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Tibebu Lemma/for UNICEF Ethiopia. Copyright UNICEF Ethiopia Seven month old Aynadis has her MUAC measured as her mother looks on, during the weekly OTP at Geter Meda Health Post Field Article Introduction Globally, more than 3.5 million children under the age of five year die each year due to the underlying causes of malnutrition. It is also estimated that 13 million infants are born each year with low birth weight (LBW), 55 million children are wasted (of which 19 million are severely wasted) and 178 million are stunted. Of the estimated 178 million stunted cases, 90% live in 36 high burden countries that include Ethiopia 1 . The consequence of the many adverse interacting elements in Ethiopia is that although malnutrition rates among children are steadily decreasing, they remain at unsatisfactorily high levels. The 2010 Ethiopian Demographic Health Survey (EDHS) 2 estimated the national prevalence of Global Acute Malnutrition (GAM) at 9.7%, with 44.4% of children estimated to be stunted and 28.7% underweight. Encouragingly, both underweight and stunting prevalence was reducing by 1.34% per year over the past decade. While this trend is clearly progressing in the right direction, Ethiopia will only reach the Millennium Development Goal (MDG) target of halving the number of underweight children if the percentage reduction is increased to at least 1.6 CMAM rollout in Ethiopia: the ‘way in’ to scale up nutrition By Dr Ferew Lemma, Dr Tewoldeberhan Daniel, Dr Habtamu Fekadu and Emily Mates Dr Ferew Lemma is Senior Nutrition Advisor to the State Minister (Programs), Federal Ministry of Health, and REACH Facilitator, based in Addis Ababa, Ethiopia. Dr Tewolde has over nine years of experience in the area of nutrition with particular focus on management of acute malnutrition. He has been a Nutrition Specialist with UNICEF Ethiopia since June 2005, previously working with Save the Children and World Vision. He has taken part in the development of Ethiopian national protocol and training materials for management of severe acute malnutrition and development of national guidelines for HIV and Nutrition. Dr. Habtamu Fekadu is Chief of Party for ENGINE (integrated nutrition programme), Save the Children US, Ethiopia. He has worked in health, nutrition, and academics in Ethiopia for the last 16 years. His considerable portfolio of experience includes Federal Ministry of Health nutrition lead on the five year National Nutrition Programme (NNP) of Ethiopia, amongst a broad range of other activities including strategy development, training and evaluation, and working with other agencies, notably UNICEF and Save the Children. Emily Mates is a public health professional with a focus in nutrition. She was lead researcher with ENN on the CMAM Conference based in Addis Ababa, where she has worked for many years in emergency and development health and nutrition programming The authors would like to mention in particular the support of Dr Abdulaziz and Mesfin Gose (Federal Ministry of Health), Sylvie Chamois (UNICEF), Pankaj Kumar and Israel Hailu (Concern Worldwide) Iassack Manyama and colleagues (ENCU/ DRMFSS) and the many other partners implementing CMAM in Ethiopia. 1 Black, R, Allen, L. H, Bhutta, Z. ., Caulfield, L. E, De Onis, M, Ezzati, M, Mathers, C, and Rivera, J. For the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. Published online Jan 17 2008. DOI:10.1016/S0140- 6736(07)61690-0 2 This data is not yet official until the full EDHS report 2010 is issued (expected December 2011). Acronyms: ASRI Accelerated Stunting Reduction Initiative CBN Community Based Nutrition CHD Community Health Day CMAM Community Management of Acute Malnutrition EDHS Ethiopian Demographic and Health Survey DRMFSS Disaster Risk Management and Food Security Section EHNRI Ethiopian Health and Nutrition Research Institute ENCU Emergency Nutrition Coordination Unit ENA Essential Nutrition Actions EOS Enhanced Outreach Strategy FFA Food Fortification Alliance FMoH Federal Ministry of Health GAM Global Acute Malnutrition GMP Growth Monitoring and Promotion GoE Government of Ethiopia HEP Health Extension Programme HEW Health Extension Worker ICCM Integrated Community Case Management IMNCI Integrated Management of Neonatal and Childhood Illnesses INGO International NGO IRT Integrated Refresher Training IYCN Infant and Young Child Nutrition LBW Low Birth Weight MAM Moderate Acute Malnutrition MDG Millennium Development Goal MOH Minstry of Health MUAC Mid Upper Arm Circumference NCHS National Centre for Health Statistics NGO Non-Governmental Organisation NNP National Nutrition Programme NNS National Nutrition Strategy OTP Outpatient Therapeutic Programme RHB Regional Health Bureau RUTF Ready-to Use Therapeutic Food SAM Severe Acute Malnutrition TFP Therapeutic Feeding Programme UNICEF United Nations Children’s Fund VAS Vitamin A Supplementation WFP World Food Programme WHO World Health Organisation WoHO Woreda Health Office ZHD Zonal Health Department 15
