (MSG) method

The specific objectives of the projects were to MSGs use 50kg cereal bags and empty oil cans. Tools needed increase availability of vegetables and eggs at The cereal bags are used for growing the Jembe – used to dig the soil that will be mixed with household level, thereby improving micronutri- produce. The oil cans are filled with rocks and other components for constructing the garden. ent status of vulnerable refugees. It was also placed in the centre of the upstanding cereal Forkjembe – used to dig the soil in hard ground areas. expected that the MSG project would improve bag. Holes are drilled in the sides and bottom of Spade – used to collect and mix the soil components. the infant and young child feeding practices of the tins. A soil blend is placed in the bag mothers, thereby improving child nutritional between the bag and the tins. Seeds are then Tinsnip/Knife – used to cut off the top part of the tin. status. MSG is a farming technology adopted in planted in the soil on the top of the bag. Tin punch – used to punch holes in the top and areas with little land space and where there is When it is time to 'thin out' the seedlings, bottom of the tin. water scarcity. Space is often at a premium in some of the small plants are removed from the Wheelbarrow – used to measure and transport the refugee camps. Furthermore, as the vegetable top and, after holes are made in the sides of the various soil parts. production takes place at household level, it has bags, the seedlings are planted along the sides the advantage of reducing workload and time Equipment needed of the bags. This means the top and sides of the Perforated tins requirements associated with more traditional bags are utilised for growing. garden systems. Sacks In areas where water is in short supply, this is Gravel clay soil The pilot project began in April 2008 with a a very economic way to utilise extremely Sand soil (main part) two day training of the selected implementing limited resources. Each bag only needs to be Manure partner (ZOA) on MSG and poultry production, watered twice daily with 5 litres of water. The Seeds held in Addis Ababa. ARRA (Administration water is poured into the tin at the centre of the Water for Refugees and Returnee Affairs) are the bag and drains through the stones down Jerry can government of Ethiopia (GoE) counterpart through to the end of the bag of soil, irrigating Suitable vegetables for MSG jointly working with UNHCR on the initiative. all the plants throughout the depth of the bag. (Common name/Somali name) Training was conducted by UNHCR HQ staff. A It is recommended to use household waste Dania – Coriander/Dania UNHCR consultant with experience working water after rinsing out clothes or bathing, and Sukuma wiki – Collards/Sukuma on MSGs in Kenya conducted training at camp also waste water from around water points. Capsicum – California wonder/Pilipilihoho However, it is important to incorporate and level (three days training per camp) and wrote a Egg plant – Black beauty/Birganya integrate waste management into the field manual. WFP provided technical advice as Spinach – Fordhok giant/Spinach programme so as not to further limit water well as providing sacks and empty vegetable oil Tomatoes – Caj, M82/ Nyanya resources necessary for other activities. A stan- cans. This phase of the project was completed Okra – Pusa sawani /Bamia dard kitchen garden requires much more water Amaranthus – Terere/Terere by November 2008. than that used in the MSG approach.

36 Field Article

and also pay from also a ‘domino effect’ as households sell or give between 2-5 Birr per away excess produce to their neighbours so that jerry can. Not enough there are small enclaves where people are plastic sheets were eating better and enjoying fresh foods. provided for water Furthermore, some of these refugees are harvesting and storage. already trying to duplicate the MSG on their UNHCR have been own initiative. trying to encourage refugees to re-cycle Conclusions and recommendations The MSG project should continue and be rolled Mulugeta Wtsadik/UNHCR, Ethiopia, 2009 water from showers and washing food. Some out to other camps while the poultry rearing households do this but project should discontinue. The poultry project only a minority. should be stopped largely due to incompatibil- ity with an MSG project, i.e. the chickens ate the There have also been MSG produce. Other reasons included expense issues around lack of and time required for implementation, diffi- variety of seeds and culty of finding an appropriate chicken breed seedlings, as well as and the need for chicken house construction inappropriate seeds, material. used in the MSG. Furthermore, some Problems with water in the MSG project beneficiaries were not necessitated a number of measures including Poultry project in action provided with adequate construction of water traps at water distribu- tools and wheelbarrows tion points to use waste water, assessment of water that be can collected through spillage and to develop recommendations for current and not all beneficiaries have been using the during the dry season, encouraging refugees to and future programming direction. sides of sacks for transplanting. Also, the prin- ciple of using a limited number of vegetables maximize water recycling, exploring the poten- The evaluation involved questionnaires that per sack is not well understood by beneficiar- tial for roof water harvesting from buildings in assessed any increases in vegetable consump- ies, project animators and the agronomist the camp and increasing the number of water tion, amounts of vegetables sold and any attached to the programme. Another issue has storage containers in the camps. decreases in percentage of monthly rations sold been pest control and vegetable diseases. There were also recommendations about the to buy vegetables. There were also questions techniques used in the MSG. For example, it is about water usage to support the MSGs and The least successful part of the pilot was the important to understand that the life of a sack is concerning egg consumption. poultry programme. There were many chal- lenges here. One issue was whether it is around nine months if good watering tech- The questionnaire was administered to 50 appropriate to combine MSG and poultry inter- niques are used. After this point, beneficiaries out of 167 households that were randomly ventions in the same refugee household, given will need to replace the sack. The animators and selected in each camp. Focus group discussions that poultry will eat crops. Another problem agronomists should also provide advice to the were also held with 15-20 randomly selected was that the chickens bought by ZOA in Addis beneficiaries on the appropriate ratio of top households who were not included in the Ababa were too young and as they were soils, manure and sand soil, which is funda- household survey and with an additional five distributed during the rainy season, a large mental to optimal growth of vegetables, water households who were not one of the 167 benefi- number of them died from disease. There was conservation and utilisation. The implementing ciary households. Data from the primary also a problem with feeding the chickens with partner should also ensure that all sides of the analysis are presented in Table 1. chicken feed being taken out of the WFP ration sack are used, that beneficiaries do not use inappropriate vegetable seeds to grow crops Other key findings from the evaluation so that there was less food available for house- like cabbage, carrot or onion and that refugees included the following; holds. The chicken feed provided by ZOA only are encouraged to establish a nursery garden • MSGs need less water than ordinary back- lasted a month. for seedlings. Furthermore, there is a need for yard gardens. The evaluation also found that follow up households who succeed to be encouraged to • Vegetables grow faster in MSGs than if from ZOA and UNHCR at camp levels has been share their experiences with the refugee camp. grown in the ground. Two harvests can be limited. Furthermore, monitoring has been There is also a need for refresher training for the obtained in the time that it takes for one weak. Certain activities that were meant to take project officer, agronomist and animators as backyard harvest. place according to the project proposal were not well as partners like ARRA. • On average, a HH recycles 60-120 litres of implemented. These included establishing a water a week. One sack needs up to 10 vegetable nursery site for seedling production, For more information, contact: Mulugeta litres of water per day. construction of water troughs in KebriBeyah WTsadik, email: [email protected] • Refugees acquired new agricultural skills. and Awbarre near the water • Households diversified their meals on distribution point, pest average three times a week. control activities, develop- An example of • There was a decreased tendency to sell multi-storey ment of field manuals on gardening rations to obtain vegetables. MSG in the local language, • Some households shared vegetables with and egg production and neighbours not included in the pilot. consumption surveillance. Challenges In spite of these prob- In spite of the MSG project success, there have lems however, the MSG been certain challenges. Perhaps the most project is well accepted by significant has been water shortages and refugees and has been spillage of water at distribution points in the requested by households Somali camps. UNHCR have tried to address not included in the pilot this issue but in some cases, problems appeared programme. The project insurmountable. Although UNHCR provides allows refugees to choose water for Somali refugees and local popula- what they want to plant and tions, there is not enough drinking water eat and contributes to a during the dry season let alone for MSG use. sense of dignity, while the Refugees have to queue at water taps and there presence of green spaces is a great deal of spillage in taking water home. and the sight of food grow- Water is also collected from rain-water birkads ing also contribute to a but people have to carry water long distances sense of well-being. There is Mulugeta Wtsadik/UNHCR, Ethiopia, 2009

37 Field Article This article describes experiences and observations around the successful decentralisation and scale up of the outpatient management of severe acute malnutrition in Ethiopia in the period 2008 to 2010. It includes achievements, the challenges around monitoring and reporting and ongoing steps needed to strengthen and assure service quality. Indrias Getachew, Ethiopia, 2010 Indrias Getachew,

ollowing up on the experience of How the OTP decentralisation started decentralising outpatient therapeutic in 2008 care in 100 districts of Ethiopia in UNICEF has been advocating for the integra- 2008 (Field Exchange, No 361), this tion of the management of severe acute Farticle describes how this was further rolled- malnutrition into the Ethiopian government out in 606 districts of Amhara, Oromia, health system since 2004. With Government SNNP and Tigray regions between 2009 and leadership, in- and out-patient care had been September 2010. successfully integrated into 165 hospitals and health centres by January 2008. However, the Background idea of integrating outpatient management Ethiopia has one of the highest children of severe malnutrition into the Health under-five mortality rates, with malnutrition Extension Programme6 (i.e. allowing health 2 contributing to 57% of all children deaths . extension workers to provide curative serv- The 2005 Demographic and Health Survey ices) was still being discussed at the time of revealed that 2.2% of children under-five are the March/April 2008 rain-failure in the 3 severely wasted , a condition associated with southern part of the country. a mortality rate of 13% (7.3 to 18.7%)4. In May 2008, dramatic and rapid increases When adopting the Millennium of severe acute malnutrition levels were Development Goals (MDGs), the Government reported in Oromia and Southern Nations, of Ethiopia (GoE) committed to halve by 2015 Nationalities and People's (SNNP) regions. children under-five malnutrition (MDG 1) and This was the result of the poor performance mortality (MDG 4). This has been reflected in of the March/April rains in the southern part its Plan for Accelerated and Sustained of the country combined with the prevailing Development to End Poverty (PASDEP, 2005- high market prices (food prices in rural 5 2010 ). The strategy under the third Health Ethiopia had risen by 250% between 2006 Health Extension Worker providing health Sector Development Programmes (HSDP III, and 20087). In these two regions alone, 193 and nutrition education during a household 2005-20105) addresses the major causes of visit, Menkere health post, Tigray region districts were affected where over 23 million child mortality that account for 90% of under people lived. The Ministry of Health (MOH) five deaths, i.e. pneumonia, neonatal condi- and international non-governmental organi- tions, malaria, diarrhoea, measles, HIV/AIDS sations (NGOs), with UNICEF support, and malnutrition. began implementing emergency feeding Decentralisation A series of nutrition articles published in programmes under the coordination of the the medical journal, The Lancet, in January Emergency Nutrition Coordination Unit and scale up of 2008 defined the magnitude and conse- (ENCU). quences of undernutrition and demonstrated The MOH concluded that the best option to the availability and potential benefits of prevent high mortality due to malnutrition outpatient proven interventions, including the manage- was to decentralise the outpatient manage- ment of severe acute malnutrition. Therefore, ment of severe malnutrition to the health increasing coverage of and access to post/sub-district level. In July 2008, UNICEF management of Outpatient Therapeutic Programme (OTP) is was requested to support the Family Health one of the key elements that contribute to the Department of the Ministry to rollout OTPs in achievements of the MDGs 1 and 4, among 100 drought affected districts of Oromia and SAM in Ethiopia other key food security and nutrition inter- SNNP regions (See Map 1). This involved ventions currently being implemented in 1,239 health posts and 2,478 health extension (2008-2010) Ethiopia. workers. Map 1: Map of the 100 districts in Oromia and SNNPR 1 selected for the OTP decentralisation in July 2008 Sylvie Chamois (2009). Decentralisation By Sylvie Chamois of out-patient management of severe List of 100 Districts (in Oromia malnutrition in Ethiopia. Field Exchange, & SNNPR) Selected for the OTP Issue No 36, July 2009. p12. http://fex. Decentralisation in 2008 ennonline.net/36/decentralisation.aspx. 2 National Strategy for Child Survival in Ethiopia, Federal Ministry of Health, Ethiopia, July 2005. 3 Defined as weight-for-height < -3 z- score. Sylvie Chamois has been a Nutrition specialist with 4 Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler and UNICEF Ethiopia and Burundi for the past 9 years. Halister Hallam. Management of Severe Before joining UNICEF, she spent 6 years working as a Acute Malnutrition in Children. The nutritionist for Action Contre la Faim, mostly in Lancet, Vol. 368, December 2006. emergency settings. 5 The PASDEP and HSDP III cover the period Sept 2005-Aug 2010, which corresponds to the Ethiopian calendar years 1998-2002. 6 The Health Extension Programme delivers primary health and nutrition Disclaimer: the findings, interpretations, and conclusions in services at sub-district level by two female Health Extension Workers based this article are those of the authors. They do not necessarily in health posts; there is one health represent the views of UNICEF, its Executive Directors, or the Districts Selected for the OTP Zone Boundary post per sub-district covering an countries that they represent and should not be attributed Decentralisation in 2008 Region Boundary average of 5,000 people. 7 to them. Data Source: UNICEF Ethiopia. Boundaries are approximate and unofficial. Graphic & Analysis FEWS NET Ethiopia food security ENCU/EWRD Ethiopia October, 2010 updates, USAID and WFP, 2008.

38 Field Article

Box 1: Some key programme definitions used in Ethiopia Coordination at regional level was led by the Regional Health Bureaus through the Health Therapeutic Feeding Unit (TFU): severe acute malnutrition in the community (social and Nutrition Task Forces. Units in hospitals and health centres offering in- mobilisation), provision of treatment for those with- patient care to the severely malnourished cases. If out medical complications with RUTFs or other Donor support OTP is not available in the catchments area, TFU offers nutrient-dense foods at home (OTP) combined with a UNICEF developed an emergency nutrition full in-patient care with Phase 1, Transition Phase and facility-based approach for those malnourished chil- response plan for 2009 and 2010 and donors Phase 2 with an average length of stay of 2 to 3 weeks. dren with medical complications (TFU or Stabilisation were invited to contribute funding. Donor When OTP is available in the catchments area, only Centre). An approach endorsed by the World Health support for the rollout of OTP in the four target the complicated severe cases, as defined by a lack of Organisation, UNICEF and Standing Committee on regions was secured from the Humanitarian appetite and the presence of medical complications, Nutrition. Response Fund (HRF), OFDA, Governments of are admitted in TFU. Usually, patients only stay as long Enhanced Outreach Strategy/ Targeted Japan and Spain, CIDA, DFID, SIDA and as they require Phase 1 treatment (2 to 7 days) and Supplementary Feeding (EOS/TSF): ECHO11. then progress to out-patient care. The EOS/TSF for Child Survival is a joint programme Out-patient Therapeutic Programme (OTP): under the United Nations Development Assistance Development of regional action plans Programme runs from health centre or health post Framework (UNDAF, 2007-2011) with the UNICEF helped to instigate the development of offering out-patient care to severely malnourished Government of Ethiopia. UNICEF is supporting the action plans in the four target regions (Amhara, cases who have appetite and who do not have any Ministry of Health (MOH) to conduct twice yearly Oromia, SNNPR and Tigray) in conjunction medical complications (this group usually represents campaigns of Vitamin A supplementation and with the Regional Health Bureaus. These four 8 over 90% of all the cases). At admission, children deworming to every child under five in the country . regions were selected on the basis that they receive a medical check to determine if they warrant In TSF selected districts, the EOS is also screening for were the most severely affected by drought in direct referral to the nearest in-patient TFU. If they are malnutrition all children under five, and pregnant and well enough to be treated as an out-patient, they lactating women9. WFP is supporting the Disaster Risk 2008, their high population density and exis- receive systematic treatment and a ration of RUTF. Management and Food Security Sector (DRMFSS) of tence of a functional Health Extension Patients are seen on a weekly or fortnightly basis, but the Ministry of Agriculture and Rural Development Programme. Regional planning took place caregivers are encouraged to return to the OTP if the (MOARD) to deliver two supplementary rations of within regional task force meetings and child’s condition deteriorates during that time. The Corn Soya Blend (CSB) and oil to children and women involved NGOs where they were able to pledge average length of stay in OTP is 4-8 weeks. identified with acute malnutrition during screening10. commitment to training and monitoring. Therapeutic Feeding Programme (TFP): Community Health Days (CHD): Adaptation of the strategy to regional Combination of in-patient (TFU) and out-patient CHDs are currently being phased-in in Ethiopia as the contexts (Afar and Somali regions) (OTP) therapeutic feeding for the treatment of severe EOS is being phased-out. It is quarterly local health acute malnutrition. events organised at the sub-district/ health post level Afar and Somali regions (arguably regions most by the health extension workers to provide Vitamin A prone to food insecurity) were not initially Community Management of Acute Malnutrition supplementation and deworming on a six-monthly included in this scale up due to the mobility of (CMAM): basis and screening of children and pregnant and their populations and consequent difficulties of International appellation for timely detection of lactating women on a quarterly basis. integrating OTPs into existing health struc- tures. Furthermore, Somali and Afar are not population dense so that health posts would This programme has been described in a It was also necessary to find the right fit for serve only a few children, also security and previous issue of Field Exchange referred to a tripartite partnership between GoE, NGOs access are continuously problematic in the earlier (No 36). Key elements of the programme and UNICEF, each playing their role for the regions. However, GoE with UNICEF and NGO were as follows. In July and August 2008, all the rollout to be successful. NGOs had difficulties support, fielded mobile health and nutrition 2,478 health extension workers were trained in engaging in the process as the GoE preferred to clinics based upon guidelines developed in the identification of severe acute malnutrition, implement the programme itself. There were March 2008. Mobile teams visit communities referral of the complicated cases to inpatient concerns expressed by the NGO community every one to two weeks to implement OTP facilities and management of the uncompli- about the proposed speed of scale up for this management as well as Integrated cated cases of severe acute malnutrition. As of type of programme and fears that quality of Management of Childhood Illnesses, promo- November 2008, 51 districts (50% of the initial service may suffer. There may also have been tion of hand washing and safe water. As of plan) were managing OTPs in 455 health posts some concerns about the possible lack of NGO September 2010, there are seven mobile clinics (36% of the total number of health posts in the role in this scale up. run by the GoE in Afar, including two using 100 districts), raising the service coverage from UNICEF advocacy role was to find the right camels. In Somali region, the GoE runs twenty 38 to 65% in the two regions' affected areas. A link between the GoE and the support NGOs mobile clinics while NGOs support another total of 27,739 children were reported to have could provide. This was achieved through three seven. been admitted in the 455 therapeutic feeding types of coordination meetings: sites with overall positive performance indica- Technical assistance for training and Type 1: Involving all parties: nutrition cluster tors: 77.6% recovery, 0.7% mortality and 4.2% follow-up meetings were held at the ENCU and defaulter rates. During the scale up, Regional Health Bureaus attended by NGOs, UN agencies, organised trainings with UNICEF and NGO The MOH has since endeavoured to relevant government counterpart support mainly targeted to health extension strengthen the existing OTPs in the 455 health agencies and donors. workers and HEP supervisors, but also includ- posts and effectively continue the rolling-out of Type 2: Between NGOs, donors and UN ing local zone and district officials. Training of the plan to the remaining 784 health posts in the agencies: regular meetings were health workers and doctors on the inpatient two regions and more widely nationally. As of organised by UNICEF as a means of management of severe acute malnutrition was September 2010, there are over 6,400 health posts encouraging donor support and to also provided with the aim of setting up a mini- delivering OTP services and 280 inpatient ensure good coordination with the mum of one inpatient unit per district for the Therapeutic Feeding Units (TFUs) in 691 districts NGO sector, and management of complicated cases. UNICEF of Ethiopia out of which 89 are supported by Type 3: Between UNICEF and the recruited six nutrition specialists to support the NGOs. This scale up by GoE is a remarkable Government. organisation and conduct training, as well as achievement. The article below details some of This resulted in agreement that there should be post-training visits and supportive supervision. the key developments in achieving this. joint monitoring of the OTPs (and TFUs) by all Training was similar to that carried out during How the OTP rollout was implemented stakeholders, e.g. GoE, NGOs and UN agencies. the 2008 decentralisation programme in Advocacy and coordination NGO collaboration was to be requested by the Oromia and SNNPR. Post- 2008 experience of decentralising outpa- GoE in those geographical areas where capacity tient management of severe acute malnutrition for OTP (and TFU) rollout was limited. The 8 Vitamin A is supplemented to children 6-59 months old and deworming tablets are administered to children 2-5 years old. in 100 districts, the GoE was keen to implement predominant NGO role in these areas should 9 Are screened for malnutrition: children 6-9 months old, the rollout through their system and to ensure and would be to support and build up visibly pregnant women and women breastfeeding a less maximum integration and capacity develop- Government capacity. These meetings were than 6 months old infant. 10 Eligibility for TSF: Children with MUAC < 12 cm and/or ment within the existing decentralised Health held for approximately one year from May 2009 bilateral oedema and women with MUAC < 21 cm. One TSF Extension Programme. UNICEF’s role was to and proved useful during a difficult transition ration is composed of 25 kg of CSB and 3 litres of oil for 3 period for various stakeholders. months. support GoE in this process. 11 See acronyms listing on page 92.

39 Field Article

Figure 1: Number of Therapeutic Feeding Programmes (OTP & TFU) and monthly report completion vitamin A supplementation and deworming rate in the four target regions (Amhara, Oromia, SNNPR and Tigray), Jan 2008 to August 201013 indicators. ii) Piloting of health extension workers 8,000 90% sending OTP data using SMS for improved timeliness and completion rate (ongoing 7,000 80% and results expected in 2011). 70% 6,000 iii) Integration of nutrition indicators into the 60% Health Management Information System 5,000 (not yet achieved)15. 50% 4,000 b) Development of joint monitoring tool and 40% system 3,000 30% Following on the recommendation to undertake 2,000 joint monitoring of the programme (GoE, NGOs 20% and UNICEF), a sub-working group chaired by 1,000 10% UNICEF was formed with ACF, Concern, GOAL, MSF-Greece and MSF-Holland. They 0 0% met weekly between May and June 2009 to develop a monitoring checklist for field assess- Jul – 09 Jul – 09 Jul – 08 Jan – 09 Jan – 09 Jan – 08 Nov – 09 Nov – 08 Mar – 09 Mar – 09 Mar – 08 May –May 09 May –May 09 May –May 08 Sept – 09 Sept – 08 ments. The tool was then discussed with the Number of TFP Report completion rate% regional authorities in Oromia and SNNPR, tested and modified between July and August 2009. It was agreed where NGOs operate, that Provision of supply and logistic support a) Improved report quality, timeliness and they were to be the partner of the MOH and In 2009, an amount of Ready to Use Therapeutic completion UNICEF for all joint monitoring work. They Food (RUTF) was imported, although the One priority was to increase and maintain high were also invited to participate as much as possi- ‘Hilina Enriched Food Processing Centre’, the monthly statistics report quality, timeliness and ble outside of their traditional support area. Nutriset franchised company, provided most of good completion rates. the supply. From 2010 onwards, UNICEF is In SNNPR, by the first week of August 2009, planning to only procure RUTF locally12. It had Figure 1 shows that the report completion a team composed of Regional Health Bureau, 16 been anticipated that NGOs would procure rate was 69% in the four target regions before NGOs , regional ENCU and UNICEF, made the their own RUTF where they were supporting the OTP rollout (Jan - Aug 2008) and dropped to final modifications to the checklist for OTP and districts, however it appears that some 42% with the OTP expansion (Sep 2008 to Dec TFU assessment, grading individual compo- preferred or expected UNICEF to procure the 2009). nents of the practices observed. It was agreed commodity on their behalf. Furthermore, a that a three tier grade banding could be useful In September 2009, the Minister of Health number of NGOs advocated for provision of to identify the level of programme support sent a letter to Regional Health Bureaus to contingency stocks in the event of shortages. needed at district level, where: emphasise the importance of getting timely and • Grade over 70%: working very well with UNICEF also became involved in some of accurate reports for enhanced programme minor support needs only the logistics of the programme where GoE monitoring. In addition, UNICEF recruited in • Grade 50-70%: working well but with some needed additional support. UNICEF would November 2009 four technical assistants, one technical and logistic support needs therefore, in some cases, distribute RUTF to attached to each regional ENCU, to look at requiring attention zonal or district level. For the remote districts, reporting systems, identify bottlenecks for • Grade under 50%: has major support needs provision for supply transportation down to quality and timely reports and take appropriate to refresh skills of staff and where the health post level was included into the actions in conjunctions with the GoE. This operational systems need to be established regional action plans. resulted in the achievement of 77% report completion rate between January and August In districts where NGOs provide minimal Enhanced programme monitoring and 2010. Reports usually reach the federal level support to MOH, the NGO in collaboration quality insurance within a maximum of one month after the end with MOH would address the agreed support Ensuring good programme monitoring and of each month of activity. needs. In all other districts, it was suggested quality proved to be challenging with the rapid that the Regional Health Bureau request addi- multiplication of OTP sites. UNICEF supported Other longer-term actions initiated by GoE tional support from UNICEF and/or selected the GoE working on the three following aspects and UNICEF on reporting are: NGOs. of programme monitoring and quality insurance: i) Development of a user-friendly software to be decentralised to the District Health The testing in Oromia and SNNPR also Offices (currently under development)14. allowed for Regional Health Bureaus and part- It is expected that this tool will improve ners to learn more about the resource needs to reporting as well as district and regional manage regular joint monitoring, especially in capacity to analyse/use data for terms of key personnel time and transportation programme management. The software needs. It was initially thought that the six addi- will also include growth monitoring, tional staff recruited by UNICEF to support the OTP rollout in the four regions would also be

Sylvie Chamois, Ethiopia, 2009 Sylvie involved in the joint supervision. However, this Table 1: Summary of results from joint monitoring assessments in the four target additional capacity coupled with the GoE and regions (Amhara, Oromia, SNNPR and Tigray), NGO capacity was not sufficient to establish September 2009 to September 201017 adequate monitoring of the programme (it takes a full week for a monitoring team to Number and % of districts scoring: assess the practice of health extension workers and health workers in 40-50% of all OTP sites Region* Number of < 50% 50-70% > 70% districts and all TFUs in one district). assessed Amhara 59 20 (34%) 27 (46%) 12 (20%) 12 As of September 2010, there is only one local RUTF factory in Ethiopia and a second one is planning to start production Oromia 53 9 (17%) 30 (57%) 14 (26%) in October 2010. SNNPR 3 0 3 (100%) 0 13 Source: TFP database, ENCU/DRMFSS/MOH, Ethiopia. 14 At the moment, the database is kept by the ENCU at Tigray 16 6 (38%) 9 (56%) 1 (6%) federal level. 15 Total 131 35 (27%) 69 (53%) 27 (20%) Health extension workers salary is conditioned to the submission of the HMIS reports to the District Health Office. *Joint monitoring started in September 2009 in Amhara and 16 Concern, GOAL, Save the Children-US, Samaritan’s Purse Oromia and in April and June 2010 in Tigray and SNNPR and International Medical Corps (IMC). Mother and child waiting for admission to respectively. 17 Source: UNICEF Ethiopia. the OTP, Senebete Senkete Health Centre, Siraro woreda, Oromia region 40 Field Article

Table 2: Number of TFUs per district and Box 2: Summary of recommendations from the four coverage survey reports hotspot priority in the four target regions (Amhara, Oromia, SNNPR and Tigray), • Ensure uninterrupted provision of service by formation of linkages to improve active case September 201018 avoiding scheduling conflicts for health extension finding during the quarterly Community Health Days screening, house-to-house visits, routine sanitation Hotspot Total Number Number of % of workers (HEWs). priority number of districts districts districts • Maintain continuous supply of therapeutic products. activities (e.g. pit latrine construction), family number* of with no with at with TFU • Improve technical skills of HEWs and health centres planning services. In all community conversations, districts TFU least 1 TFU staff through formal and on-the-job training. HEWs should raise awareness on the links between 1 176 70 106 60% • Strengthen record keeping, training (formal and the TFP and the Growth Monitoring sessions, on-the-job) and monitoring progress of registered especially when cases of SAM are identified. 2 96 52 44 46% beneficiaries. • In Community-Based Nutrition districts, give 3 99 75 24 24% • Establish regular supportive supervision for HEWs refresher training to CHWs to replace those who Total 371 197 174 47% by their Health Extension Programme (HEP) are no longer active and to ensure sufficient supervisors and district focal persons. numbers to satisfy the district’s plan of one CHW to * Districts affected by food insecurity and in need of humanitar- ian assistance are classified into hotspots priority 1 (high), 2 • Continue joint monitoring assessments (GoE, NGO serve 25 to 30 households. (medium), 3 (low) and 4 (not affected). and UNICEF). • In Tigray, establish OTP service at sub-district/health • Ensure involvement of community health worker post level in the northern rural parts of the district. Table 3: Summary results from TFP coverage (CHWs) in active case finding and defaulter tracing. • Improve RUTF storage facilities at district level and surveys conducted in each of the four target • Integrate TFP with other health/nutrition/food in all health facilities to protect it from rats/rodents. 19 regions, 2010 security programmes in the district. For example, the District assessed and date* OTP period OTP point coverage coverage Indrias Getachew, Ethiopia, 2010 Wadela, Amhara region, 19% 10.4% Map 2: Map of hotspot districts (priority 1, 2 and 3) March 2010 in Amhara, Oromia, SNNP and Tigray regions and Arsi Negele, Oromia region, 48.8% 21.2% presence of TFU, September 2010 January 2010 Mareko, SNNP region, January 60.9% 37.8% 2010 Tahtay Machew, Tigray region, 56.2% 27.3% March 2010

Consequently, in September 2009 UNICEF developed a Project Cooperation Agreement with the NGO Population Service International (PSI) to deploy twenty field monitors in an effort to boost programme quality in all hotspot districts in the four largest regions. A total of 131 districts were monitored from September 2009 onwards. As of September 2010, 20% of districts were working very well with minor Hotspot Priority Districts support needs only (ranked over 70%), 53% Hotspot Districts First Priority were working well but with some technical and (Priority 1, 2, & 3) in logistic support needs requiring attention (50- Amhara, Oromia, SNNP Second Priority 70%) and 27% have major support needs to and Tigray Regions and Third Priority Presence of TFU, refresh skills of staff and where operational Ethiopia, September Hotspot Districts with the Presence of TFU systems need to be established (under 50%), 2010 TFU (Table 1). A child and mother at Menkere Data Source: UNICEF Ethiopia. Boundaries are approximate and unofficial. Graphic & health post, Tigray region In spite of the impressive increase in service Analysis ENCU/EWRD Ethiopia October, 2010 access that has been achieved in districts that have rolled out OTP to health posts at sub- vise OTP activities. Some supervisors are sani- tunities provided by the CBN programme district level, the monitoring has helped to tarians, not health staff, and are not familiar enhanced training and support for health exten- identify key areas where the programme needs with the programme. Some districts lack the sion workers and community health workers. strengthening. full quota of supervisors (one per five health Community mobilisation needs to be strength- The availability of one functional TFUs per post). Lack of capacity and effective manage- ened in districts that have as yet not included it district as planned is still limited. Sixty per cent ment from District Health Offices managers in the training or programme set up. and lack of transport to facilitate visits to OTP of ‘priority 1’ hotspot districts have at least one Another issue is that some NGOs are still in sites may also contribute to shortcomings. TFU, compared with 46% of districts in hotspot implementation mode, providing nurses to When assessing the programme, the monitors priority 2 and 24% in hotspot priority 3 (see work alongside health extension workers for (GoE, PSI/ UNICEF and NGO) also build the Table 2). Also see Map 2. each OTP (involved in recording, reporting, capacity of the HEP supervisors and District The low proportion of referral from OTP to supply management and child treatment). It is Health Offices managers using the checklist TFU in some districts is also a concern and intended that NGOs work to develop capacities and providing on-the-job support. should be studied further. It is not known how by mentoring, supporting quarterly reviews much of this is due to very early detection Health extension workers in most districts and developing District Health Offices skills to reducing the number of complicated cases, or observed so far urgently need follow up train- manage monthly reporting and supply as highlighted in the four TFP coverage surveys ing to refresh/strengthen their skills. OTP management systems, rather than providing conducted recently (Table 3), for other reasons protocols are not always being maintained, and staff to help service delivery. On the other hand, affecting access. These include low level of errors in anthropometry are still observed. This some NGOs are still facing difficulties working active community mobilisation and lack of can result in moderate acute malnutrition cases on capacity building and dialogue is still skills among some health extension workers to included in the programme, and unduly long required to achieve the smooth partnership that identify and refer the complicated cases, care- length of stay. Recording and reporting also UNICEF is promoting. remains a challenge. A system for regular giver refusal to go to the TFU because it is too In addition, there is insufficient access to safe supply management and distribution is yet to far, lack of capacity to pay for transport, lack of water at health post level. It was recently be established in many districts. food for caregivers, opportunity cost for care- suggested in Amhara that whether OTP sites givers of staying away from their home, etc. Where Therapeutic Feeding Programmes have sanitary latrines and safe water should be Health Extension Programme supervision and Community-Based Nutrition (CBN) by MOH is not always working adequately due programmes co-exist, the District Health Office 18 Source: UNICEF Ethiopia. to lack of trained staff skilled to mentor/super- has sometimes failed to capitalise on the oppor- 19 Source: EHNRI.

41 Source: TFP database, ENCU/ DRMFSS/MOH,Ethiopia 3 (low) and4(notaffected). affected by* Districts food andinneedofhumanitarianassistance are insecurity 1(high), classifiedinto hotspotspriority programme monitoring. and conductregular surveys aspartoftheir the capacityofregional authorities toplanfor validate thenewmethodologybefore building a time). A subsequent stepwillbetopilotand allow forassessmentofmore thanonedistrictat areas (atthemoment,methodologydoesnot programme coverageoverwidergeographic ology thatwouldallowassessmentof propose totheMOHacoveragesurveymethod- in byConcernandUNICEFtodevelop address theissues(seeBox1). level andactionplanswere developedto recommendations were discussedatregional January andMarch 2010(Table 3).Findingsand cal supportineachofthefourregions in completed bytheEHNRIwithConcerntechni- building, onecoverageassessmentwas exposure tothemethodologyandcapacity programme areas (individualdistricts).For has beenusedpreviously byNGOsinsmall Sampling (CSAS)methodology. Theapproach coverage usingtheCentricSystematic Area Institute (EHNRI)toassessTFP programme Ethiopian HealthandNutritionResearch and Concerntobuildthecapacityof UNICEF developedapartnershipwithMOH c) rhoea andpneumonia(January2010). with thecommunitytreatment ofmalaria,diar- Management ofChildhoodIllnessestogether has alsobeenincludedintheCommunityCase provision inaletterdatedJanuary2010.This the StateMinisterofHealthauthorised tered bythehealthextensionworkers,although assessments andmonitoring. an additionalindicatorforinclusionduring 4 3 2 1 nb* priority Hotspot SNNPR and Tigray), Jan. 2008to August 2010 Figure 2:OTP & TFU monthlyinthefour admissionsandperformance target regions (Amhara, Oromia, (Amhara, Oromia, SNNPRand Tigray), 2010 September Table 4:Numberandcoverage ofOTP & TFU pertypeofhealthfacilityinthefour target regions 10,000 15,000 20,000 25,000 In September2010,aconsultantwasbrought surveys Partnership forprogramme coverage Routine drugs are notalwaysbeingadminis- 5,000 Admission 0 606 235 99 96 176 woreda No. of

Jan – 08

Feb – 08 12,486 3,844 2,326 2,203 4,113 Posts of Health Total no. Mar – 08 Apr –08 Source: UNICEFEthiopia. Number of TFP 1,651 3,122 OTP running No. ofHP May – 08 6,100 524 803 Jun – 08 Jul – 08

Aug – 08 48.9% 13.6% 34.5% 74.9% 75.9% OTP running % ofHP Sep – 08 Oct – 08

Nov – 08 1,258 482 95 224 457 Centres of Health Total no.

Mortality rate % Mortality Dec – 08 Jan – 09

Feb – 09 602 99 43 151 309 OTP running No. ofHC Mar – 09 Apr –09 Centralandregional government • Key amongsttheseare: utory factorstothesuccessofthisprogramme. There havebeenanumberofimportantcontrib- Key contributingfactorstosuccess of SPHEREstandards cases needingspecialisedinpatientcare. tion casesreducing thenumberofcomplicated now earlierdetectionofsevere acutemalnutri- running TFUs(Table 4).Consequently, there is health centres andhospitalsrespectively respectively running OTPsand17%92%of and 48%ofhealthpostscentres for severe acutemalnutritionhasreached 49% country. Inlessthantwoyears,servicecoverage severe acutemalnutritioninfourregions ofthe services forthemajorityoffamiliesaffected by space oftime,managedtoprovide accessto The GovernmentofEthiopiahas,withinashort Progress andresults severe acutemalnutritionlevels. preparedness torespond toanyincreases in tion intermsofnationalcapacityand defaulter rates(Table 5). Also seeFigure 2. indicators: 82%recovery, 0.7%mortalityand5% four regions withoverallpositiveperformance in andout-patienttherapeuticfeedingsitesthe children were reported tohavebeenadmitted January 2008and August 2010,atotalof370,559 May – 09 47.9% 20.5% 45.3% 67.4% 67.6% OTP running % ofHC implemented through the EthiopianHealth of CommonChildhoodIllnesses part oftheCommunityCaseManagement of severe acutemalnutrition isnowfully programme. Theoutpatient management services intothewiderdecentralisedhealth severe acutemalnutritionandtointegrate guidelines ondecentralisedtreatment of commitment todeveloppoliciesand Furthermore, keymonitoringresults interms Jun – 09 Lastly, theGoEisnowinamuchbetterposi- Defaulter rate % Jul – 09

Aug – 09 214 22 24 44 124 TFU running No. ofHC Sep – 09 Oct – 09

Nov – 09 17.0% 4.6% 25.3% 19.6% 27.1% TFU running % ofHC Dec – 09 Jan – 10 62 28 10 9 15 Hospital of Total no. Feb – 10 20 Report completionrate % Report are impressive. Between Mar – 10 Apr –10 May – 10 57 25 9 9 14 running TFU Hospital No. of Jun – 10 Jul – 10

Aug – 10 2 (medium), 91.9% 89.3% 90.0% 100.0% 93.3% running TFU Hospital % of 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Sylvie Chamois,email:[email protected] For more information,contact: admission rateinsomedistricts. of issues,includingthereasons forlowTFU programme evaluationand tostudyanumber urgent toconduct a comprehensive implementation, itisbecomingincreasingly Growth Standards). Finally, after twoyearsof priority asEthiopiaadoptsthenewWHO malnutrition (thiswillbecomeanevengreater malnutrition andprevention ofsevere acute expanded managementofmoderateacute Extension Programme, and improved and community healthworkersoftheHealth Ministry ofWater Resources andlinkingwith water andhealthservicesbyworkingwith These shouldincludeimproved accesstosafe other programmes mustalso tobedeveloped. programme implementation. Linkageswith the capacityofsupervisorsincharge of essential toaddress servicequalityandbuild Continued jointsupervisionvisitsare also sector toabsorbtheprogramme cost. increased allocationoffundstotheHealth the programme, togetherwithadvocacyforan step towards fullyintegratingandsustaining sions andperformance)willbeanimportant Management InformationSystem(newadmis- sion ofbasicTFP indicatorsintotheHealth supply andlogisticissues.Similarly, theinclu- Drug/Commodity Listtoresolve someofthe therapeutic feedingitemsintheEssential district. Itwillalsobeimportanttoinclude to reach aminimumlevelofoneTFUper at healthpostlevelandexpandTFUcoverage Key nextstepsare tocontinuetheOTP roll-out Ways forward Source: TFPdatabase, ENCU/DRMFSS/ MOH,Ethiopia. 20 Simplicityandefficacy ofOTP approach • Enhancedcoordination betweenGoE, • Higheducationallevels,technicalskills • Advocacytopromote thisapproach andto • Extension Programme. Non respondents and from TFU to OTP Transfer from OTP to TFU transferMedical Defaulter Died Cured Number ofadmissions completed % ofreports

Table 5: OTP & TFU in the performance four target regions (Amhara, Oromia, SNNPR and Tigray), Jan. 2008 to Aug. 2010 Standards inDisasterResponse. The SPHEREproject,HumanitarianCharterandMinimum (patients andcaregivers). extension workers)andserviceusers both fortheserviceproviders (health best effect. could contributeskillsandresources to environment inwhichallstakeholders UNICEF, NGOsanddonorscreating an doctors. health extensionworkers,nursesand and commitmentamongstprogramme staff field levelactors. provide technicalassistancetoallrelevant working withinthehealthsector, e.g. 8,054 (2.4%) 28,357 (8.6%) 3,627 (1.1%) 15,392 (4.7%) 2,481 (0.7%) 272,261 (82.5%) 370,559 63.4% performance TFP Field Article – – – < 15% < 10% > 75% – – standards SPHERE 42 Field Article History of nutritional status and Concern’s response in Concern Ethiopia Dessie Zuria woreda, Ethiopia

By Sarah Style

Sarah graduated with a Masters in Public Health Nutrition from the London School of Hygiene and Tropical Medicine in 2009. She recently returned from Ethiopia having completed an internship with Concern Ethiopia.

