Special 40th issue: focus on Ethiopia - Field Exchange

February 2011 Issue 40ISSN 1743-5080 (print)<strong>Special</strong> <strong>40th</strong> <strong>issue</strong>: <strong>focus</strong> on Ethiopia

View of the audience of a drama held during a Productive Safety NetProgramme (PSNP) pay day session in Tigray-Hintalo Wajirat, EthiopiaCredit: P Fracassi, Ethiopia, 20101

ContentsField Articles7 Enhanced Outreach Strategy/Targeted Supplementary Feeding forChild Survival in Ethiopia (EOS/TSF)11 Can the Nutrition Information System be ‘trusted’ to build onavailable data sources?13 Oxfam’s Somaliland-Ethiopia Cross Border Drought PreparednessProject17 Emergency Food Security and Livelihoods Project in Amhara andOromia regions22 The RAIN programme25 Emergency Food Security and Livelihoods Project in Amhara andOromia regions31 Beyond the indicators: Assessing project impact on children’s lives35 The experience of multi-storey gardens in Ethiopian refugee camps38 Decentralisation and scale up of outpatient management of SAM inEthiopia (2008-2010)43 History of nutritional status and Concern's response in Dessie Zuriaworeda, Ethiopia48 Rapid response and long-term solutions: Christian Aid and foodsecurity in Ethiopia49 Completing the Jigsaw Puzzle: Joint Assessment Missions (JAM)52 World Vision programme for severe acute malnutrition in SNNPR56 Market-led Livelihood Recovery and Enhancement Programme andintegrating ENAs58 An overview of REST’s implementation of the Productive SafetyNet Programme61 Maintaining GOAL’s capacity to support surveillance in Ethiopia65 Joint Emergency Operation Plan: NGO response to emergency foodneeds in Ethiopia68 Integrating OTP into routine health services – CONCERN’sexperiences75 The Targeted Supplementary Feeding Programme (TSF)78 Value chain approach to increase production of RUTF/CSBAgency Profile21 Profile and overview of the church’s role in emergency response45 EHNRI: profile and role in the National Nutrition Programme55 School of Nursing and Midwifery & Pre-Service Training onNutrition, Hawassa University, Ethiopia74 The Ethiopian Orthodox Church Development and Inter-Church AidCommissionProgramme Profile32 The Emergency Nutrition Coordination Unit of Ethiopia: roles,responsibilities and achievements64 The Evolution of Ethiopian Government’s Early Warning SystemAdministrativeRegions and Zonesof EthiopiaNews79 Standardised training package on SMART methodologyreleased by ACF Canada79 Treatment of severe malnutrition now a core competency inhealth80 Building national capacity in HIV and Nutrition80 Scale up Nutrition (SUN): a new global movement80 Regional CMAM meeting in Ethiopia 201181 Training and workshop to integrate IYCF in CMAM82 Updated HTP resource material for nutrition in emergenciestrainingResearch82 Early stages of a ‘Food by Prescription’ programme for HIVinfected adults84 Emotional Stimulation for acutely and severely malnourishedchildren in SNNPR85 Critical analysis of MICAH programme87 Linking PSNP and NNP: experiences and challenges89 Post-drought restocking: Can its impact be sustainable?91 Food insecurity and mental health among community healthvolunteers in Ethiopia92 AcronymsBeneshangulGumuzAddisAbabaGambellaTigrayAmharaAfarOromiaSNNPRDire DawaHarariSomaliAdapted from graphic produced by UN Emergencies Unit for Ethiopia, March 2000, ©Reliefweb.Adapted from ©United Nations World Food Programme 2010. All rights reserved.Invite to submit material to Field ExchangeMany people underestimate the value of their individual field experiencesand how sharing them can benefit others working in the field. At ENN, weare keen to broaden the scope of individuals and agencies that contributematerial for publication and to continue to reflect current field activities andexperiences in emergency nutrition.Many of the articles you see in Field Exchange begin as a few lines in an emailor an idea shared with us. Sometimes they exist as an internal report thathasn’t been shared outside an agency. The editorial team at Field Exchangecan support you in write-up and help shape your article for publication.To get started, just drop us a line. Ideally, send us (in less than 500 words) yourideas for an article for Field Exchange, and any supporting material, e.g. anagency report. Tell us why you think your field article would be of particularinterest to Field Exchange readers. If you know of others who you thinkshould contribute, pass this on – especially to government staff andlocal NGOs who are underrepresented in our coverage.Send this and your contact details to:Marie McGrath, Sub-editor/Field Exchange,email: marie@ennonline.netMail to: ENN, 32 Leopold Street, Oxford, OX4 1TW, UK.Tel: +44 (0)1865 324996 Fax: +44 (0)1865 324997Visit www.ennonline.net to update your mailing details, to make sureyou get your copy of Field Exchange.If you are not the named recipient of this Field Exchange copy, keep itor pass it on to someone who you think will use it. We’d appreciate ifyou could let us know of the failed delivery by email:office@ennonline.net or by phone/post at the address above.2

ForewordA Simons/FH Ethiopia, 2009Over twenty five years on from the famine of the 1980s which resulted in many thousands of deathsand devastated livelihoods, Ethiopia today is a country that has placed nutrition and food securityconcerns at the heart of its development. The launch of the first Ethiopian National Nutrition Strategyand implementation of the National Nutrition Programme are testament to the national drive tosignificantly improve the population’s nutritional status and to manage the threats to people’s nutrition and foodsecurity posed by recurrent emergencies.This special <strong>issue</strong> of Field Exchange <strong>focus</strong>es 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 thecountry’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 thesearticles reflects the results of many years of lesson learning both within Ethiopia and internationally. Challengesremain 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 <strong>issue</strong> of Field Exchange provides a unique and comprehensive picture of Ethiopia’s nutrition andfood security programming. It is of value, not only as a resource for those of us in Ethiopia who are working in acomplex nutrition and food security environment, but also to others in emergency prone and food insecurecountries 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 partnershipwith many UN, NGO, church and community based organisations, academic institutions and coordinating bodiesas documented here is undoubtedly saving countless lives and, whilst much still needs to be done to tackle foodinsecurity and undernutrition, these endeavours are providing a better tomorrow for millions of Ethiopians.H. E Dr Kesetebirhan Admassu, State Minister of HealthDr Ferew Lemma, Senior Nutrition AdvisorFrom the EditorSimon Rolph, EthiopiaEthiopia is a diverse country where a significantproportion of the population live on orbelow the poverty line, where food insecurityis widespread and rates of acute malnutritionare often at or above the international threshold thatdefines an emergency situation. Levels of chronicmalnutrition are also high. Food and nutrition crisesarising from the effects of drought, floods, marketfluctuations and, at times, political instability arefrequently faced. The challenges today are enormousbut over the past 25 years, the Government ofEthiopia (GoE), with the technical support and budgetaryassistance of many donors, UN agencies,non-governmental organisations and institutions hasdeveloped an impressive array of national nutrition,food security, livelihoods and health related policies,programmes and systems. These are driving nutritionand food security improvements and should ensurethat the massive loss of lives and livelihoods seen atthe height of the famine in the mid-1980s, doesn’tarise again.This <strong>40th</strong> <strong>issue</strong> of Field Exchange (FEX) shines aspotlight on this immense progress in Ethiopia, 25years on from the mid-1980s crisis. It contains sixagency/programming profiles and twenty field articleswritten by national and international actorsabout nutrition and food security related programming.The profiles and articles provide insights intosome of the key nutrition and food security/livelihoodsrelated structures and programmes inEthiopia, covering early warning, response, recoveryand longer-term programming.Government agencies and structuresThe first profile is on the government’s Early WarningSystem (EWS). Written by Kassahun Bedada Beyi, itplots the EWS evolution from an ad-hoc system in the1970s, to a highly centralised, somewhat cumbersomesystem with minimal community involvementin the 1980s to the current system which is highlydecentralised and takes account of local early warningknowledge. Ethiopia’s EWS, as with manyemergency prone country experiences, is not withoutits problems. It will no doubt continue to evolveas it manages complex data and strives to strengthenits communication channels and to ensure timelyand appropriate responses in areas of the countryexposed to acute food and nutrition insecurity.3

EditorialInstitutionally linked to the government’s EWS isthe well-established Emergency NutritionCoordination Unit (ENCU). Isaack Manyama andcolleagues describe the unit’s growing mandatesince its inception in 2000, at which time the qualityand coordination of nutrition surveys in Ethiopia wasseverely constrained and links to the EWS were minimal.The ENCU has seen considerable expansionsince 2005 and today, it is mandated to coordinate,quality assure and disseminate emergency nutritionassessments as well as to coordinate nutrition clusteractivities, strengthen EWS capacity and related operationalresearch in Ethiopia.The ENCU is possibly one of a very few dedicatedunits of its type in sub-Saharan Africa and has aconsiderable wealth of experience and knowledge ofcoordinating many agencies concerned with nutritionassessment and response. Interestingly, since itsinception, over 600 nutrition surveys have beencarried out in Ethiopia, which, when the logistics andrelated costs are taken into account, raises questionsabout the relative merits of cross-sectional surveys incontrast to a nutrition surveillance system.Another key national structure is the EthiopianHealth and Nutrition Research Institute (EHNRI)which has considerable experience of working at the‘coal face’ of nutrition related problems in Ethiopia.With over 450 staff, the EHNRI has (among manyresponsibilities), the mandate to support the governmentwith implementation of the National NutritionProgramme (NNP) providing analysis of the magnitudeand determinants of malnutrition in Ethiopia,capacity mapping for implementing the NNP andundertaking operational research. It’s most recentnational survey work confirms the need to <strong>focus</strong> onthe determinants of undernutrition in the under 2year age group, the target group for the NNP, alongwith women of reproductive age.The existence of the EHNRI gives Ethiopia aunique ‘home grown’ capacity to drive the NNP and,arguably, enables government to have a self-determineddialogue with the myriad of donors andagencies that operate in Ethiopia. This is not tosuggest that Ethiopia has all the nutrition capacity itneeds to implement its programmes. As the articlewritten by Aweke Yilma from Hawassa Universityhighlights, the need for teaching/faculty staff to betrained in nutrition so that they in turn can expandthe existing nurse and midwifery undergraduatetraining curricula to include nutrition is highlightedas a significant need. The need for pre-service trainingon nutrition is likely to be an <strong>issue</strong> in many ofEthiopia’s universities and training institutions and,where efforts are made to upgrade faculty staffknowledge and skills. As described in the article writtenby Kate Sadler and Elizabeth N Bontrager fromTufts University, this offers a clear way forward forbuilding capacity in nutrition among Ethiopia’s keygraduates.Local NGOs and church-based agenciesThe article by the REST Mekelle Team from Ethiopia’slargest home-grown NGO, the Relief Society of Tigray(REST) provides an insight into the evolution of a relativelysmall organisation, which started out in the1970s working with drought affected Tigrayan’s, tothe organisation it is today - 700 staff strong,commanding a multi-million dollar budget and workingin both emergency and long-term programming.This article describes REST’s approach to the implementationof the large-scale Productive Safety NetsProgramme (PSNP) and the impact of the PSNP onlevels of wasting and stunting, on dietary diversityand on household food security - all of which reportedlyshowed improvement over a 3 year period.Whilst nutrition is not a specific technical competenceof REST staff, it is interesting to note theconcerted efforts made to try and capture nutritionimpact in their work.Two profiles reflect the work of two of the largestchurch based organisations in Ethiopia – theEthiopian Orthodox Church Development and Inter-Church Aid Commission by Gebreselassie Atsbahhaand the Ethiopian Evangelical Church Mekane Yesus,by Deed Jaldessa and Debela Kenea. Both highlightthe considerable community reach and resources ofthe Church in mounting emergency responses and inlonger term programming. What is interesting, is howthese Church groups have formed dedicated departmentsfor overseeing their humanitarian anddevelopment programming. They are increasinglyclosely aligned to government policies and prioritiesand are able to help fill gaps in responding to foodsecurity crises, largely through food aid distributions.A gap identified by both groups in these articles istheir lack of nutrition capacity, which they are aimingto address in the future.Ethiopia’s history of large scale emergencies hasmeant that many international agencies have workedin Ethiopia for 20 to 30 years or more. These agencieshave therefore been afforded the opportunity toimplement numerous relief and/or developmentprogrammes and to refine approaches as lessonshave been learnt. Many of the articles in this <strong>issue</strong> ofField Exchange therefore reflect lesson learningamongst agencies over a significant period of time.Emergency assessmentsThere are three articles on emergency assessment.The first, by Zeine Muzeiyn and Ewnetu Yohannesdescribes the work undertaken in Goal’s EarlyWarning Department involving field based assessmentsin so called ‘hot spot’ woredas (districts)identified by the GoE’s ENCU and how this informationfits into decision making and response. BetweenAugust 2005 and June 2010, GOAL Ethiopiaconducted 60 nutrition surveys and intervened inapproximately 95% of woreda’s with an identifiedneed. GOAL’s nutrition survey staff carry out surveyswith government staff at woreda and regional level inorder to build their capacity in planning and conductingsurveys, analysing data and report writing.The second article dealing with assessment is byPatrizia Fracassi. This article provides a personal viewof the strengths and weaknesses of the country’snutrition information system, as well as a vision forthe future.The third article by Alison Oman from UNHCRdescribes the agency’s joint assessment mission(JAM) process with WFP for refugees and how this hasevolved since the mid-1990s. This article draws heavilyon the experiences of implementing JAM’s inEthiopian refugee camps and shows the wide rangeof information gathered in an assessment, e.g. foodsecurity and coping strategies, logistics, non-fooditems, market prices, health, nutrition and the environment.The process of consensus building is key asit not only encourages assessment from a multisectoralviewpoint, but also ensures that therecommendations reflect the capacities and expertiseof the agencies involved.Addressing moderate acute malnutritionSupplementary feeding programmes (SFPs) are thesubject of three articles. The first article by JuttaNeitzel from WFP describes the national targetedsupplementary feeding (TSF) programme implementedby the GoE and WFP which is part of thegovernment’s Extended Outreach Strategy (EOS).Initially, the TSF covered 325 woredas when establishedin 2004, but due to soaring food prices as wellas diminished donor support in early 2008, theprogramme had to be downscaled so that today, itonly covers 168 priority woredas and approximatelyone million children. The TSF has a fairly uniquedesign for the TSF in that food distributions only takeplace every three months and there are no anthropometricmeasurements of children betweendistributions. A TSF evaluation study conducted in2008 found limited impact (on mid-upper armcircumference (MUAC)), largely due to food sharingat home and high inclusion error. The programmealso encountered a number of challenges includinglogistical problems in more inaccessible areas of thecountry, delayed communication of screening resultsand weak linkages with other programmes.The second article by Selamawit Negash fromUNICEF describes the national Enhanced OutreachStrategy (EOS) programme, which links health extensionservices and staff (HEW’s) and services with theTSF. The GoE and implementing partners haveachieved extraordinary coverage with the EOS.During the second round 2009 EOS activity, 11.5million children aged 6-59 months were supplementedwith Vitamin A and 7 million childrenbetween 24-59 months were de-wormed. In addition,3.9 million children and 820,000 pregnant andlactating women (PLW) were screened for acutemalnutrition. Out of these, 318,000 children and150,000 PLW were found to be malnourished andreferred to TSF and out-patient therapeutic feeding(OTP) respectively A number of factors that havecontributed to the high coverage of the EOS aredescribed: the frequent specialised training of HEW’sto strengthen their capacity for social mobilisation,the participation of a large number of public healthinstitutions and participation of NGOs. Successfulcommunity mobilisation and demand for EOS servicesare partly attributed to the financial incentives(per diems) provided for the local HEWs and volunteers.Almost 70% of the total EOS budget isexpended on per diemsThe third article on SFP’s has been written bySarah Style from Concern Worldwide. In 2008, anarea classified as a ‘hot spot’ due to failure of the shortbelg rains, resulted in Concern Ethiopia initiating aTSF programme which has been continuously operationalsince then. However, rates of wasting in theworeda have remained relatively un-changed. TheTSF programme, although well implemented asevidenced by high coverage rates, has poor recoveryrates and high re-admission rates, (2009 recovery rate27%, non-recovery rate 59%, re-admission rate 57%).Investigations suggest that an inadequate generalration, lack of access to the PSNP as well as climaticand topographical constraints, the health environmentand poor caring practices, are key factorslimiting effectiveness. Linkages with the general fooddistribution (GFD) is limited and the impossibility ofregistering the whole population for the PSNP andGFD means that sharing of the supplementary foodamongst non-beneficiary children is commonplace.The author concludes that improvements in rates ofwasting in this context might be beyond the scopeand capacity of nutrition interventions such as SFP’s.Such limitations with traditional approaches to theprevention and treatment of moderate acute malnutritionare the subject of considerable workinternationally.Christian Aid/Caroline Waterman4

EditorialAddressing severe acute malnutritionThere are three articles on the implementation ofprogrammes to treat severe acute malnutrition(SAM), a research piece sharing work on the impact ofemotional stimulation on SAM outcomes, and afurther article on the challenges of securing affordableready to use therapeutic foods (RUTF). SylvieChamois from UNICEF Ethiopia describes the impressivescale up of the GoE OTP to over 6,400 healthposts (at the time of writing) in 691 woredas. The articledescribes how scale up was achieved and keychallenges faced. The enabling factors identified forscale up included advocacy and coordination, donorsupport, development of regional action plans, technicalassistance for training and follow up, provisionof supply and logistics support and enhancedprogramme monitoring and quality assurance.Ensuring good programme monitoring and qualityproved to be particularly challenging with the rapidmultiplication of OTP sites.The vast majority of OTP sites are achievingSPHERE standards and UNICEF considers that therehave been a number of important contributoryfactors to the success of this programme. Particularlynoteworthy are the GoE’s commitment to developpolicies and guidelines on decentralised treatment ofSAM and to integrate services into the wider decentralisedhealth programme, advocacy by agenciessuch as UNICEF, high educational levels, technicalskills and commitment amongst programme staffworking within the health sector and enhanced coordinationbetween the key actors.Another article written by Sisay Sinamo describesthe World Vision Ethiopia (WVE) programme for treatmentof SAM (called Community Therapeutic Care(CTC) at the time), between 2005 and 2007. Lessonslearnt were then used to inform the design of asubsequent programme in 2009 with h had a more‘hands-off’ approach. In the 2009 programme, WVEstaff <strong>focus</strong>ed on capacity building of partners ratherthan direct implementation. This was described as a‘minimum support’ approach. In addition, WVEsupplied a protection ration for children dischargedfrom the OTP, as it could not be assumed that thesechildren would be enrolled on the TSF programme.Emily Mates from Concern Worldwide describesthe history of Concern’s programme that evolvedfrom an innovative emergency intervention, into alonger-term initiative aimed at supporting theMinistry of Health (MoH) to integrate treatment servicesfor SAM within the routine health system – theNational CMAM (N-CMAM) programme. The N-CMAMteam assisted the MoH in selected areas of fourregions (Oromia, Tigray, SNNP and Amhara). Theapproach used a process of incremental capacitybuilding from the outset to ensure that the ownershipof the programme was always firmly in thehands of the MoH. Concern provided a minimalsupport package of theoretical and practical trainingin OTP and in-patient SAM case management, as wellas joint supportive supervision and follow-up,A Simons/FH Ethiopia, 2010community mobilisation mapping and facilitation ofregular dissemination workshops to facilitate sharingof experiences.A number of key factors promoted an enablingenvironment within which the N-CMAM programmecould achieve its objectives, e.g. continuous andsufficient funding from July 2005, and a strong <strong>focus</strong>on training of the N-CMAM team in how to supportpartner staff rather than directly implementprogrammes. Numerous lessons have been learntfrom the experience, e.g. the length of time that theprocess of integration requires and the importance ofusing both formal and informal channels of communicationand networking to muster influence.An article by Play Therapy Action describes earlyfindings from a study to explore impact of introducingemotional stimulation and good parenting skills,in addition to emergency therapeutic food distribution,for SAM children. Investigated in 47 outreachtherapeutic sites and one hospital in the SNNPRegion, preliminary results found faster weight gain,less developmental damage of the acute malnutrition‘event’, and positive ‘knock on’ effects of theinterventions on care of other children, on themother’s mental well-being and her empowerment,and on family life.An article by Yuki Isogai from the World Bank (WB)outlines how the cost of treating the severely andmoderately malnourished in Ethiopia is ‘too high’ as alarge share of the feeding products, i.e. RUTF andCSB, have to be imported from abroad. She poses thequestion-‘why hasn’t the private sector stepped in tofill the local supply gap’? The WB Ethiopian NutritionTeam conducted a thorough review of this questionand identified three major <strong>issue</strong>s, which are interlinkedwith each other: lack of market information,low access to finance; and weak value chain. Theauthor argues that the problems affecting the wholevalue chain need to be tackled simultaneously if asolution is to be found. To do this will requires astrong public private partnership involving privatecompanies, commercial banks, farms, NGOs, UNagencies and donors.Reaching pastoralists and livelihood programmesTwo field articles specifically <strong>focus</strong> on pastoralists,who represent a significant minority in Ethiopia. DrAbay Bekele writes about Oxfam UK’s Somaliland-Ethiopia cross-border programme. At the heart ofthe programme is a concern to build strong, representativepastoral organisations, through whichpastoralists can better understand and claim theirrights and manage the development services theyneed. Principle aims include improved institutionalcapacity for drought preparedness linked toAldei Yimam (male, 20months) has been inand out of SFP andOTP on five occasions(Gelsha kebele)Concern Ethiopiaenhanced community preparedness capacity, andimproved integrated natural resource managementto ensure increased access to and availability ofpasture, fodder and water so that households canpreserve their assets. A key lesson from the earlyphases of the project is that the <strong>focus</strong> of pastoralistinterventions should be to strengthen the communityand risk reduction strategies, rather than simplyfill material gaps through resource provision.Save the Children (UK) has been providingsupport to pastoral communities in Ethiopia foralmost 20 years with current programmes in theSomali and Afar regions. The PILLAR project, which isdescribed in the article by Holly Welcome Radice andcolleagues, seeks to contribute to community leveldrought risk reduction <strong>focus</strong>ing on the three pillars ofpastoralism – people, livestock and natural resources.The article <strong>focus</strong>es on the project’s impact on thelives of children. Children belonging to familiesinvolved in water point construction, small scale irrigationand income generating activitymicro-projects reported that they had more time forleisure and more time with their parents. They alsospent less time on chores and attended school moreregularly.There are five articles written about programmesaimed at supporting the livelihoods of farmers inEthiopia, which include market based analyses forhigh value commodities. The first of these is byAndrew Simmons who writes about the Food for theHungry (FFH) Market-led Livelihood Recovery andEnhancement Programme (MLREP). This programmeaims to improve the food and livelihood securitystatus of smallholders in SNNP region. Theprogramme targets PSNP beneficiaries to help thembuild assets and graduate from the PSNPprogramme. The approach involves building uponand integrating livelihood components identifiedfollowing the results of a value chain analysis (VCA)study. The analysis provides the answer to the question,‘which commodity should be pushed further interms of ease of access to input and output markets?After the completion of the first year of the MLREP,initial benefits were seen at the household level interms of income generation. However, there was noobvious evidence that this increased income wasbeing put to use to improve the nutrition and healthoutcomes of the most vulnerable members of thefamily.An article by Todd Flower from Mercy Corpsdescribes the Revitalising Agricultural/pastoralIncomes and New markets (RAIN) programme - amultimillion dollar OFDA/USAID funded programmebeing implemented for three years (2009 to 2012) inzones in the Oromia Region with four borderingzones of the Somali Region. RAIN seeks to protect,promote, and diversify livelihoods as a means ofincreasing households’ resilience to shocks. The RAINprogramme <strong>focus</strong>es on market systems and providessupport by creating linkages between various marketparticipants. In the first year of the programme,several value chains were identified and evaluatedincluding live animals, hides and skins, milk, fruitsand vegetables, and peanuts. The RAIN programmeworks to improve access to agricultural inputsupplies to assist producers in meeting availablemarket demand.Another article by Shekar Arnand from Oxfamdescribes the emergency and food security livelihoods(EFSL) project which is part of the GlobalAgricultural Scale up (GASU) initiative started byOxfam four years ago. The GSAU programme inEthiopia has worked with farmers on many crops. Ithas now been decided to use a scalable model forthree commodities, honey, coffee and sesame. Thesehave also been identified by the GoE as high valueexport crops.The EFSL component arose out of Oxfam’s awarenessthat their target farmers are often exposed to5

EditorialHayat Seid, female, 29 months, has beenin and out of OTP and SFP five timesemergencies caused by drought, flood, marketturbulence and climate change. The idea is thereforeto embed a humanitarian response programmewithin the programme to prevent farmers fromfalling into ‘the poverty trap’. The EFSL project aims’to protect those farmers that are vulnerable toimpact of drought and other shocks’. Key lessonslearnt so far from the EFSL include the understandingthat asset poor households are less able to applyresource management practices and that the onsetof natural disasters presents new business opportunitiesfor microfinance institutions (MFI) especially inrural areas.An article by Antoinette Powell describesChristian Aids (CA’s) response to a series of emergenciesand subsequent work with implementingpartners to rebuild lives and livelihoods andstrengthen disaster preparedness. Christian Aidworks through a range of implementing partnerswith some of the most marginalised communities inEthiopia, including pastoralist communities in thecountry’s south and farmers in SNNP region. Concernabout the effects of climate change has recentlyprompted Christian Aid to fund one of its partners,Citizens Solidarity for the Campaign Against Faminein Ethiopia (CS-CAFÉ),to carry out a study on climatechange.The article written by Mulugeta Wtsadik fromUNHCR describes a multi-story gardens (MSG)programme in refugee camps for Eritreans andSomalis. Mulugeta outlines how a pilot MSGprogramme was established in three camps toaddress problems of anaemia and to compensate fora WFP ration considered inadequate in terms ofmicronutrients like iron and zinc. The pilot projectbegan in April 2008 and has had a significant impacton the diversity of foods available to beneficiaryhouseholds – particularly in terms of fruits andvegetables. Water shortages have been the mainproblem with the programme, although variousmethods have been employed to conserve scarcewater in the more arid camps.Large-scale safety net programmingAfter many years of implementing food reliefprogrammes through the old EmploymentGeneration Scheme (EGS), implementing partnersreached a view that there had to be a better way ofmeeting transient emergency needs. The EGS activitieswere poorly managed and ultimatelyunproductive so that recipients rarely graduated toany level of food security and remained dependenton annual food relief packages. The advent of thePSNP in 2005 was a reflection of this learning. Thevision for the PSNP, which uses food and/or cash as aresource transfer, was to use resources more imaginativelyto help build up productive assets and soenable beneficiaries to graduate out of structuralpoverty and chronic food insecurity. The multiannualand multi-donor commitment to thisprogramme reflects this vision.Concern EthiopiaAn article on the PSNP by Matt Hobson and SarahColl-Black from the World Bank describes how thePSNP has developed over the last 5 years, its achievementsand major challenges.By 2009, the PSNP supported 7.6 million people in290 chronically food insecure woredas in eight of thecountry’s 10 regions. This demonstrates that largescale cash and/or food transfers are operationally andlogistically possible in resource-poor, low-incomerural settings. However, between 2007 and 2009,only around 280,000 individuals graduated from thePSNP, which although not insignificant (especiallygiven the adverse events of 2008), falls well short ofthe national goal. Deficiencies in implementation,due to limited human and physical capacity, underminethe potential impact of the PSNP, whileensuring quality implementation in all programmeareas remains a significant challenge for the future.An article by Alix Carter from CARE Ethiopiadescribes the Joint Emergency Operation Plan (JEOP)which has existed in different iterations since 1984.JEOP targets food insecure households who are notcovered though the PSNP. It thus provides a complementaryintervention to prevent acute foodshortages from depleting overall communityprogress gained through PSNP.The JEOP is activatedin close collaboration with the GoE when chronicfood insecurity is exacerbated by emergency shocks,requiring additional coverage of emergency foodrelief. The partnership was re-activated in 2000 underits current form with five member internationalNGOs. More recently, REST and SC-UK have joined. Asa result of recurrent shocks, JEOP has been operationalin seven of the last ten years, providing onethird of all emergency food relief in Ethiopia to anaverage of 1.8 million beneficiaries at each round.A major challenge for the JEOP is delays andchanges in allocation of food aid figures to partneragencies’ caused, in large measure, by communicationand capacity gaps between or at different levelsof Government. Another difficulty is the arrival ofhuge shipments of commodities to ports and warehouses,creating congestion and difficulty forpartners to secure enough space for their commoditystorage. In addition, secondary transport to distributionsites has proven difficult for some JEOP partnersand different strategies have been used to overcomethese problems. In the Extended JEOP, partner agenciesare considering options for a pooled transportsystem that could circumvent these logistical <strong>issue</strong>sin the future.Concluding remarksThe articles in this special <strong>issue</strong> of Field Exchangeshow clearly how a range of actors are playing a vitalrole in testing and developing new and more effectiveprogramming approaches, disseminatingfindings and then advocating for adoption and scaleup of evidence based programming to address acutemalnutrition, food insecurity and support moresustainable livelihoods in Ethiopia. There is a strongcommitment by GoE to invest in scaled up programming.The two best examples are the scale up of theOTP and the PSNP.A Simons/FH Ethiopia, 2009Women work in tree and fodder nurseriesas part of the cash for work schemeThe GoE has also proven itself over many years tobe ‘fiercely independent’ of international agencies. Itsemergency and development philosophy withrespect to external actors is very much along thelines of ‘work with us, help us to develop the capacityto implement programming and then leave us aloneto do it’. Most international agencies working inEthiopia have embraced this and invest considerableresources in building national capacity. This can onlybode well for Ethiopia and its capacity to prepare,respond and recover from emergencies in the future.There are, however, as highlighted in some the articlesin this <strong>issue</strong>, risks associated with rapid scale upwhere the demands for implementing ‘best-practice’and high quality programmes can outstrip capacityfor delivery. This is a challenge facing many countries,not only Ethiopia, and will be the subject of international<strong>focus</strong> as the international Scaling up Nutrition(SUN) initiative gets underway.The extent to which programmes are joined up,coherent and integrated to maximise nutritionalobjectives is a challenge. For example, SFPs will notbe effective if general rations or basic food security isinadequate and integrating the TSF with OTP, or PSNPwith TSF/OTP households, need to be fully grasped.There are also a number of specific challenges forGoE and its implementing partners. For example,scale up of local production of RUTF for the treatmentof SAM and the need to bring prices down so that thecurrent roll out of OTP and TFP can be sustained.Another challenge relates to the large case load ofMAM in Ethiopia. It is widely acknowledged bothwithin and outside of Ethiopia that the current TSF isnot a panacea and that much work needs to be doneto develop an evidenced MAM strategy, underpinnedby a clear implementation plan to reach the largenumber of MAM population affected.Despite these challenges, Ethiopia appears, withminimal publicity and fuss, to have manoeuvred itselfaway from being the country which, in many previousyears grabbed the international humanitarianspotlight as a result of drought and famine. Sadly,other countries have taken its place. The good newsis that famine early warning and response systems inEthiopia have been considerably strengthenedthrough many years of programme implementationand learning.This <strong>issue</strong> of Field Exchange has tried to capture thearray of national and international policies,programmes and systems that have been put in placeto drive nutrition and food security developments inEthiopia. Many of these developments have beenadapted from international policies and evidencebasedgood practice in key areas of nutrition, as well asfrom lessons learnt from within Ethiopia on what doesand doesn’t work within the country’s specific political,socio-economic and cultural context. There is much tolearn from this experience and we hope that thisspecial <strong>issue</strong> of Field Exchange plays some small part indisseminating the many lessons learned by the GoEand the myriad of national and international actorsinvolved in humanitarian work in Ethiopia.Jeremy Shoham, EditorCarmel Dolan, Guest editor

Enhanced OutreachStrategy/ TargetedSupplementaryFeeding for ChildSurvival in Ethiopia(EOS/ TSF)A child receiving vitamin Asupplements during EOS inTigray region, Adwa DistrictIndrias Getachew, UNICEF Ethiopia, 2009By Selamawit Negash, Nutrition<strong>Special</strong>ist, UNICEF EthiopiaSelamawit Negash (MPH) has beenworking as a Nutrition <strong>Special</strong>ist withUNICEF Ethiopia since April 2007.From December 2005 to March 2007she worked with WHO Ethiopia as aSupplemental ImmunisationActivities (SIA) officer. She was aNutrition Team Leader in Federal Ministry of Health,Ethiopia from January 2002 to November 2005.The author would like to acknowledge Sylvie Chamoisand Orla O’Neill for their valuable inputs for this article.The author would also like to acknowledge all otherswho have kindly commented on the draft article.Disclaimer: the findings, interpretations, and conclusions inthis article are those of the author. They do not necessarilyrepresent the views of UNICEF, its Executive Directors,or the countries that they represent and should not beattributed to them.Field ArticleEthiopia has one of the highest underfive mortality rates of all developingcountries, due largely to thecombined effect of a high incidenceof infectious diseases and inadequate infantand young child nutrition. Results from the2005 Demographic & Health Survey (DHS)reported the chronic malnutrition rate amongchildren under 5 years (stunting) to be 46%and acute malnutrition (wasting) 11% 1 . About27% of women are malnourished (Body MassIndex (BMI) < 18.5 2 ). Vitamin A deficiency(VAD) is a severe public health problemaffecting 30-95% of children 6-59 months ofage in all 11 regions of the country 3 . In addition,food insecurity and poverty remains athreat, as Ethiopia has been exposed torepeated droughts, resulting in chronic foodinsecurity for the last four decades. Periodicepisodes of acute food shortage still occur inmany parts of the country and continue tojeopardise the nutritional status of the mostvulnerable, especially children. The situationhas been described as a constant state ofchronic emergency and therefore effectivehealth and nutrition interventions need toaddress the long-term and periodic emergencyneeds underlying this complexsituation.Rationale and programme designThe Enhanced Outreach Strategy/TargetedSupplementary Feeding (EOS/TSF) is thefirst national programme in Ethiopia to linkcommunity-based preventive health serviceswith a ration of supplementary food forwomen and children who are identified asmalnourished 4 . It is one of the leadingapproaches to address child survival andmalnutrition and yet its establishment in 2004was triggered as a response to the acutefamine that affected many parts of the countryin 2003. It was also introduced as atransition strategy towards the establishmentof the Ministry of Health (MOH)’s HealthExtension Programme (HEP), which aims toextend primary health care services to meetthe population’s long term health and nutritionneeds at community level.In 2001/2002, progress had been made toincrease the Vitamin A supplementation(VAS) coverage using the opportunity ofpolio and measles National ImmunisationDays. However, coverage was not more than64% and it included only one dose. Theprimary objective of EOS was to increasetwice yearly VAS coverage that wasextremely low. The opportunity was alsotaken to include deworming to promotenormal growth and prevent malnutritionamong children under the age of five. Before2003, moderate acute malnutrition (MAM)was addressed only through blanket supplementaryfeeding distributed together withfood aid in drought affected districts. Theintroduction of the EOS was seen as anopportunity to target MAM for TSF in a muchwider coverage than seen before. However,due to capacity/resources <strong>issue</strong>s, screeningfor acute malnutrition and TSF were startedin 325 drought prone districts only 5 .Partnership was developed betweenUNICEF, WFP and the Government ofEthiopia (GoE) under the United NationsDevelopment Assistance Framework(UNDAF, 2007-2011). A memorandum ofunderstanding, signed by Disaster RiskManagement and Food Security Sector(DRMFSS), MOH, UNICEF and WFP,outlined the roles and responsibilities of eachparty. Whilst UNICEF and WFP providefinancial resources and technical support,coordination, implementation and managementof the EOS/TSF were and remain underthe responsibility of the MOH and DRMFSSboth at federal and regional levels. See Figure1 for an illustration of how the EOS/TSF isorganised.Figure 1: Illustration of how EOS/TSF is organisedMOH/ UNICEFEOS (every 6 months) at kebele level:• Vitamin A supp. (6-59 months old)• De-worming (2-5 years old)• Screening for acute malnutrition (children 6-59months, pregnant and lactating women)Children and womenwith severe acutemalnutritionAt health facility level (hospital, health centreand health post):• Therapeutic Feeding Programme (In and Outpatienttreatment of severe malnutrition)Initially, the EOS/TSF target was to covermore than 90% of the 6.8 million childrenaged 6-59 months old and 1.5 million pregnantand lactating women (PLW) living in 325drought prone districts. However, thereremained an additional 6.4 million children in299 ‘non-EOS districts’. These were notcovered by EOS/TSF interventions becausethe districts were not considered as the mostvulnerable and ‘drought prone’. In 2005, theMOH and partners decided to extend itscover to reach these additional 6.4 millionchildren in the 299 ‘non-EOS’ districts with apackage of biannual vitamin A supplementationand deworming only. Nutritionalscreening and TSF were not included due toresource limitations.ObjectivesThe overall objective of the EOS is to reducemortality and morbidity in children underfive by providing low cost, high impact childsurvival interventions at community level.The specific objectives are:1Ethiopia Demographic and Health Survey, 20052ibid3National Vitamin A Deficiency Survey Report, EthiopianHealth and Nutrition Research Institute, 20064Mission Report, Enhanced Outreach Strategy/TargetedSupplementary Food for Child Survival Interventions,Ethiopia, Andrew Hall and Tanya Khara, November-December 20065In 2008, the number of TSF districts reduced from 325to 167 due to resource constraints.Children,pregnant andlactatingwomenscreened withmalnutritionScreening dataDRMFSS/ WFPTSF (every 3 months) at kebelelevel:• Supplementary FoodDistribution (treatment ofmoderate malnutrition andprevention of severemalnutrition)DRMFSS/ UNICEFENCU at regional and federallevel:• compilation of EOS data,data quality check, nutritionsituation analysis,coordination of emergencynutrition responseSource: UNICEF Ethiopia.ENCU: Emergency Nutrition Coordination Unit; EOS/TSF: Enhanced Outreach Strategy Targeted Supplementary Feeding; MOH:Ministry of Health; DRMFSS: Disaster Risk Managment and Food Security Sector7

Field Article• In all districts of Ethiopia except AddisAbaba and every 6 months:- > 90% of children 6-59 months old aresupplemented with high dose vitamin A.- > 90% of children 2-5 years old aredewormed.• In all districts of Ethiopia except AddisAbaba and once a year:- > 90% of children 9-23 months old arevaccinated against measles if they havemissed routine vaccination.• In TSF selected districts:- > 90% of children 6-59 months old andPLW are screened for malnutrition andreferred to TSF when acutelymalnourished.EOS is also used as an opportunity to integrateother interventions, such as measles catch upand follow-up campaigns, tetanus toxoid andpolio supplemental immunisation activities,long-lasting insecticide treated nets (ITN)distribution and iodine supplementation. Someof the districts are also using the opportunity toconduct routine Expanded Programme ofImmunisation (EPI) outreaches.EOS activities are part of the Ethiopiangovernment Health Sector Development Planand one of the sub components in the NationalNutrition Programme (NNP) 6 . UNICEF issupporting EOS as per its Country ProgrammeAction Plan (2007-2011) under the output“eighty percent of children and mothers indrought-prone districts receiving high-impact,community health and nutrition services everysix months through the EOS”. It is also part ofthe UNDAF Humanitarian Response andRecovery and Food Security sub-component for“improved health and nutrition status of 90% ofchildren and PLW in chronically food-insecureareas through outreach activities”.Modalities of EOS service deliveryEvery six months and with UNICEF support,Regional Health Bureaus organise the EOS. Eachdistrict that is not a TSF district has one EOSteam per sub-district, composed of one healthworker and one HEW. These staff mobilise thecommunity to come to the nearest health poston a specific day, the EOS day. On EOS day, theEOS team deworms and supplements withvitamin A all children under five years. In manyFigure 2: Children (6-59m) reached by EOSservices per year (2004-2009)12,000,00010,000,0008,000,0006,000,0004,000,0002,000,00001,389,4382,576,6204,946,8118,269,75310,154,37510,760,19810,937,89411,156,69811,179,01711,179,0172004 - 1st Round2004 - 2nd Round2005 - 1st Round2005 - 2nd Round2006 - 1st Round2006 - 2nd Round2007 - 1st Round2007 - 2nd Round2008 - 1st Round2008 - 2nd Round2009 - 1st Round2009 - 2nd RoundAchievements: # of children coveredNational target children in Child Survival11,812,67311,490,616instances, the Regional Health Bureaus take theopportunity to deliver other essential services,such as measles vaccination, tetanus vaccination,mosquito net distribution, HIV/AIDSprevention, iodine capsules distribution, etc.In TSF districts, the EOS team is expandedwith an additional two health staff, generallyone HEW and one support staff, to undertakethe screening of children and PLW. Screenersmeasure the mid-upper arm circumference(MUAC) and check for bilateral oedema.Children and women eligible for TSF are registeredin a book and given a TSF ration card. Inaddition to receiving the TSF ration, childrenidentified with severe acute malnutrition 7 arealso referred to the nearest Therapeutic FeedingProgramme (TFP).Comprehensive social mobilisation isconducted to ensure all eligible children andmothers come to the health post. One teamsupervisor is assigned to support 3-6 teams.The team supervisors provide all-roundsupport, including management and logisticsupport, technical support and identify problemsand constraints and plan for betterperformance of next the day.Two months before the implementation ofEOS, training of trainers is given to district/zonal health managers (coordinators andsupervisors) by regional and central facilitators.At the same time, district level micro-plans areFigure 3: Survey VAS Coverage andAdministrative VAS Coverage by region, PostCampaign Coverage Evaluation survey, June-September 2008100%80%60%40%20%0%85.1%56.5%Somali86.1%92.9%Dire Dawa89.1%90.4%SNNPR92.1%93.7%Amhara93.2%86.3%Afar94%92.3%Harar94%98.9%BenshangulGumuz96%88%Oromia98.9%92.7%TigraySurvey Vitamin A supplementation (VAS) coverageprepared. Training of trainers and micro-plansare completed once every year. Two standardformats are provided for easy calculation of theneeds, both in terms of operational costs andsupplies. One to two weeks before the implementation,service providers (supervisors,health workers, HEWs and support staff) aretrained for two days by the district trainers.Training of service providers is given on everyround, i.e. every six months. The training isbased on the national guideline 8 .ResultsAfter the introduction of EOS, the service coveragehas consistently increased, providing keyproven child survival interventions (low cost,high impact interventions) to children and PLWevery 6 months. Since the start of theprogramme, the number of children reached byEOS services has progressively increased (seeFigure 2 and Table 1). The EOS programme6The NNP is a long-term programme that will be implemented in two phases for the next 10 years, each phaselasting five years. The current NNP phase I spanning fromJuly 2008 to June 2013. The NNP targets the most vulnerablei.e. under 5 year children, particularly those under 2years, PLW, and adolescents. The objective of the NNP is tohalve malnutrition from 1990 levels (underweight in childrenunder 5y) by 2015 that constitutes the non-income targetof the MDG 1. It also explicitly aims to reduce child stunting,wasting, and low birth weight rates by half by 2010, towhich the NNP will contribute as an integral part of the HEP.7Eligibility for TFP: children with MUAC < 11 cm and/orbilateral oedema.8Guidelines, Enhanced Outreach Strategy for Child SurvivalInterventions, Ethiopia, Federal Ministry of Health, March2006Table 1: EOS results per year and per round (2004-2009)2004 2005 2006 2007 2008 2009R1 R2 R1 R2 R1 R2 R1 R2 R1 R2 R1 R2Vitamin 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 11,397,948No. 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 10,707,244VAS 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 7,352,881No 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 7,092,712Deworming 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 4,309,853No 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 3,941,853Screening 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 acutemalnutrition and referred to TSFSource: Federal Ministry of Health, EOS data base, 201085,522(6.6%)211,445(8%)302,030(6.5%)247,870(5%)425,199(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 1,053,370 895,645 961,173No of PLW screened 158,928 343,602 584,363 643,751 834,773 1,416,739 1,072,234 1,125,284 707,730 830,953 788,392 829,813Screening 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 acutemalnutrition and referred to TSF33,010(20.8%)79,033(23%)150,472(25.7%)117,508(18.3%)165,386(19.8%)528,766(8.6%)216,461(20.6%)479,030(8%)236,450(22.1%)351,232(7.2%)228,715(20.3%)416,269(12%)175,358(24%)438,862(10.2%)178,445(24.8%)498,833(12.8%)171,433(21.7%)318,353(8.1%)150,046(18.1%)8

Field ArticleTable 2: EOS and measles, vitamin A and dewormingcoverage by region, 2006Region Measles Vitamin A DewormingSurveycoverageAdmin.coverageSurveycoverageAdmin.coverageSurveycoverageAdmin.coverageOromia 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%Tigray 95.2% 82.8% 98.7% 83.9% 86.6% 86%B.Gumuz 90.2% 101% 89.6% 71% 67.1% 71%Somali 85% 91% 84.4% 89% 83% 88%Indrias Getachew, UNICEF Ethiopia, 2009Health extension worker assessing the nutritionalstatus of a child using MUAC measurement duringEOS in Tigray region, Adwa Districreached its peak activity level in 2006/2007.Using the EOS approach the programme is nowcovering the entire country, except AddisAbaba city administration, reaching more than11 million children every six months.Based on routine administrative reports, theEOS coverage has exceeded the planned targetfor each round for vitamin A supplementation,deworming and nutritional screening. Duringthe second round of the 2009 EOS, 11.5 millionchildren aged 6-59 months were supplementedwith vitamin A and 7 million children aged 24-59 months were dewormed. In addition, 3.9million children and 820,000 PLW werescreened for acute malnutrition. From these,318,000 children and 150,000 PLW were found tobe malnourished and referred to the TSF/TFP.Monitoring and evaluationBetween March and May 2006, a measles followup campaign was conducted in Oromia,Amhara, Tigray, Somali, SNNP and BenishangulGumuz regions 9 . The campaign was integratedwith the EOS interventions. Following thecampaign, a coverage evaluation survey wasconducted between June and Sept 2006 to validatethe administrative coverage report 10 . TheEPI cluster methodology was used to design andconduct the survey. A total of 8,116 householdswere assessed. The survey identified that integratedchild survival interventions coverage washigh and very close to administrative reports,with little variation between each study area (seeTable 2).Another coverage survey was conducted in2008 to validate EOS coverage data collectedthrough routine administrative systems. Thisinvolve gathering household level data onselected indicators such as VAS, dewormingand nutritional screening 11 . It was a crosssectional survey conducted in 42 districts inOromia, Amhara, SNNPR, Tigray, Somali, Afarand Benishangul Gumuz regions. Six districtsfrom each region were randomly selected andin each district, nine sub-districts were assessedusing a 30 by 30 cluster methodology. A total of900 households with children under five yearswere assessed.The results showed that the overall coverageof the EOS campaign was very high and above80%. It also confirmed that the post-campaigncoverage estimates for VAS, deworming, andnutritional screening were not necessarily thesame as those found in routine administrativeEOS reports (Figure 3).In addition to achieving high coverage, EOShas been found to be a cost effective strategy forchild survival 12 . The ‘EOS costing study’conducted in 2006 has estimated that the costper life saved is equivalent to only $58 forVitamin A, and $228 for integrated interventionsincluding measles. In conclusion, thestudy found that EOS interventions areextremely cost-effective and a good investmentfor Ethiopia 13 .Despite the favourable unit costs of deliveringlife saving interventions such as VAS anddeworming, there is no direct evidence that theEOS/TSF is having a positive impact on mortalityreduction and improving the nutritionalstatus of children enrolled in the programme. Ameta-analysis of the effectiveness of VAS tocontrol young child morbidity and mortality indeveloping countries showed that improvingthe vitamin A status reduces mortality rates bysome 23% 14 . However, in Ethiopia it is not possibleto quantify the impact of EOS because thereis no baseline data or case-control study forcomparison. A formula developed by Pelletieret al 15 was used to estimate the life savingimpact of EOS. Based on this method, it is estimatedthat 171,000 under five children’s deathare prevented through the EOS/TSF every year.Factors contributing to high coverage inthe EOS programmeFactors contributing to high coverage in theEOS programme include:• The specialised training conducted beforeevery round of EOS for health serviceproviders to strengthen capacity. This helpsto overcome the high staff turnover in thehealth system.• Social mobilisation has been the key effort toget people to attend the EOS centres, and itwas central to achieving 90% coverage 16 .High community participation, created bypublic announcement and mobilisationduring the screening time, promoted EOSservice uptake, which has a knock-on effect inpromoting general health service uptake atsub-district level.• It creates community demand wherebymothers/caregivers appreciate dewormingbecause of a visible immediate effect.9Bale, Borena, Guji, East Showa and Arsi zones of Oromiaregion, North Wollo, SouthWollo and Waghimra zones ofAmhara region, all districts of Tigray region, all districts ofB. Gumuz region, all districts of Somali region and Gurage,Wolayita, Dauro, Siltie, Hadiya, Kembata Tembaro zonesand Konta, Alaba districts, and Awassa, SNNPR.10Coverage Survey Report on Integrated Child SurvivalInterventions In Oromia, Amhara, SNNPR, Tigray, Somaliand Benishangul Gumuz National Regional States ofEthiopia, UNICEF Addis Ababa, December 200611Post campaign Evaluation Survey of round 1 2008Enhanced Outreach Strategy in Ethiopia, Addis .ContinentalInstitute of Public Health, October 200812Feedler, J. and Chuko, T. 2006. Enhanced OutreachStrategy Costing Study. Micronutrient Initiative, A2Z, WorldBank, UNICEF13The Macroeconomic Commission on Health classifies allhealth interventions that have a cost per life saved that isthe equivalent of less than per capita GDP as “highly costeffective”.14Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabeG, Ross AC, and Harvey B - Effectiveness of Vitamin ASupplementation in the Control of Young Child Morbidityand Mortality in Developing Countries; ACC/SCN State-ofthe-ArtSeries, Nutrition Policy Discussion Paper No.13, 1993• The EOS programme benefits from theparticipation of a large number of publichealth institutions at all administrativelevels and of non-governmental organisations(NGOs).• Its cost effectiveness is proven and anumber of donors have been supporting theprogramme since the start.• Added EOS services like measlesvaccination, ITN distribution and iodinesupplementation have contributed to loweringthe average cost per person served.• Successful community mobilisation anddemand for the service is attributable to thefinancial incentives (outreach allowances)provided for the local HEWs and volunteers.About 68% of the total costs of EOS are foroutreach allowances 17 .ChallengesDuring the course of its implementation, EOS hasalso encountered some significant challenges:Poor nutritional screening data quality hasbeen an <strong>issue</strong>. The Outcome Evaluation Studyof the TSF programme in Ethiopia 18 conductedby WFP in 2008 highlighted a very high inclusionerror of the TSF beneficiaries screenedduring the EOS (46% mistakenly admitted intothe TSF). Efforts made since to improve thequality of nutrition screening measurementsinclude providing training before every roundof EOS, simplification of the screening methodologyto reduce risks of error (from a two-stagescreening comprising of MUAC and weightfor-heightto MUAC only), wide-spreaddissemination of posters in local languages, anduse of a new MUAC tape with a colour code toboth help HEWs understand screening proceduresand to increase the beneficiary’sawareness of their entitlement. While noting thecontinuous improvement of screening dataquality 19 , the Emergency Nutrition CoordinationUnit 20 still encounters problems with the dataretrieved from systematic checks.15Pelletier, DL, E.A. Fongillo, Jr., D.G. Schroeder, and J.P.Habitch. 1994. A methodology for estimating the contributionof malnutrition to child mortality in developing countries.Journal of Nutrition 124 (10 SUPPL.): 2106s-2122s16Mission Report, Enhanced Outreach Strategy/TargetedSupplementary Food for Child Survival Interventions,Ethiopia, Andrew Hall and Tanya Khara, November-December 200617Feedler, J. and Chuko, T. 2006. Costing Study. EnhancedOutreach Strategy, Micronutrient Initiative, A2Z, WorldBank, UNICEF18Outcome evaluation study of the Targeted SupplementaryFood (TSF) programme in Ethiopia; World Food Programme;Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MDMSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH.19The ENCU checks show regular decreases in the proportionof districts with unreliable screening data. Those with unreliabledata amounted to 48% in 2008 Round 1, 44% in 2008Round 2, and 47% in 2009 Round 1, 27 % in 2009 Round 2.20The Emergency Nutrition Coordination Unit (ENCU), whichis the technical arm of Disaster Management and FoodSecurity Sector (DMFSS), with the support of UNICEF, wasestablished in 2000 to coordinate emergency nutritionassessments and interventions. ENCU is doing qualitycheck for EOS nutritional screening data.9

Field ArticleDue to poor quality, the EOS screening datacannot be used for trend analysis in the contextof nutrition surveillance. While reporting ispart of every six monthly EOS refresher training,late data compilation and reporting stilloccurs.MOH leadership to manage the logisticsneed and programme information/datamanagement has been limited. Supply anddistribution of resources at national scale is achallenge for all programmes without a MOHNational Logistics Master Plan that is still notfully functional.Except for staff salary and overhead cost,there is no budget allocation from governmentfor EOS programme. The programme issupported by international donors through inkind assistance (vitamin A capsules from theCanadian International Development Agency(CIDA) and the Micronutrient Initiative (MI)),and financial contributions for supplies andoperational costs (CIDA, MI, SpanishGovernment, Australian Aid, UNOCHA,USAID, different national committees forUNICEF, etc.). Donor’s funding commitment isusually for one or two rounds so that it is difficultto plan for the longer-term.Future Direction: EOS transition into the HEPThe Health Extension Programme (HEP) is thelong term and sustainable strategy for deliveringthe child survival and maternal packagesunder EOS. While the EOS will continue to beimplemented, its pilot transition to the HEPwas started in 39 selected districts fromAmhara, Oromia, Tigray and SNNPR.Two modalities are envisaged to provideEOS services in the HEP package:• The first and main mode is the CommunityHealth Days (CHDs) that will be organisedby the HEWs on a quarterly basis to allowmore frequent identification and early treatmentof the malnourished cases. The vitaminA and deworming will continue to be deliveredevery six months. The CHDs areunderway since the end of 2008.• The second mode would be part of theroutine activity at the health post andduring home visits by the HEWs, in orderto maximise the current ‘missed’opportunity and enhance coverage (this hasnot yet started).The main rationales for the transition are:• Creating a mechanism for the sustainabledelivery of child survival service packagesas part of the HEP by maintaining thecurrent EOS coverage of 90%.• Giving responsibility to the local distric andsub-district to plan, implement and monitorprogrammes.• To help the HEWs to organise and executethe services as part of their regular workand ultimately to increase local ownershipand service delivery capacity.As of now, 170 districts have started implementingCHDs. In 2009, more than 1.3 millionchildren 6-59 months have received VAS andabout 800,000 children 24-59 months weredewormed through the CHD modality. In addition,1.3 million children 6-59 months werescreened for acute malnutrition. Post-CHDcoverage surveys were conducted in October2009 in three regions 21 . The preliminary report isshowing coverage is ranging from 58% to 73%for VAS 22 .LessonsEOS in conjunction with TSF seems to be ahighly relevant action for the local environment.This is partly due to the prevailing criticalnutrition and health situation in large areas ofthe country, where on average 47% of childrensuffer from chronic malnutrition. For sustainability,the GOE has prepared a plan for EOStransition in HEP with phase by phase exitstrategy for EOS. The plan is to be implementedwithin the MOH’s Health Sector DevelopmentPlan IV (period 2010-2014). It is important tomake sure that the transition is smooth and thatthe HEP will be able to maintain the currentgain in EOS.Availability of financial incentives associatedwith EOS has played an important role in thesuccess of EOS. However, there are alsoconcerns regarding the sustainability of its highcoverage when the financial incentives are withdrawn.For example, it will be difficult tomaintain the high level of engagement ofCommunity Health Workers (that are volunteers)if financial incentives are removed. Thiswill have a negative impact on programmecoverage. The reliance on pure volunteerism tosupport community mobilisation remains achallenge to any community-based programme.The process of screening children usingMUAC instead of weight-for-height has helpedto identify more severely malnourished childrenwho are at risk of death. In addition, itmakes the task much simpler for the HEWs andreduces risks of error attached to conductingtwo stage screening (i.e. using both MUAC andweight for height).The EOS screening should ensure that onlyacutely malnourished children get access tosupplementary feeding. However, the currentsafeguard mechanisms in EOS/TSF are notenough to adequately prevent distortion 23 . Inaddition, there is no formal appeal process forindividuals if they feel that they have beenunfairly excluded 24 . EOS/TSF partners arecurrently working on improving supervisionand monitoring during EOS/CHD screeningand conducting intensive community awarenessand social mobilisation before, during andafter the EOS/CHD screening to mitigate theproblem in the short-term. Dialogue is ongoingwith Ministry officials and donors to discussthe actions necessary to improve the overallmanagement of MAM in the country. A redesignof nutritional screening andmanagement of MAM is required, both torespond to the immediate need to overcome thehigh inclusion error 25 and to strengthen the211,391 children sampled in 1,103 households in Tigray,Oromia and SNNPR less than 2 weeks after the CHD22The proportion of VA supplementation was 73.3% in SNNP51.9% in Tigray 62.9% in Oromia Regions. The proportionof children de-wormed was 65.8% in SNNP, 35.4% Tigrayand 52.4% in Oromia regions. The proportion of screenedchildren was higher 89.4% in Tigray, 73.5% in Oromia and66.6% in SNNP Regions23Aid, Accountabilities and Distortion, An exploratory studyinto possible distortion in donor-supported developmentprogrammes in Ethiopia, Productive Safety Nets Programme;Protection of Basic Services Grant; Humanitarian ReliefProgramme; Enhanced Outreach Strategy – TargetedSupplementary Feeding Programme, Report prepared byDFID on behalf of, and for the consideration of, theDevelopment Assistance Group, Ethiopia, 23rd March 201024ibid25Outcome evaluation study of the Targeted SupplementaryFood (TSF) programme in Ethiopia; World Food Programme;Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MDMSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH. TheENCU checks show regular decreases in the proportion ofdistricts with unreliable screening data: it was 48 per cent in2008 Round 1; 44 per cent in 2008 Round 2; 47 per cent inprogramme through establishing appropriatesafeguard mechanisms. Re-design should alsolook to secure wider coverage and use of alternativeproducts for management of MAM.Ethiopia has achieved encouraging progressin recent years in detecting and managing acutemalnutrition through EOS and the expansion ofthe national TFP. At the same time, there is agrowing understanding that it is time to investin a more comprehensive approach at householdand community level to prevent andmanage all causes of malnutrition. TheCommunity Based Nutrition programme(CBN) is the first compressive nutritionprogramme to address some of the immediate,underlining and basic cause of malnutrition inEthiopia. Started at the end of 2008, CBN isbeing implemented in 170 districts so far. CBNactivities are centred on the Triple-A (assess,analyse, act) approach, which helpsparents/caregivers and community membersto assess the situation of children and women,analyse causes of the problems and take feasibleactions at family and community level.Monthly growth monitoring and promotion isconducted for children under two years, whichis the most vulnerable period and when theimpact of early childhood malnutrition can bereversed. In all of the CBN districts, servicesunder the EOS package are being delivered asquarterly CHDs. The CBN has establishedeffective referral linkages to the management ofacute malnutrition.In many countries, social security hasreduced poverty and inequality by half andmore 26 . There is evidence that social protectionin a form of cash transfer has improved thenutritional status of children 27,28,29 . While most ofthe EOS/TSF districts are chronically food insecure,the current management of MAM is notadequately linked with existing food assistance/food security programmes. Foodsharing has been noted in TSF outcome evaluationstudy conducted by WFP 30 . It is one of thecultural mechanisms to cope with food insecurity.Therefore, targeting a malnourished childin poor family will not be enough to get therequired programme effectiveness. Poor families/communitiesneed to be targeted for socialsecurity programming. One possible way toimprove programme effectiveness lies with thepossibility of changing the targeting mechanismto include not just anthropometry, but alsotargeting families of vulnerable children forbasic social protection.For more information, contact: SelamawitNegash, email: snegash@unicef.org2009 Round 1 and 27 per cent in 2009 Round 2.26International Labour Office, ‘Can Low income countriesafford Basic Social Security?’, Social Security Policy Briefing,no.3 ILO, Social Security Department, Geneva, 2008.27Rutstein S. O, Effects of preceding birth Intervals onneonatal, infants and under five years mortality andnutritional status in developing countries: evidence fromthe demographic and health surveys. International Journalof Gynecology anad Obstetrics, Vol.89, Supplement 1, April2005, PP S7-S24.28Erhlich, Isaac and Jinyoung Kim, ‘Has Social securityInfluenced Family Formation and fertility in OECDCountries? An Economic and Econometric analysis’’, NBERWorking Paper no. 12869, National Bureau of EconomicResearch, Cambridge, MA, January 200729Boldrin Michele, Mariacristina De nardi and Larry Jones,‘Fertility and Social Security’, NBER Working Paper no.11146, National Bureau of Economic Research, Cambridge,MA, February 2005.30Outcome evaluation study of the Targeted SupplementaryFood (TSF) programme in Ethiopia; World Food Programme;Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew,MD MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH.10

Field ArticleChild screening in Fedis woreda duringCommunity Health DayCan theNutritionInformationSystem be‘trusted’ tobuild onavailabledata sources?By Patrizia FracassiPatrizia holds an M.Sc. inDevelopment Management.Over the past two years, shehas consulted in Ethiopia forUNICEF and the World Bank.She previously worked forUNICEF Uganda as aNutrition <strong>Special</strong>ist and forItalian NGOs, CESVI (Cooperazione e Sviluppo)and Ucodep (Unity and Cooperation forDevelopment of Peoples, now Oxfam Italia) inVietnam as Country Representative andProgramme Manager. She also developed andmanages the technical content for thewebsite: www.motherchildnutrition.org.Patrizia would like to acknowledge teammembersfrom the federal and regionalEmergency Nutrition Coordination Units andfrom UNICEF Nutrition and Food SecuritySection for their continuous support, andespecially government representatives at alllevels for their willingness to share informationand give their valuable insights.The findings, interpretations and conclusions inthis article are those of the author. They do notnecessarily represent the views of UNICEF, itsExecutive Directors or the countries that theyrepresent and should not be attributed to them.P Fracassi, Ethiopia, 2008In Ethiopia, the role of the nationalNutrition Information System (NIS) hasbeen clearly stated in the EthiopianNational Nutrition Programme (NNP).There are three constituent parts to this role.These provide a ‘comprehensive’ and holisticstructure to NIS design: to support timely warningand adequate interventions at woreda andhigher levels, to develop, manage and evaluatethe NNP at all levels, and to inform othersectors like agriculture, water/sanitation andeconomic development. This comprehensivevision for the NIS is to inform understanding ofthe nutritional situation with respect to chronicand newly occurring problems, as well as thecauses of these problems, and how these changeover time in order to help in decision-making atall levels. However, while the NIS can effectivelyaccommodate and be ‘open’ to anunlimited amount of data, the ability to triggeran effective and appropriate response requiresthat the information is timely, reliable andconsistent. These conditions ultimately determinethe basic parameters upon which theinitial choice of information for the NIS is made.Put simply, all data should be trusted andcontinuously available, data should be triangulatedto generate ‘context-specific’ andevidence-based information and there shouldbe a clear process, agreed by all actors, to feedinformation into decision-making.Unique data situation in EthiopiaEthiopia is in quite a unique position because,over the last thirty years, large amounts of datahave been collected by the Early WarningSystem (EWS), including health and nutritioninformation. However, the nutrition informationcollected by the EWS (see Box 1) providesonly scattered data - mostly alert signals basedupon ‘observable’ degeneration. Data iscollected directly from health workers at ‘criticaltimes’ and without systematic comparisonwith what would be ‘normal’ for a given time ofyear. Nutritional assessments are requiredduring these critical times to confirm ‘emergencies’but the seasonality of these critical timescreates a widespread, simultaneous demand forassessments, which rarely can be adequatelymet.In recent years, targeting of surveys has beenimproved through increased use of routine datasources, at least to indicate where an assessmentis most urgently needed. Nutrition data are nowavailable and accessible on a monthly and quarterlybasis at the lowest levels due in largemeasure to three programmes: The CommunityBased Nutrition programme (CBN), theTherapeutic Feeding Programme (TFP) andCommunity Health Days (CHD) (See Box 1).These routine systems are the monitoring backboneof the NNP, which - at least theoretically -can be combined to inform timely warning andbe shared with other sectors. Similarly, anumber of diseases are also currently beingtracked on a weekly basis through the PublicHealth Emergency Management (PHEM)system (see Box 1). Thus, there is a very realpotential for the EWS to systematically tap intospecific data from existing health informationsources and vice-versa. This will be most effectiveif a consensus is reached on key indicators,in particular for timely warning. The key question,ultimately, is whether decision-makersfrom all sectors are willing to exchange and useavailable routine data to inform their decisionsand response.Children with their caregivers on OTP dayin Chalenqo Health Centre, Fedis woredaNutrition data managementWhile there are ‘trust’ <strong>issue</strong>s on data quality andcredibility, the administrative decentralisationand existence of a widespread health network,creates the rare opportunity to build capacities,accountability and transparency at lower levelslike the woreda and the kebele.Initial data collectors are volunteers andfrontline health practitioners. Many report thatdata collection is an additional burden to theiralready crowded agenda. After the initial collection,data flows up through various levels viasupervisors and health officials. However, littlefeedback is given through the system so thatpeople directly involved have a limited sense ofwhat is actually done with the informationprovided. The sheer volume of reports storedtestifies to the regularity of data collectionundertaken and the immediate priority thatshould be given to improve the ‘efficiency’ ofthe process. Currently, asking for nutritioninformation from a woreda official leads to apaper-chase given the amount of report formscollated. Where officials have been providedwith a computer, data appears to have beenregularly updated. Given the increased requirementsfor information management, it seemsinevitable that woreda Health Offices will movefrom a paper-based system to a computerisedone, allowing them to perform data qualitychecks that otherwise are time consuming andprone to mistakes if done manually. The implicationhere is that woreda level officials aremostly young, often computer-literate, professionalswith degrees. Provision of adequatetools/software to practically manage informationcan help build their capacity to implementthe system. If information is not properlyvalued at woreda level, where most data arecollated and ‘checked’, then the task of qualityassurance at higher levels is nigh-on impossible.Added value of NIS: triangulation of dataWhat is ‘new’ in the NIS paradigm is therequirement for ‘triangulation’ to provideevidence-based information for decisionmaking.This implies that collected data are notinterpreted in isolation but are brought togetherfrom different sources. The strength of triangulationis the ‘contextualisation’ of the data,meaning numbers and/or standardised observationsare grounded in ‘local knowledge’.Frontline practitioners in health-posts haveaccess to nutrition and health informationthrough regular contact with patients. Withnutrition, for example, they are in the best positionto judge if the deteriorating weight of achild during monthly growth monitoring orhis/her admission in the OutpatientTherapeutic Programme (OTP) is linked to lackof food in the family or to other causes likeillness, inappropriate feeding practices, etc. It isthis ‘proximity’ that allows for the triangulationto be most helpful at community level wherebyP Fracassi, Ethiopia, 200811

Field Articleroot causes of malnutrition can be identified. An examplewhere this could be used is in chronically foodinsecure areas supported by the Productive Safety NetProgramme (PSNP) where risk financing mechanismsexist to address new chronic or temporary food insecurity.By monitoring increases in underweight (as anearly indicator) and OTP admissions (as a late indicator),frontline health practitioners, who are members ofthe Food Security Task Forces (FSTF), can play a crucialrole in providing information for appeal processes.However, the credibility of their information willdepend on their full understanding that risk financingmechanisms are only accessible when malnutrition islinked to food insecurity. Thus, triangulation of data atsource is a kind of check by key people before informationis fed into the decision-making processes orreported to higher levels.Trust, accountability and transparencyIn Ethiopia, in line with governmental decentralisation,woreda and kebele level administrations have beengiven increased power to analyse, assess and act on theirown changing situation. They are therefore moreresponsible and accountable for both development andemergency response. Addressing the challenges of howinformation can feed into decision-making will ensurethe credibility and sustainability of the NIS. At themoment, available data from routine sources are notadequately linked to information use. The main challengefor data utilisation at higher levels is that sourcesare not fully trusted while at lower levels there are limitationsover capacities and mandate. While data qualityassurance can be built into the system, especially byimproving lower-level capacity, more emphasis needs tobe given to the human aspect. ‘Trust’ cannot be builtwithout attention to the role played by each stakeholder,starting with frontline practitioners. ‘Accountability’cannot be acquired if there is no hand over of responsibility.‘Transparency’ cannot be promoted withoutmaking response and feedback more visible.The NIS in Ethiopia can be built upon coupling availabledata sources with adequate technical supportprovided throughout the health system. However,technical inputs are not enough to ensure its sustainability.A sense of ‘value’ is what motivates people andwithout it, the simple transmission of data to higherlevels will not provide incentive to stakeholders for theirinput. ‘Triangulation’ is most effective at communitylevel where individual data sets can be compared atsource and understood within a given context.Frontline practitioners play a crucial role in building thecredibility of the NIS but this can only come about withincreased recognition of the role they play in informingdecision-making. As the process of decentralisationcontinues within Ethiopia, important decisions to betaken at the lowest levels, risk financing mechanismsbeing an example, will require bringing together availabledata from different sources. This, in turn, will relyincreasingly on key people accountable for informingthis process at the frontline. Before trusting theNutrition Information ‘System’, a vote of confidenceshould be given to empowering the information‘Source’. Credibility, after all, should always start withthe people.P Fracassi, Ethiopia, 2010For more information, contact: Patrizia Fracassi, email:pat.fracassi@gmail.comTalking about data with DevelopmentAgents in Checheho kebele, Lay GayintP Fracassi, Ethiopia, 2008Queuing during HD in Fedis WoredaBox 1: A guide to key systems and programmes in Ethiopia implemented by the GovernmentThe Early Warning System (EWS) is implementednationally under the Disaster RiskManagement Food Security Sector(DRMFSS). Information are collected atkebele level by Development Agents andpassed to the Woreda Early Warning FoodSecurity Task Force. The Task Force analysesand interprets data and submits reports tothe regional level and to the Woreda Council.Collected information include: rainfall condition,crop condition, migratory pests, inputsupply, livestock condition; human healthcondition, water access and availability,education related information, fast on-setdisasters (flash and seasonal river floods,landslides, conflict, forest fire outbreak andlivestock diseases outbreak and humanepidemics), grain, livestock and othercommodities prices, coping mechanisms,emergency relief responses. Information isfed into decision-making processes for classificationof emergency affectedareas/woredas and relief allocation. InProductive-Safety-Net Program woredas, EWinformation is used to help programme thenewly established Contingency Funds. Inaddition, the DRMFSS is responsible for theimplementation of bi-annual seasonal (belgand mehr) multi-sectoral assessments.Information is used to identify acutely foodinsecure woredas and estimate the numberof affected population in need of relief.The emergency nutrition surveys arecoordinated by the regional and federalEmergency Nutrition Coordination Units(ENCU) under the DRMFSS. Surveys areconducted by non-governmental organisations(NGOs) and/or governmentmulti-sectoral teams using the SMARTmethodology. ENCU is responsible for thetechnical quality through an approvalprocess of the initial proposal and final findings.Request for an emergency nutritionsurvey should come or be endorsed by theworeda/regional authority based on EWinformation and/or results from the biannualassessments. Information is used toconfirm ‘emergencies’ and mobilize responsefor relief and selective feeding programmes.The Community Based NutritionProgramme (CBN), started in 2007, is nowexpanding in 150 woredas covering all kebeles.The programme is implemented byVolunteer Community Health Workers(vCHWs) under the supervision of the HealthExtension Workers. It includes monthlyGrowth Monitoring and Promotion (GMP) ofchildren under two years with referral ofthose who are severely underweight, notgaining weight for two months or with otherhealth problems. Pregnant and LactatingWomen (PLW) receive folic acid supplementationand are mobilised for antenatal care,safe delivery and other maternal services.Community Conversation (CC) is conductedmonthly to assess child malnutrition, analysecauses and plan for action (Triple A CycleApproach). Collected information includes:number of children under two years,number of weighed children, children withnormal weight, underweight and severeunderweight, number of trained and reportingvCHWs, number of implemented CCsessions and participants. Indicators aredisaggregated by gender.The Community Health Days (CHD) areimplemented every three-months andexpected to cover all 150 CBN woredas.MUAC screening is conducted for all children6-59 months and for PLW. Those identified asmalnourished are referred to therapeuticfeeding programmes or supplementaryfeeding, where available. Every six months,children are additionally provided withVitamin A and deworming. Collected informationincludes: targeted population(children 6-59 months), coverage of childand PLW MUAC screening, coverage ofVitamin A and deworming supplementation.Children and PLW are grouped on the basisof MUAC as follows: MUAC >12 cm, MUACbetween 11-11.9 cm and MUAC

