Attachment

FOOD AND
NUTRITION
TECHNICAL
ASSISTANCE
Review of Incorporation of Essential

Nutrition Actions into Public Health
Programs in Ethiopia
January 2008
Joan Jennings
Mesfin Beyero Hirbaye
FANTA
FHI 360
1825 Connecticut Ave., NW
Washington, DC 20009-5721
Tel: 202-884-8000 Fax: 202-884-8432
[email protected] www.fantaproject.org
Review of Incorporation of Essential Nutrition Actions
into Public Health Programs in Ethiopia
January 2008
Prepared by:
Joan Jennings, Consultant
Mesfin Beyero Hirbaye, Consultant
Food and Nutrition Technical Assistance (FANTA) Project
FHI 360
This report is made possible by the generous support of the American people through the support
of the Office of Health, Infectious Disease, and Nutrition, Bureau for Global Health, United
States Agency for International Development (USAID) and the USAID Mission in Ethiopia,
under terms of Cooperative Agreement No. HRN-A-00-98-00046-00, through the FANTA
Project, operated by FHI 360. The contents are the responsibility of FHI 360 and do not
necessarily reflect the views of USAID or the United States Government.
Food and Nutrition Technical Assistance Project (FANTA)

)+,1825 Connecticut Ave., NW Washington, DC 20009-5721
Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fantaPDLO@IKL.org Website: www.fantaproject.org
Table of Contents
ACRONYMS.................................................................................................................................................i
EXECUTIVE SUMMARY .........................................................................................................................iii
1. OBJECTIVES OF THE REVIEW............................................................................................................ 1
2. BACKGROUND ...................................................................................................................................... 1
2.1 Health Services in Ethiopia ................................................................................................................ 1
2.2 Nutrition in Ethiopia........................................................................................................................... 2
2.3 Essential Nutrition Actions and Key Contact Points .......................................................................... 3
2.4 Activities by LINKAGES to Support Adoption of ENA in Ethiopia................................................. 4
2.4.1 In partnership with the F-MOH and other actors, creating national level support and ownership
through advocacy and strategy development for ENA implementation............................................... 5
2.4.2 Developing behavior change messages and materials to strengthen and harmonize information
across multiple partners, including the F-MOH and NGOs ................................................................. 5
2.4.3 Capacity building and training of F-MOH, NGOs and university partners to integrate ENA into
their programs ...................................................................................................................................... 6
2.4.4 Strengthening training of health professionals through incorporation of ENA in pre-service
curriculum by the Carter Center EPHTI and universities. ................................................................... 6
2.5 Essential Services for Health in Ethiopia and ENA ........................................................................... 6
3. METHODOLOGY OF THE ENA REVIEW ........................................................................................... 7
4. MAIN FINDINGS .................................................................................................................................... 8

4.1 Nutrition and ENA at National Level................................................................................................. 8
4.1.1 Advocacy..................................................................................................................................... 8
4.1.2 National Nutrition Strategy ......................................................................................................... 9
4.1.3 National Strategy for IYCF ......................................................................................................... 9
4.1.4 Control and Prevention of Micronutrient Deficiencies ............................................................... 9
4.1.5 Baby Friendly Hospital Initiative ................................................................................................ 9
4.1.6 ENA and Health Management Information Systems ................................................................ 10
4.2 Incorporation of ENA into Health and Nutrition Programming....................................................... 11
4.2.1 The Federal Ministry of Health ................................................................................................. 11
4.2.2 Essential Services for Health in Ethiopia .................................................................................. 11
4.2.3 MOH Health Services at RHBs and ZHO/DHOs...................................................................... 12
4.2.4 ENA Counseling at the Community Level................................................................................ 13
4.2.5 UNICEF .................................................................................................................................... 15
4.2.6 NGOs......................................................................................................................................... 16
4.2.7 ENA and Management of SAM ................................................................................................ 17
4.3 ENA and Pre-service Training of Health Professionals ................................................................... 17
5. FACTORS THAT FACILITATED THE INSTITUTIONALIZATION OF ENA ................................ 20
6. FACTORS THAT INHIBITED THE INSTITUTIONALISM OF ENA ............................................... 21
ANNEXES
Annex 1. Scope of Work ........................................................................................................................ 22
Annex 2. Websites, Documents and Presentations for ENA Review.................................................... 26
Annex 3: List of Site Visits and Key Informants at National and Regional Levels ............................... 28
Annex 4. Itinerary of Site Visits ............................................................................................................. 30
Annex 5. Map of Districts Visited.......................................................................................................... 33
Review of Incorporation of Essential Nutrition Actions into Public Health Programs in Ethiopia
ACRONYMS
ANC Ante-Natal Care
AJJDC American Jewish Joint Distribution Committee
BCC Behavior Change Communication
BFHI Baby Friendly Hospital Initiative
CARE Cooperation for Assistance and Relief Everywhere
CBGMP Community Based Growth Monitoring and Promotion
CHP Community Health Promoter
C-IMCI Community Integrated Management of Childhood Illness
CMBS Code of Marketing of Breastmilk Substitutes
CRS Catholic Relief Service
CTC Community Therapeutic Care
DHS Demographic and Health Survey
ENA Essential Nutrition Actions
EPHTI Ethiopia Public Health Training Initiative
EPI Expanded Program of Immunization
ESHE Essential Services for Health in Ethiopia
FANTA Food and Nutrition Technical Assistance
F-MOH Federal Ministry of Health
FHD Family Health Department
FP Family Planning
GH Global Health
HEW Health Extension Worker
HMIS Health Management Information System
HSDP Health Sector Development Program
ICD Institute for Curriculum Development
IMNCI Integrated Management of Newborn and Childhood Illness
IMC International Medical Corps
IR Intermediate Result
IRT Integrated Refresher Training
IU International Unit
IYCF Infant and Young Child Feeding
LAM Lactational Amenorrhea Method
LCD Liquid Crystal Display
M&E Monitoring and Evaluation
MOH Ministry of Health
NU Nutrition Unit
NNS National Nutrition Strategy
NGO Non-Governmental Organization
NWG Nutrition Working Group
PASDEP Plan for Accelerated and Sustained Development to End Poverty
PMTCT Prevention of Mother to Child Transmission
PRSP Poverty Reduction Strategy Program
RHB Regional Health Bureau
i
SAM Severe Acute Malnutrition