The author acknowledges the technical and editorial support of Emily Mates in writing this article and the work and support of the Concern Ethiopia team. Focus group discussion in Guguftu kebele to investigate underlying causes of malnutrition

Serdem, a lowland kebele (village) situated near hoods programme in 2007, initially targeting 11 the town of Kombolcha was selected also. All of the 31 kebeles in the woreda. Some of the key children providing case studies were purpo- problems to be addressed were low rainfall, crop sively selected based on having been readmitted productivity and production (particularly in the (some on more than one occasion) to the SFP. higher-highland areas) and lack of agricultural essie Zuria is one of 21 woredas Primary and secondary data was also reviewed diversification and non-agricultural sources of (districts) in of including (but not limited to) Concern’s 2006 income. Although this programme has not been Amhara Region, Northern Ethiopia. Dessie Zuria Livelihoods Analysis (also building running for long and therefore cannot yet be The nutrition situation in Dessie on suggestions from the Agricultural and Rural expected to have solved all of these problems, DZuria has remained at ‘serious’ levels for the past Development Agency), 2008-09 recovery infor- we have not seen a reduction in chronic acute 10 years, with the global acute malnutrition mation, 2008-09 early warning information malnutrition, even with TSF interventions, the (GAM) rate only once dropping below 10% (cut (Concern and woreda) and 2008-10 Dessie Zuria Governments general food distribution (GFD) off advised by Ethiopian guidelines to classify an Nutrition Surveys that included reports from the and the Ethiopian social protection mechansism, emergency situation) in 2004 in the presence of Woreda Agriculture and Rural Development the Productive Safety Net Programme (PSNP) an emergency feeding programme (Figure 1). Office (WARDO). (that provides food or cash for work for the poorest of the poor). In 2008, Dessie Zuria was classified as a ‘hot The relatively static nutrition situation in spot’ area by the regional early warning depart- Dessie Zuria implies that this high level of acute It has been suggested that the “repeated ment due to failure of the short belg rains on malnutrition is becoming ‘typical’ for this popu- ‘emergency’ operations are in fact serving the which the majority of the population depend. lation, who in the face of chronic food insecurity, function of a welfare or safety net programme in Following the results of a nutrition survey, are finding it increasingly difficult to recover the face of chronic poverty in the Wollo area of Concern Ethiopia initiated a targeted supple- from the repeated shocks. The chronic food inse- Ethiopia2”. mentary feeding programme (TSFP) in July 2008, curity in the woreda is also evident in the high which has continuously operated since then. prevalence of stunting. The July 2010 nutrition Key challenges to improving Dessie However, malnutrition rates in the woreda to survey estimated global stunting at 47.5% (this is Zuria’s nutrition situation date have remained relatively un-changed, not significantly above the national average)1. The following key challenges were highlighted despite two years of a TSFP intervention. The This figure is unlikely to be inclusive of older age from analysis of the FGDs and case studies as TSFP has been a well implemented programme, stunted children as survey team leaders were well the aforementioned review of primary and evidenced by high coverage rates (October 2008, trained to ascertain age using local seasonal secondary information provided by relevant TSFP period coverage 84.5%, TSFP point cover- calendars and had a good understanding of Dessie Zuria woreda offices and Concern. age 68.3%). However, recovery rates have been child developmental stages. The leaders were Climatic conditions and topography sub-optimal, particularly during 2009 (recovery therefore able to validate the likelihood of the Dessie Zuria rainfall is erratic and precarious. rate 27%, non-recovery rate 59%, re-admission reported ages. Only when age was unclear, was Although the rains this year have improved, rate 57%) thus raising the question of what is the height cut off of betweeen 65-110cm (proxy 6 woreda reports and surveys have indicated that going on in this area that may have contributed months to 5 years) used to consider children for the belg rains have been wholly inadequate for to the lower than hoped for recovery rates in the the survey. Whilst harvests have been particu- the last 3 years leading to insufficient or non- programme. larly poor in the last three years, indications are existent crop production. This was further In order to further investigate this issue, three that an increasing number of households are confirmed by the FGDs and case studies. The focus group discussions (FGDs) and four case unable to support themselves, even in a year of higher-highlands, being totally belg dependent, studies were carried out in selected distribution good harvest. have been particularly affected. They are also areas in the woreda. In order to provide as repre- Concern has been present in Dessie Zuria for more vulnerable to climatic variations due to sentative a selection as possible within the time 10 years where it has supported the woreda being dominated by sloping land, with the soil allowed, two areas, Guguftu and Gelsha, known through both development and emergency erosion and colder weather making it difficult to for their chronic nutritional status were selected. programmes. Based on the findings of the 2006 grow crops. Additionally, small land holdings Both are situated in the higher highlands. livelihoods analysis, Concern initiated a liveli- and population pressure, exacerbated by poor

Figure 1: Prevalence of GAM and SAM in Dessie Zuria woreda (2003 – 2010) 1 National average for stunting is 46.5% 18 (Ethiopia DHS, 2005). 2 16 Sharp and Devereux, 2004. 'Destitution in Concern Ethiopia 14 Wollo (Ethiopia): 12 chronic poverty as a 10 crisis of household % 8 and community livelihoods', Journal 6 of Human 4 Development and 2 Capabilities, 5: 2, 227 — 247. 0 http://dx.doi.org/ 10.1080/146498804 2000225140 Jun – 09 Jun – 08 Jun – 07 Jun – 06 Jun – 05 Jun – 04 Jun – 03 Dec –09 Dec Dec –08 Dec Dec –07 Dec Dec –06 Dec Dec –05 Dec Dec –04 Dec Dec –03 Dec Mar – 10 Mar – 09 Mar – 08 Mar – 07 Mar – 06 Mar – 05 Mar – 04 Mar – 03 Sept – 09 Sept – 08 Sept – 07 Sept – 06 Sept – 05 Sept – 04 Hayat Seid, female, Sept – 03 29 months, has been Global acute malnutrition (GAM) % Severe acute malnutrition (SAM) % in and out of OTP and SFP five times 43 Field Article resource management and overuse, have also led (again being addressed by the livelihoods to declining productivity. programme). Although the woreda’s current food security situation is showing improvement In order to further investigate this link, the due to a productive belg performance in readmission rates from Concern’s supplemen- Concern Ethiopia June/July, unless this trend continues over the tary feeding programmes (SFPs) from July 2009 longer-term, the nutrition situation will most to June 2010 were analysed at kebele level and by likely remain bleak in the absence of further agro-climatic zone. The results found that the multi-sectoral action including expansion of the five kebeles with the highest readmission rates Concern livelihood programme. were all from the higher highlands (as opposed to the highlands, midlands or lowlands). This Food Aid gives testament to this area’s increased vulnera- In April 2010, nutrition survey results indicated bility to factors leading to food insecurity, such that although the main source of income was as a colder environment resulting in higher household’s own production, 82.4% of house- Beyenech Hussen (female, 19 months) metabolic rate, smaller land holding, erosion and holds had access to food aid. This is nearly has been in and out of OTP and SFP on the slow recovery of SFP beneficiaries, with high double that of 2008, increasing pressure on 4 occasions (Guguftu kebele) numbers requiring re-admission to the resources. While GFD and PSNP have inevitably programme. aided household food security to some extent, community activities. The community mobilisa- Food insecurity focus group discussions have indicated that tion has led to greater awareness among the distributions are often less than that forcasted by The livelihoods and livelihood assets in Dessie mothers and caregivers and increased their abil- the woreda, in terms of quantity and frequency Zuria are also frequently affected by shocks. ity to detect early signs of malnutrition, as well of provision (of cash/grain). Additionally, in Livelihoods analysis has indicated that crop as contributing to improvements in hygiene Seredem, cash rations in March 2010 were found production cannot be expected to offer much by practices and utilisation of health services. to be of little value due to price increases in the way of outputs except in very limited areas such Furthermore, local transporters are charging less market. FGDs and case studies highlighted the as in the lowlands, where crops depend on the for any transportation to health centres realising influence of these factors on communities’ more reliable meher rains and less undulating that this is for their children. Nevertheless, chil- inability to recover as well as the recovery being topography. Case studies conducted with dren’s nutritional status could also benefit from exacerbated by the limited linkage between GFD parents of moderately acutely malnourished an increased involvement of traditional healers and SFP beneficiary lists. However, it was also (MAM) children repeatedly readmitted to SFPs, in any future health-related interventions in pointed out that where provided in sufficient found that due to crop failures and lack of other order to improve health seeking behaviours. quantities, the GFD/PSNP did help to reduce nutritional produce, households are often unable sharing of SFP among households. Health environment to use the SFP ration as intended i.e. as a supple- Nutrition survey results regularly reveal that ment for the normal family diet. FGDs Poor infant feeding practices less than half of all households (44%) have access confirmed that the poorest of the poor are In this district, inadequate infant feeding prac- to protected water supplies and just over half frequently unable to provide additional food tices are suspected to have a considerable (53%) report to using a pit latrine. Observations from their own production to supplement SFP influence on children’s ability to recover from from the field confirmed the poor sanitation and food. This means that even with supplementary malnutrition, and to maintain their recovery. hygiene conditions in which some families are food, beneficiaries’ food intake is insufficient for FGDs have found that feeding infants a mixed living. For example, many households in the recovery. This is further compounded by diet of water and breastmilk is a common occur- highlands live with their animals and their frequent sharing of the SFP food with other rence. This is worrying, given the poor water, excreta. Whilst this is reported to be a method of hungry siblings not in the feeding programme. sanitation and hygiene (WASH) conditions in the increasing warmth in the cold highland areas, it Although parents knew that the SFP food was woreda (see below) and the likely exposure of is also likely to be a source of increased infec- intended only for the malnourished child, they infants to harmful pathogens. All caregivers tions and illness to younger children. As a result found it impossible to ignore the hungry cries of reported to having received education on sanita- of the poor WASH conditions in households, their other children who were not enrolled. tion and hygiene provided during Concern’s SFP nutrition surveys consistently find diarrhoea to Despite education on use of the supplementary distributions and by community outreach, and be the most prevalent illness among children food at every distribution site, one case study therefore had improved knowledge in this area. under 5 years and accounts for approximately mother admitted to eating the SF food that was However, some added that although they had 60% of illness. Concern has over the last few intended for her child, in order to improve the received this education, it was sometimes diffi- years significantly increased activities to provide quality of her breastmilk. In children >6 months, cult to implement practically, due to heavy work clean water pumps to a greater number of kebe- supplementary food rations are intended for loads and lack of family support. les. Nevertheless, it appears that further consumption by the child to complement breast- Data from nutrition surveys has consistently development in WASH infrastructure is feeding. indicated a low prevalence of exclusive breast- required, to aid improvements in Dessie Zuria’s The dependency on agriculture is also dispro- feeding in infants < 6 months. In the most recent nutrition situation. portionately large, given the precarious weather nutrition survey (July 2010), introduction of Coping strategies conditions. Although the woreda’s climate and complementary foods from 6 to 9 months was The seriousness of the Dessie Zuria situation is topography make it difficult to grow a diverse reported by only 66% of caregivers. This indi- highlighted by the type of coping strategies that range of crops, there is a need for agricultural cates that complementary foods are frequently households have adopted, the most poignant of diversification to reduce reliance on single crops; introduced too late. Many infants are receiving which is related to the dramatic decrease in a key objective of Concern’s livelihood only breastmilk/water for too long, therefore not under-5 population over recent years. The programme. More climatically tolerant seeds obtaining sufficient energy or nutrients to meet under-5 population has declined rapidly, reduc- have been introduced in the last two years as a their increased needs. This is further exacerbated ing from 18.0% in 2005 to 10.8% in 2010 (Figure recovery mechanism and have proved a success. by the inadequate quality and quantity of 2). This begs the question as to why people have FGDs highlighted that potato seeds have complementary foods. Higher rates of malnutri- provided a good opportunity for recovery as tion are consistently found in children aged 6 to Figure 2: Under-5 population (% of total they can be eaten, used as a cash crop and are 29 months, compared to older age groups. FGDs population) in Dessie Zuria (2005 – 2010) suited to the ecological zone. Expansion of such also identified that many caregivers often prefer activities could aid in improving communities to take their sick child to traditional healers 19 poor dietary diversity. Diets are dominated by rather than modern health services. Some house- 18 carbohydrates with little fruit/vegetable holds still rely on traditional/spiritual healing to 17 consumption, exacerbated by limited knowledge cure their children of malnutrition due to a belief 16 15 of caregivers in the preparation of nutritious in the ‘evil eye’, suggesting that they might not % food. Consumption of meat and meat products is identify the cause of the sickness as being nutri- 14 almost non-existent; farmers cannot afford to eat tion related. FGDs and case studies indicated 13 the products as they need to sell their live- that such beliefs tended to be more common of 12 stock/meat as a source of income. The older carers such as grandparents, whereas most 11 10 population’s resilience to agricultural shocks is of the younger women demonstrated their 2005 2006 2007 2008 2009 2010 further reduced by the lack of off-farm activities, understanding of the health and nutrition Under 5 Population (%) as back up strategies in case of crop failure related education provided through Concern’s

44 Field Article stopped having babies - the steady decline indicates that this is not a mortality issue. EHNRI The Government’s efforts to scale up family planning services and uptake have increased over the last few years and are likely to have considerably influenced this decline. Furthermore, according to FGDs, households have been more willing to embrace these efforts over the last five years, due to the high levels of food insecu- Profile and role in the National Office, 2010 EHNRI Public Relations rity. Participants indicated that people are choosing to have fewer children as they simply cannot afford to feed so many Nutrition Programme Entrance to EHNRI compound mouths. Many individuals stated that once the situation improves they wish to start having more children again, for security in Name: Ethiopian Health and Nutrition Research Institute (EHNRI) their old age and to help them with farm Address: Gulelle Arbegnoch Street (the former Pasteur Institute) activities. Gulele Sub City P.O.B. 5456, Addis Ababa, Ethiopia Conclusions Phone: +251 11 2133499 Despite the current improvement in food Fax: +251 11 2757722 security, the woreda’s reliance on unreliable Website: http://www.ehnri.gov.et and erratic rainfall suggests that this Director General Dr. Tsehaynesh Messele improvement may be short lived; studies in Deputy Director General: Dr. Amha Kebede (Research Technology Transfer) the larger Wollo area have found that poverty appears to be worsening rather Contact: Dr. Cherinet Abuye (Director, Food Science and Nutrition Research Directorate) Email: [email protected] than improving3. Without Concern’s pres- ence in Dessie Zuria over the past 10 years, mortality rates are likely to have declined, running of the Pasteur Institute and it was This article is based on a meeting between along with progress in the area of liveli- renamed the Central Laboratory and Research Carmel Dolan, ENN and Dr Cherinet, Director, hoods, health and nutrition which evidently Institute. Towards the end of the twentieth Food Science and Nutrition Research century, it evolved into the National Research has been made. However, the situation is Directorate. complex. Improvement in agricultural Institute of Health (NRIH), which focused its production, for example, cannot be ‘stand- Dr Cherinet began working for the ENI, energy on making significant contributions alone’ and requires “an integrated and predecessor to the EHNRI, in 1988 and has towards improving the health of the country. been Director of the Food Science and holistic approach involving various sectors Ethiopian Nutrition Institute (ENI) 4 Nutrition Research Directorate at EHNRI since and sub-sectors” . Additionally, it is impor- 2009. Previously he held various positions The Children’s Nutrition Unit (CNU) was tant to consider the “physical and economic within the institution including assistant founded in 1962 as a joint Ethio-Swedish project. access that a child or his or her caregiver has researcher, senior researcher and team leader. It became the ENI in 1968, when the Ethiopian to that food, the caregiver's knowledge of He holds a PhD in Public Health (Nutritional Government took over responsibility for and how to use available food and to properly Epidemiology) and an MSc in Applied increased the scope of the nutrition programmes care for the child, the caregiver's own health Nutrition. to include pregnant and lactating women, status, and the control the caregiver has Dr Cherinet would like to thank the follow- school-age children and other adult groups. It over resources within the household that ing staff for their contributions to this article: carried out nutrition and food science related 5 might be used to nourish the child” . SFP Dr. Tsehaynesh Messele (EHNRI Director research and interventions, as well as providing alone cannot prevent occurrence of malnu- General), Dr. Amha Kebede (EHNRI Deputy nutrition training and laboratory services to the trition and therefore is not a complete Director General), Ms. Aregash Samuel (Food public, universities and other organisations. This surprise that SFP inputs over the last two Science and Dietetics Research Case Team was realised by specialist teams working on years has not translated into improvements Leader), Ms. Lakech Goitom (Associate medical nutrition, community nutrition, food in malnutrition rates. What is clear, Researcher – Food Science and Dietetics), Ms. production, training and information, and however, is that SFP interventions cannot be Tsehay Assefa (Associate Researcher – through its well-equipped Food Science and successful without regular and sufficient Nutrition), Mr. Habtamu Fafa (Nutrition Nutrition laboratories. general rations. Based on these research Research Case Team Leader). findings, a strategic multi-faceted, multi- Major achievements of the ENI include the sectoral response is required, that addresses development of a National Food Composition both acute malnutrition and its root causes. Historical overview Table, development and production of a supple- mentary food for infants and children called This response should include, amongst The Ethiopian Health and Nutrition Research FAFFA (meaning ‘to grow big and strong’), as others, infant and young child feeding inter- Institute (EHNRI) is the result of a merger in well as other types of complementary and thera- ventions and enabling increased food access April 1995 between the former National peutic foods. It also developed a strong presence to families with young children through Research Institute of Health (NRIH), the in local communities through establishing field provision of small livestock and agriculture Ethiopian Nutrition Institute (ENI), and the stations to carry out surveys and research on inputs. There are also plans for WASH inter- Department of Traditional Medicine (DTM) of aspects of nutrition, the production, storage and ventions to work towards changing the Ministry of Health. The EHNRI, as a preparation of locally available foods, and negative behavioural practices. Looking to government organisation, is the primary body through the dissemination of educational mate- the future, it will be useful to see how the in Ethiopia for carrying out research, training rials and information to the public. malnutrition situation changes and why, so and providing services for the public and that the whole community learn how best to organisations in the areas of health and nutri- National Nutrition baseline survey dissemination protect the nutritional status of its children. tion. workshop – Dr Amha giving the opening speech For more information, contact: National Research Institute of Health [email protected] (NRIH) The NRIH was the oldest of the three units and began life as the Medical Research Institute in 3 See footnote 2. 1942. In the late 1950’s, it became the Pasteur 4 Chanyalew D. (2005). Food Security and Malnutrition in Institute of Ethiopia, following an agreement Ethiopia. Chapter 3. An Assessment of the causes of Office, 2010 EHNRI Public Relations malnutrition in Ethiopia: A contribution to the with the Pasteur Institute of Paris and named formulation of a national nutrition strategy. International after the French chemist Louis Pasteur (1822- Food Policy Research Institute. Washington. USA. 1895) who invented the first vaccine for rabies. 5 Benson T, Shekar M. (2006). Trends and Issues in Child Undernutrition. Disease and Mortality in Sub-Saharan In the early 1970’s, it was agreed that the Africa, 2nd Edition. 2006. Washington. World Bank. Ethiopian Government would take over the

45 Agency profile

Department of Traditional Medicine infections, malaria, and tuberculosis and Table 1: Nutritional status of children 6-23 and (DTM) strengthening of laboratories at central and 6-59 months of age regional level. Also, there is significant collab- The DTM was established in 1979 under the Indicators Measure* Survey findings Ministry of Health to undertake research, and oration with JICA, WHO, and local and (June 2009) international Rotarians for polio surveillance. promote the production and use of traditionally 6-23 6-59 used medicines. This was at a time when almost In collaboration with WHO and the months months Foundation for Innovative New Diagnostics 80% of the Ethiopian population relied on tradi- Stunted Height for age <-2SD z 33.8% 37.6% tional medicines to treat various ailments. Major (FIND), EHNRI has set up a lot testing centre score for malaria with the objective of providing this research was undertaken to develop safe, effec- Wasted Weight for height 16.0% 11.7% tive drugs from selected medicinal plants being service for the whole of Africa. This centre is <-2SD z score used and to identify those that could have a one of only three globally, the other two being Underweight Weight for age <-2SD z 34.6% 33.9% potentially harmful effect on the population. in Cambodia and The Philippines. A Rapid score Test Kit has also been established at EHNRI. Hundreds of medicinal plant species were iden- *Based on NCHS/CDC Reference Population 1977. tified and their uses determined for various At present there is also strong collaboration types of ailments. with the governments of China and South Table 2: Breastfeeding and complementary feed- Korea on research into traditional medicines. ing statuses of children 0-23 months of age The mandate of the EHNRI Support for the National Nutrition Indicators* Survey findings The NRIH/ENI/DTM merger allowed the (June 2009) bringing together of complementary expertise Programme Ever breastfed 97.4% and laboratory facilities to allow for maximum One of the most significant programmes that utilisation of available resources and create an the Institute is currently involved in is the Breastfed within the first hour of life 45.5% atmosphere conducive to research. More National Nutrition Programme (NNP). The Fed colostrum (first breast milk after 60.2% recently, the Institute implemented ‘Business NNP is an ambitious nutrition programme, birth) Process Re-engineering’ to facilitate a restructur- developed by the Ministry of Health with Exclusively breastfed from 0-5 months 51.4% ing of the organisation and its activities so that it partners, in order to implement the country’s old can more effectively discharge its responsibilities first National Nutrition Strategy endorsed in Aged between 6-9 months and intro- 59.2% in line with the Ethiopia Health Sector February 2008. It is designed to not only duced to complementary food at 6-7 Development Plan (HSDP III/IV (HSDP IV address emergency interventions and food months covers the period 2010-2015). HSDP IV is geared insecurity but also focus on preventive inter- *Based on WHO indicators and methodology. towards protecting and promoting the health ventions, as well as address the fragmented Table 3: Maternal nutrition practices during and wellbeing of the nation. nature of past interventions by taking into pregnancy and lactation account the multi-sectoral nature of nutrition. Under the new structure, a Director General Indicators Survey findings The overall aim is to reduce the magnitude of and two Deputy Director Generals head the (June 2009) malnutrition in Ethiopia, particularly amongst EHNRI. One of the deputies heads the Research Percentage of women who had four or 36.3% the most vulnerable groups of children under and Technology Transfer wing of the Institute, more antenatal clinic visits during last five, pregnant and lactating women, and which is tasked with tackling priority public pregnancy people living with HIV (PLHIV). health and nutrition problems through problem Food consumption during pregnancy 11.6% focused research in order to improve the health The Food Science and Nutrition Research increased of the country. The other deputy heads the Directorate (FSNRD), part of the Research and Food consumption during pregnancy 52.5% Public Health Emergency Management division Technology Transfer wing of the Institute, is decreased of the Institute, which works to anticipate, carrying out NNP activities as part of its regu- Received iron-folate as part of 17.3% prevent, prepare for, detect, and respond to lar operations. The mandate of the directorate antenatal care public health threats so that negative health and is, firstly, to determine and monitor the magni- Showed symptoms of night blindness 32.2% socio-economic impacts are minimised. tude, distribution and determinants of (proxy for vitamin A deficiency) malnutrition in the country and, secondly, to The Institute also has the mandate to establish Women 15-49 years old who received 17.6% carry out effective research to develop an vitamin A within 2 months of giving birth and maintain a high quality, sustainable labora- evidence base that offers innovative solutions tory system throughout Ethiopia. This delivers Households using iodised salt (goitre 5.1% to reduce and eradicate malnutrition. Research prevention) quality and accessible laboratory services relat- includes the development of new food prod- ing to the occurrence, causes, prevention and ucts and processing and preservation diagnosis of major diseases of public health Nutrition surveys and understanding technologies. The directorate also offers labo- importance and to establish and support factors that cause malnutrition ratory services to the public and organisations, National Laboratory Quality Assurance An integrated national nutrition baseline nutrition supports curriculum development and teach- programmes and systems. survey has already been designed and successfully ing at universities, and carries out demand conducted by EHNRI in June 2009 at the national The Institute is well placed to carry out all of based ‘on-the-job’ training for various organi- level. The aim was to collect information on basic its tasks, with almost 200 research and technical sations on health and nutrition related topics. indicators of nutritional status such as under-five, staff, 250 support staff and well-equipped labo- This Directorate has been responsible for adolescent girl and maternal malnutrition and ratories. It also benefits from the generous many innovative nutrition interventions in morbidity. Within the household, conditions such support of the Government of Ethiopia and vari- Ethiopia since its inception, including the as food security, clean water, safe sanitation facili- ous national and international organisations, development of food composition tables, ties, hygiene practices, maternal care practices and with total funds of around 25 million birr and menu development for chronic health prob- access to health services can have an impact on the $20 million USD per year (in cash and in kind) lems and micronutrient research. Currently, nutritional situation, so data was also collected on received. with the advent of the NNP, nutrition is once these indicators, amongst others. Organisations that support the Institute again in the spotlight in Ethiopia at a time The survey report, which includes the full include WHO, UNICEF, World Bank, Centre for when the economy has been enjoying steady results of the survey, can be found at Disease Control (CDC) Atlanta, Japan growth. However, this has not been matched www.ehnri.gov.et. As expected, the findings are International Cooperation Agency (JICA), the by a corresponding fall in the level of malnu- mostly in line with the Ethiopia Demographic Food and Agriculture Organisation (FAO) and trition that development can bring. Health Survey (EDHS) 2005, but serve to highlight various non-governmental organisations The Directorate’s role in the NNP is based the magnitude of the nutrition problems in through joint research projects. Also, collabora- around carrying out critical surveys and Ethiopia and the importance of NNP implementa- tive research projects are carried out with local research that will create a greater understand- tion. The NNP particularly focuses on the period universities, as well as with international part- ing of the current nutrition situation in the from birth to two years of age, which is seen as the ners, research institutes and institutions of country and help to shape the scaling up of ‘critical window’ for the promotion of good higher learning. the programme. The Directorate also under- growth, health, and behavioural development Current major programmes include joint takes monitoring and evaluation of various through optimal infant and young child feeding. cooperation with CDC for a national surveil- components of the programme as they are Thus indicators relating to this age group are the lance study of HIV/AIDS, sexually transmitted implemented, and the NNP as a whole. most critical to understand since this is where

46 Agency profile

Assessment of national capacity for such as quality of services, data quality, Listening to the opening speech at the programme scale-up to reach pastoralist National Nutrition baseline survey implementing the NNP dissemination workshop EHNRI also commissioned a series of studies in communities, and Health Extension Worker order to create a clearer picture of the nutrition skills. Other areas of research focus include the professionals available from federal to sub- feasibility of local production of micronutrient- district levels to implement the NNP and the rich processed foods, using micronutrient capacity of nutrition training institutions to powders to improve complementary food qual- supplement and strengthen this cadre. A further ity, effectiveness of the media to deliver BCC EHNRI Public Relations Office, 2010 EHNRI Public Relations study was conducted to assess current behaviour messages, and micronutrient interventions, such change communication activities, with a view to as pregnant women’s compliance to daily iron developing a comprehensive communication supplementation. framework that would complement the imple- This research will be carried out and results mentation of the various NNP activities. disseminated over the next two years, so that they Major findings of the two studies on person- will have a direct impact on current and planned nel and training for nutrition found that there is programmes being implemented as part of the a shortage of trained professionals at federal, NNP. Furthermore, each year of the NNP, EHNRI regional, zonal and district levels to effectively will identify with nutrition partners the most crit- implement the NNP. Recommendations focused ical operations research that needs to be carried on developing a uniform structure at each level out as part of the ORP in order to improve NNP with clearly defined roles, placing greater signif- implementation. icance on in-service training and developing a interventions are most needed. Major findings Establishing a national nutrition database new generation of nutrition professionals. This is EHNRI also has the responsibility to set up and related to this age group are highlighted in the to be achieved through creating a Technical Table 1. run a comprehensive nutrition database. Its Advisory Group to support universities to purpose is not to take over the role of existing The nutritional status figures of both the 6-23 strengthen existing and develop new short and sources of nutrition information, such as the months and 6-59 months groups fluctuated. degree courses and strong nutrition curriculum, database held at the Emergency Nutrition Mothers from rural areas with a low Body Mass focusing on university staff development and Coordination Unit (ENCU), but rather to gather Index (BMI) and mothers with low levels of creating greater linkages between universities. ‘under one roof’ all emergency, programmatic education were at greater risk of having a Behaviour Change Communication in the and nutrition survey data from existing sources. malnourished child. The nutritional status of the NNP This will enable the interpretation and use of this child also depended on their age and the region Systematic behaviour change approaches are data effectively for inputs into management that they live in. Children between 18-23 months extremely important to bring acceptance of decisions, long term planning, evaluation and were more likely to be stunted (43%), those nutrition interventions in communities. related purposes for the CBN and other nutri- between 12-17 months had higher rates of wast- However, this communication study found that tion-related programmes. ing (17.5%) and those between 24-35 months current nutrition behaviour change communica- Potential outputs from the database in order were more commonly underweight (39.3%). tion (BCC) activities are fragmented and Children were more likely to be stunted in to meet these needs include quarterly bulletins under-exploited. A framework, under which containing interpretation of risks to nutrition Amhara and Afar, wasted in Afar and Somali, new BCC activities should be developed, has and underweight in Afar and Tigray regions. from early warning and nutritional data, quar- been produced as part of the study, The BCC terly reports monitoring nutritional outcomes Key survey results related to breast and framework aims to increase the capacity of each and NNP implementation, and annual publica- complementary feeding are indicated in Table 2. household to use existing food resources to tions on the state of nutrition in Ethiopia to The breastfeeding results particularly varied maximum advantage by taking into account estimate long-term nutritional trends and factors based on the mother’s level of education. Government policy, socio-economic status, determining these. At the same time, stakehold- Mothers with a higher level of education were culture, and gender issues. The study also ers will be able to request specific data from more likely to have ever breastfed their child, outlined the actors that should be involved in EHNRI as required. breastfed within the first hour of life and fed planning and implementing new BCC activities colostrum to their newborn infant. and the training necessary for them. All of these A positive future studies are available at www.ehnri.gov.et. There are exciting times ahead for EHNRI, and Maternal nutrition is critical to ensure the particularly the FSNRD, as it continues to play a health of the mother during pregnancy and after Research focus for the NNP significant role in implementing the NNP, birth, and to ensure the strong development of One of EHNRI’s strengths is in its research including the ORP, developing the nutrition the child. If the mother does not receive suffi- capacity. It was on this basis that it was given the database and also carrying out micronutrient cient nutrition and supplementation during mandate to set up and run the Operational surveys and numerous evaluation studies. The pregnancy, there is a good chance that this may Research Programme (ORP). This programme, Directorate is also advocating for a food fortifica- adversely affect the development of the child. as part of the NNP, exists due to the recognition tion agenda and plans to conduct studies on Key indicators related to the nutritional status of of the complexities inherent in programme various aspects of fortification at the community pregnant and lactating women found in the implementation. It aims to identify and carry out and industrial levels. Further studies are survey are shown in Table 3. studies that can ultimately bring about new planned on the relationship between nutrition insights and understanding to improve imple- Increased food consumption and iron-folate and chronic health problems, as well as on food mentation and shape the scaling-up of the NNP. supplementation was more likely amongst consumption patterns and composition. By doing this, it provides managers and policy- younger women, those who lived in an urban Furthermore, quality control and quality assur- makers with the information they need to area and those of higher educational status. ance work will continue on the salt iodisation improve the existing delivery activities and plan Symptoms of night blindness were less likely programme as it continues to be scaled up. future ones. and vitamin A supplementation higher for The Directorate has high ambitions to be at the women living in urban areas and those with The programme is ambitious in its size and forefront of all nutrition interventions in the higher levels of education. For iodised salt, a scope, and potentially one of the largest of its country and sees the NNP as a great opportunity higher percentage of rural households, kind ever carried out in nutrition. A lot of the to increase the capacity of the young but dedi- compared to urban households, were using it. groundwork is already in place. To ensure that cated staff through their work, with numerous high quality studies are carried out that can The little change found in key nutritional partners and increased opportunities for training. inform nutrition programme planning and indicators since the Ethiopia DHS survey of 2005 This is indeed a huge opportunity for the implementation, selection of the research entities shows that many challenges remain. However, Directorate to push forward and continue to to carry out the studies will be done through a the next few years, during which the various make a significant contribution to the success of competitive-bidding process. components of the NNP will be implemented, is the NNP, as well as for the country to banish the the critical time that interventions will be scaled Priority research areas have been identified high rates of malnutrition to the annals of history. up. An end line survey, planned to take place and agreed upon in consultation with nutrition during 2013, should show the impact of these partners. These include on issues specifically For more information, contact: Dr. Cherinet interventions. related to Community Based Nutrition (CBN) Abuye, email: [email protected]

47 Field Article Rapid response By Antoinette Powell Antoinette Powell is the Communications and and long-term Information Officer, Africa with Christian Aid since 2007. solutions: Previously she worked as Advocacy Officer, The African Christian Aid and Child Policy Forum in Addis Ababa, Ethiopia (2005 – 2006).

food security in The author would like to acknowledge the Christian Aid Ethiopia office staff, in particular Suku Deda's village of Sabant in Cathy Riley, Country Manager, for her support southern Ethiopia was devastated Ethiopia by drought (see case study) with this article. Mesfin Teklu, WV, Ethiopia, 2006 WV, Mesfin Teklu,

ood insecurity is a deep-rooted problem people face and the solutions most appropriate Following the failure of seasonal rains in late for Ethiopia. With almost half the coun- to each context. Working through local partners 2005, large parts of southern Ethiopia faced seri- try’s population of 78.6 million living in at the grassroots level is also considered essen- ous water shortages. Vast areas of crops were lost deep and long-term poverty, many tial to maximise impact and ensure and with pastoralists and sedentary farmers Fpeople are vulnerable to drought and moderate sustainability. These organisations also provide unable to find pasture and water, many livestock and severe acute malnutrition. With millions of a key connection to the rapidly changing envi- died. More than two million people were Ethiopians regarded as chronically food inse- ronment and alert to potential emergency affected, leaving them uncertain of how they and cure, even in years when the rains are good, situations. When emergencies do strike they are their families would survive. This is reflected in many face uncertainty over how they will feed already based within the communities that need the situation of one woman, Suku Deda: support, and so are often better able to respond their families each day, every year. Suku Deda was caring for her ten children in with agility than organisations that need to Sabant village, southern Ethiopia when this drought When Christian Aid began working in bring in staff and resources. Ethiopia in the 1970s, the country – and indeed devastated the herd of cattle she had carefully the whole of the Sahel region – was suffering Such an approach enables Christian Aid to increased year on year in order to support them. the devastating effects of a famine which left adapt emergency response to ensure that the Along with other women in the community, Suku had hundreds of thousands dead. Less than ten support meets the needs of each affected popu- set up a cooperative through which she sold milk and years later, Ethiopia was once again in the grip lation. For example, in 1984 when Christian Aid cheese enabling them to earn a small income and of another drought which led to what BBC jour- could not reach the northern areas worst ensure their children had enough to eat each day. The nalist Michael Buerk described as a “biblical affected by Ethiopia’s drought by travelling drought devastated this business with the women’s famine”. At its height, the 1984/85 famine was north from Addis Ababa, cash was provided to cattle dying one by one, leaving them with no food claiming hundreds of lives each day in the the Emergency Relief Desk based in Sudan to and no source of income. Having worked deter- Mekelle Relief Camp in the northern Tigray purchase grain locally and provide it to affected minedly to build her business, Suku was reduced to region of Ethiopia alone. Further food shortages communities. More recently, the Ethiopian waiting for external help saying, “If nothing comes, followed the 1984-1985 famine in 1992, 1994, Evangelical Church Mekane Yesus (EECMY), we can do nothing. We will just wait and sit and die.” supported by Christian Aid, set up a cash for 2000 and 2002, and more recently in 2005 and Christian Aid partner, the EECMY, works work project in southern Ethiopia enabling 2008. These emergencies highlight the persist- with some of the most marginalised communi- communities to purchase locally available food ent food insecurity which characterises life for ties in Ethiopia including pastoralist when their crops failed. many Ethiopians. communities in the country’s south. Recognising Christian Aid response Surviving drought and developing that many people – like Suku – had been left In each of these emergencies, Christian Aid communities without any means to feed their families follow- responded rapidly through a network of part- Although ensuring that food aid and other relief ing the failed rains in 2005, EECMY responded ners to provide relief and rehabilitation support reaches communities in need is critical during quickly. With food still available in the south, to those most in need. These partners – local droughts and other emergencies, humanitarian despite people’s inability to afford it, they organisations based within the communities response must work alongside longer term solu- provided cash injections to avoid damaging the with which Christian Aid work – are central to tions to poverty. So, when the immediate needs local economy by bringing in supplies at the Christian Aid’s capacity to respond in emergen- during or in the aftermath of a disaster have expense of those already available. At the same cies, as well as the organisation’s wider been met and the eyes of the world move on, time they also realised that this was an oppor- development work. Christian Aid remains non- Christian Aid partners remain with the affected tunity to put in place measures to help protect operational I the belief that local organisations, communities ensuring that the long-term work communities from the effects of other droughts rooted in the communities they support, are of rebuilding lives and livelihoods is not that would inevitably occur in the future. best placed to understand the issues local neglected. EECMY’s cash for work project provided not only a welcome source of income for families, Case Study 1: Muhe Shehu Ibrahim’s story but also brought communities together to build structures including ponds to catch rain water. Muhe’s father and grandfather were both farmers, ox for cheap prices and bought the food for expensive This has enabled them to make better use of this but growing enough for the family to eat had always prices - so we still faced problems because we could- scarce resource in the years that have followed. been difficult. In 1984, this task became impossible. n’t afford to buy enough food.” “In 1984/1985, for the first time, we received food Fifteen-year-old Dhaba, who is a Borana Despite the failure of many farmers to grow water- assistance,” explains Muhe. “There was a funeral pastoralist, described EECMY’s project saying, hungry crops like sorghum and teff, many Ethiopians committee. That committee had one job; to organise “If anyone else came here to do this work we note that the rivers in the northern Amhara region funerals. They were paid in food. For almost a year we would be so disappointed. This is our opportu- never ran completely dry. It was simply that without continued to bury people.” nity to work on our own development and I effective irrigation systems, families like Muhe’s could want to be a part of this.” Muhe and his father before him had no irrigation not make use of the little water that remained available. system and had relied on just two crops – heavily Christian Aid partner Water Action worked with Muhe Increasing resilience to avoid disaster dependent on water – to feed their family. “My father and others from his community, providing training to It is not only in the aftermath of emergencies and my grandfathers used to plough these lands. help them make best use of the water available to that Christian Aid’s partners carry out projects. Production was very difficult,” says Muhe. “They were them, suggesting drought resistant crops which can full-time farmers. Everything was natural. We Increasing communities’ resilience to disaster is be planted at different times of the year and installing produced only teff and sorghum; we didn’t know any another key aspect of the organisation’s work an irrigation system. other crops”. “There was a drought and we faced diffi- on agriculture and other food security projects cult problems. For teff and sorghum we could only “I produce three times a year,” says Muhe. “Since Water in Ethiopia. This has brought a radical change have one harvest. When the rains didn’t come we had Action, I haven’t thought about food problems.” in the lives of men like Muhe Shehu Ibrahim no harvest, we were forced to sell our ox. We sold the

48 Field Article Field Article who lives in Harbu in the north west of the will not remain effective if we do not also Amhara region (see case study 1). When keep an eye on the context in which we are carrying out interventions like described, working. While scientific evidence on the which aim to reduce communities’ resilience causes – and indeed future effects - of shifting Completing to natural disasters, Christian Aid is keen not weather patterns around the world remains only to identify areas where these events are inconclusive, it looks likely that the changes the Jigsaw particularly likely. The organisation also Ethiopia has already seen are a result of targets the communities least able to cope climate change caused by increasing CO2 because of high levels of poverty and who in emissions. Ethiopia reports an average rise in Puzzle: Joint many cases have been pushed to the margins temperature across the country of 0.2oC every of society. decade for the last 50 years and an increasing Assessment number of droughts. With patterns of rainfall Working with three Ethiopian organisa- predicted to become even more uncertain in tions, Agri-Service Ethiopia, Action for the coming years, this is a phenomenon that Missions Development and Women Support any development agency working to help Association, Christian Aid is currently imple- Ethiopians lift themselves out of poverty menting a project funded by the European simply cannot afford to ignore. (JAM) Union to increase the food security of house- holds in Dasenach, Maalee and South Ari In 2009, Christian Aid funded one of its By Allison Oman woredas in South Omo zone in Southern partners, Citizens Solidarity for the Campaign Nations, Nationalities and Peoples Region Against Famine in Ethiopia (CS-CAFÉ), to Allison is the Senior Regional Nutrition and Food Security (SNNPR). Despite facing annual food short- conduct a study on climate change. The study Officer for UNHCR based in ages lasting between six and nine months, found that awareness about climate change Nairobi, Kenya. She works with these areas have been left out of many develop- has dramatically increased during the past 10 countries in the region to give ment initiatives within the SNNPR where years, and that farmers are increasingly notic- technical support and advice on South Omo is located. Consequently levels of ing changes that may well be climate-related. a wide range of interventions, including food distribution, IYCF, poverty remain high, with over 50% of the These include increased incidence of insects, CMAM, food and cash vouchers and coordi- population living below the poverty line. And weeds, plant and animal diseases, changes to nates/collaborates with key partners for camp yet these woredas lie along the Omo River that potential crop growing periods, and shifts in and non-camp based refugee populations. She is could be used to provide irrigation for the which areas are suitable for growing crops. a proud member of the Nairobi Nutritionists. surrounding areas and for fishing. This project The findings of this study will enable Special acknowledgements to Kate Ogden and will involve developing small scale irrigation Christian Aid to work with partners to iden- Mark Gordon of WFP for their warm and fluid schemes which, along with ensuring that a tify how they can support communities to partnership on refugee issues, and to the team more diverse range of seeds are planted and adapt to the changing weather patterns they members of the recent JAM in Ethiopia and the organic fertilisers are produced and used, are already seeing, and how to mitigate the UNHCR nutritionist Mulugeta W/T Sadik. Finally, thanks to those who temporarily find themselves should increase crop yields across the area. In impacts of climate change in their work. without a country or home, and graciously allow addition, training and support for fisheries and us to work with them to resolve the problems The Ethiopian Civil Society Network on livestock production will ensure that commu- inherent in living as a refugee in a camp or non- Climate Change (ECSNCC) is a non-govern- nities are less dependent on one food source. camp setting - reminding us that being a refugee mental organisation which began a localised is a context, not an identity. Although 20 per cent of the population campaign on climate change as part of required food aid in 2009, if these natural Countdown to Copenhagen in September resources were fully utilised the area could 2009. ECSNCC used their network to collect produce enough food without relying on exter- signatures calling for climate justice and to nal support: Christian Aid is working with hold events such as climate hearings across these communities to exploit this potential. Ethiopia. Work helping communities to adapt Addressing climate change to the changing climate within Ethiopia is ood security continues to be a chal- lenging and often elusive This work on the ground, responding to complemented by Christian Aid’s campaign possibility for many of the almost 2 emergencies and building people’s resilience at international level which calls for swift million camp-based refugees so that floods, droughts and other extreme action by governments around the world, and Fworldwide. In East and the Horn of Africa, weather conditions do not become disasters, particularly in industrial nations, to curb carbon emissions. almost every country in the region hosts protracted refugee situations, where A future without hunger refugees live encamped and rely primarily While Christian Aid will continue to respond on food aid to meet their monthly food to the emergency needs of Ethiopians affected requirements. UNHCR partners closely by the country’s high levels of food insecurity, with the World Food Programme (WFP) to the organisation believes that with continued meet the basic food needs of the refugees in support it will be possible to break this cycle places where food aid is required. WFP is of hunger. By drawing on its experience of committed to supplying approximately Mesfin Teklu, WV, Ethiopia, 2006 WV, Mesfin Teklu, building communities’ resilience to drought 2100 kcal/person/day in situations where and other disasters and looking for new the refugees are not able to significantly or opportunities for this work, the organisation consistently contribute to their own food aims to change the outlook for some of the intake - a situation in many of the refugee poorest and most marginalised Ethiopian camps in East and Horn of Africa, including communities. Ethiopia. UNHCR, within the overall mandate of protection, is focused on ensur- In the face of climate change, Christian Aid ing that the food is part of the overall basic will seek to mitigate its impacts and support assistance package and meets the minimum people to adapt. Despite the increasing chal- nutritional requirements, at times augment- lenges the changing climate brings, Christian ing the general food distribution with Aid believes that communities who need food complementary foods when necessary to aid year after year can be supported to bolster micronutrient content or enhance achieve self-sufficiency where neither chil- dietary diversification. dren nor adults go to bed hungry each day. Joint assessment missions (JAM) For further information, contact: Antoinette In order to assess the food security and Powell, email: [email protected], coping mechanisms of refugee caseloads, telephone: +44 (0)20 7523 2288 (UK) joint assessment missions (JAM) have been

49 Field Article

Case study 1: Discussions with the Women's Association In Malkadida Camp

During lively discussions with the Women’s Association in Malkadida Camp, Dollo Ado, Ethiopia, Aisha explained her monthly use of the ration: I have a family size of five. When I get my ration I receive a 50kg bag of wheat grain and an

Lubna Khan, Ethiopia, 2010 additional 30kg in a sack. I sell the 30kg for 2birr/kg and receive 60 birr. With this money I purchase milk, tomatoes and some firewood. If there is money later in the month, I might buy some onions and potatoes. I take the 50kg sack to the mill and I have to pay one scoop payment for every 2 scoops I grind. The prices are very high. We then eat the wheat flour with the red beans, oil, sugar and famix (CSB) plus the food I bought at the market. Often the food does not make it to the end of the month and I borrow from friends or take food from the store- keeper on credit. We prepare the wheat in three ways- if it is flour, we make injera (flat bread), if it is semi-ground we make ugali (porridge) and if it is unground, we grind it by hand, soak it and cook it with beans and oil- but it is not good like this for the children, it gives them stom- ach ache. I would like to buy rice and pasta but it is very expensive in the market, so I eat what I am given and sell what I can to buy a few other essentials. Aisha, Malkadida Camp, October 2010 Children in Melkadida Camp

organised since 1994 and are carried out in most basket that has a value of approximately 2,100 losses from refugees having to mill the whole- protracted refugee situations every two years. kcal/per person/per day, with commodities grain cereal (primarily maize) distributed. The These review/re-assessment missions are a that have adequate protein and fat content, as 350 kcal addition was meant to make-up for unique opportunity for UNCHR and WFP to well as key micronutrients in sufficient quan- both the losses in milling (dehusking/milling undertake a joint analysis of the ongoing tity. In practice, the ration rarely meets 100% of the cereal into flour reduces the overall quan- context in the field and determine program- these key benchmarks, often due to very low tity) as well as the cost of milling (most refugees matic options for supporting the refugee levels of vitamin C, iron, or calcium. The ration use commercial mills). It assumes that after caseload with food and other needs. A JAM caloric value can also be adjusted if external milling deductions, the ration meets the 2100 Guideline, drafted in 2004 and revised in 2008, factors such as an unusual demographic situa- kcal average ration level. The refugees in represents a working manual with many tools tion (predominantly adult men in a camp or a Ethiopia are considered to be highly dependent and suggestions for best practice in examining high altitude camp) suggest that a higher on food aid because of their lack of economic food and non-food needs and fulfilling organi- caloric value is needed for a majority of a popu- opportunities, including agricultural produc- sational responsibilities. These are laid out in lation. tion. The majority of refugees in Ethiopia are the 2002 (updated in 2010) memorandum of living in arid lands isolated from major It should be noted that the ‘magic number’ understanding (MOU) between UNHCR and commerce, systematic employment opportuni- of 2100/kcal/day is not the actual daily caloric WFP. According to the guidelines, “The ulti- ties or even agricultural production. Therefore intake for any single group, but rather repre- mate goal of the partnership between UNHCR the refugees on average are not able to meet sents a household average based on a family of and WFP is to ensure that food security and their own food needs and rely heavily on the five where there are two adults and three chil- related needs of the refugees and returnees (and food aid provided. dren. It is based on the assumption that the persons of concern) that UNHCR is mandated overall ration will be pooled by the family and Unfortunately, the food aid is quite monoto- to protect and assist are adequately addressed.” shared out according to need, so that the house- nous with very little variation for refugees (MOU, paragraph 2.1). hold members with higher caloric need will living in protracted refugee situations like Food aid provision to refugees have their ration augmented by the ration of Ethiopia. Refugees receive a ration basket that UNHCR provides complementary foods and those with lower caloric need (young children). provides cereal, oil, pulses, fortified blended selective nutritional supplies where indicated. The demographic profile of the household is food, sugar and salt. In order to diversify the In some refugee situations worldwide, refugees very important - for smaller household sizes, if diet to acquire fresh fruits and vegetables, have access to formal legal labour, to agricul- there are several children and one adult, then spices and occasional animal products (meat, tural lands for own cultivation or to significant the calories will be most likely sufficient as the eggs, and milk), refugees will often sell or livelihood opportunities that support their abil- pooled calories can be shared and will meet the exchange part of the ration to purchase other ity to provide some or all of the food for adult caloric needs. However for a household food items. Often these sales/exchanges of themselves. In some places, the location of the with one adult, there are often food shortages ration items for other food items are at very refugee camps (dry, desertified areas) or the when the individual is fully dependent on the poor terms of trade due to surplus of food aid political situation (no freedom of movement or ration, because the 2100 kcal does not meet the after distribution and the high cost of bringing no work permits available) or demographic daily requirements of an adult. One of the chal- fresh foods into the often remote areas. In many constraints (camps of new arrivals, camps of lenges of a JAM is to ensure that the ration cases, refugees are selling food aid for less than primarily women and young children, or value and commodity composition is appropri- the actual cost of the food (including transport). camps far from economic opportunities) curtail ate for the majority of the refugees in the camp. However, the need for diversified and more balanced diets, with foods that are culturally the possibility of refugees growing or purchas- Food basket of refugees in Ethiopia appropriate or more appreciated, represents an ing their own food. In these instances, food aid Food security in an encamped refugee setting, important trade for refugees and goes beyond is requested by the host government and in such as in Ethiopia, Kenya, Djibouti, and the actual cost or value of the food. The JAM most situations provided by WFP. Sudan, is often centred around a food aid ration will often note that the high level of sale of the that is intended to provide most, if not all, of the Refugees are also in need of non-food items ration reflects a desire for dietary diversity to average 2100 kcal/ person/day target for (NFI). Some essential NFI are provided by both enhance the nutritional value of the meal households. The JAM exercise determines UNHCR on a periodic basis (or as a ‘one-off’ or the palatability of the monotonous ration whether or not this level of food aid is required distribution) such as cooking fuel, kitchen sets (see case study 1). and plastic sheeting. Additional NFIs provided by seeking to determine how refugees are by other implementing partners or groups coping within the camp, what access they have The challenge of JAM include books, clothes or shoes, while some to income such as agricultural land or daily An ongoing issue in JAM in assessing the level NFIs are not provided at all, e.g. wash basins, labour, and whether there are any clear indica- of food security is to determine what refugees combs, adornments, tea kettles. In refugee tions that a majority of refugees are able to meet need in terms of food and NFIs based on what settings where there are few economic opportu- some or all of their own food needs. they receive through food aid and NFI, and nities, the refugees will often use the sale of the Refugees in Ethiopia are currently receiving what a refugee household can self-provide in ration to purchase NFIs that are not provided. approximately 2,450 kcal/per person per day terms of own production, income, remittances, savings, and barter/trade. Clearly agencies WFP, according to international standards, because the JAM in 2008 determined that an would prefer to spend the least resources has determined that a ‘full ration’ is a food additional 350 kcal was needed to replace the