Field ArticleField ArticleOxfam’sSomaliland-EthiopiaCross Border DroughtPreparedness ProjectBy Abay BekeleA community birkad in theHarshin-Somali regionAbay Bekele works for Oxfam GB as Senior Pastoral Programme Manager. He hasover nine years of technical and managerial experience in pastoral developmentand humanitarian programming. He has also managed programmes inACDI/VOCA, SC US and CARE International in Ethiopia. He holds a Doctor ofVeterinary Medicine from Addis Ababa University.The author would like to thank the staff of Oxfam GB Somaliland and Ethiopia andHorn of Africa, east and Central Africa, that designed and implemented RDD I and II projects, particularlyHelen Bushell, Abdirahim Salah, Mustapha Mohammud, Million Ali, and Elias Kebede. <strong>Special</strong>thanks go to Jeremy Shoham for his invaluable support in putting documents and materialstogether and revisions of drafts.The author is particularly grateful to the many pastoralist communities, partners with whom Oxfamhas been working to end poverty and suffering in Ethiopia.Oxfam’s Somaliland-Ethiopia Cross Border Drought PreparednessProject is implemented as a component of Oxfam GB’s 15-yearregional pastoral initiative that covers six countries in the Horn andEast Africa 1 . This initiative is divided into 3-year phases. In theSomali region of Ethiopia, implementation started in 2002 and is now in thesecond phase, whilst in Somaliland the first phase started in 2005. The firstphase of Oxfam’s Ethiopia-Somaliland Cross Border Drought PreparednessProject (see map) ran from January 2008 – June 2009. The second phase, whichwas funded under the European Commission Humanitarian Office (ECHO)Regional Drought Decision (RDD), was a 12-month project implemented inpartnership with HAVOYOCO (Horn of Africa Voluntary Youth Committee)and ended in June 2010.The regional pastoral initiative is based on the idea that the key <strong>issue</strong> inreducing poverty and marginalisation in pastoral communities is increasingthe level and quality of pastoralists’ participation and representation. At theheart of the programme is a concern to build strong, representative pastoralorganisations, through which pastoralists can better understand and claimtheir rights and manage the development services they need. Strengtheningdrought management capacity (at technical, organisational and institutionallevels) and working to reduce vulnerability to drought is a central aspect of thepastoral development programme.Figure 1: Location of Ethiopia-Somaliland Cross Border Drought Preparedness ProjectGalbeed and Toghdeerin SomalilandHarshin Woreda, SomaliRegion, EthiopiaMillion Ali, Ethiopia, 2008The ECHO RDD support for the secondphase from July 2009 to June 2010 was seen asthe time to consolidate the activities, learningand outcomes of the first phase.Background to the projectThe pastoralist populations in Ethiopia andSomaliland are exposed to multiple hazards.Continued and increasing frequency of droughtcombined with a weakened asset base andcoping mechanisms has resulted in high levelsof risk. Frequent droughts lead to inadequateaccess to and availability of both water andpasture. Rapid population growth and a decliningnatural resource base have exacerbated thenegative impact of the recurrent droughts.The major water source for pastoralists andtheir livestock is surface water collected inwater catchments (birkads) during the rainyseason. There is also an increasing trend ofexpanding underground cement water tanks.Some of the water facilities in pastoral communitiesare privately owned although a largenumber are communally owned, particularlywater pans/catchments. Though communallymanaged water facilities offer good coverageto various social groups within pastoralcommunities, there are increasing concerns interms of their maintenance. Overall, the existingwater sources are inadequate to providewater for human and livestock needs, evenduring normal times. The situation worsensusually during periods of water stress. Duringthis time, competition over water and pastureoften results in conflict and forces pastoraliststo travel for longer distances with weakenedlivestock to find water. The stress induced bylong-distance migrations leads to an erosion ofthe social capital and social support networksamongst the pastoralists, Access to basic socialservices such as education and health facilitiesis also disrupted, rendering this group lessresilient to the increased incidence of drought.At the same time, the stress-induced migrationsnegatively affect the health andproductivity of livestock, leading to a significantincrease in livestock mortality duringdrought periods. As the health of the livestockdeteriorates, pastoralists resort to sellinganimals, thus crowding the market and leadingto a drop in prices. This reduces the incomeof the pastoral households at a time whenprices of all other consumables tend to go up,hence weakening the purchasing power of thepastoralists. The end results are loss of assets,destitution and, finally, dropping out frompastoralism. ‘Drop out’ pastoralists tend tomigrate to urban settlements to access humanitarianrelief and other basic social services.These situations create a sub-group of thepopulation around large towns and villageswho lack the skills to take part in economicactivities in their new settings.Communities living in adjacent borderareas are often inter-dependent (in terms ofculture and ethnicity, language, sharingcommon resources, trade and marketingroutes), and the causes of their poverty areinter-linked. This is particularly the case inpastoral areas where pasture and water needto be accessed by resource users on both sidesof the border. Furthermore, communities sharinga common border are faced with similarenvironmental conditions, socio-economicconstraints and risk profiles. Effective natural1Sudan, Ethiopia, Somalia, Kenya, Uganda, and Tanzania.13

Field Articleresource management, conflict managementand development work therefore requires jointaction. Of particular relevance to theSomaliland-Ethiopia Cross Border DroughtPreparedness Project are <strong>issue</strong>s of trade, charcoalproduction, livestock trekking routes andwater points. For example, poverty reduction inborder areas cannot be achieved without peacebuilding,and most conflicts have a cross-borderdynamic. As well as mitigating risk (conflict,disease), cross-border work can also add value,by opening up social/economic opportunities(trade, natural resource management (NRM),education) – this is particularly the case giventhe trade routes and links between Somalilandand Ethiopia.Project strategyThe principles of cross border programming asapplied to the Ethiopia-Somaliland CrossBorder Drought Preparedness Project havelargely been developed from prior thinking andconsultations over a period of years. Theprogramme strategy is based on Oxfam GB’s‘one programme’ approach and Oxfam GB’sand HAVOYOCO understanding that the crossborder project should be:• Proactive in nature and involve high qualitywork with communities• Programmatic and strategic, i.e. <strong>focus</strong>ed onstrengthening institutions/processes, notjust activities• Jointly planned and owned by communities,local partner organisations or by bothgovernments• Addressing <strong>issue</strong>s that can only be tackledby common action and/or coordination onboth sides of the border• Used to achieve wider impact by influencingpolicy and practice on a regional basis• Flexible and responsive to changes in anoperating context• Built on shared learning and understandingSituation analysisAssessments carried out in Ethiopia in Januaryand March 2009 in Harshin Woreda and inSomaliland during the first week of May 2009were instrumental in informing the proposalput to ECHO for the second phase of the crossborder project. The findings revealed thatvulnerable pastoral households were facingincreasing livelihood erosion as droughtsbecame more frequent and coping capacityextremely weakened. Communities identifiedthe effect of drought on vulnerable householdsas a core problem, highlighting that lack ofproper, integrated management of naturalresources (water and rangeland) leads toscarcity of water and pasture, as well as naturalresource and environmental degradation. Theassessment also identified privatisation ofcommunal grazing land, limiting mobility andavailability of resources, poor access to basicsocial services, erosion of social capital andresource based conflict as interrelated problemsassociated with the effect of drought.Within the current disaster managementsystem (on the Somaliland side) there is a functioning,although often ad hoc, disastermanagement coordination structure and a foodsecurity and nutrition information system.However, the absence of government in acentral strong position is a clear limitation inrelation to effectiveness, efficiency and sustainability.Furthermore, little attention has beenpaid to strengthening of the organisationalcapacity of community-based institutions toparticipate in the decision-making process inrespect of matters affecting their welfare. Inrelation to this, women in pastoral societies arehighly marginalised and face multiple burdensin terms of bearing responsibility for mostproductive and reproductive tasks, while lackingcomparable authority over productiveresources and decision making processes. Theseburdens tend to increase during times ofdrought stress and conflict. Preparedness planningand capacity is seen as an urgent need.Phase II objectives and expectedoutcomesThe proposal for phase II submitted to ECHOstates that pastoralist vulnerability to droughtwill be addressed by <strong>focus</strong>ing upon the naturalresource base and the management of naturalresources, capacity for effective droughtpreparedness and response and supportingcommunities to preserve their asset base intimes of drought stress. The principal objectiveof the project is to ensure that communities,local government and civil society organisationsin Somaliland and the Somali region ofEthiopia are better prepared to manage thenegative impacts of droughts.Three expected results (outcomes) for Phase IIare:Result 1: Improved institutional capacity fordrought preparedness linked to enhancedcommunity preparedness capacity.Greater emphasis was placed on this resultduring the second phase, recognising thelimited achievements during phase I. The <strong>focus</strong>is to improve community access to early warninginformation from national/regionalauthorities, awareness of the drought cycle, anddrought risk management at community level.This is supported by the development andimprovement of contingency plans with clearlydemarcated roles and responsibilities.Result 2: Improved integrated natural resourcemanagement (NRM) to ensure increased accessto and availability of pasture, fodder and water.Here the project <strong>focus</strong>es upon mapping of thenatural resource base as a tool for planning inboth a humanitarian and development context.Mapping exercises are built upon by ensuringthe effective management of water points(including hygiene practices) and pasturemanagement. Based on studies undertakenduring phase I, the <strong>issue</strong> of land enclosure wasto be taken up at a policy and advocacy level.Result 3: Households better able to preservetheir assets throughout the drought cycle.The emphasis here is on working to ensure thatlevels of vulnerability to drought do notincrease amongst pastoral populations by helpingto ensure household assets are preservedduring times of stress. This involves reviewingand addressing <strong>issue</strong>s of coverage of veterinaryservices offered by Community Animal HealthWorkers (CAHWs), reviewing livestockmarketing for effective livestock off-take duringtimes of drought stress and building the capacityamongst livestock marketing cooperatives,Woreda DPPO (Disaster Prevention andPreparedness Office), pharmacists and privatevets in drought related livestock diseases anddrought response.Phase II activitiesTarget populationThe project was implemented in the cross-Abay Bekele, Ethiopia, 2010border areas of Harshin, Somali region ofEthiopia and in Odwayine, Durqsi, Ballidhiig(Togdheer Region) and Farawayne,Allaybadaye and Belligubedle (districts ofGalbeed province of Somaliland). The bordercommunities are mainly from Isaac clan sharingthe same ethnic denomination.A total of 76,000 people in 9,500 householdswere expected to benefit directly from the interventionas shown in Table 1. The beneficiariesare pastoral men, women, children, youth andthe elderly. Among the general population inSomali region of Ethiopia, 90% are pastoralistswhile those in Somaliland constitute 60-65% ofthe population.The activities implemented in phase II inorder to achieve the three results aresummarised in Box 1. Approximately 76,000people (9,500 households) directly benefitedfrom the integrated NRM of water and pastureresources as well as capacity building activitiestargeted by the project. Woreda, district andregional authorities, community-based organisationsplayed a key and predominant role inthe planning, implementation and monitoringof the project. By improving the management ofwater and pasture resources and reinforcinglocal capacities, all the Harshin population(80,215 people of whom over 45% are women)indirectly benefit from the project. Many ofthese benefit from the technical supportprovided by the implementing team.Woreda and regional government institutionsand community-based organisations alsobenefit from capacity building and technicalsupport provided by the project. InSomaliland, the implementing local partner,HAVOYOCO, the community pastoral organizations(POs), the districts/regions authoritiesand the national level government departmentsincluding, the national disaster authority andthe Ministry of Pastoral Development andEnvironment of Somaliland, benefit from institutionalcapacity support. On the Ethiopia side,the respective woreda and regional governmentinstitutions of Livestock, Crop and RuralDevelopment, Water, Energy and Mines, DPPWatering camel from a birkadin the Harshin-Somali region14

Field ArticleAbay Bekele, Ethiopia, 2010Table 1: Profile of intervention targets in Phase IITotal populationin target area*Total number of householdsin target districts**Total directbeneficiariesTotal direct beneficiaryhouseholdsSomalilandGalbeed (project will be working 100,800 12,600 14,729 1,841in 3 of the 10 districts)Togdheer (project working in 3 111,600 13,950 21,271 2,659of the 6 districts)Total Somaliland 212,400 26,550 36,000 4,500EthiopiaHarshin Woreda 80,215 10,027 40,000 5,000Total Somaliand and Ethiopia 292,615 36,577 76,000 9,500*Target area given as districts the project is working in, rather than the region.** Each household has on average 8 people.Box 1: Phase II activities by anticipated resultResult 1: Improved institutional capacity for disasterrisk reduction linked to enhanced communitypreparedness capacity.• Awareness raising on disaster risk reduction(DRR)/drought cycle management topics forpastoral organisations, traditional leaders,women groups, traditional meteorologists andgovernment (district commissioners, villagehead-men and governors (regional and districtlevel)) in Somaliland.• Ten community mapping sessions on droughtpreparedness including mobility patterns,water and pasture resources for contingencyplanning in Harshin.• Five trainings on DRR and five follow upmeetings with CAHWs to strengthen a communitybased early warning information systemusing data collected by CAHWs and linked tothe district DPPB office.• District disaster contingency planning workshop,facilitated by DPPB with communityparticipation, to establish a drought contingencyplan in Harshin District. Also, support toNERAD (National Environment Research andDisaster Management) to develop a nationaland district contingency planning methodologyfor Somaliland as well as a national plantogether with six district drought contingencyplans.• Conduct an early warning system (EWS) usersurvey and use this as a basis to develop anEWS for Somaliland.• Study tour for NERAD, HAVOYOCO and OxfamGB Somaliland to Ethiopia/Kenya to see howthese two countries’ disaster risk managementagencies (including EWS systems) and mechanismsare set up and function.Result 2: Improved integrated NRM to ensureincreased access to and availability of pasture,fodder and water.• Cross border integrated natural resourcemanagement mapping of the project area<strong>focus</strong>ing on water, pasture resources andpossible migration routes in partnership withthe Food and Agriculture Organisation (FAO).• Joint dialogue workshops on findings of naturalresource management (NRM) mapping andland enclosures study from previous phase ofRDD in partnership with FAO and line bureausand ministries (proposed formulation of a crossborder NRM technical working group)Mobility, a key pastoral livelihoodstrategy (Kebribeyah Somali region)• Construction of five community birkads andnatural resources management training andfollow up coaching for five birkad communitymanagement committees.• Construction of four rainwater harvesting tanksin four schools and operations and maintenancetraining and follow up coaching for four teachers.• Technical vocational skills course for 10 masonsand carpenters on the construction and maintenanceof water structures and roof waterharvesting system.• Gully erosion control and re-seeding of 6 sq.km of pastureland including provision of toolsto community members.• Technical and policy level support to theMinistry of Pastoral Development andEnvironment of Somaliland to advance theformulation of the national Land Tenure Policy.This includes convening a stakeholder’s reviewmeeting (to include participants from Ethiopiaby way of joint learning) and incorporating thefindings of the land enclosures study from theprevious phase of the RDD.Result 3: Households better able to preserve theirassets throughout the drought cycle.• A cross border study to investigate the possiblerole of Community Animal Health Workers(CAHWs) in drought preparedness andresponse including tackling drought relateddiseases and the overall performance ofCAHWS in respect to their given mandate.• Dissemination of study findings to nationalbodies via national workshops in SomalilandandSomali Region (government, FAO and agenciesengaged with CAHWS working) to help strengthenCAHWS training through the updating ofnational and agency training guidelines.• Used study findings to develop training guidelineson the management of drought relateddiseases and trained CAHWS on the same. Atotal of 22 CAHWS were trained in Somaliland.• Support the Livestock, Crop and RuralDevelopment Bureau in Somali Region ofEthiopia to roll out the national guideline forthe Design and Establishment of CAHWS viaholding a regional orientation session (targetingFAO, Agricultural Bureau DPPB, NGO’s, etc.)and two district orientation sessions (targetingCAHWS, district veterinary technicians, livestock marketing cooperatives, private vets andprivate pharmacies).and Health are key beneficiaries from the differenttrainings and institutional developmentsupport.Amongst target beneficiaries are the POs atcommunity level and (in Somaliland) districtlevel community development and preparednesscommittees.Management and coordinationIn order to administer and deliver the project, aProject Management Team was formed and ledby the Somali Region, Pastoral ProgrammeManager. The Ethiopia project lead reflected achange in approach from phase I which was ledby Somaliland. The switch to Ethiopia reflectsthe larger project on the Ethiopia side of theborder and the greater project managementcapacity correspondingly budgeted within theEthiopia team.Monitoring, Evaluation and LearningIn Phase I of the project, a Monitoring,Evaluation and Learning (MEL) guide wasdeveloped and a project baseline established. Inphase II, the MEL guide and baseline wasadapted to incorporate a Logical Framework.Project implementing teams conductedmonthly field monitoring by providingmonthly progress reports. These monitoringexercises have been conducted to check theprogress made against plans and hold discussionswith stakeholders (communities, localauthorities and NGOs). The implementing teamheld monthly coordination meetings to makedecisions based on an analysis of the monitoringdata, and the outcome of the meetings wereshared with Oxfam Nairobi Office and FAO(flash report). During such reviews, Oxfam GBdiscussed with beneficiaries the relevance of theproposed activities for the next semester andtook their comments into account.A final internal evaluation was conducted bya team of Oxfam GB senior staff from Ethiopiaand Somaliland, and representatives of NGOand government bureaus. The baseline surveywas repeated and the results compared with thebaseline carried out at the start of the project.Lessons learnt during the first twoproject phasesAccess to and types of rangelandsA key finding of the natural resource study inphase II of the project was that communal landsare being increasingly privatised, i.e. theybecome land enclosures. The process seems tobe influenced by endogenous [erosion ofcustomary institutions, intra-clan competition,erosion of communalism and populationgrowth] and exogenous [weak grass rootgovernment institutions, expansion of settlementand social services, commercialization ofrangeland products and climate change]factors. This leads to erosion of livelihoods aslivestock numbers decrease, so that morepeople become involved in selling charcoal as ameans of survival. Charcoal is used domesticallyor sold to the Middle East.During phase II, Oxfam GB has tried to buildcommunity capacity, e.g. through developingwater capacity (cement lined wells) and rehabilitatingrangelands via the community.A number of negative impacts and challengesof the programme have emerged. Aswater points were developed, communitiesstarted acquiring their own private birkads. Thenumber of birkads on the Ethiopian sideincreased significantly but the amount of graz-15

Field ArticleTable 2: Profile of beneficiaries by result/sectorResult /SectorNumber ofbeneficiaries inSomalilandResult 1:Disaster preparedness, local disastermanagement componentsResult 2:Disaster preparedness, small-scaleinfrastructure and servicesResult 3:Food assistance, short term foodsecurity and livelihood support.ing land remained the same, leading to rangelanddegradation during the dry season inparticular. The number of birkads in the area ofthe project has now reached more than 5000.Livestock come to access the water and grazethe fields around the water points leading torangeland degradation. Wealthy householdsstarted selling water and natural resource sharingmechanisms changed as livelihoodsdeclined. Overall there has been a process ofcommercialisation so that water and grass areincreasingly purchased. Water is nowcommonly sold during drought and dry seasonperiods.The total number of water points rehabilitatedduring the two phases has beenapproximately 500 (approx 10%). There are twoways to manage birkads – privately andcommunally. Most of the constructed or rehabilitatedbirkads have been constructed for thecommunity but private birkads tend to bebetter managed than communal ones. Anotherlesson from phase II has been that it is importantto support the capacity to manage thewater points (financially and institutionally) sothat these resources are sustainable.An important finding from this experiencefor Oxfam GB, who are now attempting tosecure funding from ECHO to continue theproject from July 2010 to December 2011, hasbeen that drought related problems cannot besolved simply by filling gaps, e.g. constructingbirkads. It is far better to build the institutionalcapacity of communities so that they canmanage their own resources more effectively.Another set of key learning points arose inrelation to types of grazing land (60%enclosed/private, 40% communal). Enclosedlands are generally well managed but most ofthe community are excluded from these lands.Usually, the grass and trees are excellent onenclosed lands. Communal lands tend to bedegraded and eroded and poorly managed. Inthe next phase of the project, Oxfam GB intendsto support the exchange of management experiencebetween enclosed and communal lands.This will be piloted in three woredas - fourcommunities per woreda. The project will usehouseholds in enclosures to train those communitieswho use communal lands, in landmanagement. To reverse the situation, pastoralfield school will be piloted to train herders andcommunity leaders. Trainees will act asresource persons in their local communities toraise the awareness level of the community onrangeland management.Another set of <strong>issue</strong>s arising out of the firsttwo phases relates to cross-border land areas.The GoE does not recognise internationalmovements over the border. Oxfam GB is thereforelooking at <strong>issue</strong>s around mobility and theNumber ofbeneficiaries inEthiopiaTotal numberof beneficiaries36,000 40,000 76,000 9,5004,800 (part of the36,000 above)25,000 (part of the40,000 above)29,800 3,7259,600 (part of above) 0 9,600 1,200Number ofhouseholdsneed to establish information systems for criticalknowledge around pastoralist livelihoodsystems. For example, with regard to livestockdiseases, how mobility is influenced by diseaseand how to share information between communities.The congregation of herds at dry seasongrazing areas favours disease transmission.However, this also gives opportunity to accessand treat a large population of animals at anyone time, and stands the best chance of breakingthe chain of transmission.Cross border livestock tradeThe structure of the market between communitiesin the cross border areas of Ethiopia andSomaliland conveys livestock to Somalilandand brings in consumer goods to Ethiopia.Oxfam GB will facilitate exchange of informationbetween the two communities.Cross border mobilitySharing information on grass and water availabilityand improved management of strategicwater points and grazing lands between thetwo cross-border communities is essential. Thiswill have to be done informally due to theGoE’s position on cross-border movements.The Oxfam GB offices in Jijiga and Somalilandplan to exchange information and also disseminateand share information between the twocommunities. The aim in the next project phasewill be gradually to institutionalise capacity toexchange information outlined above. It is alsohoped to take relevant government staff fromEthiopia and Somaliland to West Africa toexpose them to cross border policy formulationand implementation in the region (Mali,Burkina Faso or Niger) and how informationsharing can work, i.e. the approach is advocacyfrom above while having an impact at grassrootslevel.Preparedness and livestock diseaseAnother key <strong>issue</strong> for the next phase of the projectis addressing preparedness. A majorproblem for pastoralists is livestock disease,especially drought induced diseases. Five keylivestock diseases for each animal species havebeen identified as part of this project making itpossible to strategise disease control measures.The most important actors with respect to livestockdiseases are CAHWs. Through theproject, eighty nine have so far been trained onthe Ethiopian side, with others trained on theSomali side. These CAHWs move with thecommunities to provide animal health serviceas they are pastoralists themselves. The projecthas been building their capacity in diseasesurveillance and diagnosis with a view to establishingcommunity early warning and responsecapacity to drought. This will help facilitatevaccination or treatment interventions.A relevant and appropriate contingency planhas been produced both on the Ethiopian andSomaliland side on the basis of assessment,analysis, consultation, and seasonal scenarios.The contingency plan includes linkages withthe regional (Ethiopia) and national(Somaliland) early warning system (EWS). It isanticipated that these linkages will be strengthenedduring the forthcoming ECHOprogramme (RDD3). Community based earlywarning indicators <strong>focus</strong> on the following keyareas: rainfall, birkad levels, pasture conditions,livestock body condition, livestock disease, andmigration in/out of the woreda. This informationis gathered by CAHWs. Focusing on theseindicators would help pilot the process andestablish the analytical linkages betweencommunity based monitoring and theregional/national EWs. In Ethiopia, CAHWsinformation is passed to animal health technicians(AHTs) in government. In Harshin thereare 13 centres with AHTs. AHTs travel to thedistrict capital each month for payment and canuse this opportunity to inform the district ofdevelopments. The project aims to developdistrict contingency plans, which will be activatedby early warning information collectedby CAHWs.On the Somaliland side, institutional capacityof the government and the technical capacityof its staff are weaker. Oxfam GB has tried tobuild capacity of DPPO equivalent staffalthough there are not many suitable governmentstaff to train. Thus, the programme isstronger on the Harshin side. Marketing activitieshave not as yet started in this project.Oxfam GB recognises that it is important toestablish preparedness first but that timely livestockmarketing will be critical further downthe line.Community vulnerabilityThe remaining pillar of the Oxfam GB crossborderproject relates to reducing communityvulnerability during drought and dry seasons.Generally, the drought and dry season favoursthe better off but if conditions are very severe, allare affected. The most vulnerable are the poor asthey lack livestock and natural resources. Theyneed alternative income generating sources.Women are the most vulnerable amongst thepoor. Women and children remain behind whenhusbands migrate. If food and money sent by thehusband diminishes, then they have to send livestockto their husbands to sell.The challenge for the Oxfam GB project ishow to reduce vulnerability of women and childrenwho remain behind during the dry season.The programme is currently attempting to identifybusiness opportunities for women.ConclusionIn conclusion, a lesson from phases I and II ofthe project is that the <strong>focus</strong> of pastoralist interventionsshould be to strengthen thecommunity and risk reduction strategies ratherthan simply fill material gaps through resourceprovision. Oxfam GB also realise that informationon the interaction of communities withneighbouring groups is a pre-requisite forunderstanding pastoralist societies and planningdevelopment initiatives. Furthermore,there is a need to find out about the majorresources in a community, where these arefound, who manages them and perhaps mostimportant of all, who benefits from them.For more information, contact: Abay Bekele,tel: +251 11 661 33 44 fax: +251 11 661 35 33,email: ABekele@oxfam.org.uk16

Field ArticleField ArticleEmergency Food Security andLivelihoods Project in Amharaand Oromia regionsBy Shekar Anand, OxfamShekar is Programme Director for Oxfam GB in Ethiopia. Past experience includesworking with OXFAM, CARE, CIDA, and Government in Aceh, India, Zimbabawe andAfghanistan. He has a post graduate in Rural Development and Management of NGOsand twenty-two years of experience in his field.The author acknowledges the work of Oxfam GB and the Ethiopia Rift Valley Womenand Children Development Association, Ethiopia.Oxfam UK has been working in Ethiopia for close to 30 years.Oxfam’s flagship coffee programme linked with the internationalcoffee house, Starbucks, has enabled the organisation’sunique positioning within agriculture and livelihoodsprogramming in Ethiopia. Oxfam UK is also leading OxfamInternational efforts to establish a single management structure for thevarious national Oxfam agencies currently working in Ethiopia.Oxfam UK currently has three types of programme in Ethiopia: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 Somaliregion. 1iii) Livelihood programming, which includes agricultural development.Agricultural development in EthiopiaThe agricultural development programme in Ethiopia is part of theGlobal Agricultural Scale Up (GASU) initiative started by Oxfam fouryears ago. This pilot initiative was initially established in three countries,Ethiopia, Honduras and India covering three continents. Tanzaniawas subsequently included. If successful the programme is to be scaledup.The Commercialisation of Agriculture for Smallholders in Ethiopia(CASHE) programme (called the Ethiopian Agricultural Scale UpProgramme until 2009) targets small farmers with at least half a hectareof land and aims to support these farmers in gaining access to, andinclusion in, markets. The programme is operating in three regions inEthioipa, namely Oromia, Amhara and Benshangul Gumuz RegionalStates. Beneficiaries are targeted on the basis of land ownership andmarket constraints. Farmers are supported in a number of ways, e.g.creating an enabling environment, value chain development of selectcommodities and market service provision.The Agricultural Scale Up programme in Ethiopia has worked withfarmers on many crops. It has now been decided to use a scalable modelfor three commodities, honey, coffee and sesame. These have also beenidentified by the government as high value crops for export. The projectensures that farmers are not dependent upon these crops for their livelihoodsbut also grow other crops.1See field article in this <strong>issue</strong>, p27-30.Farmers at workOxfam, Ethiopia, 2008Oxfam’s work has <strong>focus</strong>sed on threedomains:• farmer needs - formation of farmer groups,improving governance, development ofskills, women’s economic leadership,increasing production and linking this tomarket access and risk reduction• the market - value chain development,assessing market needs and where formalmarkets exist, food processors, workingwith the private sector, and• lessons learned - for example, buildingOxfam capacity, developing and advocatingat policy forums at local, national andregional levels and coordinating with stakeholders.The Agricultural Scale Up programme strategyis about pulling rather than pushing people outof poverty. The approach builds on the assetsand capacities of farmers who are not food insecure.The theory is that by <strong>focus</strong>ing on thisstratum of society, it will be possible to make acontribution to the overall economy of thecountry and resulting GDP. It will create greaterwealth and development for the country than astrategy which <strong>focus</strong>es upon the poor and mostfood insecure. The approach <strong>focus</strong>es on productiveareas and productive capacity.However, Oxfam are aware that their targetfarmers are often exposed to emergencies likedrought, flood, market turbulence and climatechange. Consequently, Oxfam have endeavouredto embed a humanitarian responseprogramme within the Agricultural Scale Upprogramme for pockets of target farmers, toprevent them from falling into the poverty trap.Small holder farmers who become food insecuredo not have access to the national ProductiveSafety Net Programme (PSNP). Furthermore,there is very little donor money for supportingagriculture. Oxfam have therefore come up withan approach called the ‘emergency food securityand livelihoods (EFSL) project’ to protect thosefarmers who are vulnerable to impact ofdrought and other shocks.Packed honeyready formarketHow the EFSL project startedThe failure of short rains in most parts ofEthiopia in 2008 resulted in drought conditionsthat affected the agricultural scale-upprogramme in Amhara and Oromia regions.Farmers in at least nine woredas requiredimmediate EFSL support for a three to fivemonth period. Oxfam elected to support thefarmers to develop agricultural infrastructurethat would help restore normal food productionlevels by the end of the harvest season, i.e.December 2008.The Oxfam EFSL project appeal proposed,first, to provide immediate support to affectedcommunities so that they could withstand theshock till the next harvest season and secondly,to stabilise food production in the long runthrough development of agricultural infrastructuresand community-managed systems.There were three primary objectives:17

Field Articlei) Respond to increasing vulnerability tofood insecurity faced by smallholderfarmers in nine target woredas of Amharaand Oromia regions through socialtransfer and a public works project.ii)Strengthen linkages between socialprotection and humanitarian responseactivities and improve sustainability andprobability of graduation of beneficiaries.This was to be achieved throughdeveloping a strategy for collaborationwith PSNP around social protection leadingto graduation in target woredas.iii) Inform long-term agriculture programmingon appropriate activities to address thehumanitarian context faced by smallholderfarmers as part of an integratedapproach.Box 1 outlines the activities planned in thedifferent regions.Management and implementingpartnersThe overall management of the project wassupervised by agricultural scale-up programmemanagers who were in charge of Amhara andOromia regions respectively. Partners wereresponsible for project implementation on theground. The project was implemented over a 16month period (September 2008 – December2009). However actual implementation of projectactivities was completed in the first 12month period and the remaining four monthswere used for evaluation, documentation oflessons learnt and wrap-up.The project was implemented by theOrganisation for Rehabilitation andDevelopment (ORDA) in Amhara region, andby Rift Valley Children and WomenDevelopment Association (RCWDA) and RuralOrganization for the Betterment of Agropastoralists(ROBA) in Oromia region. Relevantgovernment departments at regional, zonal andworeda levels were consulted during the courseof implementation.Target beneficiariesIn Amhara region, a total of 2,300 households(11,500 people) in six woredas were directlyinvolved in and benefited from this project,constituting at least 13% of the affected populationin these woredas. All of the beneficiarieswere also the beneficiaries of the AgriculturalScale Up Programme (1,080 householdstargeted on malt barley value chain and around1,220 households on honey value chain interventions).It was estimated that about 88,000people in these woredas indirectly benefitedfrom the project interventions.In Oromia region, a total of 3,050 households(15,250 people) in three woredas (Arsi Negelle,Kore and Kofele), in 15 kebeles of LanganoShala locality, were directly involved in andbenefited from this project. It is estimated thatabout 75,000 people in these woredas indirectlybenefited from the project interventions. All ofthe beneficiaries in Oromia region were alsobeneficiaries of the Agricultural Scale UpProgramme.Impact of the programmeChanges in household incomeAccording to implementing partners and beneficiaries,the increase in income as a result of theEFSL project has improved households’ accessto food and assisted households to pay back theloans they received from saving and creditgroups/institutions. The extra income has alsoBox 1: Project activity planAmhara region• EFSL assessment and planning with communities• Construction of 5 grain banks in five malt barleygrowing Woredas• Construction of 4 honey collection centres ineach honey Woreda• Construction of access roads- 33 Km• Provision of around 150kg bee forage seed andplanting on 50 hectares• Capacity and skill building of communities onmaintenance and use of community structuresand CBRM approach and mechanisms• Establishing community-managed revolvingfunds for 50,000 birr in two locations in eachworedaOromia region• EFSL assessment and planning with communities• Cleaning and maintaining 22 irrigation schemes• Maintenance of rural roads (100 km)• Soil and Water conservation structures (25)• Provision of vegetable seeds to 780 households• Provision of farm tools & equipment to 780householdsenabled households to bridge the hunger gapand deal with food price inflation, improvedaccess to agricultural inputs, particularly thosethat increase the productivity of high valuecommodities and enabled households to buyproductive assets such as livestock.Furthermore, almost all households targeted bythe project now send their children to school.Data show a clear increasing trend in incomefrom Oct/Nov 2008 to May and June, 2009,after which income fluctuated up and down.Most of the beneficiaries interviewed indicatedthat there has been a considerable increase inincome.Diversification of sources of livelihoodsImplementing partners and beneficiaries citedthe following as examples of livelihood diversificationdue to the project:• Increased on-farm and off-farm activities,such as beehive production due to therevolving loan scheme and incomegenerating activities.• Increased number of small holder farmersengaged in employment opportunitiescreated through cash for work.• Increased production of malt barely crop.Increased availability of foodAccording to implementing partners and beneficiariesthis has been achieved through anumber of means:• The transfer of cash resource to vulnerablehouseholds through public work hasCoffee production in Ethiopia• Establishing/strengthening market informationcentres• Capacity and skill building of communities onmaintenance and use of community structuresand on the Community Based ResourceManagement (CBRM) approach and mechanisms• Establishing community-managed revolvingfunds for 50,000 birr in two locations in eachworedaAmhara and Oromia regions• Social Security assessments conducted intargeted woredas• Consultative review of PSNP and other foodsecurity programmes• Consultation and strategy developmentthrough learning from the response• Baseline survey/ assessments• Monitoring of project implementation• Documenting lessons learnt and dissemination• Conducting mid term and final evaluation• Application of learning in developmentprogrammes and policy advocacyincreased capacity of households topurchase food items from local markets.• The provision of farm tools and equipmentenabled farmers to undertake farm activitiesmore effectively coupled with the varioussoil and water conservation measures, e.g.the construction of check dams, cut offdrains, and hill side terraces in areas thatare highly susceptible to erosion and landdegradation. These measures have led to anincrease in production and productivity.• The training and technical support given tofarmers in improved agronomic practices likeseed beds preparation, technique of sowingseeds on the beds, mulching system, shadingsystem and improved ways of wateringseedling in different stages, have allcontributed to increased production of crops.Access to potable water supplyAccess to potable water has improved througha number of means (more water points (faucets)and construction of pot/calabash stands) leadingto improved water consumption bothduring the wet and dry seasons. It was alsoreported that the use of safe water supply hassignificantly contributed to improvements inhealth status of people, as well as improvedchildren’s school enrolment – particularly girls,as the time children spend on fetching waterhas decreased. The majority of water collectiontrips used to take 90 minutes but have nowreduced to 30 minutes. Furthermore, womenwere spending less time queuing.18Oxfam, Ethiopia

Field ArticleAccess to local marketsThe construction and maintenance of feederroads improved access of particularly marginalisedcommunities in the intervention areas tomarket and also to other social services, such ashealth.Asset creation and ownershipMost households have created productive andnon productive assets following the project intervention.There has also been a marked increasein holdings of livestock and other productiveassets and a reduction in distress sales of assets.Prices of cereals in local marketsThe situation in Kofele woreda is typical ofother woredas where the prices of cereal andlivestock have declined or remained more orless stable (except for the price of bulls whichhave shown exceptional fluctuations in themonths of December 2008 and March 2009 asshown in Figure 1).The results of market assessment conductedby the World Food Programme (WFP) duringthe project year are presented in Table 1. Theseindicate that in Oromia region, the prices ofCase study: Mohamed KediroOxfam, EthiopiaMohamed Kediro is 28 years old and lives in KoreWoreda, Shifa kebele Biftu village/Got/Ganda. Hehas a family of nine (three adults and six childrenbelow the age of 18 years).Mohamed described how after the intervention,household income has increased as he is beingprovided with improved seed (malt barley) whilethe chronic problem of potable water has alsobeen addressed. Furthermore, availability ofhousehold food has increased. Mohamed hasparticipated in training on crop management.The project has provided him with financialsupport and improved seed varieties. But hereported there has been no change in his livestockmanagement, as this is not well addressedby the project.As a result of his participation in the project, hehas now accrued important productive assets –he has bought one sheep, constructed a newhouse and has bought a bed.Increased availability of foodAccording to implementing partners and beneficiariesthis has been achieved through a numberof means:• The transfer of cash resource to vulnerablehouseholds through public work hasincreased capacity of households to purchasefood items from local markets.• The provision of farm tools and equipmentenabled farmers to undertake farm activitiesmore effectively coupled with the various soiland water conservation measures, e.g. theconstruction of check dams, cut off drains, andstaple food such as maize, wheat and sorghumin quintals have generally declined over theyear of the intervention. The same pattern wasobserved in Amhara region for maize andsorghum, although the price of wheat increasedabove the normal seasonal patterns. Accordingto WFP, at national level, local prices of majorstaple foods continued to decrease as a result ofthe continued market stabilisation programmeimplemented by government and continuedfood aid interventions.Improved awareness about the benefits oforganised actionsKnowledge and awareness amongst membersof self help groups (SHG) on developmentrelated <strong>issue</strong>s has increased. Members explainthe importance of organizing into groups by alocal saying ‘Jirbiin walitti yaatee arba hiiti’,which means that ‘when threads come together,they could tie an elephant’. The group savingsinitiated in each SHG has started to play a rolein reducing the vulnerability of group membersduring production shocks. Currently all theSHGs have at least a monthly saving schemeand regular forums for discussion.hill side terraces in areas that are highlysusceptible to erosion and land degradation.These measures have led to an increase inproduction and productivity.• The training and technical support given tofarmers in improved agronomic practices likeseed beds preparation, technique of sowingseeds on the beds, mulching system, shadingsystem and improved ways of wateringseedling in different stages, have allcontributed to increased production of crops.Access to potable water supplyAccess to potable water has improved through anumber of means (more water points (faucets)and construction of pot/calabash stands) leadingto improved water consumption both during thewet and dry seasons. It was also reported thatthe use of safe water supply has significantlycontributed to improvements in health status ofpeople, as well as improved children’s schoolenrolment – particularly girls, as the time childrenspend on fetching water has decreased. Themajority of water collection trips used to take 90minutes but have now reduced to 30 minutes.Furthermore, women were spending less timequeuing.Access to local marketsThe construction and maintenance of feederroads improved access of particularly marginalisedcommunities in the intervention areas tomarket and also to other social services, such ashealth.Asset creation and ownershipMost households have created productive andnon productive assets following the projectintervention. There has also been a markedincrease in holdings of livestock and otherproductive assets and a reduction in distresssales of assets.Prices of cereals in local marketsThe situation in Kofele woreda is typical of otherworedas where the prices of cereal and livestockhave declined or remained more or less stable(except for the price of bulls which have shownexceptional fluctuations in the months ofDecember 2008 and March 2009 as shown inFigure 1).Participation of farmers in the constructionof the grain banks indicates that there is anincreased knowledge among farmers about thebenefits of being organised and workingtogether in grain marketing, as they are now ina better position to influence the market.Saving patternsReview of the available data indicates that thereis still a low level of household saving. Forinstance, the saving and investment of heads ofhouseholds in Bugna woreda for the month ofMarch 2009 show that 100 heads of householdssaved/invested a total of 1,657 birr, i.e. 16.57birr per household. In Arsi Negelle woreda inFebruary 2009, only 160 birr saved/ invested by189 households, i.e. 0.846 birr per household.Changes in gender relationsInterventions in high value crop promotion,public works and cash transfers, potable watersupply and the support to off-farm incomegenerating activities have all enabled women toaddress both their practical and strategic needs.Women have been equipped with important lifeskills in areas such as small scale businessdevelopment, entrepreneurship, petty tradingand the production of vegetables and fruits.There are clear indications of changesregarding women’s participation in communitylevel processes, including political participationand leadership. Interventions have also startedto change gender based division of labour, withmen and boys now assisting women and girlsin household activities such as fetching water.There has also been a significant shift in decision-making.More than half of women nowdecide whether or not to participate in communityaffairs. A considerable number of womenare now members of either committees or leadersof community organisations, including theirsaving and credit cooperatives, and are free tomake decisions either to join such communityorganisations or not. Some of the womenpointed out that because they are now economicallyin a better position, they can expressthemselves more freely and forcibly.Key challengesDue to increasing food prices, the cashprovided through cash for work programmes isbecoming inadequate to enable recipients topurchase foods similar to those provided in afood for work programme, thereby discouragingparticipation in the programme. Managingfood price instability is a long standing policychallenge. With mixed experiences of agriculturalprice policy reforms, this has re-emergedas a contemporary policy <strong>issue</strong>.The project targeted only a portion of thetotal population in the woredas worst hit by thefood crisis. There has been an increasingdemand, particularly for financial support fromthose areas in the woreda that were not targetedby the project. This has led to a situation wherenumbers enrolled in public work activities havein some cases almost doubled compared toplanned number of beneficiaries. This dilutesfinancial resources transferred per head.Stakeholders, government and the communityhave limited experience, as well as capacity,to effectively manage public work activities andcash transfers to vulnerable groups. This has, insome cases, resulted in the late or untimelydelivery of project inputs to beneficiaries.Furthermore, price inflation of important projectinputs has forced project expenditures over andabove the planned budget.19

Field ArticleTable 1: Prices of cereals in selected regions in April, 2010Markets Major Current Price change (%) Average ChangeCommodity Price1Y 6M 1M 1Y 6M 1M4. Regional average (BIRR/100KG)Oromia Maize 406 -11.0 -13.6 -4.1Wheat 550 0.6 -17.5 -8.3Sorghum 403 -22.7 -25.5 -1.6Tigray Maize 432 -18.9 -29.4 7.3Wheat 592 0.9 -22.0 -9.9Sorghum 486 -11.4 -26.9 -11.5Somali Maize 390 -23.5 -1.9 -4.9Wheat 375 -39.5 -22.7 -21.1Sorghum 300 -31.8 -50.8 -15.2SNNPR Maize 362 -21.1 10.2 -5.2Wheat 578 -7.5 -2.0 5.6Sorghum 385 -6.1 -11.5 0.0Amahara Maize 413 -6.4 -11.4 -3.2Wheat 578 18.0 10.3 8.9Sorghum 450 -13.1 0.0 -16.5Note: Price increase above normal fluctuationNormal price fluctuationPrice decrease below normal price fluctuationY: year; M: monthOxfam, Ethiopia, 2008Figure 1: Average price of livestock and crops in local markets in Kofele wereda6000500040003000200010000Nov. 08Dec. 08Jan. 09Feb. 09Mar. 09Apr. 09May. 09Jun. 09Jul. 09Aug. 09Sep. 09Oct. 09Source: ROBA, Monthly Market Assessment DataMaking modern bee hivesBullCowHeiferSheep/goatDonkeyHorse/muleWheat (Quintal)Quintal of barleyQuintal of maizeQuintal of beansQuintal of malt barleyLessons learnedHouseholds who are poorer in terms of ownershipof physical assets are less able to applyresource management practices (such as landmanagement, improved farming practices, etc)and hence they obtain lower yield and lowerincome.Facilitating rural credit facilities and providingcredit support to poor rural communitiescontributes towards enhancing their involvementin different income generating activitiesthat increase income level.Farmers’ access to credit should be improvedthrough the formation of saving and creditgroups/cooperatives. More saving and creditcooperatives should be established and theirinstitutional capacity built up through training,provision of materials, seed, money or workingcapital.The onset of natural disasters presents newopportunities for microfinance institutions(MFI) especially in rural areas. MFIs can act as alogical mechanism for disaster relief, reconstruction,rehabilitation, and development.Disaster-oriented microfinance services may bein the form of new and temporary servicesdeveloped as a post-disaster response, or as partof the menu of services already being providedby the institution. Microfinance programmesthat target female clients are likely to have thegreatest impact on household well being.Relief and development are not separateentities. They are interdependent and should beconsidered as such when planning and implementingprojects.Some vulnerable households are labourconstrained and hence may not be able toprovide the labour required to participate inpublic works. Hence there is likelihood thatchildren under the age of 18 become involvedin public work programmes. Additional informationis required to determine whetherchildren have participated in cash for workprogrammes or not. Other data such as schoolparticipation of children and the work loads ofwomen and girls should also be collected andanalyzed to monitor and mitigate unintendedoutcomes.Implementing this type of project within ashort time-frame is a challenge, as there islimited time for community sensitisation,organisation, mobilisation, monitoring andtraining. More time should be allocated toensure effective implementation, follow-up andsupport, as well as to assess progress and monitorimpacts.ConclusionsThe project has made significant contributions inprotecting consumption during times of foodcrisis and also saving beneficiaries’ by providingcash, credit/loan and other agricultural inputslike high value seeds and farm tools. This hasenabled beneficiaries not only to protect theirassets but to go beyond that to create/buildadditional productive and non-productive assetsin a short period of time. All of the importantresults and outcomes achieved so far have positivelyimpacted on the capacity of thecommunity to prevent, manage and mitigatevulnerability and shocks. Project interventionshave contributed to the gradual stabilisation ofmarket prices of major agricultural commodities,which in turn improved the access of householdsto food and enabled them to buy goods atreasonable prices. However, the problems ofchronic vulnerability and high level malnutritionstill persist in the project intervention areas.More efforts are required to understand andrespond to this chronic vulnerability.The project also contributed to the countries’awareness of social protection, the ways inwhich it could be implemented, and the opportunitiesfor poverty reduction that it offers. Thismade the project a welcome support for policydialogue, demonstrating the possibilities ofimplementing social protection programmes inthe country.The added value of the project is that ithelped maximise opportunities for high-valuecrop production as an alternative source ofincome by building the capacity of farmers andfarmer-led local institutions. The promotion ofmarket-oriented agricultural products, such ashigh-value crops, is of paramount importancein the process of quickly changing the lives offarmers who struggle to get out of extremepoverty and vulnerability.Activities undertaken have directlycontributed to improvement in the access ofhouseholds to local markets. However, theadoption of improved agricultural technologiesin general and the use of improved essentialagricultural inputs- including organic fertilizer,in particular, is minimal among farmers in theproject intervention areas.In order to improve farmers’ access to inputsand to markets, future programmes in the areashould build the institutional capacity of localgovernment, community-based organizationssuch as service cooperatives and saving andcredit associations. Efforts should be exerted tointroduce a number of new and improved technologiesto the farming system in the woredas.In order for the Agricultural Scale Upprogramme and EFSLP to become the countryapproach, Oxfam recognise the need to comeup with evidence of impact for Governmentand donors. Oxfam are no longer alone in advocatingthis approach. The World Bank hasrecently invested 300 million dollars into anagricultural growth programme (AGP) thattargets food secure districts. Oxfam staff havebeen employed as consultants to work on anAGP operations manual.Disseminating lessons to government hasbeen slow although Oxfam have convened thefirst forum on agriculture, which has beenfollowed by two GoE led national forums. TheOxfam approach converges well with GoE’sPASDEP 1 (Poverty Reduction Policy) whichadvocates for agricultural development ledindustrialisation.This programme has managed to integratehumanitarian activities into a developmentproject by transferring resources in a differentway. Oxfam are hopeful that the approach willcontinue to be emulated by other agenciesincluding Government.For more information, contact: Shekhar Anand,email: sanand22@hotmail.com1Plan for Accelerated and Sustained Development to EndPoverty20

Agency ProfileProfile andoverview ofthe church’srole inemergencyresponseWhen Dhabe’s pastoralist Borana community lost many of their cattleduring a drought, EEC-MYs cash–for-work scheme offered them a lifeline,enabling them to buy food and put in place measures to reducethe impact of future disasters.Christian Aid / Caroline WatermanBy Deed Jaldessa and Debela KeneaDeed Jaldessa has over two decades experience in developmentwork in rural Ethiopia and currently leads TheEthiopian Evangelical Church Mekane Yesus Developmentand Social Services Commission (EECMY-DASSC) as anational Director. He has a BSc in Agriculture and a M.Sc. inNatural Resources management and sustainable agriculture.Debela Kenea is Relief Programme Coordinator with theEECMY-DASSC. Born to a livestock rearing pastoralist familyin a very remote, dry and harsh environment in southernEthiopia, he is one of the luckiest children born in that areato be educated through the work of Norwegian LutheranMission and Ethiopian Evangelical Church Mekane.We acknowledge invaluable support of many organisations and individuals.To mention a few related to current relief and rehabilitation programmes:UNOCHA/Christian AID, Act alliance, and Finchurchaid. Our words of appreciationalso go to Mrs. Carmel Dolan for encouraging us to prepare the articleand facilitating its publication and for her vital editorial inputs. Our thanksgo to Ms. Marie McGrath for follow-up of the process and importantreminders to finalise the work.The Ethiopian Evangelical Church MekaneYesus (EECMY) was established as anational church in Ethiopia in January1959. As part of the mission of the church,EECMY set out to work in the areas of health,education and community development underits Development Department. This gave birth toa full incorporation of the ‘Holistic Ministry’concept of the church, developed and communicatedto the Lutheran Communion (LutheranWorld Federation (LWF)) in 1972. The HolisticMinistry concept is based on the broad understandingof human needs (physical, social andspiritual). The EECMY Development and SocialServices Commission (EECMY-DASSC) is alegally registered 1 faith-based developmentagency that took over the responsibility of theformer Development Department of theChurch in 2000, as required by the nationalpolicy of the Ethiopian Government. TheCommission has robustly continued to work onhumanitarian emergency response to disasteraffected populations, building on strong experiencesfrom the early 1970s and mid 1980s whenthe country faced widespread famine.The EECMY-DASSC works in partnershipwith sister churches, development and humanitarianagencies in Ethiopia, Europe and NorthAmerica. It is a leading member of churchnetworks, such as the LWF, Action by ChurchesTogether (ACT) Alliance and other evangelicalfellowships in the country and abroad. Theoverall budget of the EECMY-DASSC in 2009was Ethiopian Birr 200 million (approximatelyUSD$ 12 million). These funds are raised fromdifferent sister churches, development andhumanitarian agencies operating throughoutthe country and worldwide.Five year strategyThe following programmes constitute the majorstrategic <strong>focus</strong> areas of the EECMY-DASSC in itscurrent five-year plan. These programme prioritiesare closely aligned with the Government‘spoverty reduction programme and theMillennium Development Goals (MDGs):1. Socio-economic development (food security,water supply, gender equality, environmentalprotection, income generation)2. Health and HIV/AIDS prevention andcontrol3. Capacity building4. Child and Youth Care and Development5. Education (formal, informal/literacy,vocational and special needs education)6. Emergency Relief Response, Disaster RiskReduction and Rehabilitation.The EECMY-DASSC works through branchoffices in 21 synods, which are local churchunits geographically located throughout thecountry. In total, the EECMY has 5.3 millionchurch members representing around 7 per centof the total population of Ethiopia.Emergency relief and rehabilitationEmergency relief is a vital part of EECMY-DASSC’s work to respond to urgenthumanitarian and further rehabilitation needs.The emergency relief response is aimed atproviding resources either directly or in coordinationwith other national and internationalsister churches and NGOs to support emer-gency affected people who cannot survivewithout assistance. Beside the emergencyresponses to urgent needs, EECMY-DASSC alsoimplements short and long term rehabilitationprogrammes <strong>focus</strong>ing on capacity building ofthose affected and their local communities, TheCommission works with Government linedepartments to secure necessary permissionsand also to ensure that services are not beingduplicated but well coordinated with otherrelief agencies. Most importantly, theCommission consult and participate with thecommunities to ensure transparency and sothat the aid provided helps meet their needs.Targeting and implementationThe overall national targeting for emergencyassistance is carried out by the Government’sDisaster Risk Management and Food SecuritySector (DRMFSS) through twice-yearly foodsecurity assessments. Household beneficiariesare targeted, screened and registered by thecommunity based participatory task force inworedas (districts) in need. The major part ofthe humanitarian response is usually coveredby the Government. The Church’s response isrequired in situations where the relevant1In accordance to the Government’s law for non-governmental organisation (NGO’s) registration for legal license,EECMY-DASSC was registered and certified by the Ministryof Justice as a development wing of the EECMY in 2000.Table 1: Humanitarian assistance by EECMY-DASSC in Ethiopia (October 2010)Region/DistrictType ofemergencyPopulationtargetedType of responseOromia region- Gasera &Madwalbu districtsSNPP Region- Aleta WandodistrictFlood anddrought17,901 General and supplementaryfood distributionDrought 20,000 General and supplementaryfood distributionSNPP Region- Yirgachaffee Drought 20,380 General and supplementaryfood distributionSNNP Region- Burji specialdistrictDrought 18,000 General and supplementaryfood distributionAmhara region- Bati district Drought 32,143 General and supplementaryfood distributionGambella region- Jikawo District Drought 15,894 General and supplementaryfood distributionGambella region Akobo DistrictTribalconflictType of responseWabe Batu synodSouth Central EthiopiaSynodSouth SynodAmaro synodNorth Central EthiopiaSynodWestern GambellaBethel Synod7,020 Non food items Western GambellaBethel SynodGambella region- Itang District Flood 10,500 Disaster Risk Management East Gambella BethelSynod21

government department, such as theDRMFSS, is unable to reach an area or needsthe support of the Church to mount aresponse. In 2009, the EECMY-DASSCresponded to emergencies in 10 woredas,reaching a total of 141,838 people with foodaid 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 supportedby the EECMY-DASSC and implemented bythe Commission’s synod offices in six differentregions of the country experiencingemergencies (see Table 1). The Commission’ssynod offices are the agents responsiblelocally for planning, implementation andsupervision of humanitarian aid in theirrespective operational areas. They also ensurecommunity and other stakeholder’s participationin decision making and providingcoordinated assistance.The EECMY-DASSC has a responsibility toensure compliance with the rules, regulationsand codes of conduct in the implementation ofprogrammes. It provides staff training toensure that they are responsible and qualifiedfor the task. Further training and capacitybuilding supports are also given to localfarmer’s association leaders, to coordinationmembers of the district task force for aid workand to other local line departments’ staff toensure that they can fulfil their responsibilityChallenges and opportunities for thefutureDelays in assessment of an emergency oftendelay the actions needed to meet criticalneeds. EECMY- DASSC will need tostrengthen its skilled human power and financialcapacity for rapid assessment, as well asits capacity to mount even more effectiveresponses in the food and nutrition sector.In many affected woredas, the community’snormal means of accessing food iscompromised by both slow and rapid onset ofdisasters. Looking back over the past years,the Churches’ contribution to food securityrelatedemergency response has beenconsiderable. To strengthen EECMY-DASSCsresponse in the future, it is important for theEECMY–DASSC to consider increasing itscapacity in a range of response and programmingareas based on a clear analysis of risksand needs. These will include:• General food distribution (free) based onthe level of the food insecurity analysis• NFIs provision• Emergency nutrition interventions• Seeds, farm tools and restocking ofanimals (goats, sheep and milk cows, oxen)• Income diversity through self-employment• Building community capacity in disasterrisk reduction and management• Provide assistance for environmentalrehabilitation and further rural/agricultural developmentAnother area in which EECMY-DASSC wouldlike to grow capacity is emergency nutritionand health support in marginal areas and inareas where displacement occurs due to variousdisasters.For more information, contact: Deed Jaldessa,email: deedja@eecmy.orgEmma Proud, Ethiopia, 2010Cash for work beneficiariesdigging soil bunds in Gashamo,Somali Region, to regeneratethe rangelandThe RAIN programmeBy Miriam Christensen and Todd FlowerMiriam Christensen was theDocumentation and InformationOfficer with the RAIN programme.She specialises in communicationsand knowledge management.Miriam now works with theInternational Labour Organisationand is based in Tanzania.The authors acknowledge the support of the U.S. Agency for InternationalDevelopment and the Office of Foreign Disaster Assistance.Rises in global food prices have led toan increase in vulnerability forareas of the world that are net foodimporters, which includes manycountries in Africa. In Ethiopia, pastoralistsand agro-pastoralist households depend on adelicate balance of trade to be able topurchase their household food requirementsbased on the value of their animal herds. Ifthe prices of animals do not also rise with theprices of staple foods, then these householdscan struggle to meet their needs.The United States Agency forInternational Development (USAID) throughthe Office of Foreign Disaster Assistance(OFDA) has been providing support tocommunities in Ethiopia for many yearsthrough short-term emergency assistanceprogrammes, such as emergency vaccinationor nutrition campaigns. These programmeshave traditionally lasted from 6 to 12 months.The global food price crisis brought about achange in these programmes, with developmentof a longer term vision of assistingpeople and communities to remove themselvesfrom the cycle of emergencyassistance.It is in this context that Mercy Corps isimplementing the Revitalising Agricultural/pastoral Incomes and New markets (RAIN)programme, a multimillion dollar OFDA/Field ArticleTodd Flower is the Chief ofParty of the RAIN programmeand has extensive experiencein implementing and managinginternational agriculturaldevelopment projects. Hespecialises in agriculturalmarket development.USAID funded programme. The RAINprogramme is being implemented for threeyears from 2009 to 2012. It is clusteredaround an inter-linked geographic areaconnecting one zone in the Oromia regionwith four bordering zones of the Somaliregion. RAIN seeks to protect, promote, anddiversify livelihoods in this strategic clusteras a means of increasing households’resilience to shocks. The RAIN programmeworks in the transitional environment fromemergency to development programmes bycombining traditional emergency interventionswith longer-term developmentactivities. This seeks to address both theimmediate needs of communities and also topromote sustainable local economic developmentand integration. Some of theseactivities include cash for work, emergencyanimal vaccination campaigns, value chainanalyses, linking producers to markets, andthe establishment of a microfinance institutionto increase access to credit. The RAINprogramme is targeting over 700,000 peoplewith these activities.RAIN objectivesThe programme has two objectives:• To protect the agricultural and pastoralproductive asset base of food insecurehouseholds to prepare them forparticipation in more profitable markets22

Emma Proud, Ethiopia, 2009Field ArticleVaccination campaign inGashamo, Somali Region• To increase and diversify the asset base offood insecure households via immediateeconomic opportunities and the developmentof high impact agriculture and nonagriculturalmarkets, that spurs privatesector investment and local economicgrowth.Implementation: natural resourcemanagementDuring the first year and under the mandate ofthe first objective, projects such as cash forwork, seasonal and emergency vaccinationcampaigns and training of community animalhealth workers were implemented. Over 1.5million animals received vaccinations thatassisted 160,000 households and so far, morethan 9,000 people have been employed underthe cash for work component of theprogramme. While such activities have beengoing on in the region for many years as individualprojects, it is the first time that such arange has been brought together under theumbrella of one programme.All cash for work activities have <strong>focus</strong>ed onnatural resource management to provide immediateassistance for poor households and toensure that resources are developed for thebenefit of the community. Natural resourcemanagement projects include activities likepond rehabilitation or other earth works thatreduce the threat of flash flooding or drought.All natural resource management activities areidentified by the participating communitythrough a community action plan. The RAINteam works together with communities on assetand risk mapping and needs assessment. Cashfor work is utilised to assist poor households torebuild their assets and pay off debts. Poorhouseholds are much more likely to be riskaverse and unable to take chances on newmarket opportunities. The cash for work helpsthese households to become more secure so thatthey can participate in profitable markets.Implementation: a market ledapproachThe second objective, to strengtheneconomic recovery and marketsystems, is what makes RAINdramatically different from traditionalOFDA funded projects.Working on market system development<strong>focus</strong>es on the long-termapproach, rather than immediate,emergency interventions.Traditional emergency approachestend to have non-governmentalorganisations (NGOs) providingservices directly. A market basedapproach, however, puts the ‘exitstrategy’ first and aims to strengthenthe local market to provide access togoods and services, so that NGOs donot have to in the future.The RAIN programme <strong>focus</strong>es onmarket systems and providessupport by creating linkagesbetween various market participants.In the first year of theprogramme, several value chainswere identified and evaluatedincluding live animals, hides andskins, milk, fruits and vegetables,and peanuts. These value chainswere selected for evaluation becausethey had the highest potential toprovide benefit for the poor in the programmearea. At least one of these commodities is animportant income source in all of the communitieswhere the programme is working.The value chain analyses included interviewswith government, private sector andcommunity members. A common theme to allof these evaluations was that farmers do nothave access to the inputs they require to investin the production of large quantities of highquality products. The RAIN programme istargeting access to agricultural input suppliesto assist producers to be able to meet availablemarket demand. Most of the markets in thisarea are considered informal, with lots of smallscale transactions in many local markets. Thereare very few large, formal businesses workingin the area. This has left the RAIN programmeto <strong>focus</strong> on the production side of the valuechain for most of these commodities. Demandis considered strong for all of these commodities.This means that any increase in productionthrough intensification and improving access tothe means of production, agricultural inputsand knowledge, will lead to a cycle of continuousupgrading for producers.Producers not only need access to agriculturalinputs but they also need informationabout how to use these inputs effectively andinformation about market demand. The RAINprogramme is working with the private sectorbecause these are the market players whoshould offer matching incentives to the producers.If the producer does well, then the inputsupplier will sell more inputs to that producer.The RAIN programme is identifying these ‘winwin’situations to improve the functionality ofthe market.The RAIN programme views the producersas customers with demands and works to linkprivate suppliers to the customers. A traditionalemergency approach might include the distributionof needed inputs by an NGO. However,this tends to lead to low investment in the longterm because the producers are unaware ofwhere they can purchase these inputs in thefuture. It is also often the case that the emergencyapproach leads to ‘dependencysyndrome’ where producers wait for the nextdistribution to occur. The RAIN programme istaking a facilitation approach to ensure sustainabilityby working with the private sector toinvest in the region.RAIN in action: the peanut chainAnother example of RAIN programme activitiesin market development is in peanuts. TheRAIN programme is working on supplythrough the agricultural input market but alsoon the demand, by connecting farmers to a leadfirm. Lead firms are identified by size (i.e.number of members of a producer’s cooperative)and their influence (i.e. whether they setthe standard for the market). RAIN set a strategicgoal to increase the competitiveness of theregional peanut sector by reducing losses,increasing production efficiency, upgradingwarehousing and storage, strengtheningmanagement capability, and facilitating linkagesto higher value markets.The RAIN programme is working with theAfran Kallo Union (AKU) and Hilina EnrichedFoods Processing Centre plc to increase incomefor peanut producers in the programme area.AKU is a union of peanut suppliers with 68member cooperatives that represent approximately48,000 individual members. HilinaEnriched Foods is a manufacturer of a ready-tousetherapeutic food (RUTF) 1 used to treatseverely malnourished children. The relationshipbetween these producers and the companywas a very typical situation. Hilina could notsource enough peanuts on the local market thatmet their stringent standards and the AKU wasunaware of the standards and available prices.Low prices on the local market led to lowinvestment by producers in production,harvest, and storage. Considering these needsgaps and opportunities, the two partners wereidentified as ideal candidates for support fromthe RAIN programme.1Plumpy’nutLoading vaccination forlivestock campaign inGashamo, SomaliRegionEmma Proud, Ethiopia, 200923

Field ArticleSeed fair beneficiary evaluatingquality of seed before purchasing atMidegatola woreda, East HarargheThe RAIN programme facilitated the signingof a production contract between Hilina andAKU in June 2010. Hilina and AKU signed asupply agreement at a 10 to 15 percent marketpremium starting July 2010. The RAINprogramme also coordinated a production andpost-harvest loss prevention training carriedout by Hilina technicians and fully paid for byAKU and Hilina. By again aligning marketincentives, the RAIN programme has been ableto create conditions where participants are willingto invest in constant upgrading to meet thisnew market demand. The RAIN programme isproviding additional support to this market byproviding a research grant for improved peanutproduction at a local university and by identifyinginput suppliers for the cooperativemembers for access to improved seeds. Finally,RAIN will supply a management consultant toensure AKU’s management team is proactivelyable to seek solutions to members’ productionand post-harvest needs in meeting with marketdemand. This consultant will help the AKUBoard, managers and members establishmanagement structures, responsibilities andtargets conducive to more proactive andresponsive leadership.In short, the RAIN programme seeks to createspace and opportunities for market-drivensystems using facilitation techniques to impactthe targeted value chains. As the peanut chainexample illustrates, the programme does this byidentifying incentive structures and working toalign them to create investment. The programmealso works to reduce risks for all participants inthe market to stimulate new market transactions.Emma Proud, Ethiopia, 2010One of the goals for theremainder of the RAINprogramme is to continueto <strong>focus</strong> on market developmentand build on thesuccesses to increase theimpact of the project in theregion. This will leavebehind better functioningmarkets that in turncontribute to sustainablelivelihoods.RAIN and microfinanceProviding access to marketsand inputs does not alwaysallow producers to invest in these opportunities.To complement these activities, the RAINprogramme is developing the first microfinanceinstitution in the Somali region to provideaccess to credit. The RAIN programme startedwith the intent of providing loan guarantees forproducer and income generating groups but itwas quickly realised that there were no microfinanceinstitutions working in the region. TheRAIN programme began working with thegovernment of the Somali region to establish anew institution, which was one of the first goalsof the new president of the region. The RAINprogramme has been providing technicalsupport by working with the national bank andregional government to create all of the documentationrequired, including a business planand memorandum of association. The RAINprogramme also provided a technical expert towork directly with the government on makingtheir budget request for the loan capital fromthe federal budget. The government has sinceheld a general assembly meeting which votedin favour of all of the documentation required,election of the new board of directors, andapproval of the shares to be distributed to thegovernment and private investors. It isexpected that the new institution will be operationalby the end of 2010.Lessons learnedThe RAIN programme has reached the halfwaypoint of implementation and many lessonshave been learned. It is often difficult to transitionstaff into a new approach. When peoplehave worked for many years on emergencyprogrammes, they are often convinced thatapproach is the best method for providingbenefits to needy people. The RAINprogramme not only had to demonstratesuccess in the project area to convince people ofthe approach, but those successes were just asnecessary for convincing staff of a new methodof operation.Agricultural markets in Ethiopia are fragmentedinto several regions. The Somali regionof Ethiopia tends to do business withSomaliland instead of selling commoditiesinternally to the rest of the country. This is dueto cultural relationships on both sides of theborder and better access and proximity to thosemarkets. The RAIN programme is workingwith producers to provide better qualitycommodities in these markets but is unable towork with the end market of commodities, likelivestock and milk, due to funding constraintsfor working across borders.Like many countries in Africa, the agriculturalinput market is highly regulated and insome cases, such as fertiliser, controlled by thegovernment. The market place for these productsbecomes a self fulfilling prophecy for thegovernment. The government believes that theprivate sector cannot provide these products ata low enough price to the producers so it stepsinto the market to provide the service directly.The private sector is then unable to competewith the government so it remains unable toprovide services and products to the producers.The RAIN programme is working to identifyexisting private sector suppliers that offer productsthat are not in direct competition with thegovernment suppliers. The programme willdemonstrate that the private sector can competeand provide benefits to producers with theseproducts. The private sector will then be in abetter position to demonstrate to the governmentthat it has the capacity to provide servicesmore efficiently.The RAIN programme is taking a holisticview of the needs of the target region andproviding emergency assistance where needed,connecting people to profitable markets, andassisting people to access capital needs forinvestment.For more information, contact: Todd Flower,email: tflower@et.mercycorps.orgEmma Proud, Ethiopia, 2010Seed fair beneficiaries queuing topurchase seed at Midegatolaworeda, East Hararghe.24

