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across the other two main regions (Amhara and
Tigray). The pace of scale up has continued,
with > 8,000 health facilities currently offering
OTP services across Ethiopia. Table 1 shows the
number and coverage of health facilities
providing CMAM services in Ethiopia.
The FMoH has guided the roll-out of the
TFP. It is no longer viewed as a response necessary
in times of emergency only. Instead it has
become part of the integrated national
approach of decentralising primary health care
services across the country, through the Health
Extension Programme (HEP). This is described
further below.
Results of national TFP scale-up
A total of 731,238 severely malnourished children
were admitted to the TFP between January 2008
and September 2011, as outlined in Figure 2.
Figure 2 clearly illustrates that the number of
children admitted each month continued to
increase with the increasing number of OTP
sites, while at the same time showing the
seasonal variation of caseloads in Ethiopia.
The performance of the TFP has been highly
successful with impressive programme results:
an average recovery (cure) rate of 82.3%,
mortality rate of 0.7% and defaulter rate of 5.0%.
All results are well above the Sphere international
recommendations, a major achievement
for this government-led national public health
initiative.
Consistently low mortality rates provide
evidence of the ability of primary health care
workers to identify and refer sick children -
those with a lack of appetite or additional
medical complications that require higher-level
health care. Note that the low mortality rate is
also related to the early case detection that
comes from having massively decentralised
services. Caregivers can access assistance earlyon
in the disease process of their child, reducing
the need for referrals of complicated cases for
in-patient care as well as the risk of death.
Table 1: District level coverage of TFP/CMAM in
Ethiopia, October 2011
Hotspot priority
number 11
Number of
districts
Number of
OTPs
1 175 3,106 192
2 138 2,677 147
3 40 655 32
4 269 1,662 102
TOTAL 622 8,100 473
Number of
SC/TFU
The low default rates also confirm the
reduced opportunity costs for caregivers when
services have been decentralised at scale. These
low default rates (for a programme that
requires more than one visit to the health facility)
also demonstrate broad community
confidence in the programme.
The wide-scale roll out of TFP/CMAM in
Ethiopia allowed for early detection of the deteriorating
nutrition situation during the 2011
Horn of Africa crisis, through identification of
the rapidly increasing admission trends in
SNNPR and Oromia regions. The country was
better prepared to mobilize resources and
further develop the capacity already built, well
before the crisis was declared globally. Most
importantly, the efforts made over the past few
years to decentralise TFP/CMAM in Ethiopia
ensured that many deaths related to SAM
during this current crisis have been averted.
An enabling context for the national TFP scale
up – The Health Extension Programme
HSDP III has been a triumph for primary health
care in Ethiopia, with massive roll-out of the
Health Extension Package (HEP). The HEP
involved the training and deploying of 33,000
female HEWs to strengthen the primary health
system (1 HEW per 2,500 population, 2 HEWs
working together at each village health post).
The HEP is well-established across the country
and some evidence of its success can be seen in
the preliminary results of the EDHS 2010,
showing a sustained decrease in infant and
under-five mortality rates. 12
The HEP was originally designed for
preventative activities only. The health leadership
in Ethiopia has proven to be adaptable
when presented with solid evidence, e.g.
TFP/CMAM programming (that was decentralised
to health post level from 2008) and
early treatment of diarrhoea, malaria and Acute
Respiratory Infections (ARI). The role of the
HEWs has now been formally widened to
include basic treatment services as outlined in
the Integrated Community Case Management
(ICCM), which has been included in the
Integrated Refresher Training (IRT) package
11
A ‘hot-spot’ classification system has been introduced in
Ethiopia where woredas are classified using concepts from
the IPC (Integrated Phase Classification) approach. The
emergency affected woredas are ranked based on the level
of existing hazards including current food security, disease
outbreak, flooding, CMAM admissions, nutrition survey
results and other related indicators. Emergency affected
woredas are classified as priority 1, 2 and 3 woredas, while
non-emergency woredas are classified as priority 4.
12
Since 2005, infant mortality has decreased by 23%, from
77 to 59 deaths per 1,000 live births. Under five mortality
currently being delivered in a phased approach
to HEWs across the country. This heralds the
full integration of TFP/CMAM into the public
health system in Ethiopia where a severely
malnourished child can access treatment in any
health facility in the same way as a child with
malaria.
The TFP reporting system
The rapid expansion of the TFP (from 1,240 sites
at the end of 2008 to 4,325 by the end of 2009, a
240% increase) ensured that the focus needed to
remain on training and capacity building of
HEWs and supervisory staff in managing SAM
treatment at health post level. Partners were
well aware that the reporting system (designed
to monitor the number of sites implementing
the programme and the quality of care, through
tracking recovery, death, default) was poorly
functioning during the first two years, but the
focus was necessarily on the capacity building
of health staff. At the beginning of 2010, as the
numbers of TFP sites continued to expand, it
became a priority to improve the reporting rate.
UNICEF recruited a TFP Reporting Officer
for each region (initially for three months but
extended to 11 months of 2010), operating
under the Emergency Nutrition Coordination
Unit (ENCU). The reporting rates significantly
improved, in part due to the TFP Reporting
Officers who worked to identify the bottlenecks
in the reporting system. In the short term, they
also acted as ‘couriers’ for the data early in
2010. See Figure 3 for the progression of TFP
expansion and reporting rate.
In order to sustain this improved reporting
rate from the regions, the ENCU conducted a
review in 2011 to document the lessons learned
of how the TFP reporting rate improved. Some
of the key lessons included the need for:
• Continuous advocacy on the importance of
timely and accurate TFP reports at regional
and woreda levels, by all nutrition staff in
the regions.
• Training of zonal and woreda Maternal and
Child Health (MCH) experts in use of the
TFP data base and completion of monthly
reports and providing supportive supervi-
has decreased by 28%, from 123 to 88 deaths per 1,000
births. EDHS preliminary results, 2010.
13
A considerable effort was also placed on establishing a
monitoring system for the TFP. Independent field monitoring
officers worked alongside RHB and woreda officials
using standardised checklists and scorecards. A detailed
description of this is provided in Field Exchange issue 40,
pages 38-42. See footnote 10 for full reference.
14
Development partners providing support include the World
Bank, UNICEF, CIDA, Dutch Government and JICA.
Figure 2: Numbers of OTP sites, SAM children admitted, percentage recovery
(cure), death and default rate, and percentage of report completion
(January 2008 – September 2011)
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Jan-08
Mar-08
May-08
Jul-08
Sept-08
Nov-08
Jan-09
Mar-09
May-09
Jul-08
Sept-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sept-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sept-11
Admission
% Death
Number of sites
% Default
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Cure
% Report completion
Figure 3: Progression of TFP expansion and reporting rates
10,000
100%
9,000
90%
8,000
80%
7,000
70%
6,000
60%
5,000
50%
4,000
40%
3,000
30%
2,000
20%
1,000
10%
0
0%
Jan-08
Mar-08
May-08
Jul-08
Sept-08
Nov-08
Jan-09
Mar-09
May-09
Jul-08
Sept-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sept-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sept-11
Number of sites
% Report compleation
17