50 Field Article

WFP and UNHCR offices as well as key the wider JAM mission in order to reach implanting partners or government representa- consensus taking all into account. This process tion. The goal of the training is to enhance of consensus is very important for the JAM understanding of the joint process, to discuss because it not only encourages assessing issues how it relates back to the shared MOU and util- from a multi-sectoral viewpoint, but also isation of the JAM Guidelines. ensures that the recommendations reflect the different capacities and expertise of the agen- Traditionally a JAM has six distinct stages: cies involved. planning and drafting of the TOR, creating the thematic teams and the thematic checklists, In the Ethiopia JAM, the different teams training of participants in the JAM before the were charged with using secondary data, field field work, undertaking the field work and work and analysis to review the current provi- review of the secondary data, information sion of services, the changes and potential analysis, and drafting of the report and key improvements in the last two years, as well as recommendations, finalisation of the report and the progress made on the JAM recommenda- A water point in Melkadida camp, Kenya development of the joint plan of action to oper- tions made in the previous JAM 2008. The JAM

Lubna Khan, Ethiopia, 2010 ationalise the recommendations. Participation 2010 focused on the relatively new Somali case- of both UNHCR and WFP is essential at all of load in the south and the expanding Eritrean needed, yet at the same time ensure that the six stages to ensure that both agencies have refugee population in the north, as well as those refugees are, to some degree, food secure. There input on the key issues to address and are part living in camps and in scattered settlements in is therefore a need to understand what refugees of the investigation and analysis. Typically a the Afar region. Key issues highlighted in the can provide and what needs to be provided.. JAM will have either five or six thematic teams TOR included the lack of meaningful durable This can vary widely from country to country, and each of the teams will comprise a mix of solutions available beyond resettlement, provi- from camp to camp and then from household to UNHCR, WFP and implementing partner staff. sion of basic assistance to the hard to reach household within the camp depending on level This adds to the richness of the discussion and caseloads (Afar and Dollo Ado) and the protec- of self-reliance of the family. the analysis as different team members have tion concerns, including sexual and gender unique perspectives and experience, yet must based violence. The report should be UNHCR and WFP undertake a JAM in order reach consensus with one another. completed by the end of November 2010 and to understand the situation, needs, risks, capac- the key issues/recommendations in the report ities and vulnerabilities of refugees with Ethiopia JAM 2010 will serve as the basis of the joint plan of action regards to food and nutritional needs. In order In the JAM which took place in Ethiopia in between UNHCR, WFP, ARRA and the imple- to understand this, the JAM must look not only October 2010, there were five thematic teams menting partners for the next two years. at the food security of an individual household, covering food security and coping strategies but also develop a basic understanding of all of (team 1), logistics, roads, warehousing, NFI and In many ways, a JAM is a jigsaw puzzle, the assistance programme s in the camp. In markets (team 2), health, nutrition, education where the different pieces come together to order to understand this it is necessary to look and school feeding (team 3), environment, shel- represent the food security of the refugees into different sectors, different programme ter, cooking fuel, livestock, WASH and living in a camp. How refugees configure their areas and the diverse causal areas that can lead agriculture (team 4), and durable solutions, lives within the limitations and opportunities of to food and nutrition security for refugees. new arrivals, refuge numbers, host community a camp, how food is shared, sold, bartered, the These include access to agricultural land, cook- and contingency plans (team 5). Three separate household decisions regarding food prefer- ing fuel sources, milling and transportation operational teams travelled to the different ences and meal planning for different costs, health and nutrition services, special areas of Ethiopia due to the large geographic household members, the purchase of necessary nutrition programmes, infant and young child distances between the camps- one team to the non-food items or additional luxury items, the feeding, income generation and livelihood North to focus on the Eritrean caseload, one possibilities of income generation, day labour opportunities, to name a few. team to the East to focus on the three Jijiga-area or employment opportunities, the opportuni- Regional JAM training Somali camps and one team to the South to ties for agricultural production or livestock raising and the provision of basic services Over the last two years, UNHCR and WFP have address the Somali caseload in Dollo Ado. The including adequate shelter, water, hygiene, been attempting to standardise the JAM process JAM organisation ensured that each team had sanitation and the availability of adequate to improve outcomes, including key achievable representation for the five thematic areas from health services. All of these are pieces that allow recommendations and a report reflecting the the different agencies and was scheduled to us to construct a profile of the households in the key issues. To that end, two joint regional train- ensure that each camp received one to two days camp in order to then determine both the ings have been organised in Rwanda and of field work. The actual information gathering opportunities for self-reliance as well as the Ethiopia, with a third planned for November of the JAM is in three distinct phases - review of need for external assistance. 2010 in Jordan. The regional trainings have secondary data, field work and then analysis. highlighted the stages of a JAM from terms of After the thematic teams have determined their For more information, contact: Allison Oman, reference (TOR) to field work to debrief to joint key findings and recommendations, these are email: [email protected] plan of action. Participants are invited from then shared with the other thematic teams in

Case study 2: A snapshot of a JAM debriefing during the field work

At 5:30pm, the last team, Team 3, arrived in a cloud of the primary groups considered vulnerable?” “Do people dust and emerged from their filthy land cruiser. They like the dome tents? What were they saying they would had been delayed in the camp in order to complete prefer for shelter?” “How soon can we end water tanker- one final focus group discussion with the community ing?” Each group presented and debated, making health workers. They entered the outdoor meeting notes on recommendations and discussing until the hall just as the sun was beginning to set. It was still entire team agreed on the issue and some possible hot, about 40 degrees, and the fluorescent lights solutions. were attracting the crickets that had hatched the day It was now 9:00pm - dinner and a shower waited and before. As each team leader rose to discuss key there were still final notes to type and changes to points and recommendations, they were dive make before the JAM in this camp was completed. bombed by a swarm of crickets, which covered their The teams would be leaving at 6:30am the next clothes and occasionally dropped into their shirts. morning for the other camp.The JAM coordinator The discussion was lively, at times heated, as the thanked everyone and called it a night, and the different groups discussed and debated the findings exhausted but excited team wandered into what of the day. “Ok, so people are selling the ration to buy remained of the evening, still debating the relative other foods- which ones?” “How much is a kg of wheat merits of wheat flour compared to wheat grain. worth?” Who is making the profit from the mill?” “How Dollo Ado, October 2010 A focus group during the Ethiopia many refugees are working with the NGOS?” “Who are JAM in Bolkolmayo camp Lubna Khan, Ethiopia, 2010

51 Field Article

orld Vision Ethiopia (WVE) is a Admissions started at seven OTP sites and the non-governmental organisation SC. A Supplementary Feeding Programme (SFP) (NGO) that has been working in component was not included, as this should be World Vision Ethiopia implementing cross- provided by the GoE Extended Outreach Wsectoral relief, rehabilitation and development Strategy/Targeted Supplementary Feeding programme programmes since 1971. A WV supported (EOS/ TSF) programme. programme to support community based Key lessons from the 2008 programme management of acute malnutrition1 in the The end of term evaluation of the programme Southern Nations and Nationalities Region for severe identified a number of key lessons: (SNNPR) has been in operation since November 2006. An effective linkage between the OTP and acute EOS/TSF programmes was not realised during WVE implements cross-sectoral program- the programme. Due to the timing of screening ming through Area based Development and registration for the EOS/TSF programme malnutrition Programmes (ADPs). These operate independ- (every six months), children discharged from ently of each other while benefiting from the OTP were not able to receive a timely regional programme office oversight and supplementary food ration from the in SNNPR national level coordination. The ‘life-cycle’ of programme. Hence, on discharge, children an ADP is usually approximately 15 years with were provided with a protection supplemen- a programme planning review following a 5 Follow up appetite testing tary food ration until the next screening and yearly cycle (current Durame ADP plan is for at a health facility registration. 2006-2010). Programming partners and stake- holders include multi-sectoral faith-based The community outreach activities are organisations (FBOs) and community-based conducted primarily through the efforts of organisations (CBOs), as well as other interna- volunteer community health promoters (CHPs) tional NGOs (INGOs), NGOs, communities and and supervised by the health extension workers the Government of Ethiopia (GoE). (HEWs). The CHPs are responsible for referrals Context from the community, making them the gate- keepers to the OTP programme. However they The SNNPR region is characterised by a highly are not supervised effectively when conducting localised pattern of micro-climates. With 45% of anthropometric measurements. In addition, the the region’s Gross Domestic Product (GDP) role of the CHP in the community does not relying on agriculture, there is a strong correla- include frequent and comprehensive screening tion between livelihood and seasonality for for malnutrition. Unless other community individuals and communities alike. screening measures are employed, the OTP A nutritional survey conducted by WVE in service coverage is likely to be low, possibly June 2006 in the Durame ADP revealed a global resulting in late presentation and increased risk acute malnutrition (GAM) rate of 8.5% and of mortality. Future community sensitisation severe acute malnutrition (SAM) rate of 1.3%. and mobilisation efforts should aim to dissemi- The crude mortality rate (CMR) and under 5 nate knowledge of community based mortality rate (U5MR) were 0.31 and 0.89 management of acute malnutrition more deaths/10,000/day, respectively. A further widely through other channels, to encourage WVE rapid assessment using mid upper arm self referral. Mesfin Teklu, WV, Ethiopia, 2006 WV, Mesfin Teklu, circumference (MUAC) in September 2006 The outcome indicators for the programme By Dr. Sisay Sinamo and found substantial moderate acute malnutrition all exceeded SPHERE standards (see Table Dr. Gedion Tefera (n=2207) and severe acute malnutrition (n=258) 1).These outcomes also compared very in children less than five years of age. Based on favourably with other community therapeutic Dr Sisay Sinamo is these assessments and at the request of the care (CTC) programmes. The period coverage Coordinator for the Health regional and zonal health offices, it was decided of the programme was estimated at 67% which, and Nutrition Coordination that a programme to manage acute malnutri- Unit with World Vision multiplied by the percentage of children cured tion at community level should be Ethiopia. A medical graduate (95%), suggests approximately 64% of needs from Addis Ababa University, implemented by WVE from October 2006. were met. Rates of reported weight gain in the he holds a Masters in Public Accordingly, a Memorandum of Understanding programme were lower than expected for a Health. He has worked in (MoU) was agreed between stakeholders for the areas of nutrition for about 10 years with prac- CTC programme (5g/kg/day). This was likely programme to run for one year until September tical field experience in community based due to the RUTF ration being shared during 2007. The programme was supported by Valid nutrition, PD Hearth programming, emergency times of need. Slow weight gains during the health and nutrition and SMART in a number of International and implemented by Ministry of programme were not reliably followed up by countries. Health (MoH) staff and three WVE staff hired to clinicians according to the ‘alert protocols’ and coordinate the activities. Dr Gedion Tefera is emer- discharge decisions were inconsistently applied. gency health and nutrition Programming approach These factors combined to lead to an extended programme manager with Commitment was obtained from the health stay in the programme for some individuals, World Vision Ethiopia. He is a which meant an increased use of resources medical graduate from Jimma bureaus at different levels and UNICEF agreed University, Ethiopia and holds to provide Ready to Use Therapeutic Food (RUTF and workload) and ultimately reduced a Masters in Public Health (RUTF) and IMCI2 drugs. An understanding the cost effectiveness of the intervention. (MPH). For the past 4 years, he was reached to establish a Stabilisation Centre The weak supervision by clinicians of the has worked in emergency nutrition and (SC) at Wota health centre. A developmental community based nutrition projects like essen- MUAC measurement taken to admit children tial nutrition package and PD/hearth. approach was adopted towards programming, meant that, in many cases, it was effectively the to develop capacity of the MoH to provide effec- CHP making the decision to admit the child to tive treatment for SAM within the routine health We would like to express our thankfulness to the OTP. Training of staff was frequently weak the community where World Vision works and system. Orientation for MoH staff took place with regard to follow up and management of to our partners, especially the Ministry of between mid November and early December cases. A weakness in logistical management at Health. We also would like to thank World Vision 2006. Eight MoH staff from seven OTPs and one all levels was found. The main weakness was in Ethiopia for allowing us to publish our field health staff from the SC were trained on OTP generated learning. Special thanks go to World ordering and regulation of the RUTF supply. Vision Canada/Nutrition Centre of Expertise and SC case management. An additional 19 WV staff who welcomed this opportunity to staff from Ethiopia, Kenya, Sudan, Somalia, publish, and to the ENN staff who supported us Uganda, Canada, US and World Vision 1 Formerly called CTC (community based therapeutic care). 2 Integrated Management of Childhood Illness during field level documentation and editing International (WVI) were also trained. of this article.

52 Field Article

Figure 1: Trend of OTP/SC admissions, 2007 Table: 2: Summary of ADP level nutrition information

70 Name of WV Sub- ADP Total Total GAM* SAM* Data When were Level where the 60 ADP office population 6-59 months Source the data data were collected collected 50 40 Quacha Birra WVUS 142,221 19,643 17.6 % 1.5 % Rapid March, 2009 ADP and District 30 Nutrition Gov Offices 20 Assessment 10 Omosheleko WVUS 204,571 34,771 24.9% 2.35 % Rapid March, 2009 ADP and District

No. of new admissions No. 0 Nutrition Gov Offices 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Assessment Programme period (weeks) Shone WVUS 228,614 38,864 34.0% 2.5 % EOS mass Dec, 2008 ADP and District OTP Admissions SC Admissions screening Gov Offices Durame WVUS 171,968 29,235 28.9% 0.5 % EOS mass Dec, 2008 ADP and District screening Gov Offices Figure 2: Admissions to SC as percentage of Total 747,374 122,513 OTP admissions, 2007 *Proxy data for GAM and SAM since based on rapid/mass screening. 100% Table 3: Project partners and areas of partnership 80% Partners Areas of partnership 60%

% UNICEF Provide some of the supplies needed for the implementation of this project such as 40% essential drugs, insecticide treated nets, and RUTF. 20% Regional Health Office Liaise logistics transfer between UNICEF and woreda MoH 0% WVE Allocate funding for the project. 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Supplement essential drugs, provide OTP/SC cards and formats, e.g. follow-up cards, tally Programme period (weeks) sheets, reporting formats, and supply protection ration that cannot be covered by other OTP Admissions SC Admissions partners. Work with the DMFSS Desk to link children discharged from the OTP to the EOS/TSF. Table 1: Programme outcomes compared with Work closely with DMFSS Desk to ensure linkage between OTP and SFP. SPHERE standards DMFSS Desk in the Facilitate supplementary food ration distribution (Corn Soya Blend, oil and sugar) for woredas Agriculture moderately malnourished children. Durame ADP OTP SPHERE standard and Rural Work with MoH to ensure proper referral between OTP and SFP. Cured 95 % > 75 % Development Offices Default 3 % < 15 % WFP Provide SFP commodities to DMFSS desk. Non-Cured 1 % Not stated Monitor distribution of SFP commodities. Died 1 % < 10% CHPs Participate in case identification, referral and follow up. All partners Participate in the project review. As the programme evolved, the admissions to the SC and OTP decreased over time (see the community-based management of acute needed to be filled. In 2009 there was no Figures 1 and 2). This is indicative of an increas- malnutrition programme, by virtue of their adequate rain during the short rainy season and ing skill level amongst the OTP clinicians in shared objective to impact their livelihood and the local administration and regional cases management, as well as of the beneficial work with vulnerable caregivers and children. Emergency Nutrition Coordination Unit effect of the decentralised public health extended a request to WVE for support. approach of community based management of Follow-on programme to manage SAM Furthermore, MOH and UNICEF with other acute malnutrition, i.e. early presentation and (2009-2010) partners planned to establish one OTP per timeliness of treatment. A general improvement In 2009, Ethiopia was affected by another short kebele and one or two therapeutic feeding unit in food security over the time period may also term mid year rain failure. Shone, Durame, (TFU) SCs per woreda. WV contributed to this have accounted for some of this positive trend. Qacha Birra and Omosheleko ADPs in SNNPR initiative through a partners’ capacity building were amongst those woredas most severely Durame ADP programming plans for 2008 approach and helped expand and strengthen affected and had not yet recovered from the included interventions that aimed to tackle the existing programmes in the four ADPs’ effects of the 2008 food crisis. underlying causes of child malnutrition and operational areas. mortality. Some of the more relevant The lessons learnt from the Durame project The current project is being implemented for programmes included care and support of (November 2005-December 2007) were instru- 12 months from October 2009. It targets an esti- people living with HIV (PLWH) and orphans mental in designing a programme to manage mated 4,559 children under five years of age and vulnerable children (OVCs), household acute malnutrition in the four ADPs. The with severe acute malnutrition in four ADPs. A food security programmes, water and sanita- programme began in October 2009 and was key aim of the project is to help build the capac- tion projects to provide potable water and based upon Government national guidelines ity of government staff in the health centres, income generation activity (IGA) schemes. for the management of SAM at both facility and health posts and community volunteers for 3 These programmes could have been linked to community level . It was developed in response smooth integration of the emergency interven- to findings of a Rapid Nutritional Assessment tion into the government system. Areas of Table 4: OTP indicators, Durame ADP, October conducted in two ADPs (Omosheleko and partnership are reflected in Table 3. Key 2009 to March 2010 Quachabira) in March 2009 and MUAC mass elements of the project envisaged at the outset Name of ADP Durame screening conducted by the EOS programmes were: No. of OTP sites 35 in December 2008 in Shone and Durame ADPs. • Implementation of community-based See Table 2 for the prevalence of GAM and No. of children admitted in OTP 273 nutrition projects in parallel with the SAM in the four ADPs. Additionally, early emergency intervention using the Essential No. of children admitted in SFP 447 warning reports from the four ADPs indicated Nutrition Actions (ENA) Approach. No of VCHWs trained on community 410 deterioration of the food security situation in based management of SAM Community education to include infant and the areas due to lack of early rain (March and young child feeding and maternal nutrition No. of MoH staff trained on community 117 April 2009). The government identified the four based management of SAM practices. ADPs as high priority areas for nutrition • The project has a number of capacity No. of WV staff trained on community 1 response. based management of SAM building elements and will be handed over at the end of the funding period (September Recovered 286 (99%) In 2008, the GoE had already started imple- 2010). During transition, the MoH will start Death 0 menting and scaling up SAM management in the four ADPs and integrating this within the to run most of the project activities. Default 0 routine health care delivery. However, the Relapse 3 (1.6%) programme had many capacity gaps that 3 Protocol for the management of SAM. Ethiopia-FMOH, 2007.

53 Field Article

• Links will be established between this After the first six months of the programme 31.7% were moderately under weight (>-3 and project and other ADPs’ food security and (to March 2010), there are already a number of <-2SD). Children found with oedema and development projects that impact household achievements: severe wasting were referred to the health facil- food production, consumption and income. ities. A ‘Positive Deviant Inquiry’ was Health facility assessment and stakeholder The OTP and SC will be linked with the conducted with the ‘Positive Deviant Mother’ analysis were conducted involving 127 health existing EOS/TSF with the ‘back up’ of a to draw on her experiences of child care, feed- posts and twenty health centres. WVE WV protection ration (see below). Acutely ing and health seeking behaviours and in order conducted joint woreda level planning work- malnourished children will be identified to develop the feeding menu and key health shops based on these assessments. The capacity through community-based screening or by messages to promote during the Nutrition gaps identified were presented to local MOH self-referral. Education and Rehabilitation Sessions (NERS office managers resulting in discussions and • The ADPs will conduct a local capacity session).Twelve days of NERS sessions were joint plans regarding how to fill these capacity assessment on management of acute organised, with each session composed of 10 gaps. malnutrition in the community to identify non-PD mothers and two PD Mothers. For each gaps. Trainings will be designed based on By the end of March 2010, the programme group, a 12 day feeding session was conducted this assessment. During the initial assessment had scaled up and was being implemented in with close monitoring and with follow up by conducted before the programme started, 125 kebeles in the four ADPs. A total of 761 the PD mothers and the HEWs. Growth moni- there are no operational SC/OTPs, facilities. volunteer CHPs have been trained and are toring was conducted on admission, during Hence, one facility will serve as an SC and working with the HEWs in OTP sites. A total of follow up, on discharge and after 12 days four or five OTP sites for initial opening in 113 OTP sites have been strengthened/estab- discharge and home follow up. A total of 240 each of the woredas. These would lished. By the end of February, 2010, 1116 mothers and their children participated. subsequently be expanded and strengthened children were in the OTP, with based on need. Where SCs and OTPs are the figure rising to 1438 chil- already in operation, these would be A volunteer community health dren at the end of March 2010. worker conducting screening strengthened based on assessment findings. • WVE and woredas MOH will conduct a one- Children discharged from day orientation session for Kebele leaders, OTP sites received CSB/Famix HEWs, CHPs, school teachers, and and vegetable oil. The ration community workers already working on comprises 8.3kg/month of community mobilisation, active case Famix and 1kg of vegetable oil detection and defaulter tracing. The HEWs per child per month. A total of from the most severely drought affected 52.016MT of CSB/Famix and kebeles will be trained first, followed by 6.153MT of vegetable oil were those in less severely affected woredas. distributed up until the end of • WVE will be responsible for the purchase of March 2010. essential medicine and other supplies needed, Other activities completed as well as hiring of vehicles for transportation during the first six months of of supplies and referrals, assisting the programme included rent- government health staff with screening and ing cars to provide onsite admission, periodic monitoring and technical support and supervi- supervision of the project implementation sion, printing and laminating together with the woredas health offices. Ethiopia, 2006 WV, Mesfin Teklu, necessary OTP guidelines and WVE will also print the different registration protocols, and hiring a nurse and two RUTF Over a 1 month period, nearly one quarter of cards (SC charts, OTP admission and ration distributors in each ADP project area. In some the children (24%, n=58) gained 0 – 200g in cards, etc) and monitor the recording and ADPs, food was provided for caregivers while weight, 13% (n=32) gained 200 – 400g, 28% the weekly and monthly reporting together they were staying at the SC. Two planned activ- (n=66) gained 400g – 1kg and nearly one third with the woredas’ health offices. ities that were not possible were purchase of (30%, n=71) gained over 1 kg. Five children • WVE will liaise with UNICEF and Regional RUTF buffer stocks due to limited budgets as a (2%) in the programme lost weight and eight Health Bureau for the timely provision of result of the economic crisis, and monthly children (3%) did not respond. Over half of the drugs and supplies to the health facilities review meetings with government health work- children (58%) were rehabilitated successfully through existing systems for logistics ers, due to competing work demands on based on PD hearth programme discharge crite- transportation. WVE will fill gaps in the government staff. ria (weight gain of at least 400g). Weight for age logistics pipeline, if needed. z score was used to determine the outcome. The Major challenges of the programme noted at The key programme design changes that proportion of children with severe underweight the six month review included: emerged from lessons learnt from the 2006/7 declined from half (51.7%, n=124) to under one- • Delayed staff recruitment programme were: quarter (23%, n=55) of the children. Follow up • Lack of routine medicines in some OTP sites • WV staff were not used to implement assessment was conducted and 85% of the • Irregular use of tally sheets at OTP sites directly the programme but focused on mothers had managed to teach their neigh- • Delay of purchase of some commodities, capacity building of partners, e.g. clinical bours to practice the new skills they had such as computers and essential medications, officers and HEWs, adopting a minimum gained. due to lengthy purchase processes. support approach. • Predicted shortage of CSB/Famix and Based on this and other experiences, WV • WVE supplied a protection ration for vegetable oil in the coming months. consider that in resource poor settings, PD children discharged from the OTP as it • Limited capacity of staff to use the WV hearth is a practical and sustainable behav- could not be assumed that these children database ioural change approach to prevent malnutrition would be enrolled on the EOS/TSF. and contribute to child well-being outcomes. • The referral system to SCs was changed to Despite these challenges, OTP programme WVE emerging policy in Ethiopia is that when rely on self-referral, where mothers/ outcomes are very good, reflected in Table 4 SAM continues at low levels, perhaps following caregivers now take their children from using Durame ADP as an example. an emergency intervention, OTP can be main- OTP to SC. Previously WV had hired streamed into the regular health system to vehicles to transport ‘complicated’ SAM Minimum support: PD Hearth WV has recently completed an exploratory PD provide services for acutely malnourished chil- children from OTP sites to SC. Hearth programme in Atbi Womberta ADP dren with PD Hearth focusing on preventative Six month review where a SAM management project had been rehabilitation services in the community. Local MOH have taken the lead in implement- phased out to a ‘minimum support project’. ing the OTP, SC and community mobilisation For more information, contact: Sisay Sinamo, Among all children under 5 years measured components, as well as beneficiaries follow-up email: [email protected] in the district, a total of 240 children were found in the community and referral to the EOS/TSF. and Dr. Gedion Tefera, underweight (weight for age <-1SD) of which Volunteers have screened and referred children email: [email protected] 51.7% were severely under weight (<-3SD) and to the OTP sites.

54 Agency profile

Plan Ethiopia and professional associations, the school offers PST on Nutrition in HIV, Integrated Management of Neonatal and School of Nursing Childhood Illnesses, Prevention of Mother to Child Transmission of HIV, Comprehensive and Midwifery & HIV/AIDS care, Palliative Care, Infection Prevention and Injection safety. These PSTs are usually conducted when students prepare to Pre-Service Training enter their clinical years, a few months before they graduate and go into the community. This on Nutrition, facilitates the immediate application of their newly acquired knowledge and skills. Hawassa University, Stakeholders, such as the WHO, Ministry of Health and Ministry of Education as well as Ethiopia employers, have clearly stated the importance of equipping the graduates with the necessary By Aweke Yilma Dubi, Head, knowledge, skills and attitude (competency) to School of Nursing & Midwifery tackle new health and nutrition problems and emerging technologies. PST is viewed as a particularly cost effective approach in terms of money and time expended. Pre-service train- ing has many advantages when compared to thiopia is one of the least developed ent academic levels, ranging from assistant in-service training (IST) in that it creates the countries in the world. According to professors, and lecturers to graduate assistants. opportunity for building the capacity of large the Government’s Interim Poverty Staff have a diverse range of professional qual- numbers of potential health professionals Reduction Strategy Paper (2000-2003), ifications in the areas of curriculum within a short period of time. The existing infra- Eover 45% of the population lives below the development, public health, international structure and system of a university/institution poverty line. A consequence of this widespread health, maternal and child health, midwifery, helps keep costs low. Furthermore, PST poverty is low levels of human capital accumu- adult health nursing. Unfortunately, the School provides a golden opportunity to equip gradu- lation. Whereas countries at the forefront of of Nursing and Midwifery has no staff trained ates with the requirements of the work development often invest in education and in nutrition or with a nutritional background. environment and enable them to integrate aggressively engage in human capacity devel- The education of nurses and midwives themselves into the community norms and opment and knowledge transfer, those who do cultures. In contrast, IST, though very useful, not or cannot often fail to bring about signifi- In order to meet the national aim of creating can be very costly in monetary terms and can cant development. Poverty reduction is a major sustainable human resource capacity for health take staff away from their place of work for issue for Ethiopia and capacity building in the and nutrition services, the School of Nursing considerable periods of time in an already public and private sectors is a key building and Midwifery offers undergraduate training under-staffed environment. block to accelerate much needed socio- to prepare the nurses and midwifes for the demanding environment of Ethiopia. This envi- economic development. Cognizant of the role the School plays in ronment is characterised by high prevalence of producing a critical mass of nurses and The Higher Education Training Capacity HIV/AIDS, high maternal and infant mortality midwives for nation building and the benefits of Building Programme is part of the development rates, malnutrition and frequent emergencies, working in collaboration with new partners and effort of the Federal Government, regional as well as high levels of staff attrition. The role stakeholders, Hawassa University is re-design- states and the private sector. This aims to create of nurses and midwives in Ethiopia has had to ing the overall university curriculum into a countrywide sustainable human resource diversify and broaden, so that in addition to modular system. This presents another opportu- capacity that is responsive to changing circum- hospital based clinical work, they need to be nity to integrate areas of concern into the stances. The development of higher education able to work in community-based programmes nursing and midwifery training programme. is among the highest national priorities. It is in areas, such as therapeutic and supplemen- viewed as the major instrument towards tary feeding and HIV. In line with this development, the School is achieving food security and alleviating poverty actively seeking collaboration with partners to To help prepare the graduates for these roles, and other social and technological problems the build the capacity of faculty members in the the School has designed a Community-Based country is facing. Hence, capacity building is area of nutrition in emergencies and in Training Programme (CBTP) and Team the cornerstone of sustainable development in HIV/AIDS and nutrition. This is needed to Training Programme (TTP). This involves Ethiopia. In addition, there is a need to build equip the teaching staff with additional skills students being deployed to remote and hard to the research capacity and address the critical and knowledge to pass onto the nurse and reach communities affected by drought, high issues of the country, particularly in relation to midwifery students though the new modular levels of malnutrition and communicable malnutrition and diseases such as HIV. approach. Existing faculty staff do not currently diseases. During this period, the students work have all the knowledge and skills to design and Hawassa University with community members to assess their health teach a new module on nutrition in emergen- and nutrition related practices, such as food Hawassa University, previously known as cies or on HIV/AIDS and nutrition. Specific intake and food taboos, infant and young child Debub University, was established in April 2000 technical areas in need of capacity development feeding practices, feeding of infants and chil- by merging three colleges, namely Hawassa for faculty staff are in infant feeding in emer- dren during periods of sickness, nutrition College of Agriculture, Wondo Genet College of gencies and community-based management of during pregnancy, food hygiene, storage and Forestry and Natural Resources, and Dilla acute malnutrition; all pressing problems in preservation. The students plan, implement College of Teachers Education and Health Ethiopia. Recently, the School has started a and evaluate activities aimed at addressing the Sciences. Located at the centre of the Great Rift discussion with World Vision Ethiopia and identified problems in collaboration with Valley in Hawassa city, the University is the Tufts University in USA on capacity building of community members. largest and most comprehensive University in faculty staff in the areas of infant and young the Southern Nations Nationalities and In addition to the CBTP and TTP child feeding and HIV/AIDS and nutrition. People’s Regional state (SNNPRs) and in the programmes that are well integrated into the This offers a positive step forward towards southern part of the country. It has 24 academic formal undergraduate curriculum, the School strengthening the quality and content of teach- departments, four institutes, three colleges and conducts pre-service trainings (PST) on new ing in the future. 58 academic programmes, with more than competencies and concepts that, although not 20,000 students involved in 41 undergraduate, formally integrated in the existing curriculum, For further information, contact: Aweke Yilma 22 Masters and 2 PhD programmes. There is 960 are seen as very important for the students Dubi, Head, School of Nursing & Midwifery, academic and 1,100 administrative staff. professional development. In collaboration University of Hawassa, Hawassa, Ethiopia. In the School of Nursing and Midwifery, with governmental and non-governmental P.O. Box 1504 there are 800 nurse and midwifery students and organisations such as Save the Children, World tel: +251 462 211 003 (Office) 30 academic and administrative staff at differ- Health Organization (WHO), World Vision, e-mail: [email protected]

55 Field Article A farmer plows his field with the traditional yoke and pair of cattle ood for the Hungry Ethiopia (FHE) began MLREP components working in Ethiopia in 1984 through aid Relief element: Cash For Work (CFW) efforts in response to the famine at that This component aims to provide temporary time. In the beginning, FHE operated employment and thus income to chronically food Fthrough partner organisations, delivering emer- insecure HHs and, at the same time, create gency food aid to those affected by the famine. productive community assets through their

A Simons/FH Ethiopia, 2010 The recurrence of famine ten years later moti- labour contribution. FHE undertakes nursery vated FHE to become an operational operations and the construction of ponds for live- non-governmental organisation (NGO), directly stock through CFW as a temporary employment implementing relief and rehabilitation scheme. The majority of the nursery workers are programmes in the country. Since that time, FHE women who have suffered from the drought and has grown tremendously and has taken further food price crisis. measures to address the root causes of poverty through tackling issues related to sustainable Micro-credit provision development. All agricultural inputs and equipment are deliv- ered to farmer groups on a credit basis through FHE implements various types of projects in the Omo-Micro Finance Institution (OMFI). The four regional states in Ethiopia: Oromia, beneficiaries are organised initially into Amhara, Southern Nations, Nationalities, and producer and marketing groups, and should People's Region (SNNPR) and Benishangul eventually grow into cooperatives by the second Gumuz. The projects include: and final years of the programme cycle. The Food Security: FHE implements relief interven- proposed programme’s agricultural inputs will tions to soften the impact of drought in be distributed on a loan basis. This differs from chronically food insecure woredas in Amhara the usual OMFI operating procedure where cash and the SNNPR. is normally disbursed to a beneficiary for a loan. In this programme, however, the input (beehive, Agriculture & Environment: This includes train- water pump, etc.) is delivered directly to the ing in agronomic practices, micro-irrigation, beneficiary and then OMFI recovers the loan animal health, fruit and coffee production, envi- value of the agricultural input over time. Market-led ronmental protection and natural resource management. Livestock/seeds Livelihood FHE intends to increase livestock productivity Child Development & Education: Social devel- through introducing higher yielding local opment, child health, education support breeds, improving livestock husbandry prac- Recovery and programme and income generating activities. tices, promotion of dairy farming and improved This programme is geared to improve the lives forage production. Further, it will work to Enhancement of children, mostly orphans. strengthen the market link for livestock produc- Health & Nutrition: Micronutrient interven- ers, so that they are able to generate better Programme tions, nutritional supplementation, dietary income from their production. The seed sub- diversification and disease control training. sector focuses on seed provision of marketable and integrating and high yield improved varieties, aiming at Water & Sanitation: Building of hand-dug and increasing and diversifying incomes and liveli- shallow wells, springs, roof catchments, potable hoods of the affected farming HHs. ENAs water supply schemes, cattle troughs, latrines, and hygiene promotion. Irrigation By Andrew Simons, Daniel Small scale irrigation is promoted through hand Gebeyehu, Getachew Gemtesa HIV/AIDS: HIV/AIDS prevention and aware- dug well construction and delivery of motorised and Markos Kidane ness education. pumps. The programme supplies locally avail- Andrew Simons is the National able materials and skilled labour during well Programme Director for Food The Market-led Livelihood Recovery and Enhancement Programme (MLREP) construction and provides water lifting pumps for the Hungry (FH) Ethiopia. He based on the depth of the well through a micro- holds an M.P.A. in International The MLREP, funded by USAID-OFDA1, was credit system arranged with OMFI. Development and has worked launched in March 2009 and is a three year in various development programmes in countries programme. The MLREP aims to improve the Value chain analysis (VCA) ranging from El Salvador, Afghanistan, Ethiopia, food and livelihood security status of small- VCA is useful for producers who are trying to Dominican Republic and Honduras. holder households in the three target districts integrate into markets in a manner which would (woredas) in SNNPR. The project covers 33 provide for sustainable income growth. VCA Daniel Gebeyehu is Director of kebeles (village associations) in the three provides the answer to the question, ‘which the Emergency Relief districts. The primary target beneficiaries of the commodity should be pushed further in terms Department for FH Ethiopia. He has a MSc in Remote Sensing project are the acute and chronically food inse- of ease of access to input and output markets?’ and GIS and a BSc in Forestry cure households (HH) in the target districts. To Four crops/commodities were identified based from Alemaya University of ensure the targeted beneficiaries will be able to upon on these ‘ease of access’ criteria: Agriculture in Ethiopia. He has realise food self sufficiency and produce surplus been with FH Ethiopia for five years. products for the unmet market demand, the Honey was strategically selected as the value project has integrated various livelihood chain to be implemented because of potential Getachew Gemtesa is Agricultural components that arose following the results of a for income gains and the central role of bees in Marketing and Livelihoods Value Chain Analysis (VCA) study (see below improving and enhancing overall food security Coordinator with FH Ethiopia. through pollination of food crops. Additionally, Getachew has a BSc degree in for more information). All interventions have plant sciences from Alemaya been planned based on the needs and potential forage seedlings that flowered were selected to University and is currently of the target communities. Targeting criteria be grown in the CFW nurseries, to link with pursuing his postgraduate developed by FHE and the government District those beneficiaries who would be focusing on studies from IGNOU in Rural Developments. Office of Agriculture (DOA) are used by local the honey value chain. Markos Kidane is Public leaders to select beneficiaries. The programme Potato is among the most efficient commodities Relations Officer with FH and is targets HHs who normally produce grain for for converting natural resources, labour and involved in hosting teams from food and sell any surplus as their sole source of capital into a high quality food. Because of its the US to project sites and writ- revenue. These HHs have been forced to short maturity period (improved variety), it is ing success stories of FH purchase grain at unprecedented costs arising interventions. very strategic at mitigating food crisis in disas- from the Global Food Price Crisis (2008-2009), during which food prices in Ethiopia escalated 1 US Agency for International Development-Office for The authors would like to thank USAID's Office significantly. Disaster Assistance for Foreign Disaster Assistance for their generous funding of the MLREP programme. 56 Field Article

• Mothers whose household builds a latrine and uses it • Households who invest in growing/ purchasing nutritious foods and are educated on preparation methods In order to measure impact, household food A Simons/FH Ethiopia, 2010 A Simons/FH Ethiopia, 2009 consumption patterns and hygiene practices An example of will be recorded through interview before the Improved beehives, which produces significantly vertical farming nutrition component is launched. Comparisons more honey that a traditional hive in a FH Project in behaviour of the households can be made when a follow up survey is completed after the ter situations and offers better opportunities to creation. However, there was no obvious programme has run for a year. Regular mini- grow more quantities of food on less land in evidence that this increased income was being KPC (knowledge, practice, and coverage) relatively short growing periods. put to use to improve the nutrition and health surveys to ascertain any improvements will outcomes of the most vulnerable members of also be undertaken. Haricot beans are ‘number one’ both in terms of the family. Therefore, it was decided to modify volume of export and revenue generated the second and third year plan to include a Raising awareness during public among all pulses grown in Ethiopia. The high nutrition education component (which will gatherings nutrition value of the crop is also encouraging take effect in early 2011). The design is based on FHE volunteers will also educate the MLREP the programme to promote mass production in the successful integration of a similar nutrition beneficiaries at MLREP temporary employment the programming areas. component into the PSNP being implemented sites (nursery and cattle ponds) and food aid commodity distribution sites (part of a different Pepper is known as a cash crop and promoting by FHE in the South Gondar woredas of relief programme) though mass education. The its increased productivity enables an increment Amhara Region called the Care-Group Model. education will mainly focus on the ENA in household income level. This type of pepper The programme will use volunteers to messages and the EHAs will focus on hand is dried and ground and makes the base ingre- disseminate nutrition and hygiene related washing at appropriate times using soap or ash, dient of common food spices (called berbere) messages to MLREP targeted beneficiary moth- creation of hand washing stations at the house- found in almost all Ethiopian cuisine. ers. Community volunteers, selected by Health hold and other community settings (e.g. Cash crops analysis Extension Workers (HEW) and kebele officials, marketplaces), proper disposal of faeces, and will be trained on Essential Nutrition Actions The VCA has pointed out marketable effective point-of-use drinking water treatment (ENA) (optimal breastfeeding, complementary commodities that can be produced with high in households. FHE will arrange 20 minute feeding, feeding of the sick child, women’s potential through provision of necessary serv- session for education before distribution and ice supports along the value chain. FHE has a nutrition, control of Vitamin A deficiency, and any kind of public work, like nurseries manage- crucial role to stimulate the support system in control of anaemia and iodine deficiency disor- ment, pond constructions and others. the target woredas to improve the productivity ders) and Essential Hygiene Actions (EHA). The Community volunteers as well as social work- and marketing of the commodities by assisting HEWs will take the lead and FHE will provide ers in the organisation will give the education farmers to adopt best agronomic, processing educational materials and facilitate the training. in collaboration with HEWs. and marketing practices. The Care-Group Model approach focuses on Lessons and opportunities Integration mothers of reproductive age who are benefici- FHE has found that even the most food inse- The MLREP programme is not a standalone aries of food aid (parallel PSNP or relief cure households are able to participate in the programmes) and MLREP activities. Mothers initiative, but rather dovetails with the micro-credit scheme established. The key is to will be divided into groups of ten to fourteen Government of Ethiopia’s (GoE) led Productive provide these households with an appropriate and each of these groups will elect one ‘leader Safety Net Programme (PSNP) programme. loan based on their needs and capabilities to mother’ who will be responsible for leading The MLREP programme targets PSNP benefici- make payments in the long-run. One key discussions in the group under the guidance of aries to help them build assets and graduate element involved with this has been for FHE to the volunteer promoter. The promoters meet from the PSNP programme. serve as a ‘middle man’ to negotiate better with the lead mothers every two weeks for terms for the farmers with the OMFI. For FHE coordinates, shares information and about two hours. Religious and community example, FHE has helped to lengthen the time collaborates closely with many actors in the leaders can also serve as co-promoters. required to pay back loans for certain agricul- programme design, implementation, monitor- During Care-Group meetings, promoters tural based loans that better coincide with the ing and evaluation of activities. At the field will teach lead mothers by using flip charts agricultural production seasons. Proper train- level, FHE works with the DOA to implement (developed in other FHE programmes) for a ing and other supplementary inputs are also the different activities planned in this sector. total of 20 sessions. Similarly, lead mothers will necessary for the successful implementation of The officers provide technical assistance in the discuss the same topic with mothers in their the micro-credit scheme. selection of sites and beneficiaries, identifica- group. After completion of the session, the tion and sourcing of appropriate inputs, the Additionally, FHE has helped significantly groups will continue the meeting and will training of beneficiaries, etc. FHE is represented by ‘pushing’ OMFI into rural kebeles. As trans- on each targeted District’s Food Security Task discuss other health and social related issues. action costs to OMFI are high for smaller loan Force and ensures the programme is integrated The cycle of all lessons should take approxi- amounts, support in capacity building - such as with the development plans of the GoE and mately ten months. Establishing mother to motorcycles for the OMFI regional field offices other NGOs. The research centre in the region mother meetings should help mothers learn the - has lowered the costs for OMFI to do business acts as a source of technologies, information ENAs and discuss issues together to help bring with the most poor. This has lowered a barrier and knowledge by providing trainers, about the desired behaviour change which can for OMFI to help improve the access to these improved varieties of agricultural inputs and improve the nutrition and health outcomes of credit services for rural vulnerable households, improved agricultural practices. The private the children in the community. making it more likely they will travel to the seed suppliers serve as reliable sources of Outcome indicators rural areas to look for loan customers. improved seed varieties. The following outcome indicators will be meas- Supplying a packaged approach is an effec- The programme has a strong coordination ured: tive way to reach desired results in as the focus with other projects and this provides FHE • Mothers who practice hand washing at two complementary inputs provide a larger impact with the opportunity to share experiences and critical times, at least. than providing single inputs. For example, research outputs that can be applied in other • Mothers of children under six months who providing bee fodder to beneficiaries, in addi- areas. practice exclusive breastfeeding based on 24 tion to the access to the microfinance loan for hour recall the beehive, will allow their ultimate honey The Care Group Model for integrating • Mothers who increase the amount of fluid production to be higher, making a better chance Essential Nutrition Actions (ENAs) during childhood diarrheal illness for successful repayment of the loan. After the completion of the first year of the • Mothers of children under 5 years using MLREP, initial benefits were seen at the HH appropriate food diversification of For further information, contact: Andrew level as far as some income generation/asset complementary feeding Simons, email: [email protected]

57 Field Article An overview of REST’s implementation of the Productive Safety Net Programme

By The Relief Society of Tigray (REST) Mekelle Team

he Relief Society of Tigray (REST) has Furthermore, REST has developed very rich household. This is a larger monthly food trans- been in existence in Ethiopia for over experiences in drought and disaster manage- fer compared to other PSNP implementing 30 years, starting out as a relatively ment and in early warning and disaster agencies. REST also distributes 4.5 small organisation in 1978 in response preparedness. This has enabled REST to initiate kg/month/person of corn soya blend (CSB) to Tto the needs of Tigrayan’s displaced because of responses to droughts or other shocks at an malnourished children (low weight for age) drought and food insecurity to neighbouring early stage. and pregnant and lactating mothers, based on Sudan. The 1984/5 famine that affected large regular growth and nutritional monitoring by As part of disaster response management, numbers of the Tigrayan population saw REST health service institutions. This food is also REST initiated a strategy that food aid ‘should implementing large scale cross border (with distributed during emergencies to PSNP and go to the people and not bring people to the Sudan) humanitarian relief programmes. In non PSNP beneficiaries. RESTs distinct food’. As a result, REST manages a number of 1987, REST oversaw the agricultural rehabilita- approach to the PSNP is on integration of activ- distribution points close to those in need in all its tion programme, established to assist 160,000 ities with other national programmes activities operational woredas and has an overall storage repatriated Tigrayan refugees to rebuild their at the woreda and village level to maximise capacity of 50,000 metric tons (MT) of food. Over livelihoods. coverage and impact. the past five years REST has delivered 393,000 Tigray is a region of over 4.3 million people MT of food assistance, 2,100 oxen, 2,550 sheep, RESTs Environmental Rehabilitation and (out of a population of 76 million in Ethiopia) in and 800 donkeys. In addition, 4,900 households Agricultural Development Department over- the north of Ethiopia. Eighty per cent of the have bought farm implements from REST. sees the natural resource management related population live in rural areas, of which the activities in the PSNP in tandem with the Implementation of the Productive majority are subsistence farmers producing, on Irrigation Development and Rural Water Safety Net Programme (PSNP) average, only 40% of their annual minimal food Supply Departments. Natural resource requirements. Gross Domestic Product (GDP) REST has been an implementing partner in the management is viewed as a key activity area in per capita is US$115.00 and 89% of the popula- national PSNP since 2006 working in six chron- order to reduce the effects of drought and soil tion earn less than US$2.00 a day. Average life ically food insecure woredas in Central, Eastern erosion, and to increase food security through expectancy is 43 years. and Southern Tigray (Ahferom, Degua irrigated agricultural production and increased Tembien, Mereb Leke, Werie Leke, Wukro and livestock holdings. Natural resource projects In 1991, REST was registered as an indige- Raya Azebo) reaching over 450,000 beneficiar- account for more than 90% of the total public nous non-governmental organisation (NGO) ies (see Figure 1). works budget. All natural resource activities are and since this time, has focused on longer term implemented at watershed level. Typically, soil development programmes whilst maintaining The PSNP is a multi-year programme with resources committed to 2014. The overall goal and water conservation projects include physi- capacity in emergency response. Today, REST is cal measures (stone bunds, hill side terrace, one of the largest indigenous NGO’s in of the programme is to make a sustained change to food security and livelihoods of trench bund, gull treatment, micro-basin and Ethiopia, with the head office in Tigray’s capi- pitting for plantation), biological measures tal, Mekelle. REST has 700 staff and is funded chronically poor communities and reduce their vulnerability to disaster shocks. The PSNP (which includes area closures for regeneration, by many donors and international NGOs, with grass strips, and afforestation) and water an annual budget of around USD$10 million utilises food and cash transfers to support household food consumption, build commu- harvesting measures (river diversion, mini (2010). REST works in 23 out of 34 woredas dam, water harvesting check dam, open hand (districts) in Tigray. nity assets and provide a platform for the engagement of the most poor in agriculture- dug well, spring development). Since 2005, REST priorities and programme areas based food security packages and programmes. REST has treated and developed over 57,000 The stated goal of REST’s programming is to The REST PSNP originally provided food trans- hectares of degraded hill sides, 442 kilometres bring about food security for households fers for a period of eight months for of large gullies, seven mini-dams, 11 river within its operational areas. REST is organised contributions to public works by able-bodied diversions, 190 water harvesting check dams into a number of departments as follows: PSNP beneficiaries, and for a period of 10 and 645 open hand wells in the PSNP woredas. • Environmental Rehabilitation and months for direct support beneficiaries Watershed management is another key natu- • Agricultural Development (disabled persons, the elderly, sick and female ral resource activity. This involves the • Irrigation Development headed households). From 2008, the transfer construction of stone walls and trenches to • Health period was similar to that of the government retain water, provide moisture for shrubs and • Education PSNP for six months for public work and direct trees, re-charge the groundwater, prevent soil • Rural Water Supply support. The food entitlement is 15 kg of grain, erosion and thereby enable cultivation in the • Relief and Rehabilitation 1.5 kg pulses and 0.45 kg oil per month per previously dry valleys and river beds of diverse • Supplies and Logistics • Planning and Coordination Figure 1: USAID/REST PSNP – Productive Safety • Research and Policy Development Net Programme Woredas Relief and Rehabilitation Gully rehabilitation to protect farm lands From its inception, REST has provided emer- gency relief across Tigray and as a result, has developed significant experience and capacity in this field. Following the end of the civil conflict in 1991, the strategy evolved to inte- grate emergency programmes within development processes. For example, free food distributions were restricted to the most vulner- able in an emergency (estimated to be around Programme Woreda Non Programme Woreda 20% of the emergency affected population at any one time) whilst the remaining 80% receive food as part of food for recovery programmes.