Field ArticleEmergency Food Security andLivelihoods Project in Amharaand Oromia regionsBy Sarah Coll-Black andMatt HobsonSarah Coll-Black is a Social Protection<strong>Special</strong>ist working with the WorldBank in Ethiopia and Kenya. She hasbeen involved with Ethiopia’sProductive Safety Net Programme(PSNP) since 2007, initially as amember of the PSNP DonorCoordination Team and then with theWorld Bank PSNP Task Team. She holdsan MPhil from the Institute ofDevelopment Studies, University ofSussex.Fiona Quinn, EthiopiaPSNP beneficaries in TigrayMatt Hobson is the DonorCoordinator for the PSNP. Previously,he worked for Save the Children asHead of Hunger Reduction inEthiopia, as well as in Somalia, SriLanka, Afghanistan and London. Priorto this, Matt worked as a human rightslawyer in private practice.This article is based on a longer publication entitled ‘Designing andImplementing a Rural Safety Net in a Low Income Setting: LessonsLearned from Ethiopia’s Productive Safety Net Program 2005-2009’by Will Wiseman, Julie Van Domelen and Sarah Coll-Black.For generations, many rural Ethiopianshave experienced significant periodswhen they were unable to meet theirbasic food needs. For over 20 years, themain response to this situation was food aid toensure basic survival. Ethiopia has receivedmore emergency support per capita than anyother Sub-Saharan African nation, with appealsrising to 14.5 million people in some years. Onaverage, 700,000 metric tons (MT) of food aidper year have been delivered in Ethiopia since1990.Serious deficiencies with the emergencyfood aid system were increasingly clear by thelate 1990s. Despite high levels of food aid, witheach emergency rural households furtherdepleted their assets and found themselvesincreasingly vulnerable to even the mostmarginal livelihood shock. Analyses of these<strong>issue</strong>s revealed that the timeliness of food aiddeliveries was a serious deficiency in thesystem. There was also growing concern of thepotentially negative effects of such largevolumes of food aid on local food markets.By late 2003, a technical group of the NewCoalition for Food Security 1 had developed aproposal to reform the emergency appealsystem in favour of an integrated approach toreducing vulnerability and food insecurity. Thisapproach brought together under a singleumbrella a range of initiatives implemented bythe Government, donors and non-governmentalorganisations (NGOs).For the Government, the objectives of theNew Coalition for Food Security (which wasled by the Prime Minister, Ato Meles Zenawi)would be largely met through implementationof the Food Security Programme (FSP). Thisconsisted of three strategic pillars:(a) Resettling households from unsustainableand environmentally degraded lands(b) Developing a safety net for chronicallyfood insecure households(c) Supplying agricultural and financialservices to food insecure households topromote their graduation out of foodinsecurity.Of these three pillars, donors embraced thesafety net, the subsequent design of whichwassupported by a safety net donor group thatengaged intensely with Government. TheProductive Safety Net Programme (PSNP) wasdesigned from late 2003 to the end of 2004 andwas launched at scale in February 2005. It wasnot meant immediately to replace the emergencyappeal system; instead the emergencyappeal system would be gradually reducedover the course of two years.PSNP Operations (2005-2009)The objective of the PSNP (2005-2009) was toensure food consumption and prevention ofasset depletion for rural food insecure householdsin a way that stimulates markets,improves access to services and naturalresources and rehabilitates and enhances thenatural environment.The PSNP provides cash and/or food transfersto households through two mechanisms:i) Chronically food insecure households withable-bodied adults receive a transfer fortheir participation in public workii) Chronically food insecure households whocannot provide labour to public works andhave no other means of support are providedan unconditional transfer. Direct supportbeneficiaries include, but are not limited to,orphans, pregnant and nursing mothers,people living with disabilities, the elderly,chronically ill individuals and femaleheadedhouseholds that are labour poor.PSNP stakeholdersThe Ministry of Agriculture and RuralDevelopment (MOARD) is responsible for themanagement of the PSNP, with the DisasterRisk Management and Food Security Sector(DRMFSS) responsible for overall programmecoordination.The Food Security Co-ordination Directorateis one of two Directorates that report to theDRMFSS and is the main implementingDirectorate for the PSNP. The Early Warningand Response Directorate (EWRD), which is thesecond Directorate under DRMFSS, providesaccurate and timely early warning informationfor the PSNP Risk Financing Mechanism (RF)and ensures linkages between PSNP RF andother humanitarian response activities. TheNatural Resource Management Directorate(NRMD) within MOARD is responsible forcoordination and oversight of the public works.The Ministry of Finance and EconomicDevelopment (MOFED) oversees financialmanagement of the programme and disbursescash resources to implementing federalministries and to the regions based on theannual plan submitted by MOARD.These federal implementation arrangementsare replicated by regions and woredas (theGovernment’s smallest administrative unit). Inaddition to programme implementation,regional and woreda bodies are responsible forensuring sound multi-sectoral coordination of1The coalition was established in 2003 to foster partnershipsto take action to lessen the impact of droughts,improve livelihoods and ensure that communities haveadequate food supplies. Funding support is from UNDP,OFDA and the World Bank.25

Field Articlethe public works. Public works planning andselection of PSNP beneficiaries occur withincommunities and kebeles.Table 1: Examples of the types of Public Works outcomes and activities communities may selectWithin this framework, non-governmentalorganisations (NGOs) and the World FoodProgramme (WFP) play important roles inimplementation because of their experiencedelivering food aid and the institutionalrequirements of some donor agencies to channelresources through NGOs. In addition,NGOs and WFP provide technical assistance tothe programme, and WFP supports theGovernment in procuring food stocks fromabroad.Donor agencies have pooled their financing– both cash and in-kind contributions – andformulated a unified stream of technical advicein support of a single programme led byGovernment. This has been led by the creationof a Donor Co-ordination Unit, expressly for thepurpose of harmonising donor positions,providing technical support to the programmeand managing all donor-to-donor and donorto-Governmentprocesses. The rights,obligations and coordination arrangements ofthe government-donor partnership for thePSNP are articulated in a Memorandum ofUnderstanding (MoU).Programme scale and coverageIn 2009, the PSNP supported 7.6 million peoplein 290 chronically food insecure woredas ineight of the country’s 10 regions. This is equivalentto roughly 10% of the national population,covering over 40% of the country’s woredas.The geographic coverage of the PSNP is shownin Map 1.The 2009 annual budget was 2,136,734,460birr in cash and 457,966.21 MT of cereals. This isequivalent to approximately $360 million – orabout 1.2% of Ethiopia’s GDP. In addition, theGovernment estimates that roughly $54 millionin government staff time is devoted to theprogramme annually. There are at least 1,780regular staff and Technical Assistants workingon the PSNP full-time, with support from14,295 Development Agents (DAs). The PSNPis integrated into the national budget system inEthiopia.Selection of beneficiariesChronically food insecure households residingin PSNP kebeles are eligible to participate in theprogramme. The PSNP ProgrammeImplementation Manual (PIM) defines a chronicallyfood insecure household as:i) Households that have faced continuousfood shortages (usually three months offood gap or more) in the last three yearsand received food assistance prior to thecommencement of the PSNP.ii) Households that have suddenly becomemore vulnerable as a result of a severe lossof assets and are unable to supportthemselves (last 1-2 years).iii) Any household without family support andother means of social protection andsupport.Based on these criteria, households are selectedto participate in the PSNP through a community-basedselection process. Once selected toparticipate in the PSNP, households areassigned to Public Works or Direct Supportdepending on the number of able-bodiedmembers.According to the PIM, households graduatefrom the PSNP when they are food sufficient,which is defined as “when a household is ableto feed itself for 12 months a year, in the absenceof programme support, as well as being able towithstand modest shocks.” A household’s foodsecurity status is assessed using a set of predeterminedregional “asset-based benchmarks”that are tailored to local conditions. Data arecollected by DAs and verified by kebele andworeda officials and vetted in communitymeetings.Regardless of whether they are PSNP participants,any households that are unhappy withthe outcome of the targeting and graduationprocesses are entitled to bring their grievancesbefore the PSNP Kebele Appeal Committee(KAC).Type, amount and timing of transfersTransfers are provided to households on amonthly basis for six consecutive months. In2009, the daily cash wage rate was 10 EBR andthe food transfer was 3 kg of cereal. Each PublicWorks household member is entitled to receivea transfer based on five days of work at theprevailing cash or food wage rate. Householdsare provided transfers of cash, food, or a temporarymix of both resources. The mix of cash andBox 1: Key indicators of the PSNP 2005-2009• 90% of PSNP participants achieve 12 monthsfood access from all sources, including PSNP,from December 2008 onwards.• 65% of households report no distress sales ofassets to meet food needs by December 2009.• 25% increase in volume of locally producedgrain in local markets by December 2009.• 75% of households in PSNP woredas reportimproved use of health and education servicesattributable to PSNP by December 2009.• 75% of households in PSNP woredas reportimproved availability of clean water andlivestock fodder by December 2009.• 90% of PSNP participants and non-participantsreport improvement in local vegetationcoverage of hillsides by December 2009.food resources tends to be used in a way thataddresses the seasonal rise in food prices leadingup to the hungry season.Public works are carried out from January toJune, during the agricultural slack season,which is relatively dry. Transfers are deliveredon a monthly basis.Operating procedures for public worksPublic works are identified and plannedthrough a participatory process at communitylevel. The Government’s Community-BasedParticipatory Watershed DevelopmentPlanning (CBPWDP) approach is the basis fordeveloping a pipeline of sub-projects, many ofwhich have a soil and water conservation <strong>focus</strong>.The woreda public works plan is integratedinto woreda development plans to ensure linkageswith other sectoral investments.Tailoring the PSNP to specific groupsThe PSNP includes a pastoral programme thataddresses the different risks and vulnerabilitiesof pastoral livelihoods in the regions of Afarand Somali and pastoral areas of Oromia, andSouthern Nations, Nationalities and PeoplesRegion (SNNPR). The programme uses publicworks and transfer payment mechanismstailored to the needs of pastoralists. It is alsoTable 1: Examples of the types of Public Worksoutcomes and activities communities may selectOutcomesCommunity Levelsub-projectsImproved landproductivity, soil fertilityrestoration and increasedland availabilityImproved marketinfrastructureImproved access todrinking and irrigationwaterIncreased availability offodderHigh school enrolmentand improvement healthstandardsArea closures, soil andwater conservationCommunity roadsCommunity water projectssuch as stream diversion,spring development,shallow wellsArea closure incorporatingconservation measuresRehabilitating, extendingand constructing primaryschools26

Field ArticleTable 2: Household consumption, assets andland access in PSNP woredas, by PSNPbeneficiary status, 2008Economic CharacteristicsTotal consumption (birr) permonth, averageHouseholdDirectSupportPublicWorksNon-PSNP627 1012 1111Land (hectares), average 1.0 1.1 1.4Assets (birr), average 2349 4568 6480designed to fit more organically with the institutionalstructures in these areas.PSNP responds to the heavy workload ofproductive and reproductive labour carried bywomen in rural Ethiopia by allowing women towork fewer hours than men for the same payand permitting them to switch to DirectSupport when pregnant or breastfeeding.PSNP risk financing mechanismsThe PSNP includes a contingency budgetequivalent to 20% of the base programme costand a risk financing facility designed torespond to transitory needs in chronically foodinsecure woredas. When households are unableto meet their immediate food needs because ofshocks, these households are described as beingtransitory food insecure.Of the contingency budget, 15% is held atregional level and 5% at woreda level. Theworeda contingency fund is used to addressunexpected needs of chronically food insecurehouseholds, such as a successful appeal to theKAC, and transitory food insecurity amongPSNP and non-PSNP households. The regionalcontingency fund is used to address transitoryfood insecurity among PSNP and non-PSNPhouseholds in PSNP woredas.The Government is currently operationalisingthe Risk Financing Mechanism to addresstransitory needs in PSNP woredas. This mechanismis designed to scale up the PSNP to covertransitory food insecure kebeles as needed, aswell as to extend the duration of benefits forexisting PSNP households, if needed.Monitoring and evaluationThe PSNP key performance indicators areprovided in Box 1. Given the flagship nature ofthe PSNP, much attention was, and continues tobe, devoted to generating robust evaluations. Aset of impact evaluations aims to measurechanges for direct and indirect beneficiaries.Design <strong>issue</strong>s and trade-offsIn 2004, the Government proposed a caseloadof 5 million chronically food insecure individuals.Donor agencies saw this figure as aminimum, with the actual number of chronicallyfood insecure people probably closer to 7.9Table 3: Use of regional contingency 2005-2008million. The PSNP <strong>focus</strong>ed on those regions andworedas that had received food aid for thepreceding three years or longer. Woreda administratorsthen selected the chronically foodinsecure kebeles, assigning the woreda’s ‘PSNPquota’ from among these areas.Within targeted woredas, chronic food insecuritywas widespread but budget constraintsrequired targeting households most in need.Within the food insecure woredas, householdeligibility criteria were reinforced by a community-basedselection process endorsed throughcommunity meetings. In addition, the wage ratefor public works sub-projects was set low so thatbetter-off households would be less tempted toseek employment through the PSNP.The annual retargeting was designed tocorrect for inclusion and exclusion errors andthus responded to changes in the relative positionsof households. A contingency budget of20% was added to the programme to coveradditional households that might becomechronically food insecure during the course ofthe program and to respond to transitory needsamong PSNP and non-PSNP households. In2006, this was augmented by the Risk FinancingFacility. The emergency response system wouldcover any transitory food insecurity beyond theavailable contingency and risk financingresources.The emergency response system would alsocontinue to cover food insecurity in non-PSNPworedas.Targeting the PSNPIn 2005, the number of households selected toparticipate in the PSNP by communities andkebeles was almost always larger than thequotas assigned by the region and woreda.Recognising the scale of exclusion inprogramme areas, the Government and donorsagreed that the October 2005 community-basedtargeting process would identify the actualnumber of chronically food insecure individuals.The Government and donors were thereforeconfident that the programme could handle alarger caseload, which was eventually (2009) setat 8.29 million people. The increase in beneficiarynumbers eased the pressure on the targetingsystem significantly.Evidence from 2008 shows that the PSNP iswell targeted to the poorest households inPSNP woredas, which have significantly lowerincomes, fewer assets and farm less land thannon-beneficiaries (Table 2). A 2008 survey oflocal service delivery in Ethiopia reported thatover 85% of respondents described the PSNPselection process as being fair.Responding to transitory needsIn 2005 and 2006, the contingency budget wasmainly used to cover additional chronically2005 2006 2007 2008No. ofbeneficaries% of regularprogrammeNo. ofbeneficaries% of regularprogrammeNo. ofbeneficaries% of regularprogrammeNo. ofbeneficariesAmhara 65,522 3% 321,160 13%Oromia 104,015 10% 219,187 16% 331,117 24% 294,859 21%SNNP 0% 132,441 10% 292,620 23% 371,457 29%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%Harari 0 0% 0 0% 0 0% 752 5%TOTAL 320,415 7% 735,618 11% 1,088,208 16% 1,486,694 22%% of regularprogrammefood insecure households and only evolvedinto a transitory response instrument in 2007. In2007, the Government proposed that theregional contingency budgets cover transitoryfood insecure households in areas where thenumbers identified by the emergency needsassessment were within this resource envelope.An emergency appeal would then be launchedonly for areas outside the PSNP.Since the start of the PSNP, the relationshipbetween the emergency response system andthe PSNP has been far from clear. Extensivedialogue between the FSCB, DPPA and donorsfinally led to an agreement in mid-2008 thatavailable regional contingency budgets wouldbe used to respond to emergency needs arisingfrom the failure of the small rains (belg) andfood price inflation. The number of peoplebenefiting from contingency resources from2005 to 2008 is shown in Table 3. These figuressuggest that the population covered by theregional contingency budget has grown incomparison with the regular PSNP programme.Types of transfersImplementation experienceStarting in 2004, food prices in Ethiopia beganto rise, spiking in mid-2005 and again in mid-2006. In both years, the Government anddonors responded by accommodating therequests of woredas, which had planned toprovide cash, to switch to food transfers. Giventhis experience with mid-year food priceincreases, many regions requested the FederalGovernment shift woredas from cash to foodtransfers in 2007. The programme accommodatedthis by allocating the first two transfers incash rather than in food, which freed up food tobe used later in the year in other woredas, andthrough a local purchase of food resources toaugment donor pledges. Unlike previous years,few mid-year requests to change the cash-foodsplit were accepted. The geographic distributionof cash and food transfers by woreda inearly 2007 is shown in Map 2.In 2008, the cash wage rate was increased forthe first time from 6 to 8 birr. The trend in 2009was towards greater requests for food transfersbecause of continuing increases in food prices.Given the resource mix available to theprogramme, coupled with budgetaryconstraints, the Government chose to allocatecash transfers for three months and then foodtransfers for three months to the vast majorityof woredas. The cash wage rate was also furtherincreased from 8 to 10 birr.Since 2005, the overall trend has beenincreasing use of cash transfers in the PSNP(Figure 1) and a growing preference amongstbeneficiaries for food only transfers (Figure 2).This move towards cash was, however, lessthan that initially predicted in the programmedesign and has largely stalled in recent years,due to global food and fuel price rises andparity <strong>issue</strong>s between cash and food. In 2009,roughly 6.65 million people received foodcombined with cash transfers.PSNP public worksWhile the PSNP design identified a menu ofeligible investments, there was a tendency to<strong>focus</strong> on natural resource management projects.One of the leading causes of previous failureof food for work programmes was the lack ofappropriate community consultation to ensurethe relevance and ownership of the assets27

Field Articlecreated. In order to address this, the design of the PSNP gavethe responsibility for the selection of public works sub-projectsto communities. To promote this high level of communityparticipation in the public works planning process, in coordinationwith Government DAs, the Community Food Security TaskForces (CFSTF) were mandated to mobilise communities toidentify the public works that would be undertaken on anannual basis. In order to formalise this approach, DAs wereprovided training on the Community-Based ParticipatoryWatershed Management Guidelines that were developed byGovernment in coordination with WFP.Map 2: Geographic Coverage of the PSNP by type of transfer, 2007Implementation experienceSince 2005, the PSNP has built a large number of public workssub-projects and evidence suggests that the performance of thepublic works component has improved over time. The 2008Public Works Review found that quality had improved overall,with some continued technical deficiencies in roads and needfor better operations and maintenance arrangements in watersupply and small-scale irrigation projects. Sustainability ofpublic works investments has been a challenge for programmesthroughout Ethiopia. In general, sustainability ratings havebeen favourable, with the lowest ratings on roads, water andirrigation projects.Despite these operational deficiencies, public worksoutcomes have generally been satisfactory with significantimpact on environmental regeneration, increased access towater supply, expanded use of small-scale irrigation andimproved access to farming training centres.Figure 1: Changing proportion of cash and food in the PSNP, as measured involume/monthly wage rate100%Direct support and tailoring the safety netIt was initially anticipated that roughly 80% of PSNP participantswould receive aid through Public Works and 20% throughDirect Support (unconditional transfers). While the number ofDirect Support beneficiaries has increased, the Direct Supportcomponent as a percentage of programme participantsremained constant (15%). This proportion varies by region andby year (Figure 3). In 2006, this proportion also varied amongworedas, ranging from 3% in Enderta, Tigray, to 25% in Boricha,SNNPR.80%60%40%20%0%Plan Actual Plan Actual Plan Actual Plan Actual2005 2006 2007 2008CashFoodOverall trend:Food for cashThe light work or community activities for Direct Supportbeneficiaries that were outlined in the PIM have not been implementedanywhere in the programme. Some woredas supportedby NGOs have experimented with crèches or childcare centres.This highlights the lack of priority given to these activities, withworedas reporting that there had been no direction to includesuch activities in their PSNP plans.Fieldwork observed progress in implementing the genderprovisions of the PIM, although this was uneven across woredasand in elements of the PIM. Women and women’s organisationstend to be well represented in PSNP decision-making structuresat lower levels, however building alliances with the Women’sAffairs Ministry at Federal and regional levels has proven to bemore difficult. Although the PIM states that the participation ofwomen in public works should be responsive to their regularwork burden, in most cases men and women were found to dothe same work and there seems to be no change in this over time.In 2006, a separate process to design and implement a pilotprogramme that aimed to tailor the PSNP to pastoral livelihoodswas launched. The pilot has demonstrated that a safety net is aneffective means of supporting chronically food insecure pastoralhouseholds, particularly those who are engaged in agropastoralismor have dropped out of the traditional, mobilepastoral livelihood system. Experience from the pilot shows thatthe targeting mechanism needs to account for differences insocial structures and social cohesion among different pastoralgroups. With regards to public works, pastoral communities areeasily mobilised to participate in the public works sub-projectsthat are relevant to their livelihoods.Currently, the Government is eager to roll out the PSNPpastoral programme to all pastoral areas, particularly into newworedas in Somali.Monitoring and evaluation (M&E)The speed with which the programme was launched led todelays both in monitoring reports and the launch of the evalua-Figure 2: Preference for payments among beneficiaries: cash, food or cash and foodpayments100%90%80%70%60%50%40%30%20%10%0%3662912567171051142270134622514101810622191013104 2 5 62006 2008 2006 2008 2006 2008 2006 2008 2006 2008All households Tigray Amhara Oromia SNNPR6681432535963116101433415352842917Food only25% cash, 75% food50% cash, 50% food75% cash, 25% foodCash onlyFigure 3: Annual Direct Support participants as a percent of PSNP population byregion30%25%20%15%10%5%0%Amhara Oromia SNNP Tigray Dire Dawa Harari TOTAL200520062007200828

Field Articletion system. There was little information onprogramme implementation during the firstmonths of the PSNP. In response, FSCB anddonors were forced to establish rapidly anInformation Centre to collect real-time informationon cash and food transfers and grainmarket prices from a sample of 40% ofprogramme woredas. These regular reportshave proven to be an important source of informationfor programme managers, as themonitoring reports have continued to be verylate and of limited use given the inconsistentquality and incomplete data.The 2006 FSP M&E Plan reduced the amountof information collected, streamlined the reportingformats and modified reporting procedures.The <strong>focus</strong> was on generating basic informationcritical to programme management.In 2007, the programme expanded the menuof independent systems reviews, augmentingthe Roving Financial Audit with RovingProcurement Audit and Roving Appeal Audit.These audits were designed to generate informationon the functioning of the programmesafeguards. 2During the same period, consensus wasreached on the need for a single logical framework.A series of joint government-donorworkshops slowly created agreement on whatthe programme aimed to achieve and how thiswould be done. The result was a more harmonizedapproach to monitoring progress towardsprogram objectives. This logical frameworkwas used in each subsequent JRIS Mission toassess implementation and was the guidingdocument for the PSNP review in 2008.As with other areas of routine monitoring,the PSNP was slow to develop a robust publicworks monitoring system as part of its managementinformation system. By 2008, apart fromintermittent monitoring through the publicworks reviews, there was still no database onpublic works projects and no tracking of publicworks standards, performance and effectiveness.Key PSNP accomplishmentsMain programme outputsIn 2009, the PSNP provided safety net supportto almost 7.6 million rural Ethiopians.Table 4: Annual direct benefits generated byPSNP (based on 2009 program parameters)Total PSNPTotal number of programme beneficiaries 7,574,480Total number of households 1,514,896Total value of transfer ($) 206,783,304PSNP Public Works beneficiariesNumber of households participating in 1,272,513public worksAverage number of participation days per 150household per yearTotal number of days of public works 190,876,896generated per yearAverage value of wages earned per 137household ($) per yearValue of wage transfer through public 173,697,975works ($) per yearPSNP Direct Support beneficiariesNumber of households benefiting from 242,383Direct SupportValue of average annual transfer per 137household ($) per yearTotal value of transfer through Direct 33,085,329Support ($) per yearImportantly, this shows that large scale cashand/or food transfers are operationally andlogistically possible in the resource-poor, lowincomerural settings in Ethiopia. The directbenefits of the programme are summarised inTable 4.Key impacts on householdsThe 2008 Impact Evaluation found PSNP participationmeasurably improved household foodsecurity, as measured by changes in selfreportedhousehold food gap. This effect wasstrongest among those households thatreceived regular, high value transfers. PSNPhouseholds exposed to drought had a 30%higher caloric acquisition growth than nonbeneficiaries.From 2005/2006 to 2007/2008, negativecoping strategies were more prevalent amongnon-PSNP households than they were amongPSNP households.Participation in PSNP public worksincreased growth in livestock holdings by 0.28Tropical Livestock Units (TLU) over comparablenon-PSNP households – equivalent to adifference of nearly three sheep.PSNP beneficiaries have increased their useof social services. Of the 46.1% of PSNP beneficiaryhouseholds reporting that they usedhealth facilities more extensively in 2006 thanthe year prior, three quarters (76%) said thiswas because of the PSNP. In 2008, one quarter(26.7%) of households reported increased use ofhealth facilities over 2007 and nearly half (47%)attributed this increase to the PSNP. In 2006,half (49.7%) of respondents stated that theykept their children in school longer than in theprevious year, and 43% attributed this to thePSNP.The 2008 Impact Assessment measured thecombined impacts of the PSNP and the OtherFood Security Programme (OFSP, the secondpillar of the FSP <strong>focus</strong>ing on providing creditservices to PSNP households). Households thatreceived high value, regular support from thePSNP and had access to the OFSP, experienced0.81 months (or 25 days) greater food securityfrom 2006 to 2008 than households receivingneither the PSNP nor OFSP. Similarly, livestockholdings of PSNP households with supportfrom the OFSP increased by 0.334 TLUs, whilethe value of their livestock increased by 14.3%as compared to non-beneficiary households.While OFSP has only a marginal impact onagricultural productivity when implementedalone, when combined with the PSNP theresults showed a 38% increase in maize yields.This suggests that by allowing households to<strong>focus</strong> on long-term investments and providingmore regular cash flow, the PSNP is a criticalelement of a strategy to effectively improveagricultural productivity.Key impacts on communitiesThe bulk of investments were concentrated insoil and water conservation (SWC) and ruralfeeder roads, with selected investments in naturalresource management and social services. In2008, 92% of households indicated that theircommunity had benefited from the constructionof roads, while 88% reported benefitingfrom SWC on communal lands. Public worksare increasingly perceived to benefit individualhouseholds as well. Public works are generallyevaluated to be of a high technical standard.Cost efficiency of the PSNPThe PSNP compares favourably with internationalexperience on public works programmes,for its targeting, high wage intensity and a lowadministrative cost due to its use of existinggovernment systems and the programme scale.Approximately 17.2% of total programme costis dedicated to staff time, administrative costsand capacity building.Graduation from the PSNPPromoting graduationTo promote graduation, PSNP participantswere to have access to the OFSP, which wasfinanced through a Federal GovernmentSpecific Purpose Grant to regions and thedonor-financed Food Security Project, amountingto roughly $100 million per year.Households were provided subsidised credit torebuild their asset base (in the case of the FoodSecurity Project which targets the poorest of thepoor) or to purchase “household packages,”which were various combinations of agriculturalinputs sometimes based on a businessplan developed with support from the extensionservice. The Government’s <strong>Special</strong>Purpose Grant also financed investments inrural infrastructure, such as roads and waterresource development, and the ResettlementProgramme.Recognising the complementary roles of thePSNP and OFSP to enable households to moveout of food insecurity, starting in 2006 theGovernment specifically targeted OFSP householdpackages to PSNP participants.Government targets were set to achieve approximately30% annual coverage of PSNPbeneficiaries with the OFSP for three years. Oneof the main challenges to achieving this coordinationwas that the agricultural extensionsystem was under-resourced and there were toofew sufficiently skilled DAs. The governmentinitiatedreform to upgrade this system wasseen to be important for the success of the PSNPand OFSP, particularly the move to allocatethree DAs to each kebele in the country and toensure that posts are filled with people holdinga diploma.Initial experience with the OFSP found thatdelivery mechanisms were not always appropriate,which was reflected in low repaymentrates and consequently low coverage.Specifically, there were no guidelines on howcredit or revolving funds should be managed.When guidelines did exist, they were notalways followed. By 2008, the Food SecurityProject had collected only 72% of loans that hadfallen due and was working with theGovernment to transfer revolving funds torural savings and credit cooperatives to ensurethat they were properly managed.The overall strategy to promote graduationhas <strong>focus</strong>ed on households with availablelabour and land. Recently, the FSCB hasexpanded the scope of support to include nonfarmactivities to better respond to the needs ofyoung people, who generally have no land, inrural areas.Determining graduationIn 2007, the Government initiated a process toset graduation criteria for the programme.2The term ‘safeguards’ refers to those mechanisms that aimto ensure that the programme resources are used for thepurposes intended.29

Field ArticleTable 5: Graduation from PSNP: Food Sufficiency and Food SecurityDefinitionApplicationFood SufficiencyA household can be deemed food sufficientwhen, “in the absence of receiving PSNP [or emergency]transfers it can meet its food needs for 12months and is able to withstand modest shocks.”At the point that a household becomes food sufficient,it no longer needs to receive transfers(except in the event of a major shock). However,further support in building household assets willbe needed before households obtain a significantdegree of resilience and are able to sustainablyaccess food and income.Thus, the Federal Government, regions anddonors developed a set of objective asset-basedbenchmarks tailored to local conditions tomeasure a household’s food security status.These benchmarks and an accompanyingGraduation Guidance Note clarified that therewere two levels of graduation: graduation fromthe PSNP upon obtaining food sufficiency andgraduation from the FSP upon obtaining foodsecurity (Table 5).While providing objective criteria againstwhich to assess the assets of households, theoverall system to identify households for graduationremained weak. Problems withcommunicating the benchmarks and graduationprocess resulted in widespread confusion.Additionally, the design of the system placed aheavy workload on DAs, who were regularlyrequired to collect detailed household data.Realistic expectations of graduationApproximately 692,002 households (around 3.5million people) received credit financed byOFSP and an additional 355,279 householdsreceived credit from the donor financed FoodSecurity Project between 2002 and 2007. Anumber of independent studies have concludedthat OFSP coverage was generally insufficientto meet the demand for loans among PSNPbeneficiaries. While government reportssuggest that access to a single household packageshould be sufficient to enable graduation,other evidence shows that the process towardsgraduation is more complex. PSNP beneficiariesindicated the need for two or threeinterventions per household to achieve foodsecurity.There has been limited progress towardsgraduation to date. Between 2007 and 2009,around 280,000 individuals graduated from thePSNP. Although this is perhaps not insignificantgiven the adverse events of 2008, it fallswell short of the national goal.Looking AheadThe next phase of the PSNP (2010-2014) is<strong>focus</strong>ed on strengthening implementation in allworedas. Measures include strengthening themonitoring system to ensure a regular flow ofdata to programme managers, adopting a morestrategic approach to capacity building, reinforcingaccountability and transparencymeasures at all levels and expanding these tothe food management system and increasingthe responsiveness of the program to transitoryshocks. Greater attention to public works isanticipated to result in more sustainable publicworks sub-projects and enhanced programmeimpact within communities.For the next phase of the PSNP, and morespecifically the broader FSP, the GovernmentFood SecurityFood security is defined as “access by all peopleat all times to sufficient food for an active andhealthy life.”The use of the phrase ‘food security’ and its definitionabove imply a degree of resilience andsuggest that food security is a relatively sustainablestate. Some households will only graduatefrom the PSNP during the programme life andwill need continued support from the householdasset building component, while other householdswill graduate completely from the FSP.has reformed the design of the OFSP in waysthat should substantially strengthen it. Thesereforms have <strong>focus</strong>ed on the institutionalarrangements for financial service delivery,including the development of multiple financialproducts tailored to the need and capacitiesof different types of households. Reforms alsoaim to strengthen the extension system andmicro enterprise development programme todeliver market-led and demand-driven supportto households.Implementing this reformulated OFSP willlikely result in higher levels of graduation fromfood insecurity within the next five years.While it is likely that the scale of the PSNP willreduce as households begin to graduate intofood sufficiency, the notion of a ‘floor’ is centralto this model - it suggests that a long-termsocial protection system in rural areas is importantin order to both protect household assetsand to create the type of agricultural productionsynergies currently witnessed between thePSNP and OFSP.Box 2: Key Lessons learned(a) The PSNP has demonstrated the value of a shiftaway from a predictable humanitarian responsesystem to a more development-oriented approachto addressing food gaps. There is evidence thatlivelihoods are stabilising and food insecurity isbeing reduced among beneficiary households.(b) Large-scale safety nets in low-income settings.The PSNP had a dramatic start, reaching around 5million citizens in the first year of operation. Itserves as an example of a rural safety net operatingat scale that reaches a large number ofdispersed, low-income rural residents with diverselivelihoods, targeted on a household basis.(c) Safety nets in drought-prone areas. The PSNP isan effective safety net tailored to agrarian contextswhile promoting longer-term improvements inrural productivity in areas affected by recurrentshocks.(d) Shifting from food aid to cash. Households canoften use cash to respond better to their needs.The PSNP offers lessons learned from one of theworld’s few large-scale efforts to shift from food tocash-based transfers.(e) Productive and pro-growth impacts of socialsafety nets. The PSNP aims to re<strong>focus</strong> the internationalcommunity’s approach to food insecurity byshifting it away from meeting short-term foodneeds through emergency relief towards addressingthe underlying causes of household foodinsecurity. The goal of the PSNP is to invest inproductive assets in rural communities, as well asprovide asset protection for households againstshocks as part of a rural growth and povertyreduction strategy.The next phase of the PSNP will consolidateand strengthen the RF mechanism to provide apredictable response to transitory food insecurityin PSNP woredas.ConclusionThe PSNP clearly demonstrates the challenge ofimplementing a social protection programme ina low-income environment. Deficiencies inimplementation resulting from limited humanand physical capacity undermine the potentialimpact of the PSNP in many areas. Ensuringquality implementation in all programme areasremains a significant challenge for the future.Nonetheless, Ethiopia’s PSNP has demonstratedthe value and potential of a transitionfrom addressing food insecurity through thehumanitarian response system to a system thatis development-oriented.Most importantly, PSNP has created, for thefirst time, a secure entitlement of households toa safety net from the Government. For the morethan seven million people who receive PSNPtransfers annually, this enables them to meetconsumption needs, mitigate risks and avoidselling productive assets during times of crisis.As a result, there is evidence that livelihoodsare stabilising and food insecurity is beingreduced among beneficiary households.Similarly, it is increasingly apparent that thepublic works investments in soil and waterconservation can result in significant improvementsin the natural environment. This needs tobe consolidated and built on.For more information, contact Sarah Coll-Black,email: scollblack@worldbank.org,Matt Hobson, email: mhobson@worldbank.organd Wolter Soer, email: wsoer@worldbank.org(f) It is possible to combine effectively productiveand protective objectives within one safety netprogramme, but measures need to be put inplace to ensure that one objective does notusurp the other. The PSNP suggests that it ispossible to implement a large-scale unconditionaltransfer programme together with a publicworks programme when there are sufficientsynergies in terms of target populations andgeographic coverage. However, attention needsto be devoted to carefully reviewing all aspects ofthe programme design and implementation toensure that the procedures and systems are inplace to deliver on both objectives.(g)The strongest implementation comes whenkey stakeholders have a shared understanding ofprogramme goals and principles. This, in part,accounts for differences in the quality of implementationfrom woreda to woreda. Ensuringownership and shared understanding with politicaland administrative stakeholders as well astechnicians is important. Further work in definingkey principles may better enable thedevelopment of this shared understanding.(h) Tailoring a safety net program to respond tospecific groups and different vulnerabilities iseasier when safety net interventions are withinthe mandate of an implementing ministry.Building linkages from the PSNP to other departmentswithin MOARD has proven to be easierthan linkages to other ministries, such asMinistries of Health and Women’s Affairs. Thissuggests that a safety net programme is bestpositioned to respond to the vulnerabilitiesunder the responsibility of a single Ministry.30

A fodder production group has decreasedSead’s time looking for pastureBeyond theindicatorsAssessing project impacton children’s livesBy Holly Welcome Radice, Maria Ruiz-Bascaran, Abebe Zewdu,Oumar Mohamud, Mekdes Asfaw, and Mahlet BezuPictures from left to right: Holly is the Head of Livelihoods & Nutrition Information Systems. Maria is theSenior Programme Manager of the RAIN project and former programme manager for PILLAR II. Abebe isthe DRR Coordinatorm Oumar is Project Coordination-Somali and Mekdes is Project Coordinator- Afar. Allwork for the PILLAR PLUS project and with Save the Children UK Ethiopia. Mahlet was previously internedwith Save the Children UK Ethiopia and currently is pursuing a masters at Lund UniversitySave the Children UK would like to thank the families in the Afar and Somali Regions that participated inthese interviews and ECHO (European Commission Humanitarian Aid Department) for funding this project.In humanitarian work, how do we knowthat we are positively reaching distinctmembers of a community? When we calculatebeneficiary households, can we be surethat everyone in the household is really benefiting?And is it clear to what extent they arebenefiting? These are questions that all nongovernmentalorganisations (NGOs) strugglewith in programme evaluation. Save theChildren UK Ethiopia recently sought to findanswers to some of these questions in one of itsprojects.For nearly 20 years, Save the Children UKhas been providing support to pastoral communitiesin Ethiopia, with current programmes inthe Somali and Afar regions. One project is adrought preparedness and risk reduction project,called PILLAR (Preparedness ImprovesLivelihoods and Resilience), funded by ECHO’sRegional Drought Decision (RDD). The projectwas implemented in two phases between April2008 and June 2010 in selected drought districtsof the Afar and Somali Regions. PILLAR seeksto contribute to community level drought riskreduction through prevention, mitigation,preparedness and response through a range ofactivities <strong>focus</strong>ing on the three pillars ofpastoralism— people, livestock and naturalresources.PILLAR has performed well against itsobjectives and indicators, with some 18,000households reached across two regions. This isgood news for the community, the NGO, andthe donor. Being a child <strong>focus</strong>ed NGO, Save theChildren UK wanted to understand and documentto what extent PILLAR has impacted thelives of children.Impact assessment involving childrenInternationally, Save the Children UK aims toensure that child participation—informed andwilling involvement of children—is meaningfullyincorporated into all its work. Some direct31benefits for children had already been revealedin the communities. A local teacher in AfamanaTibedha in Afar had mentioned that since theconstruction of a water point in the village,students were attending classes more regularlyand enrolment had increased by 40%. To get asense of some of PILLAR’s impacts on children,Save the Children UK conducted a rapid fieldassessment in six beneficiary communities andcase studies of six beneficiary children werecompleted. The case studies were based on<strong>focus</strong> group discussions and individual interviewswith selected beneficiaries anddiscussions held separately with adult beneficiariesand their children.Children who were interviewed belonged tofamilies that were involved in water pointconstruction, small scale irrigation and incomegenerating activity micro-projects. According tothose children and their caregivers, projectimpacts were seen similarly. Broadly theanswers of the interviewed children werecentred on two categories, household andpersonal for children, as shown in Table 1.These findings show that the interventionswent well beyond what was measured in theindicators—availability of water in the dryseason and protected / diversifying livelihoods—andthat the interventions had layers ofTable 1: Project impact as seen by childrenHousehold• Increased foodconsumption• Increased food diversity• Increased access to basicneeds (e.g. school supplies,medical)• Increased food and milkproduction• Availability of items forpurchase• Access to clean waterPersonal for children• More leisure time• More time withparents• Less time withchores• Regular attendanceat school• Punctuality atschool• More time forstudiesMahlet Bezu, Ethiopia, 2009Geraud Laval, Ethiopia, 2008Field Articleeffect. Immediate results such as better nutrition,access to basic needs, access to clean waterwere valued by the children. Most hearteningwere the reports of increased school attendanceand reduction in time spent on chores and evenmore time to play. These indirect benefits arepositive and encouraging for long termcommunity resilience as education is a keycomponent to improving livelihoods.Children as direct beneficiariesSuch an assessment is not scientific by anymeans, but the value is obvious. It serves as asingular opportunity to ‘ground truth’ the effectof interventions on different groups within apopulation. For Save the Children UK’s implementationteam, this exercise was helpful to seethe layers of impact that the project has had.Children in the interviewed beneficiary householdsclearly directly benefited from theinterventions on personal, household andcommunity levels.In a project <strong>focus</strong>ing on communityresilience, children may normally be viewed asindirect beneficiaries. Additionally, the humanitariannature of the project could be mistakenlyviewed as only providing short term insuranceagainst shocks. However, this rapid assessmenthas discounted both of these theories. Childrenin these communities have received direct,immediate benefits. If these benefits identifiedare maintained, the investment will surely havea profound affect on the future of individualchildren’s lives and ultimately on communityresilience.Ultimately, the assessment gave some ideasregarding what interventions to build on, betterto target children in disaster risk management(DRM). The next phase of PILLAR will workdirectly with the children in Alternative BasicEducation schools. This scheme will pilot children-ledDRM committees that will look tobuild the capacity of children and their caregiversto be better able to reduce disaster riskswithin their own communities.Finally, such an assessment is an opportunityto listen to and learn from children. Fosteringthe practice of voicing opinions and contributingto community matters can be anempowering process. In pastoral communities,such as those targeted in PILLAR, being able tospeak on behalf of one’s community is an essentialtool in reduction of vulnerability todrought. It can encourage a generation to beproactively contributing to their own community’sinvolvement in early warning, earlyresponse and community preparedness.For more information, contact: Holly WelcomeRadice, email: Holly.R@scuk.org.etWomen targeted byincome generationactivities in Fik,Somali region

Programme profileThe Emergency Nutrition Coordination Unit of Ethiopiaroles, responsibilities and achievementsBy Isaack B. Manyama, Gugsa Abate and Mathewos TamiruIsaack B. Manyama is ENCUTeam Leader and NutritionCluster Coordinator forEthiopiaGugsa Abate is Nutrition<strong>Special</strong>ist at the ENCUMathewos Tamiru is InformationAnalyst at the ENCUThe Emergency Nutrition Coordination Unit (ENCU) is located in the Disaster Risk Management and FoodSecurity Sector (DRMFSS), Ministry of Agriculture and Rural Development, Ethiopia.The history of the Emergency NutritionCoordination Unit (ENCU) can bedivided into two five-year phases:Phase One, the inception phase (2000-2005) and Phase Two, the expansion phase(2005-2010).Inception Phase (2000-2005)Recurrent drought has been a key feature ofEthiopian life for several decades leading towidespread crop and pasture failure and periodicsevere humanitarian crises. In response,Ethiopia has carried out numerous seasonalneeds and nutrition assessments andprogramme activities. Initially, the nutritionassessments were characterised by a lack ofnational level standardisation and coordination,leading to duplication and misguidedallocation of resources. In the year 2000, forexample, a study into the quality of nutritionsurveys in Ethiopia 1 found that only fivepercent of the 200 nutrition surveys conductedover a 7 year period were of acceptable quality.As a result, the ENCU was established inNovember 2000 within the Early WarningDepartment (EWD) of the then DPPA (DisasterPreparedness and Prevention Agency nowDisaster Risk Management and Food SecuritySector (DRMFSS) under the Ministry ofAgriculture. At its inception, the ENCU wasfunded by WFP and later by UNICEF. Sincethen, ENCU’s routine activities continue to befunded by UNICEF, while staff costs have interchangeablybeen funded by both agencies.At the time of inception, the ENCU wascharged with fulfilling three major functions:a) Coordination of emergency nutritionassessments, quality assurance andresponses. A total of 266 surveys werecoordinated by the ENCU during the firstphase.b) Establishment of a Multi-Agency NutritionTask Force (MANTF) for coordination,information sharing and discussion oftechnical <strong>issue</strong>s among nutrition partnersworking in Ethiopia. The MANTF forumwas established and is operational to date.c) Collection and collation of reports andresults of nutrition surveys conductedthroughout the country and nutritioninformation database. The Nutrition database was established in 2005 and regularlyupdated since then.Standardisation and harmonisation of emergencyassessments and response was not amongthe major functions of the ENCU at inception.However the ENCU coordinated the developmentof the National Emergency NutritionAssessment guideline in 2002, which aimed tostandardise emergency nutrition assessments inEthiopia. In 2004, emergency nutrition interventionguidelines were developed to harmoniseand standardise implementation and managementof nutrition programmes.Expansion Phase (2005-2010)By 2005, it was evident amongst partners andgovernment that ENCU had played a significantrole in coordination of emergencynutrition assessments and response and therefore,its mandate and functions at federal levelwere expanded. In order to fulfil its extendedrole, staffing also increased from one to fourstaff (one team leader, one nutrition specialist,one information analyst and one administrativeassistant). In the second half of 2006, regionallevel ENCUs (R-ENCU) were established infive drought-prone regions (SNNP, Tigray,Amhara, Oromia and Somali) as part ofstrengthening the early warning system andcoordination of emergency nutrition response.Each R-ENCU is integrated within the FoodSecurity, Disaster Prevention and Preparedness(FSDPP) of the respective region. All the five R-ENCUs are fully operational, with two staff: aninformation analyst and nutrition expert. Theexpansion of the ENCU at regional level wassupported by UNICEF with funding from theEuropean Commission until 2009, whenUNICEF took over. The establishment of a R-ENCU in Afar region is currently in progress.Following the roll out of the NutritionCluster approach at national level in 2007, theENCU mandate again expanded to includecoordination of Nutrition Cluster activities. Inaddition, to its previous roles on coordinationand quality assurance of emergency nutritionassessments, information management anddissemination, and coordination amongst partners,the ENCU has assumed three newfunctions:• Capacity strengthening of early warningsystem at federal and regional levels• Coordination of Nutrition Cluster activities• Coordination of operational research onemergency nutrition assessments.The functions of the ENCU are described ingreater detail below.Coordination and quality assurance ofemergency nutrition assessments andresponseAnalysis of the nutrition situationThe nutrition situation in Ethiopia is monitoredby analysing admission trends of new severeacute malnutrition cases in TherapeuticFeeding Programme (TFP), analysing nutritionrelated early warning data and informationsystems received from woreda (district),regional and national level. Depending on thesituation, emergency nutrition surveys (baseline,monitoring or end-line) are conductedbased on the existing national guidelines toascertain the situation and recommend appropriateresponses. The nutrition situation is alsomonitored through updating the woredas identifiedas ‘hotspot woredas’ based on pre-agreedcriteria. The ’hotspot woreda’ update is undertakenas a consultative process carried out atthe regional and federal level. A guideline hasbeen developed to standardise the classification/updateprocess, which enables key actorsto prioritise areas requiring particular <strong>focus</strong>.The ENCU plays a key role in provision ofnutrition information used during the classificationprocess as well as coordination andsharing of the hotspot list with nutrition clusterpartners after approval of the DRMFSS.The Government also conducts bi-annualfood security assessments, and monthly newTFP admissions are summarised in addition tothe routine TFP admission trend analysisoutlined above. Unusual increases in TFPadmissions in March to May period informs theDRMFSS EWS and partners of a likely worseningnutrition situation in the forthcoming‘hunger period’ (from June to August in agrariancommunities 2 ). The DRMFSS/ENCU triangulatesthe TFP data and survey results with otherfood security information and provides an estimateof the anticipated prevalence ofmalnutrition in the respective assessmentperiod. This level of prevalence is applied to theestimated total number of rural under-five chil-1Spiegel et al (2004). Quality of Malnutrition AssessmentSurveys Conducted During Famine in Ethiopia JAMA.2004;292:613-6182The hungry season is January to February in the pastoralistcommunities.32

Programme profiledren (usually 14.5% 3 of the rural population)from the woredas requiring humanitarian assistance.Based on this analysis, beneficiariesneeding either therapeutic or supplementaryfeeding are estimated for the period covered bythe Humanitarian Requirement Document(HRD) <strong>issue</strong>d by the Ethiopian Government.Quality assurance of standard surveysAll nutrition survey proposals are approved bythe ENCU before they are undertaken. Partnersplanning to conduct emergency nutritionassessment are required to prepare a surveyproposal and submit this for review and validation.The proposal is reviewed in terms ofobjective/rationale, methodology, plannedanalysis and how the survey will be organisedin the field. In the process, partners’ capacity isassessed and if deemed to be low, considerationis given for alternative or additional partners toconduct the assessment. After the review iscomplete, written feedback is provided to therespective partner. Since March 2006, allsurveys have been planned, implemented andanalyzed using SMART methodology andEmergency Nutrition Assessment (ENA) software(2007 version).Upon completion of the survey, partners arerequired to submit the raw data to FederalENCU for quality checks. The data is scrutinisedaccording to agreed criteria along withrespective preliminary reports before the reportis shared with government and partners. A totalof 237 nutrition surveys were carried out basedon the SMART 4 methodology between 2006 and2010 and checked by ENCU. So far, only 10surveys have been rejected because of poor dataquality. The remaining 227 surveys’ findingshave been published in the ENCU quarterlybulletin of emergency nutrition and posted inthe DRMFSS web site: www.dppc.gov.et/pages/ENCU.htm. Preliminary reports of therespective surveys are reviewed in terms ofcontent and interpretation and are cross-checkedwith recommended reporting format. They arealso checked to ensure that conclusions, recommendationsand classification of the nutritionsituation are coherent and consistent with informationbased on anthropometric and contextualfactors (for example, water and sanitation, foodsecurity and health related indicators).Feedback is provided to the respective partneron the quality status of their survey. It isimportant to note that the quality of surveysand the accompanying reports depend verymuch on the existing human resources at thatparticular point in time within theagency/partner. Where there is high staffturnover among partners, sustaining high qualitysurveys cannot always be guaranteed. In thecase of poor quality surveys, bilateral discussionsand clarifications are conducted and inmost cases, partners accept the ENCU’s feedbackand recommendations. The surveysclassified as ‘acceptable’ are submitted to theDRMFSS with a note on the data quality andreport for information and approval. After theDRMFSS approval, the respective partner isinformed and requested to organise a feedbackat regional/woreda level where the assessmentwas conducted, including planning for appropriateresponse.Apart from surveys, quality assurance hasbeen expanded to cover Community BasedNutrition (CBN), Community Health DayTable 1: Number of nutrition surveys conducted in Ethiopia by region, 2000-2010Region 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 TotalSNNPR 9 5 35 30 14 25 20 16 36 26 9 225Oromia 3 2 20 27 22 20 14 6 9 13 13 149Amhara 5 9 24 17 9 7 6 4 8 13 9 111Somali 8 5 5 5 8 11 12 2 0 7 1 64Tigray 0 0 6 7 3 3 0 8 0 4 1 32Afar 0 0 4 5 1 6 4 2 1 1 2 26Gambella 0 0 0 0 0 0 0 0 0 0 1 1Beneshangul gumuz 0 0 0 0 0 0 0 0 0 1 0 1Harari 0 0 0 0 0 0 0 1 0 0 0 1Total 25 21 94 91 57 72 56 39 54 65 36 610(CHD) and Enhanced Outreach Strategy (EOS)community based bi- annual screening data.ENCU have also developed the EOS screeningquality checks guideline currently being integratedinto the EOS implementation guideline.Table 1 shows the number of nutritionsurveys conducted in Ethiopia since the inceptionof the ENCU.Coordination of Emergency NutritionResponsesEmergency nutrition responses/interventionsare usually triggered by acute malnutritionprevalence threshold levels, as per 2004 emergencynutrition intervention guideline. Since itis not possible to conduct standard assessmentsin all hotspots, woredas classified as priority 1are given preference for implementationand/or strengthening the existing nutritioninterventions.The relevant federal and R-ENCU contactcapable and willing partners to initiate emergencynutrition interventions in the identifiedworedas, through monthly, ad hoc or bilateralmeetings. During the meetings, consensus isreached with regard to who, what where andhow (i.e. process to be followed in engagementof the regional and woreda authorities). Thisaverts duplication of coordination efforts andoverlaps among partners. However, sometimespartners engage with the regional authoritiesdirectly and therefore the above mentionedprocesses are not necessary.Coverage of emergency nutrition interventionsin hotspot woredas is monitored on amonthly basis based on national and Spherestandard indictors and shared among partners.The ENCU also uses the information to advocatefor expansion of interventions in hotspotworedas, particularly priority 1 that may notyet be covered, or in new emerging hotspotareas. Overall, the performance of emergencyinterventions has been impressive and consistentlyabove national and Sphere standardsthresholds in recent years.Information management anddisseminationA nutrition database has been created to storesurvey results as well as other data from largescale programmes such as the EOS andProductive Safety Net Programme (PSNP).Over the last 10 years, 592 nutrition surveyshave been conducted in hotspot woredas andthe raw data and summary reports of thesesurveys are posted on the DRMFSS web site(see Table 1). The survey results are used forinformation sharing and for triggering nutritioninterventions, which have saved manylives.The nutrition information available is regularlyanalysed and shared electronically andwith nutrition cluster partners throughmonthly MANTF meetings. ENCU also disseminatesthe information through its emergencynutrition bulletin (available atwww.dppc.gov.et/pages/ENCU.htm), whichprovides detailed analysis and presentation ofthe survey results and TFP monthly admissionsand other performance indicators on a quarterlybasis. Moreover, monthly nutritionsituation updates are prepared and shared withkey government departments and agencies. Inaddition, ENCU hosts many consultation meetingswith missions, consultants from partners,and donors inside and outside the country whowish to learn how the ENCU works and toengage in information sharing. There has beenalso improved analysis, knowledge and utilisationof nutrition information for planning,decision making and for monitoring the evolvingnutrition situation at national and regionallevels.Capacity strengtheningThe ENCU has <strong>focus</strong>ed on four main areas tosupport capacity strengthening:i) Capacity mappingii) Training on emergency nutritionassessmentsiii) Database development and informationmanagementiv) Revision/development of guidelinesi) Capacity mappingThe ENCU in collaboration with partners hasdeveloped a food and nutrition ‘3W’s’ matrix ofwho is doing what and where. This toolcontains a wealth of information for each of theworedas, such as hotspot ranking, surveyresults, and nutrition interventions beingimplemented and by respective partners. It alsoprovides information on food aid allocation,dispatch information and challenges experienced,provided by the WFP country office.This tool is updated on a monthly basis. TheENCU use the tools to monitor the interventioncoverage in terms of availability of TFP and TSFservices in the hotspot woredas and in woredaswhere needs are not being met. The ENCU alsomaps the technical capacities of the nutritioncluster partners in terms of conducting standardassessment and emergency nutritioninterventions. This matrix is completed throughmeetings and bilateral discussions and feedbackwith respective partners.ii) Training on emergency nutritionassessments3The 14.5 percent is based on the FMOH estimates4Standardised Monitoring and Assessment in relief andTransition33

Programme profileThe ENCU <strong>focus</strong>es on planning and conductingcapacity building sessions to ensure that partnersat national and regional level use the latestknowledge and skills in nutrition assessments.For example, a series of SMART trainings wereconducted at federal and regional levels toenhance skills and knowledge of the staff ofDRMFSS and its partnering NGO agencies. Thetraining is aimed at harmonising planning,implementation, analysis and reporting ofnutrition assessments. As a result, partners’capacities for conducting standard emergencynutrition surveys have significantly improvedat both regional and national levels.The use of the SMART methodology hasrevolutionised the execution of the standardassessment in Ethiopia. Benefits includeimproved and shortened planning time forstandard surveys, i.e. reduced the challenge ofmanual calculation of sample size, number ofclusters and assigning clusters based on probabilityproportion to size of the population. Theinbuilt plausibility check in the ENA softwareprovides nutritionist and survey teams with theability to assess the quality of the data collectedwhile the survey is in process. Also, as part ofquality assurance at the ENCU, the plausibilitycheck guides whether the survey data andinformation is worth using for planning anddecision making.iii) Database development and informationmanagementThe ENCU is currently in the process ofstrengthening the R- ENCU’s capacity with theaim of decentralising expertise for emergencynutrition assessment, quality insurance, andsituation analysis and data management. A userfriendly TFP database to be used at woredalevel is also in the process of development. Thiswill facilitate utilisation of nutrition informationfor planning, decision making, andmonitoring/early warning, and enhance andimprove reporting at woreda level.iv) Revision/development of guidelinesThe ENCU has coordinated the developmentand revision of the national emergency assessmentand intervention guidelines to ensure thatpartners implement emergency nutrition activitiesbased on the latest knowledge, skills andbest practice in the field. The 2002 emergencyassessment guideline, for example, was revisedin 2008 in line with SMART and ENA software.The 2004 emergency intervention guideline isin the process of being revised to incorporatethe 2008 Global Nutrition Cluster interventiontool kit. A stand alone moderate acute malnutrition(MAM) guideline will also be developedto guide and standardise implementation ofsupplementary feeding programmes in thecountry. Also in 2010, ENCU coordinated thedevelopment of new methodology for seasonalassessments and timely response <strong>focus</strong>ing onstrengthened information and surveillancesystem in line with the Governments DisasterRisk Management (DRM) policy.Coordination of the Nutrition ClusterAlignment of the MANTF with the IASCWhen the nutrition cluster approach was introducedglobally in 2007, it was not a newapproach in Ethiopia. Similar nutrition coordinationmechanisms existed through theMANTF. The main objective of the clusterapproach at global and national level is tostrengthen humanitarian response by demandinghigh standards of predictable leadership,accountability and partnership in emergencyresponse. In Ethiopia, the Government took thecluster lead through sectoral task forces led bythe respective ministries. In view of this, ENCUwas mandated to coordinate nutrition clusteractivities and the MANTF terms of referencewere revised to align with the IASC andnational level cluster guidance note. It is importantto understand that the emergency nutritionsituation in Ethiopia is characterised as slowonset chronic emergency and therefore, largelypredictable. This predictability calls forsustained and reliable coordination with capacitiesto implement the cluster approachintegrated within the government structures.UNICEF has created four fixed term positionsat the ENCU in 2010 to ensure stable,predictable, effective coordination and leadershipof the nutrition cluster activities inEthiopia. he role of the Nutrition Cluster hasbeen to ensure application of national standards,guidelines and protocols in emergencyassessment and response, advocate partnersand government for timely assessment andresponse, undertake data and information , andquality assurance. ENCU liaises closely withUNICEF, the nutrition cluster lead agency, onall the above responsibilities. It also advocatesfor donor funding among nutrition cluster partners.UNICEF, Nutrition Cluster lead agencyalso has the role of “provider of last resort”when all other options for emergency relatedresponse are exhausted.Decentralisation of the Cluster ApproachA major development achieved by the ENCUhas been the roll out of the nutrition clusterapproach to the regions. This has significantlyimproved awareness of cluster partners’responsibilities, contingency planning/preparedness, as well as the strengthening ofnutrition information analysis and sharingamong partners in the five regions with R-ENCUs. However, plans are under way tostrengthen the regional nutrition cluster capacitiesfor coordination of emergency assessmentsand response where it is weak.Standardisation of emergency nutritionintervention proposalsIn order to standardise the preparation of theproposals and assist partners to be <strong>focus</strong>ed inproposal preparation, the ENCU prepared adetailed nutrition cluster proposal outlinebased on the Humanitarian Relief Fund (HRF)format. This was intended to shorten the timefor proposal review and facilitate acceleratedapproval and release of HRF funds to therespective partners, with an overall objective ofimproving timeliness and coordination ofemergency nutrition responses. The ENCUorganises a joint nutrition cluster review bysharing the original proposal with a reviewcommittee composed of six members(UNOCHA, UNICEF, WFP, UNFPA (gender)and ENCU) and two members normally fromNGOs who are not related to the proposalapplication. All members participate equally inthe review process and decision making.Individual reviewers’ comments are discussedduring a joint review organised by ENCU and ajoint feedback note is prepared and shared withHRF based on the consensus from the reviewcommittee.During the review process the committeeensures that the proposal has addressed all theimportant <strong>issue</strong>s as per national interventionguidelines and format. The application is ratedon a four point scale of quality. Based on thelevel, the proposal is either recommended forHRF board review and funding or re-submittedto the cluster for final consideration for fundingor, it is rejected. In situations where the partnersare not able to get funds from donorsbilaterally or the cluster faces inadequate funding,ENCU communicates with the respectivedonors directly or through UNICEF and advocateson the importance of funding theproposed interventions. In most cases the advocacyhas been successful.One of the limitations of the cluster reviewprocess in Ethiopia is that not all emergencynutrition intervention proposals are reviewedby the nutrition cluster. Partners with adequatefunds or funded bilaterally usually do notsubmit their proposals to the nutrition clusterfor review. Despite this, the cluster reviewprocess has proven to be an important advancein helping to avert duplication of efforts,maximise resources and increase coverage ofnutrition interventions in hotspot woredas.Operational research on emergencynutrition assessmentsENCU/DRMFSS has been collaborating withnational and international bodies in conductingoperational research particularly in the area ofemergency nutrition assessment. For example,in 2006, with funding from the EuropeanCommunity through UNICEF Ethiopia, ENCUcommissioned a study into the relationshipbetween weight-for-height, MUAC and bodyshape in pastoralist, agro pastoralist and agrarianpopulations in Ethiopia 5 . The findingshelped to shed light on the implications of interpretingnutrition survey results in pastoralistpopulations and to improve understanding,both within Ethiopia and at a global level,regarding the applicability and appropriatenessof MUAC vs. WHZ indicator use to assess thenutrition situation in such communities,.In 2009, ENCU/DRMFSS, in collaborationwith Nutrition Works 6 , conducted secondarydata analysis of the contextual factors identifiedduring emergency nutrition surveys. The resultof the study was presented and discussed bynutrition cluster partners in Ethiopia inSeptember 2009 7 . There were consensuses thatthe final emergency nutrition assessmentguideline should reflect the report/studyrecommendations and standardise the collection,analysis and reporting of the contextualfactors, as in the case of anthropometric andmortality information collected during thesurveys. As a result of the recommendation,contextual factors are now included in the 2008revised national emergency guidelines beingfunded by UNOCHA-HRF in Ethiopia and thefinalisation of the 2008 draft guideline hasstarted.5ENCU 2007: Report concerning the analysis of datacollected for the MUAC/weight for height/body shaperesearch study. Prepared by Mark Myatt, Institute ofOphthalmology, University College London. See summary inField Exchange, Issue No 34 (2008). M Myatt et al. Effectof body shape on weight-for-height and MUAC in Ethiopia.October 2008. p12. http://fex.ennonline.net/34/effect.aspx6Nutrition Works (a partnership of international nutritionistsbased in UK7Nutrition Works, 2009. Analysis of Nutrition Surveys inEthiopia, Workshop Report September 22-23rd AddisAbaba. See summary in Field Exchange, Issue No 37(2009). Contextual data collection in nutrition surveys inEthiopia, November 2009. p14.http://fex.ennonline.net/37/contextual.aspx34

Programme profileFuture challenges andopportunities for the ENCUFundingDuring the mid-term review of theUNICEF country programme in 2009,it was recommended to incorporate theENCU as part of the UNICEF structurefrom mid 2010, with four fixed termpositions. This presents an opportunityfor establishing effective leadershipand in particular, predictable coordinationof the nutrition cluster activities aspart of UNICEF’s Core Commitmentfor Children in emergencies, whilemaintaining close coordination withthe government. Despite the reinforcementof technical staff, the ENCU’sroles and mandate continues to expandand the workload remains a significantchallenge. In light of this, UNICEF andDRMFSS have recently agreed torecruit additional staff to <strong>focus</strong> onstrengthening of the ENCU nutritioninformation systems.Moderate acute malnutritionOver the years, ENCU and cluster partnershave faced significant challengesin management, monitoring, evaluation,reporting and coordination ofnutrition interventions addressingMAM. The 2004 emergency interventionguideline provides limitedguidance on the implementation ofMAM interventions, reflecting the lackof guidance at the global level. Thereare also challenges with the adoptionof WHO growth standards and therelated implications on the implementationof emergency nutritioninterventions. Moreover, TFP interventionsare not always linked withsupplementary feeding programmesand other related interventions.Recognising these challenges, aproposal for revision of the 2004 guidelinesand development of separateMAM guideline has been accepted bythe government and the revisionprocess has started. This provides aunique and timely opportunity foraddressing MAM and other relevantemergency nutrition interventionsbased on recent developments in thistechnical area.Assessing pastoral populationsThe lack of international consensus onhow the nutrition situation in pastoralistpopulations should be assessed andcharacterised in view of their bodyshape continues to present challenges.To address this, the ENCU/DRMFSShas initiated development of pastoralistsurvey method studies incollaboration with Action Contre laFaim (ACF) Ethiopia and nutritionpartners in Ethiopia that may lead toseparate methods for nutrition assessmentsin pastoralist populations in thefuture.Linking nutrition and foodsecurity/livelihoods programmesAnother significant challenge has beenthe absence of or weak linkagesbetween emergency nutrition interventionsand long term food security/livelihood and emergency recoveryprogrammes. Focus is now beingplaced on articulating alignment offuture emergency nutrition interventionswith implementation of newgovernment policies in relation toDRM and Public Health EmergencyManagement (PHEM). This is alsolikely to be addressed by the proposedguideline revisions. Lack or delayedestablishment of a nutrition information/surveillancesystem, however,will continue to impair the effectivenessof the envisaged early warningsystems, on which preparedness,prevention, mitigation and earlyresponse components of the DRMpolicy are based. The existence of theR-ENCU presents a unique opportunityfor improved coordination ofemergency nutrition assessments,timely response, monitoring and evaluation,accountability, and qualityassurance of emergency nutritioninterventions which is currently weak.Information systemsOver the years, ENCU has built a reservoirof nutrition data and informationthat can be used as a reference for afuture information system that integratesemergency and non-emergencynutrition information. Such a systemcan provide an important input fordevelopment of nutrition data andinformation for disaster risk mitigationand prevention in line with the government’sDRM policy.The ongoing OTP roll out implementedby the federal Ministry ofHealth (FMOH) provides a uniqueopportunity for integration of managementof acute malnutrition into longerterm nutrition programmes, such asCBN and micronutrient deficiencycontrol programmes.The Government’s NationalNutrition Programme (NNP) providesconsiderable opportunities for the integrationof emergency andnon-emergency nutrition informationsystems, as well as integration of theENCU functions into the governmentstructures. The paradigm shift fromcrisis management to risk mitigationand prevention requires strengthenedand improved early warning systemsof all the sectors including nutrition.The integration of ENCU into thegovernment working system includespreparation and implementation ofcommon DRMFSS-ENCU/UNICEFannual work plans supported byUNICEF. This ensures governmentownership and presents positive signsfor future integration within thegovernment structures. ENCU has alsosecured government and partners trustin the ENCU’s work and strengthenedlinkages between respective governmentinstitutions, UN agencies, donorsand NGOs implementing emergencynutrition activities in Ethiopia.For more information, contact:Isaack B. Manyama,email: isaackm@dppc.gov.etField ArticleThe experienceof multi-storeygardens inEthiopianrefugee campsAn example of gardeningin a camp settingMulugeta Wtsadik/UNHCR, Ethiopia, 2009By Mulugeta WTsadikMulugeta WTsadik is food security and nutrition officer withUNHCR Ethiopia since 2004. She has a degree in rural development.Since 1997, she has worked on food security andnutrition programmes with a number of organisations.UNHCR Ethiopia officer, Administration Refugee-ReturneeAffairs (ARRA) and ZOA Refugee Care wish to thank all thepeople directly or indirectly implementing the multi-storeygarden (MSG) and poultry production. We acknowledge theimportant contributions of the following individuals withoutwhose hard work and support the pilot project could nothave materialised: Ms Sabine Wahining (UNHCR Ethiopia),Ms Allison Oman (UNHCR Kenya), Mr Ahmed Fall Baba(UNHCR HQ), Mr Tesfaye Bekel (UNHCR Ethiopia), Dr DejeneKebede (UNHCR Ethiopia), Mir Ajit Fernando, Ketyibelu andG/Giories (UNHCR Sub-office in Shire), Mir Bekele and DerejeBogale (UNHCR sub-office in Jijiga) and Mr John BoscoKinama (JTZ in Dadaab, Kenya) who conducted field trainingfor national staff and refugees..35

Field ArticleEthiopia hosts around 112,201 refugees.Approximately 1,564 reside as urbanrefugees, while the remainder live ineight different refugee camps. Themajority of refugees are of Somali (K/Beyah,Shedr, Awbarre and Boqolmayo), Sudanese(Fugnido and Sherkole) and Eritrean (Mayani,Asayta and Shimelba) nationalities.UNHCR have regularly conducted nutritionsurveys amongst this refugee population. Since2007, the nutrition surveys have also includedmeasurement of haemoglobin usinghaemocues. These surveys have found alarminglevels of anaemia despite the fact that fortifiedblended food has been provided since 2007 -when corn soya blend (CSB) was introduced tothe general ration by the World FoodProgramme (WFP). Slight but insubstantialimprovements in anaemia rates have beenobserved since. In 2008 and 2009, data stillshowed an anaemia prevalence >20%, with upto 42% prevalence among children under fiveyears. Anaemia prevalence amongst women ofreproductive age ranged from 6% to 27%. Giventhis, UNHCR now provides CSB to all childrenbetween 6 and 23 months. This complementsthe WFP ration of wheat, vegetable oil, CSB,pulses, salt and sugar. It is assumed that withsuch high levels of anaemia, there are probablyother micronutrient deficiencies in the camps,e.g. zinc. Zinc levels have not been measured asthe required methods are too complicated,given the location of the camps and the logisticalinfrastructure needed.Multi storey gardens and poultryprojectsIn order to address this micronutrient problemand more generally improve food security,UNHCR undertook a pilot programme of introducingmulti-storey gardens (MSG) and poultryinto three camps (Shimbelba – Eritreanrefugees, Awbarre and Kebribeyah – Somalirefugees). This initiative was funded throughUNHCR regional and HQ funding.The specific objectives of the projects were toincrease availability of vegetables and eggs athousehold level, thereby improving micronutrientstatus of vulnerable refugees. It was alsoexpected that the MSG project would improvethe infant and young child feeding practices ofmothers, thereby improving child nutritionalstatus. MSG is a farming technology adopted inareas with little land space and where there iswater scarcity. Space is often at a premium inrefugee camps. Furthermore, as the vegetableproduction takes place at household level, it hasthe advantage of reducing workload and timerequirements associated with more traditionalgarden systems.The pilot project began in April 2008 with atwo day training of the selected implementingpartner (ZOA) on MSG and poultry production,held in Addis Ababa. ARRA (Administrationfor Refugees and Returnee Affairs) are thegovernment of Ethiopia (GoE) counterpartjointly working with UNHCR on the initiative.Training was conducted by UNHCR HQ staff. AUNHCR consultant with experience workingon MSGs in Kenya conducted training at camplevel (three days training per camp) and wrote afield manual. WFP provided technical advice aswell as providing sacks and empty vegetable oilcans. This phase of the project was completedby November 2008.Table 1: Nutritional status of children 6-23 and 6-59 months of ageCamp K/Beyah Awbarre ShimelbaNo. of beneficiaries40 45 43(households) surveyedNo. (%) who developed MSGs 37 (91%) 39 (93%) 43 (100%)No. of sacks developed bybeneficiaryNo. (%) beneficiaries havestarted to harvest vegetablesNo. (%) beneficiaries whohave sold vegetablesNo. (%) beneficiaries eateneggsNo. (%) beneficiaries whohave recycled water1 sack (0%)2 sacks (2%)3 sacks (5%)4 sacks (7%)5 sacks (70%)6+ sacks (7%)Implementation of the project commenced inJanuary 2009 with ZOA providing the initialfunding. UNHCR funding commenced in April2009. One hundred and sixty seven householdswere selected in each pilot camp with eachhousehold encouraged to construct five MSGs.Households were also provided with threepoultry (one cock and two females). Targetbeneficiaries were family members with a caseof anaemia or malnutrition, large femaleheadedfamilies and people living withHIV/AIDS. Some model farmers and other‘interested’ people were also selected.Evaluation of pilot projectAn evaluation of the pilot was conducted inOctober 2009 by UNHCR/ZOA and ARRA. Theevaluation objectives were to identify lessonslearned and challenges of the project in relation toimplementation capacity and cost effectiveness,MSGs use 50kg cereal bags and empty oil cans.The cereal bags are used for growing theproduce. The oil cans are filled with rocks andplaced in the centre of the upstanding cerealbag. Holes are drilled in the sides and bottom ofthe tins. A soil blend is placed in the bagbetween the bag and the tins. Seeds are thenplanted in the soil on the top of the bag.When it is time to 'thin out' the seedlings,some of the small plants are removed from thetop and, after holes are made in the sides of thebags, the seedlings are planted along the sidesof the bags. This means the top and sides of thebags are utilised for growing.In areas where water is in short supply, this isa very economic way to utilise extremelylimited resources. Each bag only needs to bewatered twice daily with 5 litres of water. Thewater is poured into the tin at the centre of thebag and drains through the stones downthrough to the end of the bag of soil, irrigatingall the plants throughout the depth of the bag.It is recommended to use household wastewater after rinsing out clothes or bathing, andalso waste water from around water points.However, it is important to incorporate andintegrate waste management into theprogramme so as not to further limit waterresources necessary for other activities. A standardkitchen garden requires much more waterthan that used in the MSG approach.1 sack (2%)2 sacks (11%)3 sacks (28%)4 sacks (20%)5 sacks (28%)6+ sacks (4%)1 sack (2%)2 sacks (7%)3 sacks (5%)4 sacks (7%)5 sacks (70%)6+ sacks (9%)30 (75%) 36 (80%) 43 (100%)0 (0%) 2 (4%) 6 (14%)Average income31 Birr/monthChickens are still small/tooimmature to lay eggs and breed31 (77%)Average 71.2 litres/weekMulti-storey gardens (MSG) methodMulugeta Wtsadik/UNHCR, Ethiopia, 2009Chickens are still small/tooimmature to lay eggs and breed28 (62%)Average 79 litres/weekAn example ofmulti-storeygardening15 (35%)Average 7.5 eggseaten per week32 (74%)Average 146litres/weekTools neededJembe – used to dig the soil that will be mixed withother components for constructing the garden.Forkjembe – used to dig the soil in hard ground areas.Spade – used to collect and mix the soil components.Tinsnip/Knife – used to cut off the top part of the tin.Tin punch – used to punch holes in the top andbottom of the tin.Wheelbarrow – used to measure and transport thevarious soil parts.Equipment neededPerforated tinsSacksGravel clay soilSand soil (main part)ManureSeedsWaterJerry canSuitable vegetables for MSG(Common name/Somali name)Dania – Coriander/DaniaSukuma wiki – Collards/SukumaCapsicum – California wonder/PilipilihohoEgg plant – Black beauty/BirganyaSpinach – Fordhok giant/SpinachTomatoes – Caj, M82/ NyanyaOkra – Pusa sawani /BamiaAmaranthus – Terere/Terere36