SCF-UK Save the Children United Kingdom
SCF-US Save the Children United States
SNNPR Southern Nations Nationalities and Peoples Region
TFC Therapeutic Feeding Center
TOT Training of Trainers
TVETC Technical and Vocational Education Training Centers
UN United Nations
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
USG United States Government
WHO World Health Organization
ZHO/DHO Zonal and/or District Health Offices
ii
EXECUTIVE SUMMARY
In FY 2003, USAID/Ethiopia introduced the Essential Nutrition Actions (ENA) package as an
approach to support the Ethiopian government and its partners in their efforts to improve the
nutrition of women and children under two years of age. USAID/Ethiopia requested the USAID/
GH LINKAGES Project to provide wide-ranging support in this strategy. When the LINKAGES
Project ended in September 2006, USAID/Ethiopia requested the bilateral Essential Services for
Health in Ethiopia (ESHE) Project to carry on implementation of the ENA approach. In FY
2007, USAID/Ethiopia requested the USAID/GH Food and Nutrition Technical Assistance
(FANTA) Project to review the degree to which the ENA approach has been incorporated into
the Ethiopia Federal Ministry of Health (F-MOH) system and multilateral and non-governmental
organization (NGO) programming, and to identify factors that have facilitated or inhibited this
integration.
Site visits and interviews with key informants were conducted by two FANTA consultants over a
period of three weeks in October 2007. Interviews and observations included government and
non-governmental institutions at the national, regional and community levels.
Findings
The Review found that among sites and institutions visited, ENA has been incorporated into the
F-MOH and NGO programming. Factors that have facilitated ENA’s incorporation into the
Ethiopian public health system include advocacy, a designated project to support ENA activities
and training of various types of health professionals at different levels of the system.
LINKAGES’s initial advocacy effort is recognized by partners and stakeholders as having
created awareness of the importance of nutrition for child survival, along with a base of
agreement and support for ENA at national and regional levels. The ability of a USAID bilateral
project, such as ESHE, to provide longer-term support and technical assistance for
institutionalization of ENA has been instrumental in maintaining and strengthening the capacity
of health workers in ENA. The strategy of integrating ENA through many different agents (e.g.
health services, pre-service training institutions, NGOs active in maternal and child health) was
considered by key informants of the Review to be worth the investment and has provided an
opportunity to reach the women and children of Ethiopia through multiple channels. The
numbers of people trained in these various public-private sectors also has created a base of skills
even as individuals change positions or move to other institutions.
Factors that have inhibited the institutionalization of ENA include the lack of formal approval for
the draft National Nutrition Strategy (NNS), lack of ENA-related indicators in the Health
Management Information System (HMIS), and lack of regularly scheduled training courses on
ENA for new and continuing health professionals. Although ENA is seen to be incorporated into
health services at regional, district and community levels in the regions supported by ESHE and
in the five pre-service training institutions visited during this Review, Ministry of Health (MOH)
administrators and university instructors note there is a lack of emphasis on ENA from higher
administrative levels due to the lack of a concerted national strategy. As review and discussion of
HMIS results often drives supervision and decision-making, ENA remains less of a priority
within management systems because of its absence among HMIS indicators. Although
iii
LINKAGES trained a great number of people who still are working within the public health
system, staff turnover is still cited as problem in continuing implementation of ENA. There is,
therefore, a continuing need for training in ENA among health workers.
iv
1. OBJECTIVES OF THE REVIEW

In FY 2003, USAID/Ethiopia introduced the ENA package as an approach to support the
Ethiopian government and its partners in their efforts to improve the nutrition of women and
children under two years of age. USAID/Ethiopia requested the USAID/GH LINKAGES Project
to provide wide-ranging support in this strategy. When the LINKAGES Project ended in
September 2006, USAID/Ethiopia requested the bilateral ESHE Project to carry on activities to
continue implementation of the ENA approach.
In FY2007, USAID/Ethiopia requested that the USAID/GH FANTA Project review the degree to
which the ENA approach has been incorporated into the Ethiopia F-MOH system and
multilateral and NGO programming, particularly by those organizations that participated in ENA
training and technical assistance through LINKAGES, such as the United Nations Children’s
Fund (UNICEF), ESHE and the Carter Center Ethiopia Public Health Training Initiative
(EPHTI). USAID/Ethiopia also requested that FANTA describe how ENA has been integrated
into pre-service curriculum by the Carter Center EPHTI, and whether the integrated curriculum
is now being implemented at the seven focus universities. The specific objective of the Review is
to identify factors that facilitated or inhibited integration of ENA.
Please refer to the Scope of Work of the Review in Annex 1.
2. BACKGROUND
2.1 Health Services in Ethiopia1
The F-MOH is into the third phase of a Health Sector Development Program (HSDP), which was
launched in 1998 within a “context of a strong government commitment to democracy and
decentralization...and to respond to the needs of the rural population who constitute about 85%
of the total.” The program is in accord with the government’s Poverty Reduction Strategy
Program (PRSP) process and addresses multiple aspects of the health system, including facility
construction and rehabilitation, health care financing, pharmaceutical systems and more. The
basic objective of the HSDP is to improve the coverage and quality of health services, which has
resulted in special programs and packages to contribute to this objective: (a) the Health Service
Extension Program; (b) the Accelerated Expansion of Primary Health Care Coverage; and (c) the
Essential Health Service Package.
The health service delivery system consists of four tiers with a primary health care unit at the
lower level, with five satellite health posts, followed by the first level of referral to a district
hospital. By 2004, coverage of health services had been extended to 64% of the population, with
the number of health centers almost tripled and the number of health posts increased by a factor
of fifty.
1
Information comes from several sources: (a) Essential Health Services Package for Ethiopia; Federal Ministry of
Health, August 2005; (b) Health Sector Development Programme II Final Evaluation Report; F-MOH, March 2006;
(c) Health Sector Development Programme III 2005/06 – 2009/2010; Ethiopia F-MOH Program and Planning
Department 2005; and (d) The Earth Institute of Columbia University Center for National Health and Development
in Ethiopia; www.cnhde.et.columbia.edu November 2007.
1
In addition to increasing coverage through the construction or rehabilitation of health facilities, a

strategy of creating a new cadre of health workers was initiated – HEWs. The HEWs are
primarily female and are deployed in pairs at the kebele level of administration and health
services (the next administrative unit below district). They undergo one year of training in
selected Technical and Vocational Education Training Centers (TVETC).
Approximately 17,000 HEWs have been trained thus far, and the accelerated program plans for
an additional 3,000 to be trained by 2009. A national evaluation of HEW capacity in 2005 found
a need for strengthening initial training and providing continuing education.2 This
recommendation resulted in the development of an 18 day Integrated Refresher Training (IRT)
course for all HEWs. The course is given by TVETC tutors and is based on Community
Integrated Management of Childhood Illness (C-IMCI) models.
2.2 Nutrition in Ethiopia
Ethiopia is known for a long history of food shortfalls and famine emergencies that contribute to
high levels of severe acute malnutrition (SAM). Less well known is that approximately one-half
of children less than five years of age are chronically malnourished as reflected in the prevalence
of stunting3 4. Ethiopia is among the nations with the highest under-five mortality rates in the
world and at least 53 percent of mortality can be attributed directly or indirectly to malnutrition5.
Planners in government agencies and the donor community have tended to address malnutrition
primarily as a food supply issue. Yet various studies have shown that it is a more complex
phenomenon that stems from various underlying determinants, including a lack of optimal
feeding practices for infants and young children.
The 2005 Ethiopia Demographic and Health Survey (DHS) reported that only one in three
infants age 4-5 months is exclusively breastfed. Among children 6-23 months, in the 24-hour
period preceding the survey, only 22 percent were fed according to three Infant Young Child
Feeding Practices (IYCF) practices reflecting the minimum of appropriate complementary
feeding practices (given breastmilk or milk products, fed at least a minimum number of times,
and fed at least a minimum diversity of food groups)6; only 11 percent of children under age
three had consumed any iron-rich food in the 24-hour period before the survey and 26 percent
any food high in vitamin A. Less than half of children age 6-59 months had received vitamin A
supplementation within the six months prior to the survey and only 21 percent of mothers had
received vitamin A post-partum; the majority (89 percent) of mothers did not take iron
supplements during pregnancy.
2
“Training of Health Extension Workers: First Intake Assessment”; Center for National Health Development in
Ethiopia, The Earth Institute at Colombia University; Addis Ababa, August 2005.
3
46% of children less than 5 years of age have a height-for-age z-score less than -2 standard deviations.
4
“Ethiopia Demographic Health Survey 2005”; Central Statistical Agency, Addis Ababa, Ethiopia and ORC Macro,
Maryland, USA; 2006.
5
Caulfield, et al. “Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia,
malaria and measles.” American Journal of Clinical Nutrition, 2004; 80: 195.
6
Macro International, 2007.
2
2.3 Essential Nutrition Actions and Key Contact Points
ENA is an approach to expand the coverage of seven affordable and evidence-based actions to
improve the nutritional status of women and children, especially those under two years of age.
The seven ENAs are:
1. Exclusive breastfeeding for children 0-5 months