58 Field Article

Micro-credit support activities and health staffs in order to facilitate the effec- REST integrates bee keeping, dairy, small rumi- tive delivery of information, education and nant, vegetable and fruit production to the needy communication (IEC) activities. PSNP beneficiaries to increase their food secu- REST/PSNP pursues nutrition and health rity. These are described in case studies in Box 1. improvements by integrating agriculture with PSNP linkages with Nutrition IEC. Interventions target women and children The PSNP is closely linked to key government (0-24 months) and focus on improving family national health and nutrition programmes diets in terms of intake/consumption and qual- including the Health Extension Programme, ity/diversity through increased farm HIV/AIDS programme, the National Nutrition production, storage and processing of high value Programme (NNP) and national Outpatient and surplus crops. Food for work and food as Vegetable production from incentive programmes are also key areas of open hand dug well Therapeutic Programme (OTP) roll-out. Linkages are through the provision of supplies activity. These make special provision for to health posts (gloves, weighing equipment, supplementary food for children, as well as crops (fruits, vegetables and drought resistant teaching aids), provision of CSB for malnour- increasing women's and community education crops) throughout the year. REST also supports ished children, capacity development including and knowledge to enhance mother and child implementation of micro-irrigation check training, and through the referral of moderately health to bring about positive behaviour change. and severely malnourished children from PSNP dams, open medium and large hand dug wells, Measuring the impact of the PSNP livestock development, crop development and households to the clinics and health posts. Environmental clean water supply activities. REST/PSNP provide capacity building Annually, it is estimated that Ethiopia loses PSNP implementation process focused on the NNP components for commu- over 1.5 billion tons of topsoil from the high- All activities are closely managed by commit- nity health workers, health extension workers lands including Tigray, which is equal to a loss tees at the community level. At the Tabia level, PSNP has two task forces: kebele/Tabia food Box 1: Micro credit support case studes security task force (KFSTF) and community food security task force (CFSTF). Both task Communal hand dug well forces have representation from local adminis- (Wukro woreda) tration, health extension, teachers, youth, and farmer and women associations. The role of the KFSTF is to consolidate public work plans, prepare PSNP plans in consultation with woreda sectors, verify PSNP clients and to eval- uate PSNP activities. Comprising three females, three males, a Landless beekeeping groups in youth representative and development agents area closures (Wukro woreda) (DA), the CFSTF is responsible for targeting the eligible communities, identifying public work Bee keeping and direct support participants and for mobilis- developed an open hand dug well for irrigation using In Ayna-alem village of Kilte-Awlaelo woreda, REST is PSNP public works. From the other food security ing the community jointly with DAs for working with young landless families to form bee- programmes he has gained credit access for a motor participatory works planning. CFSTF also keeping groups in areas where there is ongoing pump and has planted tomatoes in his half hectare of organise public meetings to discuss the watershed management that allows bee fodder to be land and earned 7,000 birr income. He was then able proposed list of PSNP beneficiaries, encourage grown (flowers). REST provides a Birr 3600 loan to to lease another half hectare of land in the village and comments from people attending the meeting each person to enable capacity building to get started increase his income to 15,000 birr. The change is seen and make amendments to the list as required, to and establish bee hives. Each bee group has, on aver- in many aspects. He says, “In the first place we are able age, 40 hives and can sell the honey as well as bee to get income and adequate and variety food, we are colonies. When managed well, 12 quintal (1 quintal = dressing well and my children are attending school, Hill side terrace to conserve 100kg) of honey can be harvested per person and sold and I am able to pay the credit.” soil and water for Birr 120 per kg. In addition, the beneficiaries raise Milk cooperative bee colonies and sell them to the market at average Established in 2005, the members of the Milk price of 700 Birr/colony. Cooperative have increased from 15 to 30. The aver- Income for water pumps age milk production capacity and profit is high as A 32 year old farmer, Gebre Kassa, lives in the eastern shown in Table 1. zone of Tigray and is one of the PSNP clients. He says that, “the safety net programme has saved our lives. Apart from the grain we get as payment, it has changed our Gebre with his work ethics. The implemented catchment treatment activ- motor pump ities recharge the ground and our degraded grazing land is saved from erosion and is rehabilitated. As a result, the village PSNP beneficiaries are able to develop open hand dug wells for irrigation and grow vegetables for the market and consumption. Income of PSNP families has increased from time to time from sale of vegetables and reach overall agreement among the community other livestock products” on the list of PSNP clients. This list is submitted to the KFSTF, which ensures there is no stigma Gebre and his family depend on subsistence farm- against the inclusion of eligible people living ing and off-farm income as daily labour. As a result of natural resource activities, he and his neighbours with HIV. The CFSTF also participate in regular review of PSNP clients, monitoring the imple- Dairy development rural Table 1: Six month milk delivery and expenditure, 2009 mentation of public works and informing families (Degua-tembien appeal process to the community. woreda) Month Milk Average Expenditure for Employment Home Net delivery revenue milk supplies costs rent profit In addition to REST’s links with the KFSTF litres Birr Birr Birr Birr Birr and CFSTF, REST is a member of the woreda January 5398 40800 24291 500 600 15409 level food security task force and technical February 5070 40800 22815 500 600 16885 assistance team. The role of REST at this level is March 5070 40800 22815 500 600 16885 to strengthen the community and woreda April 6540 52700 29430 500 600 22170 management capability through capacity build- ing and technical assistance. May 6300 52600 28350 500 600 23150 Total 28,378 227,700 127,701 2,500 3,000 94,499 59 Field Article of 1.5 million tons of grain to the country’s These results are encouraging and suggest that Gully treatment to harvest. Soil erosion is a very serious threat to the PSNP activities are having a positive impact reduce soil erosion food security and requires urgent management on nutrition outcomes. When compared to the and stabilize land in Tigray and the PSNP areas. Soil loss in the non-REST PSNP (control) area, the prevalence so as to enhance ground water PSNP woredas was estimated at 42 rates of wasting, stunting and underweight recharge tons/hectare/year before the PSNP. Based on were also lower in the PSNP areas. This the PSNP impact assessment (conducted by the suggests that the change in prevalence was due World Bank), the average soil loss is now esti- to the impact of the PSNP. mated at 19.4 tons/hectare/annum. This means Understanding the causes of stunting that the watersheds and treated land activities The REST policy and research unit studied the are saving the region an estimated 1.1 million determinants of child stunting in the REST tons of soil per annum, and have the potential PSNP woredas using regression analysis (see to continue having such a positive impact. Table 3). The study found that the chance of The planting and area closures that have stunting among children from households who been put in place also have the potential to are dependent on the PSNP increased contribute significantly to carbon sequestration. compared to those who depend on producing There are likely to be local and global benefits and purchasing their own food. Households maintain a minimum level of food security, i.e. in terms of potential earnings from carbon cred- who own livestock were found to be less likely the ability to access food, was also assessed its, as well as reduced global warming as a to have stunted children. Family size, as (following the FANTA guidelines1). Typically, result of reduced green house gases. expected, was strongly associated with the the months of June to September are the food probability of a child being stunted, with the gap months when food insecurity is most Asset ownership risk of child stunting being higher if the house- severe in Tigray. The 2008 survey showed that Resiliency grows in parallel with the accumula- hold had more family members. Likewise, a 70% of PSNP households had adequate food for tion of productive assets by integrating other mother’s education is negatively correlated at least eight months in a year, of which only food security packages into PSNP target house- with child stunting, i.e. a mother who is literate four months was from a household’s own holds. This entails providing diverse had a lower probability of a child who was production. The 2008 findings were an agricultural inputs and technologies to asset stunted compared with those who are illiterate. improvement on the baseline survey findings less poor households in a manner that enables Access to nutrition education is negatively and and this improvement was attributed to three them to own motor pumps, livestock, money, significantly correlated with levels of stunting. interlinked factors: the PSNP food transfers to built houses in nearby towns, and fruit trees to This suggests that a mother of a child who has meet immediate household food gaps, the produce more and diverse range of food crops been exposed to nutrition education has a lower creation of local employment and income and livestock for consumption and for market. probability of a stunted child, compared with generation opportunities, and use of the PSNP As a result, households are more confident in those who have not participated in nutrition as a stepping stone to access other food security taking out additional loans to maximize their education. packages. income. Current research studies indicate that there is no significant difference in oxen owner- The results also showed that child stunting is According to the survey results, the major ship among the households. This indicates that more likely to be prevalent in households who reasons given by respondents for failing to most households own oxen as the result of don’t have a toilet. Access to a potable water produce sufficient annual food needs were income increment and credit access form PSNP source was found to decrease the risk of stunt- shortage/absence of land (49%), rainfall short- and other food security programmes. ing, however, this was not statistically ages/excess (36%), lack of oxen (16%) and crop significant. One interesting result from the losses due to damage, pests, disease and flood- Nutritional status regression analysis was that contrary to the ing (5%). The major coping strategies practiced In 2008, REST carried out a nutrition survey1 to general impression, a child from a female by the people in the project areas during food identify whether any changes in prevalence of headed household was less likely to be stunted shortages were reported as borrowing cash or wasting, stunting or underweight had been than a child from a male headed household, food (22%), eating less preferred food (21%) and achieved in the PSNP programme areas though this difference was not statistically eating fewer meals per day (25%). compared to the baseline survey prevalence significant. identified in 2005. The findings were also Farmers confirmed that the PSNP had compared to the prevalence of wasting, stunt- Overall, the analysis of determinants of child helped minimise household level stress associ- ing and underweight in a non-PSNP (control) stunting level signifies that increasing access to ated with hunger and poverty. It enabled them woreda (Hintalo wajirat). Table 2 presents some livestock (cows and shoats), female literacy, to salvage their productive assets rather than of the findings. nutrition education and latrines has role to play forcibly selling them to cover consumption in reducing the prevalence of levels of stunting needs, and allowed them avoid distress migra- The prevalence rates of wasting, stunting in Tigray. tion in search of food and employment. The and underweight were found to have reduced food for work activities ensured short-term in 2008 from the baseline levels reported in Household food security 2005, by 2.6%, 11.8% and 10.7% respectively. Information on the number of months in the 1 30 by 30 cluster methodology was employed in all six PSNP woredas. last year in which a household was not able to 2 MSc by Teklebirhan Aydebeb Table 2: Prevalence (%) of underweight, stunting and wasting among children 2005 to Table 3: Parameter estimates of a logistic model for determinants of children stunting level (N = 5391) 2008 and relative to non-REST PSNP* Coefficient Standard error Z Significance level P>z [95% Confidence Interval] Indicators REST PSNP Non REST Gender -.0074053 .085988 -0.09 0.931 -.1759387 .1611281 PSNP Age of mother .0002603 .0050509 0.05 0.959 -.0096394 .01016 Baseline Target Actual Actual 2005 2008 2008 2007 Family size .0382093 .0182387 2.09 0.036 ** .002462 .0739566 % of children 7.2% 2% 4.6% 12.5% PSNP beneficiary .2180809 .0648287 3.36 0.001*** .091019 .3451429 0-60 months that Irrigation plot .1096148 .0857793 1.28 0.201 -.0585095 .2777391 are wasted Duration of breast feeding .0110853 .0201191 0.55 0.582 -.0283474 .0505179 (<-2WHZ) Nutrition education -.3741028 .1689836 -2.21 0.027 ** -.7053046 -.042901 % of children 50% 34% 38.2% 42.4% 0-60 months that Water availability -.0582521 .0645057 -0.90 0.366 -.1846809 .0681768 are stunted Latrine availability -.0992738 .0790179 -1.26 0.100 -.2541461 .0555985 (-2HAZ) Full vaccination -.1772792 .9174281 -0.19 0.847 -1.975405 1.620847 % of children 45% 32% 34.3% 34.8% 0-60 months that Oxen per capita .0212997 .1831977 0.12 0.907 -.3377613 .3803607 are underweight Cow per capita -.5413497 .1443165 -3.75 0.000*** -.8242049 -.2584946 (-2WAZ) Shoat per capita -.1123467 .0482356 -2.33 0.020** -.2068868 -.0178066 WHZ: weight for height z score; HAZ: height for age z score; Literacy of mother -.1688753 .0675757 -2.50 0.012** -.3013212 -.0364295 WAZ: weight for age z score * The woreda taken for non-REST PSNP was Hintalo wajirat (2007)2. Note: ** = significant at p<0.05; *** = significant at p<0.01.

60 Field Article employment opportunities for many of the resource poor farmers in the project area and additional relief food assistance coming to the area, further acting to stabilise the situation. Dietary diversity The household dietary diversity score is a proxy indicator for socio- economic status and the ability of households to access food. Household dietary diversity score is reflected in the number of differ- Ethiopia, 2010 Hailu Sitotaw, ent food groups consumed over a given reference period. To gauge the level of dietary diversity, sample households were asked about the number of different food groups consumed using a 24 hour recall period and a broader non-time bound question about numbers of foods consumed2. The results of the survey indicate that the overall mean Maintaining GOAL’s dietary diversity score in the REST PSNP project area is five. This implies that, on average, households had consumed about five differ- ent food groups within the previous day indicating a 47% improvement capacity to support against the baseline figure of 3%. The main factors contributing to the improvement of the dietary diversity score are expanded and diversi- surveillance in fied production of crops and vegetables and expanded mainstreaming MUAC measurement by GOAL Ethiopia Nutrition of health and nutrition education through the REST PSNP and other Survey Team, Abaya Food Security Programmes over the last four years. Ethiopia Woreda, Borena zone, Oromia region Future challenges and opportunities in the REST PSNP woredas Drought Although the PSNP has significantly improved household resilience to thiopia has suffered from numerous natural and shocks in Tigray, drought and increasing market shocks man-made emergencies and continues to be (inflation/price increases) continue to threaten the livelihoods of the vulnerable to rapid and slow onset emergen- poor. These can potentially undermine the assets developed both cies. Since the major famine in 1984/85, under the PSNP and with REST’s programmes more widely. To Econsiderable efforts have been made to install a credible preserve the PSNP results, additional efforts are required in water and effective early warning system (EWS) as part of harvesting and management and the provision of potable water emergency preparedness to enable a timely disaster supplies both for humans and livestock. Drought and other shocks response. In line with improvements internationally in could also undermine the improvements seen in nutritional status of early warning and emergency assessment tools, the children under five, particularly levels of wasting which are sensitive government of Ethiopia has increased its drive to to short term shocks. develop a more effective EWS. It has been supported by Inflation many international agencies in this endeavour who, in The increase in food prices is affecting food security, especially given turn, have made use of new methods such as the that the majority of PSNP beneficiaries are net food purchasers Household Economy Approach (HEA) and, more (Tigray has the second highest food price inflation in Ethiopia). recently, the Integrated Humanitarian Phase Although the PSNP transfers are assisting PSNP households to absorb Classification (IPC) system (introduced by USAID and the food prices to a certain extent, additional shocks (drought, hail, FAO respectively). A new EWS has been established in flooding) are compounding factors. For direct support beneficiaries Ethiopia to classify woredas (districts) according to the (the disabled, orphans, the elderly, people living with HIV/AIDS) extent of food insecurity using ‘hotspot’ monitoring (see who have no other sources of income, price increases and the reduc- articles on DRMSS and on ENCU in this issue of Field tion of food transfers in the programme from 10 to eight months could Exchange). have a negative impact on this group. At the same time, the government’s focus on manag- Lack of strong market intermediaries ing emergencies has also changed from the traditional The production of economic crops like vegetables, spices, and fruit is disaster management approach to a more advanced and expanding in rural communities, especially as access to irrigation water scientific ‘disaster risk management’ (DRM) approach. through the public works is increasing. Lack of strong market interme- This emphasises ‘domestic knowledge and community diaries, however, in these rural and marginalised areas is creating a capacity’ for prevention and mitigation of an impending disincentive to production. Additional efforts are needed, therefore, to emergency. The DRM approach has enabled communi- strengthen the market environment by developing market infrastruc- ties to play a leading role in related activities through ture, market information dissemination systems, and strengthening the application of indigenous early warning knowledge. market intermediaries. Thus, communities have a chance to share local solu- tions for local problems. Such indigenous practices are PSNP graduation taken account of in the EWS, which monitors any Graduation from PSNP needs special attention. To encourage house- changes to this normal behaviour and indicates when hold to graduate and reduce risks associated with graduation, emergency interventions may be needed. households who are in a good position to progress towards graduation should get a food transfer for fewer months than other client groups. Background to GOAL Like many international non-governmental organisa- Health and nutrition tions (INGOs), GOAL Ethiopia started nutrition Using screening and nutrition surveys could help to highlight poten- programming in 1984 in response to the large scale tial areas that need special attention. In addition, nutrition survey on famine in the northern areas of the country. In 2003, the impact of PSNP could be used to design approaches to achieve following a large-scale food security crisis, GOAL greater impact on nutrition outcomes, particularly stunting. Ethiopia expanded its operational presence to two Conclusion regions, namely SNNPR (Southern National and The roll out of the PSNP through which the most vulnerable house- Nationalities Peoples Region) and Oromia Region. This holds are guaranteed food resources has helped in maintaining operation supported eight large woredas to implement and/or improving nutrition levels. This is complemented by therapeutic and supplementary feeding programmes for increases in confidence and aspirations by PSNP households evident under fives and pregnant and lactating mothers. GOAL in their widened participation in food security packages that in turn also started working on recovery and development have enhanced the ability to cope with shocks. programmes in the areas of livelihoods, child survival and development and in some areas, WASH (water, For further information, contact: Tesfay Desta, email sanitation and hygiene) activities are being imple- [email protected] mented.

61 Field Article

By Zeine Muzeiyn and Ewnetu Yohannes Table 1: Process indicators for hotspot monitoring Weather condition such as onset of rain, cessation time, number days with dry spells, Zeine Muzeiyn has been working in the area of Nutrition occurrence of hailstorm, flood situation. for the last seven years. Before he joined GOAL Ethiopia, he had been working in West Darfur, Sudan, as a nutrition Crop production and livestock condition such as dietary diversification, availability of programme manager for Concern Worldwide in IDP and staple foods, land preparation, land cultivated and covered by seed, condition of Refuge camps. He has an extensive field experience in the harvest, agricultural inputs supply, herd size, pasture status, milk production/head/day. area of Nutrition. Currently he is a country nutrition Market price such as major food crops price, livestock price, source of supply, terms of programme coordinator for GOAL Ethiopia. trade between livestock (goat) and major food crop (maize), crop price during harvest/dry season, price of livestock during harvesting/dry season. Ewnetu Yohannes had a thirteen years experience in the Socio-economic conditions such as migration, wages per day, other sources of income, area of Nutrition, Health and Livelihood expert and coping capacity of the community. worked in government and local NGOs. Since 2009, he has been working as an Early Warning System Development Officer for GOAL Ethiopia. Table 2: Process indicators and associated severity scale Indicator Scale of Measurement measures/assessed Class 1 Class 2 Class 3 Class 4 Class 5 Thanks goes to GOAL Ethiopia Senior survey coordinator who provided Livestock death None >0-≤2% of >2 - ≤10% of >10 - ≤25% of >25% of valuable inputs. herds herds herds herds School drop-out ≤5% of >5 - ≤10% of >10 - ≤25% of >25 - ≤50% of >50% of students students students students students Sales of productive None Moderate High Very high Exhausted assets Increased sales of Normal Moderate High Very high Very high firewood and GOAL Ethiopia aims to respond to any emergency in Ethiopia charcoal (within its operational capacity) in a timely manner through its HRP Consumption of No No No Yes Yes (Humanitarian Response Programme), which has three arms: an Early seeds Warning Department, a Survey and Assessment Department and an Consumption of None Sometimes Few days Most days All days Operational Response Unit. health threatening foods Process and outcome indicators used in the EWS Increased begging No No No Yes Yes The Government collects two types of early warning indicators to Increased request for None ≤5% of >5% - ≤10% of >10 - ≤20% of >20% of identify hotspot woredas: process indictors and outcome indicators. external assistance households households households households Each hotspot woreda is divided into three types, priority 1, 2 and 3 Switching in None Normal Few items Some items Most items relating to the severity of the situation. A priority 1 woreda is the most livelihood protection switched switched switched severely affected, needing urgent humanitarian intervention whilst expenditure priority 2 and 3 woredas, though needing assistance, do not require Reduction of meals ≤5% >5% - ≤15% >15% - ≤30% >30% - ≤50% >50% the scale of response needed in a priority 1 woreda. Typically, in reduction reduction reduction reduction reduction Priority 2 woredas, strengthening existing aid interventions and close HH level destocking None Normal High Very high Massive follow up is recommended whereas in priority 3 woredas, close (commercial, follow up on the food security situation and other related aggravating slaughtering) factors may be needed. Table 3: Food insecurity indicator description and livelihood impact At the time of writing this article (Sept 2010), there were 335 Indicators description Impact on livelihoods hotspot woredas flagged in Ethiopia. This represents a significant number of potentially needy woredas and highlights the ongoing Highly Above Normal (HAN) (1). Large Improvement – (Risk: Minimal). Occurrence need for an effective EWS and response capacity. Indicator is above average or conditions of, or likely predicted event improving livelihoods. are improving (a very high positive Stress Indicators: no impact, very huge, large Government-led multi-agency teams go to pre-selected food inse- change, above average) (>=25%) positive change from normal. cure areas in each region to assess potential hotspot woredas; Above Normal (AN) (2). Indicator is Improving – (Moderate Risk: Hazard). Occurrence of assessment timing is informed by seasonality. The criteria used above average or conditions are or likely predicted event improving livelihoods. during the assessment includes levels of acute malnutrition, food improving (a positive change above Stress Indicators: no impact, large positive change average) (>10 to <25%) from normal (small change). security situation, therapeutic feeding programme admissions, stress conditions and levels of migration among others (see Table 1). The Normal (N) (3). The process indicator is Improving or Small Change. Normal or very small classification process is carried out at the regional and reviewed at just about average (a small change change from normal conditions prevail. Process below average) (10%) Indicators: small negative change from normal federal level. Where necessary, overall prioritisation of the woredas is (moderate). reviewed. For example, on the first assessment or hotspot classifica- tion which categorises a woreda as priority 1, the situation may have Below Normal (4). Process indicator Severe. Stress Indicator indicates very high abnor- shows a huge negative change from mal conditions stressing livelihoods, with high improved to such an extent that it can be re-classified as priority 2 or average (>25 /<50%) vulnerability. Stress Indicators: large and 3 according to the multi-agency assessment of the indicators. compounding negative changes. Examples of process indicators for estimating levels of food insecu- Failure/ Critical (5). Process indicator Very Severe: Stress indicator show alarming rity are sales of assets, unusual livestock death, increased school show a strong major likely impact on proportions and leading to immediate impact on livelihoods (>50%) livelihoods stress, with high vulnerability. Stress drop-out, consumption of wild foods, increased begging, increased Indicators: have immediate, large and request for external assistance, and reduction of meals eaten daily. compounding negative changes. Most stress indicators are showing how a particular hazard affects the population and the strategies they deploy to survive. Table 2 provides Table: 4 Outcome indicators: health and nutrition thresholds by severity scale an overview of how these process indicators are classified according to a scale of 1-5, with 5 being the worst level of food insecurity and Indicator Scale of Measurement livelihood erosion. Table 3 describes the indicators and associated measures/ Class 1 Class 2 Class 3 Class 4 assessed livelihood impact.1 Global acute <3% WFH* <-2 3% - <10% WFH <-2 10% - 15% WFH >15% (WFH Outcome indicators reflect the magnitude of the shock on those malnutrition z-score z-score <-2 z-score <-2 z-score) affected and are normally reflected through the deterioration of health (GAM) prevalence Migration Normal Spread Concentrated Distress 1 Source of Tables 1-4: Guidelines for Analysis and Identification of Areas of Concern (Hot Spots) for Effective Food Security Monitoring and Programme Decision Making, the Displacement None Spread Concentrated Distress Early Warning Working Group (EWWG) chaired by the Disaster Risk management and Food Security Sector (DRMFSS) - Ministry of Agriculture and Rural Development Morbidity Normal Serious Severe Critical (MoARD) - Federal democratic Republic of Ethiopia, September 2009. Crude <0.5 /10000/day 0.5 - <1 /10000/day 1 - 2 /10000/day >2 /10000/day Mortality 62 Field Article

Box 1: Micro credit support case studes are gathered. This data is used to guide programmatic intervention and/or to provide A 65 year old man was noted using a plough and use this opportunity to secure my food needs”. To verify the relevant government entities with qualita- sowing seeds one month earlier than normal in a this indigenous knowledge, the GOAL EWS officer tive information on food security and its village. At that time, the GOAL EW officers were went back one month later to monitor the status of prospect. collecting the EWS data from the village and asked the the area ploughed and witnessed that this was the man “why are you ploughing and sowing unusually early only farm with green maize seedlings. Others had not In lieu of the assessment findings and subse- in the dry season when the rains are not due for another started ploughing their land and missed the good quent recommendations, if GOAL has the month?” The old man replied, “you know my son, I am opportunity offered by the earlier ‘shower’ rains. capacity and the authorisation to intervene in an old person and have grown up watching the ‘signs’ of an unsupported woreda, it will do so in line Because of this evidence, the trend to plant earlier ‘good’ and ‘bad’ season in my village for a long time. I has expanded to other villages with farmers practicing with recommendations made. Over the last 63 follow the wind direction at dry season. If it blows from this ‘indigenous early warning information and use the months (from August 2005 to June 2010), GOAL the west-east direction, then I know the coming rainfall ‘early’ shower rain to grow a fast growing local maize Ethiopia has conducted 60 nutrition surveys (a will start early. When it blows from the east-west, the rain seed called ‘yanase’. They also sow hybrid maize seed small number of which were on behalf of other will be late. This is why I have started to plough and sow in normal rainfall time in the month of March. maize seed and wait the onset of early shower rain and NGOs in collaboration with the ENCU) and has intervened in approximately 95% of woreda’s with an identified need for management of and nutritional statuses of the affected commu- where quality assurance checks are in place. acute malnutrition. nity. The health and nutrition thresholds The data and report is then shared with the Focus on Capacity Development applied to for the indicators to define the extent Federal level along with other similar partners GOAL nutrition survey staff always carries out of an emergency are outlined in Table 4. during the monthly national EW meetings. The surveys with government staff at woreda and Federal level triangulates this information and In most cases, the presence of disease regional levels and focus on building govern- finally shares it with the ENCU for action, if outbreaks, food insecurity and high rate of ment capacity in planning and conducting needed. On average, the whole process takes acute malnutrition are the main driving force surveys, analysing data and report writing. one month from information collection up to for implementing an assessment. Typically, the Moreover, as a part of sustainable capacity sharing the findings to partners and other Early Warning Department is alerted by the building, one person from the Government government offices. health sector when there is an unusual increase Regional Health Bureau takes an active role in in acute malnutrition cases attending health GOAL nutrition assessment capacity analysing and writing the draft survey report. facilities. Based on the information received, GOAL staff attends the EW coordination meet- GOAL also recognises the significance of standardised nutrition surveys are conducted ings at federal level during which the list of HEWs in collecting locally pertinent food secu- to assess the situation and make recommenda- hotspot woredas is issued. Agreement is then rity and health/nutrition information on a daily tions for possible nutrition intervention. reached on the agencies responsible for nutri- basis, which provides information for the GOAL’s Support to the EWS tion assessment of these woredas, with the aim government when considering some form of of verifying whether the EWS data is reliable in GOAL’s Early Warning Department collects emergency intervention. In recognition of this, terms of detecting increases in prevalence’s of EW information through field based assess- GOAL provides a two-day standardised nutri- global and severe acute malnutrition (GAM ments undertaken by GOAL staff who work tion survey training for HEW’s followed by a and SAM). through the Government’s rural health exten- practical session before the commencement of sion workers (HEWs) and in response to rapid GOAL Ethiopia maintains 21 staff at any one the actual data collection. This training is assessments undertaken by the Government’s time to support nutrition surveys. Each survey provided for any woreda where a nutrition ENCU (Emergency Nutrition Coordination costs approximately USD$ 8,500, which survey is going to be conducted. Unit) that flag ‘hotspots’. includes vehicle hire to carry out data gathering Since food insecurity has a cyclical nature in and data analysis and dissemination. GOAL The GOAL EW officers travel extensively at Ethiopia, the numbers of hotspot woredas capacity in this area is funded by the US Office woreda level, collecting and screening early varies and the government demand for for Disaster Assistance (OFDA) and ECHO warning indicators and/or reports from the conducting nutrition surveys will also vary. (European Commission Humanitarian Office). field. In all areas, including GOAL’s RDP (Rural GOAL has established a good reputation over In any month, GOAL has capacity to lead on up Development Programme), GOAL uses routine time within government for carrying out reli- three nutrition surveys depending on the information collection and triangulates it with able and high quality surveys and therefore, context. In 2009, a total of nine nutrition Government and UN agency assessment demand for GOAL’s experience in this area is surveys were carried out in the country, of reports. If information concurrently indicates high. However, there is a limit to the direct which four were undertaken by GOAL in the deterioration of a situation to a Priority 1 or support that GOAL can or should undertake in hotspot woredas. Three of these surveys Priority 2 status, upon request by the ENCU, a this regard. It is particularly important that showed levels of acute malnutrition to be above GOAL nutrition survey and assessment team is regional capacity is further developed to meet the levels defined as an emergency in Ethiopia. deployed to verify the severity of the situation. the demand for nutrition surveys and EWS Between January to June 2010, 12 nutrition This involves a standardised nutrition survey assessments over the long term. GOAL is surveys have been carried out by GOAL using the SMART (standard measurement and committed to focusing on capacity develop- Ethiopia of which three were conducted in assessment research tool) methodology. ment in the ongoing programme of work in priority 1 hotspot woredas. Ethiopia. In addition, each month GOAL EWS focal Since GOAL is operational in many areas in persons at regional level monitor and collect For more information, contact Zeine Muzeiyn, Ethiopia, it is often necessary to do base line qualitative data from systematically selected email: [email protected] and Ewnetu survey, follow up survey and end line survey at woredas and kebeles (a group of villages) using Yohannes, email: [email protected] different times. Moreover, GOAL is often key informants. The key informants are made approached by the Federal ENCU and Federal up of 12-20 people who represent the commu- Disaster risk management and food security nity and include woman, religious leaders’, sector (DRMFSS) to do nutrition survey for youth and aged people with indigenous knowl- partners and for regional ENCU consumption. edge. They are involved in group discussions To be able to conduct all of these surveys, undertaken every month at which they discuss GOAL Ethiopia found it necessary to increase in depth any forewarning signs of changes in

the quality and quantity of the survey team. Ethiopia, 2010 Hailu Sitotaw, social and economic trends in the village, GOAL plans to increase its capacity to carry out disease outbreaks, increases in cases of acute four nutrition surveys in any one month by malnutrition, etc. An example of the benefits of increasing the nutrition team to 28. capturing indigenous early warning informa- tion is described in the case study in Box 1. As well as collecting mortality and anthro- pometric data during the nutrition surveys, After the monthly information is analyzed data on health behaviour, recent sickness, child by the GOAL regional focal personnel, a report care, market prices, migration and food security is submitted to the GOAL Addis Ababa office Height measurement by GOAL Ethiopia Nutrition Survey Team, Abaya Woreda, Borena zone, Oromia region 63 Programme profile

The Evolution of Ethiopian Government’s

Early Warning System Dr Kassahun Bedada Beyi

Dr Kassahun Bedada Beyi is Early Warning and Response Case Team Coordinator with the Early Warning and Response Directorate. This is located within the Disaster Management and Food Security Sector of the Ministry of Agriculture and Rural Development. He holds a BSc in Plant Science and a MSc in Pest Control. He has a longstanding engagement on early warning activities.

The author would like to acknowledge the support of the Early Warning and Response Directorate.

isaster Management structures and The permanent reporting system was called carrying out their own early warning activities systems have a relatively short the ‘Early Warning System (EWS)’ and empha- and there was considerable duplication of history in Ethiopia having evolved sised the prediction of food shortages, to efforts. distinguish it from its more ad-hoc surveillance after the ‘great famine’ of 1973/74 The socio–political and economic change Dwhen the first government institution, the predecessor. Rather than set up a new agency to adopted in the country, particularly after the execute this new EWS, the TWG also recom- Relief and Rehabilitation Commission (RRC) ratification of the new constitution in 1995, was mended that the national EWS programme be was created. The RRC (subsequently called the geared towards decentralisation of power and implemented collaboratively by of the follow- Disaster Prevention and Preparedness responsibility to the Regional States and a ing agencies: Commission (DPPC)) had responsibility for decentralised disaster management system. • The Relief and Rehabilitation Commission providing support to disaster affected popula- Emphasis was placed on the role of local • The National Meteorological Service tions, particularly for those affected by severe communities for planning, implementation and Agency (NMA) drought. Around this time, the need to develop evaluation of relief measures. In the process, the • The Planning and Programming Department an early warning system (EWS) as a crucial evolution of a new disaster management system of the Ministry of Agriculture (MOA) component of disaster management become and the implementation of civil service reform • The Livestock and Meat Board of MOA apparent, as over a quarter of a million deaths brought about major changes to the implemen- • The EHNRI in the central and northern highland areas of tation of disaster management in the country. the country were reported. The lack of a A key principle adhered to when the EWS was national preparedness strategy and the absence officially launched was that activities should be The establishment of the Disaster of an effective EWS revealed a pressing need to undertaken utilising existing government struc- Management and Food Security Sector concentrate and strengthen the government’s tures and thereby maximising the use of In 2008, the power and responsibility of the capacity to produce early warning information existing resources. The DPPC is the agency DPPA shifted to the Ministry of Agriculture and on which to base its response to future emer- responsible for monitoring the food situation in Rural Development (MoARD) [now MOA]. gencies. the country and for taking appropriate meas- MoARD established the Disaster Management and Food Security Sector (DRMFSS) comprised The birth of Ethiopia’s Early Warning ures to mitigate these shortages and therefore, of two directorates. One of the directorates, the System was given the mandate to coordinate the EWS. Early Warning and Response Directorate The Ethiopian economy has largely been Other agencies were given the responsibility for data collection. (EWRD), is today responsible for collection, dependent on subsistence agricultural produc- analysis and dissemination of early warning tion and any climatic abnormalities can have a Preparatory activities, including the training information on all disasters that impact on food direct effect on food production and ultimately and posting of the first DPPC field agents, security. on food availability. Therefore, food production arrangement for programme funding and monitoring became a key component of the design work occupied most of 1976. The new The current system EWS. EWS programme was finally officially launched The EWRD collects early warning information on a regular basis from the District (woreda) level in The Ethiopian Health and Nutrition in January 1977 and remained in place for eight nine Regional States and one administrative Research Institute (EHNRI), backed by the RRC years until the establishment of the Food council. The EWRD also works with the govern- took a leading role in the 1970s in the evolution Information System (FIS) by the Food and ment’s Emergency Nutrition Coordination Unit of the EWS. A system known as the ‘Disaster Agricultural Organisation (FAO) in 1984. (ENCU), which is a unit of the EWRD and has a Area Assessment’ was developed to assess the The EWS and FIS continued to be imple- wider mandate to quality control all nutrition levels of food insecurity among drought mented simultaneously until the collaborative studies in the country (see article on the ENCU in affected cropping and pastoral communities. effort could not be sustained and eventually, the this issue of Field Exchange). The system had weaknesses, however, in that it FIS committee dissolved and the Early Warning did not provide continuous monitoring data to and Planning Service at the DPPC (later changed Examples of the types of early warning indica- inform decision making, though aspects of this to the Disaster Preparedness and Prevention tors collected include: system still form part of the national EWS Agency-DPPA with additional mandate) took • The occurrence of extreme conditions (hail today. over the full operation of the FIS in 1985. storms, unseasonal rainfall, extreme temperature) In 1975, an Inter-ministerial Technical The system was highly centralised in that • Ploughed and cultivated land available Working Group (TWG) was convened under data collection, analysis, interpretation and • Supply and distribution of agricultural the auspices of the DPPC. The role of the TWG report writing were carried out in the capital, inputs, e.g. fertiliser was to advise on the technical aspects of a Addis Ababa. Appeals for international relief • Crop condition and production prospects strengthened system that could provide more assistance, relief allocations and decisions • Disease and pest outbreaks affecting crops reliable and continuous food security and nutri- regarding relief interventions were communi- and livestock tion data by which to assess the national food cated from the central level. The role of local • Supply of feed and water for livestock and nutrition situation. Subsequently, in 1976, authorities and communities in early warning • Sudden movement of livestock the TWG recommended that a permanent and response was minimal. • Nutrition status of the population, system be established to continuously collect particularly in pastoral areas, and with the information related to food and nutrition. This The DPPA, although responsible for the appearance of increased incidence or ‘hot would link with the activities of government interventions, had also been dependent on spots’ agencies with mandated responsibilities for other line departments for the collection of • Emergence of conflicts various aspects of agriculture and food produc- most of the data needed for early warning. At • Spread of human diseases tion, including nutrition. the same time, these institutions were also

64 Programme Profile Field Article

The Regional States each have their own Disaster Management Bureau. Within these, Regional Early Joint Emergency Operation Plan Warning Officers are based. Early Warning Offices also exist at woreda level. In four states (Tigray,

Amhara, Oromia and SNNPR) they are well estab- Ethiopia, 2008 CRS, NGO response to emergency lished. In pastoral woredas in Somalie, Afar, Gambela, Benshangul-gumz regional states, they are not fully established. food needs in Ethiopia The Early Warning Officers are responsible for the collection of information from the grass roots level. Originally, the system was designed so that woreda level officers, upon receiving information from the grass roots level, would compile and analyse the information. This information is then transferred to the zone and regional offices and also to the federal EWRD electronically. However, the internet system is not yet functional so information is collected using telephone communication from the Zonal Disaster Management Offices. Information from zonal and A scene from Karsa woreda, East woreda level is compiled and analysed together with Hararghe Zone, Oromia Region additional information collected from line ministries and other information sources, notably the NMA. By Alix Carter The early warning information is disseminated on a Alix Carter has worked in the humanitarian sector in Ethiopia for almost three regular basis through a monthly Early Warning and years. She is currently working as the Humanitarian Accountability Advisor at Response Bulletin prepared in the national working CARE Ethiopia, supporting with emergency programmes in sectors of nutrition, language (Amharic) and more recently in English. This WASH, agriculture/livelihood, food aid, humanitarian reform, and climate change is distributed to regional states and different stake- adaptation/disaster risk reduction. holders in Addis Ababa. The Bulletin contains detailed information on rainfall patterns, crop and livestock Many thanks to all the Joint Emergency Operation Plan (JEOP) partners - CRS (JEOP lead agency), conditions, terms of trade (shoat to maize), food prices, CARE, World Vision, FHE, Save the Children US, Save the Children UK, and REST - for their time and water availability, nutrition survey data, nutrition effort provided through information and interviews with key staff members responsible for programme coverage and relief pledges (food and implementing and managing JEOP. non-food items) by region. It also includes information on funding shortfalls by sector (food, nutrition, water and sanitation, education etc) and contains a summary of the key findings from the EWS data. mergency food relief continues to be a recurrent need in Ethiopia since the Ethiopian famine of the 1980s, which was so severe that The regional states are expected to duplicate the it demanded global attention and response. Institutional donors EW information and distribute it within their region. and non-governmental organisations (NGO) have been respond- Woreda offices are also expected to duplicate the Eing with emergency food relief during crisis years for decades to alleviate information and distribute it to community farmer’s hunger. Massive food shortages resulting from severe drought plague the training centres where farmers gather to exchange country and drastically hinder production in this predominantly rain fed information with development agents and with each agricultural economy with 83% of livelihoods in the agriculture sector1. other. The Government of Ethiopia recognised that a system to prepare proac- tively for cycles of drought while addressing chronic food insecurity was Utilisation of the EWS required to protect its citizens. It responded in 2005 by creating one of the The government’s EWS has evolved considerably largest safety net programmes in Africa – the Productive Safety Net over the years from an ad-hoc surveillance system in Programme (PSNP)2 (see article in this issue of Field Exchange by Matthew the 1970s that focused on drought affected areas, to a Hobson. highly centralised system in the 1980s which, though more effective did not involve affected communities Despite the positive impact of PSNP, the need for emergency food aid in decision making, to today’s system, which is during times of acute food insecurity and shock still persists, as the highly decentralised. The current system utilises local resources in PSNP are not enough to address all vulnerable populations knowledge and information at the grass roots level and mitigate acute food insecurity. The US Government reports that 25 and has a bi-directional dissemination process of million people in Ethiopia go hungry every year, the most chronically food early warning information. Today’s system also inte- insecure being children under five years and women3. The Government of grates nutrition information, pastoral as well as Ethiopia’s humanitarian appeal of January 2010 identified 5.2 million cropping area information, and is linked to monitor- people in need of humanitarian food relief assistance across the country ing programmatic response capacity. this year.4 Emergency food aid programmes administered jointly by the Government, World Food Programme (WFP) and NGOs remain essential It can be said that the EWS is becoming successful to meet the food needs of Ethiopians and control malnutrition and deaths as the demand for EWS related information is resulting from hunger. This article discusses one such programme, the increasing, the range of stakeholders to which EWS Joint Emergency Operation Plan (JEOP) – a consortium food relief information is disseminated is growing and informa- programme implemented by seven NGO partners. Implementation by tion contained in the EWS bulletins is in greater NGOs of this type of programme is rare, as large scale emergency food aid demand. The development of a woreda-net internet programmes are usually implemented through WFP channels in other infrastructure will increase the speed and transmis- countries. However, through collaborative partnership and continued sion of EW information from the grass roots. In funding from the United States Agency for International Development addition, the EWRD is working to include satellite (USAID) Food for Peace Programme (FFP), NGO partners Catholic Relief information in the EWS to monitor the food produc- Services (CRS), Save the Children (SC) US and UK, CARE Ethiopia, World tion condition in all areas and to predict the likely Vision, Food for the Hungry Ethiopia (FHE), and Relief Society of Tigray occurrence of disasters ahead of time more effec- (REST) are playing an active role in addressing emergency food needs tively. across Ethiopia for almost two million people per distribution (round).