Field ArticlePoultry project in actionand to develop recommendations for currentand future programming direction.The evaluation involved questionnaires thatassessed any increases in vegetable consumption,amounts of vegetables sold and anydecreases in percentage of monthly rations soldto buy vegetables. There were also questionsabout water usage to support the MSGs andconcerning egg consumption.The questionnaire was administered to 50out of 167 households that were randomlyselected in each camp. Focus group discussionswere also held with 15-20 randomly selectedhouseholds who were not included in thehousehold survey and with an additional fivehouseholds who were not one of the 167 beneficiaryhouseholds. Data from the primaryanalysis are presented in Table 1.Other key findings from the evaluationincluded the following;• MSGs need less water than ordinary backyardgardens.• Vegetables grow faster in MSGs than ifgrown in the ground. Two harvests can beobtained in the time that it takes for onebackyard harvest.• On average, a HH recycles 60-120 litres ofwater a week. One sack needs up to 10litres of water per day.• Refugees acquired new agricultural skills.• Households diversified their meals onaverage three times a week.• There was a decreased tendency to sellrations to obtain vegetables.• Some households shared vegetables withneighbours not included in the pilot.ChallengesIn spite of the MSG project success, there havebeen certain challenges. Perhaps the mostsignificant has been water shortages andspillage of water at distribution points in theSomali camps. UNHCR have tried to addressthis <strong>issue</strong> but in some cases, problems appearedinsurmountable. Although UNHCR provideswater for Somali refugees and local populations,there is not enough drinking waterduring the dry season let alone for MSG use.Refugees have to queue at water taps and thereis a great deal of spillage in taking water home.Water is also collected from rain-water birkadsbut people have to carry water long distancesMulugeta Wtsadik/UNHCR, Ethiopia, 2009and also pay frombetween 2-5 Birr perjerry can. Not enoughplastic sheets wereprovided for waterharvesting and storage.UNHCR have beentrying to encouragerefugees to re-cyclewater from showers andwashing food. Somehouseholds do this butonly a minority.There have also been<strong>issue</strong>s around lack ofvariety of seeds andseedlings, as well asinappropriate seeds,used in the MSG.Furthermore, somebeneficiaries were notprovided with adequatetools and wheelbarrowsand not all beneficiaries have been using thesides of sacks for transplanting. Also, the principleof using a limited number of vegetablesper sack is not well understood by beneficiaries,project animators and the agronomistattached to the programme. Another <strong>issue</strong> hasbeen pest control and vegetable diseases.The least successful part of the pilot was thepoultry programme. There were many challengeshere. One <strong>issue</strong> was whether it isappropriate to combine MSG and poultry interventionsin the same refugee household, giventhat poultry will eat crops. Another problemwas that the chickens bought by ZOA in AddisAbaba were too young and as they weredistributed during the rainy season, a largenumber of them died from disease. There wasalso a problem with feeding the chickens withchicken feed being taken out of the WFP rationso that there was less food available for households.The chicken feed provided by ZOA onlylasted a month.The evaluation also found that follow upfrom ZOA and UNHCR at camp levels has beenlimited. Furthermore, monitoring has beenweak. Certain activities that were meant to takeplace according to the project proposal were notimplemented. These included establishing avegetable nursery site for seedling production,construction of water troughs in KebriBeyahand Awbarre near the waterdistribution point, pestcontrol activities, developmentof field manuals onMSG in the local language,and egg production andconsumption surveillance.In spite of these problemshowever, the MSGproject is well accepted byrefugees and has beenrequested by householdsnot included in the pilotprogramme. The projectallows refugees to choosewhat they want to plant andeat and contributes to asense of dignity, while thepresence of green spacesand the sight of food growingalso contribute to asense of well-being. There isMulugeta Wtsadik/UNHCR, Ethiopia, 2009An example ofmulti-storeygardeningalso a ‘domino effect’ as households sell or giveaway excess produce to their neighbours so thatthere are small enclaves where people areeating better and enjoying fresh foods.Furthermore, some of these refugees arealready trying to duplicate the MSG on theirown initiative.Conclusions and recommendationsThe MSG project should continue and be rolledout to other camps while the poultry rearingproject should discontinue. The poultry projectshould be stopped largely due to incompatibilitywith an MSG project, i.e. the chickens ate theMSG produce. Other reasons included expenseand time required for implementation, difficultyof finding an appropriate chicken breedand the need for chicken house constructionmaterial.Problems with water in the MSG projectnecessitated a number of measures includingconstruction of water traps at water distributionpoints to use waste water, assessment ofwater that be can collected through spillageduring the dry season, encouraging refugees tomaximize water recycling, exploring the potentialfor roof water harvesting from buildings inthe camp and increasing the number of waterstorage containers in the camps.There were also recommendations about thetechniques used in the MSG. For example, it isimportant to understand that the life of a sack isaround nine months if good watering techniquesare used. After this point, beneficiarieswill need to replace the sack. The animators andagronomists should also provide advice to thebeneficiaries on the appropriate ratio of topsoils, manure and sand soil, which is fundamentalto optimal growth of vegetables, waterconservation and utilisation. The implementingpartner should also ensure that all sides of thesack are used, that beneficiaries do not useinappropriate vegetable seeds to grow cropslike cabbage, carrot or onion and that refugeesare encouraged to establish a nursery gardenfor seedlings. Furthermore, there is a need forhouseholds who succeed to be encouraged toshare their experiences with the refugee camp.There is also a need for refresher training for theproject officer, agronomist and animators aswell as partners like ARRA.For more information, contact: MulugetaWTsadik, email: WTSADIK@unhcr.org37

Indrias Getachew, Ethiopia, 2010Field ArticleThis article describes experiences and observations around the successfuldecentralisation and scale up of the outpatient management of severe acutemalnutrition in Ethiopia in the period 2008 to 2010. It includes achievements,the challenges around monitoring and reporting and ongoing steps needed tostrengthen and assure service quality.Health Extension Worker providing healthand nutrition education during a householdvisit, Menkere health post, Tigray regionDecentralisationand scale up ofoutpatientmanagement ofSAM in Ethiopia(2008-2010)By Sylvie ChamoisSylvie Chamois has been a Nutrition specialist withUNICEF Ethiopia and Burundi for the past 9 years.Before joining UNICEF, she spent 6 years working as anutritionist for Action Contre la Faim, mostly inemergency settings.Disclaimer: the findings, interpretations, and conclusions inthis article are those of the authors. They do not necessarilyrepresent the views of UNICEF, its Executive Directors, or thecountries that they represent and should not be attributedto them.Following up on the experience ofdecentralising outpatient therapeuticcare in 100 districts of Ethiopia in2008 (Field Exchange, No 361), thisarticle describes how this was further rolledoutin 606 districts of Amhara, Oromia,SNNP and Tigray regions between 2009 andSeptember 2010.BackgroundEthiopia has one of the highest childrenunder-five mortality rates, with malnutritioncontributing to 57% of all children deaths 2 .The 2005 Demographic and Health Surveyrevealed that 2.2% of children under-five areseverely wasted 3 , a condition associated witha mortality rate of 13% (7.3 to 18.7%) 4 .When adopting the MillenniumDevelopment Goals (MDGs), the Governmentof Ethiopia (GoE) committed to halve by 2015children under-five malnutrition (MDG 1) andmortality (MDG 4). This has been reflected inits Plan for Accelerated and SustainedDevelopment to End Poverty (PASDEP, 2005-2010 5 ). The strategy under the third HealthSector Development Programmes (HSDP III,2005-2010 5 ) addresses the major causes ofchild mortality that account for 90% of underfive deaths, i.e. pneumonia, neonatal conditions,malaria, diarrhoea, measles, HIV/AIDSand malnutrition.A series of nutrition articles published inthe medical journal, The Lancet, in January2008 defined the magnitude and consequencesof undernutrition and demonstratedthe availability and potential benefits ofproven interventions, including the managementof severe acute malnutrition. Therefore,increasing coverage of and access toOutpatient Therapeutic Programme (OTP) isone of the key elements that contribute to theachievements of the MDGs 1 and 4, amongother key food security and nutrition interventionscurrently being implemented inEthiopia.Map 1: Map of the 100 districts in Oromia and SNNPRselected for the OTP decentralisation in July 2008Districts Selected for the OTPDecentralisation in 2008List of 100 Districts (in Oromia& SNNPR) Selected for the OTPDecentralisation in 2008Zone BoundaryRegion BoundaryData Source: UNICEF Ethiopia. Boundaries are approximate and unofficial. Graphic & AnalysisENCU/EWRD Ethiopia October, 2010How the OTP decentralisation startedin 2008UNICEF has been advocating for the integrationof the management of severe acutemalnutrition into the Ethiopian governmenthealth system since 2004. With Governmentleadership, in- and out-patient care had beensuccessfully integrated into 165 hospitals andhealth centres by January 2008. However, theidea of integrating outpatient managementof severe malnutrition into the HealthExtension Programme 6 (i.e. allowing healthextension workers to provide curative services)was still being discussed at the time ofthe March/April 2008 rain-failure in thesouthern part of the country.In May 2008, dramatic and rapid increasesof severe acute malnutrition levels werereported in Oromia and Southern Nations,Nationalities and People's (SNNP) regions.This was the result of the poor performanceof the March/April rains in the southern partof the country combined with the prevailinghigh market prices (food prices in ruralEthiopia had risen by 250% between 2006and 2008 7 ). In these two regions alone, 193districts were affected where over 23 millionpeople lived. The Ministry of Health (MOH)and international non-governmental organisations(NGOs), with UNICEF support,began implementing emergency feedingprogrammes under the coordination of theEmergency Nutrition Coordination Unit(ENCU).The MOH concluded that the best option toprevent high mortality due to malnutritionwas to decentralise the outpatient managementof severe malnutrition to the healthpost/sub-district level. In July 2008, UNICEFwas requested to support the Family HealthDepartment of the Ministry to rollout OTPs in100 drought affected districts of Oromia andSNNP regions (See Map 1). This involved1,239 health posts and 2,478 health extensionworkers.1Sylvie Chamois (2009). Decentralisationof out-patient management of severemalnutrition in Ethiopia. Field Exchange,Issue No 36, July 2009. p12. http://fex.ennonline.net/36/decentralisation.aspx.2National Strategy for Child Survival inEthiopia, Federal Ministry of Health,Ethiopia, July 2005.3Defined as weight-for-height < -3 z-score.4Steve Collins, Nicky Dent, Paul Binns,Paluku Bahwere, Kate Sadler andHalister Hallam. Management of SevereAcute Malnutrition in Children. TheLancet, Vol. 368, December 2006.5The PASDEP and HSDP III cover theperiod Sept 2005-Aug 2010, whichcorresponds to the Ethiopian calendaryears 1998-2002.6The Health Extension Programmedelivers primary health and nutritionservices at sub-district level by twofemale Health Extension Workers basedin health posts; there is one healthpost per sub-district covering anaverage of 5,000 people.7FEWS NET Ethiopia food securityupdates, USAID and WFP, 2008.38

Field ArticleBox 1: Some key programme definitions used in EthiopiaTherapeutic Feeding Unit (TFU):Units in hospitals and health centres offering inpatientcare to the severely malnourished cases. IfOTP is not available in the catchments area, TFU offersfull in-patient care with Phase 1, Transition Phase andPhase 2 with an average length of stay of 2 to 3 weeks.When OTP is available in the catchments area, onlythe complicated severe cases, as defined by a lack ofappetite and the presence of medical complications,are admitted in TFU. Usually, patients only stay as longas they require Phase 1 treatment (2 to 7 days) andthen progress to out-patient care.Out-patient Therapeutic Programme (OTP):Programme runs from health centre or health postoffering out-patient care to severely malnourishedcases who have appetite and who do not have anymedical complications (this group usually representsover 90% of all the cases). At admission, childrenreceive a medical check to determine if they warrantdirect referral to the nearest in-patient TFU. If they arewell enough to be treated as an out-patient, theyreceive systematic treatment and a ration of RUTF.Patients are seen on a weekly or fortnightly basis, butcaregivers are encouraged to return to the OTP if thechild’s condition deteriorates during that time. Theaverage length of stay in OTP is 4-8 weeks.Therapeutic Feeding Programme (TFP):Combination of in-patient (TFU) and out-patient(OTP) therapeutic feeding for the treatment of severeacute malnutrition.Community Management of Acute Malnutrition(CMAM):International appellation for timely detection ofThis programme has been described in aprevious <strong>issue</strong> of Field Exchange referred toearlier (No 36). Key elements of the programmewere as follows. In July and August 2008, all the2,478 health extension workers were trained inthe identification of severe acute malnutrition,referral of the complicated cases to inpatientfacilities and management of the uncomplicatedcases of severe acute malnutrition. As ofNovember 2008, 51 districts (50% of the initialplan) were managing OTPs in 455 health posts(36% of the total number of health posts in the100 districts), raising the service coverage from38 to 65% in the two regions' affected areas. Atotal of 27,739 children were reported to havebeen admitted in the 455 therapeutic feedingsites with overall positive performance indicators:77.6% recovery, 0.7% mortality and 4.2%defaulter rates.The MOH has since endeavoured tostrengthen the existing OTPs in the 455 healthposts and effectively continue the rolling-out ofthe plan to the remaining 784 health posts in thetwo regions and more widely nationally. As ofSeptember 2010, there are over 6,400 health postsdelivering OTP services and 280 inpatientTherapeutic Feeding Units (TFUs) in 691 districtsof Ethiopia out of which 89 are supported byNGOs. This scale up by GoE is a remarkableachievement. The article below details some ofthe key developments in achieving this.How the OTP rollout was implementedAdvocacy and coordinationPost- 2008 experience of decentralising outpatientmanagement of severe acute malnutritionin 100 districts, the GoE was keen to implementthe rollout through their system and to ensuremaximum integration and capacity developmentwithin the existing decentralised HealthExtension Programme. UNICEF’s role was tosupport GoE in this process.severe acute malnutrition in the community (socialmobilisation), provision of treatment for those withoutmedical complications with RUTFs or othernutrient-dense foods at home (OTP) combined with afacility-based approach for those malnourished childrenwith medical complications (TFU or StabilisationCentre). An approach endorsed by the World HealthOrganisation, UNICEF and Standing Committee onNutrition.Enhanced Outreach Strategy/ TargetedSupplementary Feeding (EOS/TSF):The EOS/TSF for Child Survival is a joint programmeunder the United Nations Development AssistanceFramework (UNDAF, 2007-2011) with theGovernment of Ethiopia. UNICEF is supporting theMinistry of Health (MOH) to conduct twice yearlycampaigns of Vitamin A supplementation anddeworming to every child under five in the country 8 .In TSF selected districts, the EOS is also screening formalnutrition all children under five, and pregnant andlactating women 9 . WFP is supporting the Disaster RiskManagement and Food Security Sector (DRMFSS) ofthe Ministry of Agriculture and Rural Development(MOARD) to deliver two supplementary rations ofCorn Soya Blend (CSB) and oil to children and womenidentified with acute malnutrition during screening 10 .Community Health Days (CHD):CHDs are currently being phased-in in Ethiopia as theEOS is being phased-out. It is quarterly local healthevents organised at the sub-district/ health post levelby the health extension workers to provide Vitamin Asupplementation and deworming on a six-monthlybasis and screening of children and pregnant andlactating women on a quarterly basis.It was also necessary to find the right fit fora tripartite partnership between GoE, NGOsand UNICEF, each playing their role for therollout to be successful. NGOs had difficultiesengaging in the process as the GoE preferred toimplement the programme itself. There wereconcerns expressed by the NGO communityabout the proposed speed of scale up for thistype of programme and fears that quality ofservice may suffer. There may also have beensome concerns about the possible lack of NGOrole in this scale up.UNICEF advocacy role was to find the rightlink between the GoE and the support NGOscould provide. This was achieved through threetypes of coordination meetings:Type 1: Involving all parties: nutrition clustermeetings were held at the ENCU andattended by NGOs, UN agencies,relevant government counterpartagencies and donors.Type 2: Between NGOs, donors and UNagencies: regular meetings wereorganised by UNICEF as a means ofencouraging donor support and toensure good coordination with theNGO sector, andType 3: Between UNICEF and theGovernment.This resulted in agreement that there should bejoint monitoring of the OTPs (and TFUs) by allstakeholders, e.g. GoE, NGOs and UN agencies.NGO collaboration was to be requested by theGoE in those geographical areas where capacityfor OTP (and TFU) rollout was limited. Thepredominant NGO role in these areas shouldand would be to support and build upGovernment capacity. These meetings wereheld for approximately one year from May 2009and proved useful during a difficult transitionperiod for various stakeholders.Coordination at regional level was led by theRegional Health Bureaus through the Healthand Nutrition Task Forces.Donor supportUNICEF developed an emergency nutritionresponse plan for 2009 and 2010 and donorswere invited to contribute funding. Donorsupport for the rollout of OTP in the four targetregions was secured from the HumanitarianResponse Fund (HRF), OFDA, Governments ofJapan and Spain, CIDA, DFID, SIDA andECHO 11 .Development of regional action plansUNICEF helped to instigate the development ofaction plans in the four target regions (Amhara,Oromia, SNNPR and Tigray) in conjunctionwith the Regional Health Bureaus. These fourregions were selected on the basis that theywere the most severely affected by drought in2008, their high population density and existenceof a functional Health ExtensionProgramme. Regional planning took placewithin regional task force meetings andinvolved NGOs where they were able to pledgecommitment to training and monitoring.Adaptation of the strategy to regionalcontexts (Afar and Somali regions)Afar and Somali regions (arguably regions mostprone to food insecurity) were not initiallyincluded in this scale up due to the mobility oftheir populations and consequent difficulties ofintegrating OTPs into existing health structures.Furthermore, Somali and Afar are notpopulation dense so that health posts wouldserve only a few children, also security andaccess are continuously problematic in theregions. However, GoE with UNICEF and NGOsupport, fielded mobile health and nutritionclinics based upon guidelines developed inMarch 2008. Mobile teams visit communitiesevery one to two weeks to implement OTPmanagement as well as IntegratedManagement of Childhood Illnesses, promotionof hand washing and safe water. As ofSeptember 2010, there are seven mobile clinicsrun by the GoE in Afar, including two usingcamels. In Somali region, the GoE runs twentymobile clinics while NGOs support anotherseven.Technical assistance for training andfollow-upDuring the scale up, Regional Health Bureausorganised trainings with UNICEF and NGOsupport mainly targeted to health extensionworkers and HEP supervisors, but also includinglocal zone and district officials. Training ofhealth workers and doctors on the inpatientmanagement of severe acute malnutrition wasalso provided with the aim of setting up a minimumof one inpatient unit per district for themanagement of complicated cases. UNICEFrecruited six nutrition specialists to support theorganisation and conduct training, as well aspost-training visits and supportive supervision.Training was similar to that carried out duringthe 2008 decentralisation programme inOromia and SNNPR.8Vitamin A is supplemented to children 6-59 months old anddeworming tablets are administered to children 2-5 years old.9Are screened for malnutrition: children 6-9 months old,visibly pregnant women and women breastfeeding a lessthan 6 months old infant.10Eligibility for TSF: Children with MUAC < 12 cm and/orbilateral oedema and women with MUAC < 21 cm. One TSFration is composed of 25 kg of CSB and 3 litres of oil for 3months.11See acronyms listing on page 92.39

Field ArticleFigure 1: Number of Therapeutic Feeding Programmes (OTP & TFU) and monthly report completionrate in the four target regions (Amhara, Oromia, SNNPR and Tigray), Jan 2008 to August 2010 138,0007,0006,0005,0004,0003,0002,0001,0000Jan – 08Mar – 08May – 08Jul – 08Sept – 08Nov – 08Number of TFPProvision of supply and logistic supportIn 2009, an amount of Ready to Use TherapeuticFood (RUTF) was imported, although the‘Hilina Enriched Food Processing Centre’, theNutriset franchised company, provided most ofthe supply. From 2010 onwards, UNICEF isplanning to only procure RUTF locally 12 . It hadbeen anticipated that NGOs would procuretheir own RUTF where they were supportingdistricts, however it appears that somepreferred or expected UNICEF to procure thecommodity on their behalf. Furthermore, anumber of NGOs advocated for provision ofcontingency stocks in the event of shortages.UNICEF also became involved in some ofthe logistics of the programme where GoEneeded additional support. UNICEF wouldtherefore, in some cases, distribute RUTF tozonal or district level. For the remote districts,provision for supply transportation down tothe health post level was included into theregional action plans.Enhanced programme monitoring andquality insuranceEnsuring good programme monitoring andquality proved to be challenging with the rapidmultiplication of OTP sites. UNICEF supportedthe GoE working on the three following aspectsof programme monitoring and quality insurance:Mother and child waiting for admission tothe OTP, Senebete Senkete Health Centre,Siraro woreda, Oromia regionJan – 09Mar – 09Sylvie Chamois, Ethiopia, 2009May – 09Jul – 09Sept – 09Nov – 09Jan – 09Mar – 09Report completion rate%May – 09Jul – 09a) Improved report quality, timeliness andcompletion90%80%70%60%50%40%30%20%10%One priority was to increase and maintain highmonthly statistics report quality, timeliness andgood completion rates.Figure 1 shows that the report completionrate was 69% in the four target regions beforethe OTP rollout (Jan - Aug 2008) and dropped to42% with the OTP expansion (Sep 2008 to Dec2009).In September 2009, the Minister of Healthsent a letter to Regional Health Bureaus toemphasise the importance of getting timely andaccurate reports for enhanced programmemonitoring. In addition, UNICEF recruited inNovember 2009 four technical assistants, oneattached to each regional ENCU, to look atreporting systems, identify bottlenecks forquality and timely reports and take appropriateactions in conjunctions with the GoE. Thisresulted in the achievement of 77% reportcompletion rate between January and August2010. Reports usually reach the federal levelwithin a maximum of one month after the endof each month of activity.0%Other longer-term actions initiated by GoEand UNICEF on reporting are:i) Development of a user-friendly software tobe decentralised to the District HealthOffices (currently under development) 14 .It is expected that this tool will improvereporting as well as district and regionalcapacity to analyse/use data forprogramme management. The softwarewill also include growth monitoring,Table 1: Summary of results from jointmonitoring assessments in the four targetregions (Amhara, Oromia, SNNPR and Tigray),September 2009 to September 2010 17Number and % of districtsscoring:Region* Number of < 50% 50-70% > 70%districtsassessedAmhara 59 20 (34%) 27 (46%) 12 (20%)Oromia 53 9 (17%) 30 (57%) 14 (26%)SNNPR 3 0 3 (100%) 0Tigray 16 6 (38%) 9 (56%) 1 (6%)Total 131 35 (27%) 69 (53%) 27 (20%)*Joint monitoring started in September 2009 in Amhara andOromia and in April and June 2010 in Tigray and SNNPRrespectively.vitamin A supplementation and dewormingindicators.ii) Piloting of health extension workerssending OTP data using SMS for improvedtimeliness and completion rate (ongoingand results expected in 2011).iii) Integration of nutrition indicators into theHealth Management Information System(not yet achieved) 15 .b) Development of joint monitoring tool andsystemFollowing on the recommendation to undertakejoint monitoring of the programme (GoE, NGOsand UNICEF), a sub-working group chaired byUNICEF was formed with ACF, Concern,GOAL, MSF-Greece and MSF-Holland. Theymet weekly between May and June 2009 todevelop a monitoring checklist for field assessments.The tool was then discussed with theregional authorities in Oromia and SNNPR,tested and modified between July and August2009. It was agreed where NGOs operate, thatthey were to be the partner of the MOH andUNICEF for all joint monitoring work. Theywere also invited to participate as much as possibleoutside of their traditional support area.In SNNPR, by the first week of August 2009,a team composed of Regional Health Bureau,NGOs 16 , regional ENCU and UNICEF, made thefinal modifications to the checklist for OTP andTFU assessment, grading individual componentsof the practices observed. It was agreedthat a three tier grade banding could be usefulto identify the level of programme supportneeded at district level, where:• Grade over 70%: working very well withminor support needs only• Grade 50-70%: working well but with sometechnical and logistic support needsrequiring attention• Grade under 50%: has major support needsto refresh skills of staff and whereoperational systems need to be establishedIn districts where NGOs provide minimalsupport to MOH, the NGO in collaborationwith MOH would address the agreed supportneeds. In all other districts, it was suggestedthat the Regional Health Bureau request additionalsupport from UNICEF and/or selectedNGOs.The testing in Oromia and SNNPR alsoallowed for Regional Health Bureaus and partnersto learn more about the resource needs tomanage regular joint monitoring, especially interms of key personnel time and transportationneeds. It was initially thought that the six additionalstaff recruited by UNICEF to support theOTP rollout in the four regions would also beinvolved in the joint supervision. However, thisadditional capacity coupled with the GoE andNGO capacity was not sufficient to establishadequate monitoring of the programme (ittakes a full week for a monitoring team toassess the practice of health extension workersand health workers in 40-50% of all OTP sitesand all TFUs in one district).12As of September 2010, there is only one local RUTF factoryin Ethiopia and a second one is planning to start productionin October 2010.13Source: TFP database, ENCU/DRMFSS/MOH, Ethiopia.14At the moment, the database is kept by the ENCU atfederal level.15Health extension workers salary is conditioned to thesubmission of the HMIS reports to the District Health Office.16Concern, GOAL, Save the Children-US, Samaritan’s Purseand International Medical Corps (IMC).17Source: UNICEF Ethiopia.40

Field ArticleTable 2: Number of TFUs per district andhotspot priority in the four target regions(Amhara, Oromia, SNNPR and Tigray),September 2010 18Hotspotprioritynumber*TotalnumberofdistrictsNumberof districtswith noTFUNumber ofdistrictswith atleast 1 TFU% ofdistrictswith TFU1 176 70 106 60%2 96 52 44 46%3 99 75 24 24%Total 371 197 174 47%* Districts affected by food insecurity and in need of humanitarianassistance are classified into hotspots priority 1 (high), 2(medium), 3 (low) and 4 (not affected).Table 3: Summary results from TFP coveragesurveys conducted in each of the four targetregions, 2010 19District assessed and date* OTP periodcoverageWadela, Amhara region,March 2010Arsi Negele, Oromia region,January 2010Mareko, SNNP region, January2010Tahtay Machew, Tigray region,March 2010OTP pointcoverage19% 10.4%48.8% 21.2%60.9% 37.8%56.2% 27.3%Consequently, in September 2009 UNICEFdeveloped a Project Cooperation Agreementwith the NGO Population Service International(PSI) to deploy twenty field monitors in aneffort to boost programme quality in all hotspotdistricts in the four largest regions. A total of131 districts were monitored from September2009 onwards. As of September 2010, 20% ofdistricts were working very well with minorsupport needs only (ranked over 70%), 53%were working well but with some technical andlogistic support needs requiring attention (50-70%) and 27% have major support needs torefresh skills of staff and where operationalsystems need to be established (under 50%),(Table 1).In spite of the impressive increase in serviceaccess that has been achieved in districts thathave rolled out OTP to health posts at subdistrictlevel, the monitoring has helped toidentify key areas where the programme needsstrengthening.The availability of one functional TFUs perdistrict as planned is still limited. Sixty per centof ‘priority 1’ hotspot districts have at least oneTFU, compared with 46% of districts in hotspotpriority 2 and 24% in hotspot priority 3 (seeTable 2). Also see Map 2.The low proportion of referral from OTP toTFU in some districts is also a concern andshould be studied further. It is not known howmuch of this is due to very early detectionreducing the number of complicated cases, oras highlighted in the four TFP coverage surveysconducted recently (Table 3), for other reasonsaffecting access. These include low level ofactive community mobilisation and lack ofskills among some health extension workers toidentify and refer the complicated cases, caregiverrefusal to go to the TFU because it is toofar, lack of capacity to pay for transport, lack offood for caregivers, opportunity cost for caregiversof staying away from their home, etc.Health Extension Programme supervisionby MOH is not always working adequately dueto lack of trained staff skilled to mentor/super-Box 2: Summary of recommendations from the four coverage survey reports• Ensure uninterrupted provision of service byavoiding scheduling conflicts for health extensionworkers (HEWs).• Maintain continuous supply of therapeutic products.• Improve technical skills of HEWs and health centresstaff through formal and on-the-job training.• Strengthen record keeping, training (formal andon-the-job) and monitoring progress of registeredbeneficiaries.• Establish regular supportive supervision for HEWsby their Health Extension Programme (HEP)supervisors and district focal persons.• Continue joint monitoring assessments (GoE, NGOand UNICEF).• Ensure involvement of community health worker(CHWs) in active case finding and defaulter tracing.• Integrate TFP with other health/nutrition/foodsecurity programmes in the district. For example, theMap 2: Map of hotspot districts (priority 1, 2 and 3)in Amhara, Oromia, SNNP and Tigray regions andpresence of TFU, September 2010Hotspot Districts(Priority 1, 2, & 3) inAmhara, Oromia, SNNPand Tigray Regions andPresence of TFU,Ethiopia, September2010Hotspot Priority DistrictsFirst PrioritySecond PriorityThird PriorityHotspot Districts with thePresence of TFUTFUData Source: UNICEF Ethiopia. Boundaries are approximate and unofficial. Graphic &Analysis ENCU/EWRD Ethiopia October, 2010vise OTP activities. Some supervisors are sanitarians,not health staff, and are not familiarwith the programme. Some districts lack thefull quota of supervisors (one per five healthpost). Lack of capacity and effective managementfrom District Health Offices managersand lack of transport to facilitate visits to OTPsites may also contribute to shortcomings.When assessing the programme, the monitors(GoE, PSI/ UNICEF and NGO) also build thecapacity of the HEP supervisors and DistrictHealth Offices managers using the checklistand providing on-the-job support.Health extension workers in most districtsobserved so far urgently need follow up trainingto refresh/strengthen their skills. OTPprotocols are not always being maintained, anderrors in anthropometry are still observed. Thiscan result in moderate acute malnutrition casesincluded in the programme, and unduly longlength of stay. Recording and reporting alsoremains a challenge. A system for regularsupply management and distribution is yet tobe established in many districts.formation of linkages to improve active casefinding during the quarterly Community Health Daysscreening, house-to-house visits, routine sanitationactivities (e.g. pit latrine construction), familyplanning services. In all community conversations,HEWs should raise awareness on the links betweenthe TFP and the Growth Monitoring sessions,especially when cases of SAM are identified.• In Community-Based Nutrition districts, giverefresher training to CHWs to replace those whoare no longer active and to ensure sufficientnumbers to satisfy the district’s plan of one CHW toserve 25 to 30 households.• In Tigray, establish OTP service at sub-district/healthpost level in the northern rural parts of the district.• Improve RUTF storage facilities at district level andin all health facilities to protect it from rats/rodents.Indrias Getachew, Ethiopia, 2010Where Therapeutic Feeding Programmesand Community-Based Nutrition (CBN)programmes co-exist, the District Health Officehas sometimes failed to capitalise on the opportunitiesprovided by the CBN programmeenhanced training and support for health extensionworkers and community health workers.Community mobilisation needs to be strengthenedin districts that have as yet not included itin the training or programme set up.Another <strong>issue</strong> is that some NGOs are still inimplementation mode, providing nurses towork alongside health extension workers foreach OTP (involved in recording, reporting,supply management and child treatment). It isintended that NGOs work to develop capacitiesby mentoring, supporting quarterly reviewsand developing District Health Offices skills tomanage monthly reporting and supplymanagement systems, rather than providingstaff to help service delivery. On the other hand,some NGOs are still facing difficulties workingon capacity building and dialogue is stillrequired to achieve the smooth partnership thatUNICEF is promoting.In addition, there is insufficient access to safewater at health post level. It was recentlysuggested in Amhara that whether OTP siteshave sanitary latrines and safe water should be18Source: UNICEF Ethiopia.19Source: EHNRI.A child and mother at Menkerehealth post, Tigray region41

Field Articlean additional indicator for inclusion duringassessments and monitoring.Routine drugs are not always being administeredby the health extension workers, althoughthe State Minister of Health authorised theprovision in a letter dated January 2010. Thishas also been included in the Community CaseManagement of Childhood Illnesses togetherwith the community treatment of malaria, diarrhoeaand pneumonia (January 2010).c) Partnership for programme coveragesurveysUNICEF developed a partnership with MOHand Concern to build the capacity of theEthiopian Health and Nutrition ResearchInstitute (EHNRI) to assess TFP programmecoverage using the Centric Systematic AreaSampling (CSAS) methodology. The approachhas been used previously by NGOs in smallprogramme areas (individual districts). Forexposure to the methodology and capacitybuilding, one coverage assessment wascompleted by the EHNRI with Concern technicalsupport in each of the four regions inJanuary and March 2010 (Table 3). Findings andrecommendations were discussed at regionallevel and action plans were developed toaddress the <strong>issue</strong>s (see Box 1).In September 2010, a consultant was broughtin by Concern and UNICEF to develop andpropose to the MOH a coverage survey methodologythat would allow assessment ofprogramme coverage over wider geographicareas (at the moment, the methodology does notallow for assessment of more than one district ata time). A subsequent step will be to pilot andvalidate the new methodology before buildingthe capacity of regional authorities to plan forand conduct regular surveys as part of theirprogramme monitoring.Table 4: Number and coverage of OTP & TFU per type of health facility in the four target regions(Amhara, Oromia, SNNPR and Tigray), September 2010Hotspotprioritynb*No. ofworedaTotal no.of HealthPostsNo. of HPrunningOTP% of HPrunningOTPTotal no.of HealthCentresNo. of HCrunningOTPProgress and resultsThe Government of Ethiopia has, within a shortspace of time, managed to provide access toservices for the majority of families affected bysevere acute malnutrition in four regions of thecountry. In less than two years, service coveragefor severe acute malnutrition has reached 49%and 48% of health posts and health centresrespectively running OTPs and 17% and 92% ofhealth centres and hospitals respectivelyrunning TFUs (Table 4). Consequently, there isnow earlier detection of severe acute malnutritioncases reducing the number of complicatedcases needing specialised inpatient care.Furthermore, key monitoring results in termsof SPHERE standards 20 are impressive. BetweenJanuary 2008 and August 2010, a total of 370,559children were reported to have been admitted toin and out-patient therapeutic feeding sites in thefour regions with overall positive performanceindicators: 82% recovery, 0.7% mortality and 5%defaulter rates (Table 5). Also see Figure 2.Lastly, the GoE is now in a much better positionin terms of national capacity andpreparedness to respond to any increases insevere acute malnutrition levels.Key contributing factors to successThere have been a number of important contributoryfactors to the success of this programme.Key amongst these are:• Central and regional governmentcommitment to develop policies andguidelines on decentralised treatment ofsevere acute malnutrition and to integrateservices into the wider decentralised healthprogramme. The outpatient managementof severe acute malnutrition is now fullypart of the Community Case Managementof Common Childhood Illnessesimplemented through the Ethiopian Health% of HCrunningOTPNo. of HCrunningTFU% of HCrunningTFUTotal no.ofHospitalNo. ofHospitalrunning TFU% ofHospitalrunning TFU1 176 4,113 3,122 75.9% 457 309 67.6% 124 27.1% 15 14 93.3%2 96 2,203 1,651 74.9% 224 151 67.4% 44 19.6% 9 9 100.0%3 99 2,326 803 34.5% 95 43 45.3% 24 25.3% 10 9 90.0%4 235 3,844 524 13.6% 482 99 20.5% 22 4.6% 28 25 89.3%606 12,486 6,100 48.9% 1,258 602 47.9% 214 17.0% 62 57 91.9%* Districts affected by food insecurity and in need of humanitarian assistance are classified into hotspots priority 1 (high), 2 (medium),3 (low) and 4 (not affected). Source: UNICEF Ethiopia.Figure 2: OTP & TFU monthly admissions and performance in the four target regions (Amhara, Oromia,SNNPR and Tigray), Jan. 2008 to August 2010Extension Programme.• Advocacy to promote this approach and toprovide technical assistance to all relevantfield level actors.• High educational levels, technical skillsand commitment amongst programme staffworking within the health sector, e.g.health extension workers, nurses anddoctors.• Enhanced coordination between GoE,UNICEF, NGOs and donors creating anenvironment in which all stakeholderscould contribute skills and resources tobest effect.• Simplicity and efficacy of OTP approachboth for the service providers (healthextension workers) and service users(patients and caregivers).Ways forwardKey next steps are to continue the OTP roll-outat health post level and expand TFU coverageto reach a minimum level of one TFU perdistrict. It will also be important to includetherapeutic feeding items in the EssentialDrug/Commodity List to resolve some of thesupply and logistic <strong>issue</strong>s. Similarly, the inclusionof basic TFP indicators into the HealthManagement Information System (new admissionsand performance) will be an importantstep towards fully integrating and sustainingthe programme, together with advocacy for anincreased allocation of funds to the Healthsector to absorb the programme cost.Continued joint supervision visits are alsoessential to address service quality and buildthe capacity of the supervisors in charge ofprogramme implementation. Linkages withother programmes must also to be developed.These should include improved access to safewater and health services by working withMinistry of Water Resources and linking withcommunity health workers of the HealthExtension Programme, and improved andexpanded management of moderate acutemalnutrition and prevention of severe acutemalnutrition (this will become an even greaterpriority as Ethiopia adopts the new WHOGrowth Standards). Finally, after two years ofimplementation, it is becoming increasinglyurgent to conduct a comprehensiveprogramme evaluation and to study a numberof <strong>issue</strong>s, including the reasons for low TFUadmission rate in some districts.For more information, contact:Sylvie Chamois, email: schamois@unicef.org25,00020,00015,00010,0005,0000Jan – 08Feb – 08Mar – 08Apr – 08May – 08Jun – 08Jul – 08Aug – 08Sep – 08Oct – 08Nov – 08Dec – 08Jan – 09Feb – 09Mar – 09Apr – 09May – 09Jun – 09Jul – 09Aug – 09Sep – 09Oct – 09Nov – 09Dec – 09Jan – 10Feb – 10Mar – 10Apr – 10May – 10Jun – 10Jul – 10Aug – 10Admission Number of TFP Mortality rate % Defaulter rate %Report completion rate %Source: TFP database, ENCU/ DRMFSS/ MOH, Ethiopia90%80%70%60%50%40%30%20%10%0%20The SPHERE project, Humanitarian Charter and MinimumStandards in Disaster Response.Table 5: OTP & TFU performance in the fourtarget regions (Amhara, Oromia, SNNPR andTigray), Jan. 2008 to Aug. 2010TFPperformanceSPHEREstandards% of reports completed 63.4% –Number of admissions 370,559 –Cured 272,261 (82.5%) > 75%Died 2,481 (0.7%) < 10%Defaulter 15,392 (4.7%) < 15%Medical transfer 3,627 (1.1%) –Transfer from OTP to TFU 28,357 (8.6%) –and from TFU to OTPNon respondents 8,054 (2.4%) –Source: TFP database, ENCU/ DRMFSS/ MOH, Ethiopia.42

Field ArticleHistory of nutritional statusand Concern’s response inDessie Zuria woreda, EthiopiaBy Sarah StyleSarah graduated with a Masters in Public Health Nutrition from the LondonSchool of Hygiene and Tropical Medicine in 2009. She recently returned fromEthiopia having completed an internship with Concern Ethiopia.Concern EthiopiaThe author acknowledges the technical and editorial support of Emily Matesin writing this article and the work and support of the Concern Ethiopia team.Focus group discussion in Guguftu kebele toinvestigate underlying causes of malnutritionDessie Zuria is one of 21 woredas(districts) in South Wollo Zone ofAmhara Region, Northern Ethiopia.The nutrition situation in DessieZuria has remained at ‘serious’ levels for the past10 years, with the global acute malnutrition(GAM) rate only once dropping below 10% (cutoff advised by Ethiopian guidelines to classify anemergency situation) in 2004 in the presence ofan emergency feeding programme (Figure 1).In 2008, Dessie Zuria was classified as a ‘hotspot’ area by the regional early warning departmentdue to failure of the short belg rains onwhich the majority of the population depend.Following the results of a nutrition survey,Concern Ethiopia initiated a targeted supplementaryfeeding programme (TSFP) in July 2008,which has continuously operated since then.However, malnutrition rates in the woreda todate have remained relatively un-changed,despite two years of a TSFP intervention. TheTSFP has been a well implemented programme,evidenced by high coverage rates (October 2008,TSFP period coverage 84.5%, TSFP point coverage68.3%). However, recovery rates have beensub-optimal, particularly during 2009 (recoveryrate 27%, non-recovery rate 59%, re-admissionrate 57%) thus raising the question of what isgoing on in this area that may have contributedto the lower than hoped for recovery rates in theprogramme.In order to further investigate this <strong>issue</strong>, three<strong>focus</strong> group discussions (FGDs) and four casestudies were carried out in selected distributionareas in the woreda. In order to provide as representativea selection as possible within the timeallowed, two areas, Guguftu and Gelsha, knownfor their chronic nutritional status were selected.Both are situated in the higher highlands.Serdem, a lowland kebele (village) situated nearthe town of Kombolcha was selected also. Allchildren providing case studies were purposivelyselected based on having been readmitted(some on more than one occasion) to the SFP.Primary and secondary data was also reviewedincluding (but not limited to) Concern’s 2006Dessie Zuria Livelihoods Analysis (also buildingon suggestions from the Agricultural and RuralDevelopment Agency), 2008-09 recovery information,2008-09 early warning information(Concern and woreda) and 2008-10 Dessie ZuriaNutrition Surveys that included reports from theWoreda Agriculture and Rural DevelopmentOffice (WARDO).The relatively static nutrition situation inDessie Zuria implies that this high level of acutemalnutrition is becoming ‘typical’ for this population,who in the face of chronic food insecurity,are finding it increasingly difficult to recoverfrom the repeated shocks. The chronic food insecurityin the woreda is also evident in the highprevalence of stunting. The July 2010 nutritionsurvey estimated global stunting at 47.5% (this isnot significantly above the national average) 1 .This figure is unlikely to be inclusive of older agestunted children as survey team leaders weretrained to ascertain age using local seasonalcalendars and had a good understanding ofchild developmental stages. The leaders weretherefore able to validate the likelihood of thereported ages. Only when age was unclear, wasthe height cut off of betweeen 65-110cm (proxy 6months to 5 years) used to consider children forthe survey. Whilst harvests have been particularlypoor in the last three years, indications arethat an increasing number of households areunable to support themselves, even in a year ofgood harvest.Concern has been present in Dessie Zuria for10 years where it has supported the woredathrough both development and emergencyprogrammes. Based on the findings of the 2006livelihoods analysis, Concern initiated a livelihoodsprogramme in 2007, initially targeting 11of the 31 kebeles in the woreda. Some of the keyproblems to be addressed were low rainfall, cropproductivity and production (particularly in thehigher-highland areas) and lack of agriculturaldiversification and non-agricultural sources ofincome. Although this programme has not beenrunning for long and therefore cannot yet beexpected to have solved all of these problems,we have not seen a reduction in chronic acutemalnutrition, even with TSF interventions, theGovernments general food distribution (GFD)and the Ethiopian social protection mechansism,the Productive Safety Net Programme (PSNP)(that provides food or cash for work for thepoorest of the poor).It has been suggested that the “repeated‘emergency’ operations are in fact serving thefunction of a welfare or safety net programme inthe face of chronic poverty in the Wollo area ofEthiopia 2 ”.Key challenges to improving DessieZuria’s nutrition situationThe following key challenges were highlightedfrom analysis of the FGDs and case studies aswell the aforementioned review of primary andsecondary information provided by relevantDessie Zuria woreda offices and Concern.Climatic conditions and topographyDessie Zuria rainfall is erratic and precarious.Although the rains this year have improved,woreda reports and surveys have indicated thatthe belg rains have been wholly inadequate forthe last 3 years leading to insufficient or nonexistentcrop production. This was furtherconfirmed by the FGDs and case studies. Thehigher-highlands, being totally belg dependent,have been particularly affected. They are alsomore vulnerable to climatic variations due tobeing dominated by sloping land, with the soilerosion and colder weather making it difficult togrow crops. Additionally, small land holdingsand population pressure, exacerbated by poorConcern EthiopiaHayat Seid, female,29 months, has beenin and out of OTP andSFP five times43Figure 1: Prevalence of GAM and SAM in Dessie Zuria woreda (2003 – 2010)1National average forstunting is 46.5%1816141210% 86420Mar – 03Jun – 03Sept – 03Dec – 03Mar – 04Jun – 04Sept – 04Dec – 04Mar – 05Jun – 05Sept – 05Dec – 05Mar – 06Jun – 06Sept – 06Dec – 06Mar – 07Jun – 07Sept – 07Dec – 07Mar – 08Jun – 08Sept – 08Dec – 08Mar – 09Jun – 09Sept – 09Dec – 09Mar – 10Global acute malnutrition (GAM) % Severe acute malnutrition (SAM) %(Ethiopia DHS, 2005).2Sharp and Devereux,2004. 'Destitution inWollo (Ethiopia):chronic poverty as acrisis of householdand communitylivelihoods', Journalof HumanDevelopment andCapabilities, 5: 2,227 — 247.http://dx.doi.org/10.1080/1464988042000225140

Field Articleresource management and overuse, have also ledto declining productivity.In order to further investigate this link, thereadmission rates from Concern’s supplementaryfeeding programmes (SFPs) from July 2009to June 2010 were analysed at kebele level and byagro-climatic zone. The results found that thefive kebeles with the highest readmission rateswere all from the higher highlands (as opposedto the highlands, midlands or lowlands). Thisgives testament to this area’s increased vulnerabilityto factors leading to food insecurity, suchas a colder environment resulting in highermetabolic rate, smaller land holding, erosion andthe slow recovery of SFP beneficiaries, with highnumbers requiring re-admission to theprogramme.Food insecurityThe livelihoods and livelihood assets in DessieZuria are also frequently affected by shocks.Livelihoods analysis has indicated that cropproduction cannot be expected to offer much byway of outputs except in very limited areas suchas in the lowlands, where crops depend on themore reliable meher rains and less undulatingtopography. Case studies conducted withparents of moderately acutely malnourished(MAM) children repeatedly readmitted to SFPs,found that due to crop failures and lack of othernutritional produce, households are often unableto use the SFP ration as intended i.e. as a supplementfor the normal family diet. FGDsconfirmed that the poorest of the poor arefrequently unable to provide additional foodfrom their own production to supplement SFPfood. This means that even with supplementaryfood, beneficiaries’ food intake is insufficient forrecovery. This is further compounded byfrequent sharing of the SFP food with otherhungry siblings not in the feeding programme.Although parents knew that the SFP food wasintended only for the malnourished child, theyfound it impossible to ignore the hungry cries oftheir other children who were not enrolled.Despite education on use of the supplementaryfood at every distribution site, one case studymother admitted to eating the SF food that wasintended for her child, in order to improve thequality of her breastmilk. In children >6 months,supplementary food rations are intended forconsumption by the child to complement breastfeeding.The dependency on agriculture is also disproportionatelylarge, given the precarious weatherconditions. Although the woreda’s climate andtopography make it difficult to grow a diverserange of crops, there is a need for agriculturaldiversification to reduce reliance on single crops;a key objective of Concern’s livelihoodprogramme. More climatically tolerant seedshave been introduced in the last two years as arecovery mechanism and have proved a success.FGDs highlighted that potato seeds haveprovided a good opportunity for recovery asthey can be eaten, used as a cash crop and aresuited to the ecological zone. Expansion of suchactivities could aid in improving communitiespoor dietary diversity. Diets are dominated bycarbohydrates with little fruit/vegetableconsumption, exacerbated by limited knowledgeof caregivers in the preparation of nutritiousfood. Consumption of meat and meat products isalmost non-existent; farmers cannot afford to eatthe products as they need to sell their livestock/meatas a source of income. Thepopulation’s resilience to agricultural shocks isfurther reduced by the lack of off-farm activities,as back up strategies in case of crop failure(again being addressed by the livelihoodsprogramme). Although the woreda’s currentfood security situation is showing improvementdue to a productive belg performance inJune/July, unless this trend continues over thelonger-term, the nutrition situation will mostlikely remain bleak in the absence of furthermulti-sectoral action including expansion of theConcern livelihood programme.Food AidIn April 2010, nutrition survey results indicatedthat although the main source of income washousehold’s own production, 82.4% of householdshad access to food aid. This is nearlydouble that of 2008, increasing pressure onresources. While GFD and PSNP have inevitablyaided household food security to some extent,<strong>focus</strong> group discussions have indicated thatdistributions are often less than that forcasted bythe woreda, in terms of quantity and frequencyof provision (of cash/grain). Additionally, inSeredem, cash rations in March 2010 were foundto be of little value due to price increases in themarket. FGDs and case studies highlighted theinfluence of these factors on communities’inability to recover as well as the recovery beingexacerbated by the limited linkage between GFDand SFP beneficiary lists. However, it was alsopointed out that where provided in sufficientquantities, the GFD/PSNP did help to reducesharing of SFP among households.Poor infant feeding practicesIn this district, inadequate infant feeding practicesare suspected to have a considerableinfluence on children’s ability to recover frommalnutrition, and to maintain their recovery.FGDs have found that feeding infants a mixeddiet of water and breastmilk is a common occurrence.This is worrying, given the poor water,sanitation and hygiene (WASH) conditions in theworeda (see below) and the likely exposure ofinfants to harmful pathogens. All caregiversreported to having received education on sanitationand hygiene provided during Concern’s SFPdistributions and by community outreach, andtherefore had improved knowledge in this area.However, some added that although they hadreceived this education, it was sometimes difficultto implement practically, due to heavy workloads and lack of family support.Data from nutrition surveys has consistentlyindicated a low prevalence of exclusive breastfeedingin infants < 6 months. In the most recentnutrition survey (July 2010), introduction ofcomplementary foods from 6 to 9 months wasreported by only 66% of caregivers. This indicatesthat complementary foods are frequentlyintroduced too late. Many infants are receivingonly breastmilk/water for too long, therefore notobtaining sufficient energy or nutrients to meettheir increased needs. This is further exacerbatedby the inadequate quality and quantity ofcomplementary foods. Higher rates of malnutritionare consistently found in children aged 6 to29 months, compared to older age groups. FGDsalso identified that many caregivers often preferto take their sick child to traditional healersrather than modern health services. Some householdsstill rely on traditional/spiritual healing tocure their children of malnutrition due to a beliefin the ‘evil eye’, suggesting that they might notidentify the cause of the sickness as being nutritionrelated. FGDs and case studies indicatedthat such beliefs tended to be more common ofolder carers such as grandparents, whereas mostof the younger women demonstrated theirunderstanding of the health and nutritionrelated education provided through Concern’sConcern EthiopiaBeyenech Hussen (female, 19 months)has been in and out of OTP and SFP on4 occasions (Guguftu kebele)community activities. The community mobilisationhas led to greater awareness among themothers and caregivers and increased their abilityto detect early signs of malnutrition, as wellas contributing to improvements in hygienepractices and utilisation of health services.Furthermore, local transporters are charging lessfor any transportation to health centres realisingthat this is for their children. Nevertheless, children’snutritional status could also benefit froman increased involvement of traditional healersin any future health-related interventions inorder to improve health seeking behaviours.Health environmentNutrition survey results regularly reveal thatless than half of all households (44%) have accessto protected water supplies and just over half(53%) report to using a pit latrine. Observationsfrom the field confirmed the poor sanitation andhygiene conditions in which some families areliving. For example, many households in thehighlands live with their animals and theirexcreta. Whilst this is reported to be a method ofincreasing warmth in the cold highland areas, itis also likely to be a source of increased infectionsand illness to younger children. As a resultof the poor WASH conditions in households,nutrition surveys consistently find diarrhoea tobe the most prevalent illness among childrenunder 5 years and accounts for approximately60% of illness. Concern has over the last fewyears significantly increased activities to provideclean water pumps to a greater number of kebeles.Nevertheless, it appears that furtherdevelopment in WASH infrastructure isrequired, to aid improvements in Dessie Zuria’snutrition situation.Coping strategiesThe seriousness of the Dessie Zuria situation ishighlighted by the type of coping strategies thathouseholds have adopted, the most poignant ofwhich is related to the dramatic decrease inunder-5 population over recent years. Theunder-5 population has declined rapidly, reducingfrom 18.0% in 2005 to 10.8% in 2010 (Figure2). This begs the question as to why people haveFigure 2: Under-5 population (% of totalpopulation) in Dessie Zuria (2005 – 2010)19181716%1514131211102005 2006 2007 2008 2009 2010Under 5 Population (%)44

Field Articlestopped having babies - the steady declineindicates that this is not a mortality <strong>issue</strong>.The Government’s efforts to scale up familyplanning services and uptake haveincreased over the last few years and arelikely to have considerably influenced thisdecline. Furthermore, according to FGDs,households have been more willing toembrace these efforts over the last fiveyears, due to the high levels of food insecurity.Participants indicated that people arechoosing to have fewer children as theysimply cannot afford to feed so manymouths. Many individuals stated that oncethe situation improves they wish to starthaving more children again, for security intheir old age and to help them with farmactivities.ConclusionsDespite the current improvement in foodsecurity, the woreda’s reliance on unreliableand erratic rainfall suggests that thisimprovement may be short lived; studies inthe larger Wollo area have found thatpoverty appears to be worsening ratherthan improving 3 . Without Concern’s presencein Dessie Zuria over the past 10 years,mortality rates are likely to have declined,along with progress in the area of livelihoods,health and nutrition which evidentlyhas been made. However, the situation iscomplex. Improvement in agriculturalproduction, for example, cannot be ‘standalone’and requires “an integrated andholistic approach involving various sectorsand sub-sectors” 4 . Additionally, it is importantto consider the “physical and economicaccess that a child or his or her caregiver hasto that food, the caregiver's knowledge ofhow to use available food and to properlycare for the child, the caregiver's own healthstatus, and the control the caregiver hasover resources within the household thatmight be used to nourish the child” 5 . SFPalone cannot prevent occurrence of malnutritionand therefore is not a completesurprise that SFP inputs over the last twoyears has not translated into improvementsin malnutrition rates. What is clear,however, is that SFP interventions cannot besuccessful without regular and sufficientgeneral rations. Based on these researchfindings, a strategic multi-faceted, multisectoralresponse is required, that addressesboth acute malnutrition and its root causes.This response should include, amongstothers, infant and young child feeding interventionsand enabling increased food accessto families with young children throughprovision of small livestock and agricultureinputs. There are also plans for WASH interventionsto work towards changingnegative behavioural practices. Looking tothe future, it will be useful to see how themalnutrition situation changes and why, sothat the whole community learn how best toprotect the nutritional status of its children.For more information, contact:concern.ethiopia@concern.net3See footnote 2.4Chanyalew D. (2005). Food Security and Malnutrition inEthiopia. Chapter 3. An Assessment of the causes ofmalnutrition in Ethiopia: A contribution to theformulation of a national nutrition strategy. InternationalFood Policy Research Institute. Washington. USA.5Benson T, Shekar M. (2006). Trends and Issues in ChildUndernutrition. Disease and Mortality in Sub-SaharanAfrica, 2nd Edition. 2006. Washington. World Bank.EHNRIProfile and role in the NationalNutrition ProgrammeName: Ethiopian Health and Nutrition Research Institute (EHNRI)Address: Gulelle Arbegnoch Street (the former Pasteur Institute)Gulele Sub City P.O.B. 5456, Addis Ababa, EthiopiaPhone: +251 11 2133499Fax: +251 11 2757722Website: http://www.ehnri.gov.etDirector General Dr. Tsehaynesh MesseleDeputy Director General: Dr. Amha Kebede (Research Technology Transfer)Contact: Dr. Cherinet Abuye (Director, Food Science and Nutrition ResearchDirectorate) Email: cherinetabuye1@yahoo.comThis article is based on a meeting betweenCarmel Dolan, ENN and Dr Cherinet, Director,Food Science and Nutrition ResearchDirectorate.Dr Cherinet began working for the ENI,predecessor to the EHNRI, in 1988 and hasbeen Director of the Food Science andNutrition Research Directorate at EHNRI since2009. Previously he held various positionswithin the institution including assistantresearcher, senior researcher and team leader.He holds a PhD in Public Health (NutritionalEpidemiology) and an MSc in AppliedNutrition.Dr Cherinet would like to thank the followingstaff for their contributions to this article:Dr. Tsehaynesh Messele (EHNRI DirectorGeneral), Dr. Amha Kebede (EHNRI DeputyDirector General), Ms. Aregash Samuel (FoodScience and Dietetics Research Case TeamLeader), Ms. Lakech Goitom (AssociateResearcher – Food Science and Dietetics), Ms.Tsehay Assefa (Associate Researcher –Nutrition), Mr. Habtamu Fafa (NutritionResearch Case Team Leader).Historical overviewThe Ethiopian Health and Nutrition ResearchInstitute (EHNRI) is the result of a merger inApril 1995 between the former NationalResearch Institute of Health (NRIH), theEthiopian Nutrition Institute (ENI), and theDepartment of Traditional Medicine (DTM) ofthe Ministry of Health. The EHNRI, as agovernment organisation, is the primary bodyin Ethiopia for carrying out research, trainingand providing services for the public andorganisations in the areas of health and nutrition.National Research Institute of Health(NRIH)The NRIH was the oldest of the three units andbegan life as the Medical Research Institute in1942. In the late 1950’s, it became the PasteurInstitute of Ethiopia, following an agreementwith the Pasteur Institute of Paris and namedafter the French chemist Louis Pasteur (1822-1895) who invented the first vaccine for rabies.In the early 1970’s, it was agreed that theEthiopian Government would take over theEHNRI Public Relations Office, 2010Entrance to EHNRIcompoundrunning of the Pasteur Institute and it wasrenamed the Central Laboratory and ResearchInstitute. Towards the end of the twentiethcentury, it evolved into the National ResearchInstitute of Health (NRIH), which <strong>focus</strong>ed itsenergy on making significant contributionstowards improving the health of the country.Ethiopian Nutrition Institute (ENI)The Children’s Nutrition Unit (CNU) wasfounded in 1962 as a joint Ethio-Swedish project.It became the ENI in 1968, when the EthiopianGovernment took over responsibility for andincreased the scope of the nutrition programmesto include pregnant and lactating women,school-age children and other adult groups. Itcarried out nutrition and food science relatedresearch and interventions, as well as providingnutrition training and laboratory services to thepublic, universities and other organisations. Thiswas realised by specialist teams working onmedical nutrition, community nutrition, foodproduction, training and information, andthrough its well-equipped Food Science andNutrition laboratories.Major achievements of the ENI include thedevelopment of a National Food CompositionTable, development and production of a supplementaryfood for infants and children calledFAFFA (meaning ‘to grow big and strong’), aswell as other types of complementary and therapeuticfoods. It also developed a strong presencein local communities through establishing fieldstations to carry out surveys and research onaspects of nutrition, the production, storage andpreparation of locally available foods, andthrough the dissemination of educational materialsand information to the public.National Nutrition baseline survey disseminationworkshop – Dr Amha giving the opening speechEHNRI Public Relations Office, 201045

Agency profileDepartment of Traditional Medicine(DTM)The DTM was established in 1979 under theMinistry of Health to undertake research, andpromote the production and use of traditionallyused medicines. This was at a time when almost80% of the Ethiopian population relied on traditionalmedicines to treat various ailments. Majorresearch was undertaken to develop safe, effectivedrugs from selected medicinal plants beingused and to identify those that could have apotentially harmful effect on the population.Hundreds of medicinal plant species were identifiedand their uses determined for varioustypes of ailments.The mandate of the EHNRIThe NRIH/ENI/DTM merger allowed thebringing together of complementary expertiseand laboratory facilities to allow for maximumutilisation of available resources and create anatmosphere conducive to research. Morerecently, the Institute implemented ‘BusinessProcess Re-engineering’ to facilitate a restructuringof the organisation and its activities so that itcan more effectively discharge its responsibilitiesin line with the Ethiopia Health SectorDevelopment Plan (HSDP III/IV (HSDP IVcovers the period 2010-2015). HSDP IV is gearedtowards protecting and promoting the healthand wellbeing of the nation.Under the new structure, a Director Generaland two Deputy Director Generals head theEHNRI. One of the deputies heads the Researchand Technology Transfer wing of the Institute,which is tasked with tackling priority publichealth and nutrition problems through problem<strong>focus</strong>ed research in order to improve the healthof the country. The other deputy heads thePublic Health Emergency Management divisionof the Institute, which works to anticipate,prevent, prepare for, detect, and respond topublic health threats so that negative health andsocio-economic impacts are minimised.The Institute also has the mandate to establishand maintain a high quality, sustainable laboratorysystem throughout Ethiopia. This deliversquality and accessible laboratory services relatingto the occurrence, causes, prevention anddiagnosis of major diseases of public healthimportance and to establish and supportNational Laboratory Quality Assuranceprogrammes and systems.The Institute is well placed to carry out all ofits tasks, with almost 200 research and technicalstaff, 250 support staff and well-equipped laboratories.It also benefits from the generoussupport of the Government of Ethiopia and variousnational and international organisations,with total funds of around 25 million birr and$20 million USD per year (in cash and in kind)received.Organisations that support the Instituteinclude WHO, UNICEF, World Bank, Centre forDisease Control (CDC) Atlanta, JapanInternational Cooperation Agency (JICA), theFood and Agriculture Organisation (FAO) andvarious non-governmental organisationsthrough joint research projects. Also, collaborativeresearch projects are carried out with localuniversities, as well as with international partners,research institutes and institutions ofhigher learning.Current major programmes include jointcooperation with CDC for a national surveillancestudy of HIV/AIDS, sexually transmittedinfections, malaria, and tuberculosis andstrengthening of laboratories at central andregional level. Also, there is significant collaborationwith JICA, WHO, and local andinternational Rotarians for polio surveillance.In collaboration with WHO and theFoundation for Innovative New Diagnostics(FIND), EHNRI has set up a lot testing centrefor malaria with the objective of providing thisservice for the whole of Africa. This centre isone of only three globally, the other two beingin Cambodia and The Philippines. A RapidTest Kit has also been established at EHNRI.At present there is also strong collaborationwith the governments of China and SouthKorea on research into traditional medicines.Support for the National NutritionProgrammeOne of the most significant programmes thatthe Institute is currently involved in is theNational Nutrition Programme (NNP). TheNNP is an ambitious nutrition programme,developed by the Ministry of Health withpartners, in order to implement the country’sfirst National Nutrition Strategy endorsed inFebruary 2008. It is designed to not onlyaddress emergency interventions and foodinsecurity but also <strong>focus</strong> on preventive interventions,as well as address the fragmentednature of past interventions by taking intoaccount the multi-sectoral nature of nutrition.The overall aim is to reduce the magnitude ofmalnutrition in Ethiopia, particularly amongstthe most vulnerable groups of children underfive, pregnant and lactating women, andpeople living with HIV (PLHIV).The Food Science and Nutrition ResearchDirectorate (FSNRD), part of the Research andTechnology Transfer wing of the Institute, iscarrying out NNP activities as part of its regularoperations. The mandate of the directorateis, firstly, to determine and monitor the magnitude,distribution and determinants ofmalnutrition in the country and, secondly, tocarry out effective research to develop anevidence base that offers innovative solutionsto reduce and eradicate malnutrition. Researchincludes the development of new food productsand processing and preservationtechnologies. The directorate also offers laboratoryservices to the public and organisations,supports curriculum development and teachingat universities, and carries out demandbased ‘on-the-job’ training for various organisationson health and nutrition related topics.This Directorate has been responsible formany innovative nutrition interventions inEthiopia since its inception, including thedevelopment of food composition tables,menu development for chronic health problemsand micronutrient research. Currently,with the advent of the NNP, nutrition is onceagain in the spotlight in Ethiopia at a timewhen the economy has been enjoying steadygrowth. However, this has not been matchedby a corresponding fall in the level of malnutritionthat development can bring.The Directorate’s role in the NNP is basedaround carrying out critical surveys andresearch that will create a greater understandingof the current nutrition situation in thecountry and help to shape the scaling up ofthe programme. The Directorate also undertakesmonitoring and evaluation of variouscomponents of the programme as they areimplemented, and the NNP as a whole.Table 1: Nutritional status of children 6-23 and6-59 months of ageIndicators Measure* Survey findings(June 2009)Stunted Height for age

Agency profileListening to the opening speech at theNational Nutrition baseline surveydissemination workshopinterventions are most needed. Major findingsrelated to this age group are highlighted in theTable 1.The nutritional status figures of both the 6-23months and 6-59 months groups fluctuated.Mothers from rural areas with a low Body MassIndex (BMI) and mothers with low levels ofeducation were at greater risk of having amalnourished child. The nutritional status of thechild also depended on their age and the regionthat they live in. Children between 18-23 monthswere more likely to be stunted (43%), thosebetween 12-17 months had higher rates of wasting(17.5%) and those between 24-35 monthswere more commonly underweight (39.3%).Children were more likely to be stunted inAmhara and Afar, wasted in Afar and Somali,and underweight in Afar and Tigray regions.Key survey results related to breast andcomplementary feeding are indicated in Table 2.The breastfeeding results particularly variedbased on the mother’s level of education.Mothers with a higher level of education weremore likely to have ever breastfed their child,breastfed within the first hour of life and fedcolostrum to their newborn infant.Maternal nutrition is critical to ensure thehealth of the mother during pregnancy and afterbirth, and to ensure the strong development ofthe child. If the mother does not receive sufficientnutrition and supplementation duringpregnancy, there is a good chance that this mayadversely affect the development of the child.Key indicators related to the nutritional status ofpregnant and lactating women found in thesurvey are shown in Table 3.Increased food consumption and iron-folatesupplementation was more likely amongstyounger women, those who lived in an urbanarea and those of higher educational status.Symptoms of night blindness were less likelyand vitamin A supplementation higher forwomen living in urban areas and those withhigher levels of education. For iodised salt, ahigher percentage of rural households,compared to urban households, were using it.The little change found in key nutritionalindicators since the Ethiopia DHS survey of 2005shows that many challenges remain. However,the next few years, during which the variouscomponents of the NNP will be implemented, isthe critical time that interventions will be scaledup. An end line survey, planned to take placeduring 2013, should show the impact of theseinterventions.EHNRI Public Relations Office, 2010Assessment of national capacity forimplementing the NNPEHNRI also commissioned a series of studies inorder to create a clearer picture of the nutritionprofessionals available from federal to subdistrictlevels to implement the NNP and thecapacity of nutrition training institutions tosupplement and strengthen this cadre. A furtherstudy was conducted to assess current behaviourchange communication activities, with a view todeveloping a comprehensive communicationframework that would complement the implementationof the various NNP activities.Major findings of the two studies on personneland training for nutrition found that there isa shortage of trained professionals at federal,regional, zonal and district levels to effectivelyimplement the NNP. Recommendations <strong>focus</strong>edon developing a uniform structure at each levelwith clearly defined roles, placing greater significanceon in-service training and developing anew generation of nutrition professionals. This isto be achieved through creating a TechnicalAdvisory Group to support universities tostrengthen existing and develop new short anddegree courses and strong nutrition curriculum,<strong>focus</strong>ing on university staff development andcreating greater linkages between universities.Behaviour Change Communication in theNNPSystematic behaviour change approaches areextremely important to bring acceptance ofnutrition interventions in communities.However, this communication study found thatcurrent nutrition behaviour change communication(BCC) activities are fragmented andunder-exploited. A framework, under whichnew BCC activities should be developed, hasbeen produced as part of the study, The BCCframework aims to increase the capacity of eachhousehold to use existing food resources tomaximum advantage by taking into accountGovernment policy, socio-economic status,culture, and gender <strong>issue</strong>s. The study alsooutlined the actors that should be involved inplanning and implementing new BCC activitiesand the training necessary for them. All of thesestudies are available at www.ehnri.gov.et.Research <strong>focus</strong> for the NNPOne of EHNRI’s strengths is in its researchcapacity. It was on this basis that it was given themandate to set up and run the OperationalResearch Programme (ORP). This programme,as part of the NNP, exists due to the recognitionof the complexities inherent in programmeimplementation. It aims to identify and carry outstudies that can ultimately bring about newinsights and understanding to improve implementationand shape the scaling-up of the NNP.By doing this, it provides managers and policymakerswith the information they need toimprove the existing delivery activities and planfuture ones.The programme is ambitious in its size andscope, and potentially one of the largest of itskind ever carried out in nutrition. A lot of thegroundwork is already in place. To ensure thathigh quality studies are carried out that caninform nutrition programme planning andimplementation, selection of the research entitiesto carry out the studies will be done through acompetitive-bidding process.Priority research areas have been identifiedand agreed upon in consultation with nutritionpartners. These include on <strong>issue</strong>s specificallyrelated to Community Based Nutrition (CBN)such as quality of services, data quality,programme scale-up to reach pastoralistcommunities, and Health Extension Workerskills. Other areas of research <strong>focus</strong> include thefeasibility of local production of micronutrientrichprocessed foods, using micronutrientpowders to improve complementary food quality,effectiveness of the media to deliver BCCmessages, and micronutrient interventions, suchas pregnant women’s compliance to daily ironsupplementation.This research will be carried out and resultsdisseminated over the next two years, so that theywill have a direct impact on current and plannedprogrammes being implemented as part of theNNP. Furthermore, each year of the NNP, EHNRIwill identify with nutrition partners the most criticaloperations research that needs to be carriedout as part of the ORP in order to improve NNPimplementation.Establishing a national nutrition databaseEHNRI also has the responsibility to set up andrun a comprehensive nutrition database. Itspurpose is not to take over the role of existingsources of nutrition information, such as thedatabase held at the Emergency NutritionCoordination Unit (ENCU), but rather to gather‘under one roof’ all emergency, programmaticand nutrition survey data from existing sources.This will enable the interpretation and use of thisdata effectively for inputs into managementdecisions, long term planning, evaluation andrelated purposes for the CBN and other nutrition-relatedprogrammes.Potential outputs from the database in orderto meet these needs include quarterly bulletinscontaining interpretation of risks to nutritionfrom early warning and nutritional data, quarterlyreports monitoring nutritional outcomesand NNP implementation, and annual publicationson the state of nutrition in Ethiopia toestimate long-term nutritional trends and factorsdetermining these. At the same time, stakeholderswill be able to request specific data fromEHNRI as required.A positive futureThere are exciting times ahead for EHNRI, andparticularly the FSNRD, as it continues to play asignificant role in implementing the NNP,including the ORP, developing the nutritiondatabase and also carrying out micronutrientsurveys and numerous evaluation studies. TheDirectorate is also advocating for a food fortificationagenda and plans to conduct studies onvarious aspects of fortification at the communityand industrial levels. Further studies areplanned on the relationship between nutritionand chronic health problems, as well as on foodconsumption patterns and composition.Furthermore, quality control and quality assurancework will continue on the salt iodisationprogramme as it continues to be scaled up.The Directorate has high ambitions to be at theforefront of all nutrition interventions in thecountry and sees the NNP as a great opportunityto increase the capacity of the young but dedicatedstaff through their work, with numerouspartners and increased opportunities for training.This is indeed a huge opportunity for theDirectorate to push forward and continue tomake a significant contribution to the success ofthe NNP, as well as for the country to banish thehigh rates of malnutrition to the annals of history.For more information, contact: Dr. CherinetAbuye, email: cherinetabuye1@yahoo.com47