2. Adequate complementary feeding for children 6-23 months with continued breastfeeding
for at least 24 months
3. Adequate nutritional care of the sick and severely malnourished child
4. Adequate nutrition for women
5. Prevention of vitamin A deficiency for women and children
6. Prevention of anemia for women and children
7. Prevention of iodine deficiency for all members of the household
Linkages/Ethiopia Final Report 2003-2006, Linkages Project, FHI 360 2007
ENA takes advantage of key contact points at critical stages in the lifecycle to deliver these
interventions so that the nutritional status of women and children improve. These contact points
are:
Pregnancy
Delivery and early neonatal consultations
Postnatal and family planning (FP) contacts
Immunization contact
Well child visits, including growth monitoring and promotion
Sick child visits, especially during and just after illness
3
Linkages/Ethiopia Final Report 2003-2006, Linkages Project, FHI 360 2007
ENA is integrated into the health system from the community to national levels, and promoted at
all appropriate health and non-health contact points to ensure consistent widespread coverage
and quality of services.
2.4 Activities by LINKAGES to Support Adoption of ENA in Ethiopia
At the request of USAID/Ethiopia, from March 2003 to September 2006, LINKAGES provided
support to the Ethiopian government and its partners for the introduction of the ENA package as
an approach to improve the nutritional status of women and children under two years of age.
Lessons learned from LINKAGES programs in other countries, particularly Madagascar, guided
program design and were adapted for Ethiopia.
4
In Ethiopia, the adoption of ENA was facilitated by four complementary actions:
2.4.1 In partnership with the F-MOH and other actors, creating national level support and
ownership through advocacy and strategy development for ENA implementation.
LINKAGES organized advocacy and technical workshops and updates for the government,
donors and implementing agencies, including PROFILES workshops. PROFILES is designed to
enable nutrition policy analysis and dialogue through a tool that quantifies the consequences of
malnutrition using computer-based models and demonstrates the contribution that improved
nutrition can make to human and economic development. This advocacy created awareness of
the magnitude of the nutritional problems in Ethiopia and the actions necessary to address them.
LINKAGES highlighted ENA as the ideal framework for an integrated approach to addressing
priority nutritional problems in Ethiopia.
The LINKAGES Project was an active member of the national level Nutrition Working Group
(NWG) (also referred to as the Nutrition Cluster of the national Partnership Forum), in
coordination with the F-MOH, UNICEF, and other key partners, such as the Ethiopian Health
and Nutrition Research Institute. This collaboration resulted in the production and approval of a
national strategy for IYCF and a draft NNS.
2.4.2 Developing behavior change messages and materials to strengthen and harmonize
information across multiple partners, including the F-MOH and NGOs
One of the main contributions of ENA to the efforts addressing the nutrition problems in
Ethiopia was its use of multiple channels/materials to strengthen and harmonize behavior change
messages. Some of the print materials that were developed to support and reinforce messages
include7:
Ethiopia booklet on ENA messages for partners
Family health card for providers and caregivers
Complementary feeding recipe book for three major staple diets
Job aids for health workers and Health Extension Workers (HEWs)
Ten steps poster on Baby Friendly Hospital Initiative (BFHI)
Counseling cards and key steps for infants feeding and Prevention of Mother-to-Child
Transmission (PMTCT)
Posters, counseling cards, leaflets for nutrition and HIV
Video on breastfeeding practices
Audio spots and stories on breastfeeding
Audio spots on complementary feeding
Audio spots on women’s nutrition
7
Electronic copies of materials developed under USAID/GH’s LINKAGES Project can be found here:
http://www.linkagesproject.org/country/ethiopia.php
5
2.4.3 Capacity building and training of F-MOH, NGOs and university partners to integrate
ENA into their programs
LINKAGES, in coordination with the F-MOH, developed six training courses8:
1. ENA Technical Course: four day course for health managers and program staff to give state-
of-the-art technical updates on the importance of nutrition, the nutrition situation in Ethiopia,
IYCF, micronutrients, women’s nutrition, behavior change communication, and monitoring
and evaluation (M&E).
2. ENA Counselors’ Course: six day course for instructors, NGO staff and health workers to
build counseling and negotiation skills through classroom and field practice
3. ENA Course for Community Promoters: two 15 hour modular courses to provide the
knowledge and skills to counsel and negotiate small “doable” actions to improve ENA
including IYCF practices and newborn care
4. Baby-Friendly Hospital Initiative: self-learning training course includes self-assessment tools
adapted for Ethiopia and facility-based learning sessions
5. Lactation Management Course: three day course for instructors, NGO staff and health
workers to strengthen breastfeeding knowledge and skills to counsel mothers
6. Lactational Amenorrhea Method (LAM): three day course for instructors, NGO staff and
health workers to strengthen knowledge and practices on LAM as a modern FP method.
LINKAGES collaborated with ESHE to provide materials (including print and electronic
materials, along with recorded radio spots), training, support and follow up for a large number of
MOH staff in the three largest of the nine regions of the country – Oromia, Amhara and the
Southern Nations Nationalities and Peoples Region (SNNPR) – which provide health services for
about 15 million people. LINKAGES also provided training and materials to various NGOs,
including those with USAID funding for Child Survival Projects and Title II Development
Assistance Programs.
2.4.4 Strengthening training of health professionals through incorporation of ENA in pre-

service curriculum by the Carter Center EPHTI and universities.
LINKAGES collaborated with the Carter Center EPHTI in improving pre-service training for
health professionals at seven of the major universities in Ethiopia and several technical
vocational schools. ENA and technical information was incorporated into general nutrition
classes for health professionals and advanced classes for pediatrics, obstetrics-gynecology,
and/or nutrition.
2.5 Essential Services for Health in Ethiopia and ENA
The ESHE Project is USAID/Ethiopia’s five-year (FY 2003-2008) bilateral initiative for child
health and health sector reform with the Ethiopian Government. The project contributes to the
achievement of the USAID Mission’s Strategic Objective 14: Human Capacity and Social
8
Training course materials are available on the LINKAGES website:
www.linkagesproject.org/publications/index.php?series=9
6
Resilience Increased by (IR 14.1) increasing the effective use of high-impact child health, FP and
nutrition services, products and practices (IR14.1). ESHE works in 64 selected districts in 12
zones in the three largest regions of Ethiopia: Amhara, Oromia and SNNPR.
ESHE focuses efforts within the Three Pillars Strategic Framework: strengthening health worker
skills, health systems, and positive health behaviors at household and community levels. ESHE
works in partnership with the F-MOH and operates within the existing structures of the Regional
Health Bureaus (RHB), Zonal and District Health Offices (ZHO/DHO), health facilities and local
communities. ESHE assists health offices in improving the quality and utilization of high-impact
child survival interventions through the Expanded Program on Immunization (EPI), ENA, and
Integrated Management of Newborn and Childhood Illness (IMNCI) interventions. Key
approaches include capacity building, community mobilization and Behaior Change
Communication (BCC)
The LINKAGES Project collaborated with the ESHE Project from FY 2003-2006. When
LINKAGES ended in FY 2006, USAID/Ethiopia requested ESHE to continue ENA in the three
focus regions (Amhara, Oromia and SNNPR) and at the national level; ESHE hired several of the
former LINKAGES national staff. ESHE continues to support the Nutrition Working Group
(NWG) and provides technical assistance, as requested by the F-MOH or RHBs, for training
health facility staff in ENA. ESHE also conducts follow-up supportive supervision in health
facilities, with ZHO/DHO staff. ESHE has not continued to support NGOs or pre-service
institutions.
3. METHODOLOGY OF THE ENA REVIEW