For more information, contact: Dr Kassahun Bedada, 1 US Government, Feed the Future, 2010 email: [email protected] 2 Hoddinott, J. IFPRI, 2010 3 US Government, Feed the Future, 2010 4 Government of Ethiopia, Humanitarian Requirements Document, January 2010

65 Field Article

History and significance of JEOP specifically, the programme planned to address Figure 1: Total emergency food needs and JEOP has existed in different forms since 1984. the immediate food security needs of drought- JEOP contribution It began life as the Churches’ Drought Action affected populations, prevent further depletion Africa /Ethiopia (CDAA/E), a faith based of household assets, and reduce distress migra- 14 7 consortium of CRS, Lutheran World Federation tion of an affected population . 12 (LWF), Ethiopian Catholic Secretariat (ECS) and As the lead agency, CRS is responsible to call Ethiopian Evangelical Church Mekane Yesus 10 forward hundreds of thousands of metric tons (EECMY). CDAA/E was initiated in response of grains, blended foods, pulses, and oil 8 to the famine of 1984 when LWF extended an commodities. The agency then oversees the invitation to other relief and development 6 logistics process from shipment at the port of agencies for a joint Catholic-Protestant appeal Djibouti until commodities are transported to 4 for Africa. Agencies recognised that the magni-

four primary warehouses placed in different Beneficiaries (millions) tude of the need was too large for any one 2 strategic locations of the country. Each of the agency to handle alone and joint action would partners is responsible for collecting their share 0 yield greater response and impact. Due to the of the commodities and arranging secondary severity of the crisis in Ethiopia, lobbying 2003 2004 2005 2006 2008 2009 transport for delivery to their respective distri- efforts for funds and food were heavily focused Beneficiaries served by JEOP bution sites across the country. on Ethiopia and a partnership dedicated to the country was formed. The partnership and its JEOP food distribution is conducted in Table 1: JEOP ration breakdown, 2010 name evolved to become Joint Relief rounds during which NGO partners distribute Partnership (JRP) in 1986 with CRS in charge of rations to targeted households. Distribution of Energy based 15 kg/person/month for all drought cereals (Wheat) affected people the coordination and logistics, like it is today.5 food to the 1.8 million (on average) beneficiar- The partnership was reactivated in 2000 under ies per round is directly conducted by each of Protein 4.5 kg/person/month for 35% of its current form, JEOP, with five members (CRS, the partner agencies, or in some cases through supplement beneficiaries considered most (Corn Soya vulnerable (children under five years SC-US, WV, FHE, CARE). CRS is the lead their local partner agencies on the ground. Blend) and pregnant and lactating women) agency. In later years, REST and SC-UK also Implementation of the programme requires Pulses (Yellow 1.5 kg/ person /month for all drought joined.6 All partners are or have been USAID very close collaboration with the Government split pea) affected people cooperating sponsors, but it has shifted from at all levels, starting with the federal DRMFSS being a faith based partnership to one which structure all the way down to regional, zonal Vegetable Oil 0.45 kg/person /month for all drought affected people includes secular agencies as well. and district level authorities. While NGOs are primarily responsible for handling and distrib- JEOP remains dormant in non crisis years. It uting commodities, the allocation of food to Case study 1: Ato Abera Yimam’s story is activated, in close collaboration with the each district and targeting of individual benefi- Government of Ethiopia, when chronic food ciaries is processed through Government Ato Abera Yimam, 50 years, lives in woreda insecurity is exacerbated by emergency shocks, channels. Due to the nature of the aid system in with his wife and seven children. Ato Abera and requiring additional coverage and emergency Ethiopia, NGOs must refer to the Government his family faced complete crop failure due to the food relief. As a result of a decade of recurrent long drought period. Without any other sources of for all allocations of emergency food relief shocks, JEOP has been operational seven of the income, his family members were on the verge of based on figures from the Humanitarian last ten years, providing a significant portion of death before they became beneficiaries of JEOP, Requirements Document, the official appeal the emergency food needs for the country (see through World Vision. “I was scared that my child mechanism of the Ethiopian Government. Figure 1). would die…. The programme is a life saver and a These appeal figures are based on the assess- true helper of the vulnerable and the poor. Had it The current JEOP was activated in August ment results of a joint multi-agency assessment not been here, I would have lost my family or they 2008 to respond to the Government’s Disaster team that conducts surveys at least twice a year would have lost me.” Of course, Abera is just one of Risk Management and Food Security Sector to determine humanitarian needs in both food millions of people with similar stories of hardship (DRMFSS) request for emergency food assis- and non food sectors. whom JEOP has addressed over the last two years. tance. This followed extended drought earlier JEOP rations are equivalent to the World in the year leading to massive food production Heath Organisation standard of 2,100 kcal of food relief amounting to almost 500,000 MT shortages and rising food prices. Lane Bunkers, intake per day (see Table 1 for a breakdown of of food and reaching over 1.8 million beneficiar- Country Representative of CRS, describes JEOP JEOP rations). Rations for each household are ies on average each round. In interviews with as “A historically significant NGO consortium with provided at local distribution sites based on each agency and through review of programme a ten-year track record of responding to emergency household size. The federal Government, CRS, documents, the impact and success of the food needs in Ethiopia. Working in close collabora- WFP, and USAID convene before each round programme are clear. Key strengths and tion with the Government of Ethiopia, the World for a prioritisation meeting to determine food achievements of JEOP are identified as follows: Food Programme, and international donors, JEOP allocations for each target region and zone. A members play a critical role in reducing food insecu- A lifeline for vulnerable households list of priority woredas8 and kebeles9 for the rity and protecting investments made through JEOP is meeting its primary mandate to save round based on the severity of the food short- long-term development projects such as the human lives. The most food-deficient house- age and the availability of resources to respond Productive Safety Net Programme and others.” holds are selected using a combination of is drawn up. A woreda level food aid task force assessment mechanisms provided by the part- USAID/FFP recently approved an comprised of officials from Government line ners and the Government. Households targeted ‘Extended JEOP’ that will continue through offices of rural agriculture and development, under JEOP are receiving timely food 2012. Extended JEOP includes new monitoring administration, health, and education is in commodities that are acting as a lifeline for and evaluation activities, a standardised joint charge of identifying the most vulnerable these families. This is expressed through count- agency Early Warning System, and capacity households to receive food rations. This process less interviews with beneficiaries undertaken building for partners. These components are of selection is challenging and at times the by each of the partners (see case study 1). intended to improve programme accountability woreda allocation provided by the federal and expand JEOP’s function as a risk assess- Government is not enough to meet local needs. ment and preparedness mechanism, in addition At the most local level, a kebele task force of 5 Solberg, R. A Miracle in Ethiopia, 1991 6 In 2009 CRS also included other international organization to its regular mandate of providing emergency local officials, elders, religious leaders, develop- including Samaritan’s Purse, GOAL, and the former Joint food relief. The significance and aspirations of ment agents, and NGO staff oversee Relief Partnership member’s Ethiopian Orthodox Church distribution at the site to ensure that the identi- (EOC) and Ethiopian Evangelical Church Mekane Yesus these new programmatic aspects are discussed (EECMY). However, these agencies are not current further below. fied households receive their rations. implementers of JEOP. 7 CRS, Fiscal Year 2009 Annual Report, October 2009 Programme design and implementation Programme impact and success 8 A woreda is an administrative division of Ethiopia (managed The JEOP consortium was responsible for one by a local government), equivalent to a district. The JEOP of 2008 was designed with the 9 A kebele is the smallest administrative unit of Ethiopia primary objective of saving human lives and third of all emergency food relief in Ethiopia similar to a ward, a neighbourhood or a localised and protecting livelihoods through the distribution of between August 2008 and June 2010. During delimited group of people. It is part of a woreda, or district, itself part of a zone, grouped into ethno-linguistic food to targeted drought-affected populations. More this period, the programme provided 14 rounds regional zones.

66 CARE Ethioia JEOP field staff at a distribution site in Chiro Woreda, Field Article West Hararghe Zone, Oromia Region Flexible and complementary to other figures impact the most needy as they are development and safety net programmes forced to wait until partners are permitted to JEOP targets food insecure households that are distribute food. JEOP partners are striving to not covered though the PSNP. It thus provides reduce these problems in future rounds.

CRS, Ethiopia, 2009 CRS, a complementary intervention to prevent acute The arrival of huge shipments of commodi- food shortages from depleting overall commu- ties to ports and warehouses in a very short nity progress gained through PSNP. JEOP seeks time frame create congestion and difficulty for to protect the large investment of donors, like partners to secure enough space for their USAID, in the PSNP and other long term devel- commodity storage, especially as most agencies opment programmes. The extended JEOP are also storing PSNP food. In addition, second- includes new elements designed to counter ary transport to distribution sites proved potential increases in need with more difficult for some JEOP partners, due to a predictable and timely response to address Protects household assets limited number of reliable transportation needs at the most critical time - between the Beneficiaries often emphasize the programme’s vendors and price fluctuations resulting from needs identification and actual food delivery. support with regards to the protection of essen- high demand and competition. These are regu- JEOP is flexible and has the ability to expand to tial household assets, such as livestock or lar challenges faced by large scale commodity all areas of the country as needed. If the imple- agricultural equipment. Without assets, a based programmes and different strategies menting partners are not operational in a family’s chances of escaping the cycle of food have been used to overcome these problems. insecurity and vulnerability, is further threat- specific area of need, CRS arranges sub-grants ened. with other partners in order to reach the most A way forward: the future of JEOP vulnerable populations. In the Extended JEOP, partner agencies are Keeps families together and children in Challenges and lessons learned considering options for a pooled transport school system that could circumvent these logistical While the programme has managed success- Migration to urban areas in search of daily issues in the future. labour is another common coping mechanism fully to meet its objectives and the partnership for farming households in times of crisis. This has been described as positive by all of the In light of the programme challenges, agen- both separates families, with males migrating implementing agencies, there are certain chal- cies emphasize the immense benefits of and leaving the burden of all domestic duties lenges. partnership. Through monthly meetings and regular communication, the seven JEOP on the females, and prevents farmers from Delays and changes in allocation of food aid members are able to share their experiences and working on their farms for the next harvest, figures to partner agencies represent one of the challenges with one another to develop solu- thus perpetuating the cycle of food insecurity. major problems faced by the programme. There tions collectively. Through combining the Fitsum Wineh, 48, a REST beneficiary in Debre have been different situations in which the food efforts and experience of all its partners, JEOP Tembien woreda of Tigray Region stated, could not be released locally until the final achieves a critical mass of capacity to provide “Without this food, my family members would have figures for the round were communicated from food relief to millions. been at serious risk, and my husband would have the central federal level and reached the had to leave to search for food for the family. He woreda. Or, an agency would be ready to Extended JEOP is currently underway and stayed home with his family and was given the distribute food in an area only to find out that will run through 2012. Food allocation will still opportunity to preserve improved seeds from being the area was no longer included in the round. be based on the humanitarian needs. This JEOP eaten and produce subsistence food for the house- Communication and capacity gaps between or phase seeks to provide more flexible and timely hold” she added. “It prevented the family from at different levels of Government are part of the assistance to all affected Ethiopians through a disintegration.” problem. The JEOP programme is very flexible two year guarantee of continued funding from A particularly moving example is provided in responding to the Government’s repeated USAID. This enables long term strategic plan- by CARE Ethiopia from its JEOP operational requests to make adjustments to the plan, such ning and a new fund management structure of district in West Hararghe Zone of Oromia as inclusion or exclusion of woredas and fluctu- a core team of experienced staff headed by a Region (see case study 2). Another example ations of beneficiary numbers which are often Chief of Party directly responsible for JEOP. comes from SC-US from amongst community required due to changing needs and priorities. Key highlights of the Extended JEOP include a members in Cheretie woreda of Somali Region. However, these delays and readjustments to new Monitoring and Evaluation system to Here, 846 people were about to be displaced to improve programme quality and accountabil- a refugee centre due to a lack of food before Case study 2: Tatuk Istala’s story ity, a joint Early Warning system which will JEOP intervened. The support enabled these standardise the data collected from each agency households to stay in their community. Cheretie Since becoming orphaned ten years ago, Tatuk to support national early warning efforts, and is now being covered by PSNP. Ishtala, 25 years (see picture), has cared for his six closer integration with nutrition and develop- younger siblings on a daily labourer income ment initiatives, like PSNP, to enhance overall equivalent to one US dollar per day. The family Strong accountability of partners coordination between sectors and programmes. Since NGOs directly administer and implement only had enough to eat once a day, if they ate at this programme, the accountability require- all. “Before we received this food, all of my siblings Collective lessons learned with regard to ments are very high – every sack of food had dropped out of school. Now, all of my brothers logistics and coordination are also addressed in and sisters, except one, are attending school. This is received into the programme must be the Extended JEOP to avoid bottle necks and because of JEOP,” Tatuk stated, “I am illiterate and I provide assistance to vulnerable people in a accounted for to USAID. The accountability don’t need my siblings to be the same. I want them to requirements for NGOs are especially stringent finish school and make an achievement.” more efficient and reliable manner. JEOP is and JEOP partners closely monitor the food striving to move beyond food response by commodities through all stages until they reach examining emergency response more broadly the beneficiaries. Partners provide full trans- and seeking additional resources in order to parency for Government counterparts through make linkages with other programming efforts, close collaboration on the ground during particularly in nutrition and livelihood protec- targeting and distribution. All JEOP partners Ethiopia, 2009 CRS, tion. Partners recognise that different strategies have a strong reputation for meeting interna- and innovations are required if Ethiopia is to tional and national humanitarian standards move beyond food aid response. The Extended and providing quality services while adhering JEOP signifies a positive step towards bridging to both donor and Government regulations. the gap between disaster preparedness and They have a long standing presence in the reduction and emergency response. country during which they have developed Tatuk Istala, a JEOP beneficiary. For more information, contact: Alix Carter, good capacity to manage effectively food relief Chiro, West programmes. All agencies have positive work- Hararghe Zone, Humanitarian Accountability Advisor, CARE ing relationships with the Government, Oromia Region Ethiopia, email: [email protected] enabling efficient and well coordinated and Lane Bunkers, Country Director, Catholic responses. Relief Services (JEOP Lead Agency), email: [email protected]

67 Field Article

By Emily Mates

Emily Mates is a public health professional with a focus in nutrition. She recently left Concern Worldwide, Ethiopia where she worked for many years in

CRS, Ethiopia, 2009 CRS, emergency and development health and nutrition programming The author would like to thank the Ministry of Health in Ethiopia, who so often showed impressive commitment for a new service that added to their already heavy workload. With thanks also to the staff of CONCERN; a privilege to work with a great team, where no task was too much nor distance too far to travel in the pursuit of supporting quality services for malnutrition.

CONCERN is especially grateful to OFDA for the generous support (both financial and otherwise) that enabled the N-CMAM programme to happen.

SNNPR MoH team on experience exchange in Tigray region

Integrating OTP into routine health services CONCERN’s experiences

his article describes the history of an find the right balance between providing the Box 1: Technical description of TFP/CMAM in international non-governmental organ- support that was required and ensuring that the Ethiopia isation (INGO)-implemented MoH were in the ‘driving-seat’ at all times. In programme that evolved from an inno- this way a strong partnership developed, with The majority of children with SAM who have no Tvative emergency intervention into a all levels of the MoH steadily gaining confi- medical complications and have a good appetite longer-term initiative, to support the Ministry dence in their ability to offer quality CMAM (around 90%) are treated as outpatients from their local health posts and health centres through the of Health (MoH) to integrate treatment services services. When the food crisis of 2008 devel- oped across much of the country, the MoH OTP. OTP services are provided on a weekly basis, for Severe Acute Malnutrition (SAM) within the where the children receive a medical check and (with support from UNICEF and partners) were routine health system. The article describes the rations of Ready to Use Therapeutic Food (RUTF), community-based management of acute able to rapidly scale-up decentralised CMAM most commonly the product Plumpy’nut®, accord- malnutrition (CMAM) approach, a timeline of services through the national Therapeutic ing to their body weight. Children stay in the CMAM programming in Ethiopia and Feeding Programme (TFP) ‘roll-out’ and imple- programme until they reach their target weight CONCERN’s national CMAM (N-CMAM) ment the required policy changes. To date, (15% increase in weight from admission or, >85% programme and a description of the N-CMAM approximately 50% of health facilities are offer- WFH, absence of oedema), which usually takes programme goal, activities and programme ing CMAM services, a huge achievement across around eight weeks. results. It concludes with a discussion of key a vast country. For children suffering from complications asso- factors contributing to the enabling environ- CMAM/TFP in Ethiopia ciated with SAM and/or no appetite and for infants ment and analysis of challenges, lessons <6 months of age, inpatient care is provided in CMAM programming is the internationally learned and programme limitations. Stabilisation Centres (SCs), also known as recommended way of treating severe acute Therapeutic Feeding Units (TFUs), which are The approach malnutrition (SAM).1 In Ethiopia, the national located in hospitals or health centres. These chil- The N-CMAM programme was implemented TFP (Therapeutic Feeding Programme) roll-out dren need specialised medical care, which is using a partnership approach, with the focus is being implemented using the CMAM- provided with in two phases (phase 1, transition firmly on ‘ownership’ by the MoH. The aim approach, as such the terms CMAM and TFP phase to phase 2) as per national protocols. Children can generally progress to outpatient care was for the programme to establish a much are often used interchangeably (see Box 1). CMAM/TFP combines in-patient and out- to complete recovery, once medical complications needed service during ‘normal’ times and to have resolved and/or appetite returned. provide a base of capacity from which services patient care for children (6-59 months) suffering could be rapidly scaled-up at times of crisis. from SAM (mid upper arm circumference The programme provided a package of ‘mini- (MUAC) <11.0cms, weight for height (WFH) Dawit tucking <70%, and/or bilateral pitting oedema). It is into RUTF during mal support’ to the MoH, which consisted of appetite test training (set-up, on-the-job and training-of- recommended that there is at least one in- trainers (ToT)), joint supervision, workshops, patient unit located in each district (woreda). experience sharing visits and community An OTP (Outpatient Therapeutic Programme) mobilisation support. The programme empha- site is ideally established in the health posts Emily Mates/Concern Ethiopia sised learning and innovation, in order to located in each village/kebele, staffed by regularly refine and adapt the approach. The community-based Health Extension Workers programme also provided considerable (HEW). The CMAM approach recommends support to CONCERN’s emergency nutrition extensive community mobilisation, as the interventions. success of OTP is dependent on a well- informed and responsive community. While the minimal support package was important, the most crucial aspect of the programme was the nature of the dialogue 1 WHO, UNICEF and SCN Informal Consultation on Community-Based Management of SAM in Children, between the partners. CONCERN attempted to Geneva, 21-23 November 2005

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Table 1: Key events timeline in Ethiopia This partnership approach was in line with CONCERN’s global strategy, which reflects a 2000 First CTC/CMAM piloted in Ethiopia (Wolayita and Hadiya Zone, SNNP Region), Valid International with move away from direct implementation CONCERN and Oxfam. towards working through local partners (for N- 2003 CTC/CMAM Research programme, Valid International/CONCERN, South Wollo Zone, Amhara Region – CMAM, the lead partner being the MoH). testing the efficacy and safety of the CTC/CMAM approach. 2003/4 Food crisis developed across many areas of the country. Many INGOs moved to programming using the Ownership, Commitment, Integration = CMAM approach, but coverage of services was low and only in certain areas. MoH-led evaluation of the Sustainability emergency response identified an urgent need for rapid scale-up of SAM services. Several words can be used to describe processes 2004 First national guidelines for the management of SAM introduced, focused on in-patient treatment. associated with sustainability: integration, ownership, commitment, all of which can be 2005 Demographic Health Survey (DHS) estimates national prevalence of acute malnutrition (children under-5) unchanged at 11%; stunting prevalence reduced by 5%, to a national rate of 47%.3 hard to define and are prone to subjectivity. It is important to note that these terms often mean 2005/6 HSDP-3 launched. Roll-out of Health Services Extension Package (HSEP) to be implemented through a different things to different people in different cadre of 35,000 female community-based Health Extension Workers (HEWs). contexts. Children suffering from SAM is an 2005 -2007 Relative period of food security across most of the country, although pockets of malnutrition remained. emotive subject, undoubtedly due to the elevated Screening figures from the new EOS programme (2004 onwards) highlighted very high levels of endemic endemic levels seen in countries such as Ethiopia, acute malnutrition.4 and its associated high mortality rate if left March 2007 MoH endorsement of the revised national SAM guidelines, including extensive description of OTP and untreated (or poorly treated). As a result, views community mobilisation. on the most appropriate strategies for treatment February Ethiopia co-hosts the launch of Lancet series on Maternal and Child Undernutrition. The National Nutrition and acceptable standards of programme quality 2008 Programme (NNP) for Ethiopia also launched5, both events providing evidence of the changing policy envi- can be somewhat contentious. ronment; with nutrition emerging from relative obscurity to the forefront of the policy agenda, at both national and international level. The term ‘ownership’ became something of a April 2008 Attendance of State Minister of Health at international CMAM conference in Washington DC. This was an mantra for the N-CMAM programme, with the important event because Ethiopia’s leading role in the continuing history of CMAM development was understanding that “ownership equals inter- reiterated, particularly with regard to government-led programming. nalisation, i.e. is self-maintaining”.2 Experience 2008/9 Food crisis developed across many areas of the country. OTP services rapidly decentralised down to health has also identified that the term ‘commitment’ post (village) level across the four main regions of the country.6 is often the single most important element that determines whether OTP services can be Origins of the ‘partnership’ approach The reaction to this frustration was to devise successfully established, and whether they will continue on or not. However, even if commit- Many NGOs responding to emergency situa- a new strategy of using a partnership approach. ment is high at OTP service delivery level tions from 2003 to 2005 using the CMAM This involved establishing CMAM services (health centre or health post), each part of the approach had highly successful programmes. (particularly OTP) in ‘non-emergency’ times health system has to be functioning on the most However, frustration arose when NGOs with the focus firmly on ‘ownership’ by the basic level, in order for the service to be success- attempted to ‘hand over’ to the MoH once the MoH, i.e. looking at involving the MoH in ful. For example, if the logistic system is poorly acute emergency phase was over. Attempts to longer-term programming from the start. It was functioning resulting in RUTF stock-outs, the achieve full transition to MoH-led service envisaged that this would not only establish a OTP service will collapse; ‘no product, no provision appeared to fail. This was most likely much needed service during ‘normal’ times, programme’ describes it well. So commit- due to the nature of emergency programming, but would also provide a capacity base from ment/ownership, while the key element, is not where substantial inputs were required to which services could be rapidly scaled-up at enough on its own. It is important to note that rapidly scale-up response to a deteriorating times of food crisis. Programming that viewed this is not unique to SAM programming. The situation. Emergency programming necessarily sustainability as the primary objective necessar- attempted integration of a new health/nutri- took on a vertical approach, as it required cars, ily required that the thinking move away from tion initiatives into routine health delivery staff, stores, supplies, etc, in order to reach the traditional emergency dominated approaches, require that the system is functioning at least at objectives of ‘saving lives’ in a timely fashion. to one of partnership. In doing so, the nature of the dialogue between the partners was the most moderate level, in order to succeed. After the peak emergency period was over, crucial element in defining the relationship Table 1 summarises the timeline of key while capacity would certainly have been built dynamics that in turn determined programme events in the evolution of acute malnutrition within the MoH through trainings, skill devel- success/failure. N-CMAM developed partner- management in Ethiopia. Table 2 summarises opment, etc, the vertical nature of ships with: the timeline in N-CMAM development. programming generally meant that the MoH • The MoH. Formal ‘Memoranda of were not the lead partner, or driver of the Understanding' (MoU) were regularly N-CMAM Programme Goal response. It was then often challenging for the signed between the MoH/Regional Health The goal of the N-CMAM programme is to MoH (in a resource-constrained environment) Bureau (RHB) and CONCERN in the four reduce morbidity and mortality associated with to assume responsibility for a programme main regions. These MoUs proved to be SAM in Ethiopia, through supporting the MoH which had not been ‘theirs’ in the first place. very important documents, as they trans- to scale-up quality CMAM services (particu- parently outlined roles, responsibilities and larly OTP) within the routine health delivery Box 2: Outline of the National Nutrition expectations of each of the partners. In system; that continues to function over the Programme (NNP) particular, they described CONCERN’s role longer-term and can therefore be rapidly as that of technical assistance, rather than expanded during times of food insecurity. The objective of this programme is better harmon- that of direct implementation. The MoUs N-CMAM activities and the ‘minimal isation and coordination of various approaches to also directed the expansion of services support’ package manage and prevent malnutrition. The NNP aims to within the regions according to the needs reduce the levels of stunting, wasting, underweight and interests of the MoH. In addition to the support given to CONCERNs and low-birth-weight infants, thus contributing to emergency interventions (see Box 3), the N- Ethiopia’s efforts to reach the relevant Millennium • UNICEF. UNICEF is mandated to support Development Goal (MDG) indicators by 2015. The government health services for management NNP consists of two main components: of SAM. They have acted as centralised 2 Handy, C. Understanding Organisations (4th Ed) 1999. a) ‘Supporting Service Delivery’ which includes Penguin. Ready to Use Therapeutic Food (RUTF) 3 Ethiopian DHS 2005 ‘increased access for the management of SAM.’ 4 procurers and suppliers to the RHBs. While the quality of EOS screening figures was not assured, b) ‘Institutional Strengthening and Capacity • Valid International. As the originator of it was the first time that screening for malnutrition had Building’. been conducted at-scale; the very high absolute numbers CMAM (originally Community Therapeutic of children <5 years with acute malnutrition provided The development of the NNP should be considered Care (CTC)) approach and long standing policy-makers with a powerful advocacy tool. 5 a major achievement for Ethiopia, as the country technical partner of CONCERN. Co-founder The NNP has been designed to translate the National endeavours to tackle its long-standing problems Nutrition Strategy into a 10- year action plan in two with malnutrition. Rigorous evaluation of the NNP of the N-CMAM programme. phases; the first phase is for 5-years 2008–2013, at an will be essential, to maximise the learning from this • Other NGOs. Through coordination fora, estimated cost of $370 million. 6 Chamois, S. ‘Decentralisation of out-patient management initiative. provision of training and support for of severe malnutrition in Ethiopia’, Field Exchange, ENN, CMAM-related activities, on request. July 2009, Issue 36.

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Table 2: N-CMAM programme timeline Figure 1: N-CMAM admissions, 2006-2009

July 2005 Grant awarded from the US Office for Disaster Assistance (OFDA) to pilot an integrated partnership approach 25000 with the MoH for scale-up of SAM services. Grant to CONCERN, sub-grant to Valid International – project 20000 implemented together in light of synergistic relationship. Valid providing the ideas/innovation, CONCERN 15000

providing the historical base and well-established systems that allowed for programming in Ethiopia. The 19770 programme was implemented jointly for two years, after which CONCERN continued alone. 10000

Oct 2005 Meeting with UNICEF with informal partnership formed. UNICEF to continue scaling-up support for the MoH 5000 12941 6354 to establish in-patient services (with some support for OTP). CONCERN/Valid to focus on supporting the MoH 0 1834 to establish OTP in selected operational areas. Jan – Dec Jan – Dec Jan – Dec Jan – Dec

Admissions to programme to Admissions 2006 2007 2008 2009 2006/7 TFP working group formed (MoH, UNICEF, CONCERN, and Valid International). Development of ‘TFP strategy paper’, which outlined the strategies and guiding principles of national scale-up of SAM treatment services. It included a summary of key elements that must be in place in order to realise the scale-up of quality SAM Figure 2: N-CMAM Programme performance services, such as training, reporting, supervision, community mobilisation, etc. 90 2005 – Early stage of the programme, with considerable time spent in building-up relationships with key MoH figures early 2007 in all four regions. OTP services commenced first in five health centres in Jimma Zone, Oromia region. Slowly 80 increasing number of OTPs established at health centre level (from 0 to 37 HCs in 21 woredas). Through 70 learning and experience, the ‘minimal support’ technical package was developed (see later), with time/energy 60 also devoted to reviewing, analysing and developing Concern’s internal CMAM strategy for Ethiopia. 50 2006 – 7 In collaboration with UNICEF, substantial support given to the MoH in developing the revised national SAM 40 guidelines, which included OTP and community mobilisation activities. 30 May 2007 Second grant from OFDA enabled rapid scale-up of CMAM services. The N-CMAM programme began to gain 20 – January influence, partly because of scale-up (from 37 to 187 health centres/posts across 87 woredas) as bigger exits of total Percentage 2010 programmes have louder voices, but also partly due to increasing engagement in what was going on in- 10 country, e.g. input into the revision of national curricula for nutrition, providing the training manual that was 0 adapted for the HEWs for OTP decentralisation, etc. Cured Death Defaulter/ Non- Medical Unknown responder transfer 2008 – 9 Considerable scale-up of CONCERN’s emergency nutrition activities (see Box 3). Support given from N-CMAM programme such as budget for supplies, trainings, vehicles, personnel, etc. 2006 2007 2008 2009

CMAM team assisted the MoH in selected areas • Joint supportive supervision and follow-up and examples of ‘best-practice’ were collected, of the four main regions (Oromia, Tigray, SNNP • Community mobilisation activities along with programme learning reviews and and Amhara) to establish and maintain OTP • Conducting pre- and post-workshop evaluations. services. As UNICEF had been supporting the assessments At the request of the MoH, N-CMAM activi- set-up and monitoring of in-patient units (TFUs • Facilitation of regular zonal and regional ties also included ToT in SAM case management, or SCs) since 2003, the N-CMAM programme dissemination workshops/review meetings participation in multi-agency food security/ focused mostly on OTP service provision and • Facilitation of experience exchange visits post-harvest needs assessments, support for EOS community mobilisation. However, where gaps • In-patient training and support was screening campaigns, support for additional existed, the team also supported the set-up of provided on an ad hoc basis, when requested monitoring & evaluation/ supervision activities, in-patient services. From 2007 onwards, expan- by the MoH, UNICEF or other INGOs. extensive attendance at national and regional sion of services was to areas identified by It is important to note that the physical inputs coordination meetings and involvement in government authorities as most in need, in the minimal support package described national initiatives, such as the recent Landscape usually determined by early warning data, above do not capture the relationship dynamics Analysis conducted in Ethiopia. identification as ‘priority hot-spot area’7 and that must also be attended to, if ownership is to EOS screening data. be achieved. The N-CMAM team worked alongside CONCERN’s health and nutrition unit to The ‘minimal support’ package was devel- Community mobilisation and additional conduct numerous assessments. From 2008 t o oped in consideration of the most important programme activities 2010, a total of 25 standard nutrition surveys areas where the MoH needed support, to estab- Community mobilisation was a strong feature and 10 rapid nutrition assessments were lish and then maintain quality services. The of the programme, with the focus on a more conducted, mainly to inform phase-in or phase- approach used a process of incremental capac- incremental version of community activation ity building to ensure that the ownership of the out of emergency nutrition activities. than the ‘campaign-style’ mass screening programme was always firmly in the hands of Additionally nine coverage surveys using mobilisation common for emergency the MoH. The minimal support package centric systematic area sampling (CSAS) programmes. CONCERN’s social development included the following activities for set-up of methodology were conducted. staff in consultation with the HEWs and other services and provision of ongoing support: Results/achievements health staff utilised a strategy in ‘new’ CMAM • OTP theoretical and in-patient SAM case areas as follows; The N-CMAM team relied on reporting chan- management trainings, particularly at start- 1) Mapping: identifying key actors and nels of the MoH which uses a particular up of services identifying community structures already in reporting format (developed by UNICEF) that • Regular on-the job/refresher trainings existence, particularly those active in in turn feeds into the centralised database for • ToT trainings health/nutrition TFP reporting which is held at Addis Ababa 2) Discussing: commencing a public health level. However, as these reports are not yet inte- grated into the regular Health Management Sometimes a sibling is given dialogue with identified volunteers, responsiiblity for bringing a including realistic time-frames of availablity Information System (HMIS) reporting system of child to OTP to screen for SAM and conduct home-visits the MoH, TFP monthly reports were sometimes for follow-up. incomplete and were rarely sent in a timely 3) Training: 1 day training including sessions fashion to regional level. It was often necessary, on underlying causes of malnutrition, use of through a mixture of supervisory visits and Emily Mates/Concern Ethiopia MUAC and importance of defaulter follow- reminder telephone calls for N-CMAM staff to up. collect ‘missing’ reports. The reporting rate is therefore estimated to be between 75-90% for As the focus of the N-CMAM programme was the statistics presented here. on innovation and learning, programme activi- ties have included conducting a number of From January 2006 to December 2009, across operational studies. These include a defaulter the four main regions, 40,899 children with tracing study regular social development SAM were admitted to OTP services estab- reviews and strategies, health system review, cost-analysis and effectiveness and investiga- 7 The Emergency Nutrition Coordination Unit (ENCU) produces a ‘hot-spot matrix’ identifying priority areas in need of tion into the role of traditional practitioners in nutritional support, which is revised every six months. identification and referral of SAM. Case studies 8 The programme continues on into 2010 but full results will not be available until early 2011.

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Table 3: N-CMAM programme performance Table 4: Training data January 2006 – December Table 5: Summary of N-CMAM regional data Jan 2006 – Dec 2010, four regions 2009, four regions review meetings/workshops by year Year Jan-Dec Jan-Dec Jan-Dec Jan-Dec Year Health Health HEW VCHW Year No. of No. of regions Total 2006 2007 2008 2009 professionals Extension Supervisors16 workshops covered number of Total number of 1,343 4,463 10,171 15,496 Workers participants discharges (n) 2006 108 42 0 565 2007 5 4 (SNNP, Oromia, 262 Cured (%) 56 61 66.9 77.3 Amhara, Tigray) 2007 380 359 0 1.339 Death (%) 1 0.9 1.2 1.1 200817 3 2 (SNNP, Oromia) 92 2008 547 1,236 113 1,965 Unknown (%)10 0 11.6 15.1 9.9 2009 11 4 (SNNP, Oromia, 897 2009 534 1,593 284 2,161 Amhara, Tigray) Defaulter (%) 35.5 20.3 12.3 7.4 Non-responder 0.5 3.2 3.1 3.2 TOTAL 1569 3230 397 6030 TOTAL 19 1251 (%) Medical transfer 7.0 3.0 1.4 1.1 access to services increased. Where children and well-informed community, considerable (%) were identified earlier in their disease process, effort and dedicated resources were therefore 100% 100% 100% 100% they generally had fewer medical complica- also employed for Community Mobilisation tions and may not have reached the stage where (CM) training, using Volunteer Community they lost their appetite. This meant that burden Health Workers (VCHWs). To ensure trainings lished at health centres, see Figure 1.8 A steady on in-patient services was further reduced and were conducted in a standardised manner, N- increase in rate of admissions was observed, minimised family and household disruption. CMAM staff developed a training manual for with the expansion of OTP services within the management of SAM during 2006-7, accord- health centres across the four regions.9 Rising Coverage ing to National Guidelines. The version has admissions could also be due to the higher One of the major principles of CMAM is been improved throughout the programme’s levels of food insecurity seen in parts of the ‘increased coverage’ of services. During 2010, life cycle, with CONCERN taking a major role country where N-CMAM was operational four coverage surveys using the CSAS method- in the development of OTP training materials during 2008/9. Table 3 and Figure 2 describe N- ology were conducted to assess coverage of the used at national level. CMAM programme performance, with a total of national TFP roll-out in the four main regions.12 31,480 discharges from January 2006 to Two of the surveys were conducted in areas Workshops December 2009. that had received N-CMAM support. The By 2006, CMAM/CTC was still relatively new to Ethiopia and had limited coverage, so a two- Table 3 and Figure 2 describe N-CMAM results were impressive, particularly for period day national workshop was hosted in Addis programme performance, with a total of 31,480 coverage which exceeded the Sphere target of > 13 Ababa to bring together the MoH, UN agencies, discharges from Janurary 2006 to December 50% in a rural area. Point coverage estimates were lower, highlighting the importance of donors and NGOs. The objective was to discuss 2009. 0Table 3 and Figure 2 demonstrate very continued efforts in community mobilisation encouraging programme results. The recovery (see above for a description of community 9 Figures presented here are for health centres as ‘roll out’ to rate steadily improved from 56% in 2006 to mobilisation activities). health post occurred gradually during the year 2009 in N- 77.3% in 2009, thus exceeding International CMAM areas. From 2010 onwards, programme figures will Sphere recommendations for >75% recovery During 2009/10, N-CMAM, in collaboration be collected from health posts. 10 During the 2007 revision of the national SAM guidelines, rate.1 Most of these gains in recovery are a with Tigray RHB, piloted a new methodology defaulters were divided into ‘unknown’ i.e. unconfirmed result of declining defaulter/unknown rates for assessing coverage of OTP services. This defaulters and ‘defaulter’ i.e. those defaulters confirmed and to some degree, the rate of medical transfer. through a home visit. The values need to be added together ‘Semi Qualitative Evaluation of Access and for the total default rate. The trend of improved recovery rates clearly Coverage’ (SQUEAC) methodology was devel- 11 The Sphere project recommends: recovery > 75%, death demonstrates the MoH becoming more confi- oped as a less resource-intensive (and therefore <10%, default < 15%, coverage > 50% (in rural areas) 12 The CSAS assessments were coordinated by the Ethiopian dent in their ability to offer quality services, more ‘MoH friendly’) way of evaluating Health and Nutrition Research Institute (EHNRI) and the with minimum technical support. It also programme coverage and identifying barriers MoH. CONCERN provided the technical support for suggests children are less likely to default, with to service access and uptake.14 Between October implementation of the surveys, which were funded by UNICEF. improved access to services and increasing 2008 and April 2010, three rounds of SQUEAC 13 Mareko woreda, Gurage zone, SNNP Region: OTP period satisfaction with the service. were implemented, with coverage steadily coverage 60.9% (95% CI: 52.8%-68.6%) and point improving with each round (half of health facil- coverage 37.8% (95% CI: 28.2%-48.1%). Taytaw Machew While an overall declining trend of defaulter woreda, Tigray Region: OTP period coverage 56.2% (95% ities reaching >50% by the third round). and unknown rates was seen, they remained CI: 44.1% - 67.8%) and OTP point coverage 27.3% (95% Encouragingly, Tigray RHB not only took the CI: 15.0% - 42.8%). high. This is largely due to the challenging 14 Myatt, M. ‘SQUEAC: Low resource method to evaluate lead by the third round, they also supplied the topography in many areas of the country and access and coverage of programmes’, Field Exchange, ENN, budget for the survey, with CONCERN provid- June 2008, Issue 33. logistical problems of ensuring that all health 15 ing technical assistance only.15 Schofield, L, et al. ‘SQUEAC in routine monitoring of CMAM facilities had an uninterrupted supply chain of programme coverage in Ethiopia’. Field Exchange, ENN, RUTF. The mortality rate was consistently low. Training of MoH health professionals March 2010, Issue 38. 16 Recognising that the new cadre of HEWs were in need of However as the number of unknown cases and community members supervision, the MoH trained and deployed HEW supervisors remains high, it is possible that some mortality Table 4 outlines the focus that was placed on from 2008 onwards. occurred within this category. As expected, 17 Fewer workshops were conducted during 2008 as many of training of health staff. It is now well-known the N-CMAM staffs were involved in Concern’s scale-up of transfer rates to in-patient care reduced as that OTP success is contingent on a responsive emergency programming (see Box 3)

Shemsiya (2 years) failing the RUTF appetite test Shemsiya with her family

Emily Mates/Concern Ethiopia Emily Mates/Concern Ethiopia Emily Mates/Concern Ethiopia

71 Field Article the current status of therapeutic care in A number of key factors/processes, listed but some were particularly accentuated with Ethiopia and formulate plans for increasing below, promoted an enabling environment CMAM. coverage of quality services. From 2007, the N- within which the N-CMAM programme could Programme specific challenges CMAM team recognised that the facilitation of achieve its objectives. Transport continues to be a major challenge for workshops/review meetings could be a valu- a) Continuous and sufficient funding from July the MoH across this vast country. Where vehi- able tool for improving the quality of services. 2005 to date, through a series of grants from cles exist, they are often in need of maintenance MoH staff involved in OTP implementation OFDA and CONCERN-sourced funding, which: and lack budget for fuel. OTP is a logistically- were brought together in the same room as key • Allowed for programme scale-up and heavy service modality due to the bulky decision makers from regional, zonal and federal continuation, with the ability to deliver on product (RUTF). Ensuring sufficient and level MoH, to discuss the challenges faced and commitments. adequate storage space also presents major devise appropriate solutions (Table 5). These • Enabled regular processes of learning, difficulties. Additionally, the service is not a workshops (while expensive and time-consum- monitoring and evaluation, with budget ‘one off’ – caregivers need to come back each ing to prepare for and conduct) provided allocated for operational studies and week for eight weeks on average, requiring the excellent opportunities both for developing co- innovative programming approaches. OTP to have regular, uninterrupted supplies to ordination and encouraging accountability • Offered dedicated budget for senior staff ensure successful outcomes. among partners. Additionally, ‘phasing-out and an expanded team at capital level that workshops’ (after emergency nutrition interven- enabled rapid response to requests for Facilitation of sufficient and adequate super- tions, see Box 3) proved important fora to technical assistance from partners (MoH, vision at-scale was problematic, especially reinforce the understanding of roles and respon- UNICEF, other NGOs), attendance at a considering the transport challenges described sibilities, including the re-design of action plans wealth of coordination fora and for staff to above. While the supervisory visits were for future activities when OTP was transferred take an active role in policy developments. always well appreciated by health staff, due to back from more intensive ‘emergency’ level • Assisted the scale-up to emergency many competing commitments, it was not easy support provided by CONCERN to full MoH programming, where required (see Box 3). for over-burdened MoH supervisory staff to management. make enough time for visits to health facilities. b) Strong focus on training of the N-CMAM Experience-sharing visits A standard supervision checklist for OTP was team in how to support partner staff, rather developed during the programme (in collabora- A learning and information-exchange visit by than undertaking direct implementation. tion with UNICEF and the MoH), and is Ethiopian MoH officials to Malawi was facili- Building the capacity of CONCERN’s partner currently being integrated within the routine tated during 2006, with representatives from required the team to deliver support from the health supervision system. UNICEF joining the trip. The goal was to learn sidelines, often a more difficult task than direct and share lessons on the treatment of SAM as implementation. Collection and collation of programme part of routine health services. The visit statistics was a major challenge. The data provided an excellent opportunity for Ethiopia c) Strong and continued focus on community presented above is only from health centres. staff to learn from Malawi’s recent national mobilisation, with dedicated Social Since the national ‘roll-out’ of TFP (2008 scale-up experience, hearing first-hand about Development staff. This helped to create the onwards) and the decentralisation of OTP serv- the successes and challenges that the Malawian ‘demand driven’ version of OTP, whereby the ices to health post level, staff providing regular MoH had faced. rapid and visible recovery of children acts as a and accurate reporting face many additional profound motivational force for parents, health hurdles. From 2008 onwards, a strategy of experi- workers and the wider community.18 ence-sharing visits for MoH staff to other High staff turnover within the MoH was the regions within country was employed. Six d) Initial targeting of districts that had experi- primary obstacle to ongoing knowledge reten- visits were organised with a total of 181 MoH enced limited INGO support, in an attempt to tion at health facilities, resulting in untrained staff travelling. Health workers who were avoid areas where dependence on NGOs for staff often found implementing OTP. Focal performing well were invited to travel to areas nutrition-related programming was highest. persons for nutrition to co-ordinate and moni- in need of encouragement, to improve Additionally, CONCERN invoked a principle tor activities at regional, zonal and district level programme performance. The success of these of not having a full-time presence in opera- were appointed. However, the high rate of staff visits hinged on the fact that advice was being tional areas. Instead, CONCERN had a base in turnover meant that it was important to involve given by the MoH to the MoH – not from the capital that could provide support and all members of the health team from the start, to CONCERN – which gave added weight to dialogue with the woreda and Regional MoH, minimise the risk of the programme collapsing recommendations of how to improve service but no permanent presence. if one person left. delivery. The visits appeared to act as powerful e) The MoUs that were regularly signed with Routine antibiotic treatment was mostly not motivational tools, with potential for longer- RHBs supplied the all-important official term impact. available at the health facilities as they are authentication for programmatic aims and supplied through a delivery system that is Discussion objectives. different RUTF supply. While the programme was always results orien- Challenges tated, it was viewed through the lens of public During programme implementation, a number health. This focus enabled it to keep going 18 ‘Temporal Integration’ Demand driven CTC. Steve Collins, of challenges were experienced. Many of them Emergency Nutrition Network (ENN) Special Supplement through the early years of low recovery rates were common to overburdened health systems, Series, No. 2, November 2004. (only 56% in 2006), in the belief that if services were incrementally established at-scale, improvements in service quality could follow. This was as long as the MoH was provided with sufficient, appropriate and well-targeted support. At present, the only benchmarks for SAM treat- ment programmes are provided through the Emily Mates/Concern Ethiopia Sphere Project. While reaching these recommenda- tions should always be the aim of the programme, it must be remembered that they have evolved from humanitarian emergency programmes that are generally implemented by well-resourced INGOs. It could be useful if suitable benchmarks for MoH-led national scale-up programmes that provide appropriate reference points for programme quality, especially during the early Welcome message by Ato Yohannes, years of implementation were developed. the Deputy Head of Tigray RHB.