Field ArticleMesfin Teklu, WV, Ethiopia, 2006Suku Deda's village of Sabant insouthern Ethiopia was devastatedby drought (see case study)Rapid responseand long-termsolutions:Christian Aid andfood security inEthiopiaBy Antoinette PowellAntoinette Powell is theCommunications andInformation Officer, Africawith Christian Aid since 2007.Previously she worked asAdvocacy Officer, The AfricanChild Policy Forum in AddisAbaba, Ethiopia (2005 – 2006).The author would like to acknowledge theChristian Aid Ethiopia office staff, in particularCathy Riley, Country Manager, for her supportwith this article.Food insecurity is a deep-rooted problemfor Ethiopia. With almost half the country’spopulation of 78.6 million living indeep and long-term poverty, manypeople are vulnerable to drought and moderateand severe acute malnutrition. With millions ofEthiopians regarded as chronically food insecure,even in years when the rains are good,many face uncertainty over how they will feedtheir families each day, every year.When Christian Aid began working inEthiopia in the 1970s, the country – and indeedthe whole of the Sahel region – was sufferingthe devastating effects of a famine which lefthundreds of thousands dead. Less than tenyears later, Ethiopia was once again in the gripof another drought which led to what BBC journalistMichael Buerk described as a “biblicalfamine”. At its height, the 1984/85 famine wasclaiming hundreds of lives each day in theMekelle Relief Camp in the northern Tigrayregion of Ethiopia alone. Further food shortagesfollowed the 1984-1985 famine in 1992, 1994,2000 and 2002, and more recently in 2005 and2008. These emergencies highlight the persistentfood insecurity which characterises life formany Ethiopians.Christian Aid responseIn each of these emergencies, Christian Aidresponded rapidly through a network of partnersto provide relief and rehabilitation supportto those most in need. These partners – localorganisations based within the communitieswith which Christian Aid work – are central toChristian Aid’s capacity to respond in emergencies,as well as the organisation’s widerdevelopment work. Christian Aid remains nonoperationalI the belief that local organisations,rooted in the communities they support, arebest placed to understand the <strong>issue</strong>s localCase Study 1: Muhe Shehu Ibrahim’s storyMuhe’s father and grandfather were both farmers,but growing enough for the family to eat had alwaysbeen difficult. In 1984, this task became impossible.“In 1984/1985, for the first time, we received foodassistance,” explains Muhe. “There was a funeralcommittee. That committee had one job; to organisefunerals. They were paid in food. For almost a year wecontinued to bury people.”Muhe and his father before him had no irrigationsystem and had relied on just two crops – heavilydependent on water – to feed their family. “My fatherand my grandfathers used to plough these lands.Production was very difficult,” says Muhe. “They werefull-time farmers. Everything was natural. Weproduced only teff and sorghum; we didn’t know anyother crops”. “There was a drought and we faced difficultproblems. For teff and sorghum we could onlyhave one harvest. When the rains didn’t come we hadno harvest, we were forced to sell our ox. We sold thepeople face and the solutions most appropriateto each context. Working through local partnersat the grassroots level is also considered essentialto maximise impact and ensuresustainability. These organisations also providea key connection to the rapidly changing environmentand alert to potential emergencysituations. When emergencies do strike they arealready based within the communities that needsupport, and so are often better able to respondwith agility than organisations that need tobring in staff and resources.Such an approach enables Christian Aid toadapt emergency response to ensure that thesupport meets the needs of each affected population.For example, in 1984 when Christian Aidcould not reach the northern areas worstaffected by Ethiopia’s drought by travellingnorth from Addis Ababa, cash was provided tothe Emergency Relief Desk based in Sudan topurchase grain locally and provide it to affectedcommunities. More recently, the EthiopianEvangelical Church Mekane Yesus (EECMY),supported by Christian Aid, set up a cash forwork project in southern Ethiopia enablingcommunities to purchase locally available foodwhen their crops failed.Surviving drought and developingcommunitiesAlthough ensuring that food aid and other reliefreaches communities in need is critical duringdroughts and other emergencies, humanitarianresponse must work alongside longer term solutionsto poverty. So, when the immediate needsduring or in the aftermath of a disaster havebeen met and the eyes of the world move on,Christian Aid partners remain with the affectedcommunities ensuring that the long-term workof rebuilding lives and livelihoods is notneglected.ox for cheap prices and bought the food for expensiveprices - so we still faced problems because we couldn’tafford to buy enough food.”Despite the failure of many farmers to grow waterhungrycrops like sorghum and teff, many Ethiopiansnote that the rivers in the northern Amhara regionnever ran completely dry. It was simply that withouteffective irrigation systems, families like Muhe’s couldnot make use of the little water that remained available.Christian Aid partner Water Action worked with Muheand others from his community, providing training tohelp them make best use of the water available tothem, suggesting drought resistant crops which canbe planted at different times of the year and installingan irrigation system.“I produce three times a year,” says Muhe. “Since WaterAction, I haven’t thought about food problems.”Following the failure of seasonal rains in late2005, large parts of southern Ethiopia faced seriouswater shortages. Vast areas of crops were lostand with pastoralists and sedentary farmersunable to find pasture and water, many livestockdied. More than two million people wereaffected, leaving them uncertain of how they andtheir families would survive. This is reflected inthe situation of one woman, Suku Deda:Suku Deda was caring for her ten children inSabant village, southern Ethiopia when this droughtdevastated the herd of cattle she had carefullyincreased year on year in order to support them.Along with other women in the community, Suku hadset up a cooperative through which she sold milk andcheese enabling them to earn a small income andensure their children had enough to eat each day. Thedrought devastated this business with the women’scattle dying one by one, leaving them with no foodand no source of income. Having worked determinedlyto build her business, Suku was reduced towaiting for external help saying, “If nothing comes,we can do nothing. We will just wait and sit and die.”Christian Aid partner, the EECMY, workswith some of the most marginalised communitiesin Ethiopia including pastoralistcommunities in the country’s south. Recognisingthat many people – like Suku – had been leftwithout any means to feed their families followingthe failed rains in 2005, EECMY respondedquickly. With food still available in the south,despite people’s inability to afford it, theyprovided cash injections to avoid damaging thelocal economy by bringing in supplies at theexpense of those already available. At the sametime they also realised that this was an opportunityto put in place measures to help protectcommunities from the effects of other droughtsthat would inevitably occur in the future.EECMY’s cash for work project provided notonly a welcome source of income for families,but also brought communities together to buildstructures including ponds to catch rain water.This has enabled them to make better use of thisscarce resource in the years that have followed.Fifteen-year-old Dhaba, who is a Boranapastoralist, described EECMY’s project saying,“If anyone else came here to do this work wewould be so disappointed. This is our opportunityto work on our own development and Iwant to be a part of this.”Increasing resilience to avoid disasterIt is not only in the aftermath of emergenciesthat Christian Aid’s partners carry out projects.Increasing communities’ resilience to disaster isanother key aspect of the organisation’s workon agriculture and other food security projectsin Ethiopia. This has brought a radical changein the lives of men like Muhe Shehu Ibrahim48

Field Articlewho lives in Harbu in the north west of theAmhara region (see case study 1). Whencarrying out interventions like described,which aim to reduce communities’ resilienceto natural disasters, Christian Aid is keen notonly to identify areas where these events areparticularly likely. The organisation alsotargets the communities least able to copebecause of high levels of poverty and who inmany cases have been pushed to the marginsof society.Working with three Ethiopian organisations,Agri-Service Ethiopia, Action forDevelopment and Women SupportAssociation, Christian Aid is currently implementinga project funded by the EuropeanUnion to increase the food security of householdsin Dasenach, Maalee and South Ariworedas in South Omo zone in SouthernNations, Nationalities and Peoples Region(SNNPR). Despite facing annual food shortageslasting between six and nine months,these areas have been left out of many developmentinitiatives within the SNNPR whereSouth Omo is located. Consequently levels ofpoverty remain high, with over 50% of thepopulation living below the poverty line. Andyet these woredas lie along the Omo River thatcould be used to provide irrigation for thesurrounding areas and for fishing. This projectwill involve developing small scale irrigationschemes which, along with ensuring that amore diverse range of seeds are planted andorganic fertilisers are produced and used,should increase crop yields across the area. Inaddition, training and support for fisheries andlivestock production will ensure that communitiesare less dependent on one food source.Although 20 per cent of the populationrequired food aid in 2009, if these naturalresources were fully utilised the area couldproduce enough food without relying on externalsupport: Christian Aid is working withthese communities to exploit this potential.Addressing climate changeThis work on the ground, responding toemergencies and building people’s resilienceso that floods, droughts and other extremeweather conditions do not become disasters,Mesfin Teklu, WV, Ethiopia, 2006will not remain effective if we do not alsokeep an eye on the context in which we areworking. While scientific evidence on thecauses – and indeed future effects - of shiftingweather patterns around the world remainsinconclusive, it looks likely that the changesEthiopia has already seen are a result ofclimate change caused by increasing CO2emissions. Ethiopia reports an average rise intemperature across the country of 0.2oC everydecade for the last 50 years and an increasingnumber of droughts. With patterns of rainfallpredicted to become even more uncertain inthe coming years, this is a phenomenon thatany development agency working to helpEthiopians lift themselves out of povertysimply cannot afford to ignore.In 2009, Christian Aid funded one of itspartners, Citizens Solidarity for the CampaignAgainst Famine in Ethiopia (CS-CAFÉ), toconduct a study on climate change. The studyfound that awareness about climate changehas dramatically increased during the past 10years, and that farmers are increasingly noticingchanges that may well be climate-related.These include increased incidence of insects,weeds, plant and animal diseases, changes topotential crop growing periods, and shifts inwhich areas are suitable for growing crops.The findings of this study will enableChristian Aid to work with partners to identifyhow they can support communities toadapt to the changing weather patterns theyare already seeing, and how to mitigate theimpacts of climate change in their work.The Ethiopian Civil Society Network onClimate Change (ECSNCC) is a non-governmentalorganisation which began a localisedcampaign on climate change as part ofCountdown to Copenhagen in September2009. ECSNCC used their network to collectsignatures calling for climate justice and tohold events such as climate hearings acrossEthiopia. Work helping communities to adaptto the changing climate within Ethiopia iscomplemented by Christian Aid’s campaignat international level which calls for swiftaction by governments around the world, andparticularly in industrial nations, to curbcarbon emissions.A future without hungerWhile Christian Aid will continue to respondto the emergency needs of Ethiopians affectedby the country’s high levels of food insecurity,the organisation believes that with continuedsupport it will be possible to break this cycleof hunger. By drawing on its experience ofbuilding communities’ resilience to droughtand other disasters and looking for newopportunities for this work, the organisationaims to change the outlook for some of thepoorest and most marginalised Ethiopiancommunities.In the face of climate change, Christian Aidwill seek to mitigate its impacts and supportpeople to adapt. Despite the increasing challengesthe changing climate brings, ChristianAid believes that communities who need foodaid year after year can be supported toachieve self-sufficiency where neither childrennor adults go to bed hungry each day.For further information, contact: AntoinettePowell, email: apowell@christian-aid.org,telephone: +44 (0)20 7523 2288 (UK)Field ArticleCompletingthe JigsawPuzzle: JointAssessmentMissions(JAM)By Allison OmanAllison is the Senior RegionalNutrition and Food SecurityOfficer for UNHCR based inNairobi, Kenya. She works withcountries in the region to givetechnical support and advice ona wide range of interventions,including food distribution, IYCF,CMAM, food and cash vouchers and coordinates/collaborateswith key partners for campand non-camp based refugee populations. She isa proud member of the Nairobi Nutritionists.<strong>Special</strong> acknowledgements to Kate Ogden andMark Gordon of WFP for their warm and fluidpartnership on refugee <strong>issue</strong>s, and to the teammembers of the recent JAM in Ethiopia and theUNHCR nutritionist Mulugeta W/T Sadik. Finally,thanks to those who temporarily find themselveswithout a country or home, and graciously allowus to work with them to resolve the problemsinherent in living as a refugee in a camp or noncampsetting - reminding us that being a refugeeis a context, not an identity.Food security continues to be a challengingand often elusivepossibility for many of the almost 2million camp-based refugeesworldwide. In East and the Horn of Africa,almost every country in the region hostsprotracted refugee situations, whererefugees live encamped and rely primarilyon food aid to meet their monthly foodrequirements. UNHCR partners closelywith the World Food Programme (WFP) tomeet the basic food needs of the refugees inplaces where food aid is required. WFP iscommitted to supplying approximately2100 kcal/person/day in situations wherethe refugees are not able to significantly orconsistently contribute to their own foodintake - a situation in many of the refugeecamps in East and Horn of Africa, includingEthiopia. UNHCR, within the overallmandate of protection, is <strong>focus</strong>ed on ensuringthat the food is part of the overall basicassistance package and meets the minimumnutritional requirements, at times augmentingthe general food distribution withcomplementary foods when necessary tobolster micronutrient content or enhancedietary diversification.Joint assessment missions (JAM)In order to assess the food security andcoping mechanisms of refugee caseloads,joint assessment missions (JAM) have been49

Field ArticleChildren in Melkadida CampLubna Khan, Ethiopia, 2010Case study 1: Discussions with the Women's Association In Malkadida CampDuring 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 anadditional 30kg in a sack. I sell the 30kg for 2birr/kg and receive 60 birr. With this money Ipurchase milk, tomatoes and some firewood. If there is money later in the month, I might buysome onions and potatoes. I take the 50kg sack to the mill and I have to pay one scooppayment for every 2 scoops I grind. The prices are very high. We then eat the wheat flour withthe red beans, oil, sugar and famix (CSB) plus the food I bought at the market. Often the fooddoes not make it to the end of the month and I borrow from friends or take food from the storekeeperon 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 itand cook it with beans and oil- but it is not good like this for the children, it gives them stomachache. I would like to buy rice and pasta but it is very expensive in the market, so I eat whatI am given and sell what I can to buy a few other essentials.Aisha, Malkadida Camp, October 2010organised since 1994 and are carried out in mostprotracted refugee situations every two years.These review/re-assessment missions are aunique opportunity for UNCHR and WFP toundertake a joint analysis of the ongoingcontext in the field and determine programmaticoptions for supporting the refugeecaseload with food and other needs. A JAMGuideline, drafted in 2004 and revised in 2008,represents a working manual with many toolsand suggestions for best practice in examiningfood and non-food needs and fulfilling organisationalresponsibilities. These are laid out inthe 2002 (updated in 2010) memorandum ofunderstanding (MOU) between UNHCR andWFP. According to the guidelines, “The ultimategoal of the partnership between UNHCRand WFP is to ensure that food security andrelated needs of the refugees and returnees (andpersons of concern) that UNHCR is mandatedto protect and assist are adequately addressed.”(MOU, paragraph 2.1).Food aid provision to refugeesUNHCR provides complementary foods andselective nutritional supplies where indicated.In some refugee situations worldwide, refugeeshave access to formal legal labour, to agriculturallands for own cultivation or to significantlivelihood opportunities that support their abilityto provide some or all of the food forthemselves. In some places, the location of therefugee camps (dry, desertified areas) or thepolitical situation (no freedom of movement orno work permits available) or demographicconstraints (camps of new arrivals, camps ofprimarily women and young children, orcamps far from economic opportunities) curtailthe possibility of refugees growing or purchasingtheir own food. In these instances, food aidis requested by the host government and inmost situations provided by WFP.Refugees are also in need of non-food items(NFI). Some essential NFI are provided byUNHCR on a periodic basis (or as a ‘one-off’distribution) such as cooking fuel, kitchen setsand plastic sheeting. Additional NFIs providedby other implementing partners or groupsinclude books, clothes or shoes, while someNFIs are not provided at all, e.g. wash basins,combs, adornments, tea kettles. In refugeesettings where there are few economic opportunities,the refugees will often use the sale of theration to purchase NFIs that are not provided.WFP, according to international standards,has determined that a ‘full ration’ is a foodbasket that has a value of approximately 2,100kcal/per person/per day, with commoditiesthat have adequate protein and fat content, aswell as key micronutrients in sufficient quantity.In practice, the ration rarely meets 100% ofthese key benchmarks, often due to very lowlevels of vitamin C, iron, or calcium. The rationcaloric value can also be adjusted if externalfactors such as an unusual demographic situation(predominantly adult men in a camp or ahigh altitude camp) suggest that a highercaloric value is needed for a majority of a population.It should be noted that the ‘magic number’of 2100/kcal/day is not the actual daily caloricintake for any single group, but rather representsa household average based on a family offive where there are two adults and three children.It is based on the assumption that theoverall ration will be pooled by the family andshared out according to need, so that the householdmembers with higher caloric need willhave their ration augmented by the ration ofthose with lower caloric need (young children).The demographic profile of the household isvery important - for smaller household sizes, ifthere are several children and one adult, thenthe calories will be most likely sufficient as thepooled calories can be shared and will meet theadult caloric needs. However for a householdwith one adult, there are often food shortageswhen the individual is fully dependent on theration, because the 2100 kcal does not meet thedaily requirements of an adult. One of the challengesof a JAM is to ensure that the rationvalue and commodity composition is appropriatefor the majority of the refugees in the camp.Food basket of refugees in EthiopiaFood security in an encamped refugee setting,such as in Ethiopia, Kenya, Djibouti, andSudan, is often centred around a food aid rationthat is intended to provide most, if not all, of theaverage 2100 kcal/ person/day target forhouseholds. The JAM exercise determineswhether or not this level of food aid is requiredby seeking to determine how refugees arecoping within the camp, what access they haveto income such as agricultural land or dailylabour, and whether there are any clear indicationsthat a majority of refugees are able to meetsome or all of their own food needs.Refugees in Ethiopia are currently receivingapproximately 2,450 kcal/per person per daybecause the JAM in 2008 determined that anadditional 350 kcal was needed to replace thelosses from refugees having to mill the wholegraincereal (primarily maize) distributed. The350 kcal addition was meant to make-up forboth the losses in milling (dehusking/millingthe cereal into flour reduces the overall quantity)as well as the cost of milling (most refugeesuse commercial mills). It assumes that aftermilling deductions, the ration meets the 2100kcal average ration level. The refugees inEthiopia are considered to be highly dependenton food aid because of their lack of economicopportunities, including agricultural production.The majority of refugees in Ethiopia areliving in arid lands isolated from majorcommerce, systematic employment opportunitiesor even agricultural production. Thereforethe refugees on average are not able to meettheir own food needs and rely heavily on thefood aid provided.Unfortunately, the food aid is quite monotonouswith very little variation for refugeesliving in protracted refugee situations likeEthiopia. Refugees receive a ration basket thatprovides cereal, oil, pulses, fortified blendedfood, sugar and salt. In order to diversify thediet to acquire fresh fruits and vegetables,spices and occasional animal products (meat,eggs, and milk), refugees will often sell orexchange part of the ration to purchase otherfood items. Often these sales/exchanges ofration items for other food items are at verypoor terms of trade due to surplus of food aidafter distribution and the high cost of bringingfresh foods into the often remote areas. In manycases, refugees are selling food aid for less thanthe actual cost of the food (including transport).However, the need for diversified and morebalanced diets, with foods that are culturallyappropriate or more appreciated, represents animportant trade for refugees and goes beyondthe actual cost or value of the food. The JAMwill often note that the high level of sale of theration reflects a desire for dietary diversity toboth enhance the nutritional value of the mealor the palatability of the monotonous ration(see case study 1).The challenge of JAMAn ongoing <strong>issue</strong> in JAM in assessing the levelof food security is to determine what refugeesneed in terms of food and NFIs based on whatthey receive through food aid and NFI, andwhat a refugee household can self-provide interms of own production, income, remittances,savings, and barter/trade. Clearly agencieswould prefer to spend the least resources50

Field ArticleA water point inMelkadida camp, Kenyaneeded, yet at the same time ensure thatrefugees are, to some degree, food secure. Thereis therefore a need to understand what refugeescan provide and what needs to be provided..This can vary widely from country to country,from camp to camp and then from household tohousehold within the camp depending on levelof self-reliance of the family.UNHCR and WFP undertake a JAM in orderto understand the situation, needs, risks, capacitiesand vulnerabilities of refugees withregards to food and nutritional needs. In orderto understand this, the JAM must look not onlyat the food security of an individual household,but also develop a basic understanding of all ofthe assistance programme s in the camp. Inorder to understand this it is necessary to lookinto different sectors, different programmeareas and the diverse causal areas that can leadto food and nutrition security for refugees.These include access to agricultural land, cookingfuel sources, milling and transportationcosts, health and nutrition services, specialnutrition programmes, infant and young childfeeding, income generation and livelihoodopportunities, to name a few.Regional JAM trainingOver the last two years, UNHCR and WFP havebeen attempting to standardise the JAM processto improve outcomes, including key achievablerecommendations and a report reflecting thekey <strong>issue</strong>s. To that end, two joint regional trainingshave been organised in Rwanda andEthiopia, with a third planned for November2010 in Jordan. The regional trainings havehighlighted the stages of a JAM from terms ofreference (TOR) to field work to debrief to jointplan of action. Participants are invited fromLubna Khan, Ethiopia, 2010WFP and UNHCR offices as well as keyimplanting partners or government representation.The goal of the training is to enhanceunderstanding of the joint process, to discusshow it relates back to the shared MOU and utilisationof the JAM Guidelines.Traditionally a JAM has six distinct stages:planning and drafting of the TOR, creating thethematic teams and the thematic checklists,training of participants in the JAM before thefield work, undertaking the field work andreview of the secondary data, informationanalysis, and drafting of the report and keyrecommendations, finalisation of the report anddevelopment of the joint plan of action to operationalisethe recommendations. Participationof both UNHCR and WFP is essential at all ofthe six stages to ensure that both agencies haveinput on the key <strong>issue</strong>s to address and are partof the investigation and analysis. Typically aJAM will have either five or six thematic teamsand each of the teams will comprise a mix ofUNHCR, WFP and implementing partner staff.This adds to the richness of the discussion andthe analysis as different team members haveunique perspectives and experience, yet mustreach consensus with one another.Ethiopia JAM 2010In the JAM which took place in Ethiopia inOctober 2010, there were five thematic teamscovering food security and coping strategies(team 1), logistics, roads, warehousing, NFI andmarkets (team 2), health, nutrition, educationand school feeding (team 3), environment, shelter,cooking fuel, livestock, WASH andagriculture (team 4), and durable solutions,new arrivals, refuge numbers, host communityand contingency plans (team 5). Three separateoperational teams travelled to the differentareas of Ethiopia due to the large geographicdistances between the camps- one team to theNorth to <strong>focus</strong> on the Eritrean caseload, oneteam to the East to <strong>focus</strong> on the three Jijiga-areaSomali camps and one team to the South toaddress the Somali caseload in Dollo Ado. TheJAM organisation ensured that each team hadrepresentation for the five thematic areas fromthe different agencies and was scheduled toensure that each camp received one to two daysof field work. The actual information gatheringof the JAM is in three distinct phases - review ofsecondary data, field work and then analysis.After the thematic teams have determined theirkey findings and recommendations, these arethen shared with the other thematic teams inthe wider JAM mission in order to reachconsensus taking all into account. This processof consensus is very important for the JAMbecause it not only encourages assessing <strong>issue</strong>sfrom a multi-sectoral viewpoint, but alsoensures that the recommendations reflect thedifferent capacities and expertise of the agenciesinvolved.In the Ethiopia JAM, the different teamswere charged with using secondary data, fieldwork and analysis to review the current provisionof services, the changes and potentialimprovements in the last two years, as well asthe progress made on the JAM recommendationsmade in the previous JAM 2008. The JAM2010 <strong>focus</strong>ed on the relatively new Somali caseloadin the south and the expanding Eritreanrefugee population in the north, as well as thoseliving in camps and in scattered settlements inthe Afar region. Key <strong>issue</strong>s highlighted in theTOR included the lack of meaningful durablesolutions available beyond resettlement, provisionof basic assistance to the hard to reachcaseloads (Afar and Dollo Ado) and the protectionconcerns, including sexual and genderbased violence. The report should becompleted by the end of November 2010 andthe key <strong>issue</strong>s/recommendations in the reportwill serve as the basis of the joint plan of actionbetween UNHCR, WFP, ARRA and the implementingpartners for the next two years.In many ways, a JAM is a jigsaw puzzle,where the different pieces come together torepresent the food security of the refugeesliving in a camp. How refugees configure theirlives within the limitations and opportunities ofa camp, how food is shared, sold, bartered, thehousehold decisions regarding food preferencesand meal planning for differenthousehold members, the purchase of necessarynon-food items or additional luxury items, thepossibilities of income generation, day labouror employment opportunities, the opportunitiesfor agricultural production or livestockraising and the provision of basic servicesincluding adequate shelter, water, hygiene,sanitation and the availability of adequatehealth services. All of these are pieces that allowus to construct a profile of the households in thecamp in order to then determine both theopportunities for self-reliance as well as theneed for external assistance.For more information, contact: Allison Oman,email: OMAN@unhcr.orgCase study 2: A snapshot of a JAM debriefing during the field workAt 5:30pm, the last team, Team 3, arrived in a cloud ofdust and emerged from their filthy land cruiser. Theyhad been delayed in the camp in order to completeone final <strong>focus</strong> group discussion with the communityhealth workers. They entered the outdoor meetinghall just as the sun was beginning to set. It was stillhot, about 40 degrees, and the fluorescent lightswere attracting the crickets that had hatched the daybefore. As each team leader rose to discuss keypoints and recommendations, they were divebombed by a swarm of crickets, which covered theirclothes and occasionally dropped into their shirts.The discussion was lively, at times heated, as thedifferent groups discussed and debated the findingsof the day. “Ok, so people are selling the ration to buyother foods- which ones?” “How much is a kg of wheatworth?” Who is making the profit from the mill?” “Howmany refugees are working with the NGOS?” “Who arethe primary groups considered vulnerable?” “Do peoplelike the dome tents? What were they saying they wouldprefer for shelter?” “How soon can we end water tankering?”Each group presented and debated, makingnotes on recommendations and discussing until theentire team agreed on the <strong>issue</strong> and some possiblesolutions.It was now 9:00pm - dinner and a shower waited andthere were still final notes to type and changes tomake before the JAM in this camp was completed.The teams would be leaving at 6:30am the nextmorning for the other camp.The JAM coordinatorthanked everyone and called it a night, and theexhausted but excited team wandered into whatremained of the evening, still debating the relativemerits of wheat flour compared to wheat grain.Dollo Ado, October 2010A <strong>focus</strong> group during the EthiopiaJAM in Bolkolmayo campLubna Khan, Ethiopia, 201051

Field ArticleWorld Visionprogrammefor severeacutemalnutritionin SNNPRBy Dr. Sisay Sinamo andDr. Gedion TeferaFollow up appetite testingat a health facilityDr Sisay Sinamo isCoordinator for the Healthand Nutrition CoordinationUnit with World VisionEthiopia. A medical graduatefrom Addis Ababa University,he holds a Masters in PublicHealth. He has worked inareas of nutrition for about 10 years with practicalfield experience in community basednutrition, PD Hearth programming, emergencyhealth and nutrition and SMART in a number ofcountries.Dr Gedion Tefera is emergencyhealth and nutritionprogramme manager withWorld Vision Ethiopia. He is amedical graduate from JimmaUniversity, Ethiopia and holdsa Masters in Public Health(MPH). For the past 4 years, hehas worked in emergency nutrition andcommunity based nutrition projects like essentialnutrition package and PD/hearth.We would like to express our thankfulness tothe community where World Vision works andto our partners, especially the Ministry ofHealth. We also would like to thank World VisionEthiopia for allowing us to publish our fieldgenerated learning. <strong>Special</strong> thanks go to WorldVision Canada/Nutrition Centre of Expertisestaff who welcomed this opportunity topublish, and to the ENN staff who supported usduring field level documentation and editingof this article.Mesfin Teklu, WV, Ethiopia, 2006World Vision Ethiopia (WVE) is anon-governmental organisation(NGO) that has been working inEthiopia implementing crosssectoralrelief, rehabilitation and developmentprogrammes since 1971. A WV supportedprogramme to support community basedmanagement of acute malnutrition 1 in theSouthern Nations and Nationalities Region(SNNPR) has been in operation sinceNovember 2006.WVE implements cross-sectoral programmingthrough Area based DevelopmentProgrammes (ADPs). These operate independentlyof each other while benefiting fromregional programme office oversight andnational level coordination. The ‘life-cycle’ ofan ADP is usually approximately 15 years witha programme planning review following a 5yearly cycle (current Durame ADP plan is for2006-2010). Programming partners and stakeholdersinclude multi-sectoral faith-basedorganisations (FBOs) and community-basedorganisations (CBOs), as well as other internationalNGOs (INGOs), NGOs, communities andthe Government of Ethiopia (GoE).ContextThe SNNPR region is characterised by a highlylocalised pattern of micro-climates. With 45% ofthe region’s Gross Domestic Product (GDP)relying on agriculture, there is a strong correlationbetween livelihood and seasonality forindividuals and communities alike.A nutritional survey conducted by WVE inJune 2006 in the Durame ADP revealed a globalacute malnutrition (GAM) rate of 8.5% andsevere acute malnutrition (SAM) rate of 1.3%.The crude mortality rate (CMR) and under 5mortality rate (U5MR) were 0.31 and 0.89deaths/10,000/day, respectively. A furtherWVE rapid assessment using mid upper armcircumference (MUAC) in September 2006found substantial moderate acute malnutrition(n=2207) and severe acute malnutrition (n=258)in children less than five years of age. Based onthese assessments and at the request of theregional and zonal health offices, it was decidedthat a programme to manage acute malnutritionat community level should beimplemented by WVE from October 2006.Accordingly, a Memorandum of Understanding(MoU) was agreed between stakeholders for theprogramme to run for one year until September2007. The programme was supported by ValidInternational and implemented by Ministry ofHealth (MoH) staff and three WVE staff hired tocoordinate the activities.Programming approachCommitment was obtained from the healthbureaus at different levels and UNICEF agreedto provide Ready to Use Therapeutic Food(RUTF) and IMCI 2 drugs. An understandingwas reached to establish a Stabilisation Centre(SC) at Wota health centre. A developmentalapproach was adopted towards programming,to develop capacity of the MoH to provide effectivetreatment for SAM within the routine healthsystem. Orientation for MoH staff took placebetween mid November and early December2006. Eight MoH staff from seven OTPs and onehealth staff from the SC were trained on OTPand SC case management. An additional 19 WVstaff from Ethiopia, Kenya, Sudan, Somalia,Uganda, Canada, US and World VisionInternational (WVI) were also trained.Admissions started at seven OTP sites and theSC. A Supplementary Feeding Programme (SFP)component was not included, as this should beprovided by the GoE Extended OutreachStrategy/Targeted Supplementary Feeding(EOS/ TSF) programme.Key lessons from the 2008 programmeThe end of term evaluation of the programmeidentified a number of key lessons:An effective linkage between the OTP andEOS/TSF programmes was not realised duringthe programme. Due to the timing of screeningand registration for the EOS/TSF programme(every six months), children discharged fromthe OTP were not able to receive a timelysupplementary food ration from theprogramme. Hence, on discharge, childrenwere provided with a protection supplementaryfood ration until the next screening andregistration.The community outreach activities areconducted primarily through the efforts ofvolunteer community health promoters (CHPs)and supervised by the health extension workers(HEWs). The CHPs are responsible for referralsfrom the community, making them the gatekeepersto the OTP programme. However theyare not supervised effectively when conductinganthropometric measurements. In addition, therole of the CHP in the community does notinclude frequent and comprehensive screeningfor malnutrition. Unless other communityscreening measures are employed, the OTPservice coverage is likely to be low, possiblyresulting in late presentation and increased riskof mortality. Future community sensitisationand mobilisation efforts should aim to disseminateknowledge of community basedmanagement of acute malnutrition morewidely through other channels, to encourageself referral.The outcome indicators for the programmeall exceeded SPHERE standards (see Table1).These outcomes also compared veryfavourably with other community therapeuticcare (CTC) programmes. The period coverageof the programme was estimated at 67% which,multiplied by the percentage of children cured(95%), suggests approximately 64% of needswere met. Rates of reported weight gain in theprogramme were lower than expected for aCTC programme (5g/kg/day). This was likelydue to the RUTF ration being shared duringtimes of need. Slow weight gains during theprogramme were not reliably followed up byclinicians according to the ‘alert protocols’ anddischarge decisions were inconsistently applied.These factors combined to lead to an extendedstay in the programme for some individuals,which meant an increased use of resources(RUTF and workload) and ultimately reducedthe cost effectiveness of the intervention.The weak supervision by clinicians of theMUAC measurement taken to admit childrenmeant that, in many cases, it was effectively theCHP making the decision to admit the child tothe OTP. Training of staff was frequently weakwith regard to follow up and management ofcases. A weakness in logistical management atall levels was found. The main weakness was inordering and regulation of the RUTF supply.1Formerly called CTC (community based therapeutic care).2Integrated Management of Childhood Illness52

Field ArticleFigure 1: Trend of OTP/SC admissions, 2007No. of new admissions7060504030201001 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52Programme period (weeks)OTP Admissions SC AdmissionsFigure 2: Admissions to SC as percentage ofOTP admissions, 2007%100%80%60%40%20%0%1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52Programme period (weeks)OTP Admissions SC AdmissionsTable 1: Programme outcomes compared withSPHERE standardsDurame ADP OTP SPHERE standardCured 95 % > 75 %Default 3 % < 15 %Non-Cured 1 % Not statedDied 1 % < 10%As the programme evolved, the admissions tothe SC and OTP decreased over time (seeFigures 1 and 2). This is indicative of an increasingskill level amongst the OTP clinicians incases management, as well as of the beneficialeffect of the decentralised public healthapproach of community based management ofacute malnutrition, i.e. early presentation andtimeliness of treatment. A general improvementin food security over the time period may alsohave accounted for some of this positive trend.Durame ADP programming plans for 2008included interventions that aimed to tackleunderlying causes of child malnutrition andmortality. Some of the more relevantprogrammes included care and support ofpeople living with HIV (PLWH) and orphansand vulnerable children (OVCs), householdfood security programmes, water and sanitationprojects to provide potable water andincome generation activity (IGA) schemes.These programmes could have been linked toTable 4: OTP indicators, Durame ADP, October2009 to March 2010Name of ADPDurameNo. of OTP sites 35No. of children admitted in OTP 273No. of children admitted in SFP 447No of VCHWs trained on community 410based management of SAMNo. of MoH staff trained on community 117based management of SAMNo. of WV staff trained on community 1based management of SAMRecovered 286 (99%)Death 0Default 0Relapse 3 (1.6%)Table: 2: Summary of ADP level nutrition informationName ofADPWV SubofficeADP TotalpopulationTotal6-59 monthsthe community-based management of acutemalnutrition programme, by virtue of theirshared objective to impact their livelihood andwork with vulnerable caregivers and children.Follow-on programme to manage SAM(2009-2010)In 2009, Ethiopia was affected by another shortterm mid year rain failure. Shone, Durame,Qacha Birra and Omosheleko ADPs in SNNPRwere amongst those woredas most severelyaffected and had not yet recovered from theeffects of the 2008 food crisis.The lessons learnt from the Durame project(November 2005-December 2007) were instrumentalin designing a programme to manageacute malnutrition in the four ADPs. Theprogramme began in October 2009 and wasbased upon Government national guidelinesfor the management of SAM at both facility andcommunity level 3 . It was developed in responseto findings of a Rapid Nutritional Assessmentconducted in two ADPs (Omosheleko andQuachabira) in March 2009 and MUAC massscreening conducted by the EOS programmesin December 2008 in Shone and Durame ADPs.See Table 2 for the prevalence of GAM andSAM in the four ADPs. Additionally, earlywarning reports from the four ADPs indicateddeterioration of the food security situation inthe areas due to lack of early rain (March andApril 2009). The government identified the fourADPs as high priority areas for nutritionresponse.In 2008, the GoE had already started implementingand scaling up SAM management inthe four ADPs and integrating this within theroutine health care delivery. However, theprogramme had many capacity gaps thatGAM* SAM* DataSourceQuacha Birra WVUS 142,221 19,643 17.6 % 1.5 % RapidNutritionAssessmentOmosheleko WVUS 204,571 34,771 24.9% 2.35 % RapidNutritionAssessmentShone WVUS 228,614 38,864 34.0% 2.5 % EOS massscreeningDurame WVUS 171,968 29,235 28.9% 0.5 % EOS massscreeningTotal 747,374 122,513*Proxy data for GAM and SAM since based on rapid/mass screening.Table 3: Project partners and areas of partnershipWhen werethe datacollectedMarch, 2009March, 2009Dec, 2008Dec, 2008Level where thedata werecollectedADP and DistrictGov OfficesADP and DistrictGov OfficesADP and DistrictGov OfficesADP and DistrictGov OfficesPartnersAreas of partnershipUNICEFProvide some of the supplies needed for the implementation of this project such asessential drugs, insecticide treated nets, and RUTF.Regional Health Office Liaise logistics transfer between UNICEF and woreda MoHWVEAllocate funding for the project.Supplement essential drugs, provide OTP/SC cards and formats, e.g. follow-up cards, tallysheets, reporting formats, and supply protection ration that cannot be covered by otherpartners.Work with the DMFSS Desk to link children discharged from the OTP to the EOS/TSF.Work closely with DMFSS Desk to ensure linkage between OTP and SFP.DMFSS Desk in theworedas Agricultureand RuralDevelopment OfficesWFPCHPsAll partnersFacilitate supplementary food ration distribution (Corn Soya Blend, oil and sugar) formoderately malnourished children.Work with MoH to ensure proper referral between OTP and SFP.Provide SFP commodities to DMFSS desk.Monitor distribution of SFP commodities.Participate in case identification, referral and follow up.Participate in the project review.needed to be filled. In 2009 there was noadequate rain during the short rainy season andthe local administration and regionalEmergency Nutrition Coordination Unitextended a request to WVE for support.Furthermore, MOH and UNICEF with otherpartners planned to establish one OTP perkebele and one or two therapeutic feeding unit(TFU) SCs per woreda. WV contributed to thisinitiative through a partners’ capacity buildingapproach and helped expand and strengthenthe existing programmes in the four ADPs’operational areas.The current project is being implemented for12 months from October 2009. It targets an estimated4,559 children under five years of agewith severe acute malnutrition in four ADPs. Akey aim of the project is to help build the capacityof government staff in the health centres,health posts and community volunteers forsmooth integration of the emergency interventioninto the government system. Areas ofpartnership are reflected in Table 3. Keyelements of the project envisaged at the outsetwere:• Implementation of community-basednutrition projects in parallel with theemergency intervention using the EssentialNutrition Actions (ENA) Approach.Community education to include infant andyoung child feeding and maternal nutritionpractices.• The project has a number of capacitybuilding elements and will be handed overat the end of the funding period (September2010). During transition, the MoH will startto run most of the project activities.3Protocol for the management of SAM. Ethiopia-FMOH, 2007.53

Field Article• Links will be established between thisproject and other ADPs’ food security anddevelopment projects that impact householdfood production, consumption and income.The OTP and SC will be linked with theexisting EOS/TSF with the ‘back up’ of aWV protection ration (see below). Acutelymalnourished children will be identifiedthrough community-based screening or byself-referral.• The ADPs will conduct a local capacityassessment on management of acutemalnutrition in the community to identifygaps. Trainings will be designed based onthis assessment. During the initial assessmentconducted before the programme started,there are no operational SC/OTPs, facilities.Hence, one facility will serve as an SC andfour or five OTP sites for initial opening ineach of the woredas. These wouldsubsequently be expanded and strengthenedbased on need. Where SCs and OTPs arealready in operation, these would bestrengthened based on assessment findings.• WVE and woredas MOH will conduct a onedayorientation session for Kebele leaders,HEWs, CHPs, school teachers, andcommunity workers already working oncommunity mobilisation, active casedetection and defaulter tracing. The HEWsfrom the most severely drought affectedkebeles will be trained first, followed bythose in less severely affected woredas.• WVE will be responsible for the purchase ofessential medicine and other supplies needed,as well as hiring of vehicles for transportationof supplies and referrals, assistinggovernment health staff with screening andadmission, periodic monitoring andsupervision of the project implementationtogether with the woredas health offices.WVE will also print the different registrationcards (SC charts, OTP admission and rationcards, etc) and monitor the recording andthe weekly and monthly reporting togetherwith the woredas’ health offices.• WVE will liaise with UNICEF and RegionalHealth Bureau for the timely provision ofdrugs and supplies to the health facilitiesthrough existing systems for logisticstransportation. WVE will fill gaps in thelogistics pipeline, if needed.The key programme design changes thatemerged from lessons learnt from the 2006/7programme were:• WV staff were not used to implementdirectly the programme but <strong>focus</strong>ed oncapacity building of partners, e.g. clinicalofficers and HEWs, adopting a minimumsupport approach.• WVE supplied a protection ration forchildren discharged from the OTP as itcould not be assumed that these childrenwould be enrolled on the EOS/TSF.• The referral system to SCs was changed torely on self-referral, where mothers/caregivers now take their children fromOTP to SC. Previously WV had hiredvehicles to transport ‘complicated’ SAMchildren from OTP sites to SC.Six month reviewLocal MOH have taken the lead in implementingthe OTP, SC and community mobilisationcomponents, as well as beneficiaries follow-upin the community and referral to the EOS/TSF.Volunteers have screened and referred childrento the OTP sites.After the first six months of the programme(to March 2010), there are already a number ofachievements:Health facility assessment and stakeholderanalysis were conducted involving 127 healthposts and twenty health centres. WVEconducted joint woreda level planning workshopsbased on these assessments. The capacitygaps identified were presented to local MOHoffice managers resulting in discussions andjoint plans regarding how to fill these capacitygaps.By the end of March 2010, the programmehad scaled up and was being implemented in125 kebeles in the four ADPs. A total of 761volunteer CHPs have been trained and areworking with the HEWs in OTP sites. A total of113 OTP sites have been strengthened/established.By the end of February, 2010, 1116children were in the OTP, withthe figure rising to 1438 childrenat the end of March 2010.Children discharged fromOTP sites received CSB/Famixand vegetable oil. The rationcomprises 8.3kg/month ofFamix and 1kg of vegetable oilper child per month. A total of52.016MT of CSB/Famix and6.153MT of vegetable oil weredistributed up until the end ofMarch 2010.Other activities completedduring the first six months ofthe programme included rentingcars to provide onsitetechnical support and supervision,printing and laminatingnecessary OTP guidelines andprotocols, and hiring a nurse and two RUTFdistributors in each ADP project area. In someADPs, food was provided for caregivers whilethey were staying at the SC. Two planned activitiesthat were not possible were purchase ofRUTF buffer stocks due to limited budgets as aresult of the economic crisis, and monthlyreview meetings with government health workers,due to competing work demands ongovernment staff.Major challenges of the programme noted atthe six month review included:• Delayed staff recruitment• Lack of routine medicines in some OTP sites• Irregular use of tally sheets at OTP sites• Delay of purchase of some commodities,such as computers and essential medications,due to lengthy purchase processes.• Predicted shortage of CSB/Famix andvegetable oil in the coming months.• Limited capacity of staff to use the WVdatabaseDespite these challenges, OTP programmeoutcomes are very good, reflected in Table 4using Durame ADP as an example.Minimum support: PD HearthWV has recently completed an exploratory PDHearth programme in Atbi Womberta ADPwhere a SAM management project had beenphased out to a ‘minimum support project’.Among all children under 5 years measuredin the district, a total of 240 children were foundunderweight (weight for age

Agency profileSchool of Nursingand Midwifery &Pre-Service Trainingon Nutrition,Hawassa University,EthiopiaBy Aweke Yilma Dubi, Head,School of Nursing & MidwiferyEthiopia is one of the least developedcountries in the world. According tothe Government’s Interim PovertyReduction Strategy Paper (2000-2003),over 45% of the population lives below thepoverty line. A consequence of this widespreadpoverty is low levels of human capital accumulation.Whereas countries at the forefront ofdevelopment often invest in education andaggressively engage in human capacity developmentand knowledge transfer, those who donot or cannot often fail to bring about significantdevelopment. Poverty reduction is a major<strong>issue</strong> for Ethiopia and capacity building in thepublic and private sectors is a key buildingblock to accelerate much needed socioeconomicdevelopment.The Higher Education Training CapacityBuilding Programme is part of the developmenteffort of the Federal Government, regionalstates and the private sector. This aims to createcountrywide sustainable human resourcecapacity that is responsive to changing circumstances.The development of higher educationis among the highest national priorities. It isviewed as the major instrument towardsachieving food security and alleviating povertyand other social and technological problems thecountry is facing. Hence, capacity building isthe cornerstone of sustainable development inEthiopia. In addition, there is a need to buildthe research capacity and address the critical<strong>issue</strong>s of the country, particularly in relation tomalnutrition and diseases such as HIV.Hawassa UniversityHawassa University, previously known asDebub University, was established in April 2000by merging three colleges, namely HawassaCollege of Agriculture, Wondo Genet College ofForestry and Natural Resources, and DillaCollege of Teachers Education and HealthSciences. Located at the centre of the Great RiftValley in Hawassa city, the University is thelargest and most comprehensive University inthe Southern Nations Nationalities andPeople’s Regional state (SNNPRs) and in thesouthern part of the country. It has 24 academicdepartments, four institutes, three colleges and58 academic programmes, with more than20,000 students involved in 41 undergraduate,22 Masters and 2 PhD programmes. There is 960academic and 1,100 administrative staff.In the School of Nursing and Midwifery,there are 800 nurse and midwifery students and30 academic and administrative staff at differentacademic levels, ranging from assistantprofessors, and lecturers to graduate assistants.Staff have a diverse range of professional qualificationsin the areas of curriculumdevelopment, public health, internationalhealth, maternal and child health, midwifery,adult health nursing. Unfortunately, the Schoolof Nursing and Midwifery has no staff trainedin nutrition or with a nutritional background.The education of nurses and midwivesIn order to meet the national aim of creatingsustainable human resource capacity for healthand nutrition services, the School of Nursingand Midwifery offers undergraduate trainingto prepare the nurses and midwifes for thedemanding environment of Ethiopia. This environmentis characterised by high prevalence ofHIV/AIDS, high maternal and infant mortalityrates, malnutrition and frequent emergencies,as well as high levels of staff attrition. The roleof nurses and midwives in Ethiopia has had todiversify and broaden, so that in addition tohospital based clinical work, they need to beable to work in community-based programmesin areas, such as therapeutic and supplementaryfeeding and HIV.To help prepare the graduates for these roles,the School has designed a Community-BasedTraining Programme (CBTP) and TeamTraining Programme (TTP). This involvesstudents being deployed to remote and hard toreach communities affected by drought, highlevels of malnutrition and communicablediseases. During this period, the students workwith community members to assess their healthand nutrition related practices, such as foodintake and food taboos, infant and young childfeeding practices, feeding of infants and childrenduring periods of sickness, nutritionduring pregnancy, food hygiene, storage andpreservation. The students plan, implementand evaluate activities aimed at addressing theidentified problems in collaboration withcommunity members.In addition to the CBTP and TTPprogrammes that are well integrated into theformal undergraduate curriculum, the Schoolconducts pre-service trainings (PST) on newcompetencies and concepts that, although notformally integrated in the existing curriculum,are seen as very important for the studentsprofessional development. In collaborationwith governmental and non-governmentalorganisations such as Save the Children, WorldHealth Organization (WHO), World Vision,Plan Ethiopia and professional associations, theschool offers PST on Nutrition in HIV,Integrated Management of Neonatal andChildhood Illnesses, Prevention of Mother toChild Transmission of HIV, ComprehensiveHIV/AIDS care, Palliative Care, InfectionPrevention and Injection safety. These PSTs areusually conducted when students prepare toenter their clinical years, a few months beforethey graduate and go into the community. Thisfacilitates the immediate application of theirnewly acquired knowledge and skills.Stakeholders, such as the WHO, Ministry ofHealth and Ministry of Education as well asemployers, have clearly stated the importanceof equipping the graduates with the necessaryknowledge, skills and attitude (competency) totackle new health and nutrition problems andemerging technologies. PST is viewed as aparticularly cost effective approach in terms ofmoney and time expended. Pre-service traininghas many advantages when compared toin-service training (IST) in that it creates theopportunity for building the capacity of largenumbers of potential health professionalswithin a short period of time. The existing infrastructureand system of a university/institutionhelps keep costs low. Furthermore, PSTprovides a golden opportunity to equip graduateswith the requirements of the workenvironment and enable them to integratethemselves into the community norms andcultures. In contrast, IST, though very useful,can be very costly in monetary terms and cantake staff away from their place of work forconsiderable periods of time in an alreadyunder-staffed environment.Cognizant of the role the School plays inproducing a critical mass of nurses andmidwives for nation building and the benefits ofworking in collaboration with new partners andstakeholders, Hawassa University is re-designingthe overall university curriculum into amodular system. This presents another opportunityto integrate areas of concern into thenursing and midwifery training programme.In line with this development, the School isactively seeking collaboration with partners tobuild the capacity of faculty members in thearea of nutrition in emergencies and inHIV/AIDS and nutrition. This is needed toequip the teaching staff with additional skillsand knowledge to pass onto the nurse andmidwifery students though the new modularapproach. Existing faculty staff do not currentlyhave all the knowledge and skills to design andteach a new module on nutrition in emergenciesor on HIV/AIDS and nutrition. Specifictechnical areas in need of capacity developmentfor faculty staff are in infant feeding in emergenciesand community-based management ofacute malnutrition; all pressing problems inEthiopia. Recently, the School has started adiscussion with World Vision Ethiopia andTufts University in USA on capacity building offaculty staff in the areas of infant and youngchild feeding and HIV/AIDS and nutrition.This offers a positive step forward towardsstrengthening the quality and content of teachingin the future.For further information, contact: Aweke YilmaDubi, Head, School of Nursing & Midwifery,University of Hawassa, Hawassa, Ethiopia.P.O. Box 1504tel: +251 462 211 003 (Office)e-mail: awekeyilma@gmail.com55

A farmer plows his field with thetraditional yoke and pair of cattleMarket-ledLivelihoodRecovery andEnhancementProgrammeand integratingENAsBy Andrew Simons, DanielGebeyehu, Getachew Gemtesaand Markos KidaneAndrew Simons is the NationalProgramme Director for Foodfor the Hungry (FH) Ethiopia. Heholds an M.P.A. in InternationalDevelopment and has workedin various developmentprogrammes in countriesranging from El Salvador, Afghanistan, Ethiopia,Dominican Republic and Honduras.Daniel Gebeyehu is Director ofthe Emergency ReliefDepartment for FH Ethiopia. Hehas a MSc in Remote Sensingand GIS and a BSc in Forestryfrom Alemaya University ofAgriculture in Ethiopia. He hasbeen with FH Ethiopia for five years.Getachew Gemtesa is AgriculturalMarketing and LivelihoodsCoordinator with FH Ethiopia.Getachew has a BSc degree inplant sciences from AlemayaUniversity and is currentlypursuing his postgraduatestudies from IGNOU in Rural Developments.Markos Kidane is PublicRelations Officer with FH and isinvolved in hosting teams fromthe US to project sites and writingsuccess stories of FHinterventions.The authors would like to thank USAID's Officefor Foreign Disaster Assistance for their generousfunding of the MLREP programme.A Simons/FH Ethiopia, 2010Food for the Hungry Ethiopia (FHE) beganworking in Ethiopia in 1984 through aidefforts in response to the famine at thattime. In the beginning, FHE operatedthrough partner organisations, delivering emergencyfood aid to those affected by the famine.The recurrence of famine ten years later motivatedFHE to become an operationalnon-governmental organisation (NGO), directlyimplementing relief and rehabilitationprogrammes in the country. Since that time, FHEhas grown tremendously and has taken furthermeasures to address the root causes of povertythrough tackling <strong>issue</strong>s related to sustainabledevelopment.FHE implements various types of projects infour regional states in Ethiopia: Oromia,Amhara, Southern Nations, Nationalities, andPeople's Region (SNNPR) and BenishangulGumuz. The projects include:Food Security: FHE implements relief interventionsto soften the impact of drought inchronically food insecure woredas in Amharaand the SNNPR.Agriculture & Environment: This includes trainingin agronomic practices, micro-irrigation,animal health, fruit and coffee production, environmentalprotection and natural resourcemanagement.Child Development & Education: Social development,child health, education supportprogramme and income generating activities.This programme is geared to improve the livesof children, mostly orphans.Health & Nutrition: Micronutrient interventions,nutritional supplementation, dietarydiversification and disease control training.Water & Sanitation: Building of hand-dug andshallow wells, springs, roof catchments, potablewater supply schemes, cattle troughs, latrines,and hygiene promotion.HIV/AIDS: HIV/AIDS prevention and awarenesseducation.The Market-led Livelihood Recoveryand Enhancement Programme (MLREP)The MLREP, funded by USAID-OFDA1, waslaunched in March 2009 and is a three yearprogramme. The MLREP aims to improve thefood and livelihood security status of smallholderhouseholds in the three target districts(woredas) in SNNPR. The project covers 33kebeles (village associations) in the threedistricts. The primary target beneficiaries of theproject are the acute and chronically food insecurehouseholds (HH) in the target districts. Toensure the targeted beneficiaries will be able torealise food self sufficiency and produce surplusproducts for the unmet market demand, theproject has integrated various livelihoodcomponents that arose following the results of aValue Chain Analysis (VCA) study (see belowfor more information). All interventions havebeen planned based on the needs and potentialof the target communities. Targeting criteriadeveloped by FHE and the government DistrictOffice of Agriculture (DOA) are used by localleaders to select beneficiaries. The programmetargets HHs who normally produce grain forfood and sell any surplus as their sole source ofrevenue. These HHs have been forced topurchase grain at unprecedented costs arisingfrom the Global Food Price Crisis (2008-2009),during which food prices in Ethiopia escalatedsignificantly.Field ArticleMLREP componentsRelief element: Cash For Work (CFW)This component aims to provide temporaryemployment and thus income to chronically foodinsecure HHs and, at the same time, createproductive community assets through theirlabour contribution. FHE undertakes nurseryoperations and the construction of ponds for livestockthrough CFW as a temporary employmentscheme. The majority of the nursery workers arewomen who have suffered from the drought andfood price crisis.Micro-credit provisionAll agricultural inputs and equipment are deliveredto farmer groups on a credit basis throughthe Omo-Micro Finance Institution (OMFI). Thebeneficiaries are organised initially intoproducer and marketing groups, and shouldeventually grow into cooperatives by the secondand final years of the programme cycle. Theproposed programme’s agricultural inputs willbe distributed on a loan basis. This differs fromthe usual OMFI operating procedure where cashis normally disbursed to a beneficiary for a loan.In this programme, however, the input (beehive,water pump, etc.) is delivered directly to thebeneficiary and then OMFI recovers the loanvalue of the agricultural input over time.Livestock/seedsFHE intends to increase livestock productivitythrough introducing higher yielding localbreeds, improving livestock husbandry practices,promotion of dairy farming and improvedforage production. Further, it will work tostrengthen the market link for livestock producers,so that they are able to generate betterincome from their production. The seed subsector<strong>focus</strong>es on seed provision of marketableand high yield improved varieties, aiming atincreasing and diversifying incomes and livelihoodsof the affected farming HHs.IrrigationSmall scale irrigation is promoted through handdug well construction and delivery of motorisedpumps. The programme supplies locally availablematerials and skilled labour during wellconstruction and provides water lifting pumpsbased on the depth of the well through a microcreditsystem arranged with OMFI.Value chain analysis (VCA)VCA is useful for producers who are trying tointegrate into markets in a manner which wouldprovide for sustainable income growth. VCAprovides the answer to the question, ‘whichcommodity should be pushed further in termsof ease of access to input and output markets?’Four crops/commodities were identified basedupon on these ‘ease of access’ criteria:Honey was strategically selected as the valuechain to be implemented because of potentialfor income gains and the central role of bees inimproving and enhancing overall food securitythrough pollination of food crops. Additionally,forage seedlings that flowered were selected tobe grown in the CFW nurseries, to link withthose beneficiaries who would be <strong>focus</strong>ing onthe honey value chain.Potato is among the most efficient commoditiesfor converting natural resources, labour andcapital into a high quality food. Because of itsshort maturity period (improved variety), it isvery strategic at mitigating food crisis in disas-1US Agency for International Development-Office forDisaster Assistance56

Field ArticleImproved beehives, which produces significantlymore honey that a traditional hiveter situations and offers better opportunities togrow more quantities of food on less land inrelatively short growing periods.Haricot beans are ‘number one’ both in terms ofvolume of export and revenue generatedamong all pulses grown in Ethiopia. The highnutrition value of the crop is also encouragingthe programme to promote mass production inthe programming areas.Pepper is known as a cash crop and promotingits increased productivity enables an incrementin household income level. This type of pepperis dried and ground and makes the base ingredientof common food spices (called berbere)found in almost all Ethiopian cuisine.Cash crops analysisThe VCA has pointed out marketablecommodities that can be produced with highpotential through provision of necessary servicesupports along the value chain. FHE has acrucial role to stimulate the support system inthe target woredas to improve the productivityand marketing of the commodities by assistingfarmers to adopt best agronomic, processingand marketing practices.IntegrationThe MLREP programme is not a standaloneinitiative, but rather dovetails with theGovernment of Ethiopia’s (GoE) led ProductiveSafety Net Programme (PSNP) programme.The MLREP programme targets PSNP beneficiariesto help them build assets and graduatefrom the PSNP programme.FHE coordinates, shares information andcollaborates closely with many actors in theprogramme design, implementation, monitoringand evaluation of activities. At the fieldlevel, FHE works with the DOA to implementthe different activities planned in this sector.The officers provide technical assistance in theselection of sites and beneficiaries, identificationand sourcing of appropriate inputs, thetraining of beneficiaries, etc. FHE is representedon each targeted District’s Food Security TaskForce and ensures the programme is integratedwith the development plans of the GoE andother NGOs. The research centre in the regionacts as a source of technologies, informationand knowledge by providing trainers,improved varieties of agricultural inputs andimproved agricultural practices. The privateseed suppliers serve as reliable sources ofimproved seed varieties.The programme has a strong coordination<strong>focus</strong> with other projects and this provides FHEwith the opportunity to share experiences andresearch outputs that can be applied in otherareas.The Care Group Model for integratingEssential Nutrition Actions (ENAs)After the completion of the first year of theMLREP, initial benefits were seen at the HHlevel as far as some income generation/assetA Simons/FH Ethiopia, 2010An example ofvertical farmingin a FH Projectcreation. However, there was no obviousevidence that this increased income was beingput to use to improve the nutrition and healthoutcomes of the most vulnerable members ofthe family. Therefore, it was decided to modifythe second and third year plan to include anutrition education component (which willtake effect in early 2011). The design is based onthe successful integration of a similar nutritioncomponent into the PSNP being implementedby FHE in the South Gondar woredas ofAmhara Region called the Care-Group Model.The programme will use volunteers todisseminate nutrition and hygiene relatedmessages to MLREP targeted beneficiary mothers.Community volunteers, selected by HealthExtension Workers (HEW) and kebele officials,will be trained on Essential Nutrition Actions(ENA) (optimal breastfeeding, complementaryfeeding, feeding of the sick child, women’snutrition, control of Vitamin A deficiency, andcontrol of anaemia and iodine deficiency disorders)and Essential Hygiene Actions (EHA). TheHEWs will take the lead and FHE will provideeducational materials and facilitate the training.The Care-Group Model approach <strong>focus</strong>es onmothers of reproductive age who are beneficiariesof food aid (parallel PSNP or reliefprogrammes) and MLREP activities. Motherswill be divided into groups of ten to fourteenand each of these groups will elect one ‘leadermother’ who will be responsible for leadingdiscussions in the group under the guidance ofthe volunteer promoter. The promoters meetwith the lead mothers every two weeks forabout two hours. Religious and communityleaders can also serve as co-promoters.During Care-Group meetings, promoterswill teach lead mothers by using flip charts(developed in other FHE programmes) for atotal of 20 sessions. Similarly, lead mothers willdiscuss the same topic with mothers in theirgroup. After completion of the session, thegroups will continue the meeting and willdiscuss other health and social related <strong>issue</strong>s.The cycle of all lessons should take approximatelyten months. Establishing mother tomother meetings should help mothers learn theENAs and discuss <strong>issue</strong>s together to help bringabout the desired behaviour change which canimprove the nutrition and health outcomes ofthe children in the community.Outcome indicatorsThe following outcome indicators will be measured:• Mothers who practice hand washing at twocritical times, at least.• Mothers of children under six months whopractice exclusive breastfeeding based on 24hour recall• Mothers who increase the amount of fluidduring childhood diarrheal illness• Mothers of children under 5 years usingappropriate food diversification ofcomplementary feedingA Simons/FH Ethiopia, 2009• Mothers whose household builds a latrineand uses it• Households who invest in growing/purchasing nutritious foods and areeducated on preparation methodsIn order to measure impact, household foodconsumption patterns and hygiene practiceswill be recorded through interview before thenutrition component is launched. Comparisonsin behaviour of the households can be madewhen a follow up survey is completed after theprogramme has run for a year. Regular mini-KPC (knowledge, practice, and coverage)surveys to ascertain any improvements willalso be undertaken.Raising awareness during publicgatheringsFHE volunteers will also educate the MLREPbeneficiaries at MLREP temporary employmentsites (nursery and cattle ponds) and food aidcommodity distribution sites (part of a differentrelief programme) though mass education. Theeducation will mainly <strong>focus</strong> on the ENAmessages and the EHAs will <strong>focus</strong> on handwashing at appropriate times using soap or ash,creation of hand washing stations at the householdand other community settings (e.g.marketplaces), proper disposal of faeces, andeffective point-of-use drinking water treatmentin households. FHE will arrange 20 minutesession for education before distribution andany kind of public work, like nurseries management,pond constructions and others.Community volunteers as well as social workersin the organisation will give the educationin collaboration with HEWs.Lessons and opportunitiesFHE has found that even the most food insecurehouseholds are able to participate in themicro-credit scheme established. The key is toprovide these households with an appropriateloan based on their needs and capabilities tomake payments in the long-run. One keyelement involved with this has been for FHE toserve as a ‘middle man’ to negotiate betterterms for the farmers with the OMFI. Forexample, FHE has helped to lengthen the timerequired to pay back loans for certain agriculturalbased loans that better coincide with theagricultural production seasons. Proper trainingand other supplementary inputs are alsonecessary for the successful implementation ofthe micro-credit scheme.Additionally, FHE has helped significantlyby ‘pushing’ OMFI into rural kebeles. As transactioncosts to OMFI are high for smaller loanamounts, support in capacity building - such asmotorcycles for the OMFI regional field offices- has lowered the costs for OMFI to do businesswith the most poor. This has lowered a barrierfor OMFI to help improve the access to thesecredit services for rural vulnerable households,making it more likely they will travel to therural areas to look for loan customers.Supplying a packaged approach is an effectiveway to reach desired results in as thecomplementary inputs provide a larger impactthan providing single inputs. For example,providing bee fodder to beneficiaries, in additionto the access to the microfinance loan forthe beehive, will allow their ultimate honeyproduction to be higher, making a better chancefor successful repayment of the loan.For further information, contact: AndrewSimons, email: asimons@fh.org57

An overview of REST’s implementationof the Productive Safety Net ProgrammeField ArticleBy The Relief Society of Tigray (REST) Mekelle TeamThe Relief Society of Tigray (REST) hasbeen in existence in Ethiopia for over30 years, starting out as a relativelysmall organisation in 1978 in responseto the needs of Tigrayan’s displaced because ofdrought and food insecurity to neighbouringSudan. The 1984/5 famine that affected largenumbers of the Tigrayan population saw RESTimplementing large scale cross border (withSudan) humanitarian relief programmes. In1987, REST oversaw the agricultural rehabilitationprogramme, established to assist 160,000repatriated Tigrayan refugees to rebuild theirlivelihoods.Tigray is a region of over 4.3 million people(out of a population of 76 million in Ethiopia) inthe north of Ethiopia. Eighty per cent of thepopulation live in rural areas, of which themajority are subsistence farmers producing, onaverage, only 40% of their annual minimal foodrequirements. Gross Domestic Product (GDP)per capita is US$115.00 and 89% of the populationearn less than US$2.00 a day. Average lifeexpectancy is 43 years.In 1991, REST was registered as an indigenousnon-governmental organisation (NGO)and since this time, has <strong>focus</strong>ed on longer termdevelopment programmes whilst maintainingcapacity in emergency response. Today, REST isone of the largest indigenous NGO’s inEthiopia, with the head office in Tigray’s capital,Mekelle. REST has 700 staff and is fundedby many donors and international NGOs, withan annual budget of around USD$10 million(2010). REST works in 23 out of 34 woredas(districts) in Tigray.REST priorities and programme areasThe stated goal of REST’s programming is tobring about food security for householdswithin its operational areas. REST is organisedinto a number of departments as follows:• Environmental Rehabilitation and• Agricultural Development• Irrigation Development• Health• Education• Rural Water Supply• Relief and Rehabilitation• Supplies and Logistics• Planning and Coordination• Research and Policy DevelopmentRelief and RehabilitationFrom its inception, REST has provided emergencyrelief across Tigray and as a result, hasdeveloped significant experience and capacityin this field. Following the end of the civilconflict in 1991, the strategy evolved to integrateemergency programmes withindevelopment processes. For example, free fooddistributions were restricted to the most vulnerablein an emergency (estimated to be around20% of the emergency affected population atany one time) whilst the remaining 80% receivefood as part of food for recovery programmes.Furthermore, REST has developed very richexperiences in drought and disaster managementand in early warning and disasterpreparedness. This has enabled REST to initiateresponses to droughts or other shocks at anearly stage.As part of disaster response management,REST initiated a strategy that food aid ‘shouldgo to the people and not bring people to thefood’. As a result, REST manages a number ofdistribution points close to those in need in all itsoperational woredas and has an overall storagecapacity of 50,000 metric tons (MT) of food. Overthe past five years REST has delivered 393,000MT of food assistance, 2,100 oxen, 2,550 sheep,and 800 donkeys. In addition, 4,900 householdshave bought farm implements from REST.Implementation of the ProductiveSafety Net Programme (PSNP)REST has been an implementing partner in thenational PSNP since 2006 working in six chronicallyfood insecure woredas in Central, Easternand Southern Tigray (Ahferom, DeguaTembien, Mereb Leke, Werie Leke, Wukro andRaya Azebo) reaching over 450,000 beneficiaries(see Figure 1).The PSNP is a multi-year programme withresources committed to 2014. The overall goalof the programme is to make a sustainedchange to food security and livelihoods ofchronically poor communities and reduce theirvulnerability to disaster shocks. The PSNPutilises food and cash transfers to supporthousehold food consumption, build communityassets and provide a platform for theengagement of the most poor in agriculturebasedfood security packages and programmes.The REST PSNP originally provided food transfersfor a period of eight months forcontributions to public works by able-bodiedPSNP beneficiaries, and for a period of 10months for direct support beneficiaries(disabled persons, the elderly, sick and femaleheaded households). From 2008, the transferperiod was similar to that of the governmentPSNP for six months for public work and directsupport. The food entitlement is 15 kg of grain,1.5 kg pulses and 0.45 kg oil per month perFigure 1: USAID/REST PSNP – Productive SafetyNet Programme WoredasProgramme WoredaNon Programme Woredahousehold. This is a larger monthly food transfercompared to other PSNP implementingagencies. REST also distributes 4.5kg/month/person of corn soya blend (CSB) tomalnourished children (low weight for age)and pregnant and lactating mothers, based onregular growth and nutritional monitoring byhealth service institutions. This food is alsodistributed during emergencies to PSNP andnon PSNP beneficiaries. RESTs distinctapproach to the PSNP is on integration of activitieswith other national programmes activitiesat the woreda and village level to maximisecoverage and impact.RESTs Environmental Rehabilitation andAgricultural Development Department overseesthe natural resource management relatedactivities in the PSNP in tandem with theIrrigation Development and Rural WaterSupply Departments. Natural resourcemanagement is viewed as a key activity area inorder to reduce the effects of drought and soilerosion, and to increase food security throughirrigated agricultural production and increasedlivestock holdings. Natural resource projectsaccount for more than 90% of the total publicworks budget. All natural resource activities areimplemented at watershed level. Typically, soiland water conservation projects include physicalmeasures (stone bunds, hill side terrace,trench bund, gull treatment, micro-basin andpitting for plantation), biological measures(which includes area closures for regeneration,grass strips, and afforestation) and waterharvesting measures (river diversion, minidam, water harvesting check dam, open handdug well, spring development). Since 2005,REST has treated and developed over 57,000hectares of degraded hill sides, 442 kilometresof large gullies, seven mini-dams, 11 riverdiversions, 190 water harvesting check damsand 645 open hand wells in the PSNP woredas.Watershed management is another key naturalresource activity. This involves theconstruction of stone walls and trenches toretain water, provide moisture for shrubs andtrees, re-charge the groundwater, prevent soilerosion and thereby enable cultivation in thepreviously dry valleys and river beds of diverseGully rehabilitation toprotect farm lands58

