R2: Institutional development and capacity building
2.1 Health extension worker supervisors able to conduct regular and quality supportive supervision to build the capacity of health and agriculture
extension workers to implement stunting reduction activities at kebele (sub district) level
2.2 Medical and Agricultural universities convening update seminars on nutrition security and stunting reduction
Nutrition Security
• Result area 3:
R 3.3 Consolidated health, nutrition and food security data base developed and piloted in the project woredas (in line with the Regional initiative)
• Result area 4: none
Expected results at national/regional level ánd woreda/kebel level are as follows:
• Result area 1:
R 1.2 Disseminate the revised multi-sectoral National Nutrition Plan in coordination with the REACH facilitators by June 2012
• Result area 2:
R 2.1 Health extension worker supervisors able to conduct regular and quality supportive supervision to build the capacity of health and agriculture extension workers to implement stunting reduction activities at kebele (sub district) level
• Result area 3: none
• Result area 4: none
Expected results only at district level or below are as follows:
• Result area 1: none
• Result area 2: none
• Result area 3: none
• Result area 4:
R 4.1: Implement integrated Community Based Nutrition program for reduction of stunting and reduction Anaemia prevalence among pregnant and lactating women
The ANSP is well aligned with UNICEF Ethiopia’s country programme (2012-2015), in particular its Survival and Health Programme Component. This component will address the major causes of disease and malnutrition among children and regional disparities thereof13. (...) It will support the GTP objectives to reach the MDGs and improve the quality of health and nutrition services and the HSDP goal to reduce morbidity, mortality and disability and improve the health and nutrition status through providing and regulating a comprehensive package of promotive, preventive, curative and rehabilitative health and nutrition through a decentralised and democratised health system”. The survival and health component also supports (among others) the UNDAF outcome of ensuring that by 2015, the Ethiopian population, in particular women, children and vulnerable groups will have improved access to and use of quality health, nutrition and WASH services. In addition, it will contribute among others to effective inter-sectoral coordination mechanisms for the implementation of national and regional plans for improved health and survival of women and children. The ANSP focus on stunting is in particular relevant in view of the revised NNP.
The ANSP builds on achievements on the one hand, supporting ongoing work in up-stream policy (in particular the revision of the NNP), strengthening institutional capacity of partners in multi-sectoral emergency needs assessments, early warning and nutrition assessments, data collection, analysis and report writing and scaling up direct nutrition interventions. On the other hand the ANSP seeks to fill gaps in knowledge and skills. These include: (i) support to HEWs; (ii) behavioural change communication for IYCF and; (iii) refresher training (IRT) for all CBN implementing woredas14.
The ANSP supports 20 woredas located in Amhara, Ormoiya and SNNP regions that are part of the 2nd tranche of the roll out of the CBN15. The selected woredas will benefit from increased support and supervision to improve existing CBN practices and strengthen multi-sectoral linkages. Whilst support to the CBN as such is appropriate, the choice (beyond UNICEF’s control) in terms of e.g. decreasing inequity may be not the most appropriate (please refer to section 2.3). ANSP activities are either an expansion of an existing activity or a new activity that would not materialize without EC funding. The summary sheet does not clearly outline which activities fall in the latter category and why. Interim reports do not shed light on this issue either. In particular the MTE had difficulties to see the added value of the ANSP. ANSP seemed to be a source of funding of the country programme, not a programme with a distinct own identity.
13 Ethiopia Country Program 2012-2015, UNICEF. Approved September 2011
14 Ethiopia Ethiopia country summary sheet
15 The CBN programme is being rolled out in tranches: tranche 1, (39 woredas, in 2008 - 2009), tranche 2 (54 woredas, in 2009 - 2010), tranche 3 (77 woredas, from 2010 - 2012), and tranche 4, an additional 100+ woredas in 2012 - 13.
Coherence, completeness and complementarity to other initiatives
The ANSP aims in particular to strengthen GoE capacity to implement the NNP and to increase support to CBN in 20 woredas. Both require capacity building in multi-sectoral approaches and strengthening multi-sectoral linkages, which ensures internal coherence. As demonstrated earlier in this section, several results are expected at federal, regional and woreda level. The activities to this end are both synergistic and coherent. For instance, dissemination of the NNP and support to multi-sectoral coordination mechanisms at federal and regional level will lead to more collaboration between different sectors and pooling of resources for capacity building also at lower levels (because the cascade approach is the preferential mode of working). Strengthened collaboration at woreda level, in turn, may help upstream policy. For example, guidelines for models for community based production of supplementary feeding or effective BCC. Another example is the development of an integrated nutrition information system (federal level) in combination with capacity building (regional level) and piloting of the sytem (woreda level).