72 Field Article

Community mobilisation mechanisms were Development of acceptance at community level. convinced that more senior staff are interested not always clear and readily available for use, While RUTF offers ‘instant’ solutions (some- enough in programme results. Initially it might resulting in a parallel system needing to be set- times described as the ‘steroid treatment’ for be necessary to conduct additional supervision up (although the programme collaborated with the dramatic results), understanding by the to ensure service quality (especially when the whatever mechanisms did exist in the commu- community of the causes of malnutrition and service is new). However, integration into nity). The UNICEF-supported Community appropriate health seeking behaviours to treat routine health service supervision must be Based Nutrition (CBN) programme now pres- and prevent it, takes a much longer time to aimed for if sustainability is to be achieved. ents an excellent opportunity to integrate SAM mature. N-CMAM Programme limitations screening into the growth monitoring activities The importance of using both formal and informal carried out by VCHPs, but the modalities of this Although a number of ‘strategy meetings’ were channels of communication and networking to have yet to be agreed. held, a strategy as such was not developed. This muster influence. As a relatively small NGO, we was partly due to the short-term funding cycles Challenges in the environment (unsurprisingly) had limited access to key deci- of the programme that presented some barriers Integration of scaled-up OTP as part of routine sion makers. It was important therefore to for the articulation of a strategic vision. Longer- health delivery provides many challenges for utilise all available openings in order to advo- term funding for N-CMAM proved elusive, an overburdened and under-resourced health cate for OTP uptake and decentralisation. despite attempts to secure it. system, including the time taken to actually Informal channels proved remarkably effective treat the children, attendance at trainings, in gaining access to important actors of the While the N-CMAM is a much more cost- reporting, ordering, transport and storage of policy making process. effective version of OTP than ‘usual’ NGO supplies, etc. supported versions, the programme remains Personality driven gains. The effect of having key relatively expensive. Considerable budget is Competing priorities within the health people in key places in the MoH, e.g. a moti- required for trainings, cars for supervision, staff system are also a challenge, since many vated zonal health head, should not be salaries, etc. health/HIV related initiatives are being ‘rolled underestimated. Having certain individuals in N-CMAM prioritised attention on OTP over out’ at the same time in Ethiopia. While key advocacy roles is also important, for exam- the establishment of in-patient services. This improvements in health services are obviously ple, the previous country representative of decision was taken for two reasons. First, exist- welcome, it does exert pressure, e.g. attendance UNICEF was a nutritionist. While the reliance ing UNICEF support for in-patient services at trainings can result in health staffs spending on key people (or one key person in an area) (described above) and second, with limited considerable time away from facilities. was undoubtedly a high risk strategy, there was CONCERN capacity, the focus (as public health Additionally ‘per-diem’ rates risk becoming often little alternative. Additionally, while the advocates) should be on the 95% of children competitive, with initiatives that pay higher person/s was in place, opportunities could who could be treated in OTP. It is acknowl- rates appearing more attractive. present themselves, providing unexpected advantages. edged that alternate views exist, that might Lessons learned consider N-CMAM should have prioritised in- Sufficient and adequate supervision is difficult to The length of time that the process of integration patient care also. achieve on a large scale. Joint supervision is essen- requires on many levels. Continual dialogue and tial and must be insisted upon to achieve There were a number of missed opportuni- interaction with key actors is needed to ensure maximum effect. Improvement in service ties. For example, linkages with preventative objectives are being met and opportunities capi- provision is only likely if the health workers are nutrition interventions were very limited, as talised on. were linkages with hygiene and other sanita- tion activities. Health education at the OTP was Box 3: Emergency programming irregular and could be sub-optimal.

During the food crisis of 2008/9, CONCERN scaled-up ‘recovered’ (according to the Ethiopian Disaster While the programme’s aims and objectives to emergency nutrition response, implementing the Prevention and Preparedness Agency (DPPA) ‘classifi- have always been to support the MoH, it is ‘full’ CMAM package (that included supplementary cation of malnutrition’). acknowledged that this particular version of N- feeding support, OTP and SC set-up) in 10 woredas. Programmatic results mostly reached Sphere CMAM remains NGO-driven, where In addition, blanket supplementary feeding distribu- recommendations, although some areas experi- sustainability after phase-out is not guaranteed. tions were implemented in selected woredas of enced poor recovery rates (see field article on Dessie SNNP, Amhara, Tigray and Oromia regions, in Zuria in this issue, ‘The history of nutrition in Dessi Conclusions attempts to contain rapidly deteriorating situations. Zuria’). The N-CMAM programme started from small Total numbers of beneficiaries treated through the beginnings and grew into a relatively large and Along with 25 standard nutrition surveys and 10 programmes during 2008/9: Rapid Nutrition Assessments, a total of five CSAS successful intervention. It capitalised on the coverage surveys to monitor the quality and impact national and international momentum that was Intervention Target group Total number of these selective feeding programmes were building around nutrition issues. It contributed of beneficiaries conducted. CONCERN placed a strong and contin- to the national roll-out of SAM treatment serv- Blanket Children 6-59 122,361 ued emphasis on coverage assessments, due to the ices that is now underway in Ethiopia, by supplementary months importance of measuring and quantifying the levels demonstrating that the MoH were well able to feeding (SF) Pregnant (3rd 20,989 of service uptake by the target population. The manage and implement OTP services of (1 month SF trimester) and reasons why some areas had high uptake and others increasing quality at-scale. It reflected that the ration low could be understood and lessons learned from lactating women process might take some time and considerable provided) (infant <6 months) both scenarios. Coverage results well exceeded the expense. Targeted SFP MAM children 6-59 54,943 Sphere recommendations (>50% coverage in a rural months area) in all but one assessment (where OTP point The national roll-out of the TFP has been coverage was estimated at 46.4%, Dessie Zuria MAM pregnant 30,069 subject to considerable effort from the MoH woreda October 2008). (3rd trimester) and (supported by UNICEF and other partners). To lactating women A key challenge for CONCERN’s emergency inter- date, approximately 30% of Ethiopia’s health (infant < 6 months) ventions was how to scale-up and then, crucially, facilities are offering OTP services, an impres- OTP 11 11,689 scale-down again, without undermining the work sive achievement over a short period of time. that had been previously done through the N-CMAM TOTAL 19 240,051 The challenge now will be how to maintain capacity building approach. The period of transition quality of the OTP, when implemented at scale. back to N-CMAM’s ‘minimal support’ approach could The difficulties of adequate monitoring, super- The decision to scale-up to the emergency be interesting, as partners were required to realign response was made either due to rising admissions expectations of assistance once the acute emer- vision and reporting are enhanced, as is the to OTP (in areas that were being supported by the N- gency period was over. Phasing-out workshops logistic burden for the health service. Strategic CMAM programme), or when the results of rapid helped to reinforce the understanding of roles and planning, along with strong leadership from the nutrition assessments or standard nutrition surveys responsibilities during the transition period, where MoH will be required, in order that the TFP roll- indicated a worsening situation. Decisions for OTP and SC services were again fully managed by out can be strengthened and maintained. phase-out of emergency interventions were only the MoH. Learning reviews were also conducted at made once results of standard nutrition surveys indi- the end of each emergency intervention, in order to For further information, contact: cated that the vulnerable population had sufficiently maximise learning for future interventions. [email protected]

73 Agency profile Field Article The Ethiopian Orthodox Church Development and Inter-Church Aid Commission Ethiopia, 2009 EOC-DIAC, By Gebreselassie Atsbahha

Gebreselassie Atsbahha is Emergency Relief Officer with the EOC- DICAC. He has over 20 years of experience in humanitarian, social protection and development works, both in governmental and non-governmental organisations in various parts of the country. His has a MSc in Land Resources Management and Environmental Protection.

The author would like to acknowledge Alive and Thrive, Ethiopia for the efforts it is making to alleviate malnutrition and the problems associated in Ethiopia. The lead- An EOC-DICAC team ership quality of Dr Teweldebirhan Hailu, senior country director of the organisation, surveying a mosquito as well as the harmony and commitment of the staff is really appreciated. breeding sites in Amhara region, Guangua district

he Ethiopia Orthodox Church (EOC) is prevention and control projects and refugee and environmental degradation. The organisa- one of the oldest churches in the world. and returnee programmes. tion has also built schools and health posts to create access for education opportunities and The church is also the largest denomi- The EOC-DICAC has more than 20 US and health services for thousands of rural family nation in Ethiopia with more than 40 European based partners and has an annual Tmillion followers, which is approximately 40- members in the country. budget of around US $ 30 million. The main 50% of the total population. One can observe donors include (but are not limited to) UNHCR, The water supply scheme construction proj- the impacts of EOC in almost all aspects of the EU,UNICEF, UNDP, Christian Aid, Dan Church ects create opportunities for millions of country’s history and present image and the Aid, ACT-Forum, Water Aid, Intermon‐Oxfam, Ethiopian people to get potable water, reduce EOC continues to play an important role in the USAID and World Vision. The EOC-DICAC the workload of women and children, minimise social, economic, cultural, educational and also works closely with other Church based and the prevalence of water borne diseases and political life of the country. Church affiliated organisations. increased awareness of hygiene and sanitation. EOC-DICAC objectives Emergency response Rural roads constructed by EOC-DICAC have also contributed to the mobility of rural In order to respond to both the emergency and During periods of drought, internal conflict and communities and increased their accessibility to longer term needs of the population, the church other emergency situations, the EOC-DICAC the nearest towns and markets. established a development wing in 1972, the supports the responses arising from the govern- Ethiopian Orthodox Church Development and ment’s national emergency appeals. The Working with women Inter-Church Aid Commission (EOC-DICAC). EOC-DICAC has the capacity to be involved in EOC-DICAC is very concerned about women’s The EOC-DICAC is one of a few active life saving interventions through the provision participation in development and makes sure ecumenical development organisations in the of food aid, farm tools, seeds, small that the following issues are addressed right country. It is engaged primarily with the objec- animals/ruminants, supply of water and other from the project design up to the phase-out of tive “to help disadvantaged communities attain basic life saving inputs. Priority is given to projects: self reliance by tackling the root causes of supplementary feeding of children and the • Encourages women to participate at all poverty, drought, conflict and HIV/AIDS by provision of a monthly take home ration (typi- levels of the project cycle and ensures promoting a sustainable development cally 4.5kg per month) to other vulnerable gender sensitivity. programmes”. The EOC-DICAC works within groups, such as the elderly and the sick. • Ensures that interventions consider women the regulations and laws governing non- in equal status with men. governmental organisations (NGOs). The EOC-DICAC also supports environmental • Built partnership and strategic alliance with Vision of EOC-DICAC is to help create a just rehabilitation activities in some areas, such as local government and civil society society in which everyone has access to the area closures, soil and water conservation struc- organisations (CSOs) to promote gender basic necessities of life. tures, seedling production and distribution. mainstreaming in development projects at EOC-DICAC activities Apart from this, the commission has tried to all levels. expedite crop production, livestock develop- To achieve its objective, EOC-DICAC is • Advocates against violence in terms of ment activities and introduce vegetables and involved in the following major areas of activity: person trafficking, as well as female genital fruit trees. By so doing, these activities aim to • Providing emergency and humanitarian mutilation and other harmful traditional have a role in improving the nutritional status assistance practices. of children and improve dietary diversity of the • Implementing rural development • Intervene in women capacity building so as target families. programmes to enable them acquire technical skills. • Building local capacities to implement In coordination with District Health Officers, • Promotes equal opportunities for women project activities for poverty reduction orientation and awareness creation on HIV and men in recruitment, staff development • Assisting vulnerable groups such as transmission, protection mechanisms and the and promotion. refugees, returnees and displaced people use of voluntary counselling and HIV testing is The basis for the emergency and development • Supporting the prevention and control of also a key activity. Pilot projects on HIV/AIDS initiatives of EOC-DICAC is the fundamental HIV/AIDS and related nutrition needs orphan care at parish churches have also shown doctrine of the Church/Bible "Everyone who • Training/education to ensure equity and promising success. has gives to those in need". The initiation of the promote optimal use of natural resources. To date, EOC-DICAC has made great strides whole effort put by the Church so far has Since its establishment, the EOC-DICAC has in its service to the disadvantaged populations emerged from its doctrine or internal spiritual implemented many relief and development of Ethiopian society and its programmes have belief that urges everyone to help those who are projects. By mid-2010, the EOC-DICAC was strengthened communities to better sustain relatively poor in the society. implementing more than thirty projects in themselves during periods of extreme hard- For further information, contact: Gebreselassie different parts of the country covering inte- ship. EOC-DICAC has succeeded in Atsbahha, P.O BOX: 503, Ethiopia. tel: + 251 grated rural development, water supply and community mobilisation to fight against the 911 687909 Fax +251 111 551455, sanitation, relief and rehabilitation, HIV/AIDS root causes of poverty, HIV/AIDS pandemic email: [email protected]

74 TSF distribution in Degehabur, Somali Region Field Article

By Jutta Neitzel

Jutta Neitzel is the Head of the Nutrition and Education Section at WFP Ethiopia. She has worked for the programme since 1997. Previously she worked for WFP in Italy and Yemen. She holds a Masters in Economics.

The author acknowledges the contributions of Gloria Kusemererwa, Targeted Supplementary Food (TSF) team leader, WFP/Judith Schule, Ethiopia, 2009 her deputy Tayech Yimar and the entire TSF team for their wisdom and input to this article and their continued dedication to backstop The Targeted the intervention and to identify creative ways to improve the Supplementary Feeding response the nutritional needs of young children in Ethiopia. The findings, interpretations, and conclusions in this article are those of the author. They do not necessarily represent the views of WFP or Programme (TSF) the country they represent and should not be attributed to them.

he Enhanced Outreach Strategy quarterly Community Health Days (CHDs) vitamin A all children under five years. On (EOS)/Targeted Supplementary Food organised and managed by the Health many occasions, Regional Health Bureaus (TSF) for Child Survival is a joint Extension Workers at kebele level. The TSF take the opportunity to deliver other essential programme under the United Nation will be continued at kebele level until the services such as measles and tetanus vaccina- TDevelopment Assistance Framework (UNDAF, rates of acute malnutrition are low enough to tions, mosquito net distribution, HIV/AIDS 2007-2011) with the Government of Ethiopia. end the programme (i.e. until impact of prevention, iodine capsules distribution, etc. UNICEF is supporting the Ministry of Health preventive programmes such as community- In TSF districts, the EOS team is expanded (MoH) to conduct twice yearly campaigns of vita- based nutrition (CBN) is effective). with another two health staff, generally one min A supplementation and deworming to every The EOS provides key Child Survival health extension worker and one support child under five in the country1. In TSF selected interventions to over 11 million children and staff, to undertake the screening of children, districts, the EOS is also screening malnutrition of 700,000 pregnant and lactating women every pregnant and lactating women. Thes- health all children under five years and pregnant and 6 months. The annual funding is US$14 staff measure the Mid-Upper Arm lactating women.2 WFP is supporting the Disaster million. Circumference (MUAC) of children under Risk Management and Food Security Sector five years and check for bilateral oedema. (DRMFSS) of the Ministry of Agriculture and Rural The annual requirements of the TSF Children and women eligible for TSF are Development (MOARD) to deliver two supple- component, with its present coverage, are registered in a book and given a TSF ration mentary rations of Corn Soya Blend (CSB) and oil currently estimated at about US$53 million, card. The registration book includes the serial to children and women identified with acute equivalent to 53,000 metric tonnes of fortified number of the distribution card4. There are malnutrition during the screening.3 blended food and vegetable oil. These quanti- ties respond to the needs of around one three carbon copies of the registration book, Overview of EOS/TSF million individuals in 168 woredas in Afar, one for the Food Distribution Agent (FDA), The Targeted Supplementary Feeding programme Amhara, Gambella, Oromia, Somali, SNNPR one for the district Health Office and one for aims to rehabilitate children under five years old as and Tigray regions. Initially, the programme the district Disaster Prevention and well as pregnant and lactating women (PLW) iden- covered 325 woredas, but due to soaring food Preparedness Office (DPPO). The registration tified as acutely malnourished during EOS prices as well as diminished donor support in book is then kept by the FDAs. The three screenings in TSF selected districts. The early 2008, the programme had to be down- carbon copies allow supervisors and field programme also aims to reduce the risk of child scaled. The initial 325 woredas were the monitors to verify that they are identical and mortality and through an awareness-raising chronically food insecure woredas identified were not manipulated. In addition to receiv- component, aspires to enhance the basic nutrition by the Government of Ethiopia during the ing the TSF ration, children identified with knowledge of mothers and other women in 2002/3 emergency. The criteria used to select the current 168 TSF woredas were: communities targeted by EOS/TSF. 1 Vitamin A is supplemented to children 6-59 months old • prevalence of moderate acute malnutrition and deworming tablets are administered to children 2-5 Ethiopia is currently among the countries with (MAM) >10% years old. the highest rates of child mortality and malnutrition 2 The following groups are screened for malnutrition: • classification as emergency hotspot children 6-9 months old, visibly pregnant women and in the world. The various long-term strategies initi- woredas in 2006/7 women breastfeeding a less than 6 month old infant 3 ated by the Government of Ethiopia, such as the • identification as a food insecure woreda The following groups are eligible for TSF: Children with Productive Safety Net Programme (PSNP) or the MUAC <12 cm and/or bilateral oedema and women with during the December 2007 meher assess- MUAC < 21 cm. One TSF ration is composed of 25 kg of Child Survival Strategy among others, started in CSB and 3 litres of oil for 3 months. ment to be a relief recipient in 2007 4 2004/5. It is anticipated that these programmes will Ration cards have serial numbers and different colours • not a PSNP woreda in 2007 and, for at each screening round take at least 5to 10 years to have significant impact. Oromia and SNNPR, whether the woreda 5 Eligible for TFP: children with MUAC <11cm and/or bilateral oedema. The EOS/TSF was developed in 2004 as a ‘stop-gap’ was rolling out the national nutrition measure to avoid additional millions of Ethiopian programme’s CBN or not. Table 1: Achieved coverage 2005-2009 children from dying or becoming malnourished in (source: MTE Team) the meantime. It was carefully designed to create a The current TSF woredas do not cover all the ‘bridge’ to the more sustainable and longer-term hotspot districts in the country. Therefore a PRRO PRRO interventions like PSNP. special mechanism has been developed to 10362.0 10665.0 undertake ‘ad hoc’ TSF distribution in Coverage 2005 2006 2007 2008 2009 The TSF replaced the provision of blanket hotspot woredas that are not TSF woredas. supplementary food rations alongside the general No. regions 7 10 10 7 7 relief food distribution. The rationale for a more Implementation and design No. woredas 165 260 342 166 202 targeted approach was to better respond to the Every six months and with UNICEF support, No. pregnant/ 0.173 0.228 0.369 0.289 0.356 needs of malnourished individuals at a critical Regional Health Bureaus organise Child lactating physical and mental development stage in their Survival campaigns. Each district (woreda) women lives and to ensure better targeting than a blanket that is not a TSF district forms one EOS team (millions) distribution. per sub-district (kebele) composed of one No. of children 0.301 0.484 0.783 0.615 0.756 health worker and one health extension under five More recently (2008), the National Nutrition worker. These mobilise the community to (millions) Programme (NNP) was approved and provides the come to the nearest health post on a specific broader framework for developing community- Total no of 0.474 0.712 1.152 0.904 1.112 day, called the EOS day. On this day, the EOS beneficiaries based nutrition capacity in Ethiopia. The EOS is (millions) now being gradually phased-out and replaced by team will de-worm and supplement with PRRO: Protracted Relief and Recovery Operation

75 Field Article severe acute malnutrition (SAM)5 are referred to regularly check on the improvement of the bene- of severely malnourished children for more the nearest Therapeutic Feeding Programme, if ficiaries’ nutritional status, WFP conducts an appropriate therapeutic care. available. outcome survey once a year including data on What challenges has the programme recovery and mortality rates. During the EOS days, MoH supervisors and faced? UNICEF field monitors undertake spot visits TSF achievements The programme has encountered a number of although number of sites visited is limited. In The EOS service coverage has been consistently challenges. The absence of a national nutrition addition, post-EOS coverage surveys are regu- high (>90%) since its inception in 2004. A TSF surveillance system and weight gain monitor- larly conducted by independent organisations. outcome evaluation study7 was conducted in ing in between the six-monthly screenings At Federal level, the Emergency Nutrition 2008. This study aimed to recruit children for a prevents regular outcome monitoring. Current Coordination Unit (ENCU) checks screening prospective cohort study in eight districts. information on the nutrition situation is data and informs the MoH, DRMFSS, UNICEF Children were to be followed up at 1,2, 3 and 6 provided through woreda-level nutrition and WFP of any aberrant data. months after enrolment in the TSF. At the time surveys, which are mostly conducted by inter- national non-governmental organisations The DPPO is responsible for compiling the of the first follow-up visit, 973 children had (NGOs) and cannot be extrapolated to regional data from the screening registration book and received TSF food and were defined as inter- or national levels. Such surveys are triggered if to request the appropriate amount of TSF food vention children, and 588 children had not a serious nutrition problem has been signalled from the regional Disaster Prevention and received TSF food and were defined as control or as follow up to nutritional programmes. Preparedness Bureau (DPPB). The DPPB is in children. Overall, at all four follow-up visits, intervention children had greater change in charge of transportation and distribution of The 2008 TSF outcome evaluation study weight-for-height z-scores from baseline than food to over 1,300 food distribution centres. The observed an inclusion of many children who control children (p< or =0.001). Weight gain food is provided by WFP to all of the regional are actually not malnourished (46% of the differed much less between the two study warehouses. All of the food transportation, surveyed group). However, the error of inclu- groups and was not statistically significant, distribution and administrative costs incurred sion clustered very closely around the 12 cm cut with the exception of the fourth follow-up by regional government are paid by WFP. off point. This error may be due to the poor visits. Changes in MUAC also did not differ quality of the screening (poor health extension TSF distribution centres are selected through greatly between the intervention and control workers skills/performance in the identifica- community participation and managed by group. However, at the first follow-up visit, the tion of malnutrition) or to external pressures to FDAs (trained and paid females from respec- difference was marginally statistically signifi- 6 get additional or less beneficiaries on the TSF tive communities) . Once the food is received cant (p=0.05). by the FDAs, the community is informed of the list. The screening methodology initially TSF distribution date. Beneficiaries come with a By the end of follow-up at 6 months, 49.2% combined a pre-selection with MUAC measure- TSF ration card and collect the ration for 3 of children with a low MUAC at baseline had a ment followed by the weight-for-height months. The food basket comprises two 3- MUAC greater than or equal to 12 cm and were calculation and oedema checking. This method monthly rations of 25 kg of Corn Soya Blend considered ‘recovered’, 47.6% had a MUAC less was complicated and highly prone to errors. In (CSB) and 3 litres of oil. The size of the ration than 12 cm and were considered ‘not recov- 2006, the methodology was simplified and a has been set to compensate for intra-household ered’, 2.9% had died, and 0.3% did not pick up new MUAC tape, using a colour code and a sharing. FDAs also pass on four nutrition either the first or second distribution and were poster were developed to increase the aware- 8 messages during the distribution. This includes considered ‘defaulted’. A similar study ness and understanding of the children’s instruction to minimise intra-household shar- conducted in 2009 showed much better results, entitlement to TSF and TFP. ing and selling of the TSF ration. with a 68% recovery rate after three months food consumption. Initially, screening was undertaken by At the food distribution stage, the DPPB is community volunteers that were new and responsible for conducting regular food moni- In 2008, compliance with TSF programme unqualified. The screening is now the responsi- toring, complemented by WFP monitoring. recommendations was generally poor. The bility of the health extension workers that are Unfortunately, DPPB monitoring results are not majority of children lived in households where qualified and regularly trained on measuring regularly shared with partners. WFPs monitors the food was consumed faster than expected, techniques. Where ENCU cannot confirm the and woreda health and DPPO focal points ate less than one-half of the TSF food, or shared validity of screening data, WFP reduces the conduct spot check visits to ensure proper the food to some extent with other persons in ration in line with the previously served implementation and support to the FDAs. In the household. The authors of the study numbers or individuals or withholds the food 2009, through regular spot check visits, WFP concluded that although the TSF programme distribution till such a time as a field verifica- monitors interviewed 2,369 beneficiaries in 111 has a beneficial effect on enrolled children, the tion exercise can be undertaken. The woredas and visited 1,245 distribution centres. effect seen was smaller than expected. withholding of food has however, only Nearly 500 centres were visited during distribu- Numerous reasons for this were suggested, happened in a few instances. tions. The monitoring visits check on whether including: ENCU’s most recent guidance notes on the the distribution process is following proce- • A large proportion of children enrolled EOS screening data quality underscores the dures, including proper documentation in the were not acutely malnourished. need to present credible screening results for registration books, registration cards, sign- • Poor compliance, i.e. food sharing (children effective TSF targeting with limited inclusion boards, etc. Monitors also conduct beneficiary living in households with increased food and exclusion errors. The note suggests more interviews 40 days after the food distribution. sharing tended to have less improvement in Beneficiary interviews enquire about food nutritional status than children in house community mobilisation and sensitisation on received and how it is used as well as obtain holds with less food sharing). EOS/TSF, training of anthropometric measur- feedback on the distribution, knowledge about • Increased food insecurity during the follow- ers, the reduction of the number of children to entitlement and nutrition awareness. Following up period so households may have be screened per HEW per day (from 200-250 to each distribution, FDAs attend a post-distribu- increased TSF sharing. 100 per day), more supervision, better quality data compilation at kebele, woredas and tion woreda review meeting to assess the A number of recommendations to address these distribution process and to discuss problems regional level, application of data quality check findings were made that included: criteria including plausible maximum levels for encountered with woreda health and DPPO The targeting needed to be improved to exclude focal points. Review meetings are conducted at moderate acute malnutrition (MAM) (15% of more children who do not have acute malnutri- children screened) and SAM (3.2%) and a maxi- district and zonal level to assess the overall EOS tion, e.g. ensuring better trained screeners, campaign performance, including the quality of mum ratio between SAM and MAM. employing supervisory checks on a portion of the screening process. EOS screening and implementing two stage 6 Currently 2,636 women FDAs are trained in the 168 WFP’s approach verifies whether allocated screening. woredas 7 Outcome evaluation study of the Targeted Supplementary TSF food is reaching beneficiaries identified The intra-household food sharing should be Food (TSF) programme in Ethiopia. World Food Programme, through the EOS-TSF screening on a timely basis, Ethiopia, June 2009. Jutta Skau, MSc; Tefera Belachew, MD minimised by more research into reasons for and enables follow up at higher levels if need be. MSc, Tsinuel Firma, MD; Bradley A. Woodruff, MD, MPH. sharing, better education of mothers and 8 Although not meeting Sphere standards many consider Commodity tracking will further benefit from increasing TSF rations. that the design of the TSF is unique and particularly the envisaged Food Management Improvement appropriate to the Ethiopian context so that it cannot and The TSF programme should be linked more Project (FMIP). As the programme does not should not be compared to traditional SFPs in terms of closely to health centres to improve the referral project monitoring data and outcome measures.

76 Field Article

by the community and hoped that the model would be used as an hence not implemented alternative in areas with accessibility issues in Tigray and Afar and/or concerns about targeting of blanket regions. In Afar region, blended food assistance through the relief there is a strong need structure. This approach has however not been for the involvement of used since. traditional clan and In 2009, WFP food monitors concluded that a kebele leaders while in number of woredas in Afar and Somali regions Tigray involvement of were not adequately screened and numbers of health extension work- beneficiaries were consequently not based on ers is going to be reality. In following up with ENCU, the govern- important. Key recom- TSF beneficiaries in Degehabur, ment could also not confirm that screening Somali Region mendations from this results were correct. The TSF distribution was

Credit: WFP/Judith Schule, Ethiopia, 2009 study included the need then cancelled. to integrate FDAs nutri- WFP has also piloted a programme using the tion education with activities of Health A cost study of the programme conducted in ‘gatekeeper concept’ aimed at a reduction in Extension workers, reducing the distance trav- Amhara and Oromia regions in 2007/8 found targeting errors. In this approach, a second elled for collection of TSF food, making mothers that excluding food items, the highest cost of screening done by WFP-employed nurses is attendance of nutrition education a necessary the TSF is related to transport which ranges undertaken. The gatekeeper concept was precondition for TSF distribution, distributing from 75% in Amhara to 79% in Oromia. Next to piloted in Afar and SNNPR as those regions smaller amounts of TSF food at a time, and more transport the highest cost is related to person- were known to suffer from high numbers of frequent distributions to prevent sharing. These nel (16% in both regions). For a ration of 25 kg false positive inclusions. The strong commit- recommendations are still being discussed with of CSB and 3 litres of oil the cost per beneficiary ment to the initiative from the side of high-level partners. per distribution was found to be $30.30 and $23 with and without considering transport. For a regional administration officials was a main As a consequence of inadequate regional factor for the success of the pilot in SNNPR. typical food distribution centre with an average food transport tendering processes and delayed number of 239 beneficiaries, the cost per year Another round of secondary screening is communication on screening results, targets for currently underway by WFP for comparison was $29,988 and $21,988 with and without timely food delivery after the identification of considering transport respectively. The study with MoH screening. Furthermore, UNICEF acute malnutrition are regularly not met. These concluded that in order to increase cost saving, has developed a funding proposal for more difficulties are exacerbated by poor infrastruc- the major strategic action that needs to be taken training and supervision so that screening can ture, e.g. in Somali and Afar regions and is better targeting both in identifying benefici- be improved. difficult terrain in Amhara region. WFP aries and geographic targeting towards most A Knowledge, Awareness and Practice continue to try to address these problems and severely affected woredas. (KAP) study conducted in 2009 compared child have had success with the prepositioning of feeding and care practices of mother/care- food within Somali region. The programme Conclusions benefitted from the ‘Hubs and Spokes system’ givers of children less than three years of age (n Since its inception, WFP and Government have which was introduced for the relief programme = 1525) with their immediate neighbourhood worked hard to roll out the TSF and maintain a and resulted in setting up numerous logistic non-beneficiaries (n= 1531) in five regions difficult logistical operation. The programme hubs. WFP are now looking more closely at (Tigray, Afar, Amhara, Oromia and SNNPR). has undoubtedly had a significant impact on introducing an adaptation of the same system The study found that overall, a large proportion the prevention and treatment of moderate into Oromia by increased prepositioning at malnutrition. While the programme does not of the beneficiary mothers had good knowl- secondary warehouses. In addition, the tender- accord with the more traditional supplemen- edge, positive attitude and appropriate ing process has improved in many regions with tary feeding design and has not reached practices related to child feeding compared to tendering now for a one year period. SPHERE targets, many view the TSF as an the control group. Significant differences were important bridging programme well suited to a observed in their knowledge about optimal Given the large number of distribution country where up until its inception, there was time of initiation of breastfeeding, duration of points (over 1300) and the difficult terrain in very little targeted provision for those children exclusive breastfeeding and optimal time for many areas, the regular monitoring of all sites is suffering or at risk from moderate malnutrition. the introduction of complementary foods a challenge for the government and UN part- WFP and Government have grappled with compared to their non-beneficiary counterparts ners. In particular, in Afar and Somali region, numerous challenges around the TSF. Some of security is an additional and serious obstacle as (P=<0.05). these are outlined above. Other issues have travel of food monitors is restrained. In 2008, been around how to strengthen linkages FDA nutrition education sessions were not WFP were facing challenges in Somali region to between the TSF and treatment of SAM, as well implemented at all food distributions and some ensure that assistance reached intended benefi- as linkages with the PSNP programme. WFP mothers missed nutrition education as ciaries. Access problems meant that screening have written a series of discussion papers on husbands were sent to collect food, especially in could not be implemented in all areas of Somali these topics. While the treatment of SAM has Amhara region. region while the blanket blended food distribu- made enormous strides in Ethiopia in recent tion as part of the general relief ration was not The conduct of nutrition education only at years as OTP roll out has increased, treatment reaching all intended beneficiaries. Therefore in distribution session sites was considered to be (and prevention) of MAM has made less April 2008, WFP started distributing food inadequate in terms of bringing behavioural progress. Numerous mechanism are in place to through a relief/TSF hybrid model, using change in child care practices. This implies the address MAM, e.g. TSF, blanket distribution of blended food, normally part of the relief need for additional follow up nutrition educa- CSB as part of relief programmes, targeted SFPs programme, through the dispatch and distribu- tion sessions and monitoring in-between implemented by international NGOs in tion structure used for TSF, i.e. DPPB distributions. woredas affected by acute food insecurity and dispatched the food which was distributed by discharge rations for those graduating from There was clear evidence that the nutrition the women FDAs. WFP used the TSF structures OTP programmes. However, WFP and the education made a significant difference in the in 17 woredas in Somali region where no Government are highly aware of the need for knowledge of mothers on the preparation of the screening had taken place since late 2006. improved coordination and a more ‘joined up’ TSF food. Although the majority of mothers had Instead of screening, all children under five strategy for improving the treatment and shared the TSF food with other people in the years and pregnant/lactating women in the prevention of MAM. To this end, WFP in collab- household, the problem was most common in woredas received supplementary food through oration with Government, have recently Tigray and Afar region (P= <0.001). This indi- the TSF distribution centres. The trained FDAs convened a meeting between key stakeholder cated the need for strict monitoring of also provided nutrition education to the agencies to begin the process of formulating a compliance and strengthening of the nutrition women receiving the food. This model was national strategy for the prevention and treat- education given at the food distribution centres expected to contribute to improved targeting of ment of MAM. in these areas. From focus group discussions it blended food to nutritionally vulnerable was observed that nutrition education messages groups, as many more delivery points were For more information, contact: Jutta Neitzel, passed by the FDA are not given due attention used than the relief programme. It was also email: [email protected]

77 Field Article Value chain approach to increase

production of RUTF/CSB By Yuki Isogai

Yuki Isogai is Operations Officer for the Ethiopia Nutrition Project/Private Sector Development Specialist with the World Bank. She has a wide range of experiences in private sector development, including in areas of public private partnership (PPP), foreign direct investment (FDI) promotion, tourism development, micro small enterprise (MSE) development, and women entrepreneurship development.

n Ethiopia, 13.7 million people face chronic where costs are compared with Malawi. In other: lack of market information, low access to food insecurity. Out of this figure, the addition, the freight costs are substantial, e.g. in finance and a weak value chain (see Figure 1). number of people who needed emergency the case of the RUTF, Plumpy’nut, the air Lack of market information food aid reached about 6.2 million in June freight costs are $2.63/kg, while the production As a number of actors are involved between the I2009. An additional 7.5 million received aid in costs are $3.46/kg. The result is that only a farmers and the customers and the chain is return for work on community projects as a part limited share of the total number of malnour- quite segmented, market signals are not flow- of the Productive Safety Net Programme (PSNP). ished people in Ethiopia can be treated using these products. ing down through suppliers. Thus, producers, In September 2006, the Government of including input suppliers and farmers, do not Ethiopia adopted its second Poverty Reduction The total value of imported inputs alone respond to the market as much as they could. Strategy Paper (PRSP), The ‘Plan for adds up to $45.99 million/year, while the total Low access to finance Accelerated and Sustained Development to RUTF/CSB market is worth, on average, about Commercial banks normally consider the risks End Poverty’ (PASDEP), called for the imple- $60 million/year. This market is significant, and of agro-processing business so high that the mentation of the National Nutrition Strategy while development partners (DPs) are willing level of collateral for related investment is set (NNS) (formulated in 2005/2006) to achieve the to purchase RUTF from local producers, local very high (up to 200%). In addition, the banking Millennium Development Goal 1 (MDG1) for production has not met the demand so far sector lacks capacity to evaluate properly the halving hunger, malnutrition and poverty. The (reflected in Table 1). However, investments in risks of new business areas, like RUTF/CSB National Nutrition Programme (NNP) was these products are profitable. For example, production. Therefore, processing companies designed and launched in 2009 in order to imple- according to a feasibility study on powdered cannot obtain loans from banks for both capital ment the NNS. It encompasses Therapeutic milk conducted by the Amhara Investment investment and working capital. Feeding Programmes (TFP), which utilise Office, the simple rate of return is 27.6%, which Ready-to-Use-Therapeutic-Foods (RUTF), and by any business standards, is profitable. The existing processing companies particu- Targeted Supplementary Food Programmes Thus, it appears that opportunities for devel- larly suffer from lack of working capital. As (TSFP) which require Corn Soya Blend (CSB). oping agro-processing businesses within agricultural products are normally available for only six months after the harvest due to lack of Local demand and supply of RUTF and CSB Ethiopia have been missed. Furthermore, storage, the factories have to purchase inputs The cost of treating the severely and moder- promotion of local production of these products would improve the coverage/timeliness of the during the six months for the whole year of ately malnourished in Ethiopia is prohibitive operation. This requires quite substantial work- since a large share of the feeding products, i.e. treatment of malnutrition and contribute to import substitution. ing capital. However, banks are reluctant to RUTF and CSB, must be imported. Table 1 lend working capital without high collateral, reflects the local supply versus demand gap. Why are local producers not meeting although a loan for working capital is for short- Furthermore, it is not only the final feeding market demand? term investment which is low risk. As a result, products that have to be imported. As the Given the large market, the question arises, the operation rate (actual production/produc- domestic supply of inputs is quite limited why the private sector in Ethiopia has not yet tion capacity) of these factories is very low, e.g. (Table 2), a large proportion of these, e.g. responded to meet this need, particularly since average of 40% or even less. powdered milk and soya bean oil, also have to DPs are willing to procure the products from be imported. This means the price of RUTF Weak value chain local producers. The World Bank Ethiopian produced in Ethiopia is quite high relative to Even if the factories had enough working capi- Nutrition Team has conducted a thorough other countries. This is highlighted in Table 3 tal to purchase all required inputs, a problem review of this question and identified three still remains. There is insufficient supply of major issues, which are interlinked with each quality inputs. This applies for the whole value Table 1: Supply/demand gap for RUTF and Corn chain, i.e. RUTF/CSB producers and inputs Soya Blend (CSB) (2008-2009) Table 3: Production costs of Plumpy’nut (oil/powdered milk suppliers). Improvement Demand Local Production (Ethiopia vs Malawi) in the quality and stability of input supply production capacity Ethiopia (2009) Malawi (2006) throughout the value chain is essential to RUTF ~3,273MT 385MT (11.7%) 1,800MT Ingredients Input % of total Input % of total increase the operation rate and reduce the level (Plumpy’nut) Costs/kg* Costs/kg* of risk for the industry. ~126,000MT 9,683MT (7.7 %) 43,200MT CSB Milk powder $0.85 40.8% $0.63 44.3% Value Chain Approach with strong (full fat) Public Private Partnership (PPP) Sugar $0.28 13.5% $0.17 12.0% Table 2: Supply/demand gap for inputs As reflected in Figure 1, production cannot be (2008-2009) Vegetable $0.38 18.3% $0.18 12.7% increased through a conventional approach that oil focuses on only one of the issues. All the issues Demand Supply Remarks Peanut $0.19 9.1% $0.18 12.7% affecting the value chain need to be tackled at butter Milk 982 MT None No. of milking cows the same time. To do so, a strong Public Private Powder ~9.9 million Mineral/Vit. $0.38 18.3% $0.26 18.3% Partnership (PPP) involving private companies, Total milk output mix ~976,615 MT commercial banks, farms, NGOs supporting Sub-total $2.08 100.0% $1.42 100.0% Soya 74,762 MT 6,790 MT farmers, UNICEF, WFP and the World Bank is Beans Other costs* $1.38 $1.18 required. Each actor will need to play a distinct Total $3.46 $ 2.60 role at various links in the chain. Production 7,242 MT None Soya will not increase if one link is broken. Bean Oil *Other costs includes labour, quality control, packaging, energy and overheads

78 Field Article News

Figure 1: Why is local production low?