Field ArticleVegetable production fromopen hand dug wellcrops (fruits, vegetables and drought resistantcrops) throughout the year. REST also supportsimplementation of micro-irrigation checkdams, open medium and large hand dug wells,livestock development, crop development andclean water supply activities.PSNP implementation processAll activities are closely managed by committeesat the community level. At the Tabia level,PSNP has two task forces: kebele/Tabia foodsecurity task force (KFSTF) and communityfood security task force (CFSTF). Both taskforces have representation from local administration,health extension, teachers, youth, andfarmer and women associations. The role of theKFSTF is to consolidate public work plans,prepare PSNP plans in consultation withworeda sectors, verify PSNP clients and to evaluatePSNP activities.Comprising three females, three males, ayouth representative and development agents(DA), the CFSTF is responsible for targeting theeligible communities, identifying public workand direct support participants and for mobilisingthe community jointly with DAs forparticipatory works planning. CFSTF alsoorganise public meetings to discuss theproposed list of PSNP beneficiaries, encouragecomments from people attending the meetingand make amendments to the list as required, toHill side terrace to conservesoil and waterreach overall agreement among the communityon the list of PSNP clients. This list is submittedto the KFSTF, which ensures there is no stigmaagainst the inclusion of eligible people livingwith HIV. The CFSTF also participate in regularreview of PSNP clients, monitoring the implementationof public works and informingappeal process to the community.In addition to REST’s links with the KFSTFand CFSTF, REST is a member of the woredalevel food security task force and technicalassistance team. The role of REST at this level isto strengthen the community and woredamanagement capability through capacity buildingand technical assistance.59Micro-credit support activitiesREST integrates bee keeping, dairy, small ruminant,vegetable and fruit production to the needyPSNP beneficiaries to increase their food security.These are described in case studies in Box 1.PSNP linkages with NutritionThe PSNP is closely linked to key governmentnational health and nutrition programmesincluding the Health Extension Programme,HIV/AIDS programme, the National NutritionProgramme (NNP) and national OutpatientTherapeutic Programme (OTP) roll-out.Linkages are through the provision of suppliesto health posts (gloves, weighing equipment,teaching aids), provision of CSB for malnourishedchildren, capacity development includingtraining, and through the referral of moderatelyand severely malnourished children from PSNPhouseholds to the clinics and health posts.REST/PSNP provide capacity building<strong>focus</strong>ed on the NNP components for communityhealth workers, health extension workersBox 1: Micro credit support case studesLandless beekeeping groups inarea closures (Wukro woreda)Bee keepingIn Ayna-alem village of Kilte-Awlaelo woreda, REST isworking with young landless families to form beekeepinggroups in areas where there is ongoingwatershed management that allows bee fodder to begrown (flowers). REST provides a Birr 3600 loan toeach person to enable capacity building to get startedand establish bee hives. Each bee group has, on average,40 hives and can sell the honey as well as beecolonies. When managed well, 12 quintal (1 quintal =100kg) of honey can be harvested per person and soldfor Birr 120 per kg. In addition, the beneficiaries raisebee colonies and sell them to the market at averageprice of 700 Birr/colony.Income for water pumpsA 32 year old farmer, Gebre Kassa, lives in the easternzone of Tigray and is one of the PSNP clients. He saysthat, “the safety net programme has saved our lives. Apartfrom the grain we get as payment, it has changed ourwork ethics. The implemented catchment treatment activitiesrecharge the ground and our degraded grazing landis saved from erosion and is rehabilitated. As a result, thevillage PSNP beneficiaries are able to develop open handdug wells for irrigation and grow vegetables for themarket and consumption. Income of PSNP families hasincreased from time to time from sale of vegetables andother livestock products”Gebre and his family depend on subsistence farmingand off-farm income as daily labour. As a result ofnatural resource activities, he and his neighboursDairy development ruralfamilies (Degua-tembienworeda)and health staffs in order to facilitate the effectivedelivery of information, education andcommunication (IEC) activities.REST/PSNP pursues nutrition and healthimprovements by integrating agriculture withIEC. Interventions target women and children(0-24 months) and <strong>focus</strong> on improving familydiets in terms of intake/consumption and quality/diversitythrough increased farmproduction, storage and processing of high valueand surplus crops. Food for work and food asincentive programmes are also key areas ofactivity. These make special provision forsupplementary food for children, as well asincreasing women's and community educationand knowledge to enhance mother and childhealth to bring about positive behaviour change.Measuring the impact of the PSNPEnvironmentalAnnually, it is estimated that Ethiopia losesover 1.5 billion tons of topsoil from the highlandsincluding Tigray, which is equal to a lossCommunal hand dug well(Wukro woreda)developed an open hand dug well for irrigation usingPSNP public works. From the other food securityprogrammes he has gained credit access for a motorpump and has planted tomatoes in his half hectare ofland and earned 7,000 birr income. He was then ableto lease another half hectare of land in the village andincrease his income to 15,000 birr. The change is seenin many aspects. He says, “In the first place we are ableto get income and adequate and variety food, we aredressing well and my children are attending school,and I am able to pay the credit.”Milk cooperativeEstablished in 2005, the members of the MilkCooperative have increased from 15 to 30. The averagemilk production capacity and profit is high asshown in Table 1.Gebre with hismotor pumpTable 1: Six month milk delivery and expenditure, 2009Month MilkdeliverylitresAveragerevenueBirrExpenditure formilk suppliesBirrEmploymentcostsBirrHomerentBirrNetprofitBirrJanuary 5398 40800 24291 500 600 15409February 5070 40800 22815 500 600 16885March 5070 40800 22815 500 600 16885April 6540 52700 29430 500 600 22170May 6300 52600 28350 500 600 23150Total 28,378 227,700 127,701 2,500 3,000 94,499

Field Articleof 1.5 million tons of grain to the country’sharvest. Soil erosion is a very serious threat tofood security and requires urgent managementin Tigray and the PSNP areas. Soil loss in thePSNP woredas was estimated at 42tons/hectare/year before the PSNP. Based onthe PSNP impact assessment (conducted by theWorld Bank), the average soil loss is now estimatedat 19.4 tons/hectare/annum. This meansthat the watersheds and treated land activitiesare saving the region an estimated 1.1 milliontons of soil per annum, and have the potentialto continue having such a positive impact.The planting and area closures that havebeen put in place also have the potential tocontribute significantly to carbon sequestration.There are likely to be local and global benefitsin terms of potential earnings from carbon credits,as well as reduced global warming as aresult of reduced green house gases.Asset ownershipResiliency grows in parallel with the accumulationof productive assets by integrating otherfood security packages into PSNP target households.This entails providing diverseagricultural inputs and technologies to assetless poor households in a manner that enablesthem to own motor pumps, livestock, money,built houses in nearby towns, and fruit trees toproduce more and diverse range of food cropsand livestock for consumption and for market.As a result, households are more confident intaking out additional loans to maximize theirincome. Current research studies indicate thatthere is no significant difference in oxen ownershipamong the households. This indicates thatmost households own oxen as the result ofincome increment and credit access form PSNPand other food security programmes.Nutritional statusIn 2008, REST carried out a nutrition survey 1 toidentify whether any changes in prevalence ofwasting, stunting or underweight had beenachieved in the PSNP programme areascompared to the baseline survey prevalenceidentified in 2005. The findings were alsocompared to the prevalence of wasting, stuntingand underweight in a non-PSNP (control)woreda (Hintalo wajirat). Table 2 presents someof the findings.The prevalence rates of wasting, stuntingand underweight were found to have reducedin 2008 from the baseline levels reported in2005, by 2.6%, 11.8% and 10.7% respectively.Table 2: Prevalence (%) of underweight,stunting and wasting among children 2005 to2008 and relative to non-REST PSNP*Indicators REST PSNP Non RESTPSNPBaseline2005% of children0-60 months thatare wasted(z [95% Confidence Interval]Gender -.0074053 .085988 -0.09 0.931 -.1759387 .1611281Age of mother .0002603 .0050509 0.05 0.959 -.0096394 .01016Family size .0382093 .0182387 2.09 0.036 ** .002462 .0739566PSNP beneficiary .2180809 .0648287 3.36 0.001*** .091019 .3451429Irrigation plot .1096148 .0857793 1.28 0.201 -.0585095 .2777391Duration of breast feeding .0110853 .0201191 0.55 0.582 -.0283474 .0505179Nutrition education -.3741028 .1689836 -2.21 0.027 ** -.7053046 -.042901Water availability -.0582521 .0645057 -0.90 0.366 -.1846809 .0681768Latrine availability -.0992738 .0790179 -1.26 0.100 -.2541461 .0555985Full vaccination -.1772792 .9174281 -0.19 0.847 -1.975405 1.620847Oxen per capita .0212997 .1831977 0.12 0.907 -.3377613 .3803607Cow per capita -.5413497 .1443165 -3.75 0.000*** -.8242049 -.2584946Shoat per capita -.1123467 .0482356 -2.33 0.020** -.2068868 -.0178066Literacy of mother -.1688753 .0675757 -2.50 0.012** -.3013212 -.0364295Note: ** = significant at p

Field Articleemployment opportunities for many of the resource poor farmers inthe project area and additional relief food assistance coming to thearea, further acting to stabilise the situation.Dietary diversityThe household dietary diversity score is a proxy indicator for socioeconomicstatus and the ability of households to access food.Household dietary diversity score is reflected in the number of differentfood groups consumed over a given reference period. To gauge thelevel of dietary diversity, sample households were asked about thenumber of different food groups consumed using a 24 hour recallperiod and a broader non-time bound question about numbers of foodsconsumed2. The results of the survey indicate that the overall meandietary diversity score in the REST PSNP project area is five. Thisimplies that, on average, households had consumed about five differentfood groups within the previous day indicating a 47% improvementagainst the baseline figure of 3%. The main factors contributing to theimprovement of the dietary diversity score are expanded and diversifiedproduction of crops and vegetables and expanded mainstreamingof health and nutrition education through the REST PSNP and otherFood Security Programmes over the last four years.Future challenges and opportunities in the REST PSNPworedasDroughtAlthough the PSNP has significantly improved household resilience toshocks in Tigray, drought and increasing market shocks(inflation/price increases) continue to threaten the livelihoods of thepoor. These can potentially undermine the assets developed bothunder the PSNP and with REST’s programmes more widely. Topreserve the PSNP results, additional efforts are required in waterharvesting and management and the provision of potable watersupplies both for humans and livestock. Drought and other shockscould also undermine the improvements seen in nutritional status ofchildren under five, particularly levels of wasting which are sensitiveto short term shocks.InflationThe increase in food prices is affecting food security, especially giventhat the majority of PSNP beneficiaries are net food purchasers(Tigray has the second highest food price inflation in Ethiopia).Although the PSNP transfers are assisting PSNP households to absorbthe food prices to a certain extent, additional shocks (drought, hail,flooding) are compounding factors. For direct support beneficiaries(the disabled, orphans, the elderly, people living with HIV/AIDS)who have no other sources of income, price increases and the reductionof food transfers in the programme from 10 to eight months couldhave a negative impact on this group.Lack of strong market intermediariesThe production of economic crops like vegetables, spices, and fruit isexpanding in rural communities, especially as access to irrigation waterthrough the public works is increasing. Lack of strong market intermediaries,however, in these rural and marginalised areas is creating adisincentive to production. Additional efforts are needed, therefore, tostrengthen the market environment by developing market infrastructure,market information dissemination systems, and strengtheningmarket intermediaries.PSNP graduationGraduation from PSNP needs special attention. To encourage householdto graduate and reduce risks associated with graduation,households who are in a good position to progress towards graduationshould get a food transfer for fewer months than other client groups.Health and nutritionUsing screening and nutrition surveys could help to highlight potentialareas that need special attention. In addition, nutrition survey onthe impact of PSNP could be used to design approaches to achievegreater impact on nutrition outcomes, particularly stunting.ConclusionThe roll out of the PSNP through which the most vulnerable householdsare guaranteed food resources has helped in maintainingand/or improving nutrition levels. This is complemented byincreases in confidence and aspirations by PSNP households evidentin their widened participation in food security packages that in turnhave enhanced the ability to cope with shocks.For further information, contact: Tesfay Desta, emailtdesta22@yahoo.comHailu Sitotaw, Ethiopia, 2010Maintaining GOAL’scapacity to supportsurveillance inEthiopiaMUAC measurement byGOAL Ethiopia NutritionSurvey Team, AbayaWoreda, Borena zone,Oromia regionEthiopia has suffered from numerous natural andman-made emergencies and continues to bevulnerable to rapid and slow onset emergencies.Since the major famine in 1984/85,considerable efforts have been made to install a credibleand effective early warning system (EWS) as part ofemergency preparedness to enable a timely disasterresponse. In line with improvements internationally inearly warning and emergency assessment tools, thegovernment of Ethiopia has increased its drive todevelop a more effective EWS. It has been supported bymany international agencies in this endeavour who, inturn, have made use of new methods such as theHousehold Economy Approach (HEA) and, morerecently, the Integrated Humanitarian PhaseClassification (IPC) system (introduced by USAID andFAO respectively). A new EWS has been established inEthiopia to classify woredas (districts) according to theextent of food insecurity using ‘hotspot’ monitoring (seearticles on DRMSS and on ENCU in this <strong>issue</strong> of FieldExchange).At the same time, the government’s <strong>focus</strong> on managingemergencies has also changed from the traditionaldisaster management approach to a more advanced andscientific ‘disaster risk management’ (DRM) approach.This emphasises ‘domestic knowledge and communitycapacity’ for prevention and mitigation of an impendingemergency. The DRM approach has enabled communitiesto play a leading role in related activities throughthe application of indigenous early warning knowledge.Thus, communities have a chance to share local solutionsfor local problems. Such indigenous practices aretaken account of in the EWS, which monitors anychanges to this normal behaviour and indicates whenemergency interventions may be needed.Background to GOALLike many international non-governmental organisations(INGOs), GOAL Ethiopia started nutritionprogramming in 1984 in response to the large scalefamine in the northern areas of the country. In 2003,following a large-scale food security crisis, GOALEthiopia expanded its operational presence to tworegions, namely SNNPR (Southern National andNationalities Peoples Region) and Oromia Region. Thisoperation supported eight large woredas to implementtherapeutic and supplementary feeding programmes forunder fives and pregnant and lactating mothers. GOALalso started working on recovery and developmentprogrammes in the areas of livelihoods, child survivaland development and in some areas, WASH (water,sanitation and hygiene) activities are being implemented.61

Field ArticleBy Zeine Muzeiyn and Ewnetu YohannesZeine Muzeiyn has been working in the area of Nutritionfor the last seven years. Before he joined GOAL Ethiopia, hehad been working in West Darfur, Sudan, as a nutritionprogramme manager for Concern Worldwide in IDP andRefuge camps. He has an extensive field experience in thearea of Nutrition. Currently he is a country nutritionprogramme coordinator for GOAL Ethiopia.Ewnetu Yohannes had a thirteen years experience in thearea of Nutrition, Health and Livelihood expert andworked in government and local NGOs. Since 2009, hehas been working as an Early Warning SystemDevelopment Officer for GOAL Ethiopia.Thanks goes to GOAL Ethiopia Senior survey coordinator who providedvaluable inputs.GOAL Ethiopia aims to respond to any emergency in Ethiopia(within its operational capacity) in a timely manner through its HRP(Humanitarian Response Programme), which has three arms: an EarlyWarning Department, a Survey and Assessment Department and anOperational Response Unit.Process and outcome indicators used in the EWSThe Government collects two types of early warning indicators toidentify hotspot woredas: process indictors and outcome indicators.Each hotspot woreda is divided into three types, priority 1, 2 and 3relating to the severity of the situation. A priority 1 woreda is the mostseverely affected, needing urgent humanitarian intervention whilstpriority 2 and 3 woredas, though needing assistance, do not requirethe scale of response needed in a priority 1 woreda. Typically, inPriority 2 woredas, strengthening existing aid interventions and closefollow up is recommended whereas in priority 3 woredas, closefollow up on the food security situation and other related aggravatingfactors may be needed.At the time of writing this article (Sept 2010), there were 335hotspot woredas flagged in Ethiopia. This represents a significantnumber of potentially needy woredas and highlights the ongoingneed for an effective EWS and response capacity.Government-led multi-agency teams go to pre-selected food insecureareas in each region to assess potential hotspot woredas;assessment timing is informed by seasonality. The criteria usedduring the assessment includes levels of acute malnutrition, foodsecurity situation, therapeutic feeding programme admissions, stressconditions and levels of migration among others (see Table 1). Theclassification process is carried out at the regional and reviewed atfederal level. Where necessary, overall prioritisation of the woredas isreviewed. For example, on the first assessment or hotspot classificationwhich categorises a woreda as priority 1, the situation may haveimproved to such an extent that it can be re-classified as priority 2 or3 according to the multi-agency assessment of the indicators.Examples of process indicators for estimating levels of food insecurityare sales of assets, unusual livestock death, increased schooldrop-out, consumption of wild foods, increased begging, increasedrequest for external assistance, and reduction of meals eaten daily.Most stress indicators are showing how a particular hazard affects thepopulation and the strategies they deploy to survive. Table 2 providesan overview of how these process indicators are classified accordingto a scale of 1-5, with 5 being the worst level of food insecurity andlivelihood erosion. Table 3 describes the indicators and associatedlivelihood impact. 1Outcome indicators reflect the magnitude of the shock on thoseaffected and are normally reflected through the deterioration of health1Source of Tables 1-4: Guidelines for Analysis and Identification of Areas of Concern(Hot Spots) for Effective Food Security Monitoring and Programme Decision Making, theEarly Warning Working Group (EWWG) chaired by the Disaster Risk management andFood Security Sector (DRMFSS) - Ministry of Agriculture and Rural Development(MoARD) - Federal democratic Republic of Ethiopia, September 2009.Table 1: Process indicators for hotspot monitoringWeather condition such as onset of rain, cessation time, number days with dry spells,occurrence of hailstorm, flood situation.Crop production and livestock condition such as dietary diversification, availability ofstaple foods, land preparation, land cultivated and covered by seed, condition ofharvest, agricultural inputs supply, herd size, pasture status, milk production/head/day.Market price such as major food crops price, livestock price, source of supply, terms oftrade between livestock (goat) and major food crop (maize), crop price duringharvest/dry season, price of livestock during harvesting/dry season.Socio-economic conditions such as migration, wages per day, other sources of income,coping capacity of the community.Table 2: Process indicators and associated severity scaleIndicatormeasures/assessedTable 3: Food insecurity indicator description and livelihood impactIndicators descriptionHighly Above Normal (HAN) (1).Indicator is above average or conditionsare improving (a very high positivechange, above average) (>=25%)Above Normal (AN) (2). Indicator isabove average or conditions areimproving (a positive change aboveaverage) (>10 to 25 /50%)Scale of MeasurementClass 1 Class 2 Class 3 Class 4 Class 5Livestock death None >0-≤2% ofherdsSchool drop-out≤5% ofstudents>5 - ≤10% ofstudents>2 - ≤10% ofherds>10 - ≤25% ofstudents>10 - ≤25% ofherds>25 - ≤50% ofstudents>25% ofherds>50% ofstudentsSales of productive None Moderate High Very high ExhaustedassetsIncreased sales of Normal Moderate High Very high Very highfirewood andcharcoalConsumption of No No No Yes YesseedsConsumption of None Sometimes Few days Most days All dayshealth threateningfoodsIncreased begging No No No Yes YesIncreased request forexternal assistanceSwitching inlivelihood protectionexpenditureNoneReduction of meals ≤5%reductionHH level destocking(commercial,slaughtering)≤5% ofhouseholds>5% - ≤10% ofhouseholdsNone Normal Few itemsswitched>5% - ≤15%reduction>15% - ≤30%reduction>10 - ≤20% ofhouseholdsSome itemsswitched>30% - ≤50%reduction>20% ofhouseholdsMost itemsswitched>50%reductionNone Normal High Very high MassiveImpact on livelihoodsLarge Improvement – (Risk: Minimal). Occurrenceof, or likely predicted event improving livelihoods.Stress Indicators: no impact, very huge, largepositive change from normal.Improving – (Moderate Risk: Hazard). Occurrence ofor likely predicted event improving livelihoods.Stress Indicators: no impact, large positive changefrom normal (small change).Improving or Small Change. Normal or very smallchange from normal conditions prevail. ProcessIndicators: small negative change from normal(moderate).Severe. Stress Indicator indicates very high abnormalconditions stressing livelihoods, with highvulnerability. Stress Indicators: large andcompounding negative changes.Very Severe: Stress indicator show alarmingproportions and leading to immediate impact onlivelihoods stress, with high vulnerability. StressIndicators: have immediate, large andcompounding negative changes.Table: 4 Outcome indicators: health and nutrition thresholds by severity scaleIndicatormeasures/assessedGlobal acutemalnutrition(GAM)prevalenceScale of MeasurementClass 1 Class 2 Class 3 Class 4

Field ArticleBox 1: Micro credit support case studes63A 65 year old man was noted using a plough andsowing seeds one month earlier than normal in avillage. At that time, the GOAL EW officers werecollecting the EWS data from the village and asked theman “why are you ploughing and sowing unusually earlyin the dry season when the rains are not due for anothermonth?” The old man replied, “you know my son, I aman old person and have grown up watching the ‘signs’ of‘good’ and ‘bad’ season in my village for a long time. Ifollow the wind direction at dry season. If it blows fromthe west-east direction, then I know the coming rainfallwill start early. When it blows from the east-west, the rainwill be late. This is why I have started to plough and sowmaize seed and wait the onset of early shower rain andand nutritional statuses of the affected community.The health and nutrition thresholdsapplied to for the indicators to define the extentof an emergency are outlined in Table 4.In most cases, the presence of diseaseoutbreaks, food insecurity and high rate ofacute malnutrition are the main driving forcefor implementing an assessment. Typically, theEarly Warning Department is alerted by thehealth sector when there is an unusual increasein acute malnutrition cases attending healthfacilities. Based on the information received,standardised nutrition surveys are conductedto assess the situation and make recommendationsfor possible nutrition intervention.GOAL’s Support to the EWSGOAL’s Early Warning Department collectsEW information through field based assessmentsundertaken by GOAL staff who workthrough the Government’s rural health extensionworkers (HEWs) and in response to rapidassessments undertaken by the Government’sENCU (Emergency Nutrition CoordinationUnit) that flag ‘hotspots’.The GOAL EW officers travel extensively atworeda level, collecting and screening earlywarning indicators and/or reports from thefield. In all areas, including GOAL’s RDP (RuralDevelopment Programme), GOAL uses routineinformation collection and triangulates it withGovernment and UN agency assessmentreports. If information concurrently indicatesthe deterioration of a situation to a Priority 1 orPriority 2 status, upon request by the ENCU, aGOAL nutrition survey and assessment team isdeployed to verify the severity of the situation.This involves a standardised nutrition surveyusing the SMART (standard measurement andassessment research tool) methodology.In addition, each month GOAL EWS focalpersons at regional level monitor and collectqualitative data from systematically selectedworedas and kebeles (a group of villages) usingkey informants. The key informants are madeup of 12-20 people who represent the communityand include woman, religious leaders’,youth and aged people with indigenous knowledge.They are involved in group discussionsundertaken every month at which they discussin depth any forewarning signs of changes insocial and economic trends in the village,disease outbreaks, increases in cases of acutemalnutrition, etc. An example of the benefits ofcapturing indigenous early warning informationis described in the case study in Box 1.After the monthly information is analyzedby the GOAL regional focal personnel, a reportis submitted to the GOAL Addis Ababa officeuse this opportunity to secure my food needs”. To verifythis indigenous knowledge, the GOAL EWS officerwent back one month later to monitor the status ofthe area ploughed and witnessed that this was theonly farm with green maize seedlings. Others had notstarted ploughing their land and missed the goodopportunity offered by the earlier ‘shower’ rains.Because of this evidence, the trend to plant earlierhas expanded to other villages with farmers practicingthis ‘indigenous early warning information and use the‘early’ shower rain to grow a fast growing local maizeseed called ‘yanase’. They also sow hybrid maize seedin normal rainfall time in the month of March.where quality assurance checks are in place.The data and report is then shared with theFederal level along with other similar partnersduring the monthly national EW meetings. TheFederal level triangulates this information andfinally shares it with the ENCU for action, ifneeded. On average, the whole process takesone month from information collection up tosharing the findings to partners and othergovernment offices.GOAL nutrition assessment capacityGOAL staff attends the EW coordination meetingsat federal level during which the list ofhotspot woredas is <strong>issue</strong>d. Agreement is thenreached on the agencies responsible for nutritionassessment of these woredas, with the aimof verifying whether the EWS data is reliable interms of detecting increases in prevalence’s ofglobal and severe acute malnutrition (GAMand SAM).GOAL Ethiopia maintains 21 staff at any onetime to support nutrition surveys. Each surveycosts approximately USD$ 8,500, whichincludes vehicle hire to carry out data gatheringand data analysis and dissemination. GOALcapacity in this area is funded by the US Officefor Disaster Assistance (OFDA) and ECHO(European Commission Humanitarian Office).In any month, GOAL has capacity to lead on upthree nutrition surveys depending on thecontext. In 2009, a total of nine nutritionsurveys were carried out in the country, ofwhich four were undertaken by GOAL inhotspot woredas. Three of these surveysshowed levels of acute malnutrition to be abovethe levels defined as an emergency in Ethiopia.Between January to June 2010, 12 nutritionsurveys have been carried out by GOALEthiopia of which three were conducted inpriority 1 hotspot woredas.Since GOAL is operational in many areas inEthiopia, it is often necessary to do base linesurvey, follow up survey and end line survey atdifferent times. Moreover, GOAL is oftenapproached by the Federal ENCU and FederalDisaster risk management and food securitysector (DRMFSS) to do nutrition survey forpartners and for regional ENCU consumption.To be able to conduct all of these surveys,GOAL Ethiopia found it necessary to increasethe quality and quantity of the survey team.GOAL plans to increase its capacity to carry outfour nutrition surveys in any one month byincreasing the nutrition team to 28.As well as collecting mortality and anthropometricdata during the nutrition surveys,data on health behaviour, recent sickness, childcare, market prices, migration and food securityHailu Sitotaw, Ethiopia, 2010are gathered. This data is used to guideprogrammatic intervention and/or to providethe relevant government entities with qualitativeinformation on food security and itsprospect.In lieu of the assessment findings and subsequentrecommendations, if GOAL has thecapacity and the authorisation to intervene inan unsupported woreda, it will do so in linewith recommendations made. Over the last 63months (from August 2005 to June 2010), GOALEthiopia has conducted 60 nutrition surveys (asmall number of which were on behalf of otherNGOs in collaboration with the ENCU) and hasintervened in approximately 95% of woreda’swith an identified need for management ofacute malnutrition.Focus on Capacity DevelopmentGOAL nutrition survey staff always carries outsurveys with government staff at woreda andregional levels and <strong>focus</strong> on building governmentcapacity in planning and conductingsurveys, analysing data and report writing.Moreover, as a part of sustainable capacitybuilding, one person from the GovernmentRegional Health Bureau takes an active role inanalysing and writing the draft survey report.GOAL also recognises the significance ofHEWs in collecting locally pertinent food securityand health/nutrition information on a dailybasis, which provides information for thegovernment when considering some form ofemergency intervention. In recognition of this,GOAL provides a two-day standardised nutritionsurvey training for HEW’s followed by apractical session before the commencement ofthe actual data collection. This training isprovided for any woreda where a nutritionsurvey is going to be conducted.Since food insecurity has a cyclical nature inEthiopia, the numbers of hotspot woredasvaries and the government demand forconducting nutrition surveys will also vary.GOAL has established a good reputation overtime within government for carrying out reliableand high quality surveys and therefore,demand for GOAL’s experience in this area ishigh. However, there is a limit to the directsupport that GOAL can or should undertake inthis regard. It is particularly important thatregional capacity is further developed to meetthe demand for nutrition surveys and EWSassessments over the long term. GOAL iscommitted to <strong>focus</strong>ing on capacity developmentin the ongoing programme of work inEthiopia.For more information, contact Zeine Muzeiyn,email: zeinem@goalethiopia.com and EwnetuYohannes, email: ewunetuy@goalethiopia.comHeight measurement by GOAL EthiopiaNutrition Survey Team, Abaya Woreda,Borena zone, Oromia region

Programme profileThe Evolution of Ethiopian Government’sEarly Warning System Dr Kassahun Bedada BeyiDr Kassahun Bedada Beyi is Early Warning and Response Case Team Coordinator with the EarlyWarning and Response Directorate. This is located within the Disaster Management and FoodSecurity Sector of the Ministry of Agriculture and Rural Development. He holds a BSc in PlantScience 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.Disaster Management structures andsystems have a relatively shorthistory in Ethiopia having evolvedafter the ‘great famine’ of 1973/74when the first government institution, theRelief and Rehabilitation Commission (RRC)was created. The RRC (subsequently called theDisaster Prevention and PreparednessCommission (DPPC)) had responsibility forproviding support to disaster affected populations,particularly for those affected by severedrought. Around this time, the need to developan early warning system (EWS) as a crucialcomponent of disaster management becomeapparent, as over a quarter of a million deathsin the central and northern highland areas ofthe country were reported. The lack of anational preparedness strategy and the absenceof an effective EWS revealed a pressing need toconcentrate and strengthen the government’scapacity to produce early warning informationon which to base its response to future emergencies.The birth of Ethiopia’s Early WarningSystemThe Ethiopian economy has largely beendependent on subsistence agricultural productionand any climatic abnormalities can have adirect effect on food production and ultimatelyon food availability. Therefore, food productionmonitoring became a key component of theEWS.The Ethiopian Health and NutritionResearch Institute (EHNRI), backed by the RRCtook a leading role in the 1970s in the evolutionof the EWS. A system known as the ‘DisasterArea Assessment’ was developed to assess thelevels of food insecurity among droughtaffected cropping and pastoral communities.The system had weaknesses, however, in that itdid not provide continuous monitoring data toinform decision making, though aspects of thissystem still form part of the national EWStoday.In 1975, an Inter-ministerial TechnicalWorking Group (TWG) was convened underthe auspices of the DPPC. The role of the TWGwas to advise on the technical aspects of astrengthened system that could provide morereliable and continuous food security and nutritiondata by which to assess the national foodand nutrition situation. Subsequently, in 1976,the TWG recommended that a permanentsystem be established to continuously collectinformation related to food and nutrition. Thiswould link with the activities of governmentagencies with mandated responsibilities forvarious aspects of agriculture and food production,including nutrition.The permanent reporting system was calledthe ‘Early Warning System (EWS)’ and emphasisedthe prediction of food shortages, todistinguish it from its more ad-hoc surveillancepredecessor. Rather than set up a new agency toexecute this new EWS, the TWG also recommendedthat the national EWS programme beimplemented collaboratively by of the followingagencies:• The Relief and Rehabilitation Commission• The National Meteorological ServiceAgency (NMA)• The Planning and Programming Departmentof the Ministry of Agriculture (MOA)• The Livestock and Meat Board of MOA• The EHNRIA key principle adhered to when the EWS wasofficially launched was that activities should beundertaken utilising existing government structuresand thereby maximising the use ofexisting resources. The DPPC is the agencyresponsible for monitoring the food situation inthe country and for taking appropriate measuresto mitigate these shortages and therefore,was given the mandate to coordinate the EWS.Other agencies were given the responsibility fordata collection.Preparatory activities, including the trainingand posting of the first DPPC field agents,arrangement for programme funding anddesign work occupied most of 1976. The newEWS programme was finally officially launchedin January 1977 and remained in place for eightyears until the establishment of the FoodInformation System (FIS) by the Food andAgricultural Organisation (FAO) in 1984.The EWS and FIS continued to be implementedsimultaneously until the collaborativeeffort could not be sustained and eventually, theFIS committee dissolved and the Early Warningand Planning Service at the DPPC (later changedto the Disaster Preparedness and PreventionAgency-DPPA with additional mandate) tookover the full operation of the FIS in 1985.The system was highly centralised in thatdata collection, analysis, interpretation andreport writing were carried out in the capital,Addis Ababa. Appeals for international reliefassistance, relief allocations and decisionsregarding relief interventions were communicatedfrom the central level. The role of localauthorities and communities in early warningand response was minimal.The DPPA, although responsible for theinterventions, had also been dependent onother line departments for the collection ofmost of the data needed for early warning. Atthe same time, these institutions were alsocarrying out their own early warning activitiesand there was considerable duplication ofefforts.The socio–political and economic changeadopted in the country, particularly after theratification of the new constitution in 1995, wasgeared towards decentralisation of power andresponsibility to the Regional States and adecentralised disaster management system.Emphasis was placed on the role of localcommunities for planning, implementation andevaluation of relief measures. In the process, theevolution of a new disaster management systemand the implementation of civil service reformbrought about major changes to the implementationof disaster management in the country.The establishment of the DisasterManagement and Food Security SectorIn 2008, the power and responsibility of theDPPA shifted to the Ministry of Agriculture andRural Development (MoARD) [now MOA].MoARD established the Disaster Managementand Food Security Sector (DRMFSS) comprisedof two directorates. One of the directorates, theEarly Warning and Response Directorate(EWRD), is today responsible for collection,analysis and dissemination of early warninginformation on all disasters that impact on foodsecurity.The current systemThe EWRD collects early warning information ona regular basis from the District (woreda) level innine Regional States and one administrativecouncil. The EWRD also works with the government’sEmergency Nutrition Coordination Unit(ENCU), which is a unit of the EWRD and has awider mandate to quality control all nutritionstudies in the country (see article on the ENCU inthis <strong>issue</strong> of Field Exchange).Examples of the types of early warning indicatorscollected include:• The occurrence of extreme conditions (hailstorms, unseasonal rainfall, extremetemperature)• Ploughed and cultivated land available• Supply and distribution of agriculturalinputs, e.g. fertiliser• Crop condition and production prospects• Disease and pest outbreaks affecting cropsand livestock• Supply of feed and water for livestock• Sudden movement of livestock• Nutrition status of the population,particularly in pastoral areas, and with theappearance of increased incidence or ‘hotspots’• Emergence of conflicts• Spread of human diseases64

Programme ProfileThe Regional States each have their own DisasterManagement Bureau. Within these, Regional EarlyWarning Officers are based. Early Warning Officesalso exist at woreda level. In four states (Tigray,Amhara, Oromia and SNNPR) they are well established.In pastoral woredas in Somalie, Afar,Gambela, Benshangul-gumz regional states, they arenot fully established.The Early Warning Officers are responsible for thecollection of information from the grass roots level.Originally, the system was designed so that woredalevel officers, upon receiving information from thegrass roots level, would compile and analyse theinformation. This information is then transferred tothe zone and regional offices and also to the federalEWRD electronically. However, the internet system isnot yet functional so information is collected usingtelephone communication from the Zonal DisasterManagement Offices. Information from zonal andworeda level is compiled and analysed together withadditional information collected from line ministriesand other information sources, notably the NMA.The early warning information is disseminated on aregular basis through a monthly Early Warning andResponse Bulletin prepared in the national workinglanguage (Amharic) and more recently in English. Thisis distributed to regional states and different stakeholdersin Addis Ababa. The Bulletin contains detailedinformation on rainfall patterns, crop and livestockconditions, terms of trade (shoat to maize), food prices,water availability, nutrition survey data, nutritionprogramme coverage and relief pledges (food andnon-food items) by region. It also includes informationon funding shortfalls by sector (food, nutrition, waterand sanitation, education etc) and contains a summaryof the key findings from the EWS data.The regional states are expected to duplicate theEW information and distribute it within their region.Woreda offices are also expected to duplicate theinformation and distribute it to community farmer’straining centres where farmers gather to exchangeinformation with development agents and with eachother.Utilisation of the EWSThe government’s EWS has evolved considerablyover the years from an ad-hoc surveillance system inthe 1970s that <strong>focus</strong>ed on drought affected areas, to ahighly centralised system in the 1980s which, thoughmore effective did not involve affected communitiesin decision making, to today’s system, which ishighly decentralised. The current system utilises localknowledge and information at the grass roots leveland has a bi-directional dissemination process ofearly warning information. Today’s system also integratesnutrition information, pastoral as well ascropping area information, and is linked to monitoringprogrammatic response capacity.It can be said that the EWS is becoming successfulas the demand for EWS related information isincreasing, the range of stakeholders to which EWSinformation is disseminated is growing and informationcontained in the EWS bulletins is in greaterdemand. The development of a woreda-net internetinfrastructure will increase the speed and transmissionof EW information from the grass roots. Inaddition, the EWRD is working to include satelliteinformation in the EWS to monitor the food productioncondition in all areas and to predict the likelyoccurrence of disasters ahead of time more effectively.For more information, contact: Dr Kassahun Bedada,email: kenushe50@yahoo.comCRS, Ethiopia, 2008Field ArticleJoint Emergency Operation PlanNGO response to emergencyfood needs in EthiopiaBy Alix CarterA scene from Karsa woreda, EastHararghe Zone, Oromia RegionAlix Carter has worked in the humanitarian sector in Ethiopia for almost threeyears. She is currently working as the Humanitarian Accountability Advisor atCARE Ethiopia, supporting with emergency programmes in sectors of nutrition,WASH, agriculture/livelihood, food aid, humanitarian reform, and climate changeadaptation/disaster risk reduction.Many thanks to all the Joint Emergency Operation Plan (JEOP) partners - CRS (JEOP lead agency),CARE, World Vision, FHE, Save the Children US, Save the Children UK, and REST - for their time andeffort provided through information and interviews with key staff members responsible forimplementing and managing JEOP.Emergency food relief continues to be a recurrent need in Ethiopiasince the Ethiopian famine of the 1980s, which was so severe thatit demanded global attention and response. Institutional donorsand non-governmental organisations (NGO) have been respondingwith emergency food relief during crisis years for decades to alleviatehunger. Massive food shortages resulting from severe drought plague thecountry and drastically hinder production in this predominantly rain fedagricultural economy with 83% of livelihoods in the agriculture sector 1 .The Government of Ethiopia recognised that a system to prepare proactivelyfor cycles of drought while addressing chronic food insecurity wasrequired to protect its citizens. It responded in 2005 by creating one of thelargest safety net programmes in Africa – the Productive Safety NetProgramme (PSNP) 2 (see article in this <strong>issue</strong> of Field Exchange by MatthewHobson.Despite the positive impact of PSNP, the need for emergency food aidduring times of acute food insecurity and shock still persists, as theresources in PSNP are not enough to address all vulnerable populationsand mitigate acute food insecurity. The US Government reports that 25million people in Ethiopia go hungry every year, the most chronically foodinsecure being children under five years and women 3 . The Government ofEthiopia’s humanitarian appeal of January 2010 identified 5.2 millionpeople in need of humanitarian food relief assistance across the countrythis year. 4 Emergency food aid programmes administered jointly by theGovernment, World Food Programme (WFP) and NGOs remain essentialto meet the food needs of Ethiopians and control malnutrition and deathsresulting from hunger. This article discusses one such programme, theJoint Emergency Operation Plan (JEOP) – a consortium food reliefprogramme implemented by seven NGO partners. Implementation byNGOs of this type of programme is rare, as large scale emergency food aidprogrammes are usually implemented through WFP channels in othercountries. However, through collaborative partnership and continuedfunding from the United States Agency for International Development(USAID) Food for Peace Programme (FFP), NGO partners Catholic ReliefServices (CRS), Save the Children (SC) US and UK, CARE Ethiopia, WorldVision, Food for the Hungry Ethiopia (FHE), and Relief Society of Tigray(REST) are playing an active role in addressing emergency food needsacross Ethiopia for almost two million people per distribution (round).1US Government, Feed the Future, 20102Hoddinott, J. IFPRI, 20103US Government, Feed the Future, 20104Government of Ethiopia, Humanitarian Requirements Document, January 201065

History and significance of JEOPJEOP has existed in different forms since 1984.It began life as the Churches’ Drought ActionAfrica /Ethiopia (CDAA/E), a faith basedconsortium of CRS, Lutheran World Federation(LWF), Ethiopian Catholic Secretariat (ECS) andEthiopian Evangelical Church Mekane Yesus(EECMY). CDAA/E was initiated in responseto the famine of 1984 when LWF extended aninvitation to other relief and developmentagencies for a joint Catholic-Protestant appealfor Africa. Agencies recognised that the magnitudeof the need was too large for any oneagency to handle alone and joint action wouldyield greater response and impact. Due to theseverity of the crisis in Ethiopia, lobbyingefforts for funds and food were heavily <strong>focus</strong>edon Ethiopia and a partnership dedicated to thecountry was formed. The partnership and itsname evolved to become Joint ReliefPartnership (JRP) in 1986 with CRS in charge ofthe coordination and logistics, like it is today. 5The partnership was reactivated in 2000 underits current form, JEOP, with five members (CRS,SC-US, WV, FHE, CARE). CRS is the leadagency. In later years, REST and SC-UK alsojoined. 6 All partners are or have been USAIDcooperating sponsors, but it has shifted frombeing a faith based partnership to one whichincludes secular agencies as well.JEOP remains dormant in non crisis years. Itis activated, in close collaboration with theGovernment of Ethiopia, when chronic foodinsecurity is exacerbated by emergency shocks,requiring additional coverage and emergencyfood relief. As a result of a decade of recurrentshocks, JEOP has been operational seven of thelast ten years, providing a significant portion ofthe emergency food needs for the country (seeFigure 1).The current JEOP was activated in August2008 to respond to the Government’s DisasterRisk Management and Food Security Sector(DRMFSS) request for emergency food assistance.This followed extended drought earlierin the year leading to massive food productionshortages and rising food prices. Lane Bunkers,Country Representative of CRS, describes JEOPas “A historically significant NGO consortium witha ten-year track record of responding to emergencyfood needs in Ethiopia. Working in close collaborationwith the Government of Ethiopia, the WorldFood Programme, and international donors, JEOPmembers play a critical role in reducing food insecurityand protecting investments made throughlong-term development projects such as theProductive Safety Net Programme and others.”USAID/FFP recently approved an‘Extended JEOP’ that will continue through2012. Extended JEOP includes new monitoringand evaluation activities, a standardised jointagency Early Warning System, and capacitybuilding for partners. These components areintended to improve programme accountabilityand expand JEOP’s function as a risk assessmentand preparedness mechanism, in additionto its regular mandate of providing emergencyfood relief. The significance and aspirations ofthese new programmatic aspects are discussedfurther below.Programme design and implementationThe JEOP of 2008 was designed with theprimary objective of saving human lives andprotecting livelihoods through the distribution offood to targeted drought-affected populations. Morespecifically, the programme planned to addressthe immediate food security needs of droughtaffectedpopulations, prevent further depletionof household assets, and reduce distress migrationof an affected population 7 .As the lead agency, CRS is responsible to callforward hundreds of thousands of metric tonsof grains, blended foods, pulses, and oilcommodities. The agency then oversees thelogistics process from shipment at the port ofDjibouti until commodities are transported tofour primary warehouses placed in differentstrategic locations of the country. Each of thepartners is responsible for collecting their shareof the commodities and arranging secondarytransport for delivery to their respective distributionsites across the country.JEOP food distribution is conducted inrounds during which NGO partners distributerations to targeted households. Distribution offood to the 1.8 million (on average) beneficiariesper round is directly conducted by each ofthe partner agencies, or in some cases throughtheir local partner agencies on the ground.Implementation of the programme requiresvery close collaboration with the Governmentat all levels, starting with the federal DRMFSSstructure all the way down to regional, zonaland district level authorities. While NGOs areprimarily responsible for handling and distributingcommodities, the allocation of food toeach district and targeting of individual beneficiariesis processed through Governmentchannels. Due to the nature of the aid system inEthiopia, NGOs must refer to the Governmentfor all allocations of emergency food reliefbased on figures from the HumanitarianRequirements Document, the official appealmechanism of the Ethiopian Government.These appeal figures are based on the assessmentresults of a joint multi-agency assessmentteam that conducts surveys at least twice a yearto determine humanitarian needs in both foodand non food sectors.JEOP rations are equivalent to the WorldHeath Organisation standard of 2,100 kcalintake per day (see Table 1 for a breakdown ofJEOP rations). Rations for each household areprovided at local distribution sites based onhousehold size. The federal Government, CRS,WFP, and USAID convene before each roundfor a prioritisation meeting to determine foodallocations for each target region and zone. Alist of priority woredas 8 and kebeles 9 for theround based on the severity of the food shortageand the availability of resources to respondis drawn up. A woreda level food aid task forcecomprised of officials from Government lineoffices of rural agriculture and development,administration, health, and education is incharge of identifying the most vulnerablehouseholds to receive food rations. This processof selection is challenging and at times theworeda allocation provided by the federalGovernment is not enough to meet local needs.At the most local level, a kebele task force oflocal officials, elders, religious leaders, developmentagents, and NGO staff overseedistribution at the site to ensure that the identifiedhouseholds receive their rations.Programme impact and successThe JEOP consortium was responsible for onethird of all emergency food relief in Ethiopiabetween August 2008 and June 2010. Duringthis period, the programme provided 14 roundsTable 1: JEOP ration breakdown, 2010Energy basedcereals (Wheat)Proteinsupplement(Corn SoyaBlend)Pulses (Yellowsplit pea)Vegetable OilField ArticleFigure 1: Total emergency food needs andJEOP contributionBeneficiaries (millions)1412108642020032004200520062008Beneficiaries served by JEOP15 kg/person/month for all droughtaffected people4.5 kg/person/month for 35% ofbeneficiaries considered mostvulnerable (children under five yearsand pregnant and lactating women)1.5 kg/ person /month for all droughtaffected people0.45 kg/person /month for all droughtaffected peopleCase study 1: Ato Abera Yimam’s story2009Ato Abera Yimam, 50 years, lives in Tenta woredawith his wife and seven children. Ato Abera andhis family faced complete crop failure due to thelong drought period. Without any other sources ofincome, his family members were on the verge ofdeath before they became beneficiaries of JEOP,through World Vision. “I was scared that my childwould die…. The programme is a life saver and atrue helper of the vulnerable and the poor. Had itnot been here, I would have lost my family or theywould have lost me.” Of course, Abera is just one ofmillions of people with similar stories of hardshipwhom JEOP has addressed over the last two years.of food relief amounting to almost 500,000 MTof food and reaching over 1.8 million beneficiarieson average each round. In interviews witheach agency and through review of programmedocuments, the impact and success of theprogramme are clear. Key strengths andachievements of JEOP are identified as follows:A lifeline for vulnerable householdsJEOP is meeting its primary mandate to savehuman lives. The most food-deficient householdsare selected using a combination ofassessment mechanisms provided by the partnersand the Government. Households targetedunder JEOP are receiving timely foodcommodities that are acting as a lifeline forthese families. This is expressed through countlessinterviews with beneficiaries undertakenby each of the partners (see case study 1).5Solberg, R. A Miracle in Ethiopia, 19916In 2009 CRS also included other international organizationincluding Samaritan’s Purse, GOAL, and the former JointRelief Partnership member’s Ethiopian Orthodox Church(EOC) and Ethiopian Evangelical Church Mekane Yesus(EECMY). However, these agencies are not currentimplementers of JEOP.7CRS, Fiscal Year 2009 Annual Report, October 20098A woreda is an administrative division of Ethiopia (managedby a local government), equivalent to a district.9A kebele is the smallest administrative unit of Ethiopiasimilar to a ward, a neighbourhood or a localised anddelimited group of people. It is part of a woreda, ordistrict, itself part of a zone, grouped into ethno-linguisticregional zones.66

CARE Ethioia JEOP field staff at adistribution site in Chiro Woreda,West Hararghe Zone, OromiaRegionProtects household assetsBeneficiaries often emphasize the programme’ssupport with regards to the protection of essentialhousehold assets, such as livestock oragricultural equipment. Without assets, afamily’s chances of escaping the cycle of foodinsecurity and vulnerability, is further threatened.Keeps families together and children inschoolMigration to urban areas in search of dailylabour is another common coping mechanismfor farming households in times of crisis. Thisboth separates families, with males migratingand leaving the burden of all domestic dutieson the females, and prevents farmers fromworking on their farms for the next harvest,thus perpetuating the cycle of food insecurity.Fitsum Wineh, 48, a REST beneficiary in DebreTembien woreda of Tigray Region stated,“Without this food, my family members would havebeen at serious risk, and my husband would havehad to leave to search for food for the family. Hestayed home with his family and was given theopportunity to preserve improved seeds from beingeaten and produce subsistence food for the household”she added. “It prevented the family fromdisintegration.”A particularly moving example is providedby CARE Ethiopia from its JEOP operationaldistrict in West Hararghe Zone of OromiaRegion (see case study 2). Another examplecomes from SC-US from amongst communitymembers in Cheretie woreda of Somali Region.Here, 846 people were about to be displaced toa refugee centre due to a lack of food beforeJEOP intervened. The support enabled thesehouseholds to stay in their community. Cheretieis now being covered by PSNP.Strong accountability of partnersSince NGOs directly administer and implementthis programme, the accountability requirementsare very high – every sack of foodreceived into the programme must beaccounted for to USAID. The accountabilityrequirements for NGOs are especially stringentand JEOP partners closely monitor the foodcommodities through all stages until they reachthe beneficiaries. Partners provide full transparencyfor Government counterparts throughclose collaboration on the ground duringtargeting and distribution. All JEOP partnershave a strong reputation for meeting internationaland national humanitarian standardsand providing quality services while adheringto both donor and Government regulations.They have a long standing presence in thecountry during which they have developedgood capacity to manage effectively food reliefprogrammes. All agencies have positive workingrelationships with the Government,enabling efficient and well coordinatedresponses.CRS, Ethiopia, 2009Field ArticleFlexible and complementary to otherdevelopment and safety net programmesJEOP targets food insecure households that arenot covered though the PSNP. It thus providesa complementary intervention to prevent acutefood shortages from depleting overall communityprogress gained through PSNP. JEOP seeksto protect the large investment of donors, likeUSAID, in the PSNP and other long term developmentprogrammes. The extended JEOPincludes new elements designed to counterpotential increases in need with morepredictable and timely response to addressneeds at the most critical time - between theneeds identification and actual food delivery.JEOP is flexible and has the ability to expand toall areas of the country as needed. If the implementingpartners are not operational in aspecific area of need, CRS arranges sub-grantswith other partners in order to reach the mostvulnerable populations.Challenges and lessons learnedWhile the programme has managed successfullyto meet its objectives and the partnershiphas been described as positive by all of theimplementing agencies, there are certain challenges.Delays and changes in allocation of food aidfigures to partner agencies represent one of themajor problems faced by the programme. Therehave been different situations in which the foodcould not be released locally until the finalfigures for the round were communicated fromthe central federal level and reached theworeda. Or, an agency would be ready todistribute food in an area only to find out thatthe area was no longer included in the round.Communication and capacity gaps between orat different levels of Government are part of theproblem. The JEOP programme is very flexiblein responding to the Government’s repeatedrequests to make adjustments to the plan, suchas inclusion or exclusion of woredas and fluctuationsof beneficiary numbers which are oftenrequired due to changing needs and priorities.However, these delays and readjustments toCase study 2: Tatuk Istala’s storySince becoming orphaned ten years ago, TatukIshtala, 25 years (see picture), has cared for his sixyounger siblings on a daily labourer incomeequivalent to one US dollar per day. The familyonly had enough to eat once a day, if they ate atall. “Before we received this food, all of my siblingshad dropped out of school. Now, all of my brothersand sisters, except one, are attending school. This isbecause of JEOP,” Tatuk stated, “I am illiterate and Idon’t need my siblings to be the same. I want them tofinish school and make an achievement.”Tatuk Istala, aJEOP beneficiary.Chiro, WestHararghe Zone,Oromia RegionCRS, Ethiopia, 2009figures impact the most needy as they areforced to wait until partners are permitted todistribute food. JEOP partners are striving toreduce these problems in future rounds.The arrival of huge shipments of commoditiesto ports and warehouses in a very shorttime frame create congestion and difficulty forpartners to secure enough space for theircommodity storage, especially as most agenciesare also storing PSNP food. In addition, secondarytransport to distribution sites proveddifficult for some JEOP partners, due to alimited number of reliable transportationvendors and price fluctuations resulting fromhigh demand and competition. These are regularchallenges faced by large scale commoditybased programmes and different strategieshave been used to overcome these problems.A way forward: the future of JEOPIn the Extended JEOP, partner agencies areconsidering options for a pooled transportsystem that could circumvent these logistical<strong>issue</strong>s in the future.In light of the programme challenges, agenciesemphasize the immense benefits ofpartnership. Through monthly meetings andregular communication, the seven JEOPmembers are able to share their experiences andchallenges with one another to develop solutionscollectively. Through combining theefforts and experience of all its partners, JEOPachieves a critical mass of capacity to providefood relief to millions.Extended JEOP is currently underway andwill run through 2012. Food allocation will stillbe based on the humanitarian needs. This JEOPphase seeks to provide more flexible and timelyassistance to all affected Ethiopians through atwo year guarantee of continued funding fromUSAID. This enables long term strategic planningand a new fund management structure ofa core team of experienced staff headed by aChief of Party directly responsible for JEOP.Key highlights of the Extended JEOP include anew Monitoring and Evaluation system toimprove programme quality and accountability,a joint Early Warning system which willstandardise the data collected from each agencyto support national early warning efforts, andcloser integration with nutrition and developmentinitiatives, like PSNP, to enhance overallcoordination between sectors and programmes.Collective lessons learned with regard tologistics and coordination are also addressed inthe Extended JEOP to avoid bottle necks andprovide assistance to vulnerable people in amore efficient and reliable manner. JEOP isstriving to move beyond food response byexamining emergency response more broadlyand seeking additional resources in order tomake linkages with other programming efforts,particularly in nutrition and livelihood protection.Partners recognise that different strategiesand innovations are required if Ethiopia is tomove beyond food aid response. The ExtendedJEOP signifies a positive step towards bridgingthe gap between disaster preparedness andreduction and emergency response.For more information, contact: Alix Carter,Humanitarian Accountability Advisor, CAREEthiopia, email: acarter@care.org.etand Lane Bunkers, Country Director, CatholicRelief Services (JEOP Lead Agency),email: lbunkers@et.earo.crs.org67

Field ArticleBy Emily MatesCRS, Ethiopia, 2009Emily Mates is a public healthprofessional with a <strong>focus</strong> innutrition. She recently left ConcernWorldwide, Ethiopia where sheworked for many years inemergency and developmenthealth and nutrition programmingThe author would like to thank the Ministry of Healthin Ethiopia, who so often showed impressivecommitment for a new service that added to theiralready heavy workload. With thanks also to the staffof CONCERN; a privilege to work with a great team,where no task was too much nor distance too far totravel in the pursuit of supporting quality services formalnutrition.CONCERN is especially grateful to OFDA for thegenerous support (both financial and otherwise)that enabled the N-CMAM programme to happen.SNNPR MoH team on experience exchange in Tigray regionIntegrating OTP into routine health servicesCONCERN’s experiencesThis article describes the history of aninternational non-governmental organisation(INGO)-implementedprogramme that evolved from an innovativeemergency intervention into alonger-term initiative, to support the Ministryof Health (MoH) to integrate treatment servicesfor Severe Acute Malnutrition (SAM) within theroutine health system. The article describes thecommunity-based management of acutemalnutrition (CMAM) approach, a timeline ofCMAM programming in Ethiopia andCONCERN’s national CMAM (N-CMAM)programme and a description of the N-CMAMprogramme goal, activities and programmeresults. It concludes with a discussion of keyfactors contributing to the enabling environmentand analysis of challenges, lessonslearned and programme limitations.The approachThe N-CMAM programme was implementedusing a partnership approach, with the <strong>focus</strong>firmly on ‘ownership’ by the MoH. The aimwas for the programme to establish a muchneeded service during ‘normal’ times and toprovide a base of capacity from which servicescould be rapidly scaled-up at times of crisis.The programme provided a package of ‘minimalsupport’ to the MoH, which consisted oftraining (set-up, on-the-job and training-oftrainers(ToT)), joint supervision, workshops,experience sharing visits and communitymobilisation support. The programme emphasisedlearning and innovation, in order toregularly refine and adapt the approach. Theprogramme also provided considerablesupport to CONCERN’s emergency nutritioninterventions.While the minimal support package wasimportant, the most crucial aspect of theprogramme was the nature of the dialoguebetween the partners. CONCERN attempted tofind the right balance between providing thesupport that was required and ensuring that theMoH were in the ‘driving-seat’ at all times. Inthis way a strong partnership developed, withall levels of the MoH steadily gaining confidencein their ability to offer quality CMAMservices. When the food crisis of 2008 developedacross much of the country, the MoH(with support from UNICEF and partners) wereable to rapidly scale-up decentralised CMAMservices through the national TherapeuticFeeding Programme (TFP) ‘roll-out’ and implementthe required policy changes. To date,approximately 50% of health facilities are offeringCMAM services, a huge achievement acrossa vast country.CMAM/TFP in EthiopiaCMAM programming is the internationallyrecommended way of treating severe acutemalnutrition (SAM). 1 In Ethiopia, the nationalTFP (Therapeutic Feeding Programme) roll-outis being implemented using the CMAMapproach,as such the terms CMAM and TFPare often used interchangeably (see Box 1).CMAM/TFP combines in-patient and outpatientcare for children (6-59 months) sufferingfrom SAM (mid upper arm circumference(MUAC)

Field ArticleTable 1: Key events timeline in Ethiopia2000 First CTC/CMAM piloted in Ethiopia (Wolayita and Hadiya Zone, SNNP Region), Valid International withCONCERN and Oxfam.2003 CTC/CMAM Research programme, Valid International/CONCERN, South Wollo Zone, Amhara Region –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 theCMAM approach, but coverage of services was low and only in certain areas. MoH-led evaluation of theemergency response identified an urgent need for rapid scale-up of SAM services.2004 First national guidelines for the management of SAM introduced, <strong>focus</strong>ed on in-patient treatment.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%. 32005/6 HSDP-3 launched. Roll-out of Health Services Extension Package (HSEP) to be implemented through acadre of 35,000 female community-based Health Extension Workers (HEWs).2005 -2007 Relative period of food security across most of the country, although pockets of malnutrition remained.Screening figures from the new EOS programme (2004 onwards) highlighted very high levels of endemicacute malnutrition. 4March 2007February2008April 2008MoH endorsement of the revised national SAM guidelines, including extensive description of OTP andcommunity mobilisation.Ethiopia co-hosts the launch of Lancet series on Maternal and Child Undernutrition. The National NutritionProgramme (NNP) for Ethiopia also launched 5 , both events providing evidence of the changing policy environment;with nutrition emerging from relative obscurity to the forefront of the policy agenda, at bothnational and international level.Attendance of State Minister of Health at international CMAM conference in Washington DC. This was animportant event because Ethiopia’s leading role in the continuing history of CMAM development wasreiterated, particularly with regard to government-led programming.2008/9 Food crisis developed across many areas of the country. OTP services rapidly decentralised down to healthpost (village) level across the four main regions of the country. 6Origins of the ‘partnership’ approachMany NGOs responding to emergency situationsfrom 2003 to 2005 using the CMAMapproach had highly successful programmes.However, frustration arose when NGOsattempted to ‘hand over’ to the MoH once theacute emergency phase was over. Attempts toachieve full transition to MoH-led serviceprovision appeared to fail. This was most likelydue to the nature of emergency programming,where substantial inputs were required torapidly scale-up response to a deterioratingsituation. Emergency programming necessarilytook on a vertical approach, as it required cars,staff, stores, supplies, etc, in order to reach theobjectives of ‘saving lives’ in a timely fashion.After the peak emergency period was over,while capacity would certainly have been builtwithin the MoH through trainings, skill development,etc, the vertical nature ofprogramming generally meant that the MoHwere not the lead partner, or driver of theresponse. It was then often challenging for theMoH (in a resource-constrained environment)to assume responsibility for a programmewhich had not been ‘theirs’ in the first place.Box 2: Outline of the National NutritionProgramme (NNP)The objective of this programme is better harmonisationand coordination of various approaches tomanage and prevent malnutrition. The NNP aims toreduce the levels of stunting, wasting, underweightand low-birth-weight infants, thus contributing toEthiopia’s efforts to reach the relevant MillenniumDevelopment Goal (MDG) indicators by 2015. TheNNP consists of two main components:a) ‘Supporting Service Delivery’ which includes‘increased access for the management of SAM.’b) ‘Institutional Strengthening and CapacityBuilding’.The development of the NNP should be considereda major achievement for Ethiopia, as the countryendeavours to tackle its long-standing problemswith malnutrition. Rigorous evaluation of the NNPwill be essential, to maximise the learning from thisinitiative.The reaction to this frustration was to devisea new strategy of using a partnership approach.This involved establishing CMAM services(particularly OTP) in ‘non-emergency’ timeswith the <strong>focus</strong> firmly on ‘ownership’ by theMoH, i.e. looking at involving the MoH inlonger-term programming from the start. It wasenvisaged that this would not only establish amuch needed service during ‘normal’ times,but would also provide a capacity base fromwhich services could be rapidly scaled-up attimes of food crisis. Programming that viewedsustainability as the primary objective necessarilyrequired that the thinking move away fromtraditional emergency dominated approaches,to one of partnership. In doing so, the nature ofthe dialogue between the partners was the mostcrucial element in defining the relationshipdynamics that in turn determined programmesuccess/failure. N-CMAM developed partnershipswith:• The MoH. Formal ‘Memoranda ofUnderstanding' (MoU) were regularlysigned between the MoH/Regional HealthBureau (RHB) and CONCERN in the fourmain regions. These MoUs proved to bevery important documents, as they transparentlyoutlined roles, responsibilities andexpectations of each of the partners. Inparticular, they described CONCERN’s roleas that of technical assistance, rather thanthat of direct implementation. The MoUsalso directed the expansion of serviceswithin the regions according to the needsand interests of the MoH.• UNICEF. UNICEF is mandated to supportgovernment health services for managementof SAM. They have acted as centralisedReady to Use Therapeutic Food (RUTF)procurers and suppliers to the RHBs.• Valid International. As the originator ofCMAM (originally Community TherapeuticCare (CTC)) approach and long standingtechnical partner of CONCERN. Co-founderof the N-CMAM programme.• Other NGOs. Through coordination fora,provision of training and support forCMAM-related activities, on request.This partnership approach was in line withCONCERN’s global strategy, which reflects amove away from direct implementationtowards working through local partners (for N-CMAM, the lead partner being the MoH).Ownership, Commitment, Integration =SustainabilitySeveral words can be used to describe processesassociated with sustainability: integration,ownership, commitment, all of which can behard to define and are prone to subjectivity. It isimportant to note that these terms often meandifferent things to different people in differentcontexts. Children suffering from SAM is anemotive subject, undoubtedly due to the elevatedendemic levels seen in countries such as Ethiopia,and its associated high mortality rate if leftuntreated (or poorly treated). As a result, viewson the most appropriate strategies for treatmentand acceptable standards of programme qualitycan be somewhat contentious.The term ‘ownership’ became something of amantra for the N-CMAM programme, with theunderstanding that “ownership equals internalisation,i.e. is self-maintaining”. 2 Experiencehas also identified that the term ‘commitment’is often the single most important element thatdetermines whether OTP services can besuccessfully established, and whether they willcontinue on or not. However, even if commitmentis high at OTP service delivery level(health centre or health post), each part of thehealth system has to be functioning on the mostbasic level, in order for the service to be successful.For example, if the logistic system is poorlyfunctioning resulting in RUTF stock-outs, theOTP service will collapse; ‘no product, noprogramme’ describes it well. So commitment/ownership,while the key element, is notenough on its own. It is important to note thatthis is not unique to SAM programming. Theattempted integration of a new health/nutritioninitiatives into routine health deliveryrequire that the system is functioning at least atmoderate level, in order to succeed.Table 1 summarises the timeline of keyevents in the evolution of acute malnutritionmanagement in Ethiopia. Table 2 summarisesthe timeline in N-CMAM development.N-CMAM Programme GoalThe goal of the N-CMAM programme is toreduce morbidity and mortality associated withSAM in Ethiopia, through supporting the MoHto scale-up quality CMAM services (particularlyOTP) within the routine health deliverysystem; that continues to function over thelonger-term and can therefore be rapidlyexpanded during times of food insecurity.N-CMAM activities and the ‘minimalsupport’ packageIn addition to the support given to CONCERNsemergency interventions (see Box 3), the N-2Handy, C. Understanding Organisations (4th Ed) 1999.Penguin.3Ethiopian DHS 20054While the quality of EOS screening figures was not assured,it was the first time that screening for malnutrition hadbeen conducted at-scale; the very high absolute numbersof children

Field ArticleTable 2: N-CMAM programme timelineJuly 2005Oct 2005Grant awarded from the US Office for Disaster Assistance (OFDA) to pilot an integrated partnership approachwith the MoH for scale-up of SAM services. Grant to CONCERN, sub-grant to Valid International – projectimplemented together in light of synergistic relationship. Valid providing the ideas/innovation, CONCERNproviding the historical base and well-established systems that allowed for programming in Ethiopia. Theprogramme was implemented jointly for two years, after which CONCERN continued alone.Meeting with UNICEF with informal partnership formed. UNICEF to continue scaling-up support for the MoHto establish in-patient services (with some support for OTP). CONCERN/Valid to <strong>focus</strong> on supporting the MoHto establish OTP in selected operational areas.2006/7 TFP working group formed (MoH, UNICEF, CONCERN, and Valid International). Development of ‘TFP strategypaper’, 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 SAMservices, such as training, reporting, supervision, community mobilisation, etc.2005 –early 2007Early stage of the programme, with considerable time spent in building-up relationships with key MoH figuresin all four regions. OTP services commenced first in five health centres in Jimma Zone, Oromia region. Slowlyincreasing number of OTPs established at health centre level (from 0 to 37 HCs in 21 woredas). Throughlearning and experience, the ‘minimal support’ technical package was developed (see later), with time/energyalso devoted to reviewing, analysing and developing Concern’s internal CMAM strategy for Ethiopia.2006 – 7 In collaboration with UNICEF, substantial support given to the MoH in developing the revised national SAMguidelines, which included OTP and community mobilisation activities.May 2007– January2010Second grant from OFDA enabled rapid scale-up of CMAM services. The N-CMAM programme began to gaininfluence, partly because of scale-up (from 37 to 187 health centres/posts across 87 woredas) as biggerprogrammes have louder voices, but also partly due to increasing engagement in what was going on incountry,e.g. input into the revision of national curricula for nutrition, providing the training manual that wasadapted for the HEWs for OTP decentralisation, etc.2008 – 9 Considerable scale-up of CONCERN’s emergency nutrition activities (see Box 3). Support given from N-CMAMprogramme such as budget for supplies, trainings, vehicles, personnel, etc.Figure 1: N-CMAM admissions, 2006-2009Admissions to programme2500020000150001000050000Jan – Dec2006Jan – Dec2007Jan – Dec2008Jan – Dec2009Figure 2: N-CMAM Programme performancePercentage of total exits9080706050403020100183463541294119770Cured Death Defaulter/ NonrespondertransferMedicalUnknown2006 2007 2008 2009CMAM team assisted the MoH in selected areasof the four main regions (Oromia, Tigray, SNNPand Amhara) to establish and maintain OTPservices. As UNICEF had been supporting theset-up and monitoring of in-patient units (TFUsor SCs) since 2003, the N-CMAM programme<strong>focus</strong>ed mostly on OTP service provision andcommunity mobilisation. However, where gapsexisted, the team also supported the set-up ofin-patient services. From 2007 onwards, expansionof services was to areas identified bygovernment authorities as most in need,usually determined by early warning data,identification as ‘priority hot-spot area’ 7 andEOS screening data.The ‘minimal support’ package was developedin consideration of the most importantareas where the MoH needed support, to establishand then maintain quality services. Theapproach used a process of incremental capacitybuilding to ensure that the ownership of theprogramme was always firmly in the hands ofthe MoH. The minimal support packageincluded the following activities for set-up ofservices and provision of ongoing support:• OTP theoretical and in-patient SAM casemanagement trainings, particularly at startupof services• Regular on-the job/refresher trainings• ToT trainingsSometimes a sibling is givenresponsiiblity for bringing achild to OTPEmily Mates/Concern Ethiopia• Joint supportive supervision and follow-up• Community mobilisation activities• Conducting pre- and post-workshopassessments• Facilitation of regular zonal and regionaldissemination workshops/review meetings• Facilitation of experience exchange visits• In-patient training and support wasprovided on an ad hoc basis, when requestedby the MoH, UNICEF or other INGOs.It is important to note that the physical inputsin the minimal support package describedabove do not capture the relationship dynamicsthat must also be attended to, if ownership is tobe achieved.Community mobilisation and additionalprogramme activitiesCommunity mobilisation was a strong featureof the programme, with the <strong>focus</strong> on a moreincremental version of community activationthan the ‘campaign-style’ mass screeningmobilisation common for emergencyprogrammes. CONCERN’s social developmentstaff in consultation with the HEWs and otherhealth staff utilised a strategy in ‘new’ CMAMareas as follows;1) Mapping: identifying key actors andidentifying community structures already inexistence, particularly those active inhealth/nutrition2) Discussing: commencing a public healthdialogue with identified volunteers,including realistic time-frames of availablityto screen for SAM and conduct home-visitsfor follow-up.3) Training: 1 day training including sessionson underlying causes of malnutrition, use ofMUAC and importance of defaulter followup.As the <strong>focus</strong> of the N-CMAM programme wason innovation and learning, programme activitieshave included conducting a number ofoperational studies. These include a defaultertracing study regular social developmentreviews and strategies, health system review,cost-analysis and effectiveness and investigationinto the role of traditional practitioners inidentification and referral of SAM. Case studiesand examples of ‘best-practice’ were collected,along with programme learning reviews andevaluations.At the request of the MoH, N-CMAM activitiesalso included ToT in SAM case management,participation in multi-agency food security/post-harvest needs assessments, support for EOSscreening campaigns, support for additionalmonitoring & evaluation/ supervision activities,extensive attendance at national and regionalcoordination meetings and involvement innational initiatives, such as the recent LandscapeAnalysis conducted in Ethiopia.The N-CMAM team worked alongsideCONCERN’s health and nutrition unit toconduct numerous assessments. From 2008 t o2010, a total of 25 standard nutrition surveysand 10 rapid nutrition assessments wereconducted, mainly to inform phase-in or phaseoutof emergency nutrition activities.Additionally nine coverage surveys usingcentric systematic area sampling (CSAS)methodology were conducted.Results/achievementsThe N-CMAM team relied on reporting channelsof the MoH which uses a particularreporting format (developed by UNICEF) thatin turn feeds into the centralised database forTFP reporting which is held at Addis Ababalevel. However, as these reports are not yet integratedinto the regular Health ManagementInformation System (HMIS) reporting system ofthe MoH, TFP monthly reports were sometimesincomplete and were rarely sent in a timelyfashion to regional level. It was often necessary,through a mixture of supervisory visits andreminder telephone calls for N-CMAM staff tocollect ‘missing’ reports. The reporting rate istherefore estimated to be between 75-90% forthe statistics presented here.From January 2006 to December 2009, acrossthe four main regions, 40,899 children withSAM were admitted to OTP services estab-7The Emergency Nutrition Coordination Unit (ENCU) producesa ‘hot-spot matrix’ identifying priority areas in need ofnutritional support, which is revised every six months.8The programme continues on into 2010 but full results willnot be available until early 2011.70