Fieldwork for the ENA Review was conducted by two FANTA consultants from October 6-27,
20079. At the national level, interviews and observations were conducted with partners and
collaborators, including the Carter Center EPHTI and UNICEF/World Bank, along with key F-
MOH staff at the federal level (Family Health Department [FHD] Nutrition Unit)10. At the
regional level, FANTA visited each of the three regions where the ESHE Project is active
(Amhara, Oromia and SNNPR) and interviewed members of the RHB FHDs. At the district
level, FANTA interviewed administrative health staff at ZHO/DHOs, and visited three district
health centers (one in each region) where service delivery staff were observed and interviewed.
At health posts in each of the three regions, FANTA selected a number of F-MOH HEWs for
interviews and observations, while at the community level, volunteer Community Health
Promoters (CHP) were visited in their homes.
FANTA also conducted interviews with instructors from five of the seven collaborating
university colleges responsible for pre-service training of health professionals, and visited two
adjunct hospitals and outpatient care facilities where doctors and interns were interviewed. Addis
Ababa University Hospital was undergoing large scale renovation and was not visited, while
instructors in obstetrics, also responsible for the BFHI, were either on leave or on vacation and
were not interviewed. Observation of the classroom teaching of ENA was not possible due to
9
See Annex 2 for list of documents and presentations analyzed for the review. See Annex 3 for list of sites visits and
key informants. See Annex 4 for itinerary of site visits. See Annex 5 for map of Ethiopia.
10
Names of key informants are not given in the report as some of those interviewed wished to remain anonymous.
7
class schedules though a few students who had received training in ENA were informally
encountered and were asked about their experience and knowledge, including a former ENA-
trained instructor now doing post-graduate study in pediatrics.
Concern Worldwide, an NGO active in incorporating ENA into the transition from emergency
response to development programming, was visited in the field. Two separate focus groups were
conducted with community workers in Concern’s Community-Based Therapeutic Care (CTC)
Program in one district of Amhara Region: two focus groups with CHPs and HEWs,
respectively. Concern field staff were also interviewed, along with the head of the District Health
Office. FANTA also interviewed several health staff from NGOs that received training from
LINKAGES in ENA. All provided information on how they had incorporated the ENA into on-
going health and nutrition programming.
4. MAIN FINDINGS
4.1 Nutrition and ENA at National Level
4.1.1 Advocacy
All stakeholders and collaborators, particularly within government structures, emphasized that
the advocacy for ENA done initially by the LINKAGES Project was a very important and
effective first step for introducing ENA. This step raised stakeholder awareness of the
relationship between improvements in feeding practices and reductions in child morbidity and
mortality, thus building a base of agreement, interest and support for the approach. F-MOH
nutrition unit staff stated that the incorporation of ENA into the draft NNS and the approval and
production of the national strategy for Infant and Young Child Feeding (IYCF) illustrates the
effect of this advocacy and the ownership by the F-MOH of ENA. Another example of the
usefulness of the ENA advocacy materials is that the Dean of the Agriculture College at the
University of Hawassa stated that this information constituted the basis of her presentation in
lobbying for the (approved) formation of an undergraduate and graduate program in nutrition at
the university.
MOH staff at the RHB FHDs stated that the region-specific nutrition information is particularly
useful and they continue to use this information in various venues, such as regional staff
meetings and/or child survival partnership forums. Regional, ZHO/DHO staff stated that the
information provides a clear and logical picture of the positive impact on maternal and child
health that can be achieved through (preventive) changes in IYCF practices. Informants
suggested periodically updating the information and continuing its dissemination. In addition,
one key informant mentioned using the momentum provided by international events, such as the
planned 2008 launch of the Lancet series on maternal and child undernutrition, to strengthen
advocacy activities in Ethiopia.
Due to Ethiopia’s history of famine and food shortfalls, the pressure to focus primarily on food
security, nutrition surveillance and/or to respond to pockets of emergencies is still one of the
strongest factors influencing approaches to nutrition at all levels. For example, nutrition has been
the responsibility of the Ministry of Agriculture as part of its food security mandate. A theme
8
that emerged from the interviews is that activities aimed at changing feeding practices compete
with national emphasis on response to SAM and emergencies. However, MOH staff who had
received training in ENA considered it to be integral to the prevention of malnutrition. Key
informants also emphasized the need for incorporating ENA into actions to address SAM, so that
communities can transition and prevent nutritional deficiencies once a crisis is past.
4.1.2 National Nutrition Strategy
Although those interviewed stated that ownership of ENA has been internalized among F-MOH
staff and partners, almost everyone also suggested that approval of a NNS that includes emphasis
on ENA is necessary for further institutionalization of the approach. With World Bank
assistance, there is momentum for official approval of a NNS. The World Bank has plans for the
formation of eight technical working groups in Ethiopia around issues such as management,
community development and HMIS to review specific issues related to completion and approval
of the NNS.
4.1.3 National Strategy for IYCF
The National Strategy for IYCF, which was developed by F-MOH in collaboration with
LINKAGES and other partners, was formally approved in 2004 and copies were distributed to all
ESHE-supported RHBs and ZHO/DHOs. The F-MOH has been responsible for the reproduction
and distribution of the document in non-ESHE supported regions and districts also. However, the
Nutrition Unit of the F-MOH notes that distribution alone is not enough to institutionalize this
strategy. One F-MOH staff suggested the development of operational guidelines is needed; all
staff agreed that an established and on-going process for orientation of new MOH staff to the
National Strategy for IYCF is necessary due to the high turnover of staff at health facilities.
4.1.4 Control and Prevention of Micronutrient Deficiencies
A National Guideline for Control and Prevention of Micronutrient Deficiencies was approved in
2004 with the objective of achieving virtual elimination of micronutrient deficiencies, including
vitamin A deficiency, anemia and iodine deficiency. The institutionalization of ENA for control
of micronutrient deficiencies is strongly linked to the availability of vitamin A supplements, iron
folate and whether or not iodized salt is available for purchase in the region.
All health facilities visited by FANTA consultants reported sufficient supplies of vitamin A.
Vitamin A is provided in 100,000 IU capsules and staff who were interviewed know the
recommended dosages for children six to 11 months, children 12 - 59 months and post-partum
mothers. Many staff have retained pamphlets on vitamin A that were provided by the USAID-
funded micronutrient project, MOST, which ended in 2006.
4.1.5 Baby Friendly Hospital Initiative
A draft Code of Marketing of Breastmilk Substitutes (CMBS) was formulated in 2005 through
collaboration between LINKAGES, the F-MOH and UNICEF and has been under review. Many
stakeholders feel that approval of the CMBS and the BFHI has “stagnated”, primarily because
9
the draft NNS has not yet been approved, resulting in a lack of accountability from the highest
levels. Ethiopia does not have any BFHI-certified hospitals as of October 2007. The Armed
Forces General Hospital, is said to have completed the BFHI ten steps and to be awaiting
evaluation. Some informants stated that this process was facilitated by the strong hierarchical
nature of management of the Armed Forces General Hospital.
4.1.6 ENA and Health Management Information Systems
Key informants stated that there will be little management or supervisory emphasis on the
incorporation of ENA into daily service provision until ENA indicators are included in health
facility monitoring information systems. In several ESHE-supported areas, ENA data is being
recorded and reported by HEWs with varying levels of collection and analysis by District or
Zonal Health Offices. The indicators most frequently encountered in site visits to health facilities
are the number of post-partum women and/or children receiving vitamin A supplements and/or
the number of children attending growth monitoring and promotion sessions (along with other
anthropometric and program information if the site also functions as an out-patient CTC
program). In some cases, HEWs recorded the number of households receiving education on
optimal breastfeeding and/or recommended complementary feeding practices for infants and
young children.
In 2006, the F-MOH underwent an iterative process to review and revise the national HMIS and
testing of the new design has been under evaluation since June 200711. Multiple stakeholders
were involved in this redesign and an initial list of 300 potential indicators was compiled. One
key objective of the HMIS review was to reduce the number of indicators collected to a
minimum and focus on regular collection of quality data, with timely analysis and management
response and action. Selection of indicators was based on the priorities of the Plan for
Accelerated and Sustained Development to End Poverty (PASDEP)12, the needs and priorities of
local authorities, and the requirements of international agreements, such as the Millennium
Development Goals, along with the HSDP.
Another consideration for selection was whether indicators were best collected through
continuous monitoring systems or through periodic methods, such as population-based surveys.
For example, it is suggested that although bednet utilization and safe sex practices are goals of
the HSDP, these would best be measured “by surveying the behavior of the population at large.”
The list was reduced to 100 indicators, which were categorized under Family Health, Disease
Prevention and Control, Resources, or Health Systems. There are 19 indicators for Family Health
to be monitored on an on-going quarterly basis. These are sub-divided in the categories of
Reproductive Health (10), Child Health (3) and Expanded Program of Immunization (6).
Nutrition-related indicators included are (a) low birth weight, and (b) proportion of children age
0-3 years with moderate/severe underweight (weight-for-age). Due to the high levels of
11
This information is taken from the “Federal Ministry of Health in Ethiopia, Health Management Information
Systems/Monitoring and Evaluation, Indicator Definitions, HMIS/M&E Technical Standards Area 1, version 1.1;
HMIS Reform Team, (draft) October 2007.”
12
The PASDEP (2005-2009) represents the second phase of Ethiopia’s PRSP process.
10
malnutrition frequently found in Ethiopia, there is concern about the quality of information
provided on institution-based growth monitoring but this indicator was included as it can provide
some indication of trends.
Many countries track vitamin A distribution within HMIS and this indicator was considered
during the period of HMIS review; however, it was not included in the recently revised system as
vitamin A is not yet given routinely nationwide in Ethiopia.
The new initiative for deployment of community-based HEWs is expected to soon reach 100
percent coverage. There will be additional discussion and revision needed to determine how to
best capture their contributions to health care using HMIS; for example, the newly revised
system notes HEWs as a source of low birth weight data, along with their potential to contribute
to a system for vital events registration.
4.2 Incorporation of ENA into Health and Nutrition Programming
4.2.1 The Federal Ministry of Health
Within the F-MOH FHD, the present head has only been in this position for several months, but
the three staff who formed the Nutrition Unit (NU) in late 2005, the final year of the LINKAGES
Project, have remained. Two NU staff reported that staff are familiar with and supportive of
ENA, having received varying degrees of training, either directly from LINKAGES or through
participating as a host for trainings of other health professionals conducted by ESHE technical
specialists. However, the perception of one NU staff member was that nutrition is not a priority
within health focus areas, which hinders their activities and effectiveness. The NU staff
expressed hope that approval of the draft NNS will bring more support to the NU.
Since the end of the LINKAGES Project in September 2006, the F-MOH NU has coordinated the
replication of ENA training in four different workshops for health professionals (primarily
nurses, with some doctors and sanitarians) that work in health facilities in what are referred to as
the “emerging regions”13 – regions of smaller total population that are perceived to have received
less resources and capacity-building in health services. The NU was responsible for reproduction
of ENA materials and funding from the World Health Organization (WHO) paid for these and
other administrative costs.
4.2.2 Essential Services for Health in Ethiopia
ESHE collaborated with LINKAGES during its implementation and, as part of its mandate from
USAID/Ethiopia, has continued to include and support ENA within its activities to strengthen
health services and health workers skills and to improve community behaviors.
The ESHE ENA Coordinator participates in the national NWG, currently chaired by UNICEF. In
October 2006 and June 2007, ESHE participated in national and regional dissemination of the
PROFILES workshop. ESHE also coordinates on-going national radio and television advocacy
for optimal breastfeeding, appropriate complementary feeding and improved women’s nutrition.
13
Afar, Somali, Gambela and Benishangul-Gumuz
11
Along with other multi-sectoral representatives, members of the ESHE team participated in the
F-MOH Annual Review (of programs, targets, achievements, etc.) at the beginning of October
2007. Small groups were formed to discuss future needs and ESHE staff participated in the
nutrition working group. This small group work, which is expected to be considered during the
development of future plans, called for continued emphasis on ENA, along with strategies for
treatment of SAM and an increased focus on micronutrients.
ESHE staff have continued to provide materials and technical assistance as trainers for health
workers in Amhara, Oromia and SNNPR. In spite of high MOH staff turnover, over 1042 health
professionals that have been trained through the five-day ENA-BCC course are still providing
services within the system. ESHE staff provided technical expertise for four training workshops
for over 150 health professionals from the emerging regions, which were coordinated by the F-
MOH NU.
ESHE regional office staff provide regular follow-up and supportive supervision to district health
staff and HEWs, particularly in the focus areas of immunization, environmental health and ENA
The new cadre of HEWs in Ethiopia is trained by the TVETC; recently ESHE has been
providing training for TVETC tutors on community mobilization and communication skills. For
HEWs, ESHE has provided technical assistance and materials to strengthen the nutrition
component of the IRT. ENA is taught in two days of the training; ESHE staff advocated for more
days without success as the IRT already includes 9 topics and is 18 days in length.
4.2.3 MOH Health Services at RHBs and ZHO/DHOs
The three RHBs that collaborate with the ESHE Project have named a nutrition focal person
within their FHD structure. The focal persons, along with one or more additional staff in the
FHDs, have all received training in ENA. The four FHD staff interviewed were enthusiastic
proponents of ENA, citing the clarity of the framework and the fact that it is action-oriented.
They were emphatic that the workload in health facilities is not an obstacle to the provision of
ENA counseling to clients, but rather that what needs to change is the attitude of service
providers. The key informants described service providers as tending to diagnose, treat and/or
prescribe for clients quickly, without much discussion or dialogue, even though there might not
be a high patient load or the pressure of many people waiting for attention. Besides teaching key
messages, the ENA training package provides training in behavior change counseling and
negotiation skills, supplying service providers with the tools needed to initiate dialogue with
clients. The FHD staff interviewed note that this component of the ENA-BCC training is unique
in their experience and consider it important and relevant for promotion of changes in any type
of health behavior.
At the ZHO/DHO level, in spite of high levels of staff turnover, at ZHO/DHOs visited by
FANTA consultants, with ESHE support there remains ENA-trained staff who can serve as
resources for ENA. All ENA materials were available in the ZHO/DHOs visited and ESHE has
facilitated packaging of health and nutrition materials into a binder that is easily located and
referred to by staff. Both RHB and ZHO/DHO staff mentioned that behavior change
communication training provided through the ENA package is excellent and an important
12
component that is relevant to all health and nutrition counseling. All nine ZHO/DHO
administrative staff interviewed were advocates of ENA and describe it as being clear, useful and
of critical importance within health services.
Within district health facilities, counseling on the recommended ENA was found to be most
strongly institutionalized in ante-natal care (ANC) service, and next in the labor and delivery
room. Many of the ANC providers are female nurses and they considered counseling on maternal
nutrition and optimal breastfeeding to be a natural fit within ANC counseling. ANC providers
displayed strong knowledge of the messages for optimal breastfeeding and maternal nutrition.
They also were familiar with the ENA job aid, which was present in an appropriate location in all
ANC services visited. ANC providers interviewed spontaneously mentioned their appreciation of
and use of the Infant Feeding-PMTCT counseling desktop flipchart provided by LINKAGES; the
guide seemed to be in use in all ANC services visited.
In the one labor and delivery room observed out of the three district health facilities visited14, an
ENA job aid was found posted in an appropriate location and staff appear familiar with its
content. The poster for 10 Steps for Breastfeeding, provided through the BFHI, was also present
in most facilities visited. Key informants reported that delayed initiation of breastfeeding until
after expulsion of the placenta still occurs. However, skin-to-skin contact and use of colostrum
was reported to be promoted, along with support for correct attachment and positioning. This
was confirmed in an unplanned observation of a mother and newborn less than one hour after
birth.
The importance of HMIS in driving service delivery is very apparent in FP services. The focus
for FP counseling, and HMIS indicators of FP, is predominantly on tabulating the number of
methods provided. Only with prompting did staff remember training received in the LAM and
stated they provide counseling in this “if mothers request it.”
In the three health centers visited, it was observed that if the health center staff member
responsible for the EPI and/or Child Health had received ENA training from LINKAGES, he or
she demonstrated more likelihood of including at least some ENA recommendations during
service provision, in particular recommendations for exclusive breastfeeding until six months of
age. Complementary feeding was not included in the recommendations as frequently as
exclusive breastfeeding. All staff in these health centers report counseling for continued and/or
increased breastfeeding of sick children; recuperative feeding was not mentioned.
4.2.4 ENA Counseling at the Community Level
In five of the ESHE target districts, a total of seven HEWs and CHPs were selected by ESHE
regional office staff and visited. The selected HEWs received basic training in nutrition during
their initial certification as HEWs and through the official IRT. However, the selected HEWs
also benefited from additional training in ENA, either from ESHE or, in the case of the CTC
program, from Concern staff. In addition, they also received strong follow-up support from
ESHE and Concern staff. Therefore, the group of HEWs that the FANTA consultants were able
14
The other two district health facilities were undergoing major renovation and reconstruction and the labor and
