The Government of Ethiopia was implementing the Community-based Management of Acute Malnutrition (CMAM) approach by establishing health facilities at the kebele level (the smallest administrative unit). The CMAM approach includes four components: Community Mobilization, Outpatient Therapeutic Program (OTP), Stabilization Center (SC), and Targeted Supplementary Feeding Program (TSFP). Many parts of Ethiopia faced critical food shortages and an increased number of malnourished children following the failed two consecutive seasonal rainfall. According to the revised 2015 Humanitarian Requirement Document (HRD) for Ethiopia (October 2015), an estimated 350,000 children are expected to be affected by severe malnutrition in 2015. Another 400,000 children were also forecasted to be admitted to the program for the treatment of Severe Acute Malnutrition (SAM) in 2016. The Somali region was one of the regions seriously hit by the drought. The poor functioning health system in the region also worsens the situation demanding additional support.
UNICEF requested Tech RRT support to help strengthen the CMAM program in Ethiopia in terms of service scale-up, case finding, program monitoring, and reporting.
In 2015 the Government of Ethiopia implemented the Community-based Management of Acute Malnutrition (CMAM) approach by establishing health facilities at the kebele level (the smallest administrative unit). This program uses a community-based approach to managing acute malnutrition among children and other vulnerable groups. Many parts of Ethiopia faced critical food shortages and an increased number of malnourished children following the failed two consecutive seasonal rainfall. Another 400,000 children are forecasted to be admitted to the program for the treatment of Severe Malnutrition (SAM) in 2016. The Somali region was one of the regions seriously hit by the drought. The poor functioning health system in the region also worsens the situation demanding additional support.
UNICEF requested Tech RRT support to help in strengthening the CMAM program in Ethiopia in terms of service scale-up, case finding, program monitoring and reporting.
Ethiopia suffered two of the worst drought waves in decades; these resulted in severe food and nutrition insecurity across the country, with the Somali Region among the most affected. In 2017 the Somali region alone shared 26% of total Severe Acute Malnutrition (SAM)) admissions in the country, a radical increase from 5% in normal years and this number is likely to increase in 2018. The proportion of children admitted to Stabilization Centers (SCs) also increased from 4% of all SAM admissions in 2016 to 8% in 2017. In response to the growing needs, UNICEF and thirteen NGOs supported the Somali Region Bureau to expand therapeutic feeding program (TFP) sites to 1,296 health facilities including 1,151 Outpatient and 143 SCs that continue to provide treatment for SAM cases across the Somali region. In addition, 210 Outreach sites managed by 35 Mobile Health and Nutrition Teams (MHNT) assist hard-to-reach Woredas and the population in IDP locations. In the Somali region, SMART survey(s) have not been conducted since 2016. As a result, there has been a loss of experience conducting SMART surveys due to the turnover of skilled staff.
UNICEF Jijiga Regional Office in consultation with Regional Health Bureau (RHB) and Disaster Prevention & Preparedness Bureau (DPPB) requested support from the Tech RRT to build survey capacity in the Somali region so that surveys can be conducted in 2018 in 4 woredas ((Kelafo, Charati, Dolo Ado, and Gunagado.
Somali region in Ethiopia faced an acute food and nutrition security crisis, with its third year of poor rains; with 83 out of 93 woredas classified as Priority 1 (P1), with the remaining 10 at P2, and the severe acute malnutrition (SAM) caseload already double the region’s projected estimate in the January 2017 Humanitarian Requirements. For the nutrition response, especially regarding Community-based Management of Acute Malnutrition (CMAM), UNICEF and partners have highlighted multiple nutrition challenges including a lack of sufficiently trained staff, low coverage of CMAM programs, hard to reach remote and Internally Displace People (IDP)communities, NGO staffing restraints, poorly skilled staff, surge staff that lack experience in CMAM. Concern Worldwide has started an intervention in one Zone in Somali and together with partners, Concern worldwide started to map out additional contribution to improve capacity and quality response to CMAM.
The Tech RRT CMAM advisor was requested in three phases:
Concern Worldwide (CWW) began working in Ethiopia in 1973 with an emergency response, which later evolved into long-term development and resilience-building programs targeting selected woredas (districts) in eight of the nine kililoch (regions) of the country. Within current programs, CWW works to address issues of sustainability and to embrace a more holistic approach to programming by addressing multiple underlying causes of poverty and implementing integrated multisectoral projects. For many of the health and nutrition projects, a Standardized Monitoring and Assessment of Relief and Transitions (SMART)was part of the assessment. CWW previously had a large survey unit in Ethiopia and led surveys throughout the country. However, due to restructuring this unit was lost which led the organization to contract out to local consultants who often produced surveys of questionable quality.
In order to implement quality surveys, technical capacity strengthening was needed. CWW Ethiopia requested the Tech RRT support in strengthening the overall emergency nutrition response by building the capacity of response stakeholders in the implementation, analysis and reporting of emergency nutrition assessments on behalf of CWW and the Ethiopian Nutrition Coordinator Unit (ENCU).
Public health emergencies were quite common in Ethiopia due to drought, flood, earthquake, epidemics of communicable diseases, dry and wet mass movement, and conflict. The 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) showed that 37% of children under 5 were stunted and 12% were severely stunted. Additionally, there was a high percentage of wasted children with as much as 32% in some regions. With regards to Infant and Young Child Feeding IYCF), 59% of infants under six months were exclusively breastfed and 6% of infants under 6 months were not breastfed at all, a dangerous and life-threatening practice. The danger at which infants are placed in an emergency is impacted by whether the child is breastfed or non-breastfed and dependent on infant formula. Infants who are dependent on infant formula are extremely vulnerable, especially in an emergency setting. Maternal nutrition is important not only for the health of the mother but also for the child. One-quarter of women of reproductive age are undernourished, leaving their children predisposed to low birth weight, short stature, lower resistance to infections, and higher risk of disease and death. Among women with a live birth in the past 5 years, 60% took Iron Folic Acid (IFA) tablets during pregnancy, and 11% took them for the recommended period of 90 or more days.