Market DPs

Little Market TA Info Loan/Guarantee Low Production Local Producers Banks

Low Input Suppliers Weak Financial TA Production Sector MFIs Standardised training package on Brokers Low Access to Finance SMART methodology released by Low Farmers Production ACF Canada Action Contre la Faim (ACF) Canada, with the support of the Inter-Agency Standing Committee DP: Development partner; TA: Technical assistance; MFI: Micro-finance initiative (IASC) of the Global Nutrition Cluster, has released the English version of the SMART Methodology Standardised Training Package (STP). To improve the market information flow, DPs The STP hopes to provide future survey teams with a standardised means of preparing them- including the World Bank, can conduct feasibility selves on how to use SMART. With some 400 persons trained in over 20 countries by ACF Canada, studies and organise dissemination workshops, participant feedback has been used to design a comprehensive and robust tool that can be applied inviting a wide range of stakeholders, i.e. farmers, in different contexts for persons with varying levels of competency. The STP has incorporated the investors and bankers. This will improve under- recent (Version 2) methodological advancements in SMART and also contains easy-to-follow standing of the market amongst key actors. presentations, simple exercises, trainer’s tips, videos as well as helpful assessment tools to comple- Bank reluctance to lend to what they perceive as ment the training experience. high risk agribusiness, unless businesses have large Access the STP by registering at http:// www.smartmethodology.org collateral, could be addressed through ‘guarantee Use this site to provide feedback, for questions or further guidance. If you experience any difficul- funds’. These funds cover a certain percentage of ties accessing the site, contact: [email protected] defaults, could be provided by DPs and would The French version is due for release shortly. help to significantly reduce the risk for banks. At the same time, technical assistance (TA) to the banking sector is a key to improve their capacity to evaluate the profitability/feasibility of new busi- nesses. Treatment of severe malnutrition The perception of banks that the agribusiness sector carries risk is not completely unfounded. now a core competency in health Due to the relatively primitive production systems at farm level, the existing processing companies By Ann Ashworth and Alan Jackson, International Malnutrition Task Force have to operate factories with unstable supplies of inputs. New investors therefore hesitate to enter Paediatricians took a giant step forward at the International Paediatric Association (IPA) the business as a ‘high tech’ factory cannot be oper- Congress in Johannesburg in August 2010 when they resolved that treatment of malnu- ated without a strong supply chain. At the same trition should become a core competency. It also had the support of the WHO, UNICEF time, there are several NGO projects supporting and other United Nations agencies. small farmers to improve the productivity and The full Resolution adopted at the Congress states: quality of agro-products which are seeking markets 1. Paediatricians and related health professionals should take responsibility for (producers). Support for processing companies leadership in addressing the urgent problem of severe malnutrition in all its forms, should be linked to these efforts on the ground. as it is a major cause of death and disability of children. The advantages of the value chain approach to 2. IPA member societies should assure that all paediatricians and related health increase the production of RUTF/CSB are: professionals have the identification and treatment of severe malnutrition as a core • The targeted market is large and relatively competency, and are certified accordingly. secured by development partner’s funds 3. National societies should examine the curriculum, training activities, and evaluation • A value chain approach simultaneously processes to ensure the inclusion of the identification and treatment of severe supports different elements of the value chain, malnutrition as a core competency. e.g. RUTF producers, groundnut farmers, milk The Resolution is one of several efforts by the International Malnutrition Task Force to powder producers, thereby creating synergy of place the problems of childhood malnutrition firmly on the agenda for paediatricians impact. This contrasts with more conventional around the world. A similar Resolution was also adopted by nutritionists and other dele- approaches where there is less joined up gates attending the Africa Nutritional Epidemiology Conference in Nairobi in October support. 2010, accepting their responsibilities and the need to take action in order to effectively • It has cross-sectoral effects, i.e. impact on address the problems of severe malnutrition. humanitarian activities and national economic growth An important next step will be for national groups to work together to translate the • It significantly contributes to import Resolution into action. It is expected that international and local non-governmental substitution organisations (NGOs) will be invited to play an important role and that key activities will • It improves the access to and the timeliness of include: delivery of relevant food products for needy • situation analyses beneficiaries. • advocacy to governments influencing deans of medical and nursing schools to include nutrition/malnutrition in curricula As a pilot study, the Ethiopia World Bank Nutrition • in-service training for all health workers on prevention and treatment of team has conducted a thorough feasibility study of malnutrition powdered milk production and means of promot- • developing effective training teams and communication strategies ing an investment and link to NGO funded dairy • identifying champions who will motivate others projects, as well as the RUTF producers. • assessing nutritional status at every contact to identify children at risk. For more information, contact: Yuki Isogai, email: A report of the IMTF pre-congress workshop can be found at http://www.imtf.org. [email protected]

79 News Building national capacity Regional CMAM meeting in HIV and Nutrition in Ethiopia 2011 By Kate Sadler In collaboration with the Government of Ethiopia and in consulta- tion with national and international agencies, the Emergency Nutrition Network (ENN) is planning a three day regional meeting Kate Sadler is a nutritionist and senior researcher with a focus on nutrition in emergencies at the on the scale-up of community based management of acute Feinstein International Centre. She worked previously with Valid International for six years and malnutrition (CMAM), to be held in Addis Ababa in November with Concern Worldwide for four years prior to that. 2011. The aim of the meeting is to facilitate the sharing of lessons learned from Ethiopia, across the region and beyond, and to build Researchers from the Feinstein International Centre and the Friedman School of Nutrition consensus on a range of issues relating to national scale-up of serv- Science and Policy at Tufts University in the USA are contributing to the development of a pre- ices to manage severe acute malnutrition. service training (PST) curriculum in HIV and nutrition for students of a variety of health professions in Ethiopia, as part of the ‘Food by Prescription (FBP)’ programme (see research A key allied global initiative under which this meeting is located piece in this issue). is the Framework for Action to Scale Up Nutrition (SUN Framework)1. The Road Map for SUN clearly articulates a pressing A Training the Trainers (TOT) Workshop was successfully delivered in September 2010 and need for improved sharing of experiences between countries and the training manual, ‘Nutrition and HIV/AIDS: A Training Manual for Nurses and Midwives’ 1 was regions on policy development and programming as one mecha- used with some modifications for the delivery of the course. The course consisted of 12 nism by which to build national capacity in nutrition. A second, modules that were delivered in a five and a half day workshop, with some of the modules smaller half day meeting will take place on Day 4, when the key being merged. Sessions included the FBP programme, treatment protocols for adults and chil- issues of relevance to the SUN will be discussed in relation to CMAM dren living and/or affected with HIV and/or living with severe and or moderate acute and scale up of actions to address all forms of undernutrition. malnutrition. The meetings are co-funded by Irish Aid and the UK The workshop included one half day of field visits, with faculty staff assigned to one of three Department for International Development (DFID). groups as follows: Group 1: Monitoring and Evaluation of FBP programme in Shashemene clinic 2. The Ethiopia meeting will identify and document the policy Group 2: Monitoring and Evaluation in an anti-retroviral treatment (ART) clinic in Awassa environment, coordination, funding mechanisms, technical and Hospital (with no food supplementation, for comparison purposes). operational considerations that are required to establish, expand Group 3: Monitoring and evaluating the commodity logistics system in relation to the and sustain service provision at national level. This forum is also programme. intended to provide policy and programme related information and guidance to countries from Africa and Asia that are planning A total of 17 faculty members and associates were trained representing four faculties national level scale-up of CMAM. The forum should inform donors (Nutrition, Public Health, Nursing and Paediatrics) from different universities. Faculty members and encourage the most effective use of future resources. for each of the faculties have, since the workshop, begun to develop plans for integrating materials from the workshop into their existing courses. The Nursing/ Paediatrics and Public Anticipated participants will be from government in a mini- Health faculties have specific courses that they can integrate the materials into. The Nutrition mum of 16 countries from Africa and a number of Asian countries. faculty found that the material could be introduced in almost all their courses. All groups Participants will be facilitated to write-up the CMAM scale-up found the material extremely relevant. experience in their respective countries as background papers and for presentation at the meeting. Donors, United Nations A key discussion held at the end of the course was the potential for integrating the training agencies, humanitarian agencies and ready to use therapeutic material into existing activities. A positive outcome of the training was that faculty staff within food (RUTF) producers will also be represented. A variety of media Hawassa University are able to work together to develop a proposal to roll out the training to will be considered to reach stakeholders unable to attend the other faculty members. This will allow for sustainability of the rollout process within Hawassa meeting. University. Kate Sadler, Ethiopia, 2010 The Tufts team anticipates working with The meeting will focus on ten thematic areas. These are: some of the faculty members at Hawassa • Policy environment, such as institutional stakeholder interests, University in Year 2 to support them as they governments ability to take on and sustain roll-out strategies. lead the TOT rollout. Jimma 0University • Funding, such as estimated costs, sources, mechanisms, could also be targeted for the next phase, sustainability. thus expanding the national capacity • Linkages within the nutrition sector and other sectors. building efforts in this crucial area of nutri- • Effectiveness of public health systems to support national roll- tion in Ethiopia. out strategies. • Operational issues, such as supplies, coverage and impact, For more information, contact: Kate scale up/scale down considerations in emergency response. The pre-service traing group at Hawassa University Sadler, email: [email protected] • Capacity development, with particular regard to national health systems. • Linkages with HIV programming, particularly in high-burden 1 East, Central and Southern Africa Community (ECSA-HC), Food and Nutrition Technical Assistance Project (FANTA), and Linkages Project, 2008. Nutrition and HIV/AIDS:A Training Manual for Nurses and Midwives. countries. Arusha, Tanzania: ECSA-HC. • Integrating infant and young child feeding measures into CMAM, as well as other preventative strategies. • Future research needs and priorities. • RUTF supplies, including local production challenges, private Scale up Nutrition (SUN): sector involvement, and development of standards within the industry. a new global movement A meeting report will be produced by ENN, providing an overview of the key issues identified and recommendations for research and policy directions and actions. Background papers prepared In April 2010 a Road Map to Scale Up Nutrition (SUN) was launched based on a SUN on selected country experiences with lessons learned in specific Framework endorsed by over 100 entities including national governments, UN agencies, thematic areas will also be produced. civil society organisations, academia, philanthropic bodies and the private sector. The SUN Road Map details the means through which national, regional and international The Goverment of Ethiopia focal point for this meeting is Dr Ferew actors will work together to establish and pursue efforts to Scale up Nutrition in countries Lemma, Senior Nutrition Advisor, Federal Ministry of Health, with a high burden of malnutrition, utilising proven interventions and through multi- Ethiopia. Contacts for the ENN organising team are Emily Mates sectoral and integrated nutrition focussed development policies and processes. (Ethiopia), email: [email protected] and Marie McGrath (UK), email: [email protected] For more information on SUN, go to http://www.unscn.org/en/nut-

working/scaling_up_nutrition_sun/sun_purpose.php 1 See news piece on this page.

80 News

and the potential to include IYCF process indicators in the WV CMAM database. Participants considered a simplified measurement approach of IYCF assessment may be more realistic for programmes; a simplified methodology should be consistent over time and the results not compared to those obtained using glob- ally-agreed indicators and measurement guidance. Action plans were developed for six countries Credit: M Lung'aho, Ethiopia, 2010 Credit: M Lung'aho, (Ethiopia, Kenya, Rwanda, Sierra Leone, Uganda and Zimbabwe), the Africa region, two training contexts (SNNP Sudan and Hawassa University, Ethiopia), and for WV Support Offices and Global Health Offices. Training of community based staff featured strongly in plans, in addition to policy/strategy updates at country level, engaging in operational research, and Training/workshop documentation of best practice and lessons learned participants to inform programming. At an agency level, opportunities for strengthen- ing technical capacity identified were WV country Training and workshop to integrate office assistance through WV-NCOE/Regional Office, development of institutional capacity in Hawassa IYCF in CMAM Summary of report1 University, developing linkages with UNICEF, and undertaking operational research. Constraints Throughout both the training and workshop, partici- Between 23 and 31 August 2010, World Vision Competency ratings (self assessment) increased pants identified many constraints to integrating IYCF International (WVI) and the Emergency Nutrition significantly pre and post training. in CMAM. The lack of a defined operational model for integrated programming limited scale up of integra- Network (ENN) held a six day training of trainers (TOT) Two day planning workshop and two day companion planning workshop in tion in action plans. Key operational research needs The specific objectives of the two day companion identified were around impact on nutritional and Ethiopia on integration of infant and young child workshop were to share cross country/agency experi- feeding (IYCF) activities into community based programme outcomes, effect on IYCF integration on ences on IYCF and CMAM, develop WV action plans to programming caseload, feasibility of integration at management of acute malnutrition (CMAM) rollout the ‘Integration of IYCF Support into CMAM 2 key contact points, how to monitor and evaluate programmes. The training took place in Shone ADP Programming’ training material, define operational and the workshop in Hawassa Region. programming within the existing CMAM framework research questions and explore WV monitoring and and cost-benefit analysis. The aim of the TOT workshop was to strengthen evaluation (M&E) around IYCF in CMAM. The 2 day the technical capacity of World Vision country, planning benefitted from the presence of Ethiopian Given the gaps in operational guidance, the regional and headquarters (HQ) staff. The aim of the university staff to consider Ethiopia-specific recom- importance of capturing experiences on integration companion workshop was to contribute to WV’s mendations. to inform programming and the need for collabora- tion and partnership were highlighted. Participants strategic planning to integrate IYCF support into its 4 Appreciative Inquiry (AI) methodology was used suggested it may benefit to learn by small scale inte- CMAM programmes at country, regional and global to explore how IYCF can best be integrated into exist- level. The companion workshop paid particular gration, e.g. integrate in one geographic area, or focus ing CMAM programmes through working groups. on strengthening IYCF with one key contact point. consideration to locating integration within the Integration was considered for key contact points in Ethiopian Governments policies and programmatic community mobilisation, Outpatient Therapeutic Conclusions guidance. Programme (OTP), Supplementary Feeding The facilitators concluded that to move forward on ENN consultants from Nutrition Policy and Practice Programme (SFP), Stabilisation Centre (SC), and other IYCF in CMAM at a national level, it is essential to iden- (NPP) led the training, supported by the ENN and WVI community services. Integration was also considered tify key government and agency partners, as well as headquarter– Nutrition Centre of Expertise (NCOE) for national level pre-service and in-service training, seek to locate interventions within national strategies technical staff. and by international agencies and local partners. and priorities. In future research, the operational model (or models) for consideration should comprise Fourteen WV programme staff from Sierra Leone, Opportunities a multi-component intervention including interper- Zimbabwe, Zambia, Ethiopia, Rwanda, Kenya and Participants envisaged good synergy and many bene- sonal IYCF counselling and negotiation, Uganda participated in the TOT. They were joined by fits of IYCF integration in CMAM including improved action-oriented group education, peer support and staff from regional and global NCOE who support acute and longer term nutrition and developmental targeted, context specific messaging. Eastern and Southern Africa, and WV support office outcomes for children, reduced relapse amongst staff from Canada and the US. An additional five treated children, and strengthened community As a next step, an initiative that looked to address participants participated in the two day planning component of CMAM programming and continuity of more closely the integration of IYCF in CMAM in the workshop from WV regional offices, the Sudan care. There were many suggestions for integration at Ethiopian context could draw on Ethiopia’s consider- Ministry of Health (MoH), and Concern Worldwide. contact points. Specific to Ethiopia (detailed in the able lessons to date from both OTP scale up and IYCF programming. Such an initiative(s) should include Five day TOT report) priority actions suggested to enable IYCF in experience documentation, operational research and The five day TOT used the ‘Integration of IYCF Support CMAM in Ethiopia included training community rapid dissemination of lessons learned. in CMAM’3 training materials as the technical content. volunteers on implementation of action-oriented It was a competency based ‘hands-on’ training built group sessions and support groups, revitalising the For more information, contact: Sarah Carr, World around adult learning principles. The approach used Health Education Talks at OTP with action-oriented Vision Canada, email: [email protected] the experiential learning cycle (a learning cycle of group sessions and support groups and, researching experience, reflecting, thinking and acting), employ- breastfeeding counselling feasibility at a designated 1 WORLD VISION International-ENN. Collaborative project to ing a variety of training methods. Two days of practice OTP follow up visit. Additional areas identified for enable Integration of IYCF Support into CMAM action included advocacy for IYCF integration with Programming at Agency and National Levels. Ethiopia. 23- sessions (Days 4 and 5) took place in health facilities 31 August, 2010. Final Report. 25 September 2010 within a half-hour’s drive of the Shone ADP. the existing NNTWG (National Nutrition Technical 2 Area Development Programme (World Vision) Working Group) in Ethiopia, development of refresher 3 Developed by the ENN in collaboration with the partnership The end of training evaluation was positive. training (in-service), and embedding IYCF into CMAM Nutrition Policy and Practice Group (NPP) in 2008, funded Participants highlighted sessions on behaviour by the GNC. Available in English and French at: in pre-service training. http://www.ennonline.net/resources/722 change, counselling skills, forming action and 4 This comprised four ‘D’s: discovery (whtat are the benefits support groups, the ‘adult learning’ approach to the Participants considered baseline IYCF information of implementing IYCF and CMAM), dream (what do we workshop facilitation, and the practical sessions as was needed to inform integrated activities and may expect to acheive through integration of IYCF in CMAM), involve surveys of Knowledge, Attitude, Practice design (how to integrate IYCF into CMAM contact points) especially helpful. Recommendations for future TOT and delivery (action plan development). were more practical field sessions, more preparation (KAP), KAPB (behaviour), KPC (coverage) and commu- 5 This comprised four ‘D’s: discovery (whtat are the benefits for field sessions to include orientation of managers nity led assessments, ideally prior to setup. of implementing IYCF and CMAM), dream (what do we expect to acheive through integration of IYCF in CMAM), of CMAM programmes, and more practical applica- A brief session on M&E discussed the benefits of design (how to integrate IYCF into CMAM contact points) tion of HIV and infant feeding recommendations. disaggregating programme age data in programmes and delivery (action plan development).

81 News Research Updated HTP resource material for nutrition in Early stages of a ‘Food by emergencies training Prescription’ programme for HIV infected adults

The Harmonised Training Package: Resource Material for Training By Elizabeth Bontrager and Kate Sadler on Nutrition in Emergencies (the HTP) is a resource package to aid course development on nutrition in emergencies. The HTP is an initiative of the IASC Global Nutrition Cluster (GNC) and has been Elizabeth Bontrager joined the Feinstein International Centre at Tufts University in 2008, where she coordinates endorsed by the GNC and its member’s agencies. Tufts’ involvement in the Food by Prescription The HTP update to produce Version 2.0 is being undertaken in programme. She holds a M.Sc. in Food Policy and Applied a 2 year ENN/NutritionWorks (NW) collaborative project1, funded Nutrition. by the US Office for Disaster Assistance (OFDA). Numerous experts from many different organisations have been involved in Kate Sadler is a nutritionist and senior researcher with a writing and reviewing content for Version 2, and have partici- focus on nutrition in emergencies at the Feinstein pated generously in the initiative. International Centre. She worked previously with Valid The HTP, Version 2 (2011) is being produced by the ENN. The HTP International for six years and with Concern World- wide for four years prior to that. is hosted by the United Nations Standing Committee on Nutrition (UNSCN) at http://www.unscn.org/en/gnc_htp/. The HTP is organised as a set of 21 modules by subject (see The authors acknowledge the support of USAID and the Food by Prescription team at Save the Children US. box), each module containing technical information, training exercises and a resource list. It can also be used by individuals to increase their technical knowledge of the sector.

The HTP Modules Section 1: Introduction and concepts s global interest in Ready-to-Use Therapeutic Foods (RUTFs) has Module 1: Introduction to nutrition in emergencies risen, their use has begun expanding beyond the realm of treating Module 2: The humanitarian system: roles, responsibilities Achildren with severe acute malnutrition (SAM). Of recent interest and coordination within the humanitarian community is the use of such products in treating Module 3: Understanding malnutrition malnourished adults living with HIV/AIDS. In this case, the food is used Module 4: Micronutrient malnutrition much like a medical prescription, intended to address malnutrition so that Module 5: Causes of malnutrition the disease can be treated more effectively.

Section 2: Nutrition needs assessment and analysis As the medications for anti-retroviral treatment (ART) have become more Module 6: Measuring malnutrition: individual assessment widely available in developing countries, greater attention has been paid Module 7: Measuring malnutrition: population assessment to the associated role of malnutrition in determining the effectiveness of Module 8: Health assessment and the link with nutrition these drugs in HIV treatment programmes. In settings both with and with- Module 9: Food security assessment and the link with out widespread food insecurity, weight loss and wasting are significant nutrition predictors of mortality among people living with HIV/AIDS (PLHIV), 1,2 Module 10: Nutrition information and surveillance even for those undergoing anti-retroviral treatment. Furthermore, malnu- systems trition at the outset of ART is strongly associated with early mortality after treatment is begun.3,4 Section 3: Interventions to prevent and treat malnutrition Module 11: General food distribution Evidence to date Module 12: Management of moderate acute malnutrition The majority of the existing research in this area has taken place in Module 13: Management of severe acute malnutrition resource-adequate settings. Here, individuals receiving food supplements Module 14: Micronutrient interventions have shown improved protein and energy intake, but no consistent Module 15: Health interventions improvements in body weight or fat mass, and only minimal improve- Module 16: Livelihoods interventions ments in CD4 count, as a measure of disease progression.5 Module 17: Infant and young child feeding Thus far, little has been done to examine the relationship between HIV, Module 18: HIV/AIDS and nutrition food supplementation and survival in resource-poor environments, where Module 19: Working with communities in emergencies malnutrition among PLHIV may be linked to food scarcity rather than (or Section 4: Monitoring, evaluation and accountability in addition to) disease, and where the effects of supplementation may be Module 20: Monitoring and evaluation quite different. One controlled study demonstrated that although a group Module 21: Standards and accountability in humanitarian receiving food supplements (in this case, individual rations of corn soy response blend (CSB) and vegetable oil) showed greater adherence to ART than the control group (which received no food), there was no significant difference in survival, CD4 count, or weight gain between the groups.6 Another study Version 2 now available (Jan 2011) – Modules 6, 7, 9, 16 and 19. Each module will be available both in word format and as a 1 Tang A, et al. Weight loss and survival in HIV-positive patients in the era of highly active anti- printer friendly pdf version. All modules will be posted on the retroviral therapy. JAIDS 2002;31:230-36. 2 Paton, NI, Sangeetha, A Earnest and R Bellamy. The impact of malnutrition on survival and UNSCN site as they become available. the CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Medicine (2006), 7, 323–330. Version 2.0 is being produced in English, with translations to 3 Zachariah, R., Fitzgerald, M., Massaquoi, M., Pasulani, O., Arnould, L., Makombe, S., Harries, follow. A.D., 2006. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi. AIDS 20, 2355-2360. 4 For more information on the HTP Version 2 revision, contact See footnote 2 5 Koethe JR, Chi B, Megazzini K, Heimburger D, Stringer JS. (2009a) Macronutrient Carmel Dolan Carmel Dolan, NutritionWorks, Supplementation for Malnourished HIV-Infected Adults: A Review of the Evidence in Resource- email:[email protected] Adequate and Resource-Constrained Settings. CID 2009;49: 787-798. 6 Cantrell R, Sinkala M, Megazinni K, Lawson-Marriott S, Washington S, Chi B, Tambatamba- Chapula B, Levy J, Stringer E, Mulenga L, Stringer J. A pilot study of food supplementation to improve adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. J 1 NW was commissioned by the GNC to develop Version 1.0 launched in 2008. Acquir Immune Defic Syndr 2008; 49:190-195.

82 Research compared the effects of a supplementary forti- prescriptions will also be disaggregated and and rollout of FBP, but it is often difficult for fied spread to those of CSB on acutely compared according to the amount of time indi- programme staff to identify and locate all the malnourished adults starting ART in Malawi. It viduals have been on ART, and baseline relevant staff. This means that some eligible found that those individuals receiving the forti- nutritional status. clients may present at the clinic but not be seen fied spread (a lipid paste made from peanuts) by trained personnel, and thus not be enrolled The study follows a sample of recruited FBP showed greater improvements in several meas- in either the programme or the study. In addi- participants from a number of randomly ures of wasting than those individuals tion, once health workers have been adequately selected health centres included in Phase I of receiving the CSB, but also showed no signifi- trained and are comfortable with the measure- the programme and a ‘control’ sample recruited cant differences in mortality, CD4 count, ART ment of relevant indicators, high rates of staff from sites that have access to ART but are not adherence, or quality of life7. turnover have meant that trained workers may yet being prescribed a food ration (to be be lost over time and replaced by new, included in Phase II of FBP programme rollout). The Food by Prescription Programme untrained staff. FBP programme staff and the Data for study participants, including all vari- (FBP) in Ethiopia Tufts team will continue to visit these sites ables needed to assess outcomes of interest as For all of the above reasons, there is growing frequently to ensure that the implementation of well as confounders, are collected during interest in programmes designed to address the the programme and the data collection are scheduled monthly clinic appointments. This links between nutrition and HIV, through being performed as necessary for both the includes completion of a patient register and a which malnourished individuals on an ART study and the programme as a whole. treatment regimen are ‘prescribed’ therapeutic Household Food Security Questionnaire. food rations in addition to their Such large programmes inevitably medications. run into challenges in the way of Discussing ART admissions, delays in procurement and pipeline Hawassa Hospital ART clinic In Ethiopia, the Ministry of Health breaks as these systems are first put (MoH) began implementing the into place. The rollout phase of FBP in ‘USAID/ Food by Prescription (FBP)’ Ethiopia has experienced this as well, programme in the summer of 2010, and both the programme and the with technical assistance provided by study have needed to accommodate Save the Children US. This changes to the nutrition protocol as programme targets beneficiaries programme staff have worked to diagnosed with either moderate address these challenges. The stan- acute malnutrition (MAM) or SAM dardisation of the food protocol to with two different products for up to account for changes in the availability six months – fortified blended food of commodities has been accommo- (FBF) packaged in individual serv- dated into the study design. ing-sized sachets for MAM cases and RUTF (Plumpy’nut) for SAM. The Strenthening national capacity aim is to improve nutritional, clinical, The Tufts team is also supporting pre- and functional outcomes beyond the service training curriculum time period of the intervention itself. development, piloting, and dissemi- nation on nutrition and HIV, in HIV-infected adults who present partnership with the Department of with malnutrition at participating Nutrition at Hawassa University (see health centres are prescribed food news item in this issue). This estab- rations according to their nutritional lishment of an HIV and nutrition status (MAM or SAM). The rations educational component for health are prescribed during monthly professionals is intended to alleviate appointments, together with clients’ some of the inconsistencies in training ART medications, and are distributed and awareness of the nutritional directly from clinic pharmacies. needs of PLHIV at the service Clients are monitored closely by provider level. health centre staff who collect both anthropometric and disease progres- Conclusions sion data during monthly This FBP programme has the potential Kate Sadler, Ethiopia, 2010 Sadler, Kate appointments. to improve both the capacity of health Examining the impact of food on health A qualitative component will be added to the professionals to address the nutritional needs of and nutrition outcomes impact study during the second year, to exam- PLHIV and the effectiveness of HIV care and A number of partners are involved in the deliv- ine issues of compliance to the food protocol treatment in Ethiopia. Currently, there is ery and assessment of the overall FBP and utilisation of the ration. Data will be almost no documented programme data that programme, including a group of researchers collected for this through a series of focus can help answer questions around the addi- from the Feinstein International Centre and the groups and key informant interviews. tional benefits to PLHIV and costs of adding Friedman School of Nutrition Science and food to an ART regimen, or of the successes and Policy at Tufts University in the USA. This Challenges thus far challenges to scaling up a programme of this team from Tufts is carrying out an effectiveness In the early stages of FBP implementation, one type. As HIV programmes embrace the need for evaluation of the programme, to determine the particular challenge for the Tufts study has a nutrition component, there is an urgent need impact of food supplementation on disease been the reliance on health centre staff for data to ‘learn by doing’ and the phased rollout of the progression and malnutrition among individu- collection. As this programme is included in the FBP programme in Ethiopia provides a great als on ART. Ethiopian MoH National Guidelines for opportunity to do just this. Data collection is HIV/AIDS and Nutrition, MoH clinic workers anticipated to take place until December 2011, Specifically, the Tufts study will examine the are required to participate in the implementa- with results expected in early 2012. effects of a food ration prescribed to malnour- tion and data collection activities for the ished HIV infected adults on recovery from programme. This often represents an additional For more information on the research, contact malnutrition, HIV disease progression, patient burden on understaffed clinics with large case- Kate Sadler, email: [email protected] or survival, and persistence of any benefit six loads. It is essential that health workers receive Elizabeth Bontrager, email: months after exit from the programme. comprehensive training as part of the FBP [email protected] Primary outcomes, to be compared between programme rollout, since many are otherwise intervention and control groups, include unfamiliar with the measurement of malnutri- 7 Ndekha M, van Oosterhout JJ, Zijlstra EE, Manary M, percent weight change, change in CD4 count, tion indicators such as BMI and mid-upper arm Saloojee H, Manary MJ. (2009b) Supplementary feeding with either ready-to-use fortified spread or corn-soy blend survival at six months from programme enrol- circumference (MUAC). A clinic worker train- ment, and Body Mass Index (BMI) at six in wasted adults starting antiretroviral therapy in Malawi: ing regimen serves as part of the introduction to a randomized, investigator blinded, controlled trial. BMJ months after discharge. The effects of the food 2009; 338:b1867.

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had to organise weekly practice groups among Emotional Stimulation for acutely and mothers and their children, or organise door to door visits for enrolled mothers to practice with them. The coaching would last for a three severely malnourished children in SNNPR months period. In the selected hospital, the coaching took place daily with inpatient chil- By Dr. Alessandro Conticini and Mrs. Valérie Quéré dren. Mothers were then requested to practice the new skills daily with their children. Dr. Alessandro Conticini joined Play Therapy Africa as Co-Director after having headed the Child Protection, Adolescent Development and HIV Programme at In 20 sites, professionals were trained to UNICEF Ethiopia, and previously senior researcher for the Macroeconomics and measure systematically the physical and Health Commission in WHO Head Quarter. His work includes directing research, emotional outcomes of the intervention. The programme formulation and evidence-based policy development for vulnerable chil- same measurements were conducted for a dren in developing countries. control group in three sites where SAM was managed but this psycho-social intervention Mrs. Valérie Quéré is a human rights lawyer and child psychotherapist, with a was not being implemented. A total of 555 chil- master degree in international human rights and a number of certifications as a PSS dren under 5 years were followed for the therapist. Mrs. Quéré has been working in the area of justice and gender based purpose of the study, 49.9% were girls. Nearly violence in several countries. Valérie directs training programmes for law enforce- one-third (32%) of admitted children were ment agents, social workers and child psychotherapists. between 12 to 23 months of age, while the remaining where equally distributed in the age range of 0-12 months, 24-35months, 36-47 PTA would like to thank the Pulitzer Foundation, Ceil, Michael months, and 48-60 months. and Christina, for their tireless and enthusiastic support. Our gratitude also to UNICEF for their facilitation and aid. Results The programme has resulted in the following documented achievements:

Methodology Increased Speed of Recovery Overall, 31.2% of children who received a The intervention sites were selected by the combination of therapeutic food and emotional Regional Bureau of Health on the basis of the stimulation were discharged from TFU and expected severity of food shortage in the moni- OTP at the end of the fourth treatment week. A tored districts. The project and its initial cumulative total of 40.7% were discharged at methodology were presented to members of all the end of the fifth treatment week. In contrast, NGOs working with malnourished children in no child was discharged before the end of the SNNPR. These professionals had an opportu- sixth week in the control group of children who nity to express their views and concerns esearch has shown that the survival only received therapeutic food. rate of malnourished children during regarding the intervention during a joint review food crises critically depends not just meeting held in Awassa town. Federal and Children who were provided with a combi- on the availability of appropriate ther- Regional authorities (DPPA and DPPB) were nation of emotional stimulation and therapeutic Rapeutic food, but also on the emotional and also present and explained the project and its feeding tended to gain weight at a faster rate physical stimulations available for both the proposed methodology to allow for consistency than children who were only provided with child and the caregiver (usually the mother). with mainstream government led programmes. therapeutic feeding. This has direct implica- Studies have shown that the combined use of The University of Awassa reviewed the inter- tions in terms of the costs of SAM management. vention in order to grant ethical approval. emergency nutrition support and emotional Prevention of emotional, development and stimulation techniques provides for lower One Health Extension Worker (HEW) and intellectual loss/damage malnutrition rates, a higher rate of child one youth/community volunteer were selected Malnourished children in the intervention survival, and quicker recovery from malnutri- by the Bureau of Health and the Bureau of group demonstrated equivalent cognitive, 1 tion . Hunger and food insecurity cause serious Youth respectively in each intervention site. emotional and development capacities as chil- mental or cognitive disabilities, especially in PTA then provided a series of practical training dren coming from the same socio-economic young children due to chronic nutritional that allowed for basic techniques of emotional environment who had not been severely deficits, lack of social/emotional stimulation, stimulation and good parenting skills to be malnourished. In contrast, malnourished chil- parent-child emotional detachment, with- acquired by trained professionals. Professionals dren in control groups demonstrated a severe drawal and neglect. At the same time, from NGOs working on the sites were also loss of cognitive, emotional and development parent-child emotional deficiencies cause trained. The training was practical and experi- potential. These data were collected using inter- reduced food intake and significantly diminish ential, meaning that the participants were nationally recognized assessment tools such as 2 the overall survival rate of children . constantly relating the newly acquired tech- the ASQ3, as well as qualitative emotional In many emergencies, hunger and food inse- niques to the ways they themselves had been development observations. raised, and the ways they were raising their curity cause severe stress and damage the Increased resilience from being exposed to psychosocial well-being of the affected popula- own children. This allowed for the trained professionals to use the approach in their own future severe and acute malnutrition tion. Conversely, the psychosocial effects of an Initial qualitative data indicate that treated chil- emergency can impair food security and nutri- domestic life before adopting it as a modus operandum in their work place. dren and caregivers may be less likely to tional status. The latter is particularly relevant relapse into acute and severe forms of malnutri- for children and their caretakers. At the end of the training, professionals were tion caused by non-food availability factors. During the 2008/2009 and 2009/2010 food requested gradually to introduce the tech- However, this initial finding will need addi- crisis in Ethiopia, with support from the niques as an additional experimental tional investigation before firm conclusions can Pulitzer Foundation and collaboration with component of the existing protocol for the be drawn. management of SAM children. Clinical supervi- UNICEF, Play Therapy Africa (PTA) took a Cross-fertilisation effect leadership role in the management of 49 sors were also deployed by PTA to ensure the quality of services provided. Mothers that had Mothers who learnt and practiced emotional outreach therapeutic sites (that include but go stimulation with their malnourished child beyond OTP sites) and one hospital in the one or more children enrolled in Therapeutic Southern Nations (SNNPR). This role involved Feeding Units (TFU), or Outpatient Therapeutic 1 Supplementing nutrition in the early years: the role of Programmes (OTP), also received coaching to early childhood stimulation to maximize nutritional inputs. the introduction of an approach whereby Child and Youth Development 2009. The World Bank, emotional stimulation and good parenting strengthen the emotional bond with their child Volume 3, N.1. skills were promoted, in addition to emergency and to stimulate him/her physically and 2 Sally Grantham-McGregor et al. Developmental potential in emotionally. The intervention was based on the first 5 years for children in developing countries. The therapeutic food distribution for severe acute Lancet 2007. Volume 369, Issue 9555, Pages 60 - 70. malnourished (SAM) children. coaching, not teaching, so that HEW and Youth 3 Ages and Stages Questionnaire (ASQ).

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started to apply the same techniques with the other children in the household and gradually sensitized and explained the purpose and benefits of the inter- Critical analysis of MICAH vention to their husbands and relatives. Increased empowerment of women and gender programme balance in community and family decision making An initial qualitative assessment4 has suggested that Summary of published research1 the effects of emotional stimulation through filial play coaching have positively impacted not just the level of maternal and child depression, but also provided for women’s empowerment within the family and communities for positive decision making. Most of he efficacy of some single nutrition size. Key indicators were assessed the mothers who participated in the emotional stimu- interventions has been frequently through structured interviews with a lation intervention reported that they felt much closer and thoroughly evaluated, e.g. iron standardised questionnaire and collection to their children, and were much more likely than T supplementation, vitamin A supplemen- of biochemical, clinical and anthropomet- control-group mothers to say that their children had tation and salt iodisation. However the ric data. The sample sizes per country become more independent and playful since recover- effectiveness (efficacy in real world were between 900 and 4801 randomly ing from SAM. Many mothers also attributed other settings) of large-scale integrated health selected households per survey. Data changes in family life to the programme, including and nutrition programmes has not been were collected by trained enumerators increases in paternal involvement in child care, the thoroughly evaluated. A recent article and clinical staff. The data were subjected cessation of harsh punishment by one or both parents, critically analyses an NGO-led large scale, to post-hoc methods of quality determi- and reductions in domestic violence. None of the multi-country 10 year micronutrient and nation and if of suitable quality, included control mothers whose children received food alone health (MICAH) programme with an in the adequacy evaluation. The magni- through the OTP programme reported such changes. adequacy evaluation (a documentation of tude of the change for each key indicator from baseline to follow-up final survey Interviewed mothers also reported a progressive time trends in the expected direction). was compared with that observed in positive involvement of neighbours by imitation. Not The MICAH programme was published controlled trials and reports of all women reported equally powerful effects. Factors launched in 1995 by World Vision Canada other large-scale programmes. If such as severe illness in the child or parent and and was implemented from 1996-2005 in improvement was of comparable magni- extreme poverty tended to mitigate the effects of five African countries, four of which are tude to the high end observed in emotional coaching. However, even many of the very reported in the paper (Ethiopia, Ghana, controlled trials, the impact was consid- poor mothers attributed remarkable changes in Malawi and Tanzania). The programme ered high. If the improvements were of a outlook and family communication to the emotional reached 4 million direct beneficiaries and range common in other programmes, the stimulation intervention. This suggests another way more than 6 million indirect beneficiaries. impact was considered moderate. If the of looking at the link between women’s empower- Context specific programme plans were change was smaller than other ment and child survival, which has been traditionally developed for each MICAH country programmes, but greater than zero, the explained by women’s agency in health seeking. We within a programme-wide framework of impact was considered low. Testing of suggest the reverse may also be true; programmes to objectives and strategies based on base- differences from baseline to follow up improve care-giving may directly contribute to line assessments of vitamin A, iron and was done by chi-square for categorical women’s empowerment, and contribute to the iodine deficiencies. Multiple interven- variables and t-tests for continuous vari- promotion of a virtuous cycle to help rescue malnour- tions, ranging from community-based ables. ished children in vulnerable communities. supplement distribution to fortifying and While further investigation is needed, the prelimi- diversifying foods to national-level advo- Results nary results suggest that a combination of emergency cacy for national policy changes, were Most collected data were of moderate or therapeutic food relief for children coupled with conducted to address the deficiencies and high quality and therefore included in the emotional stimulation has a leveraging effect, not just target groups identified. Interventions adequacy evaluation.There were moder- on the short term survival and physical and emotional were integrated into existing systems, ate to large improvements in vitamin A outcomes for children, but also on the prevention of structures and services, wherever possi- status in Ethiopian school-age children, in long term consequences5. It also suggests that the ble, to increase potential for sustainability. children less than 5 years of age in introduction of emotional stimulation techniques Table 1 summarises the MICAH activities. Tanzania and Ghana and amongst moth- ers in Ghana. Iodine status improved in through a coaching approach leads to a gradual shift Programme areas within countries Malawi and Tanzania. Anaemia rates and in the ways children are cared for within the commu- were poor and rural, where few or no malaria prevalence decreased in women, nity, increasing the probability of a less violent and other major development organisations pregnant women and pre-school children more nurturing environment. Mothers were found to were operational. A comparison of in Ghana, Malawi, and Tanzania, but continue practising emotional stimulation and good MICAH data with Demographic Health anaemia increased in Ethiopian women. parenting skills principles well beyond the official Surveys (DHS) data for national rural Large increases were reported for rates of ending of the programme, suggesting some form of samples suggests that the selected areas exclusive breastfeeding (EBF) and immu- sustainability. Finally, the increased speed of recovery were similar to or worse off than the rural nisation. Child growth improved to the by emotionally stimulated children, and the reported average in each country at baseline. If the maximum that would be predicted with low proportion of relapse among them seem to DHS data are extrapolated back to the the given interventions. suggest that the proposed intervention could baseline year, assuming a linear trend, contribute to reducing the overall intervention costs of then 1997 MICAH indicators in Ethiopia Discussion severe acute malnutrition. were worse than DHS for Vitamin A Most of the collected data were consid- For more information, contact: Alessandro Conticini, capsule coverage in children < 5 years of ered of good quality. The exceptions were email: [email protected] age, and better for measles coverage and anthropometric data in Ethiopia, anthro- latrine access. pometric data for children under six The full report, Emotional Stimulation in the Context Methods months in Ghana and Malawi, breastmilk of Emergency Food Interventions Final Report Addis retinol analysis and urinary iodine in Cross-sectional surveys were conducted Ababa – August 2009, is available at: Tanzania and EBF data in all countries. in each programme area at baseline www.ennonline.net and search Resources An evaluation of the change in indicators (1996/7), the end of phase one (2000) and over time (adequacy evaluation) revealed the end of phase 11 (2004). The surveys 4 H. Epstein and A. Conticini. “Each child comes with his own luck”? were conducted in the same month of the A psychosocial intervention for malnourished children strengthens parental and spousal bonds in Ethiopia. Manuscript submitted for year in each country. Two-stage cluster 1 An adequacy evaluation of a 10-year,four-country review, 2010. sampling was employed, in which clus- nutrition and health programme. Peter R Berti, 5 See also S. Grantham-McGregor et al. Nutritional supplementation, ters were randomly selected using Alison Mildon, Kendra Siekmans, Barbara Main and psychosocial stimulation, and mental development of stunted Carolyn MacDonald. Int. J. Epidemiol. Advance children: the Jamaican Study. Lancet 1991;338(8758):1-5. probability proportional to population Access published March 3, 2010

85 Research many positive results of the MICAH Table 1: Summary table of MICAH interventionsa programme (see Table 2). MICAH programme Ethiopia Ghana Malawi Tanzania staff reported five aspects of the programme b that they believe uniquely contributed to the Approximate number of ‘direct’ beneficiaries 1.8 million 150,000 1.8 million 255,420 positive results: Total implementation cost, US$ million 16.6 3.3 14.5 3.2 Total cost of evaluation, US$ 559,345 147,866 1,293,018 172,243 Results-based management identified c programme activities that were not producing Total cost, US$ million 17.0 3.5 15.5 3.3 positive outcomes and allowed for mid-stream US$ per direct beneficiary per year (Phase I/Phase II) 1.39/0.83 3.37/2.14 1.06/5.06 1.85/1.28 corrections. Examples include: Objective Strategy Target group/activity Ethiopia Ghana Malawi Tanzania • The decision in Malawi (following the 2000 Increase Vitamin A Pre-school children D, T, M P, D, T, A, M D, T, M intake and supplementation evaluation) to reduce the geographic School-age children D, T, A, M spread and intensify the intervention in a bioavailability of micronutri- Post-partum women D, T, M P, D, T, A, M D, T, M smaller area to ensure all participants ents (iron, received the interventions. iodine and Iron Pre-school children P, D, T, A, M P, D, T, A, M P, D, T, M vitamin A) supplementation • Provision of regular, intensive technical School-age children P, D, T, A, M support in the form of regular email Women of childbearing age P, D, T, A, M P, D, T, A, M correspondence, monitoring and support Pregnant women P, T, M P, D, T, A, M P, D, T, A, M P, D, T, M visits by World Vision technical staff and Fortification Iodized salt promotion P, D, T, A, M P, D, T, A, M T, A, M T, A, M expert consultants, and annual training workshops. Small-scale flour fortification P, D, T, A, M P, D, T, A, M • Implementation of a broad-based integrated Dietary Small animal rearing P, D, T, A, M P, D, T, M P, D, T, A, M P, D, T, M diversification package of interventions rather than relying Vegetable gardens P,D,T,A,M P, D, T, M P, D, T, A, M P, D, T, M on a single ‘magic bullet’ intervention. Fruit tree cultivation P, D, T, A, M P, D, T, M P, D, T, A, M P, D, T, M • Community participation in programme Infant and young Promotion of optimal T, A, M T, A, M T, A, M T, A, M design, implementation, monitoring and child feeding breastfeeding and evaluation, which meant some interventions complementary feeding could be tailored to suit community Reduce Water and Provision of clean water P, D, T, M P, D, T, M P, D, T, M P, D, T, M prevalence of sanitation preferences. This was especially relevant to Latrine construction P, D, T, M P, D, T, M P, D, T, M P, D, T, M animal husbandry, where existing practices diseases that affect Garbage disposal T, M T, M T, M T, M differed from community to community. micronutrient construction • Regular supervision of staff in communities. status (diarrhoeal, Malaria control ITN distribution P, D, T, M P, D, T, M P, D, T, M P, D, T, M There were fewer positive results in Ethiopia, parasitic and Chemoprophylaxis to P, D, M M P, D, T, M P, D, T, M vaccine- pregnant women which may be because the intervention efforts preventable) were diluted over a larger number of benefici- Malaria treatment to P, D, M T P, D, T, M P, D, T, M aries compared to other countries. However, pre-school children there was a positive impact on vitamin A status Treatment of worms Deworming of pre-school P, D, T, M P, D, T, M P, D, T, A, M P, D, T, M in school-age children – both an uncommon and parasites children target and success. Deworming of school-age P, D, T, M P, D, T, M P, D, T, A, M P, D, T, M children In an attempt to estimate the impact of Schistosomiasis treatment P, D, T, M P, D, T, M P, D, T, A, M P, D, T, M MICAH independent of other local and global Immunization Support EPI campaigns P, D, T, M P, D, T, M P, D, T, M D, T, M influences, comparisons were made with DHS Diarrhoea treatment Promotion of ORT T T P, D, T T data for the national, rural samples. Table 2 shows the change in those indicators for which HIV/AIDS prevention IEC re: HIV and AIDS T T T T there were both MICAH and DHS data at base- Build local Education Health and nutrition IEC to T, M D, T, M D, T, M D, T, M capacity for communities line or follow-up and end-line. The change is delivery measured as the difference of the differences systems to Staff and partner training T T T T (the difference between the MICAH difference improve Advocacy Influence national policies A A A A micronutrient on nutrition issues between end-line and baseline and the DHS status difference between end-line and baseline). For Use of media to T, A T, A T, A T, A most indicators in all four countries, MICAH communicate nutrition and health messages areas outperformed rural areas of the country P: procurement; D: delivery/distribution (includes both transport to distribution sites such as health centres and direct delivery to as a whole. The comparison groups are not beneficiaries); T: training (includes both community education and training of implementing staff/volunteers); A: advocacy; M: moni- perfectly suited as control groups - different toring; ITN: insecticide-treated bednet; EPI: expanded programme on immunization; ORT: oral rehydration therapy; IEC: Information, years, baseline conditions and other differences Education and Communication. a Blank cells indicate that MICAH did not work on that target group/activity in that country. not related to MICAH. However, the MICAH b Based on target population in MICAH programme communities; not including the significant number of indirect beneficiaries performance compared with the DHS (along (e.g. 4.7 million in Malawi) of MICAH’s national advocacy and intervention efforts (e.g. iodized salt coverage, EPI and vitamin A with the general concordance between cover- supplementation (VAS) campaigns). c Costs are in US$ and based on exchange rates applicable at the time of purchase. World Vision Canada technical support and age and outcome indicators in MICAH programme management costs, as well as overhead costs at country and Canada levels, are included. samples) suggests the improvements amongst Source of table: Berti et al (2010). See footnote 1. programme beneficiaries are greater than the general trends, and greater than would have Table 2: Standard deviations (SDs) of continuous variables in MICAH surveys in baseline (1996 or occurred MICAH was not implemented. 1997), follow-up (2000) and endline (2004) Ethiopia Ghana Malawi Tanzania Although the evaluation has documented SD SD SD SD the trends over time, it still falls short of a full Year 1997 2000 2004 1997 2000 2004 1996 2000 2004 1997 2000 2004 adequacy evaluation - the causal pathway Breast milk retinol (μmol/l) 1.4 0.5 22.8 13.6 should be relatively short and simple, the expected impact must be large and confound- Urinary iodine-school age children 25.4 140.0 132.1 76.9 98.0 20.5 38.9 (μg/l) ing must be unlikely. Haemoglobin Women (g/dl) 1.8 1.1 1.6 1.9 1.9 1.4 1.7 1.6 2.1 1.9 2.0 Conclusions Haemoglobin – pregnant women 1.7 1.1 1.5 2.2 1.6 1.5 1.7 1.6 1.5 1.6 2.3 1.7 Numerous nutrition and health impacts were (g/dl) observed in the intervention areas, often of a Haemoglobin- children <5 years of 2.3 1.8 1.5 1.8 1.8 1.7 1.8 1.9 1.6 magnitude equal to or larger than observed in age (g/dl) controlled interventions or trials. These results Height for age (z score) 1.5 1.4 1.3 1.2 1.2 1.5 1.5 1.2 1.5 1.5 1.3 show the value of integrated long-term inter- Weight for age (z score) 1.3 1.1 1.3 1.2 1.2 1.4 1.5 1.1 1.4 1.4 1.3 ventions.