Field Article percentage points per year. This implies the need to intensify and scale-up known high impact nutrition interventions and those that address wasting. Figure 1 describes the changes in malnutrition prevalence from 2000-2010. The Government of Ethiopia (GoE) has developed a five-year development plan, the Growth and Transformation Plan (GTP), for the period 2010/11 to 2014/15. The main objectives of the GTP include: i) Maintain an average real Gross Domestic Product (GDP) growth rate of 11% and attain the MDGs ii) Expand and ensure the quality of education and health services and achieve MDGs in the social sector iii) Establish suitable conditions for sustainable nation building, through the creation of a stable democratic and developmental state iv) Ensure the sustainability of growth by realizing all of the above objectives within a stable macro-economic framework. Under the umbrella of the GTP, the GoE launched the fourth Health Sector Development Programme (HSDP-IV). The new (and final) HSDP IV (2010 – 2015) places a strong focus on maternal health issues and has considerably more focus on nutrition than the three previous plans. There are 16 nutrition indicators within HSDP-IV, examples of which include reducing the stunting prevalence from 46% to 37%, reducing the prevalence of wasting from 11% to 3%, and increasing household utilisation of iodised salt from 4% to 95% 3 . During the course of implementation of the previous health sector development programme (HSDP-III 2005/6 – 2009/10), a National Nutrition Strategy (NNS) was developed and launched in 2008. The NNS is operationalised through the National Nutrition Programme (NNP), a 10- year initiative aiming to reduce the levels of stunting, wasting, underweight and LBW infants. The first phase is for five years (2008–2013), at an estimated cost of 370 million USD and consists of two main components: ‘Supporting Service Delivery’ and ‘Institutional Strengthening and Capacity Building’. The overall objective is better harmonisation and coordination of the various approaches to manage and prevent malnutrition. The service delivery arm of the NNP has four sub-components: a) Sustaining Enhanced Outreach Strategy (EOS) with Targeted Supplementary Food (TSF) and transitioning of EOS into the Health Extension Package (HEP), b) Health Facility Nutrition Services, c) Community Based Nutrition (CBN) and d) Micronutrient Interventions. A process of revision and extension of the NNP has recently commenced (October 2011) for two main reasons: i. To align the end of the first phase with the HSDP IV and MDGs, i.e. extend the first phase by 2 years to 2015 ii. To strengthen initiatives that were not adequately addressed in the original document and include initiatives that have emerged since the NNP was devised. For example: • Accelerated Stunting Reduction Initiative (ASRI) - inclusive of maternal nutrition, Infant and Young Child Nutrition (IYCN) • Food Fortification Alliance (FFA), goals and objectives for improving micronutrient status • Strengthening of multi-sectoral linkages – key sectors include; agriculture, education, water and energy, labour and social protection, finance and economic development, women’s children and youth affairs • Social protection policy and nutrition related indicators • Moderate acute malnutrition (MAM) programming and the development of improved linkages between preventive and treatment programming • School health and nutrition (SHN) CMAM/TFP roll-out in Ethiopia The term Therapeutic Feeding Programme (TFP) is used in Ethiopia to describe the treatment of Severe Acute Malnutrition (SAM). Much has already been written about Ethiopia’s scale up experience to date 5 , so the history and development of the TFP in Ethiopia is only briefly summarised here. Community based management of acute malnutrition (CMAM) in Ethiopia traditionally does not include the management of MAM. Hence the discussion below focuses on SAM management only. A small pilot for CMAM was first conducted in Southern Ethiopia in 2000. A research programme in three countries (Malawi, Ethiopia and South Sudan) followed, implemented from 2002 by Valid International and Concern Worldwide, to test the efficacy and safety of the CMAM approach. A food security crisis due to drought developed across many areas of the country during 2003/4. This crisis was the catalyst for many international non-governmental organisations (INGOs) to adopt the CMAM approach of treating the majority of cases as outpatients, as they became overwhelmed trying to manage the high caseloads of malnourished children arriving at the Therapeutic Feeding Centres (TFCs). 6 From 2004/5, the Federal Ministry of Health (FMoH), alongside partners including UNICEF and others, commenced scale-up of SAM treatment services. This involved developing guidelines and establishing more in-patient and out-patient services across the country. In 2007, following international endorsement of the CMAM approach, 7 the national protocol for SAM treatment was revised to include detailed guidance for the Outpatient Therapeutic Programme (OTP) and community mobilisation activities. 3 Recalculated by Tulane University. 4 As the DHS 2010 was not out during the HSDP-IV preparation, DHS 2005 was used as a benchmark. 5 Field Exchange issue 40. Emergency Nutrition Network. http://fex.ennonline.net/40/contents.aspx 6 TFCs were often established in a health centre compound with erection of a large tent, and heavy presence of NGO staff to manage the cases on a daily basis. 7 WHO/WFP/UNSCN/UNICEF. Community-Based Management of Severe Acute Malnutrition. A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund, 2007. http://www.who. Figure 1: Nutrition indices EDHS 2000*, 2005* and 2010 Percentage 70 60 50 40 30 20 10 0 57.8 42.1 12.9 51.5 34.9 12.4 2000 2005 2010 44.4 28.7 Underweight Stunting Wasting * Recalculated using World Health Organisation (WHO) Growth Standards 4 for 2000 and 2005 Box 1. Overview of the TFP in Ethiopia The TFP combines in-patient and out-patient care for children suffering from SAM (mid upper arm circumference (MUAC) 50% in rural communities, >70% in urban populations and >90% in a camp situation. The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva, 2011 Edition. Sphere Project.www.sphereproject.org 9.7 16
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