delivery rooms could not be observed.
13
to observe and interview may not be representative considering the amount of training that they
have received. One unplanned counseling session by an HEW was observed while the other
HEWs were requested to conduct mock counseling sessions15. Assessment was made of the
correctness of messages, the appropriateness of messages (e.g. for ante-natal counseling versus a
sick child visit), the order of priority of messages (e.g. frequency and consistency of
complementary feeding versus specific food recommendations), and whether or not HEWs
displayed or made reference to negotiation skills for BCC.
Based on the examples of messages the selected HEWs chose to convey to clients, and on
responses to additional questions from the FANTA consultants, these HEWs demonstrated
comprehensive knowledge of the ENA messages, particularly on recommendations for optimal
breastfeeding. They also demonstrated a command of, the reasons for these recommendations in
terms of benefits for mother and child. When asked to give an example of positive change seen
in child feeding practices, the most frequent answer from HEWs and CHPs was either the use of
colostrum or the practice of exclusively breastfeeding the child until six months of age.
HEWs observed during actual and mock counseling sessions include ENA counseling messages
fluidly within broader ANC counseling. HEWs demonstrated an easy rapport with clients, clearly
comfortable in asking questions or seeking additional information. All HEWs and CHPs in the
districts visited spontaneously mentioned some aspect of BCC skills, which is an integral
component in the LINKAGES ENA-BCC training package. Examples include: “listen first, then
give advice based on what was said;” “in order to help the mother, you must understand how she
is feeling;” and “it is important to have a dialogue with the person you are counseling.” The
HEWs demonstrated techniques that encourage dialogue during mock counseling
demonstrations. They stressed that they suggest practical and possible actions for improvement
in nutrition practices.
In addition to individual observations and interviews, two focus groups were conducted with 21
HEWs and five CHPs participating in a CTC Program implemented by Concern in a district that
also receives ESHE support. In focus groups, the knowledge of complementary feeding
messages demonstrated by those HEWs interviewed was strong, but not quite as comprehensive
as for optimal breastfeeding. All HEWs emphasized introduction of food at six months of age,
improving the preparation of the traditional gruel as a thicker porridge, and frequency of feeding.
Most HEWs spontaneously mentioned that these practices are just as important, if not more
important, than food availability issues. Several HEWs noted that when mothers must leave the
home, they now leave expressed breast milk in a clean cup for the caregiver to give to the child.
HEWs perceived the most challenging recommendation to be related to active feeding, as
mothers are busy and this is not a traditional practice.
HEWs were provided by ESHE with a demonstration tool showing different locally available
grains and pulses. This is used to recommend combining ingredients in the traditional
gruel/porridge and appears to have been very useful in increasing a focus on the best use of
15
It should also be noted that during an unplanned visit to one Health Post, the two HEWs received more than 15
clients during a 2 hour period. The majority of these clients were requesting testing for malaria; the HEWs were well
supplied with Rapid Diagnostic Test kits.
14
household resources. For example, some HEWs suggested that families trade amongst
themselves to obtain a variety. In one instance, however, the HEWs prioritized this message
above all others and feel they have little useful advice for a mother with only one type of grain,
failing to recognize the importance and benefits of more frequent feeding and thicker consistency
of porridge made from even one type of grain. One exceptional HEW kept a few local fruits and
vegetables handy, as examples of additional ways in which to enrich a child’s diet as “they are
rich in vitamins.” She also used the traditional coffee cup (which is about 150 ml in size) to
demonstrate the amounts a child should eat as they get older.
The HEWs observed and interviewed tended to focus on supplementation and fortification
options for micronutrients, rather than local food sources. In terms of promoting the consumption
of vitamin A-rich foods, during observation of actual and mock counseling, HEWs displayed
confusion as to which fruits and vegetables are high in vitamin A. Occasionally an HEW
mentioned iron-rich foods among messages for pregnant women. However, in general, HEWs
report counseling pregnant women to use iron folate supplements distributed at ante-natal care
visits and obtain vitamin A supplements available to post-partum women and children at health
posts and during periodic MOH campaigns.
Among the BCC materials available, the laminated Complementary Feeding Counseling Card
appeared to be one of the most valuable tools for HEWs, who use the pictures to discuss
recommendations with mothers with low levels of literacy, as is common. HEWs also used the
order of these pictures as a visual reminder of the key messages while providing counseling,
which helps structure and organize the counseling they provide. HEWs also demonstrated use of
the Family Health Card to provide a variety of health and nutrition messages and job aids
developed by LINKAGES (ENA counseling messages presented for each of the six common
contact points of health services).
4.2.5 UNICEF
UNICEF Nutrition and Food Security staff expressed appreciation of the strengths of ENA,
including its appropriateness, its clarity and the framework for messages. UNICEF’s primary
focus is on Community-Based Growth Monitoring and Promotion (CBGMP) that leads to
analysis and action at community level. The UNICEF Country Program for 2007-2011 for
Ethiopia calls for “growth monitoring and promotion, nutrition counseling, promotion and
protection of exclusive breastfeeding, optimal complementary feeding practices, improved
hygiene and sanitation practices, micronutrient supplementation and appropriate fortification
activities for micronutrients, targeted supplementary feeding, and community based monitoring
information package”16 within the UNICEF Nutrition and Food Security Program.
A nutrition instructor from one of the universities offering pre-service training on ENA
conducted a review of the CBGMP component of the national Food Security Project, which
encompasses multi-sector activities and is supported by multiple actors, including the World
Bank and UNICEF. The review notes that “caring aspects of the causes of malnutrition can be
16
Government of Ethiopia - UNICEF Country Programme Action Plan 2007 – 2011.
15
addressed through household level BCC (counseling) of mothers and caregivers”17 and suggests
that HEWs or community volunteers conducting CBGMP need on-the-job training in nutrition
skills, including BCC and ENA.
UNICEF has recently printed 4.5 million copies of the Family Health Card, which includes ENA
messages, for use throughout the country. UNICEF staff have continued to use PROFILES
nutrition advocacy information in various venues, including recently in the keynote speech for a
meeting of the Ethiopian Nutrition Society. UNICEF regrets that the LINKAGES Project could
not have had a longer term for implementation, noting that they were very active and innovative
partners as members of the Nutrition Working Group (NWG). It was also noted that the on-going
national initiative for HEWs would benefit from a focused project like LINKAGES.
UNICEF has also provided funds to ZHO/DHOs for replication of ENA training in non-ESHE
supported districts. In addition, UNICEF provided funds for district level trainings in
management of SAM, and these workshops have included information on ENA. The Oromia
RHB, serving the largest region in Ethiopia with an estimated population of 26 million, receives
funds from UNICEF to support mass media activities and FHD staff have found the radio spots
provided by LINKAGES to be quite useful for disseminating information in this challenging
coverage area.
In coordination with the Government of Ethiopia, partnership with the International Fund for
Agriculture Development, and with support from UNICEF, the Belgium Survival Fund also has
incorporated ENA into the nutrition component of an integrated food security program in two
districts in Tigray and two districts in Oromia.
4.2.6 NGOs
Ten NGOs18 received training and follow-up performance monitoring from LINKAGES. Six of
these were contacted in person or by phone/email during this ENA Review. All six have
conducted training and provided materials to hundreds of health facility partners in the districts
where they implement maternal-child health programming. Several MOH staff at zonal or
district level report participation as co-trainers in these workshops.
At present each of the NGOs retained only one or two of the staff that were originally trained by
LINKAGES. However, all six of the NGOs contacted that received training from LINKAGES
stated that they have replicated ENA training for other health staff in their organization and
report the incorporation of ENA into new USAID-funded Child Survival and Health Grant
Program projects and into other health programming (such as environmental health or
reproductive health) that is funded by other sources, including private donations and foundations.
17
“Community Based Child Growth Component of Food Security Project: Strengths & Weaknesses and
Recommendation on the Way Forward (A 100-Day Plan)”, December 2006.
18
American Jewish Joint Distribution Committee, CARE, Concern, Canadian Physicians AID Relief, CRS,
Ethiopian Orthodox Church Development and Inter Church Aid Commission, GOAL, SCF-UK, SCF-US, World
Vision Ethiopia.
16
4.2.7 ENA and Management of SAM
In March 2007, with support from UNICEF, WHO and others, an updated document was issued
by the F-MOH of Ethiopia entitled: “Protocol for the Management of Severe Acute
Malnutrition.” For management of SAM in infants up to six months of age, there is emphasis in
the Protocol that “the whole objective of treatment of these patients is to return them to full
exclusive breastfeeding.” For management of SAM in children over six months of age (inpatient
and/or outpatient care), however, there is only one line of text in support of continued
breastfeeding. There is no emphasis of its importance, nor any explanation of the benefits,
nutritional content, contribution to preventing future relapse, etc. Recommendations for
complementary feeding are also absent from the protocol. Only at the end of the detailed sections
on treatment is there reference to conducting regular health and nutrition education group
sessions using an annex that contains messages suitable for lesson plans. This annex in the
Protocol contains much of the information found in the ENA package, along with other
information, but not as concisely or clearly as in ENA.
The role of ENA in management of SAM was discussed in a recent meeting of the NWG. The
issues related to transition from emergency to development and the importance of including
preventive approaches within emergency response in Ethiopia are pending the institutionalization
of a community-based approach to SAM.
Several NGOs interviewed CARE, GOAL, the IMC, SFC-US and SFC-UK, implementing
community-level emergency response programs for SAM have also incorporated ENA into
program models. The recent experience of ESHE in Bolosso Sore district in SNNPR underlines
the importance of ongoing preventive nutrition education in areas that periodically require the
services of emergency response programs. ESHE was requested to provide assistance to this
district after funding ended for the emergency response programs. There was apprehension that
there would be an increase in the rate of malnutrition after the program exit. With support for
integration of ENA into district health facilities, along with other critical components of ESHE
initiatives, monitoring results showed nutritional status to be maintained or improved.
AJJDC maintains a health facility to serve the Felasha population in Gondar. This clinic also
functions as a Therapeutic Feeding Center (TFC). Staff received cascade training in ENA from a
central office staff member trained by LINKAGES. The clinic was observed to emphasize
counseling on optimal breastfeeding, including support with attachment and positioning, as a
central component of TFC care. Also emphasized was the importance of promoting positive
feeding practices by caretakers to prevent relapse after recovery.
4.3 ENA and Pre-service Training of Health Professionals
The LINKAGES Project collaborated with the Carter Center EPHTI in Ethiopia to integrate
ENA into lesson plans and printed lecture notes for basic human nutrition advanced pediatrics
and obstetrics/gynecology courses. Concurrently, questions related to ENA were incorporated
into exams for these classes. With the recent initiative to revise and accelerate Health Officers’
training, the Carter Center has also incorporated ENA into this curriculum. The collaboration
17
between LINKAGES and the Carter Center initiative focused on the seven major pre-service
training universities at that time: Addis Ababa, Haromaya, Hawassa, the Armed Forces, Gondar,
Jimma and Mekele Universities.19
The LINKAGES Project provided training to university instructors using the ENA technical
course and the ENA-Training of Trainers (TOT) course, with an additional focus on elements of
BCC, adult learning principles and classroom instruction methodologies. Instructors also
attended workshops on topics such as the integration of ENA in basic, advanced, and
professional courses, along with development of ENA lesson plans. Several of these instructors
then also functioned as “master trainers”, providing co-facilitation of trainings along with
LINKAGES or, later, with ESHE staff.
Instructors at five of the seven collaborating universities were interviewed and stated that the
integration of ENA in formal lecture notes and exams has helped institutionalize the approach
within pre-service training20. These university instructors demonstrated familiarity with the
technical information and key concepts of ENA and all remarked on the conciseness, structure
and practical nature of ENA as one of its key strengths. Several instructors particularly
mentioned that the focus on data from Ethiopia in the ENA materials provided motivates
students and sparks their interest in ENA. All instructors described ENA and teaching materials
as being clear and easy to understand by students.
Trained instructors have all the ENA materials provided available and consider the provision of
compact disks of materials to have been an excellent reference support, along with printed
materials. The Carter Center EPHTI initiative helped provide the universities with computers,
liquid crystal display (LCD) projectors and overhead projectors, and the instructors have
embraced these tools and are confident in their use. One instructor noted the use of a
breastfeeding demonstration video that comes from an IMNCI package of materials. Only one
instructor was enthusiastic about using innovative ENA methods such as demonstration breasts
and infant doll to provide orientation on correct attachment and positioning. All instructors
mentioned the large number of students in any class as a limitation to the use of innovative
methods (such as small group work or individual role play or demonstration). Classes can be as
large as 50 students or more, while there is usually only time for a few days of lecture to go over
ENA. For example, the basic human nutrition class at Jimma University is composed of seven
modules and maternal-child nutrition is one module (note that information on micronutrients is
also touched upon in another module). The lecture emphasis appeared to be strongest on optimal
breastfeeding and micronutrients, followed by complementary feeding. The interviewed
instructors stated that maternal nutrition only receives a brief mention due to the volume of
material to be gotten through in the courses. One instructor stated that he not only
comprehensively addresses all of the ENA in his course, but also includes additional education
on lactation management.
19
Since then, many additional pre-service institutions have been opened throughout the country.
20
Official university review and approval of revised curricula occurs less frequently than the every five years
indicated and the integration of ENA into lecture notes, exams, etc., has not officially been approved as a revised
curriculum at any university. It is unclear, however, how much practical implication official approval would have on
teaching, as teachers have significant individual control for their courses while the (approved) lecture notes
constitute the basis for what is to be covered in any class.
18
As in other sectors in Ethiopia, staff turnover is a critical challenge. Of the five universities
contacted, the proportion of instructors who had been trained by LINKAGES and who continued
teaching ranged from a high of five out of six (Addis Ababa University, but with two on leave or
sabbatical) to a low of zero (Haromaya University, with hopes that one might return after
completing higher education in nutrition). At least two or three instructors were still present at
the other three universities visited, and all trained instructors were advocates of ENA. Those
instructors who did not receive training from LINKAGES and are newly assigned to teach ENA
within classes admitted they only address those elements that they feel confident in their capacity
to respond to student questions.
Although this review did not include a review of student test scores, instructors stated that, based
on exam results, students have not had difficulty in learning ENA information; again the clarity
of the framework and conciseness of the approach is cited. A few students were spontaneously
encountered on campus or during visits of university health facilities. These students were
quizzed on optimal breastfeeding and complementary feeding knowledge. Their capacity ranged
widely; none displayed a comprehensive knowledge of all seven ENA. A post-graduate student
now specializing in pediatrics, who had received ENA-TOT training as an instructor in general
medicine, stated: “Our generation of doctors includes counseling on nutrition in patient care
because we know about the importance of optimal breastfeeding, complementary feeding and
micronutrients. We, the younger students, are proud to be the ones promoting this knowledge.”
Opportunities to put new knowledge into clinical practice come from clinical rounds, patient case
presentations by students and hospital internships (for post-graduate students). Instructors trained
in ENA all state that counseling on breastfeeding is touched upon in review of all student clinical
work, but many perceive that clinical rounds do not permit enough time for an in-depth focus on
correct attachment or other lactation management issues. Basic promotion of breastfeeding
seems to readily fit into clinical care during labor and delivery. For pediatric services, the
tendency is to focus on student identification and treatment of infectious disease, with only brief
focus on complementary feeding or other nutrition issues. Several doctors who had received
ENA training as recent medical students and are now working at a university hospital say they
question students on ENA messages when students present cases from the Pediatrics or the
Obstetrics Departments.
The training of health professionals often includes a rural community placement experience,
particularly for those students at Jimma and/or Addis Ababa University. Instructors rotate week-
long visits with students and note that the amount of malnutrition encountered by students in
communities tends to lead them to an increased focus on ENA. All instructors interviewed noted
that many of their students choose to write a paper on some aspect of optimal breastfeeding, to
fulfill course requirements.
Several hospitals adjunct to universities were undergoing renovation during this ENA Review,
however, those that were visited had many or all of the ENA job aid posters placed in correct
locations and prominent positions, including the outpatient clinic services of one university.
Familiarity with and use of these job aids ranged widely. For example, multiple copies of the
correct job aid were located in the Labor and Delivery Unit of one hospital and the two attending
doctors (who had been trained in ENA as medical students) were fully cognizant of the poster
19
recommendations. They also spontaneously located the LINKAGES desktop flipchart for Infant
Feeding - PMTCT counseling and spoke of its value for counseling patients. On the other hand,
in another Labor and Delivery Unit the job aid was prominently displayed, yet the ward nurses
had no familiarity with this tool (and had received no training in ENA).
5. FACTORS THAT FACILITATED THE INSTITUTIONALIZATION OF