86 Research

Audience of drama held during PSNP meeting (Laygiant) P Fracassi, Ethiopia P Fracassi,

Linking PSNP and NNP: experiences and challenges

Summary of report1

recent pilot project focused on identify- narrow focus on: PSNP/NNP linkage opportunities ing implementation and eventually • Quantity of food, rather than quality and Findings from the preparatory study together scale‐up opportunities to link two appropriateness of diet for PLW and young with a general overview of the PSNP/NNP A – nationwide programmes in Ethiopia the children. policy framework were used to inform the Productive Safety Net Programme (PSNP) and • Productivity and marketability of foods, Consensus Building Workshops conducted in the National Nutrition Programme (NNP). rather than their nutritional content for all four pilot woredas and kebeles between 28th improved household diet. The selection of the pilot woredas within each September and 16th October 2009. Three major • Dietary intake and food security with region was based on the presence of both PSNP ‘linkage’ opportunities between PSNP and limited attention given to other well known and NNP, and specifically on availability of the NNP were agreed upon for implementation at contributing factors to malnutrition like Community Based Nutrition (CBN) programme, institutional and community levels: disease, child care, access to health services a sub-component of the NNP. A further selection • Capacity Building on Nutrition Security for and environmental conditions. of one kebele in each woreda was made, based key members of the FSTF at woreda, kebele on agro‐ecological signifiers and were as follows: The most effective institutional arrangement for and community levels. Tigray Region – Hintalo Wajirat, Fikre Alem coordination at woreda and kebele levels • Behavioural Change Communication using kebele appeared to be the Food Security Task Forces Education Entertainment (BCCEE) during Amhara Region – Lay Gayint, Shesho kebele (FSTF). According to KIIs findings, the active payday sessions and other public gatherings. SNNP Region – Domot Sore, Shiamba kebele involvement of multiple‐sector partners in the BCCEE encourage PSNP beneficiaries to Oromia Region – Gameches woreda, FSTF was the result of continuous working rela- optimise use of both local and transferred Kokuriftu, Agemti, Sre Kelo tionships, strengthened through shared resources for improved nutrition security. Geto and Homicho kebeles. objectives and basic compatibility of interests. • Focused attention to PSNP PLW to protect In contrast, at regional level, it was noted there and enhance their nutritional status and Preparatory study were too many coordination platforms, with that of their children under two years of age. A preparatory study was conducted at regional overlapping functions resulting in increased Experiences from SNNP and Oromia showed and community levels between 21st July and fragmentation. that at an institutional level, nutrition security 22nd August 2009. Primary data were collected can be incorporated in the capacity building from 39 PSNP/NNP stakeholders through key Primary data from KIIs revealed a number of process of Food Security Task Forces, which informant interviews (KIIs). In addition, a total inter‐sectoral experiences of cooperation at comprise multi‐sector members from agricul- of eight focus‐group discussions (FGDs) were kebele level, although not strictly linked with ture, water, health, education, and Youth and conducted in four pilot kebeles involving 28 addressing malnutrition. Findings from FGDs Women’s Affairs. Half‐day sessions were female and 23 male PSNP beneficiaries. highlighted that a genuine community involve- ment required understanding and taking into included in Watershed Management Training It was found that stakeholders held some account economic, practical and cultural (Domot Sore, SNNP) and in the PSNP review common perspectives of malnutrition, causes motives that influence food production and meeting (Oromia, Gameches) targeting over 100 and solutions. While those interviewed recog- access, as well as consumption decisions at people including 70 Development Agents (DAs). nised that pregnant and lactating women household level. Basics on nutrition were provided during (PLW) and children are the most nutritionally Consensus‐Building Workshops to increase vulnerable groups, their answers indicated a These findings from the preparatory study understanding of the nutritional value of differ- are in line with recommendations by others2 to ent types of foods and on specific dietary “plan multi‐sectorally but continue to imple- requirements for PLW and young children. ment sectorally”. Many of the institutional Improved awareness of the nutrition outcomes barriers for improved inter‐organisational rela- to which PSNP could contribute was discussed tionships first reflect administrative amongst food security and agriculture stake- organisation in sectors/programmes and holders, considering more rigorously who second, nutrition as a cross‐cutting issue, fitting benefits from their interventions. For example, P Fracassi, Ethiopia, 2010 P Fracassi, poorly within this framework. Working in an the nutrition value of selected crop varieties incremental and opportunistic manner appears should be included and accounted for. likely to succeed with the current institutional Meanwhile activities with a direct nutritional structures in Ethiopia. ‘Coordination’ and benefit, like poultry‐management schemes, ‘cooperation’ over specific issues like quality of improved post‐harvest storage and food dietary intake for children and PLW appear to processing techniques or home gardening can be be a promising focus of exchange between PSNP and NNP stakeholders. Mainstreaming 1 Linkages Report (final draft). By Patrizia Fracassi and Lioul of nutrition into the PSNP is expected to Berhanu (2010). Edited by Simon Rolph. Drama (counselling by a HEW) 2 Maxwell, S. & Conway, T. 2000. Perspectives on partnership. conducted during PSNP pay day maximise the impact of the programme among OED Working Paper Series, No. 6, World Bank, session (Tigray-Hintalo Wajirat) beneficiaries. Washington, DC.

87 Research promoted in household business or investment among children under two years can be ensured families receiving aid are being nutritionally plans for increased food and nutrition security through the dissemination of monitored and that their nutritional anthro- Community‐Based Nutrition (CBN) monthly pometry is included in the evaluation of the Experiences from Tigray, Amhara and SNNP data and Community Health Days (CHD) quar- PSNP. show that BCCEE can be mainstreamed within terly data. Currently, CBN programme provides PSNP pay‐day sessions and/or public gather- NNP and PSNP stakeholders at federal and data on underweight and severe underweight ings to promote changes within the households regional levels work together on how to main- among children under 2 years. CHD and the community. Nutrition and care‐related stream nutrition security within the existing programme provides data on MUAC<12cm behavioural problems were initially identified training curriculum. MUAC<11cm or bilateral oedema among chil- by a technical team composed of volunteer dren 6‐59 months and MUAC<21com among The links between food production and members from the kebele FSTF. Technical teams PLW. In addition, monitoring of access and util- consumption should become part of the discus- chose drama as the medium and emphasised isation of essential health and nutrition services sion on how to incorporate agricultural and messages around the life‐cycle sequence from by PSNP PLW can generate communal data for nutritional considerations from the outset. The pregnancy, lactation, to young child feeding joint planning among members of the Food existing Training Manual could be the starting from six to 24 months of age. PSNP beneficiaries Security Task Forces. point. The Ministry of Health could support involved as performers received an orientation these joint trainings so that key members of the on drama and rehearsed under the guidance of a A ‘linkage’ evaluation was conducted infor- FSTF at different levels become change agents professional theatre performer. Key people at mally with key PSNP and NNP stakeholders, to promote adequate and diversified diet for kebele level, such as the Chairman, the Manager, focusing on their view of feasibility and scala- PLW and children under two years. the DAs and Health Extension Workers (HEWs), bility of identified and implemented linkage facilitated events. Woreda level PSNP/NNP opportunities. None of the stakeholders For immediate scale‐up of identified ‘linkages’ stakeholders attended the events in all regions. believed that scaling‐up should be a challenge, at community level: Regional and zonal food security stakeholders especially for capacity building or for the Capacity building on nutrition security rolled participated in SNNP where the drama BCCEE. Furthermore, no institutional barrier out to kebele and community FSTF members. addressed family planning and childbirth spac- could be identified to ‘monitoring access and DAs, HEWs, Community Health Workers ing issues, a reflection of the common concerns utilisation of health and nutrition services by (CHWs), women’s and youth representatives of both the food security and health sectors, as PSNP PLW’. are well placed to engage with male and female well as those of the community. Recommendations PSNP farmers for designing interventions and developing/adopting technologies. Challenges in implementation For immediate scale‐up of identified linkages Interventions and technologies should take into Implementation of the linkage opportunity at institutional level: account agro‐ecology, household economy, with the PSNP to target PLW has proved to be The NNP Coordination Body and PSNP Joint livelihood strategies and cultural norms that challenging in all regions. To monitor the utili- Strategic Oversight Committee work together influence household decisions over food sation of health and nutrition services by PSNP to ensure that identified linkages are main- production, access and use. PLW, ‘on the job ‘orientation sessions were streamed in their respective programmes. The organised with HEWs and DAs in all pilot NNP document (2008), the PSNP document Kebele FSTFs should integrate BCCEE kebeles. These sessions examined key indica- (2009) and the revised PSNP Planning during pay‐day sessions and public gatherings. tors using registers and records from available Implementation Manual (PIM) (2010) already Experiences from implementation show that routine services and nutrition programmes. provide the policy framework to justify the this activity can be managed at community Additional behavioural indicators related to need for a multi-sectoral approach. level provided the quality of the technical dietary habits of PLW and young children were content is supervised by the HEWs. DAs and NNP/PSNP regional and federal coordina- also included in the checklist. The initial PLW HEWs can play a significant role in facilitating tion bodies endorse and ensure the inclusion of identification was expected to happen during the dialogue with the community to influence linkages in respective sector plans, enforce the annual PSNP registration but this proved to intra-household dynamics that affect nutrition- implementation through mutually agreed be either impossible or where figures were ally vital decisions with regards to allocation of monitoring mechanisms and evaluate perform- available, the numbers were questionable (e.g. different quantities and types of food to PLW ance jointly. registered 12% PLW while the commonly esti- and young children. mated percentage is 3.5%). Nutritional objectives and outputs associ- For implementation of identified linkages at ated with PSNP impact and outcome indicators The establishment of work teams among institutional and community levels: such as ‘reduced malnutrition’ and ‘increased PSNP PLW was also discussed with the kebele It is recommended to start the component access and use of health services’ are incorpo- FSTF to promote PLW involvement in ‘light’ which ‘focuses attention on PSNP PLW’ in one ‐ rated in PSNP annual plans at community, works during the non exemption time from pilot woreda looking more carefully at the role kebele and woreda levels. This will enable public work (i.e. before four months of preg- that PSNP and NNP key stakeholders can have management of resource allocations, incentives nancy and ten months post partum). Work on actual operational output. teams were foreseen to be the basis for the and systems of accountability around them. In formation of Interest Groups among PSNP line with the NNP Sub‐Component 2(d), the A small number of indicators should be women/PLW to engage in production activities NNP ensures that young children and PLW in prioritised by PSNP and NNP stakeholders for with nutritional benefits. Further links were expected with existing development programmes, such as the Household Asset Building Programme (HABP) or community‐based services, such as micro‐finance and technical assistance. While interviewed PSNP‐HABP stakeholders were P Fracassi, Ethiopia, 2010 P Fracassi, open to diversifying production investments, they pointed out that other partners like the Women’s Affairs, NGOs or Youth Affairs should be involved in forming and supporting these groups. This ‘linkage’ opportunity goes beyond the PSNP and requires much more time and inputs from different partners to become operational. Interviewed PSNP stakeholders emphasised the potential contribution of the health sector in monitoring the PSNP key indicators but acknowledged limited information sharing between them both. Monitoring of malnutrition

Drama conducted during PSNP meeting (Laygiant) 88 Research monitoring of PSNP PLW utilisation of essential health and nutrition. The initial ‘window of opportu- nity’ could be reduced to pregnancy up to 11 months Post-drought restocking post partum instead of pregnancy to 24 months (as this corresponds more or less to the exemption time of PSNP PLW from Public Work). Can its impact be sustainable? Direct links should be established between the By Ahmed Alkadir Mohammed FSTF (particularly the early warning system (EWS)) and nutrition programming such as CBN and CHD for monthly and quarterly sharing of data on nutri- Ahmed Alkadir Mohammed is currently a Disaster Risk Management Specialist tional status of children and PLW in PSNP kebeles. with the World Bank, Productive Safety Net Programme (PSNP) Team. Prevously he spent 16 months as a Nutrition Project Consultant with the World Bank in The establishment of Interest Groups among Ethiopia to facilitate and coordinate the overall activities of World Bank Funded PSNP PLW/women needs the involvement of other Nutrition Project in Ethiopia. He is a graduate of Addis Ababa University (BSc partners like the Women’s Affairs and/or Youth Management) and of Tufts University (MA in Humanitarian Assistance, 2007). Affairs to support groundwork. ‐ I would like to acknowledge my thesis advisor and instructor, Daniel Maxwell, who well equipped Product value chain assessment and technical me in my research. Also, Daniel, Michael Delaney and Abera Tola from Oxfam America, the assistance will still remain the responsibility of agri- Feinstein International Centre Master of Arts in Humanitarian Assistance (MAHA) programme cultural partners. instructors, and all my Boston based friends. I appreciate Ana Hammock who assisted me in edit- ing the research paper and Erin Boyd in the enrolment of the programme. PSNP and NNP stakeholders should optimise the role of home economists in SNNP, Oromia and On a personal level, I acknowledge the supports of my brother Mekonnene Alkadir, my spouse Tigray by linking them with the HEWs and CHWs Shemsiya Ali, and my children Megfira Ahmed and Olyad Ahmed. My greatest gratitude goes to to strengthen post‐harvest activities, as a necessary the role of my mam, Ade Monina Hussein Megnaka, who played significant role in laying ground link between food production and consumption. of accessing quality childhood education that became the basis for my success in my academic and career development Potential linkages for further discussion: Protection and enhancement of nutritional status of PSNP Orphans and Vulnerable Adolescents (OVAs) through their involvement in ‘Healthy Life Style’ clubs.

Food fortification, such as inclusion of home forti- This article reflects some of the findings of Ahmed’s fication micronutrient powders for children under two years and PLW during food or cash transfers MSc thesis on post-drought restocking of pastoral 1 and fortification at milling stage of the PSNP food households (2007) transfer. Supplementation of PSNP food/cash transfers he livelihoods of pastoral communi- mentation of alternative interventions by through local production of ‘special blended food’ ties depend on livestock production. agencies (non-governmental organisa- for children 6‐11 months and PLW. On a small‐scale, TLivestock provide basic subsistence tions (NGOs). NGOs have been shifting this activity could be linked with the establishment foods such as milk, meat and blood and are their programmes toward livestock based of Interest Groups and with an increased role of the also used for wealth accumulation, pres- interventions to address the impact of Home Economists at woreda level. tige, insurance and inheritance. The recurrent drought. These interventions income generated from the sale of livestock include de-stocking, water, veterinary ‐ ‐ Promotion of high nutrient bio fortified crops serves to buy additional food items, crops service, restocking, and fodder provision. (e.g. high protein maize and orange flesh sweet and clothing. Moreover, livestock are used Post drought restocking in pastoral potato) and improved breeds of poultry, small rumi- as a means of transportation, dowry in communities has become an important nants and cows through collaboration with research marriage and to fulfill reciprocal (social) area of research in Ethiopia and Kenya. institutes to test and promote selected varieties. obligations. Therefore, any adverse factor Pioneers of restocking have demonstrated which impacts negatively on livestock For more information, contact: Patrizia Fracassi, a number of objectives (advantages) of threatens the livelihood and life of pastoral email: [email protected] post-drought restocking. Among other communities. things, reintegrating families into a Recurrent droughts in Ethiopia and pastoral way of life is shown as one of the Kenya have claimed the lives of livestock objectives. It is also indicated that restock- Drama (man helping with water) and depleted herd sizes. The adverse ing is contributing to food security and a conducted during PSNP pay day impact of drought on livestock is signifi- balanced diet (children), as well as session (Tigray-Hintalo Wajirat) cant in Ethiopia and Kenya. For instance, improving economic and social standing6. Ethiopia lost 90% of calves, 45% of cows However, a number of professionals in

P Fracassi, Ethiopia, 2010 P Fracassi, and 22% of mature males between 1983- this field argue that many restocked 19842 , 37% of cattle between 1984-1986 pastoralists do not return to a pastoral and 60% of cattle from 1999-20003. Kenya lifestyle and are likely to become destitute (Turkana) lost 90% of cattle, 80% of sheep and goats, 40% of camels in 1979-804, as well as 28% of cattle and 18% of sheep and 1 Post-drought Restocking of Pastoral Households: Can its impact be sustainable? Master of Arts in 5 goats in 1991 in Northern Kenya . This loss Humanitarian Assistance e Program, Friedman of livestock affects families, particularly School of Nutrition Science and Policy, Tufts University, May 2007. Thesis Advisor: Maxwell, children, women and elders, as their food Daniel (Associate Professor, Friedman School of security is dependent on livestock. It is Nutrition Science and Policy) also pushing pastoral households into 2 Coppock, D. L. 1994. The Borena plateau of southern Ethiopia; Synthesis of pastoral research, destitution and forcing them to drop out of development and change, 1980-91. Addis Ababa: the pastoral way of life. International Livestock Center for Africa (ILCA). 3 Coppock, D.L. (2000). GL-CRSP Annual Report 2000. The traditional means of self-restock- 4 Hogg, R. (1985). Restocking pastoralists in Kenya: A strategy for relief and rehabilitation. ODI Pastoral ing have been eroded in the pastoral Development Network Paper 19c. Overseas community, due to recurrent drought, Development Institute, London. raiding, conflict, environmental degrada- 5 Barton and Morton, forthcoming publication. 6 The Development Fund (2007). Impact Assessment tion and an increase in population. This of the Goat Restocking Project in Afar, Zone-2, has prompted the search for and imple- Berhale.Addis Ababa. 2007 (Aynalem Haile)

89 Research in a short period of time. This raises the ques- above this level are expected to accumulate Critical factors that hinder the tion of whether the impact of restocking is livestock and grow their herds12. Based on the sustainability of post-drought sustainable and if not, why not? discussion with pastoralists in Afar Zone of restocking Ethiopia, 30 – 40 small ruminants are the mini- This review has identified the following critical The objectives of this article are to explore mum stock to start a pastoralist way of life13 factors: post-drought restocking interventions, high- (Development Fund, 2007) while 50 – 70 sheep • Failure of restocking the needy and skilled light their limitations, and suggest practical and goats in a proportion defined by the house- pastoralists who have a livestock level elements that need to be improved in the hold and of the right age for immediate significantly below the CLT (or the destitute) future. These objectives are looked at in terms breeding are suggested for restocking imple- to the level of CLT. of the sustainability of restocking impact in mentation in the Somali region of Ethiopia14. A • Failure of targeting herders whose herd size reintegrating (maintaining) restocked families similar study in Northern Kenya also demon- is below but closer to the CLT. into the pastoral way of life. The article strated presence of the poverty trap and the • Failure of providing the right composition discusses restocking interventions in the CLT that enables pastoralists to accumulate of animals (quantity, sex, age, types, pastoralist areas of Ethiopia and Kenya. It livestock and grow their herds. breeding, milk productive species). argues that if the right sets of critical factors are • Failure to consider key contextual factors that considered in design and implementation, the From a restocking perspective, the studies will affect the outcome of the restocking and impact of post-drought restocking can be suggest not only who should be restocked, but the need for other supporting interventions sustainable with regard to reintegrating (main- also the necessity to restock pastoralists to a to address these factors (raiding, conflict, taining) restocked families into a pastoral way minimum critical threshold level in order to veterinary service, pasture/fodder, water). of life. However, restocking affected pastoral- ensure sustenance, enable herd growth and • Shortage of livestock in the region (resulting ists to the level of a Critical Livestock recovery from shocks15. The importance of in restocking with non-adaptable and Thresholds (CLT) is key. improved veterinary service, livestock and diseased animals). herders’ security, and dry season water avail- • Loss of rangelands. The livelihood framework analysis ability are also emphasised as means to protect • Limited size of funding and inadequate The livelihoods framework is one of the and build assets16. approaches applied by a number of humanitar- food aid. ian and development organisations to examine Other related factors • Absence of social and economic the livelihood of a given community and to Many NGO interventions elect to supply small infrastructures (hindering emergence and help design appropriate interventions. animals (such as goats and sheep) rather than adoption of non-pastoral activities). According to the livelihood analysis, pastoral cattle, although some pastoral communities are Recommendations communities in the Horn of Africa are vulnera- dependent on a range of livestock and produce The following are recommended to improve the ble to recurrent drought, humans and animal from their herds. Small animals alone may not sustainable impact of post-drought restocking diseases, cattle raiding, conflict, bad gover- therefore ensure food security for these interventions: nance and policies, poor social and economic pastoralists17. In other contexts, small animals • Restock pastoralists to a minimum of the CLT. infrastructure and loss of grazing lands. To such as goats are preferred as they give milk for • Target not only the capable needy and determine the implications of this analysis on the consumption of children and elders and skilled destitute pastoralists, but also target post-drought restocking, a number of factors forage easily from bushes and shrubs encroach- those who have live stock levels below but must be considered : hindrance of mobility, ments18. Many small NGOs implement closer to the CLT. lack of access to and loss of range land, live- restocking programmes using disaster relief • Provide the right composition of live-stock. stock mortality, poor productivity of milk, and funds19. If animals are bought from other • Consider the existing situation and provide off-spring and diminished herd growth. These regions, their age, reproductive and milk packages of supporting interventions. all adversely impact the sustainability of productive capacity, adaptability and disease • Coordinate interventions to tackle resources restocking. profile should be analysed20. Lack of trans- constraints. parency in the purchase process is observed to • Research and design comprehensive guide The poverty trap analysis be one of the limitations in restocking projects. lines for restocking. In the field of economics, the poverty trap refers In 1985 and 1987, destitute Borenas were • Formulate and apply a viable land utilisation to the situation where individuals, communi- restocked with animals bought by traders, policy. ties, regions or economies are caught in extreme which resulted in a number of disadvantages 7 • Research and advocacy on the promotion poverty and unable to get out of this condition . for the pastoralists21. In some instance, sale of and funding of non-pastoral activities and This analysis is fundamentally based on a the restocking animals has been observed in the development of social and economic Critical Assets Threshold (CAT). It asserts that order to buy other livestock and grain, for infrastructures. households that possess assets equal to or payment as part of a bride price and to finance • Consider and implement restocking projects above these thresholds recover from shocks, traditional ceremonies22. In order to prevent within a broader development plan and accumulates assets and escape poverty, while beneficiaries slaughtering and eating their new Disaster Risk Management approach. those who have assets below these critical herd, it is recommended to provide food for 9 to thresholds experience decline and collapse of 12 months during the restocking programme23. For more information, contact: Ahmed Alkadir, assets and persistent poverty. In addition, this All these factors should be considered during email: [email protected]; analysis implies that if a shock leaves a house- planning restocking interventions. [email protected] hold’s assets equal to or above the critical thresholds, then recovery and growth is possi- ble and vice versa8. (In pastoral communities of 7 Izhar, B (2005). Why Poverty Traps Emerge 15 McPeak and Barrett, 2001. See footnote 9. 8 Carter, R and Barrett, B (2004). The Economics of Poverty 16 Barrett, B et al (2006). Welfare Dynamics in Rural Kenya Ethiopia and Kenya, the risk of falling into the Traps and Persistent Poverty: An assets-based Approach. and Madagascar. Journal of Development Studies. Vol. 42, poverty trap is directly related to the produc- BASICS CRSP Management Entity, Department of No. 2, 248-277 tive livestock assets held at household level and Agricultural and Applied Economics, University of Wisconsin- 17 Oba, G (1992). Ecological Factors in Land Use Conflict, Madison. Land Administration and Food and Food Insecurity in whether this is equal to or above the CLT. The 9 McPeak, G and Barrett, B (2001). Differential Risk Exposure Turkana, Kenya. ODI Pastoralist Development Network CLT is necessary for sustenance, herd growth, and Stochastic Poverty Traps Among East African Pastoralists. Paper 33a. London: Overseas Development Institute. American Journal of Agriculture and Economics. 18 Ayle Gebre-Mariam (1989). Analysis of the progeny history 9 increase in return and recovery from shocks . 10 International Committee of the Red Cross (ICRC). 2004. of heifers and does and their off springs: Case of animals; “A threshold value is the number of animals Livestock Study in the Greater Horn of Africa. Nairobi/Kenya. restocked to re-settlers at Yavello, Mega and Moyale in 11 It should be noted that the focus of this paper is on the 1985 and 1987. Addis Ababa. required to support a person or a family if that significance of a ‘self-sufficient’ livestock herd size that 19 Toulmin, C (1995). Tracking Through Drought: Options for person or family was to rely totally on animals should be considered in restocking interventions. The authors Destocking and Restocking. In Living within uncertainty: 10 have used different ways of expressing the critical livestock New Direction in Pastoral Development in Africa. 95-115 for all his or their needs.” threshold for Northern Kenya and Southern Ethiopia, i.e. per (Ed. Ian Scoones). London: Intermediate Technology capita and livestock unit. Generally, approximately 4.5TLU Publications. Toulmin, C (1987). Drought and the Farming A study in Southern Ethiopia demonstrates per capita is suggested as a self-sufficiency threshold Sector: Loss of Animals and Post-Drought Rehabilitation. the presence of the poverty trap among the necessary in more arid rangelands not suffering widespread Developement Policy Review 5(2):125-148. degradation (McPeak 2000). 20 USAID-Office of Foreign Disaster Assistance: Livestock Borena pastoralists. The study identified that 12 Barrett, Bet al (2002). Poverty Traps and Resource Interventions: Important Principles for OFDA. 11-19-02. household herd size thresholds are 10 livestock Degradation. BASIS Brief. No. 6 http://www.usaid.gov/our_work/humanitarian_assistance 13 See footnote 6. 21 Ayele Gebre/Mariam, 1989 (footnote 8) and Development 11 units , below which a household is economi- 14 Save the Children Ethiopia (UK) ( 2005). Terminal Evaluation Fund, 2000 cally not viable and thus enters a downward of the Restocking/Rehabilitation Program for the Internally 22 See footnote 8. Displaced Persons (IDPs) in Fik Zone of the Somali Region 23 See footnote 10 spiral of poverty. However, those who are of Ethiopia.Acacia Consultants Ltd, 00606\Nairobi, Kenya.

90 Research Food insecurity and mental health among community

health volunteers in Ethiopia Summary of published research1

Findings recent study examined self-reported had been volunteering for more than 12 months) household food insecurity and symp- and newcomers (who had just started volun- The data showed that food insecurity is highly toms of common mental disorders teering at the time of the baseline survey). prevalent (~80%) among AIDS care volunteers A in Addis Ababa, that it is associated with house- (CMD) among 110 community health AIDS care The researchers used generalised estimating hold economic factors, and that it is linked to volunteers living in Addis Ababa, Ethiopia equations that account for associations between during the height of the 2008 food crisis. In the symptoms of common mental disorders. responses given by the same participants over Surprisingly, the volunteers in this urban face of a late-maturing HIV/AIDS epidemic three survey rounds, to model the longitudinal and poorly-distributed public health services, sample did not report increasingly severe food response profiles of food insecurity, CMD insecurity or CMD during the peak of the 2008 volunteerism in community health care has symptoms, and socio-behavioural and micro- grown substantially over the past decade in food crisis. This is a counter-intuitive result that economic covariates. To help explain the would not be predicted in analyses of popula- Addis Ababa. Public health facilities rely heav- patterns observed in the response profiles and ily on the training of volunteers, who provide tion-level data, such as those used in regression results, the researchers examined econometrics simulations. home-based palliative care, support drug adher- qualitative data that contextualised the cogni- ence and mediate patient’s access to clinical tion and reporting behaviour of AIDS care The authors of the study explored a number treatment and non-governmental organisation volunteers, as well as potential observation of possible explanations as to why this poor (NGO) assistance. Volunteers typically serve for biases inherent in longitudinal, community- urban sample was buffered from the local food a period of 18 months, caring for at least five based research. crisis. One posited explanation was that suffi- non-kin patients, under the supervision of a ciency of accessible food is a potentially local NGO. After 18 months, patients are re- The Household Food Insecurity Access Scale subjective assessment sensitive to shifting inter- assigned to a new group of volunteer recruits (HFIAS) was translated into Amharic, and then nal standards and social comparisons. Since and graduating volunteers leave the service back translated and revised. Participant house- volunteer caregivers repeatedly interact with with unknown prospects for employment. holds were classified into four levels of food care recipients and other volunteers who are insecurity according to a perceived to be poorer and hungrier, food inse- scheme that closely paral- curity is prone to response shifts in the sample. Volunteer support may benefit lels the published HFIAS This is partly supported by the fact that caregivers as well as beneficaries protocol. To assess the newcomers were more likely than veterans to distribution of CMD symp- report improved food insecurity status at toms, the researchers used Rounds 2 and 3. Another possible explanation K Maes, Ethiopia, 2008 a 29-item version of the or factor may be the impact of volunteerism on WHO self-reporting ques- wellbeing. Other longitudinal studies have tionnaire (SRQF) which shown that adult volunteers enjoy better physi- incorporates eight items cal and mental health and lower risk of derived from Amharic mortality than non-volunteers. This might idioms of distress. The explain why mental health did not worsen over SRQF has been previously time in the sample. In other words, mental translated to Amharic and health could have been buffered from stressors tested for content, construct by the psychological benefits mediated by AIDS and criterion validity. care volunteers’ unique social networks and Participants were religious beliefs. This is illustrated by represen- presented with yes or no tative quotes from volunteers who were response categories for interviewed in the study. For instance, a 32- each SRQF item/symptom. year-old single mother said that, “In all my life, Though the SRQF is not a what makes me happiest is [to see those The study addressed two principle questions. diagnostic tool, it was assumed that higher patients] being human—being able to work and First, did rising food prices in Addis Ababa in scores were indicative of greater likelihood of feed themselves.” A 35-year-old unmarried 2008 lead to greater experiences of food insecu- having a common mental disorder. man said, “Being a volunteer caregiver will get rity and concomitant rise in CMD symptoms you to...sympathize with human beings... Participants estimated monthly household amongst volunteers in the sample? Secondly, do Sometimes I will get aid from NGOs [in return income at all three rounds. This income was factors such as food aid, per capita income or for volunteering]; but you have to forget this divided by total number of people in the house- participation in microfinance clubs explain the thing. By believing in God...and doing God’s hold. Participants also answered three observed patterns of self-reported food insecu- work, you can live.” questions addressing household economic rity and CMD amongst the volunteers? coping ‘to fulfil basic needs’ in the past three The authors raise important policy ques- The surveys were administered to a sample months: whether they had started a new tions; should the apparent resilience of the of community AIDS care volunteers from two income-generating activity, sold household study population be supported with food or local NGOs, Hiwot HIV/AIDS Prevention goods, and/or kept students home from school other material aid? Should they be relieved of Control and Support Organisation and Medhin to help in income generation or food prepara- their duties with efforts to put care and support Social Centre, which provide home-based care tion. The study categorised participants in the hands of paid professionals? Or should for people with AIDS accessing treatment at a according to whether they or anyone in their they become paid community health workers? public hospital in southwest Addis Ababa households engaged in one or more of these The authors conclude the paper by arguing for (ALERT hospital). coping measures versus none in the three further studies addressing links between food months prior to the survey. insecurity, mental health, and the potential Four Ethiopian research assistants were benefits of altruism. trained for data collection that took place over At each round, participants reported three rounds over the course of 2008. The whether they were receiving free food aid from For more information, contact: Kenneth Maes, sample included 110 volunteer caregivers (99 NGOs and what kinds of food they were receiv- email: [email protected] women and 11 men) of adult patients receiving ing. Participants also reported their total treatment at the ALERT Hospital. The gender number of care recipients, whether they were ratio reflected the overwhelming proportion of caring for at least one bedridden care recipient 1 Maes. K et al (2010). Food insecurity and mental health: Surprising trends among community health volunteers in women in the volunteer population. The sample and the total number of hours per week spent Addis Ababa, Ethiopia during the 2008 food crisis. Social was divided into subgroups of ‘veterans’ (who in volunteer activities. Science and Medicine 70 (2010), pp 1450-1457

91 Acronyms ACF Action Contre la Faim FDA Food Distribution Agent OFDA Office for Disaster Assistance (USAID) ACT Action of Churches Together FFP Food for Peace Programme OFSP Other Food Security Programme ADP Area based Development Programme (World FGD Focus group discussion OMFI Omo-Micro Finance Institution Vision) FHE Food for the Hungry - Ethiopia ORDA Organisation for Rehabilitation and Development AHT Animal health technician FIND Foundation for Innovative New Diagnostics ORP Operational Research Programme AKU Afran Kallo Union FMIP Food Management Improvement Project OTP Outpatient Therapeutic Programme ARRA Administration for Refugees and Returnee FMOH Federal Ministry of Health OVA Orphans and Vulnerable Adolescents Affairs FSNRD Food Science and Nutrition Research OVC Orphans and Vulnerable Children BCC Behaviour change communication Directorate PASDEP Plan for Accelerated and Sustained BMI Body mass index FSTF Food Security Task Force Development to End Poverty CAHWs Community Animal Health Workers GAM Global acute malnutrition PHEM Public Health Emergency Management CASHE Commercialisation of Agriculture for GASU Global Agricultural Scale Up PILLAR Preparedness Improves Livelihoods and Smallholders in Ethiopia GDP Gross Domestic Product Resilience CBN Community Based Nutrition GoE Government of Ethiopia PIM Programme Implementation Manual CBO Community based organisation HAVOYOCO Horn of Africa Voluntary Youth Committee PLW Pregnant and lactating women CBRM Community Based Resource Management HEA Household Economy Approach PLWH People living with HIV CBTP Community Based Training Programme HEP Health Extension Programme PO Pastoral organisation CC Community conversation HEW Health extension worker PRRO Protracted Relief and Recovery Operation CDC Centre for Disease Control (Atlanta) HH Household PSNP Productive Safety Net Programme CDAA/E Churches’ Drought Action Africa /Ethiopia HMIS Health Management Information System PST Pre-service training CESVI Cooperazione e Sviluppo (Italy) RAIN Revitalising Agricultural/pastoral Incomes and HRF Humanitarian Response Fund CFSTF Community Food Security Task Force New markets HRD Humanitarian Requirement Document CHD Community Health Day RCWDA Rift Valley Children and Women Development HRP Humanitarian Response Programme Association CIDA Canadian International Development Agency HSDP Health Sector Development Plan RDD Regional Drought Decision (ECHO) CLT Critical Livestock Threshold HSEP Health Services Extension Package RDP Rural Development Programme CM Community mobilisation HTP Harmonised Training Package R-ENCU Regional ENCU CMAM Community based management of acute IFHP Integrated Family Health Programme malnutrition REST Relief Society of Tigray IGA Income generating activities CMR Crude mortality rate RF Risk Financing Mechanism IMC International Medical Corps CNU Children’s Nutrition Unit ROBA Rural Organisation for the Betterment of IMCI Integrated Management of Childhood Illness Agro-pastoralists CRS Catholic Relief Services INGO International non-governmental organisation RUTF Ready to use therapeutic food CSAS Centric systematic area sampling IPC Integrated Humanitarian Phase Classification SAM Severe acute malnutrition CSB Corn Soy Blend ITN Insecticide treated nets SC Stabilisation centre CS-CAFÉ Citizens Solidarity for the Campaign Against Famine in Ethiopia JAM Joint Assessment Mission SC US Save the Children US CSO Civil society organisation JEOP Joint Emergency Operation Plan SFP Supplementary Feeding Programme CTC Community-based Therapeutic Care JICA Japan International Cooperation Agency SUN Scale Up Nutrition DFID Department for International Development KAC Knowledge, Attitude, Coverage SMART Standardised Monitoring and Assessment of Relief and Transitions (UK) KAP Knowledge, Attitude, Practice SNNPR Southern Nations, Nationalities, and People's DHS Demographic Health Survey KAPB Knowledge, Attitude, Practice, Behaviour Region DOA District Office of Agriculture Kebele The smallest administrative unit of Ethiopia SQUEAC Semi Qualitative Evaluation of Access and DPPA Disaster Prevention and Preparedness Agency similar to a ward, a neighbourhood or a Coverage localised and delimited group of people. It is part of a woreda. SWC Soil and water conservation DPPO Disaster Prevention and Preparedness Office KFSTF Kebele/tabia food security task force TFP Therapeutic Feeding Programme DRM Disaster risk management LWF Lutheran World Federation TFU Therapeutic Feeding Unit DRMFSS Disaster Risk Management and Food Security TLU Tropical Livestock Unit Sector MANTF Multi-Agency Nutrition Task Force TOT Training of trainers DRR Disaster risk reduction M&E Monitoring and evaluation TSF Targeted Supplementary Food DTM Department of Traditional Medicine MEL Monitoring, Evaluation and Learning TTP Team Training Programme ECHO European Commission Humanitarian Aid MFI Microfinance institutions Department MLREP Market-led Livelihood Recovery and Ucodep Unity and Cooperation for Development of Peoples (now Oxfam Italia) ECS Ethiopian Catholic Secretariat Enhancement Programme MOARD Ministry of Agriculture and Rural Development UNDAF United Nations Development Assistance ECSNCC Ethiopian Civil Society Network on Climate Framework Change MoPDE Ministry of Pastoral Development and Environment of Somaliland UNHCR United Nations High Commissioner for EDK Emergency drug kit Refugees MoU Memorandum of Understanding EDHS Ethiopia Demographic Health Survey UNICEF United Nations Children’s Fund MP Micro-plans EECMY Ethiopian Evangelical Church Mekane Yesus UNOCHA United National Office for Coordination of E-EOS Expanded-EOS MSG Multi-storey gardens Humanitarian Affairs EFSL Emergency Food Security and Livelihoods MUAC Mid upper arm circumference USAID United States Agency for International EHNRI Ethiopian Health and Nutrition Research N-CMAM National CMAM Development Institute NCOE Nutrition Centre of Expertise (World Vision) VAD Vitamin A deficiency ENA Emergency Nutrition Assessment NERS Nutrition Education and Rehabilitation VAS Vitamin A supplementation ENCU Emergency Nutrition Coordination Unit Sessions VCA Value Chain Analysis ENI Ethiopian Nutrition Institute NFI Non food item VCHWs Volunteer Community Health Workers EOC Ethiopian Orthodox Church NGO Non-governmental organisation WASH Water, Sanitation and Hygiene EOC- EOC-Development and Inter-Church Aid NIS Nutrition Information System WFP World Food Programme DICAC Commission NNP National Nutrition Programme Woreda An administrative division of Ethiopia (managed EOS Enhanced Outreach Strategy NNS National Nutrition Strategy by a local government), equivalent to a district EPI Expanded programme on immunisation and itself part of a zone, grouped into ethno- NRIH National Research Institute of Health linguistic regional zones. EU European Union NRMD Natural Resource Management Directorate WorHO Woreda Health Office EWRD Early Warning and Response Directorate NERAD National Environment Research and WVE World Vision Ethiopia EWS Early Warning System Disaster Management See also key programme definitions in Box 1, p39 and a guide FBO Faith based organisation NRM Natural resource management to key systems and programmes in Ethiopia implemented by the government on p12, Box 1. 92 Corrections to Field Exchange 39 Our apologies for a number of errors in Field Exchange 39. The Kismayo, Mogadishu, Bayand Bakool are regions Figure 3: Consumption trends across the of Southern Somalia and not Somaliland as stated (Analysis of looting in the Somali war, Field Exchange 39, p22). three schools Note also a correction to Figures 1, 2 and 3 of the article 'Acceptability trial of a novel RUTF based on soy, lentils and rice' (p12-13). The online edition of Field Exchange 39 has been corrected. 30

Figure 1: Comparison of average energy intakes Figure 2: Weight gain (g/kg/child), n=69 25 (n=69) 20 15 60 15 10 g/kg/child 10 5 40 5 0 0 20 -5 123456789 day number

kcal intake/kg/child kcal -10 Plumpynut RUTF BP100 grams of weight/kg child of weight/kg grams 0 Plumpynut energy intake RUTF energy intake Plumpynut RUTF Note: The first two days of data for BP100 are missing because it was provided as a biscuit, rather than a porridge. BP100 energy intake BP100 Note: The dashed line represents 75% of the Plumpy’nut® energy intake

The Emergency Nutrition Network (ENN) grew out of a series of interagency meetings focusing on food and nutritional aspects of emergencies. The meetings were hosted by Editorial team Office Support Field Exchange UNHCR and attended by a number of UN agencies, NGOs, donors and Jeremy Shoham Katherine Kaye academics. The Network is the result of a shared commitment to supported by: Marie McGrath Matt Todd improve knowledge, stimulate learning and provide vital support and Deirdre Handy Thom Banks encouragement to food and nutrition workers involved in Carmel Dolan emergencies. The ENN officially began operations in November 1996 (Guest Editor) Website and has widespread support from UN agencies, NGOs, and donor Design governments. The network aims to improve emergency food and Phil Wilks nutrition programme effectiveness by: Orna O’Reilly/Big Cheese Design.com • providing a forum for the exchange of field level experiences • strengthening humanitarian agency institutional memory Contributors for this issue • keeping field staff up to date with current research and evaluation findings H. E Dr Kesetebirhan Allison Oman, • helping to identify subjects in the emergency food and Admassu, Dr. Sisay Sinamo, nutrition sector which need more research. Dr. Ferew Lemma, Dr. Gedion Tefera, Selamawit Negash, Aweke Yilma Dubi, The main output of the ENN is a tri-annual publication, Field Patrizia Fracassi, Andrew Simons, Exchange, which is devoted primarily to publishing field level articles Abay Bekele, Daniel Gebeyehu, and current research and evaluation findings relevant to the Shekar Anand, Getachew Gemtesa, emergency food and nutrition sector. Deed Jaldessa, Markos Kidane, Debela Kenea, The Relief Society of The main target audience of the publication are food and nutrition Miriam Christensen, Tigray (REST) Mekelle workers involved in emergencies and those researching this area. The Todd Flower, Team, reporting and exchange of field level experiences is central to ENN Sarah Coll-Black, Zeine Muzeiyn, activities. Matt Hobson, Ewnetu Yohannes, Holly Welcome Radice, Kassahun Bedada Beyi, Maria Ruiz-Bascaran, Alix Carter, The Team Abebe Zewdu, Emily Mates, Jeremy Shoham (Editor), Oumar Mohamud, Gebreselassie Atsbahha, Marie McGrath (Sub-editor) Mekdes Asfaw, Jutta Neitzel, and Carmel Dolan are ENN Mahlet Bezu, Yuki Isogai, Technical Directors. Isaack B. Manyama, Kate Sadler, Gugsa Abate, Elizabeth Bontrager, Mathewos Tamiru, Dr. Alessandro Conticini, Thom Banks is the Katherine Kaye is Mulugeta WTsadik, Mrs. Valérie Quéré, ENN's fulltime Desk the part-time Sylvie Chamois, Ahmed Alkadir Operations Officer administration Sarah Style, Mohammed, and provides logistical assistant at the Antoinette Powell, Dr. Cherinet Abuye. and project support ENN. Thanks for the pictures to: to the ENN team. Caroline Waterman, Mesfin Teklu, Chloe Angood is a nutritionist working part-time Concern Ethiopia, Lubna Khan, with ENN on a number of projects and supporting Indrias Getachew, Andrew Simons, Human Resources. Patrizia Fracassi, Hailu Sitotaw, Abay Bekele, CRS, Oxfam, Emily Mates, Emma Proud, EOC-DIAC, Matt Todd is the ENN Orna O’ Reilly Mahlet Bezu, Judith Schule, financial manager, designs and Geraud Laval, Kate Sadler, overseeing the ENN produces all of Mulugeta Wtsadik, Kenneth Maes, accounting systems, ENN’s publications. Sylvie Chamois, WFP photo library. budgeting and EHNRI Public Relations financial reporting. Office, Phil Wilks Cover (www.fruitysolutions.com) manages ENN’s website. Mother and child on Community Health Day, Fadis Woreda, Ethiopia; P Fracassi, Ethiopia, 2008 Back Cover; A boy in Harar market Simon Rolph, Ethiopia, 2009

The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156) and a company limited by guarantee and not The opinions reflected in Field Exchange having a share capital in the UK (company registration no: 4889844). articles are those of the authors and do The production and distribution of this bumper issue of Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENN not necessarily reflect those of their Field Exchange 40 was made possible through funding Directors/Trustees: Marie McGrath, Jeremy Shoham, Bruce Laurence, Nigel agency (where applicable). from OFDA and Irish Aid to meet additional costs. Milway, Victoria Lack, Arabella Duffield

93 A scene from Dire Dawa market Credit: Simon Rolph, Ethiopia, 2009 Credit: Simon Rolph,

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