Field ArticleTable 3: N-CMAM programme performancedata Jan 2006 – Dec 2010, four regionsYearJan-Dec2006Jan-Dec2007Jan-Dec2008Jan-Dec2009Total number of 1,343 4,463 10,171 15,496discharges (n)Cured (%) 56 61 66.9 77.3Death (%) 1 0.9 1.2 1.1Unknown (%) 10 0 11.6 15.1 9.9Defaulter (%) 35.5 20.3 12.3 7.4Non-responder 0.5 3.2 3.1 3.2(%)Medical transfer 7.0 3.0 1.4 1.1(%)100% 100% 100% 100%lished at health centres, see Figure 1. 8 A steadyincrease in rate of admissions was observed,with the expansion of OTP services withinhealth centres across the four regions. 9 Risingadmissions could also be due to the higherlevels of food insecurity seen in parts of thecountry where N-CMAM was operationalduring 2008/9. Table 3 and Figure 2 describe N-CMAM programme performance, with a total of31,480 discharges from January 2006 toDecember 2009.Table 3 and Figure 2 describe N-CMAMprogramme performance, with a total of 31,480discharges from Janurary 2006 to December2009. 0Table 3 and Figure 2 demonstrate veryencouraging programme results. The recoveryrate steadily improved from 56% in 2006 to77.3% in 2009, thus exceeding InternationalSphere recommendations for >75% recoveryrate.1 Most of these gains in recovery are aresult of declining defaulter/unknown ratesand to some degree, the rate of medical transfer.The trend of improved recovery rates clearlydemonstrates the MoH becoming more confidentin their ability to offer quality services,with minimum technical support. It alsosuggests children are less likely to default, withimproved access to services and increasingsatisfaction with the service.While an overall declining trend of defaulterand unknown rates was seen, they remainedhigh. This is largely due to the challengingtopography in many areas of the country andlogistical problems of ensuring that all healthfacilities had an uninterrupted supply chain ofRUTF. The mortality rate was consistently low.However as the number of unknown casesremains high, it is possible that some mortalityoccurred within this category. As expected,transfer rates to in-patient care reduced asTable 4: Training data January 2006 – December2009, four regionsYearHealthprofessionalsHealthExtensionWorkersHEWSupervisors 16VCHW2006 108 42 0 5652007 380 359 0 1.3392008 547 1,236 113 1,9652009 534 1,593 284 2,161TOTAL 1569 3230 397 6030access to services increased. Where childrenwere identified earlier in their disease process,they generally had fewer medical complicationsand may not have reached the stage wherethey lost their appetite. This meant that burdenon in-patient services was further reduced andminimised family and household disruption.CoverageOne of the major principles of CMAM is‘increased coverage’ of services. During 2010,four coverage surveys using the CSAS methodologywere conducted to assess coverage of thenational TFP roll-out in the four main regions. 12Two of the surveys were conducted in areasthat had received N-CMAM support. Theresults were impressive, particularly for periodcoverage which exceeded the Sphere target of >50% in a rural area. 13 Point coverage estimateswere lower, highlighting the importance ofcontinued efforts in community mobilisation(see above for a description of communitymobilisation activities).During 2009/10, N-CMAM, in collaborationwith Tigray RHB, piloted a new methodologyfor assessing coverage of OTP services. This‘Semi Qualitative Evaluation of Access andCoverage’ (SQUEAC) methodology was developedas a less resource-intensive (and thereforemore ‘MoH friendly’) way of evaluatingprogramme coverage and identifying barriersto service access and uptake. 14 Between October2008 and April 2010, three rounds of SQUEACwere implemented, with coverage steadilyimproving with each round (half of health facilitiesreaching >50% by the third round).Encouragingly, Tigray RHB not only took thelead by the third round, they also supplied thebudget for the survey, with CONCERN providingtechnical assistance only. 15Training of MoH health professionalsand community membersTable 4 outlines the <strong>focus</strong> that was placed ontraining of health staff. It is now well-knownthat OTP success is contingent on a responsiveTable 5: Summary of N-CMAM regionalreview meetings/workshops by yearYearNo. ofworkshopsNo. of regionscovered2007 5 4 (SNNP, Oromia,Amhara, Tigray)Totalnumber ofparticipants2622008 17 3 2 (SNNP, Oromia) 922009 11 4 (SNNP, Oromia,Amhara, Tigray)897TOTAL 19 1251and well-informed community, considerableeffort and dedicated resources were thereforealso employed for Community Mobilisation(CM) training, using Volunteer CommunityHealth Workers (VCHWs). To ensure trainingswere conducted in a standardised manner, N-CMAM staff developed a training manual forthe management of SAM during 2006-7, accordingto National Guidelines. The version hasbeen improved throughout the programme’slife cycle, with CONCERN taking a major rolein the development of OTP training materialsused at national level.WorkshopsBy 2006, CMAM/CTC was still relatively newto Ethiopia and had limited coverage, so a twodaynational workshop was hosted in AddisAbaba to bring together the MoH, UN agencies,donors and NGOs. The objective was to discuss9Figures presented here are for health centres as ‘roll out’ tohealth post occurred gradually during the year 2009 in N-CMAM areas. From 2010 onwards, programme figures willbe collected from health posts.10During the 2007 revision of the national SAM guidelines,defaulters were divided into ‘unknown’ i.e. unconfirmeddefaulters and ‘defaulter’ i.e. those defaulters confirmedthrough a home visit. The values need to be added togetherfor the total default rate.11The Sphere project recommends: recovery > 75%, death 50% (in rural areas)12The CSAS assessments were coordinated by the EthiopianHealth and Nutrition Research Institute (EHNRI) and theMoH. CONCERN provided the technical support forimplementation of the surveys, which were funded byUNICEF.13Mareko woreda, Gurage zone, SNNP Region: OTP periodcoverage 60.9% (95% CI: 52.8%-68.6%) and pointcoverage 37.8% (95% CI: 28.2%-48.1%). Taytaw Machewworeda, Tigray Region: OTP period coverage 56.2% (95%CI: 44.1% - 67.8%) and OTP point coverage 27.3% (95%CI: 15.0% - 42.8%).14Myatt, M. ‘SQUEAC: Low resource method to evaluateaccess and coverage of programmes’, Field Exchange, ENN,June 2008, Issue 33.15Schofield, L, et al. ‘SQUEAC in routine monitoring of CMAMprogramme coverage in Ethiopia’. Field Exchange, ENN,March 2010, Issue 38.16Recognising that the new cadre of HEWs were in need ofsupervision, the MoH trained and deployed HEW supervisorsfrom 2008 onwards.17Fewer workshops were conducted during 2008 as many ofthe N-CMAM staffs were involved in Concern’s scale-up ofemergency programming (see Box 3)Shemsiya (2 years) failingthe RUTF appetite testShemsiya with her familyEmily Mates/Concern Ethiopia Emily Mates/Concern Ethiopia Emily Mates/Concern Ethiopia71

the current status of therapeutic care inEthiopia and formulate plans for increasingcoverage of quality services. From 2007, the N-CMAM team recognised that the facilitation ofworkshops/review meetings could be a valuabletool for improving the quality of services.MoH staff involved in OTP implementationwere brought together in the same room as keydecision makers from regional, zonal and federallevel MoH, to discuss the challenges faced anddevise appropriate solutions (Table 5). Theseworkshops (while expensive and time-consumingto prepare for and conduct) providedexcellent opportunities both for developing coordinationand encouraging accountabilityamong partners. Additionally, ‘phasing-outworkshops’ (after emergency nutrition interventions,see Box 3) proved important fora toreinforce the understanding of roles and responsibilities,including the re-design of action plansfor future activities when OTP was transferredback from more intensive ‘emergency’ levelsupport provided by CONCERN to full MoHmanagement.Experience-sharing visitsA learning and information-exchange visit byEthiopian MoH officials to Malawi was facilitatedduring 2006, with representatives fromUNICEF joining the trip. The goal was to learnand share lessons on the treatment of SAM aspart of routine health services. The visitprovided an excellent opportunity for Ethiopiastaff to learn from Malawi’s recent nationalscale-up experience, hearing first-hand aboutthe successes and challenges that the MalawianMoH had faced.From 2008 onwards, a strategy of experience-sharingvisits for MoH staff to otherregions within country was employed. Sixvisits were organised with a total of 181 MoHstaff travelling. Health workers who wereperforming well were invited to travel to areasin need of encouragement, to improveprogramme performance. The success of thesevisits hinged on the fact that advice was beinggiven by the MoH to the MoH – not fromCONCERN – which gave added weight torecommendations of how to improve servicedelivery. The visits appeared to act as powerfulmotivational tools, with potential for longertermimpact.DiscussionWhile the programme was always results orientated,it was viewed through the lens of publichealth. This <strong>focus</strong> enabled it to keep goingthrough the early years of low recovery rates(only 56% in 2006), in the belief that if serviceswere incrementally established at-scale,improvements in service quality could follow.This was as long as the MoH was provided withsufficient, appropriate and well-targetedsupport.At present, the only benchmarks for SAM treatmentprogrammes are provided through theSphere Project. While reaching these recommendationsshould always be the aim of the programme,it must be remembered that they have evolvedfrom humanitarian emergency programmes thatare generally implemented by well-resourcedINGOs. It could be useful if suitable benchmarksfor MoH-led national scale-up programmes thatprovide appropriate reference points forprogramme quality, especially during the earlyyears of implementation were developed.Emily Mates/Concern EthiopiaA number of key factors/processes, listedbelow, promoted an enabling environmentwithin which the N-CMAM programme couldachieve its objectives.a) Continuous and sufficient funding from July2005 to date, through a series of grants fromOFDA and CONCERN-sourced funding, which:• Allowed for programme scale-up andcontinuation, with the ability to deliver oncommitments.• Enabled regular processes of learning,monitoring and evaluation, with budgetallocated for operational studies andinnovative programming approaches.• Offered dedicated budget for senior staffand an expanded team at capital level thatenabled rapid response to requests fortechnical assistance from partners (MoH,UNICEF, other NGOs), attendance at awealth of coordination fora and for staff totake an active role in policy developments.• Assisted the scale-up to emergencyprogramming, where required (see Box 3).b) Strong <strong>focus</strong> on training of the N-CMAMteam in how to support partner staff, ratherthan undertaking direct implementation.Building the capacity of CONCERN’s partnerrequired the team to deliver support from thesidelines, often a more difficult task than directimplementation.c) Strong and continued <strong>focus</strong> on communitymobilisation, with dedicated SocialDevelopment staff. This helped to create the‘demand driven’ version of OTP, whereby therapid and visible recovery of children acts as aprofound motivational force for parents, healthworkers and the wider community. 18d) Initial targeting of districts that had experiencedlimited INGO support, in an attempt toavoid areas where dependence on NGOs fornutrition-related programming was highest.Additionally, CONCERN invoked a principleof not having a full-time presence in operationalareas. Instead, CONCERN had a base inthe capital that could provide support anddialogue with the woreda and Regional MoH,but no permanent presence.e) The MoUs that were regularly signed withRHBs supplied the all-important officialauthentication for programmatic aims andobjectives.ChallengesDuring programme implementation, a numberof challenges were experienced. Many of themwere common to overburdened health systems,Field Articlebut some were particularly accentuated withCMAM.Programme specific challengesTransport continues to be a major challenge forthe MoH across this vast country. Where vehiclesexist, they are often in need of maintenanceand lack budget for fuel. OTP is a logisticallyheavyservice modality due to the bulkyproduct (RUTF). Ensuring sufficient andadequate storage space also presents majordifficulties. Additionally, the service is not a‘one off’ – caregivers need to come back eachweek for eight weeks on average, requiring theOTP to have regular, uninterrupted supplies toensure successful outcomes.Facilitation of sufficient and adequate supervisionat-scale was problematic, especiallyconsidering the transport challenges describedabove. While the supervisory visits werealways well appreciated by health staff, due tomany competing commitments, it was not easyfor over-burdened MoH supervisory staff tomake enough time for visits to health facilities.A standard supervision checklist for OTP wasdeveloped during the programme (in collaborationwith UNICEF and the MoH), and iscurrently being integrated within the routinehealth supervision system.Collection and collation of programmestatistics was a major challenge. The datapresented above is only from health centres.Since the national ‘roll-out’ of TFP (2008onwards) and the decentralisation of OTP servicesto health post level, staff providing regularand accurate reporting face many additionalhurdles.High staff turnover within the MoH was theprimary obstacle to ongoing knowledge retentionat health facilities, resulting in untrainedstaff often found implementing OTP. Focalpersons for nutrition to co-ordinate and monitoractivities at regional, zonal and district levelwere appointed. However, the high rate of staffturnover meant that it was important to involveall members of the health team from the start, tominimise the risk of the programme collapsingif one person left.Routine antibiotic treatment was mostly notavailable at the health facilities as they aresupplied through a delivery system that isdifferent RUTF supply.18‘Temporal Integration’ Demand driven CTC. Steve Collins,Emergency Nutrition Network (ENN) <strong>Special</strong> SupplementSeries, No. 2, November 2004.Welcome message by Ato Yohannes,the Deputy Head of Tigray RHB.72

Field ArticleCommunity mobilisation mechanisms werenot always clear and readily available for use,resulting in a parallel system needing to be setup(although the programme collaborated withwhatever mechanisms did exist in the community).The UNICEF-supported CommunityBased Nutrition (CBN) programme now presentsan excellent opportunity to integrate SAMscreening into the growth monitoring activitiescarried out by VCHPs, but the modalities of thishave yet to be agreed.Challenges in the environmentIntegration of scaled-up OTP as part of routinehealth delivery provides many challenges foran overburdened and under-resourced healthsystem, including the time taken to actuallytreat the children, attendance at trainings,reporting, ordering, transport and storage ofsupplies, etc.Competing priorities within the healthsystem are also a challenge, since manyhealth/HIV related initiatives are being ‘rolledout’ at the same time in Ethiopia. Whileimprovements in health services are obviouslywelcome, it does exert pressure, e.g. attendanceat trainings can result in health staffs spendingconsiderable time away from facilities.Additionally ‘per-diem’ rates risk becomingcompetitive, with initiatives that pay higherrates appearing more attractive.Lessons learnedThe length of time that the process of integrationrequires on many levels. Continual dialogue andinteraction with key actors is needed to ensureobjectives are being met and opportunities capitalisedon.Box 3: Emergency programmingDuring the food crisis of 2008/9, CONCERN scaled-upto emergency nutrition response, implementing the‘full’ CMAM package (that included supplementaryfeeding support, OTP and SC set-up) in 10 woredas.In addition, blanket supplementary feeding distributionswere implemented in selected woredas ofSNNP, Amhara, Tigray and Oromia regions, inattempts to contain rapidly deteriorating situations.Total numbers of beneficiaries treated through theprogrammes during 2008/9:Intervention Target group Total numberof beneficiariesBlanketsupplementaryfeeding (SF)(1 month SFrationprovided)Children 6-59monthsPregnant (3rdtrimester) andlactating women(infant 50% coverage in a ruralarea) in all but one assessment (where OTP pointcoverage was estimated at 46.4%, Dessie Zuriaworeda October 2008).A key challenge for CONCERN’s emergency interventionswas how to scale-up and then, crucially,scale-down again, without undermining the workthat had been previously done through the N-CMAMcapacity building approach. The period of transitionback to N-CMAM’s ‘minimal support’ approach couldbe interesting, as partners were required to realignexpectations of assistance once the acute emergencyperiod was over. Phasing-out workshopshelped to reinforce the understanding of roles andresponsibilities during the transition period, whereOTP and SC services were again fully managed bythe MoH. Learning reviews were also conducted atthe end of each emergency intervention, in order tomaximise learning for future interventions.convinced that more senior staff are interestedenough in programme results. Initially it mightbe necessary to conduct additional supervisionto ensure service quality (especially when theservice is new). However, integration intoroutine health service supervision must beaimed for if sustainability is to be achieved.N-CMAM Programme limitationsAlthough a number of ‘strategy meetings’ wereheld, a strategy as such was not developed. Thiswas partly due to the short-term funding cyclesof the programme that presented some barriersfor the articulation of a strategic vision. Longertermfunding for N-CMAM proved elusive,despite attempts to secure it.While the N-CMAM is a much more costeffectiveversion of OTP than ‘usual’ NGOsupported versions, the programme remainsrelatively expensive. Considerable budget isrequired for trainings, cars for supervision, staffsalaries, etc.N-CMAM prioritised attention on OTP overthe establishment of in-patient services. Thisdecision was taken for two reasons. First, existingUNICEF support for in-patient services(described above) and second, with limitedCONCERN capacity, the <strong>focus</strong> (as public healthadvocates) should be on the 95% of childrenwho could be treated in OTP. It is acknowledgedthat alternate views exist, that mightconsider N-CMAM should have prioritised inpatientcare also.There were a number of missed opportunities.For example, linkages with preventativenutrition interventions were very limited, aswere linkages with hygiene and other sanitationactivities. Health education at the OTP wasirregular and could be sub-optimal.While the programme’s aims and objectiveshave always been to support the MoH, it isacknowledged that this particular version of N-CMAM remains NGO-driven, wheresustainability after phase-out is not guaranteed.ConclusionsThe N-CMAM programme started from smallbeginnings and grew into a relatively large andsuccessful intervention. It capitalised on thenational and international momentum that wasbuilding around nutrition <strong>issue</strong>s. It contributedto the national roll-out of SAM treatment servicesthat is now underway in Ethiopia, bydemonstrating that the MoH were well able tomanage and implement OTP services ofincreasing quality at-scale. It reflected that theprocess might take some time and considerableexpense.The national roll-out of the TFP has beensubject to considerable effort from the MoH(supported by UNICEF and other partners). Todate, approximately 30% of Ethiopia’s healthfacilities are offering OTP services, an impressiveachievement over a short period of time.The challenge now will be how to maintainquality of the OTP, when implemented at scale.The difficulties of adequate monitoring, supervisionand reporting are enhanced, as is thelogistic burden for the health service. Strategicplanning, along with strong leadership from theMoH will be required, in order that the TFP rolloutcan be strengthened and maintained.For further information, contact:concern.ethiopia@concern.net73

Agency profileThe Ethiopian OrthodoxChurch Development andInter-Church Aid CommissionBy Gebreselassie AtsbahhaField ArticleEOC-DIAC, Ethiopia, 2009Gebreselassie Atsbahha is Emergency Relief Officer with the EOC-DICAC. He has over 20 years of experience in humanitarian, socialprotection and development works, both in governmental andnon-governmental organisations in various parts of the country.His has a MSc in Land Resources Management and EnvironmentalProtection.The author would like to acknowledge Alive and Thrive, Ethiopia for the efforts it ismaking to alleviate malnutrition and the problems associated in Ethiopia. The leadershipquality of Dr Teweldebirhan Hailu, senior country director of the organisation,as well as the harmony and commitment of the staff is really appreciated.An EOC-DICAC teamsurveying a mosquitobreeding sites in Amhararegion, Guangua districtThe Ethiopia Orthodox Church (EOC) isone of the oldest churches in the world.The church is also the largest denominationin Ethiopia with more than 40million followers, which is approximately 40-50% of the total population. One can observethe impacts of EOC in almost all aspects of thecountry’s history and present image and theEOC continues to play an important role in thesocial, economic, cultural, educational andpolitical life of the country.EOC-DICAC objectivesIn order to respond to both the emergency andlonger term needs of the population, the churchestablished a development wing in 1972, theEthiopian Orthodox Church Development andInter-Church Aid Commission (EOC-DICAC).The EOC-DICAC is one of a few activeecumenical development organisations in thecountry. It is engaged primarily with the objective“to help disadvantaged communities attainself reliance by tackling the root causes ofpoverty, drought, conflict and HIV/AIDS bypromoting a sustainable developmentprogrammes”. The EOC-DICAC works withinthe regulations and laws governing nongovernmentalorganisations (NGOs). TheVision of EOC-DICAC is to help create a justsociety in which everyone has access to thebasic necessities of life.EOC-DICAC activitiesTo achieve its objective, EOC-DICAC isinvolved in the following major areas of activity:• Providing emergency and humanitarianassistance• Implementing rural developmentprogrammes• Building local capacities to implementproject activities for poverty reduction• Assisting vulnerable groups such asrefugees, returnees and displaced people• Supporting the prevention and control ofHIV/AIDS and related nutrition needs• Training/education to ensure equity andpromote optimal use of natural resources.Since its establishment, the EOC-DICAC hasimplemented many relief and developmentprojects. By mid-2010, the EOC-DICAC wasimplementing more than thirty projects indifferent parts of the country covering integratedrural development, water supply andsanitation, relief and rehabilitation, HIV/AIDSprevention and control projects and refugeeand returnee programmes.The EOC-DICAC has more than 20 US andEuropean based partners and has an annualbudget of around US $ 30 million. The maindonors include (but are not limited to) UNHCR,EU,UNICEF, UNDP, Christian Aid, Dan ChurchAid, ACT-Forum, Water Aid, Intermon‐Oxfam,USAID and World Vision. The EOC-DICACalso works closely with other Church based andChurch affiliated organisations.Emergency responseDuring periods of drought, internal conflict andother emergency situations, the EOC-DICACsupports the responses arising from the government’snational emergency appeals. TheEOC-DICAC has the capacity to be involved inlife saving interventions through the provisionof food aid, farm tools, seeds, smallanimals/ruminants, supply of water and otherbasic life saving inputs. Priority is given tosupplementary feeding of children and theprovision of a monthly take home ration (typically4.5kg per month) to other vulnerablegroups, such as the elderly and the sick.EOC-DICAC also supports environmentalrehabilitation activities in some areas, such asarea closures, soil and water conservation structures,seedling production and distribution.Apart from this, the commission has tried toexpedite crop production, livestock developmentactivities and introduce vegetables andfruit trees. By so doing, these activities aim tohave a role in improving the nutritional statusof children and improve dietary diversity of thetarget families.In coordination with District Health Officers,orientation and awareness creation on HIVtransmission, protection mechanisms and theuse of voluntary counselling and HIV testing isalso a key activity. Pilot projects on HIV/AIDSorphan care at parish churches have also shownpromising success.To date, EOC-DICAC has made great stridesin its service to the disadvantaged populationsof Ethiopian society and its programmes havestrengthened communities to better sustainthemselves during periods of extreme hardship.EOC-DICAC has succeeded incommunity mobilisation to fight against theroot causes of poverty, HIV/AIDS pandemicand environmental degradation. The organisationhas also built schools and health posts tocreate access for education opportunities andhealth services for thousands of rural familymembers in the country.The water supply scheme construction projectscreate opportunities for millions ofEthiopian people to get potable water, reducethe workload of women and children, minimisethe prevalence of water borne diseases andincreased awareness of hygiene and sanitation.Rural roads constructed by EOC-DICAC havealso contributed to the mobility of ruralcommunities and increased their accessibility tothe nearest towns and markets.Working with womenEOC-DICAC is very concerned about women’sparticipation in development and makes surethat the following <strong>issue</strong>s are addressed rightfrom the project design up to the phase-out ofprojects:• Encourages women to participate at alllevels of the project cycle and ensuresgender sensitivity.• Ensures that interventions consider womenin equal status with men.• Built partnership and strategic alliance withlocal government and civil societyorganisations (CSOs) to promote gendermainstreaming in development projects atall levels.• Advocates against violence in terms ofperson trafficking, as well as female genitalmutilation and other harmful traditionalpractices.• Intervene in women capacity building so asto enable them acquire technical skills.• Promotes equal opportunities for womenand men in recruitment, staff developmentand promotion.The basis for the emergency and developmentinitiatives of EOC-DICAC is the fundamentaldoctrine of the Church/Bible "Everyone whohas gives to those in need". The initiation of thewhole effort put by the Church so far hasemerged from its doctrine or internal spiritualbelief that urges everyone to help those who arerelatively poor in the society.For further information, contact: GebreselassieAtsbahha, P.O BOX: 503, Ethiopia. tel: + 251911 687909 Fax +251 111 551455,email: gats2005@gmail.com74

TSF distribution in Degehabur, Somali RegionThe TargetedSupplementary FeedingProgramme (TSF)WFP/Judith Schule, Ethiopia, 2009Field ArticleBy Jutta NeitzelJutta Neitzel is the Head of the Nutrition and Education Section atWFP Ethiopia. She has worked for the programme since 1997.Previously she worked for WFP in Italy and Yemen. She holds aMasters in Economics.The author acknowledges the contributions of GloriaKusemererwa, Targeted Supplementary Food (TSF) team leader,her deputy Tayech Yimar and the entire TSF team for their wisdomand input to this article and their continued dedication to backstopthe intervention and to identify creative ways to improve theresponse the nutritional needs of young children in Ethiopia.The findings, interpretations, and conclusions in this article are thoseof the author. They do not necessarily represent the views of WFP orthe country they represent and should not be attributed to them.The Enhanced Outreach Strategy(EOS)/Targeted Supplementary Food(TSF) for Child Survival is a jointprogramme under the United NationDevelopment Assistance Framework (UNDAF,2007-2011) with the Government of Ethiopia.UNICEF is supporting the Ministry of Health(MoH) to conduct twice yearly campaigns of vitaminA supplementation and deworming to everychild under five in the country 1 . In TSF selecteddistricts, the EOS is also screening malnutrition ofall children under five years and pregnant andlactating women. 2 WFP is supporting the DisasterRisk Management and Food Security Sector(DRMFSS) of the Ministry of Agriculture and RuralDevelopment (MOARD) to deliver two supplementaryrations of Corn Soya Blend (CSB) and oilto children and women identified with acutemalnutrition during the screening. 3Overview of EOS/TSFThe Targeted Supplementary Feeding programmeaims to rehabilitate children under five years old aswell as pregnant and lactating women (PLW) identifiedas acutely malnourished during EOSscreenings in TSF selected districts. Theprogramme also aims to reduce the risk of childmortality and through an awareness-raisingcomponent, aspires to enhance the basic nutritionknowledge of mothers and other women incommunities targeted by EOS/TSF.Ethiopia is currently among the countries withthe highest rates of child mortality and malnutritionin the world. The various long-term strategies initiatedby the Government of Ethiopia, such as theProductive Safety Net Programme (PSNP) or theChild Survival Strategy among others, started in2004/5. It is anticipated that these programmes willtake at least 5to 10 years to have significant impact.The EOS/TSF was developed in 2004 as a ‘stop-gap’measure to avoid additional millions of Ethiopianchildren from dying or becoming malnourished inthe meantime. It was carefully designed to create a‘bridge’ to the more sustainable and longer-terminterventions like PSNP.The TSF replaced the provision of blanketsupplementary food rations alongside the generalrelief food distribution. The rationale for a moretargeted approach was to better respond to theneeds of malnourished individuals at a criticalphysical and mental development stage in theirlives and to ensure better targeting than a blanketdistribution.More recently (2008), the National NutritionProgramme (NNP) was approved and provides thebroader framework for developing communitybasednutrition capacity in Ethiopia. The EOS isnow being gradually phased-out and replaced byquarterly Community Health Days (CHDs)organised and managed by the HealthExtension Workers at kebele level. The TSFwill be continued at kebele level until therates of acute malnutrition are low enough toend the programme (i.e. until impact ofpreventive programmes such as communitybasednutrition (CBN) is effective).The EOS provides key Child Survivalinterventions to over 11 million children and700,000 pregnant and lactating women every6 months. The annual funding is US$14million.The annual requirements of the TSFcomponent, with its present coverage, arecurrently estimated at about US$53 million,equivalent to 53,000 metric tonnes of fortifiedblended food and vegetable oil. These quantitiesrespond to the needs of around onemillion individuals in 168 woredas in Afar,Amhara, Gambella, Oromia, Somali, SNNPRand Tigray regions. Initially, the programmecovered 325 woredas, but due to soaring foodprices as well as diminished donor support inearly 2008, the programme had to be downscaled.The initial 325 woredas were thechronically food insecure woredas identifiedby the Government of Ethiopia during the2002/3 emergency. The criteria used to selectthe current 168 TSF woredas were:• prevalence of moderate acute malnutrition(MAM) >10%• classification as emergency hotspotworedas in 2006/7• identification as a food insecure woredaduring the December 2007 meher assessmentto be a relief recipient in 2007• not a PSNP woreda in 2007 and, forOromia and SNNPR, whether the woredawas rolling out the national nutritionprogramme’s CBN or not.The current TSF woredas do not cover all thehotspot districts in the country. Therefore aspecial mechanism has been developed toundertake ‘ad hoc’ TSF distribution inhotspot woredas that are not TSF woredas.Implementation and designEvery six months and with UNICEF support,Regional Health Bureaus organise ChildSurvival campaigns. Each district (woreda)that is not a TSF district forms one EOS teamper sub-district (kebele) composed of onehealth worker and one health extensionworker. These mobilise the community tocome to the nearest health post on a specificday, called the EOS day. On this day, the EOSteam will de-worm and supplement withvitamin A all children under five years. Onmany occasions, Regional Health Bureaustake the opportunity to deliver other essentialservices such as measles and tetanus vaccinations,mosquito net distribution, HIV/AIDSprevention, iodine capsules distribution, etc.In TSF districts, the EOS team is expandedwith another two health staff, generally onehealth extension worker and one supportstaff, to undertake the screening of children,pregnant and lactating women. Thes- healthstaff measure the Mid-Upper ArmCircumference (MUAC) of children underfive years and check for bilateral oedema.Children and women eligible for TSF areregistered in a book and given a TSF rationcard. The registration book includes the serialnumber of the distribution card 4 . There arethree carbon copies of the registration book,one for the Food Distribution Agent (FDA),one for the district Health Office and one forthe district Disaster Prevention andPreparedness Office (DPPO). The registrationbook is then kept by the FDAs. The threecarbon copies allow supervisors and fieldmonitors to verify that they are identical andwere not manipulated. In addition to receivingthe TSF ration, children identified with1Vitamin A is supplemented to children 6-59 months oldand deworming tablets are administered to children 2-5years old.2The following groups are screened for malnutrition:children 6-9 months old, visibly pregnant women andwomen breastfeeding a less than 6 month old infant3The following groups are eligible for TSF: Children withMUAC

Field Articlesevere acute malnutrition (SAM) 5 are referred tothe nearest Therapeutic Feeding Programme, ifavailable.During the EOS days, MoH supervisors andUNICEF field monitors undertake spot visitsalthough number of sites visited is limited. Inaddition, post-EOS coverage surveys are regularlyconducted by independent organisations.At Federal level, the Emergency NutritionCoordination Unit (ENCU) checks screeningdata and informs the MoH, DRMFSS, UNICEFand WFP of any aberrant data.The DPPO is responsible for compiling thedata from the screening registration book andto request the appropriate amount of TSF foodfrom the regional Disaster Prevention andPreparedness Bureau (DPPB). The DPPB is incharge of transportation and distribution offood to over 1,300 food distribution centres. Thefood is provided by WFP to all of the regionalwarehouses. All of the food transportation,distribution and administrative costs incurredby regional government are paid by WFP.TSF distribution centres are selected throughcommunity participation and managed byFDAs (trained and paid females from respectivecommunities) 6 . Once the food is receivedby the FDAs, the community is informed of theTSF distribution date. Beneficiaries come with aTSF ration card and collect the ration for 3months. The food basket comprises two 3-monthly rations of 25 kg of Corn Soya Blend(CSB) and 3 litres of oil. The size of the rationhas been set to compensate for intra-householdsharing. FDAs also pass on four nutritionmessages during the distribution. This includesinstruction to minimise intra-household sharingand selling of the TSF ration.At the food distribution stage, the DPPB isresponsible for conducting regular food monitoring,complemented by WFP monitoring.Unfortunately, DPPB monitoring results are notregularly shared with partners. WFPs monitorsand woreda health and DPPO focal pointsconduct spot check visits to ensure properimplementation and support to the FDAs. In2009, through regular spot check visits, WFPmonitors interviewed 2,369 beneficiaries in 111woredas and visited 1,245 distribution centres.Nearly 500 centres were visited during distributions.The monitoring visits check on whetherthe distribution process is following procedures,including proper documentation in theregistration books, registration cards, signboards,etc. Monitors also conduct beneficiaryinterviews 40 days after the food distribution.Beneficiary interviews enquire about foodreceived and how it is used as well as obtainfeedback on the distribution, knowledge aboutentitlement and nutrition awareness. Followingeach distribution, FDAs attend a post-distributionworeda review meeting to assess thedistribution process and to discuss problemsencountered with woreda health and DPPOfocal points. Review meetings are conducted atdistrict and zonal level to assess the overall EOScampaign performance, including the quality ofthe screening process.WFP’s approach verifies whether allocatedTSF food is reaching beneficiaries identifiedthrough the EOS-TSF screening on a timely basis,and enables follow up at higher levels if need be.Commodity tracking will further benefit fromthe envisaged Food Management ImprovementProject (FMIP). As the programme does notregularly check on the improvement of the beneficiaries’nutritional status, WFP conducts anoutcome survey once a year including data onrecovery and mortality rates.TSF achievementsThe EOS service coverage has been consistentlyhigh (>90%) since its inception in 2004. A TSFoutcome evaluation study 7 was conducted in2008. This study aimed to recruit children for aprospective cohort study in eight districts.Children were to be followed up at 1,2, 3 and 6months after enrolment in the TSF. At the timeof the first follow-up visit, 973 children hadreceived TSF food and were defined as interventionchildren, and 588 children had notreceived TSF food and were defined as controlchildren. Overall, at all four follow-up visits,intervention children had greater change inweight-for-height z-scores from baseline thancontrol children (p< or =0.001). Weight gaindiffered much less between the two studygroups and was not statistically significant,with the exception of the fourth follow-upvisits. Changes in MUAC also did not differgreatly between the intervention and controlgroup. However, at the first follow-up visit, thedifference was marginally statistically significant(p=0.05).By the end of follow-up at 6 months, 49.2%of children with a low MUAC at baseline had aMUAC greater than or equal to 12 cm and wereconsidered ‘recovered’, 47.6% had a MUAC lessthan 12 cm and were considered ‘not recovered’,2.9% had died, and 0.3% did not pick upeither the first or second distribution and wereconsidered ‘defaulted’. 8 A similar studyconducted in 2009 showed much better results,with a 68% recovery rate after three monthsfood consumption.In 2008, compliance with TSF programmerecommendations was generally poor. Themajority of children lived in households wherethe food was consumed faster than expected,ate less than one-half of the TSF food, or sharedthe food to some extent with other persons inthe household. The authors of the studyconcluded that although the TSF programmehas a beneficial effect on enrolled children, theeffect seen was smaller than expected.Numerous reasons for this were suggested,including:• A large proportion of children enrolledwere not acutely malnourished.• Poor compliance, i.e. food sharing (childrenliving in households with increased foodsharing tended to have less improvement innutritional status than children in households with less food sharing).• Increased food insecurity during the followupperiod so households may haveincreased TSF sharing.A number of recommendations to address thesefindings were made that included:The targeting needed to be improved to excludemore children who do not have acute malnutrition,e.g. ensuring better trained screeners,employing supervisory checks on a portion ofEOS screening and implementing two stagescreening.The intra-household food sharing should beminimised by more research into reasons forsharing, better education of mothers andincreasing TSF rations.The TSF programme should be linked moreclosely to health centres to improve the referralof severely malnourished children for moreappropriate therapeutic care.What challenges has the programmefaced?The programme has encountered a number ofchallenges. The absence of a national nutritionsurveillance system and weight gain monitoringin between the six-monthly screeningsprevents regular outcome monitoring. Currentinformation on the nutrition situation isprovided through woreda-level nutritionsurveys, which are mostly conducted by internationalnon-governmental organisations(NGOs) and cannot be extrapolated to regionalor national levels. Such surveys are triggered ifa serious nutrition problem has been signalledor as follow up to nutritional programmes.The 2008 TSF outcome evaluation studyobserved an inclusion of many children whoare actually not malnourished (46% of thesurveyed group). However, the error of inclusionclustered very closely around the 12 cm cutoff point. This error may be due to the poorquality of the screening (poor health extensionworkers skills/performance in the identificationof malnutrition) or to external pressures toget additional or less beneficiaries on the TSFlist. The screening methodology initiallycombined a pre-selection with MUAC measurementfollowed by the weight-for-heightcalculation and oedema checking. This methodwas complicated and highly prone to errors. In2006, the methodology was simplified and anew MUAC tape, using a colour code and aposter were developed to increase the awarenessand understanding of the children’sentitlement to TSF and TFP.Initially, screening was undertaken bycommunity volunteers that were new andunqualified. The screening is now the responsibilityof the health extension workers that arequalified and regularly trained on measuringtechniques. Where ENCU cannot confirm thevalidity of screening data, WFP reduces theration in line with the previously servednumbers or individuals or withholds the fooddistribution till such a time as a field verificationexercise can be undertaken. Thewithholding of food has however, onlyhappened in a few instances.ENCU’s most recent guidance notes on theEOS screening data quality underscores theneed to present credible screening results foreffective TSF targeting with limited inclusionand exclusion errors. The note suggests morecommunity mobilisation and sensitisation onEOS/TSF, training of anthropometric measurers,the reduction of the number of children tobe screened per HEW per day (from 200-250 to100 per day), more supervision, better qualitydata compilation at kebele, woredas andregional level, application of data quality checkcriteria including plausible maximum levels formoderate acute malnutrition (MAM) (15% ofchildren screened) and SAM (3.2%) and a maximumratio between SAM and MAM.6Currently 2,636 women FDAs are trained in the 168woredas7Outcome evaluation study of the Targeted SupplementaryFood (TSF) programme in Ethiopia. World Food Programme,Ethiopia, June 2009. Jutta Skau, MSc; Tefera Belachew, MDMSc, Tsinuel Firma, MD; Bradley A. Woodruff, MD, MPH.8Although not meeting Sphere standards many considerthat the design of the TSF is unique and particularlyappropriate to the Ethiopian context so that it cannot andshould not be compared to traditional SFPs in terms ofproject monitoring data and outcome measures.76

Field ArticleTSF beneficiaries in Degehabur,Somali RegionWFP has also piloted a programme using the‘gatekeeper concept’ aimed at a reduction intargeting errors. In this approach, a secondscreening done by WFP-employed nurses isundertaken. The gatekeeper concept waspiloted in Afar and SNNPR as those regionswere known to suffer from high numbers offalse positive inclusions. The strong commitmentto the initiative from the side of high-levelregional administration officials was a mainfactor for the success of the pilot in SNNPR.Another round of secondary screening iscurrently underway by WFP for comparisonwith MoH screening. Furthermore, UNICEFhas developed a funding proposal for moretraining and supervision so that screening canbe improved.A Knowledge, Awareness and Practice(KAP) study conducted in 2009 compared childfeeding and care practices of mother/caregiversof children less than three years of age (n= 1525) with their immediate neighbourhoodnon-beneficiaries (n= 1531) in five regions(Tigray, Afar, Amhara, Oromia and SNNPR).The study found that overall, a large proportionof the beneficiary mothers had good knowledge,positive attitude and appropriatepractices related to child feeding compared tothe control group. Significant differences wereobserved in their knowledge about optimaltime of initiation of breastfeeding, duration ofexclusive breastfeeding and optimal time forthe introduction of complementary foodscompared to their non-beneficiary counterparts(P=

Field ArticleValue chain approach to increaseproduction of RUTF/CSB By Yuki IsogaiYuki Isogai is Operations Officer for the Ethiopia Nutrition Project/Private Sector Development <strong>Special</strong>istwith the World Bank. She has a wide range of experiences in private sector development, including in areasof public private partnership (PPP), foreign direct investment (FDI) promotion, tourism development, microsmall enterprise (MSE) development, and women entrepreneurship development.In Ethiopia, 13.7 million people face chronicfood insecurity. Out of this figure, thenumber of people who needed emergencyfood aid reached about 6.2 million in June2009. An additional 7.5 million received aid inreturn for work on community projects as a partof the Productive Safety Net Programme (PSNP).In September 2006, the Government ofEthiopia adopted its second Poverty ReductionStrategy Paper (PRSP), The ‘Plan forAccelerated and Sustained Development toEnd Poverty’ (PASDEP), called for the implementationof the National Nutrition Strategy(NNS) (formulated in 2005/2006) to achieve theMillennium Development Goal 1 (MDG1) forhalving hunger, malnutrition and poverty. TheNational Nutrition Programme (NNP) wasdesigned and launched in 2009 in order to implementthe NNS. It encompasses TherapeuticFeeding Programmes (TFP), which utiliseReady-to-Use-Therapeutic-Foods (RUTF), andTargeted Supplementary Food Programmes(TSFP) which require Corn Soya Blend (CSB).Local demand and supply of RUTF and CSBThe cost of treating the severely and moderatelymalnourished in Ethiopia is prohibitivesince a large share of the feeding products, i.e.RUTF and CSB, must be imported. Table 1reflects the local supply versus demand gap.Furthermore, it is not only the final feedingproducts that have to be imported. As thedomestic supply of inputs is quite limited(Table 2), a large proportion of these, e.g.powdered milk and soya bean oil, also have tobe imported. This means the price of RUTFproduced in Ethiopia is quite high relative toother countries. This is highlighted in Table 3Table 1: Supply/demand gap for RUTF and CornSoya Blend (CSB) (2008-2009)RUTF(Plumpy’nut)CSBDemandLocalproductionProductioncapacity~3,273MT 385MT (11.7%) 1,800MT~126,000MT 9,683MT (7.7 %) 43,200MTTable 2: Supply/demand gap for inputs(2008-2009)MilkPowderSoyaBeansSoyaBean OilDemand Supply Remarks982 MT None No. of milking cows~9.9 millionTotal milk output~976,615 MT74,762 MT 6,790 MT7,242 MT Nonewhere costs are compared with Malawi. Inaddition, the freight costs are substantial, e.g. inthe case of the RUTF, Plumpy’nut, the airfreight costs are $2.63/kg, while the productioncosts are $3.46/kg. The result is that only alimited share of the total number of malnourishedpeople in Ethiopia can be treated usingthese products.The total value of imported inputs aloneadds up to $45.99 million/year, while the totalRUTF/CSB market is worth, on average, about$60 million/year. This market is significant, andwhile development partners (DPs) are willingto purchase RUTF from local producers, localproduction has not met the demand so far(reflected in Table 1). However, investments inthese products are profitable. For example,according to a feasibility study on powderedmilk conducted by the Amhara InvestmentOffice, the simple rate of return is 27.6%, whichby any business standards, is profitable.Thus, it appears that opportunities for developingagro-processing businesses withinEthiopia have been missed. Furthermore,promotion of local production of these productswould improve the coverage/timeliness of thetreatment of malnutrition and contribute toimport substitution.Why are local producers not meetingmarket demand?Given the large market, the question arises,why the private sector in Ethiopia has not yetresponded to meet this need, particularly sinceDPs are willing to procure the products fromlocal producers. The World Bank EthiopianNutrition Team has conducted a thoroughreview of this question and identified threemajor <strong>issue</strong>s, which are interlinked with eachTable 3: Production costs of Plumpy’nut(Ethiopia vs Malawi)Ethiopia (2009) Malawi (2006)Ingredients InputCosts/kg*Milk powder(full fat)% of total InputCosts/kg*% of total$0.85 40.8% $0.63 44.3%Sugar $0.28 13.5% $0.17 12.0%Vegetable $0.38 18.3% $0.18 12.7%oilPeanut $0.19 9.1% $0.18 12.7%butterMineral/Vit. $0.38 18.3% $0.26 18.3%mixSub-total $2.08 100.0% $1.42 100.0%Other costs* $1.38 $1.18Total $3.46 $ 2.60*Other costs includes labour, quality control, packaging,energy and overheadsother: lack of market information, low access tofinance and a weak value chain (see Figure 1).Lack of market informationAs a number of actors are involved between thefarmers and the customers and the chain isquite segmented, market signals are not flowingdown through suppliers. Thus, producers,including input suppliers and farmers, do notrespond to the market as much as they could.Low access to financeCommercial banks normally consider the risksof agro-processing business so high that thelevel of collateral for related investment is setvery high (up to 200%). In addition, the bankingsector lacks capacity to evaluate properly therisks of new business areas, like RUTF/CSBproduction. Therefore, processing companiescannot obtain loans from banks for both capitalinvestment and working capital.The existing processing companies particularlysuffer from lack of working capital. Asagricultural products are normally available foronly six months after the harvest due to lack ofstorage, the factories have to purchase inputsduring the six months for the whole year ofoperation. This requires quite substantial workingcapital. However, banks are reluctant tolend working capital without high collateral,although a loan for working capital is for shortterminvestment which is low risk. As a result,the operation rate (actual production/productioncapacity) of these factories is very low, e.g.average of 40% or even less.Weak value chainEven if the factories had enough working capitalto purchase all required inputs, a problemstill remains. There is insufficient supply ofquality inputs. This applies for the whole valuechain, i.e. RUTF/CSB producers and inputs(oil/powdered milk suppliers). Improvementin the quality and stability of input supplythroughout the value chain is essential toincrease the operation rate and reduce the levelof risk for the industry.Value Chain Approach with strongPublic Private Partnership (PPP)As reflected in Figure 1, production cannot beincreased through a conventional approach that<strong>focus</strong>es on only one of the <strong>issue</strong>s. All the <strong>issue</strong>saffecting the value chain need to be tackled atthe same time. To do so, a strong Public PrivatePartnership (PPP) involving private companies,commercial banks, farms, NGOs supportingfarmers, UNICEF, WFP and the World Bank isrequired. Each actor will need to play a distinctrole at various links in the chain. Productionwill not increase if one link is broken.78

Field ArticleNewsFigure 1: Why is local production low?MarketDPsLowProductionLittle MarketInfoLocal ProducersTALoan/GuaranteeBanksTALowProductionLowProductionInput SuppliersBrokersFarmersLow Accessto FinanceWeak FinancialSectorMFIsDP: Development partner; TA: Technical assistance;MFI: Micro-finance initiativeTo improve the market information flow, DPsincluding the World Bank, can conduct feasibilitystudies and organise dissemination workshops,inviting a wide range of stakeholders, i.e. farmers,investors and bankers. This will improve understandingof the market amongst key actors.Bank reluctance to lend to what they perceive ashigh risk agribusiness, unless businesses have largecollateral, could be addressed through ‘guaranteefunds’. These funds cover a certain percentage ofdefaults, could be provided by DPs and wouldhelp to significantly reduce the risk for banks. Atthe same time, technical assistance (TA) to thebanking sector is a key to improve their capacity toevaluate the profitability/feasibility of new businesses.The perception of banks that the agribusinesssector carries risk is not completely unfounded.Due to the relatively primitive production systemsat farm level, the existing processing companieshave to operate factories with unstable supplies ofinputs. New investors therefore hesitate to enterthe business as a ‘high tech’ factory cannot be operatedwithout a strong supply chain. At the sametime, there are several NGO projects supportingsmall farmers to improve the productivity andquality of agro-products which are seeking markets(producers). Support for processing companiesshould be linked to these efforts on the ground.The advantages of the value chain approach toincrease the production of RUTF/CSB are:• The targeted market is large and relativelysecured by development partner’s funds• A value chain approach simultaneouslysupports different elements of the value chain,e.g. RUTF producers, groundnut farmers, milkpowder producers, thereby creating synergy ofimpact. This contrasts with more conventionalapproaches where there is less joined upsupport.• It has cross-sectoral effects, i.e. impact onhumanitarian activities and national economicgrowth• It significantly contributes to importsubstitution• It improves the access to and the timeliness ofdelivery of relevant food products for needybeneficiaries.As a pilot study, the Ethiopia World Bank Nutritionteam has conducted a thorough feasibility study ofpowdered milk production and means of promotingan investment and link to NGO funded dairyprojects, as well as the RUTF producers.For more information, contact: Yuki Isogai, email:yisogai@worldbank.orgStandardised training package onSMART methodology released byACF CanadaAction Contre la Faim (ACF) Canada, with the support of the Inter-Agency Standing Committee(IASC) of the Global Nutrition Cluster, has released the English version of the SMART MethodologyStandardised Training Package (STP).The STP hopes to provide future survey teams with a standardised means of preparing themselveson how to use SMART. With some 400 persons trained in over 20 countries by ACF Canada,participant feedback has been used to design a comprehensive and robust tool that can be appliedin different contexts for persons with varying levels of competency. The STP has incorporated therecent (Version 2) methodological advancements in SMART and also contains easy-to-followpresentations, simple exercises, trainer’s tips, videos as well as helpful assessment tools to complementthe training experience.Access the STP by registering at http:// www.smartmethodology.orgUse this site to provide feedback, for questions or further guidance. If you experience any difficultiesaccessing the site, contact: info@smartmethodology.orgThe French version is due for release shortly.Treatment of severe malnutritionnow a core competency in healthBy Ann Ashworth and Alan Jackson, International Malnutrition Task ForcePaediatricians took a giant step forward at the International Paediatric Association (IPA)Congress in Johannesburg in August 2010 when they resolved that treatment of malnutritionshould become a core competency. It also had the support of the WHO, UNICEFand other United Nations agencies.The full Resolution adopted at the Congress states:1. Paediatricians and related health professionals should take responsibility forleadership in addressing the urgent problem of severe malnutrition in all its forms,as it is a major cause of death and disability of children.2. IPA member societies should assure that all paediatricians and related healthprofessionals have the identification and treatment of severe malnutrition as a corecompetency, and are certified accordingly.3. National societies should examine the curriculum, training activities, and evaluationprocesses to ensure the inclusion of the identification and treatment of severemalnutrition as a core competency.The Resolution is one of several efforts by the International Malnutrition Task Force toplace the problems of childhood malnutrition firmly on the agenda for paediatriciansaround the world. A similar Resolution was also adopted by nutritionists and other delegatesattending the Africa Nutritional Epidemiology Conference in Nairobi in October2010, accepting their responsibilities and the need to take action in order to effectivelyaddress the problems of severe malnutrition.An important next step will be for national groups to work together to translate theResolution into action. It is expected that international and local non-governmentalorganisations (NGOs) will be invited to play an important role and that key activities willinclude:• situation analyses• advocacy to governments influencing deans of medical and nursing schools toinclude nutrition/malnutrition in curricula• in-service training for all health workers on prevention and treatment ofmalnutrition• developing effective training teams and communication strategies• identifying champions who will motivate others• assessing nutritional status at every contact to identify children at risk.A report of the IMTF pre-congress workshop can be found at http://www.imtf.org.79

Building national capacityin HIV and NutritionBy Kate SadlerKate Sadler is a nutritionist and senior researcher with a <strong>focus</strong> on nutrition in emergencies at theFeinstein International Centre. She worked previously with Valid International for six years andwith Concern Worldwide for four years prior to that.Researchers from the Feinstein International Centre and the Friedman School of NutritionScience and Policy at Tufts University in the USA are contributing to the development of a preservicetraining (PST) curriculum in HIV and nutrition for students of a variety of healthprofessions in Ethiopia, as part of the ‘Food by Prescription (FBP)’ programme (see researchpiece in this <strong>issue</strong>).A Training the Trainers (TOT) Workshop was successfully delivered in September 2010 andthe training manual, ‘Nutrition and HIV/AIDS: A Training Manual for Nurses and Midwives’ 1 wasused with some modifications for the delivery of the course. The course consisted of 12modules that were delivered in a five and a half day workshop, with some of the modulesbeing merged. Sessions included the FBP programme, treatment protocols for adults and childrenliving and/or affected with HIV and/or living with severe and or moderate acutemalnutrition.The workshop included one half day of field visits, with faculty staff assigned to one of threegroups as follows:Group 1: Monitoring and Evaluation of FBP programme in Shashemene clinic 2.Group 2: Monitoring and Evaluation in an anti-retroviral treatment (ART) clinic in AwassaHospital (with no food supplementation, for comparison purposes).Group 3: Monitoring and evaluating the commodity logistics system in relation to theprogramme.A total of 17 faculty members and associates were trained representing four faculties(Nutrition, Public Health, Nursing and Paediatrics) from different universities. Faculty membersfor each of the faculties have, since the workshop, begun to develop plans for integratingmaterials from the workshop into their existing courses. The Nursing/ Paediatrics and PublicHealth faculties have specific courses that they can integrate the materials into. The Nutritionfaculty found that the material could be introduced in almost all their courses. All groupsfound the material extremely relevant.A key discussion held at the end of the course was the potential for integrating the trainingmaterial into existing activities. A positive outcome of the training was that faculty staff withinHawassa University are able to work together to develop a proposal to roll out the training toother faculty members. This will allow for sustainability of the rollout process within HawassaUniversity.Kate Sadler, Ethiopia, 2010The pre-service traing group at Hawassa UniversityScale up Nutrition (SUN):a new global movementThe Tufts team anticipates working withsome of the faculty members at HawassaUniversity in Year 2 to support them as theylead the TOT rollout. Jimma 0Universitycould also be targeted for the next phase,thus expanding the national capacitybuilding efforts in this crucial area of nutritionin Ethiopia.For more information, contact: KateSadler, email: kate.sadler@tufts.edu1East, 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.Arusha, Tanzania: ECSA-HC.In April 2010 a Road Map to Scale Up Nutrition (SUN) was launched based on a SUNFramework endorsed by over 100 entities including national governments, UN agencies,civil society organisations, academia, philanthropic bodies and the private sector. TheSUN Road Map details the means through which national, regional and internationalactors will work together to establish and pursue efforts to Scale up Nutrition in countrieswith a high burden of malnutrition, utilising proven interventions and through multisectoraland integrated nutrition <strong>focus</strong>sed development policies and processes.For more information on SUN, go to http://www.unscn.org/en/nutworking/scaling_up_nutrition_sun/sun_purpose.php1See news piece on this page.NewsRegional CMAM meetingin Ethiopia 2011In collaboration with the Government of Ethiopia and in consultationwith national and international agencies, the EmergencyNutrition Network (ENN) is planning a three day regional meetingon the scale-up of community based management of acutemalnutrition (CMAM), to be held in Addis Ababa in November2011. The aim of the meeting is to facilitate the sharing of lessonslearned from Ethiopia, across the region and beyond, and to buildconsensus on a range of <strong>issue</strong>s relating to national scale-up of servicesto manage severe acute malnutrition.A key allied global initiative under which this meeting is locatedis the Framework for Action to Scale Up Nutrition (SUNFramework) 1 . The Road Map for SUN clearly articulates a pressingneed for improved sharing of experiences between countries andregions on policy development and programming as one mechanismby which to build national capacity in nutrition. A second,smaller half day meeting will take place on Day 4, when the key<strong>issue</strong>s of relevance to the SUN will be discussed in relation to CMAMand scale up of actions to address all forms of undernutrition.The meetings are co-funded by Irish Aid and the UKDepartment for International Development (DFID).The Ethiopia meeting will identify and document the policyenvironment, coordination, funding mechanisms, technical andoperational considerations that are required to establish, expandand sustain service provision at national level. This forum is alsointended to provide policy and programme related informationand guidance to countries from Africa and Asia that are planningnational level scale-up of CMAM. The forum should inform donorsand encourage the most effective use of future resources.Anticipated participants will be from government in a minimumof 16 countries from Africa and a number of Asian countries.Participants will be facilitated to write-up the CMAM scale-upexperience in their respective countries as background papersand for presentation at the meeting. Donors, United Nationsagencies, humanitarian agencies and ready to use therapeuticfood (RUTF) producers will also be represented. A variety of mediawill be considered to reach stakeholders unable to attend themeeting.The meeting will <strong>focus</strong> on ten thematic areas. These are:• Policy environment, such as institutional stakeholder interests,governments ability to take on and sustain roll-out strategies.• Funding, such as estimated costs, sources, mechanisms,sustainability.• Linkages within the nutrition sector and other sectors.• Effectiveness of public health systems to support national rolloutstrategies.• Operational <strong>issue</strong>s, such as supplies, coverage and impact,scale up/scale down considerations in emergency response.• Capacity development, with particular regard to nationalhealth systems.• Linkages with HIV programming, particularly in high-burdencountries.• Integrating infant and young child feeding measures intoCMAM, as well as other preventative strategies.• Future research needs and priorities.• RUTF supplies, including local production challenges, privatesector involvement, and development of standards within theindustry.A meeting report will be produced by ENN, providing an overviewof the key <strong>issue</strong>s identified and recommendations for researchand policy directions and actions. Background papers preparedon selected country experiences with lessons learned in specificthematic areas will also be produced.The Goverment of Ethiopia focal point for this meeting is Dr FerewLemma, Senior Nutrition Advisor, Federal Ministry of Health,Ethiopia. Contacts for the ENN organising team are Emily Mates(Ethiopia), email: emily@ennonline.net and Marie McGrath (UK),email: marie@ennonline.net80

NewsCredit: M Lung'aho, Ethiopia, 2010Training/workshopparticipantsTraining and workshop to integrateIYCF in CMAM Summary of report 1Between 23 and 31 August 2010, World VisionInternational (WVI) and the Emergency NutritionNetwork (ENN) held a six day training of trainers (TOT)and two day companion planning workshop inEthiopia on integration of infant and young childfeeding (IYCF) activities into community basedmanagement of acute malnutrition (CMAM)programmes. The training took place in Shone ADP 2and the workshop in Hawassa Region.The aim of the TOT workshop was to strengthenthe technical capacity of World Vision country,regional and headquarters (HQ) staff. The aim of thecompanion workshop was to contribute to WV’sstrategic planning to integrate IYCF support into itsCMAM programmes at country, regional and globallevel. The companion workshop paid particularconsideration to locating integration within theEthiopian Governments policies and programmaticguidance.ENN consultants from Nutrition Policy and Practice(NPP) led the training, supported by the ENN and WVIheadquarter– Nutrition Centre of Expertise (NCOE)technical staff.Fourteen WV programme staff from Sierra Leone,Zimbabwe, Zambia, Ethiopia, Rwanda, Kenya andUganda participated in the TOT. They were joined bystaff from regional and global NCOE who supportEastern and Southern Africa, and WV support officestaff from Canada and the US. An additional fiveparticipants participated in the two day planningworkshop from WV regional offices, the SudanMinistry of Health (MoH), and Concern Worldwide.Five day TOTThe five day TOT used the ‘Integration of IYCF Supportin CMAM’ 3 training materials as the technical content.It was a competency based ‘hands-on’ training builtaround adult learning principles. The approach usedthe experiential learning cycle (a learning cycle ofexperience, reflecting, thinking and acting), employinga variety of training methods. Two days of practicesessions (Days 4 and 5) took place in health facilitieswithin a half-hour’s drive of the Shone ADP.The end of training evaluation was positive.Participants highlighted sessions on behaviourchange, counselling skills, forming action andsupport groups, the ‘adult learning’ approach to theworkshop facilitation, and the practical sessions asespecially helpful. Recommendations for future TOTwere more practical field sessions, more preparationfor field sessions to include orientation of managersof CMAM programmes, and more practical applicationof HIV and infant feeding recommendations.Competency ratings (self assessment) increasedsignificantly pre and post training.Two day planning workshopThe specific objectives of the two day companionworkshop were to share cross country/agency experienceson IYCF and CMAM, develop WV action plans torollout the ‘Integration of IYCF Support into CMAMProgramming’ training material, define operationalresearch questions and explore WV monitoring andevaluation (M&E) around IYCF in CMAM. The 2 dayplanning benefitted from the presence of Ethiopianuniversity staff to consider Ethiopia-specific recommendations.Appreciative Inquiry (AI) methodology 4 was usedto explore how IYCF can best be integrated into existingCMAM programmes through working groups.Integration was considered for key contact points incommunity mobilisation, Outpatient TherapeuticProgramme (OTP), Supplementary FeedingProgramme (SFP), Stabilisation Centre (SC), and othercommunity services. Integration was also consideredfor national level pre-service and in-service training,and by international agencies and local partners.OpportunitiesParticipants envisaged good synergy and many benefitsof IYCF integration in CMAM including improvedacute and longer term nutrition and developmentaloutcomes for children, reduced relapse amongsttreated children, and strengthened communitycomponent of CMAM programming and continuity ofcare. There were many suggestions for integration atcontact points. Specific to Ethiopia (detailed in thereport) priority actions suggested to enable IYCF inCMAM in Ethiopia included training communityvolunteers on implementation of action-orientedgroup sessions and support groups, revitalising theHealth Education Talks at OTP with action-orientedgroup sessions and support groups and, researchingbreastfeeding counselling feasibility at a designatedOTP follow up visit. Additional areas identified foraction included advocacy for IYCF integration withthe existing NNTWG (National Nutrition TechnicalWorking Group) in Ethiopia, development of refreshertraining (in-service), and embedding IYCF into CMAMin pre-service training.Participants considered baseline IYCF informationwas needed to inform integrated activities and mayinvolve surveys of Knowledge, Attitude, Practice(KAP), KAPB (behaviour), KPC (coverage) and communityled assessments, ideally prior to setup.A brief session on M&E discussed the benefits ofdisaggregating programme age data in programmesand the potential to include IYCF process indicators inthe WV CMAM database. Participants considered asimplified measurement approach of IYCF assessmentmay be more realistic for programmes; a simplifiedmethodology should be consistent over time and theresults not compared to those obtained using globally-agreedindicators and measurement guidance.Action plans were developed for six countries(Ethiopia, Kenya, Rwanda, Sierra Leone, Uganda andZimbabwe), the Africa region, two training contexts(SNNP Sudan and Hawassa University, Ethiopia), andfor WV Support Offices and Global Health Offices.Training of community based staff featured stronglyin plans, in addition to policy/strategy updates atcountry level, engaging in operational research, anddocumentation of best practice and lessons learnedto inform programming.At an agency level, opportunities for strengtheningtechnical capacity identified were WV countryoffice assistance through WV-NCOE/Regional Office,development of institutional capacity in HawassaUniversity, developing linkages with UNICEF, andundertaking operational research.ConstraintsThroughout both the training and workshop, participantsidentified many constraints to integrating IYCFin CMAM. The lack of a defined operational model forintegrated programming limited scale up of integrationin action plans. Key operational research needsidentified were around impact on nutritional andprogramme outcomes, effect on IYCF integration onprogramming caseload, feasibility of integration atkey contact points, how to monitor and evaluateprogramming within the existing CMAM frameworkand cost-benefit analysis.Given the gaps in operational guidance, theimportance of capturing experiences on integrationto inform programming and the need for collaborationand partnership were highlighted. Participantssuggested it may benefit to learn by small scale integration,e.g. integrate in one geographic area, or <strong>focus</strong>on strengthening IYCF with one key contact point.ConclusionsThe facilitators concluded that to move forward onIYCF in CMAM at a national level, it is essential to identifykey government and agency partners, as well asseek to locate interventions within national strategiesand priorities. In future research, the operationalmodel (or models) for consideration should comprisea multi-component intervention including interpersonalIYCF counselling and negotiation,action-oriented group education, peer support andtargeted, context specific messaging.As a next step, an initiative that looked to addressmore closely the integration of IYCF in CMAM in theEthiopian context could draw on Ethiopia’s considerablelessons to date from both OTP scale up and IYCFprogramming. Such an initiative(s) should includeexperience documentation, operational research andrapid dissemination of lessons learned.For more information, contact: Sarah Carr, WorldVision Canada, email: sarah_carr@worldvision.ca1WORLD VISION International-ENN. Collaborative project toenable Integration of IYCF Support into CMAMProgramming at Agency and National Levels. Ethiopia. 23-31 August, 2010. Final Report. 25 September 20102Area Development Programme (World Vision)3Developed by the ENN in collaboration with the partnershipNutrition Policy and Practice Group (NPP) in 2008, fundedby the GNC. Available in English and French at:http://www.ennonline.net/resources/7224This comprised four ‘D’s: discovery (whtat are the benefitsof implementing IYCF and CMAM), dream (what do weexpect to acheive through integration of IYCF in CMAM),design (how to integrate IYCF into CMAM contact points)and delivery (action plan development).5This comprised four ‘D’s: discovery (whtat are the benefitsof implementing IYCF and CMAM), dream (what do weexpect to acheive through integration of IYCF in CMAM),design (how to integrate IYCF into CMAM contact points)and delivery (action plan development).81

NewsUpdated HTP resourcematerial for nutrition inemergencies trainingThe Harmonised Training Package: Resource Material for Trainingon Nutrition in Emergencies (the HTP) is a resource package to aidcourse development on nutrition in emergencies. The HTP is aninitiative of the IASC Global Nutrition Cluster (GNC) and has beenendorsed by the GNC and its member’s agencies.The HTP update to produce Version 2.0 is being undertaken ina 2 year ENN/NutritionWorks (NW) collaborative project 1 , fundedby the US Office for Disaster Assistance (OFDA). Numerousexperts from many different organisations have been involved inwriting and reviewing content for Version 2, and have participatedgenerously in the initiative.The HTP, Version 2 (2011) is being produced by the ENN. The HTPis 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 (seebox), each module containing technical information, trainingexercises and a resource list. It can also be used by individuals toincrease their technical knowledge of the sector.ResearchEarly stages of a ‘Food byPrescription’ programme forHIV infected adultsBy Elizabeth Bontrager and Kate SadlerElizabeth Bontrager joined the Feinstein InternationalCentre at Tufts University in 2008, where she coordinatesTufts’ involvement in the Food by Prescriptionprogramme. She holds a M.Sc. in Food Policy and AppliedNutrition.Kate Sadler is a nutritionist and senior researcher with a<strong>focus</strong> on nutrition in emergencies at the FeinsteinInternational Centre. She worked previously with ValidInternational for six years and with Concern World- widefor four years prior to that.The authors acknowledge the support of USAID and the Food byPrescription team at Save the Children US.The HTP ModulesSection 1: Introduction and conceptsModule 1: Introduction to nutrition in emergenciesModule 2: The humanitarian system: roles, responsibilitiesand coordinationModule 3: Understanding malnutritionModule 4: Micronutrient malnutritionModule 5: Causes of malnutritionSection 2: Nutrition needs assessment and analysisModule 6: Measuring malnutrition: individual assessmentModule 7: Measuring malnutrition: population assessmentModule 8: Health assessment and the link with nutritionModule 9: Food security assessment and the link withnutritionModule 10: Nutrition information and surveillancesystemsSection 3: Interventions to prevent and treat malnutritionModule 11: General food distributionModule 12: Management of moderate acute malnutritionModule 13: Management of severe acute malnutritionModule 14: Micronutrient interventionsModule 15: Health interventionsModule 16: Livelihoods interventionsModule 17: Infant and young child feedingModule 18: HIV/AIDS and nutritionModule 19: Working with communities in emergenciesSection 4: Monitoring, evaluation and accountabilityModule 20: Monitoring and evaluationModule 21: Standards and accountability in humanitarianresponseVersion 2 now available (Jan 2011) – Modules 6, 7, 9, 16 and 19.Each module will be available both in word format and as aprinter friendly pdf version. All modules will be posted on theUNSCN site as they become available.Version 2.0 is being produced in English, with translations tofollow.For more information on the HTP Version 2 revision, contactCarmel Dolan Carmel Dolan, NutritionWorks,email:cmadolan@aol.com1NW was commissioned by the GNC to develop Version 1.0 launched in 2008.As global interest in Ready-to-Use Therapeutic Foods (RUTFs) hasrisen, their use has begun expanding beyond the realm of treatingchildren with severe acute malnutrition (SAM). Of recent interestwithin the humanitarian community is the use of such products in treatingmalnourished adults living with HIV/AIDS. In this case, the food is usedmuch like a medical prescription, intended to address malnutrition so thatthe disease can be treated more effectively.As the medications for anti-retroviral treatment (ART) have become morewidely available in developing countries, greater attention has been paidto the associated role of malnutrition in determining the effectiveness ofthese drugs in HIV treatment programmes. In settings both with and withoutwidespread food insecurity, weight loss and wasting are significantpredictors of mortality among people living with HIV/AIDS (PLHIV),even for those undergoing anti-retroviral treatment. 1,2 Furthermore, malnutritionat the outset of ART is strongly associated with early mortality aftertreatment is begun. 3,4Evidence to dateThe majority of the existing research in this area has taken place inresource-adequate settings. Here, individuals receiving food supplementshave shown improved protein and energy intake, but no consistentimprovements in body weight or fat mass, and only minimal improvementsin CD4 count, as a measure of disease progression. 5Thus far, little has been done to examine the relationship between HIV,food supplementation and survival in resource-poor environments, wheremalnutrition among PLHIV may be linked to food scarcity rather than (orin addition to) disease, and where the effects of supplementation may bequite different. One controlled study demonstrated that although a groupreceiving food supplements (in this case, individual rations of corn soyblend (CSB) and vegetable oil) showed greater adherence to ART than thecontrol group (which received no food), there was no significant differencein survival, CD4 count, or weight gain between the groups. 6 Another study1Tang A, et al. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviraltherapy. JAIDS 2002;31:230-36.2Paton, NI, Sangeetha, A Earnest and R Bellamy. The impact of malnutrition on survival andthe CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Medicine(2006), 7, 323–330.3Zachariah, R., Fitzgerald, M., Massaquoi, M., Pasulani, O., Arnould, L., Makombe, S., Harries,A.D., 2006. Risk factors for high early mortality in patients on antiretroviral treatment in arural district of Malawi. AIDS 20, 2355-2360.4See footnote 25Koethe JR, Chi B, Megazzini K, Heimburger D, Stringer JS. (2009a) MacronutrientSupplementation for Malnourished HIV-Infected Adults: A Review of the Evidence in Resource-Adequate and Resource-Constrained Settings. CID 2009;49: 787-798.6Cantrell 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 toimprove adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. JAcquir Immune Defic Syndr 2008; 49:190-195.82