ENA
The Review found that among sites and institutions visited, ENA has been incorporated in the F-
MOH and NGO programming.
LINKAGES’s initial advocacy effort was recognized by partners and stakeholders as having
created awareness of the importance of nutrition for child survival, along with a base of
agreement and support for ENA at national and regional levels. Prior perceptions of food
security as only a food availability issue seems to have changed. Stakeholders at national level,
regional level and universities continue to extract from the advocacy materials provided, for use
in their own nutrition advocacy efforts.
The ability of a USAID bilateral project, such as ESHE, to provide longer term support and
technical assistance for institutionalization of ENA has been instrumental in maintaining and
strengthening the capacity of health workers in ENA. As a key partner at the national level,
ESHE is able to continue to advocate for nutrition. For improving health service quality,
stakeholders emphasize the importance of systems for follow-up and supportive supervision that
ESHE promotes and supports.
The strategy of integrating ENA through many different channels (e.g. health services, pre-
service training institutions, NGOs active in maternal child health) is considered by key
informants of the Review to be worth the investment and has provided an opportunity to reach
the women and children of Ethiopia through multiple channels. The numbers of people trained in
these various public-private sectors also has created a cadre of skilled health workers even as
individuals change positions or move to other institutions. Many of those interviewed cite the
LINKAGES strategy of providing training to a large number of health professionals as having
resulted in a continued focus on ENA through the existing trained health workers that remain.
The Review found at least one, if not several, persons that had received training to still be
present at all levels and in almost all institutions.
Incorporation of ENA in pre-service training harmonized knowledge and health messages among
new graduates and existing health professionals. Staff at pre-service universities and MOH
health administrations note that this harmonization has facilitated a more rapid
institutionalization within the health system. ENA instructors continue to make use of the ENA
support materials that were provided as reference materials for their lecture preparations. The
trained instructors that remain at pre-service training universities are highly knowledgeable
advocates for ENA. Brief interviews with a few students seem to show that ENA messages are
still being taught to students.
20
Those health facility administrators and service providers interviewed for the Review who
directly received training in ENA have retained strong and comprehensive technical knowledge
which they attribute to the clarity, structure and practical nature of the ENA training package.
The ENA support materials provided also continue to be available
6. FACTORS THAT INHIBITED THE INSTITUTIONALIZATION OF ENA