The focus on stunting reduction through increased multi-sectoral collaboration is coherent with the general policy environment (SUN, REACH) and NNP strategic objectives (SO). The ANSP directly supports SO1, SO2 as well as SO4 and SO5. Activities consist of an interesting mix of nutrition-specific and nutrition-sensitive intervention. Through collaboration with new partners in mainstreaming nutrition (such as the MOE, the MOA and the Bureau of Women, Youth and Child Affairs) the SNSP supports new nutrition-sensitive activities which complement existing nutrition specific activities in the health sector, and at times improve their coverage (out-of school youths). In doing so, the ANSP fills some important gaps as elaborated in Ethiopia’s country summary sheet –although activities have been adjusted in some cases to reflect new realities.
The geographical concentration of pillar 4 interventions is in 20 woredas, which were selected by the government of Ethiopia (GoE) because of their high levels of stunting and food insecurity (selection criteria for the CBN program). The ANSP strengthens and complements routine CBN activities among others by (supporting) capacity building of health staff (IRT), ensuring supplies (for deworming and reduction of anaemia) and strengthening growth monitoring and promotion including BCC for improved infant and young child feeding practices (IYCF).The combination with UNICEF’s WASH, for the water supply component in 8 woredas, andt for sanitation and hygiene in all 20 woredas, is coherent and complementary.
The ANSP in Ethiopia is a multi-stakeholder partnership (institutionalized through various Memoranda of Understanding/agreements) of UNICEF, various universities (Addis Ababa University, University of Bahir Dar) and NGOs which support GoE departments at federal and regional level as well as governement structures (health facilities and schools) at woreda levels. The ANSP aims in particular to strengthen GoE capacity to ensure the scale up of nutrition through a multi-sectoral approach at national, district and sub-county level and deliver on the UNAP commitments related to the strengthening of the policy, legal and international frameworks and the capacity to effectively plan, implement monitor and evaluate nutrition programming (R 1.1 and R 2.1). In addition several results (R 2.2, R 2.3 and R 4.2) relate to communication and advocacy, in line with the UNAP objective to create awareness of and maintain national interest in and commitment to improving and supporting nutrition programs. In doing so, the ANSP fills some important gaps as identified in the gap analysis undertaken as part of the UNAP development16.
Monitoring frameworks
The monitoring framework for Ethiopia is based of UNICEF’s conceptual model for nutrition (UNICEF 1990 and Lancet 2008). Starting form this frame-work, the logical model was built on outocmes and outputs planned for Ethiopia. The model is concise and straightfoward, clearly indicating the relation between activities and outcomes and outputs. Indicators include WASH indicators such as handwashing coverage and knowledge on hygiene. An indicator table, linked to the logic model shows the operational definition of indicators, the responsible agency, methods and data sources to be used and the frequency and time-line for monitoring.
16 The gap analysis consisted of comparing recent performance in Uganda in addressing young child and maternal nutrition with potential and desired performance. Please refer to page 11 of the UNAP.
The four year workplan is based on (a simplified version of) this indicator table. There are no major discrepancies between the (revised ) four year workplan and the subsequent workplans for year 1 and year 2 (apart from some delays, please refer to section 2.7.1). Objectively verifiable indicators (OVIs) are well defined but not quantified for pillar 4 (for example: increase by 10 percentage points from the base-line). Base-line data are yet to be incorporated. Also, in the translation from the indicator table into the workplan, OVIs on outputs have been partly lost.
Unfortunately, interim reports don’t report on progress of the implementation of activities but only of results (in unmeasurable termns as “on track” or “delayed”). It is unclear whether the the indicator table is (still) used for monitorin purposes.
2.2 Equity Focus
In terms of where to operate, UNICEF followed advice and direction from GoE. The CBN programme focuses on densely populated food insecure agrarian regions in Amhara, Oromia, SNNPR and Tigray, which have the highest rates of stunting in Ethiopia. Woredas targeted by the ANSP were already part of the CBN and could thus quickly absorb additional support. By comparison targeting the harder to reach communities such as those found in the developing regions could have been more challenging, but these would be less able demonstrate impact from a strengthened CBN programme.
Levels of stunting in the four CBN regions at tghe start of the programme were worse than in other regions of Ethiopia (as per the selection criteria). However, the evaluation of the effectiveness of the CBN shows that stunting levels declined substantially17 from 51% to 41% in less than three years. The level of stunting in the ANSP target woredas is 37%, somewhat lower than the national average as estimated in the revised NNP (40%). In any case, the level of stunting is a public health concern warranting extra support.
The focus on rural areas is justified as the data in the table below demonstrate. Rural children are more often stunted and rural women are more likely to suffer from anaemia. Disparities in terms of education, wealth quintile, sanitation facilities and water-source between urban and rural are substantial. Data are from the latest Ethiopian Demographic and Health Survey.