The Tech RRT Remote Support was two-fold and happened in two different phases.
A May 2018 multi-sector assessment highlighted the significant humanitarian needs, particularly in environmental health, hygiene and sanitation in Deder woreda which had a population of 314,935. The nutrition situation in the area was exacerbated by overcrowding and internal displacement on the Somali-Oromia border. The under-five population was estimated at 16.4%, with a birth rate of 3.4%. The prevalence of malnutrition for infants under 6 months is not known. However, a survey conducted for children under 5 years in October 2009 and October 2013 showed Global Acute Malnutrition (GAM) fluctuating between 5.2% and 10%. In March 2017 screening showed a GAM of 3.8% in children 6-59 months. Given the persistent vulnerability of the woreda area in terms of food insecurity, high birth rate, and limited focus on maternal nutrition and Infant and Young Child Feeding (IYCF) it was needed the management of malnutrition for under 6 months using the MAMI approach.
Despite a dedicated Management of at-risk Mothers and Infants (MAMI) Advisor at GOAL Ethiopia, the position was new with little experience in MAMI. Therefore, GOAL Ethiopia requested technical support from Tech RRT MAMI Advisor to support and transfer knowledge to GOAL’s MAMI Advisor and to develop high-quality training materials for use in the RCT.
The humanitarian situation in the Tigray Region was a deep concern for refugees. The ongoing conflict displaced more than 21 million people and left more than 5.2 million people in need of food and other humanitarian assistance. Malnutrition among young children and breastfeeding women was a major concern despite that humanitarian response is facing increasing threats and security risks. The ongoing conflict, on the other hand, hindered the timely collection of nutrition data to inform response programs as well as advocacy. Humanitarian workers were moved to safer places, worsening data collection such that there were no nutrition assessments conducted in the Northern part of Ethiopia. The little fainted nutrition data gathered indicates that 76,363 children in Tigray Region were screened with proxy Global Acute Malnutrition (GAM) and Severe Acute (SAM) Malnutrition prevalence of 25.7% and 2.7% respectively. However, the data lacked credibility because it was not gathered by experts.
Due to the increase in humanitarian nutrition partners and more financial resources allocated in response to Tigray, there was a need to assess the nutrition situation. The GNC TST advisor was requested to support nutrition data collection to understand the severity of the nutrition situation.
The conflict in Tigray in November 2020 propelled the region to a complex crisis that made humanitarian response very difficult. The humanitarian situation was extremely dire and continued to deteriorate. Nutrition partners working at the community level noted challenges in accessing basic needs food, clothing, shelter, health, and nutrition services continued to heighten the vulnerabilities of girls and women to various forms of GBV including but not limited to sexual violence, sex for survival, sexual exploitation and abuse, intimate partner violence, and child marriage. The Emergency Nutrition Coordination Unit (ENCU) -estimated that in 2022 there were about 115,829 severely malnourished and 338,091 moderately malnourished children. No representative nutrition assessment has been conducted in the last 2 years but a desk review of secondary data during the Meher assessment unveiled a proxy SAM rate of 2.9% and GAM of 19.6% in the region. The ENCU partners in Tigray following the resumption of supplies in the region have embarked on scaling up the nutrition response, A trainer of trainers reached 84 health workers who are scheduled. There were six active national NGOs that were implementing nutrition activities. The Nutrition Cluster wanted to develop a nutrition cluster operational response plan and capacitation strategies that will harmonize the response approaches undertaken by humanitarian partners.
The Nutrition Cluster sought remote support from the GNC Technical Alliance to develop this response plan.
Developed a list of nutrition actions
Developed nutrition cluster operational response plan and capacitation strategies for Tigray 2022-2023
Developed a package of tools that NGOs can use
Developed an orientation package for partners to familiarize themselves with the tools
Malnutrition is a significant public health problem in Ethiopia. According to the 2019 Ethiopian Demographic Health Survey (EDHS), 53% of under-five mortality was associated with malnutrition while stunting at 37% and wasting at 7.27.2The prevalence of both stunting and wasting was higher than the average for Africa, which is 29.1% and 6.4%, respectively. Furthermore, the prevalence of wasting worsens during emergencies, requiring immediate nutrition response. Over the years, Ethiopia has experienced several disasters and man-made emergencies such as drought, floods, locust invasions, and conflict, which resulted in internal displacement and damage to crops and animals. These emergencies put children and mothers at a greater risk of malnutrition, by preventing communities from practicing proper IYCF behaviors and impeding access to essential health and nutrition services. Therefore, establishing and strengthening programmes towards the promotion, protection, and support of optimal IYCF practices was essential, particularly during emergencies. One programme is the Infant and Young Child Feeding during Emergency which had several challenges including Limited coverage, limited information on IYCF-E needs of the population, lack of IYCF practices, and lack of procedures for care of nonbreastfed infants.
The national operational guideline for IYCFE was endorsed by the government, however, there was a need to operationalize it at all levels which includes orientation to health workers. Additionally, there was no standard for the national training manual for IYCF-E. The monitoring and reporting systems for IYCF practices were also lacking. As the GNC TST support was requested. This TST followed the previous support which was conducted in 2020.
Developed a draft IYCF-E costed action and Implementation plan in consultation with the UNICEF Nutrition specialist.
Developed the IYCF-E training manual working with IYCF-E TWG
Integrated GBV-related activities in the training materials.