The lack of formal approval for the draft NNS was cited by several key informants as a critical
obstacle to institutionalization of ENA. Although ENA is seen to be incorporated into health
services at regional, district and community levels in the regions supported by ESHE and in the
five pre-service training institutions visited during this ENA Review, MOH administrators and
university instructors note there is a lack of emphasis on ENA from higher administrative levels
due to the lack of a concerted national strategy.
The HMIS currently in use and the recently revised HMIS do not include indicators related
specifically to ENA. As review and discussion of HMIS results often drives supervision and
decision-making, and without clearly identifiable ENA indicators, ENA remains less of a priority
within management systems.
Although LINKAGES trained a great number of people who still are working within the public
health system, staff turnover is still cited as problem in continuing use of ENA. The government
of Ethiopia has recognized the need for formalized refresher training of HEWs and ENA has
been incorporated into this IRT; however, plans for additional training necessitated by HEW
attrition have not yet been addressed. Similarly, a formalized structure for refresher training of
other health professionals is not in place. As staff turnover continues, gaps in knowledge and
skills at health service institutions remains a problem that affects both service delivery and
management and supervision.
A health service culture which incorporates ENA into all recommended health delivery contact
points has not yet been established, even among workers trained in ENA. ANC services at the
health facilities visited during this review show the strongest institutionalization of the approach.
ENA continues to be integrated into pre-service training by those instructors who were trained by
LINKAGES. However, new instructors were reported to be uncomfortable instructing on ENA
without training or direct orientation, and there is no “push” within the system for them to seek
out orientation from trained instructors or other sources.
Within the pre-service training institutions, practicum experiences are not yet maximized for
strengthening student capacity in ENA. There appears to continue to be a higher priority on
disease recognition and treatment, rather than on health and nutrition prevention, and clinical
rounds are said to lack sufficient time for fully counseling mothers on recommended IYCF
practices.
21
Annex 1. Scope of Work
Food and Nutrition Technical Assistance Project (FANTA)