Researchcompared the effects of a supplementary fortifiedspread to those of CSB on acutelymalnourished adults starting ART in Malawi. Itfound that those individuals receiving the fortifiedspread (a lipid paste made from peanuts)showed greater improvements in several measuresof wasting than those individualsreceiving the CSB, but also showed no significantdifferences in mortality, CD4 count, ARTadherence, or quality of life 7 .The Food by Prescription Programme(FBP) in EthiopiaFor all of the above reasons, there is growinginterest in programmes designed to address thelinks between nutrition and HIV, throughwhich malnourished individuals on an ARTtreatment regimen are ‘prescribed’ therapeuticfood rations in addition to theirmedications.In Ethiopia, the Ministry of Health(MoH) began implementing the‘USAID/ Food by Prescription (FBP)’programme in the summer of 2010,with technical assistance provided bySave the Children US. Thisprogramme targets beneficiariesdiagnosed with either moderateacute malnutrition (MAM) or SAMwith two different products for up tosix months – fortified blended food(FBF) packaged in individual serving-sizedsachets for MAM cases andRUTF (Plumpy’nut) for SAM. Theaim is to improve nutritional, clinical,and functional outcomes beyond thetime period of the intervention itself.HIV-infected adults who presentwith malnutrition at participatinghealth centres are prescribed foodrations according to their nutritionalstatus (MAM or SAM). The rationsare prescribed during monthlyappointments, together with clients’ART medications, and are distributeddirectly from clinic pharmacies.Clients are monitored closely byhealth centre staff who collect bothanthropometric and disease progressiondata during monthlyappointments.Examining the impact of food on healthand nutrition outcomesA number of partners are involved in the deliveryand assessment of the overall FBPprogramme, including a group of researchersfrom the Feinstein International Centre and theFriedman School of Nutrition Science andPolicy at Tufts University in the USA. Thisteam from Tufts is carrying out an effectivenessevaluation of the programme, to determine theimpact of food supplementation on diseaseprogression and malnutrition among individualson ART.Specifically, the Tufts study will examine theeffects of a food ration prescribed to malnourishedHIV infected adults on recovery frommalnutrition, HIV disease progression, patientsurvival, and persistence of any benefit sixmonths after exit from the programme.Primary outcomes, to be compared betweenintervention and control groups, includepercent weight change, change in CD4 count,survival at six months from programme enrolment,and Body Mass Index (BMI) at sixmonths after discharge. The effects of the foodKate Sadler, Ethiopia, 2010prescriptions will also be disaggregated andcompared according to the amount of time individualshave been on ART, and baselinenutritional status.The study follows a sample of recruited FBPparticipants from a number of randomlyselected health centres included in Phase I ofthe programme and a ‘control’ sample recruitedfrom sites that have access to ART but are notyet being prescribed a food ration (to beincluded in Phase II of FBP programme rollout).Data for study participants, including all variablesneeded to assess outcomes of interest aswell as confounders, are collected duringscheduled monthly clinic appointments. Thisincludes completion of a patient register and aHousehold Food Security Questionnaire.Discussing ART admissions,Hawassa Hospital ART clinicA qualitative component will be added to theimpact study during the second year, to examine<strong>issue</strong>s of compliance to the food protocoland utilisation of the ration. Data will becollected for this through a series of <strong>focus</strong>groups and key informant interviews.Challenges thus farIn the early stages of FBP implementation, oneparticular challenge for the Tufts study hasbeen the reliance on health centre staff for datacollection. As this programme is included in theEthiopian MoH National Guidelines forHIV/AIDS and Nutrition, MoH clinic workersare required to participate in the implementationand data collection activities for theprogramme. This often represents an additionalburden on understaffed clinics with large caseloads.It is essential that health workers receivecomprehensive training as part of the FBPprogramme rollout, since many are otherwiseunfamiliar with the measurement of malnutritionindicators such as BMI and mid-upper armcircumference (MUAC). A clinic worker trainingregimen serves as part of the introduction toand rollout of FBP, but it is often difficult forprogramme staff to identify and locate all therelevant staff. This means that some eligibleclients may present at the clinic but not be seenby trained personnel, and thus not be enrolledin either the programme or the study. In addition,once health workers have been adequatelytrained and are comfortable with the measurementof relevant indicators, high rates of staffturnover have meant that trained workers maybe lost over time and replaced by new,untrained staff. FBP programme staff and theTufts team will continue to visit these sitesfrequently to ensure that the implementation ofthe programme and the data collection arebeing performed as necessary for both thestudy and the programme as a whole.Such large programmes inevitablyrun into challenges in the way ofdelays in procurement and pipelinebreaks as these systems are first putinto place. The rollout phase of FBP inEthiopia has experienced this as well,and both the programme and thestudy have needed to accommodatechanges to the nutrition protocol asprogramme staff have worked toaddress these challenges. The standardisationof the food protocol toaccount for changes in the availabilityof commodities has been accommodatedinto the study design.Strenthening national capacityThe Tufts team is also supporting preservicetraining curriculumdevelopment, piloting, and disseminationon nutrition and HIV, inpartnership with the Department ofNutrition at Hawassa University (seenews item in this <strong>issue</strong>). This establishmentof an HIV and nutritioneducational component for healthprofessionals is intended to alleviatesome of the inconsistencies in trainingand awareness of the nutritionalneeds of PLHIV at the serviceprovider level.ConclusionsThis FBP programme has the potentialto improve both the capacity of healthprofessionals to address the nutritional needs ofPLHIV and the effectiveness of HIV care andtreatment in Ethiopia. Currently, there isalmost no documented programme data thatcan help answer questions around the additionalbenefits to PLHIV and costs of addingfood to an ART regimen, or of the successes andchallenges to scaling up a programme of thistype. As HIV programmes embrace the need fora nutrition component, there is an urgent needto ‘learn by doing’ and the phased rollout of theFBP programme in Ethiopia provides a greatopportunity to do just this. Data collection isanticipated to take place until December 2011,with results expected in early 2012.For more information on the research, contactKate Sadler, email: kate.sadler@tufts.edu orElizabeth Bontrager, email:elizabeth.bontrager@tufts.edu7Ndekha M, van Oosterhout JJ, Zijlstra EE, Manary M,Saloojee H, Manary MJ. (2009b) Supplementary feedingwith either ready-to-use fortified spread or corn-soy blendin wasted adults starting antiretroviral therapy in Malawi:a randomized, investigator blinded, controlled trial. BMJ2009; 338:b1867.83

Emotional Stimulation for acutely andseverely malnourished children in SNNPRBy Dr. Alessandro Conticini and Mrs. Valérie QuéréDr. Alessandro Conticini joined Play Therapy Africa as Co-Director after havingheaded the Child Protection, Adolescent Development and HIV Programme atUNICEF Ethiopia, and previously senior researcher for the Macroeconomics andHealth Commission in WHO Head Quarter. His work includes directing research,programme formulation and evidence-based policy development for vulnerable childrenin developing countries.Mrs. Valérie Quéré is a human rights lawyer and child psychotherapist, with amaster degree in international human rights and a number of certifications as a PSStherapist. Mrs. Quéré has been working in the area of justice and gender basedviolence in several countries. Valérie directs training programmes for law enforcementagents, social workers and child psychotherapists.Research has shown that the survivalrate of malnourished children duringfood crises critically depends not juston the availability of appropriate therapeuticfood, but also on the emotional andphysical stimulations available for both thechild and the caregiver (usually the mother).Studies have shown that the combined use ofemergency nutrition support and emotionalstimulation techniques provides for lowermalnutrition rates, a higher rate of childsurvival, and quicker recovery from malnutrition1 . Hunger and food insecurity cause seriousmental or cognitive disabilities, especially inyoung children due to chronic nutritionaldeficits, lack of social/emotional stimulation,parent-child emotional detachment, withdrawaland neglect. At the same time,parent-child emotional deficiencies causereduced food intake and significantly diminishthe overall survival rate of children 2 .In many emergencies, hunger and food insecuritycause severe stress and damage thepsychosocial well-being of the affected population.Conversely, the psychosocial effects of anemergency can impair food security and nutritionalstatus. The latter is particularly relevantfor children and their caretakers.During the 2008/2009 and 2009/2010 foodcrisis in Ethiopia, with support from thePulitzer Foundation and collaboration withUNICEF, Play Therapy Africa (PTA) took aleadership role in the management of 49outreach therapeutic sites (that include but gobeyond OTP sites) and one hospital in theSouthern Nations (SNNPR). This role involvedthe introduction of an approach wherebyemotional stimulation and good parentingskills were promoted, in addition to emergencytherapeutic food distribution for severe acutemalnourished (SAM) children.PTA would like to thank the Pulitzer Foundation, Ceil, Michaeland Christina, for their tireless and enthusiastic support. Ourgratitude also to UNICEF for their facilitation and aid.MethodologyThe intervention sites were selected by theRegional Bureau of Health on the basis of theexpected severity of food shortage in the monitoreddistricts. The project and its initialmethodology were presented to members of allNGOs working with malnourished children inSNNPR. These professionals had an opportunityto express their views and concernsregarding the intervention during a joint reviewmeeting held in Awassa town. Federal andRegional authorities (DPPA and DPPB) werealso present and explained the project and itsproposed methodology to allow for consistencywith mainstream government led programmes.The University of Awassa reviewed the interventionin order to grant ethical approval.One Health Extension Worker (HEW) andone youth/community volunteer were selectedby the Bureau of Health and the Bureau ofYouth respectively in each intervention site.PTA then provided a series of practical trainingthat allowed for basic techniques of emotionalstimulation and good parenting skills to beacquired by trained professionals. Professionalsfrom NGOs working on the sites were alsotrained. The training was practical and experiential,meaning that the participants wereconstantly relating the newly acquired techniquesto the ways they themselves had beenraised, and the ways they were raising theirown children. This allowed for the trainedprofessionals to use the approach in their owndomestic life before adopting it as a modusoperandum in their work place.At the end of the training, professionals wererequested gradually to introduce the techniquesas an additional experimentalcomponent of the existing protocol for themanagement of SAM children. Clinical supervisorswere also deployed by PTA to ensure thequality of services provided. Mothers that hadone or more children enrolled in TherapeuticFeeding Units (TFU), or Outpatient TherapeuticProgrammes (OTP), also received coaching tostrengthen the emotional bond with their childand to stimulate him/her physically andemotionally. The intervention was based oncoaching, not teaching, so that HEW and YouthResearchhad to organise weekly practice groups amongmothers and their children, or organise door todoor visits for enrolled mothers to practice withthem. The coaching would last for a threemonths period. In the selected hospital, thecoaching took place daily with inpatient children.Mothers were then requested to practicethe new skills daily with their children.In 20 sites, professionals were trained tomeasure systematically the physical andemotional outcomes of the intervention. Thesame measurements were conducted for acontrol group in three sites where SAM wasmanaged but this psycho-social interventionwas not being implemented. A total of 555 childrenunder 5 years were followed for thepurpose of the study, 49.9% were girls. Nearlyone-third (32%) of admitted children werebetween 12 to 23 months of age, while theremaining where equally distributed in the agerange of 0-12 months, 24-35months, 36-47months, and 48-60 months.ResultsThe programme has resulted in the followingdocumented achievements:Increased Speed of RecoveryOverall, 31.2% of children who received acombination of therapeutic food and emotionalstimulation were discharged from TFU andOTP at the end of the fourth treatment week. Acumulative total of 40.7% were discharged atthe end of the fifth treatment week. In contrast,no child was discharged before the end of thesixth week in the control group of children whoonly received therapeutic food.Children who were provided with a combinationof emotional stimulation and therapeuticfeeding tended to gain weight at a faster ratethan children who were only provided withtherapeutic feeding. This has direct implicationsin terms of the costs of SAM management.Prevention of emotional, development andintellectual loss/damageMalnourished children in the interventiongroup demonstrated equivalent cognitive,emotional and development capacities as childrencoming from the same socio-economicenvironment who had not been severelymalnourished. In contrast, malnourished childrenin control groups demonstrated a severeloss of cognitive, emotional and developmentpotential. These data were collected using internationallyrecognized assessment tools such asthe ASQ 3 , as well as qualitative emotionaldevelopment observations.Increased resilience from being exposed tofuture severe and acute malnutritionInitial qualitative data indicate that treated childrenand caregivers may be less likely torelapse into acute and severe forms of malnutritioncaused by non-food availability factors.However, this initial finding will need additionalinvestigation before firm conclusions canbe drawn.Cross-fertilisation effectMothers who learnt and practiced emotionalstimulation with their malnourished child1Supplementing nutrition in the early years: the role ofearly childhood stimulation to maximize nutritional inputs.Child and Youth Development 2009. The World Bank,Volume 3, N.1.2Sally Grantham-McGregor et al. Developmental potential inthe first 5 years for children in developing countries. TheLancet 2007. Volume 369, Issue 9555, Pages 60 - 70.3Ages and Stages Questionnaire (ASQ).84

Researchstarted to apply the same techniques with the otherchildren in the household and gradually sensitizedand explained the purpose and benefits of the interventionto their husbands and relatives.Increased empowerment of women and genderbalance in community and family decision makingAn initial qualitative assessment 4 has suggested thatthe effects of emotional stimulation through filial playcoaching have positively impacted not just the level ofmaternal and child depression, but also provided forwomen’s empowerment within the family andcommunities for positive decision making. Most ofthe mothers who participated in the emotional stimulationintervention reported that they felt much closerto their children, and were much more likely thancontrol-group mothers to say that their children hadbecome more independent and playful since recoveringfrom SAM. Many mothers also attributed otherchanges in family life to the programme, includingincreases in paternal involvement in child care, thecessation of harsh punishment by one or both parents,and reductions in domestic violence. None of thecontrol mothers whose children received food alonethrough the OTP programme reported such changes.Interviewed mothers also reported a progressivepositive involvement of neighbours by imitation. Notall women reported equally powerful effects. Factorssuch as severe illness in the child or parent andextreme poverty tended to mitigate the effects ofemotional coaching. However, even many of the verypoor mothers attributed remarkable changes inoutlook and family communication to the emotionalstimulation intervention. This suggests another wayof looking at the link between women’s empowermentand child survival, which has been traditionallyexplained by women’s agency in health seeking. Wesuggest the reverse may also be true; programmes toimprove care-giving may directly contribute towomen’s empowerment, and contribute to thepromotion of a virtuous cycle to help rescue malnourishedchildren in vulnerable communities.While further investigation is needed, the preliminaryresults suggest that a combination of emergencytherapeutic food relief for children coupled withemotional stimulation has a leveraging effect, not juston the short term survival and physical and emotionaloutcomes for children, but also on the prevention oflong term consequences 5 . It also suggests that theintroduction of emotional stimulation techniquesthrough a coaching approach leads to a gradual shiftin the ways children are cared for within the community,increasing the probability of a less violent andmore nurturing environment. Mothers were found tocontinue practising emotional stimulation and goodparenting skills principles well beyond the officialending of the programme, suggesting some form ofsustainability. Finally, the increased speed of recoveryby emotionally stimulated children, and the reportedlow proportion of relapse among them seem tosuggest that the proposed intervention couldcontribute to reducing the overall intervention costs ofsevere acute malnutrition.For more information, contact: Alessandro Conticini,email: ptafrica@hotmail.comThe full report, Emotional Stimulation in the Contextof Emergency Food Interventions Final Report AddisAbaba – August 2009, is available at:www.ennonline.net and search Resources4H. Epstein and A. Conticini. “Each child comes with his own luck”?A psychosocial intervention for malnourished children strengthensparental and spousal bonds in Ethiopia. Manuscript submitted forreview, 2010.5See also S. Grantham-McGregor et al. Nutritional supplementation,psychosocial stimulation, and mental development of stuntedchildren: the Jamaican Study. Lancet 1991;338(8758):1-5.Critical analysis of MICAHprogrammeSummary of published research 1The efficacy of some single nutritioninterventions has been frequentlyand thoroughly evaluated, e.g. ironsupplementation, vitamin A supplementationand salt iodisation. However theeffectiveness (efficacy in real worldsettings) of large-scale integrated healthand nutrition programmes has not beenthoroughly evaluated. A recent articlecritically analyses an NGO-led large scale,multi-country 10 year micronutrient andhealth (MICAH) programme with anadequacy evaluation (a documentation oftime trends in the expected direction).The MICAH programme waslaunched in 1995 by World Vision Canadaand was implemented from 1996-2005 infive African countries, four of which arereported in the paper (Ethiopia, Ghana,Malawi and Tanzania). The programmereached 4 million direct beneficiaries andmore than 6 million indirect beneficiaries.Context specific programme plans weredeveloped for each MICAH countrywithin a programme-wide framework ofobjectives and strategies based on baselineassessments of vitamin A, iron andiodine deficiencies. Multiple interventions,ranging from community-basedsupplement distribution to fortifying anddiversifying foods to national-level advocacyfor national policy changes, wereconducted to address the deficiencies andtarget groups identified. Interventionswere integrated into existing systems,structures and services, wherever possible,to increase potential for sustainability.Table 1 summarises the MICAH activities.Programme areas within countrieswere poor and rural, where few or noother major development organisationswere operational. A comparison ofMICAH data with Demographic HealthSurveys (DHS) data for national ruralsamples suggests that the selected areaswere similar to or worse off than the ruralaverage in each country at baseline. If theDHS data are extrapolated back to thebaseline year, assuming a linear trend,then 1997 MICAH indicators in Ethiopiawere worse than DHS for Vitamin Acapsule coverage in children < 5 years ofage, and better for measles coverage andlatrine access.MethodsCross-sectional surveys were conductedin each programme area at baseline(1996/7), the end of phase one (2000) andthe end of phase 11 (2004). The surveyswere conducted in the same month of theyear in each country. Two-stage clustersampling was employed, in which clusterswere randomly selected usingprobability proportional to populationsize. Key indicators were assessedthrough structured interviews with astandardised questionnaire and collectionof biochemical, clinical and anthropometricdata. The sample sizes per countrywere between 900 and 4801 randomlyselected households per survey. Datawere collected by trained enumeratorsand clinical staff. The data were subjectedto post-hoc methods of quality determinationand if of suitable quality, includedin the adequacy evaluation. The magnitudeof the change for each key indicatorfrom baseline to follow-up final surveywas compared with that observed inpublished controlled trials and reports ofother large-scale programmes. Ifimprovement was of comparable magnitudeto the high end observed incontrolled trials, the impact was consideredhigh. If the improvements were of arange common in other programmes, theimpact was considered moderate. If thechange was smaller than otherprogrammes, but greater than zero, theimpact was considered low. Testing ofdifferences from baseline to follow upwas done by chi-square for categoricalvariables and t-tests for continuous variables.ResultsMost collected data were of moderate orhigh quality and therefore included in theadequacy evaluation.There were moderateto large improvements in vitamin Astatus in Ethiopian school-age children, inchildren less than 5 years of age inTanzania and Ghana and amongst mothersin Ghana. Iodine status improved inMalawi and Tanzania. Anaemia rates andmalaria prevalence decreased in women,pregnant women and pre-school childrenin Ghana, Malawi, and Tanzania, butanaemia increased in Ethiopian women.Large increases were reported for rates ofexclusive breastfeeding (EBF) and immunisation.Child growth improved to themaximum that would be predicted withthe given interventions.DiscussionMost of the collected data were consideredof good quality. The exceptions wereanthropometric data in Ethiopia, anthropometricdata for children under sixmonths in Ghana and Malawi, breastmilkretinol analysis and urinary iodine inTanzania and EBF data in all countries.An evaluation of the change in indicatorsover time (adequacy evaluation) revealed1An adequacy evaluation of a 10-year,four-countrynutrition and health programme. Peter R Berti,Alison Mildon, Kendra Siekmans, Barbara Main andCarolyn MacDonald. Int. J. Epidemiol. AdvanceAccess published March 3, 201085

Researchmany positive results of the MICAHprogramme (see Table 2). MICAH programmestaff reported five aspects of the programmethat they believe uniquely contributed to thepositive results:Results-based management identifiedprogramme activities that were not producingpositive outcomes and allowed for mid-streamcorrections. Examples include:• The decision in Malawi (following the 2000evaluation) to reduce the geographicspread and intensify the intervention in asmaller area to ensure all participantsreceived the interventions.• Provision of regular, intensive technicalsupport in the form of regular emailcorrespondence, monitoring and supportvisits by World Vision technical staff andexpert consultants, and annual trainingworkshops.• Implementation of a broad-based integratedpackage of interventions rather than relyingon a single ‘magic bullet’ intervention.• Community participation in programmedesign, implementation, monitoring andevaluation, which meant some interventionscould be tailored to suit communitypreferences. This was especially relevant toanimal husbandry, where existing practicesdiffered from community to community.• Regular supervision of staff in communities.There were fewer positive results in Ethiopia,which may be because the intervention effortswere diluted over a larger number of beneficiariescompared to other countries. However,there was a positive impact on vitamin A statusin school-age children – both an uncommontarget and success.In an attempt to estimate the impact ofMICAH independent of other local and globalinfluences, comparisons were made with DHSdata for the national, rural samples. Table 2shows the change in those indicators for whichthere were both MICAH and DHS data at baselineor follow-up and end-line. The change ismeasured as the difference of the differences(the difference between the MICAH differencebetween end-line and baseline and the DHSdifference between end-line and baseline). Formost indicators in all four countries, MICAHareas outperformed rural areas of the countryas a whole. The comparison groups are notperfectly suited as control groups - differentyears, baseline conditions and other differencesnot related to MICAH. However, the MICAHperformance compared with the DHS (alongwith the general concordance between coverageand outcome indicators in MICAHsamples) suggests the improvements amongstprogramme beneficiaries are greater than thegeneral trends, and greater than would haveoccurred MICAH was not implemented.Although the evaluation has documentedthe trends over time, it still falls short of a fulladequacy evaluation - the causal pathwayshould be relatively short and simple, theexpected impact must be large and confoundingmust be unlikely.ConclusionsNumerous nutrition and health impacts wereobserved in the intervention areas, often of amagnitude equal to or larger than observed incontrolled interventions or trials. These resultsshow the value of integrated long-term interventions.Table 1: Summary table of MICAH interventions a Ethiopia Ghana Malawi TanzaniaApproximate number of ‘direct’ beneficiaries b 1.8 million 150,000 1.8 million 255,420Total implementation cost, US$ million 16.6 3.3 14.5 3.2Total cost of evaluation, US$ 559,345 147,866 1,293,018 172,243Total cost, US$ million c 17.0 3.5 15.5 3.3US$ per direct beneficiary per year (Phase I/Phase II) 1.39/0.83 3.37/2.14 1.06/5.06 1.85/1.28Objective Strategy Target group/activity Ethiopia Ghana Malawi TanzaniaIncrease Vitamin APre-school children D, T, M P, D, T, A, M D, T, Mintake andbioavailabilitysupplementationSchool-age childrenD, T, A, Mof micronutrients(iron,Post-partum women D, T, M P, D, T, A, M D, T, Miodine and IronPre-school children P, D, T, A, M P, D, T, A, M P, D, T, Mvitamin A) supplementationSchool-age childrenP, D, T, A, MWomen of childbearing age P, D, T, A, M P, D, T, A, MPregnant women P, T, M P, D, T, A, M P, D, T, A, M P, D, T, MFortification Iodized salt promotion P, D, T, A, M P, D, T, A, M T, A, M T, A, MReduceprevalence ofdiseases thataffectmicronutrientstatus(diarrhoeal,parasitic andvaccinepreventable)Build localcapacity fordeliverysystems toimprovemicronutrientstatusDietarydiversificationInfant and youngchild feedingSmall-scale flour fortificationP, D, T, A, M P, D, T, A, MSmall animal rearing P, D, T, A, M P, D, T, M P, D, T, A, M P, D, T, MVegetable gardens P,D,T,A,M P, D, T, M P, D, T, A, M P, D, T, MFruit tree cultivation P, D, T, A, M P, D, T, M P, D, T, A, M P, D, T, MPromotion of optimal T, A, M T, A, M T, A, M T, A, Mbreastfeeding andcomplementary feedingWater andProvision of clean water P, D, T, M P, D, T, M P, D, T, M P, D, T, MsanitationLatrine construction P, D, T, M P, D, T, M P, D, T, M P, D, T, MGarbage disposalT, M T, M T, M T, MconstructionMalaria control ITN distribution P, D, T, M P, D, T, M P, D, T, M P, D, T, MChemoprophylaxis topregnant womenP, D, M M P, D, T, M P, D, T, MTreatment of wormsand parasitesMalaria treatment topre-school childrenP, D, M T P, D, T, M P, D, T, MDeworming of pre-school P, D, T, M P, D, T, M P, D, T, A, M P, D, T, MchildrenDeworming of school-age P, D, T, M P, D, T, M P, D, T, A, M P, D, T, MchildrenSchistosomiasis treatment P, D, T, M P, D, T, M P, D, T, A, M P, D, T, MImmunization Support EPI campaigns P, D, T, M P, D, T, M P, D, T, M D, T, MDiarrhoea treatment Promotion of ORT T T P, D, T THIV/AIDS prevention IEC re: HIV and AIDS T T T TEducationHealth and nutrition IEC to T, M D, T, M D, T, M D, T, McommunitiesStaff and partner training T T T TAdvocacyInfluence national policies A A A Aon nutrition <strong>issue</strong>sUse of media tocommunicate nutrition andhealth messagesT, A T, A T, A T, AP: procurement; D: delivery/distribution (includes both transport to distribution sites such as health centres and direct delivery tobeneficiaries); T: training (includes both community education and training of implementing staff/volunteers); A: advocacy; M: monitoring;ITN: insecticide-treated bednet; EPI: expanded programme on immunization; ORT: oral rehydration therapy; IEC: Information,Education and Communication.aBlank cells indicate that MICAH did not work on that target group/activity in that country.bBased on target population in MICAH programme communities; not including the significant number of indirect beneficiaries(e.g. 4.7 million in Malawi) of MICAH’s national advocacy and intervention efforts (e.g. iodized salt coverage, EPI and vitamin Asupplementation (VAS) campaigns).cCosts are in US$ and based on exchange rates applicable at the time of purchase. World Vision Canada technical support andprogramme management costs, as well as overhead costs at country and Canada levels, are included.Source of table: Berti et al (2010). See footnote 1.Table 2: Standard deviations (SDs) of continuous variables in MICAH surveys in baseline (1996 or1997), follow-up (2000) and endline (2004)EthiopiaSDGhanaSDMalawiSDTanzaniaSDYear 1997 2000 2004 1997 2000 2004 1996 2000 2004 1997 2000 2004Breast milk retinol (μmol/l) 1.4 0.5 22.8 13.6Urinary iodine-school age children(μg/l)25.4 140.0 132.1 76.9 98.0 20.5 38.9Haemoglobin Women (g/dl) 1.8 1.1 1.6 1.9 1.9 1.4 1.7 1.6 2.1 1.9 2.0Haemoglobin – 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(g/dl)Haemoglobin- children

ResearchP Fracassi, EthiopiaAudience of drama held duringPSNP meeting (Laygiant)Linking PSNP and NNP:experiences and challengesSummary of report 1 1Linkages Report (final draft). By Patrizia Fracassi and LioulArecent pilot project <strong>focus</strong>ed on identifyingimplementation and eventuallyscale‐up opportunities to link twonationwide programmes in Ethiopia – theProductive Safety Net Programme (PSNP) andthe National Nutrition Programme (NNP).The selection of the pilot woredas within eachregion was based on the presence of both PSNPand NNP, and specifically on availability of theCommunity Based Nutrition (CBN) programme,a sub-component of the NNP. A further selectionof one kebele in each woreda was made, basedon agro‐ecological signifiers and were as follows:Tigray Region – Hintalo Wajirat, Fikre AlemkebeleAmhara Region – Lay Gayint, Shesho kebeleSNNP Region – Domot Sore, Shiamba kebeleOromia Region – Gameches woreda,Kokuriftu, Agemti, Sre KeloGeto and Homicho kebeles.Preparatory studyA preparatory study was conducted at regionaland community levels between 21st July and22nd August 2009. Primary data were collectedfrom 39 PSNP/NNP stakeholders through keyinformant interviews (KIIs). In addition, a totalof eight <strong>focus</strong>‐group discussions (FGDs) wereconducted in four pilot kebeles involving 28female and 23 male PSNP beneficiaries.It was found that stakeholders held somecommon perspectives of malnutrition, causesand solutions. While those interviewed recognisedthat pregnant and lactating women(PLW) and children are the most nutritionallyvulnerable groups, their answers indicated aDrama (counselling by a HEW)conducted during PSNP pay daysession (Tigray-Hintalo Wajirat)P Fracassi, Ethiopia, 2010narrow <strong>focus</strong> on:• Quantity of food, rather than quality andappropriateness of diet for PLW and youngchildren.• Productivity and marketability of foods,rather than their nutritional content forimproved household diet.• Dietary intake and food security withlimited attention given to other well knowncontributing factors to malnutrition likedisease, child care, access to health servicesand environmental conditions.The most effective institutional arrangement forcoordination at woreda and kebele levelsappeared to be the Food Security Task Forces(FSTF). According to KIIs findings, the activeinvolvement of multiple‐sector partners in theFSTF was the result of continuous working relationships,strengthened through sharedobjectives and basic compatibility of interests.In contrast, at regional level, it was noted therewere too many coordination platforms, withoverlapping functions resulting in increasedfragmentation.Primary data from KIIs revealed a number ofinter‐sectoral experiences of cooperation atkebele level, although not strictly linked withaddressing malnutrition. Findings from FGDshighlighted that a genuine community involvementrequired understanding and taking intoaccount economic, practical and culturalmotives that influence food production andaccess, as well as consumption decisions athousehold level.These findings from the preparatory studyare in line with recommendations by others 2 to“plan multi‐sectorally but continue to implementsectorally”. Many of the institutionalbarriers for improved inter‐organisational relationshipsfirst reflect administrativeorganisation in sectors/programmes andsecond, nutrition as a cross‐cutting <strong>issue</strong>, fittingpoorly within this framework. Working in anincremental and opportunistic manner appearslikely to succeed with the current institutionalstructures in Ethiopia. ‘Coordination’ and‘cooperation’ over specific <strong>issue</strong>s like quality ofdietary intake for children and PLW appear tobe a promising <strong>focus</strong> of exchange betweenPSNP and NNP stakeholders. Mainstreamingof nutrition into the PSNP is expected tomaximise the impact of the programme amongbeneficiaries.PSNP/NNP linkage opportunitiesFindings from the preparatory study togetherwith a general overview of the PSNP/NNPpolicy framework were used to inform theConsensus Building Workshops conducted inall four pilot woredas and kebeles between 28thSeptember and 16th October 2009. Three major‘linkage’ opportunities between PSNP andNNP were agreed upon for implementation atinstitutional and community levels:• Capacity Building on Nutrition Security forkey members of the FSTF at woreda, kebeleand community levels.• Behavioural Change Communication usingEducation Entertainment (BCCEE) duringpayday sessions and other public gatherings.BCCEE encourage PSNP beneficiaries tooptimise use of both local and transferredresources for improved nutrition security.• Focused attention to PSNP PLW to protectand enhance their nutritional status andthat of their children under two years of age.Experiences from SNNP and Oromia showedthat at an institutional level, nutrition securitycan be incorporated in the capacity buildingprocess of Food Security Task Forces, whichcomprise multi‐sector members from agriculture,water, health, education, and Youth andWomen’s Affairs. Half‐day sessions wereincluded in Watershed Management Training(Domot Sore, SNNP) and in the PSNP reviewmeeting (Oromia, Gameches) targeting over 100people including 70 Development Agents (DAs).Basics on nutrition were provided duringConsensus‐Building Workshops to increaseunderstanding of the nutritional value of differenttypes of foods and on specific dietaryrequirements for PLW and young children.Improved awareness of the nutrition outcomesto which PSNP could contribute was discussedamongst food security and agriculture stakeholders,considering more rigorously whobenefits from their interventions. For example,the nutrition value of selected crop varietiesshould be included and accounted for.Meanwhile activities with a direct nutritionalbenefit, like poultry‐management schemes,improved post‐harvest storage and foodprocessing techniques or home gardening can beBerhanu (2010). Edited by Simon Rolph.2Maxwell, S. & Conway, T. 2000. Perspectives on partnership.OED Working Paper Series, No. 6, World Bank,Washington, DC.87

Researchpromoted in household business or investmentplans for increased food and nutrition securityExperiences from Tigray, Amhara and SNNPshow that BCCEE can be mainstreamed withinPSNP pay‐day sessions and/or public gatheringsto promote changes within the householdsand the community. Nutrition and care‐relatedbehavioural problems were initially identifiedby a technical team composed of volunteermembers from the kebele FSTF. Technical teamschose drama as the medium and emphasisedmessages around the life‐cycle sequence frompregnancy, lactation, to young child feedingfrom six to 24 months of age. PSNP beneficiariesinvolved as performers received an orientationon drama and rehearsed under the guidance of aprofessional theatre performer. Key people atkebele level, such as the Chairman, the Manager,the DAs and Health Extension Workers (HEWs),facilitated events. Woreda level PSNP/NNPstakeholders attended the events in all regions.Regional and zonal food security stakeholdersparticipated in SNNP where the dramaaddressed family planning and childbirth spacing<strong>issue</strong>s, a reflection of the common concernsof both the food security and health sectors, aswell as those of the community.Challenges in implementationImplementation of the linkage opportunitywith the PSNP to target PLW has proved to bechallenging in all regions. To monitor the utilisationof health and nutrition services by PSNPPLW, ‘on the job ‘orientation sessions wereorganised with HEWs and DAs in all pilotkebeles. These sessions examined key indicatorsusing registers and records from availableroutine services and nutrition programmes.Additional behavioural indicators related todietary habits of PLW and young children werealso included in the checklist. The initial PLWidentification was expected to happen duringthe annual PSNP registration but this proved tobe either impossible or where figures wereavailable, the numbers were questionable (e.g.registered 12% PLW while the commonly estimatedpercentage is 3.5%).The establishment of work teams amongPSNP PLW was also discussed with the kebeleFSTF to promote PLW involvement in ‘light’works during the non‐exemption time frompublic work (i.e. before four months of pregnancyand ten months post partum). Workteams were foreseen to be the basis for theformation of Interest Groups among PSNPwomen/PLW to engage in production activitieswith nutritional benefits. Further links wereexpected with existing developmentprogrammes, such as the Household AssetBuilding Programme (HABP) orcommunity‐based services, such asmicro‐finance and technical assistance. Whileinterviewed PSNP‐HABP stakeholders wereopen to diversifying production investments,they pointed out that other partners like theWomen’s Affairs, NGOs or Youth Affairsshould be involved in forming and supportingthese groups. This ‘linkage’ opportunity goesbeyond the PSNP and requires much more timeand inputs from different partners to becomeoperational.Interviewed PSNP stakeholders emphasisedthe potential contribution of the health sector inmonitoring the PSNP key indicators butacknowledged limited information sharingbetween them both. Monitoring of malnutritionP Fracassi, Ethiopia, 2010among children under two years can be ensuredthrough the dissemination ofCommunity‐Based Nutrition (CBN) monthlydata and Community Health Days (CHD) quarterlydata. Currently, CBN programme providesdata on underweight and severe underweightamong children under 2 years. CHDprogramme provides data on MUAC

Researchmonitoring of PSNP PLW utilisation of essentialhealth and nutrition. The initial ‘window of opportunity’could be reduced to pregnancy up to 11 monthspost partum instead of pregnancy to 24 months (asthis corresponds more or less to the exemption timeof PSNP PLW from Public Work).Direct links should be established between theFSTF (particularly the early warning system (EWS))and nutrition programming such as CBN and CHDfor monthly and quarterly sharing of data on nutritionalstatus of children and PLW in PSNP kebeles.The establishment of Interest Groups amongPSNP PLW/women needs the involvement of otherpartners like the Women’s Affairs and/or YouthAffairs to support groundwork.Product‐value chain assessment and technicalassistance will still remain the responsibility of agriculturalpartners.PSNP and NNP stakeholders should optimisethe role of home economists in SNNP, Oromia andTigray by linking them with the HEWs and CHWsto strengthen post‐harvest activities, as a necessarylink between food production and consumption.Potential linkages for further discussion:Protection and enhancement of nutritional status ofPSNP Orphans and Vulnerable Adolescents (OVAs)through their involvement in ‘Healthy Life Style’clubs.Food fortification, such as inclusion of home fortificationmicronutrient powders for children undertwo years and PLW during food or cash transfersand fortification at milling stage of the PSNP foodtransfer.Supplementation of PSNP food/cash transfersthrough local production of ‘special blended food’for children 6‐11 months and PLW. On a small‐scale,this activity could be linked with the establishmentof Interest Groups and with an increased role of theHome Economists at woreda level.Promotion of high‐nutrient bio‐fortified crops(e.g. high protein maize and orange flesh sweetpotato) and improved breeds of poultry, small ruminantsand cows through collaboration with researchinstitutes to test and promote selected varieties.For more information, contact: Patrizia Fracassi,email: pat.fracassi@gmail.comDrama (man helping with water)conducted during PSNP pay daysession (Tigray-Hintalo Wajirat)P Fracassi, Ethiopia, 2010Post-drought restockingCan its impact be sustainable?By Ahmed Alkadir MohammedAhmed Alkadir Mohammed is currently a Disaster Risk Management <strong>Special</strong>istwith the World Bank, Productive Safety Net Programme (PSNP) Team. Prevouslyhe spent 16 months as a Nutrition Project Consultant with the World Bank inEthiopia to facilitate and coordinate the overall activities of World Bank FundedNutrition Project in Ethiopia. He is a graduate of Addis Ababa University (BScManagement) and of Tufts University (MA in Humanitarian Assistance, 2007).I would like to acknowledge my thesis advisor and instructor, Daniel Maxwell, who well equippedme in my research. Also, Daniel, Michael Delaney and Abera Tola from Oxfam America, theFeinstein International Centre Master of Arts in Humanitarian Assistance (MAHA) programmeinstructors, and all my Boston based friends. I appreciate Ana Hammock who assisted me in editingthe research paper and Erin Boyd in the enrolment of the programme.On a personal level, I acknowledge the supports of my brother Mekonnene Alkadir, my spouseShemsiya Ali, and my children Megfira Ahmed and Olyad Ahmed. My greatest gratitude goes tothe role of my mam, Ade Monina Hussein Megnaka, who played significant role in laying groundof accessing quality childhood education that became the basis for my success in my academicand career developmentThis article reflects some of the findings of Ahmed’sMSc thesis on post-drought restocking of pastoralhouseholds (2007) 1The livelihoods of pastoral communitiesdepend on livestock production.Livestock provide basic subsistencefoods such as milk, meat and blood and arealso used for wealth accumulation, prestige,insurance and inheritance. Theincome generated from the sale of livestockserves to buy additional food items, cropsand clothing. Moreover, livestock are usedas a means of transportation, dowry inmarriage and to fulfill reciprocal (social)obligations. Therefore, any adverse factorwhich impacts negatively on livestockthreatens the livelihood and life of pastoralcommunities.Recurrent droughts in Ethiopia andKenya have claimed the lives of livestockand depleted herd sizes. The adverseimpact of drought on livestock is significantin Ethiopia and Kenya. For instance,Ethiopia lost 90% of calves, 45% of cowsand 22% of mature males between 1983-1984 2 , 37% of cattle between 1984-1986and 60% of cattle from 1999-2000 3 . Kenya(Turkana) lost 90% of cattle, 80% of sheepand goats, 40% of camels in 1979-80 4 , aswell as 28% of cattle and 18% of sheep andgoats in 1991 in Northern Kenya 5 . This lossof livestock affects families, particularlychildren, women and elders, as their foodsecurity is dependent on livestock. It isalso pushing pastoral households intodestitution and forcing them to drop out ofthe pastoral way of life.The traditional means of self-restockinghave been eroded in the pastoralcommunity, due to recurrent drought,raiding, conflict, environmental degradationand an increase in population. Thishas prompted the search for and implementationof alternative interventions byagencies (non-governmental organisations(NGOs). NGOs have been shiftingtheir programmes toward livestock basedinterventions to address the impact ofrecurrent drought. These interventionsinclude de-stocking, water, veterinaryservice, restocking, and fodder provision.Post drought restocking in pastoralcommunities has become an importantarea of research in Ethiopia and Kenya.Pioneers of restocking have demonstrateda number of objectives (advantages) ofpost-drought restocking. Among otherthings, reintegrating families into apastoral way of life is shown as one of theobjectives. It is also indicated that restockingis contributing to food security and abalanced diet (children), as well asimproving economic and social standing 6 .However, a number of professionals inthis field argue that many restockedpastoralists do not return to a pastorallifestyle and are likely to become destitute1Post-drought Restocking of Pastoral Households:Can its impact be sustainable? Master of Arts inHumanitarian Assistance e Program, FriedmanSchool of Nutrition Science and Policy, TuftsUniversity, May 2007. Thesis Advisor: Maxwell,Daniel (Associate Professor, Friedman School ofNutrition Science and Policy)2Coppock, D. L. 1994. The Borena plateau ofsouthern Ethiopia; Synthesis of pastoral research,development and change, 1980-91. Addis Ababa:International Livestock Center for Africa (ILCA).3Coppock, D.L. (2000). GL-CRSP Annual Report 2000.4Hogg, R. (1985). Restocking pastoralists in Kenya:A strategy for relief and rehabilitation. ODI PastoralDevelopment Network Paper 19c. OverseasDevelopment Institute, London.5Barton and Morton, forthcoming publication.6The Development Fund (2007). Impact Assessmentof the Goat Restocking Project in Afar, Zone-2,Berhale.Addis Ababa. 2007 (Aynalem Haile)89

Researchin a short period of time. This raises the questionof whether the impact of restocking issustainable and if not, why not?The objectives of this article are to explorepost-drought restocking interventions, highlighttheir limitations, and suggest practicalelements that need to be improved in thefuture. These objectives are looked at in termsof the sustainability of restocking impact inreintegrating (maintaining) restocked familiesinto the pastoral way of life. The articlediscusses restocking interventions in thepastoralist areas of Ethiopia and Kenya. Itargues that if the right sets of critical factors areconsidered in design and implementation, theimpact of post-drought restocking can besustainable with regard to reintegrating (maintaining)restocked families into a pastoral wayof life. However, restocking affected pastoraliststo the level of a Critical LivestockThresholds (CLT) is key.The livelihood framework analysisThe livelihoods framework is one of theapproaches applied by a number of humanitarianand development organisations to examinethe livelihood of a given community and tohelp design appropriate interventions.According to the livelihood analysis, pastoralcommunities in the Horn of Africa are vulnerableto recurrent drought, humans and animaldiseases, cattle raiding, conflict, bad governanceand policies, poor social and economicinfrastructure and loss of grazing lands. Todetermine the implications of this analysis onpost-drought restocking, a number of factorsmust be considered : hindrance of mobility,lack of access to and loss of range land, livestockmortality, poor productivity of milk, andoff-spring and diminished herd growth. Theseall adversely impact the sustainability ofrestocking.The poverty trap analysisIn the field of economics, the poverty trap refersto the situation where individuals, communities,regions or economies are caught in extremepoverty and unable to get out of this condition 7 .This analysis is fundamentally based on aCritical Assets Threshold (CAT). It asserts thathouseholds that possess assets equal to orabove these thresholds recover from shocks,accumulates assets and escape poverty, whilethose who have assets below these criticalthresholds experience decline and collapse ofassets and persistent poverty. In addition, thisanalysis implies that if a shock leaves a household’sassets equal to or above the criticalthresholds, then recovery and growth is possibleand vice versa 8 . (In pastoral communities ofEthiopia and Kenya, the risk of falling into thepoverty trap is directly related to the productivelivestock assets held at household level andwhether this is equal to or above the CLT. TheCLT is necessary for sustenance, herd growth,increase in return and recovery from shocks 9 .“A threshold value is the number of animalsrequired to support a person or a family if thatperson or family was to rely totally on animalsfor all his or their needs.” 10A study in Southern Ethiopia demonstratesthe presence of the poverty trap among theBorena pastoralists. The study identified thathousehold herd size thresholds are 10 livestockunits 11 , below which a household is economicallynot viable and thus enters a downwardspiral of poverty. However, those who areabove this level are expected to accumulatelivestock and grow their herds 12 . Based on thediscussion with pastoralists in Afar Zone ofEthiopia, 30 – 40 small ruminants are the minimumstock to start a pastoralist way of life 13(Development Fund, 2007) while 50 – 70 sheepand goats in a proportion defined by the householdand of the right age for immediatebreeding are suggested for restocking implementationin the Somali region of Ethiopia 14 . Asimilar study in Northern Kenya also demonstratedpresence of the poverty trap and theCLT that enables pastoralists to accumulatelivestock and grow their herds.From a restocking perspective, the studiessuggest not only who should be restocked, butalso the necessity to restock pastoralists to aminimum critical threshold level in order toensure sustenance, enable herd growth andrecovery from shocks 15 . The importance ofimproved veterinary service, livestock andherders’ security, and dry season water availabilityare also emphasised as means to protectand build assets 16 .Other related factorsMany NGO interventions elect to supply smallanimals (such as goats and sheep) rather thancattle, although some pastoral communities aredependent on a range of livestock and producefrom their herds. Small animals alone may nottherefore ensure food security for thesepastoralists 17 . In other contexts, small animalssuch as goats are preferred as they give milk forthe consumption of children and elders andforage easily from bushes and shrubs encroachments18 . Many small NGOs implementrestocking programmes using disaster relieffunds 19 . If animals are bought from otherregions, their age, reproductive and milkproductive capacity, adaptability and diseaseprofile should be analysed 20 . Lack of transparencyin the purchase process is observed tobe one of the limitations in restocking projects.In 1985 and 1987, destitute Borenas wererestocked with animals bought by traders,which resulted in a number of disadvantagesfor the pastoralists 21 . In some instance, sale ofthe restocking animals has been observed inorder to buy other livestock and grain, forpayment as part of a bride price and to financetraditional ceremonies 22 . In order to preventbeneficiaries slaughtering and eating their newherd, it is recommended to provide food for 9 to12 months during the restocking programme 23 .All these factors should be considered duringplanning restocking interventions.7Izhar, B (2005). Why Poverty Traps Emerge8Carter, R and Barrett, B (2004). The Economics of PovertyTraps and Persistent Poverty: An assets-based Approach.BASICS CRSP Management Entity, Department ofAgricultural and Applied Economics, University of Wisconsin-Madison.9McPeak, G and Barrett, B (2001). Differential Risk Exposureand Stochastic Poverty Traps Among East African Pastoralists.American Journal of Agriculture and Economics.10International Committee of the Red Cross (ICRC). 2004.Livestock Study in the Greater Horn of Africa. Nairobi/Kenya.11It should be noted that the <strong>focus</strong> of this paper is on thesignificance of a ‘self-sufficient’ livestock herd size thatshould be considered in restocking interventions. The authorshave used different ways of expressing the critical livestockthreshold for Northern Kenya and Southern Ethiopia, i.e. percapita and livestock unit. Generally, approximately 4.5TLUper capita is suggested as a self-sufficiency thresholdnecessary in more arid rangelands not suffering widespreaddegradation (McPeak 2000).12Barrett, Bet al (2002). Poverty Traps and ResourceDegradation. BASIS Brief. No. 613See footnote 6.14Save the Children Ethiopia (UK) ( 2005). Terminal Evaluationof the Restocking/Rehabilitation Program for the InternallyDisplaced Persons (IDPs) in Fik Zone of the Somali Regionof Ethiopia.Acacia Consultants Ltd, 00606\Nairobi, Kenya.Critical factors that hinder thesustainability of post-droughtrestockingThis review has identified the following criticalfactors:• Failure of restocking the needy and skilledpastoralists who have a livestock levelsignificantly below the CLT (or the destitute)to the level of CLT.• Failure of targeting herders whose herd sizeis below but closer to the CLT.• Failure of providing the right compositionof animals (quantity, sex, age, types,breeding, milk productive species).• Failure to consider key contextual factors thatwill affect the outcome of the restocking andthe need for other supporting interventionsto address these factors (raiding, conflict,veterinary service, pasture/fodder, water).• Shortage of livestock in the region (resultingin restocking with non-adaptable anddiseased animals).• Loss of rangelands.• Limited size of funding and inadequatefood aid.• Absence of social and economicinfrastructures (hindering emergence andadoption of non-pastoral activities).RecommendationsThe following are recommended to improve thesustainable impact of post-drought restockinginterventions:• Restock pastoralists to a minimum of the CLT.• Target not only the capable needy andskilled destitute pastoralists, but also targetthose who have live stock levels below butcloser to the CLT.• Provide the right composition of live-stock.• Consider the existing situation and providepackages of supporting interventions.• Coordinate interventions to tackle resourcesconstraints.• Research and design comprehensive guidelines for restocking.• Formulate and apply a viable land utilisationpolicy.• Research and advocacy on the promotionand funding of non-pastoral activities andthe development of social and economicinfrastructures.• Consider and implement restocking projectswithin a broader development plan andDisaster Risk Management approach.For more information, contact: Ahmed Alkadir,email: amohammed1@worldbank.org;alkadir91@hotmail.com15McPeak and Barrett, 2001. See footnote 9.16Barrett, B et al (2006). Welfare Dynamics in Rural Kenyaand Madagascar. Journal of Development Studies. Vol. 42,No. 2, 248-27717Oba, G (1992). Ecological Factors in Land Use Conflict,Land Administration and Food and Food Insecurity inTurkana, Kenya. ODI Pastoralist Development NetworkPaper 33a. London: Overseas Development Institute.18Ayle Gebre-Mariam (1989). Analysis of the progeny historyof heifers and does and their off springs: Case of animals;restocked to re-settlers at Yavello, Mega and Moyale in1985 and 1987. Addis Ababa.19Toulmin, C (1995). Tracking Through Drought: Options forDestocking and Restocking. In Living within uncertainty:New Direction in Pastoral Development in Africa. 95-115(Ed. Ian Scoones). London: Intermediate TechnologyPublications. Toulmin, C (1987). Drought and the FarmingSector: Loss of Animals and Post-Drought Rehabilitation.Developement Policy Review 5(2):125-148.20USAID-Office of Foreign Disaster Assistance: LivestockInterventions: Important Principles for OFDA. 11-19-02.http://www.usaid.gov/our_work/humanitarian_assistance21Ayele Gebre/Mariam, 1989 (footnote 8) and DevelopmentFund, 200022See footnote 8.23See footnote 1090

ResearchFood insecurity and mental health among communityhealth volunteers in Ethiopia Summary of published research 1Arecent study examined self-reportedhousehold food insecurity and symptomsof common mental disorders(CMD) among 110 community health AIDS carevolunteers living in Addis Ababa, Ethiopiaduring the height of the 2008 food crisis. In theface of a late-maturing HIV/AIDS epidemicand poorly-distributed public health services,volunteerism in community health care hasgrown substantially over the past decade inAddis Ababa. Public health facilities rely heavilyon the training of volunteers, who providehome-based palliative care, support drug adherenceand mediate patient’s access to clinicaltreatment and non-governmental organisation(NGO) assistance. Volunteers typically serve fora period of 18 months, caring for at least fivenon-kin patients, under the supervision of alocal NGO. After 18 months, patients are reassignedto a new group of volunteer recruitsand graduating volunteers leave the servicewith unknown prospects for employment.Volunteer support may benefitcaregivers as well as beneficariesThe study addressed two principle questions.First, did rising food prices in Addis Ababa in2008 lead to greater experiences of food insecurityand concomitant rise in CMD symptomsamongst volunteers in the sample? Secondly, dofactors such as food aid, per capita income orparticipation in microfinance clubs explain theobserved patterns of self-reported food insecurityand CMD amongst the volunteers?The surveys were administered to a sampleof community AIDS care volunteers from twolocal NGOs, Hiwot HIV/AIDS PreventionControl and Support Organisation and MedhinSocial Centre, which provide home-based carefor people with AIDS accessing treatment at apublic hospital in southwest Addis Ababa(ALERT hospital).Four Ethiopian research assistants weretrained for data collection that took place overthree rounds over the course of 2008. Thesample included 110 volunteer caregivers (99women and 11 men) of adult patients receivingtreatment at the ALERT Hospital. The genderratio reflected the overwhelming proportion ofwomen in the volunteer population. The samplewas divided into subgroups of ‘veterans’ (whohad been volunteering for more than 12 months)and newcomers (who had just started volunteeringat the time of the baseline survey).The researchers used generalised estimatingequations that account for associations betweenresponses given by the same participants overthree survey rounds, to model the longitudinalresponse profiles of food insecurity, CMDsymptoms, and socio-behavioural and microeconomiccovariates. To help explain thepatterns observed in the response profiles andregression results, the researchers examinedqualitative data that contextualised the cognitionand reporting behaviour of AIDS carevolunteers, as well as potential observationbiases inherent in longitudinal, communitybasedresearch.The Household Food Insecurity Access Scale(HFIAS) was translated into Amharic, and thenback translated and revised. Participant householdswere classified into four levels of foodinsecurity according to ascheme that closely parallelsthe published HFIASprotocol. To assess thedistribution of CMD symptoms,the researchers useda 29-item version of theWHO self-reporting questionnaire(SRQF) whichincorporates eight itemsderived from Amharicidioms of distress. TheSRQF has been previouslytranslated to Amharic andtested for content, constructand criterion validity.Participants werepresented with yes or noresponse categories foreach SRQF item/symptom.Though the SRQF is not adiagnostic tool, it was assumed that higherscores were indicative of greater likelihood ofhaving a common mental disorder.K Maes, Ethiopia, 2008Participants estimated monthly householdincome at all three rounds. This income wasdivided by total number of people in the household.Participants also answered threequestions addressing household economiccoping ‘to fulfil basic needs’ in the past threemonths: whether they had started a newincome-generating activity, sold householdgoods, and/or kept students home from schoolto help in income generation or food preparation.The study categorised participantsaccording to whether they or anyone in theirhouseholds engaged in one or more of thesecoping measures versus none in the threemonths prior to the survey.At each round, participants reportedwhether they were receiving free food aid fromNGOs and what kinds of food they were receiving.Participants also reported their totalnumber of care recipients, whether they werecaring for at least one bedridden care recipientand the total number of hours per week spentin volunteer activities.FindingsThe data showed that food insecurity is highlyprevalent (~80%) among AIDS care volunteersin Addis Ababa, that it is associated with householdeconomic factors, and that it is linked tosymptoms of common mental disorders.Surprisingly, the volunteers in this urbansample did not report increasingly severe foodinsecurity or CMD during the peak of the 2008food crisis. This is a counter-intuitive result thatwould not be predicted in analyses of population-leveldata, such as those used ineconometrics simulations.The authors of the study explored a numberof possible explanations as to why this poorurban sample was buffered from the local foodcrisis. One posited explanation was that sufficiencyof accessible food is a potentiallysubjective assessment sensitive to shifting internalstandards and social comparisons. Sincevolunteer caregivers repeatedly interact withcare recipients and other volunteers who areperceived to be poorer and hungrier, food insecurityis prone to response shifts in the sample.This is partly supported by the fact thatnewcomers were more likely than veterans toreport improved food insecurity status atRounds 2 and 3. Another possible explanationor factor may be the impact of volunteerism onwellbeing. Other longitudinal studies haveshown that adult volunteers enjoy better physicaland mental health and lower risk ofmortality than non-volunteers. This mightexplain why mental health did not worsen overtime in the sample. In other words, mentalhealth could have been buffered from stressorsby the psychological benefits mediated by AIDScare volunteers’ unique social networks andreligious beliefs. This is illustrated by representativequotes from volunteers who wereinterviewed in the study. For instance, a 32-year-old single mother said that, “In all my life,what makes me happiest is [to see thosepatients] being human—being able to work andfeed themselves.” A 35-year-old unmarriedman said, “Being a volunteer caregiver will getyou to...sympathize with human beings...Sometimes I will get aid from NGOs [in returnfor volunteering]; but you have to forget thisthing. By believing in God...and doing God’swork, you can live.”The authors raise important policy questions;should the apparent resilience of thestudy population be supported with food orother material aid? Should they be relieved oftheir duties with efforts to put care and supportin the hands of paid professionals? Or shouldthey become paid community health workers?The authors conclude the paper by arguing forfurther studies addressing links between foodinsecurity, mental health, and the potentialbenefits of altruism.For more information, contact: Kenneth Maes,email: kennycmaes@gmail.com1Maes. K et al (2010). Food insecurity and mental health:Surprising trends among community health volunteers inAddis Ababa, Ethiopia during the 2008 food crisis. SocialScience and Medicine 70 (2010), pp 1450-145791

AcronymsACFACTAction Contre la FaimAction of Churches TogetherADP Area based Development Programme (WorldVision)AHT Animal health technicianAKU Afran Kallo UnionARRA Administration for Refugees and ReturneeAffairsBCC Behaviour change communicationBMI Body mass indexCAHWs Community Animal Health WorkersCASHE Commercialisation of Agriculture forSmallholders in EthiopiaCBN Community Based NutritionCBO Community based organisationCBRM Community Based Resource ManagementCBTP Community Based Training ProgrammeCC Community conversationCDC Centre for Disease Control (Atlanta)CDAA/E Churches’ Drought Action Africa /EthiopiaCESVI Cooperazione e Sviluppo (Italy)CFSTF Community Food Security Task ForceCHD Community Health DayCIDA Canadian International Development AgencyCLT Critical Livestock ThresholdCM Community mobilisationCMAM Community based management of acutemalnutritionCMR Crude mortality rateCNU Children’s Nutrition UnitCRS Catholic Relief ServicesCSAS Centric systematic area samplingCSB Corn Soy BlendCS-CAFÉ Citizens Solidarity for the Campaign AgainstFamine in EthiopiaCSO Civil society organisationCTC Community-based Therapeutic CareDFID Department for International Development(UK)DHS Demographic Health SurveyDOA District Office of AgricultureDPPA Disaster Prevention and Preparedness AgencyDPPO Disaster Prevention and Preparedness OfficeDRM Disaster risk managementDRMFSS Disaster Risk Management and Food SecuritySectorDRR Disaster risk reductionDTM Department of Traditional MedicineECHO European Commission Humanitarian AidDepartmentECS Ethiopian Catholic SecretariatECSNCC Ethiopian Civil Society Network on ClimateChangeEDK Emergency drug kitEDHS Ethiopia Demographic Health SurveyEECMY Ethiopian Evangelical Church Mekane YesusE-EOS Expanded-EOSEFSL Emergency Food Security and LivelihoodsEHNRI Ethiopian Health and Nutrition ResearchInstituteENA Emergency Nutrition AssessmentENCU Emergency Nutrition Coordination UnitENI Ethiopian Nutrition InstituteEOC Ethiopian Orthodox ChurchEOC-DICACEOSEPIEUEWRDEWSFBOEOC-Development and Inter-Church AidCommissionEnhanced Outreach StrategyExpanded programme on immunisationEuropean UnionEarly Warning and Response DirectorateEarly Warning SystemFaith based organisationFDA Food Distribution AgentFFP Food for Peace ProgrammeFGD Focus group discussionFHE Food for the Hungry - EthiopiaFIND Foundation for Innovative New DiagnosticsFMIP Food Management Improvement ProjectFMOH Federal Ministry of HealthFSNRD Food Science and Nutrition ResearchDirectorateFSTF Food Security Task ForceGAM Global acute malnutritionGASU Global Agricultural Scale UpGDP Gross Domestic ProductGoE Government of EthiopiaHAVOYOCO Horn of Africa Voluntary Youth CommitteeHEA Household Economy ApproachHEP Health Extension ProgrammeHEW Health extension workerHH HouseholdHMIS Health Management Information SystemHRF Humanitarian Response FundHRD Humanitarian Requirement DocumentHRP Humanitarian Response ProgrammeHSDP Health Sector Development PlanHSEP Health Services Extension PackageHTP Harmonised Training PackageIFHP Integrated Family Health ProgrammeIGA Income generating activitiesIMC International Medical CorpsIMCI Integrated Management of Childhood IllnessINGO International non-governmental organisationIPC Integrated Humanitarian Phase ClassificationITN Insecticide treated netsJAM Joint Assessment MissionJEOP Joint Emergency Operation PlanJICA Japan International Cooperation AgencyKAC Knowledge, Attitude, CoverageKAP Knowledge, Attitude, PracticeKAPB Knowledge, Attitude, Practice, BehaviourKebele The smallest administrative unit of Ethiopiasimilar to a ward, a neighbourhood or alocalised and delimited group of people. It ispart of a woreda.KFSTF Kebele/tabia food security task forceLWF Lutheran World FederationMANTF Multi-Agency Nutrition Task ForceM&E Monitoring and evaluationMEL Monitoring, Evaluation and LearningMFI Microfinance institutionsMLREP Market-led Livelihood Recovery andEnhancement ProgrammeMOARD Ministry of Agriculture and Rural DevelopmentMoPDE Ministry of Pastoral Development andEnvironment of SomalilandMoU Memorandum of UnderstandingMP Micro-plansMSG Multi-storey gardensMUAC Mid upper arm circumferenceN-CMAM National CMAMNCOE Nutrition Centre of Expertise (World Vision)NERS Nutrition Education and RehabilitationSessionsNFI Non food itemNGO Non-governmental organisationNIS Nutrition Information SystemNNP National Nutrition ProgrammeNNS National Nutrition StrategyNRIH National Research Institute of HealthNRMD Natural Resource Management DirectorateNERAD National Environment Research andDisaster ManagementNRM Natural resource managementOFDA Office for Disaster Assistance (USAID)OFSP Other Food Security ProgrammeOMFI Omo-Micro Finance InstitutionORDA Organisation for Rehabilitation and DevelopmentORP Operational Research ProgrammeOTP Outpatient Therapeutic ProgrammeOVA Orphans and Vulnerable AdolescentsOVC Orphans and Vulnerable ChildrenPASDEP Plan for Accelerated and SustainedDevelopment to End PovertyPHEM Public Health Emergency ManagementPILLAR Preparedness Improves Livelihoods andResiliencePIM Programme Implementation ManualPLW Pregnant and lactating womenPLWH People living with HIVPO Pastoral organisationPRRO Protracted Relief and Recovery OperationPSNP Productive Safety Net ProgrammePST Pre-service trainingRAIN Revitalising Agricultural/pastoral Incomes andNew marketsRCWDA Rift Valley Children and Women DevelopmentAssociationRDD Regional Drought Decision (ECHO)RDP Rural Development ProgrammeR-ENCU Regional ENCUREST Relief Society of TigrayRF Risk Financing MechanismROBA Rural Organisation for the Betterment ofAgro-pastoralistsRUTF Ready to use therapeutic foodSAM Severe acute malnutritionSC Stabilisation centreSC US Save the Children USSFP Supplementary Feeding ProgrammeSUN Scale Up NutritionSMART Standardised Monitoring and Assessment ofRelief and TransitionsSNNPR Southern Nations, Nationalities, and People'sRegionSQUEAC Semi Qualitative Evaluation of Access andCoverageSWC Soil and water conservationTFP Therapeutic Feeding ProgrammeTFU Therapeutic Feeding UnitTLU Tropical Livestock UnitTOT Training of trainersTSF Targeted Supplementary FoodTTP Team Training ProgrammeUcodep Unity and Cooperation for Development ofPeoples (now Oxfam Italia)UNDAF United Nations Development AssistanceFrameworkUNHCR United Nations High Commissioner forRefugeesUNICEF United Nations Children’s FundUNOCHA United National Office for Coordination ofHumanitarian AffairsUSAID United States Agency for InternationalDevelopmentVAD Vitamin A deficiencyVAS Vitamin A supplementationVCA Value Chain AnalysisVCHWs Volunteer Community Health WorkersWASH Water, Sanitation and HygieneWFP World Food ProgrammeWoreda An administrative division of Ethiopia (managedby a local government), equivalent to a districtand itself part of a zone, grouped into ethnolinguisticregional zones.WorHO Woreda Health OfficeWVE World Vision EthiopiaSee also key programme definitions in Box 1, p39 and a guideto key systems and programmes in Ethiopia implemented bythe government on p12, Box 1.92

Corrections to Field Exchange 39Our apologies for a number of errors in Field Exchange 39. The Kismayo, Mogadishu, Bayand Bakool are regionsof Southern Somalia and not Somaliland as stated (Analysis of looting in the Somali war, Field Exchange 39, p22).Note also a correction to Figures 1, 2 and 3 of the article 'Acceptability trial of a novel RUTF based on soy, lentilsand rice' (p12-13). The online edition of Field Exchange 39 has been corrected.Figure 3: Consumption trends across thethree schools30Figure 1: Comparison of average energy intakes(n=69)kcal intake/kg/child6040200Plumpynut energy intakeRUTF energy intakeBP100 energy intakeNote: The dashed line represents 75% of the Plumpy’nut® energy intakeFigure 2: Weight gain (g/kg/child), n=69grams of weight/kg child151050-5-10PlumpynutBP100RUTFg/kg/child25201510501 2 3 4 5 6 7 8 9day numberPlumpynutRUTF BP100Note: The first two days of data for BP100 are missing because it wasprovided as a biscuit, rather than a porridge.Editorial teamJeremy ShohamMarie McGrathDeirdre HandyCarmel Dolan(Guest Editor)DesignOrna O’Reilly/BigCheese Design.comH. E Dr KesetebirhanAdmassu,Dr. Ferew Lemma,Selamawit Negash,Patrizia Fracassi,Abay Bekele,Shekar Anand,Deed Jaldessa,Debela Kenea,Miriam Christensen,Todd Flower,Sarah Coll-Black,Matt Hobson,Holly Welcome Radice,Maria Ruiz-Bascaran,Abebe Zewdu,Oumar Mohamud,Mekdes Asfaw,Mahlet Bezu,Isaack B. Manyama,Gugsa Abate,Mathewos Tamiru,Mulugeta WTsadik,Sylvie Chamois,Sarah Style,Antoinette Powell,Office SupportKatherine KayeMatt ToddThom BanksWebsitePhil WilksContributors for this <strong>issue</strong>Thanks for the pictures to:Caroline Waterman,Concern Ethiopia,Indrias Getachew,Patrizia Fracassi,Abay Bekele,Oxfam,Emma Proud,Mahlet Bezu,Geraud Laval,Mulugeta Wtsadik,Sylvie Chamois,EHNRI Public RelationsOffice,Allison Oman,Dr. Sisay Sinamo,Dr. Gedion Tefera,Aweke Yilma Dubi,Andrew Simons,Daniel Gebeyehu,Getachew Gemtesa,Markos Kidane,The Relief Society ofTigray (REST) MekelleTeam,Zeine Muzeiyn,Ewnetu Yohannes,Kassahun Bedada Beyi,Alix Carter,Emily Mates,Gebreselassie Atsbahha,Jutta Neitzel,Yuki Isogai,Kate Sadler,Elizabeth Bontrager,Dr. Alessandro Conticini,Mrs. Valérie Quéré,Ahmed AlkadirMohammed,Dr. Cherinet Abuye.Mesfin Teklu,Lubna Khan,Andrew Simons,Hailu Sitotaw,CRS,Emily Mates,EOC-DIAC,Judith Schule,Kate Sadler,Kenneth Maes,WFP photo library.CoverMother and child on Community HealthDay, Fadis Woreda, Ethiopia;P Fracassi, Ethiopia, 2008Back Cover; A boy in Harar marketSimon Rolph, Ethiopia, 2009The opinions reflected in Field Exchangearticles are those of the authors and donot necessarily reflect those of theiragency (where applicable).Field Exchangesupported by:The production and distribution of this bumper <strong>issue</strong> ofField Exchange 40 was made possible through fundingfrom OFDA and Irish Aid to meet additional costs.The Emergency Nutrition Network (ENN)grew out of a series of interagency meetings <strong>focus</strong>ing on food andnutritional aspects of emergencies. The meetings were hosted byUNHCR and attended by a number of UN agencies, NGOs, donors andacademics. The Network is the result of a shared commitment toimprove knowledge, stimulate learning and provide vital support andencouragement to food and nutrition workers involved inemergencies. The ENN officially began operations in November 1996and has widespread support from UN agencies, NGOs, and donorgovernments. The network aims to improve emergency food andnutrition programme effectiveness by:• providing a forum for the exchange of field level experiences• strengthening humanitarian agency institutional memory• keeping field staff up to date with current research and evaluationfindings• helping to identify subjects in the emergency food andnutrition sector which need more research.The main output of the ENN is a tri-annual publication, FieldExchange, which is devoted primarily to publishing field level articlesand current research and evaluation findings relevant to theemergency food and nutrition sector.The main target audience of the publication are food and nutritionworkers involved in emergencies and those researching this area. Thereporting and exchange of field level experiences is central to ENNactivities.The TeamThom Banks is theENN's fulltime DeskOperations Officerand provides logisticaland project supportto the ENN team.Matt Todd is the ENNfinancial manager,overseeing the ENNaccounting systems,budgeting andfinancial reporting.Phil Wilks(www.fruitysolutions.com)manages ENN’s website.Jeremy Shoham (Editor),Marie McGrath (Sub-editor)and Carmel Dolan are ENNTechnical Directors.Katherine Kaye isthe part-timeadministrationassistant at theENN.Chloe Angood is a nutritionist working part-timewith ENN on a number of projects and supportingHuman Resources.Orna O’ Reillydesigns andproduces all ofENN’s publications.The Emergency Nutrition Network (ENN) is a registered charity in the UK(charity registration no: 1115156) and a company limited by guarantee and nothaving a share capital in the UK (company registration no: 4889844).Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENNDirectors/Trustees: Marie McGrath, Jeremy Shoham, Bruce Laurence, NigelMilway, Victoria Lack, Arabella Duffield93

A scene from Dire Dawa marketCredit: Simon Rolph, Ethiopia, 200994

Emergency Nutrition Network (ENN)32, Leopold Street, Oxford, OX4 1TW, UKTel: +44 (0)1865 324996Fax: +44 (0)1865 324997Email: office@ennonline.netwww.ennonline.net