Consultant Name: Joan Jennings
Review of Incorporation of Essential Nutrition Actions into Public Health Programs in

Ethiopia
Technical Manager: Alison Tumilowicz
Period of performance: September – November 2007
Project Number: 2620-63-1-00
Total Number of Days: Up to 42 days
1) Objectives
In 2003, the USAID-funded LINKAGES / FHI 360introduced the Essential Nutrition Actions
(ENA) package as an approach to support the Ethiopian government and its partners in their
efforts to improve the nutrition of women and children less than two years of age. LINKAGES
ended in September, 2006. USAID/Ethiopia wishes to review the degree in which the ENA
approach has been incorporated into the Ethiopia Federal Ministry of Health (FMOH),
multilateral and non-governmental organization (NGO) programming, particularly by those
organizations that participated in ENA training and technical assistance through LINKAGES:
UNICEF, the Essential Service for Health in Ethiopia (ESHE) project and the Institute for
Curriculum Development.
The consultant will be part of a team that includes a local consultant and the FANTA Technical
Manager. The review will take place over a period of 4 months from September, 2007 to
November, 2007.
The objectives of the review are to:

1. Review and describe how the ENA approach has been incorporated into the government
and non-governmental organizations (NGOs) health programming either in the public
health system or private sector, including programming by UNICEF and ESHE;
2. Describe how the ENA approach has been integrated into pre-service curriculum by the
Institute for Curriculum Development and whether the integrated curriculum is being
implemented now at the seven focus universities;
3. Identify factors that facilitated or inhibited integration of the ENA approach; and
4. Provide recommendations to optimize the use of ENA and strengthen nutrition
programming in Ethiopia.
22
2) Background
ENA is a strategy or approach to expand the coverage of seven affordable and evidence-based
actions to improve the nutrition of women and children, especially those under the age of two.
The seven Essential Nutrition Actions are:

• Exclusive breastfeeding for children 0-6 months
• Adequate complementary feeding for children 6-24 months with continued breastfeeding
for at least 24 months
• Adequate nutritional care of the sick and severely malnourished child
• Adequate nutrition for women
• Prevention of vitamin A deficiency for women and children
• Prevention of anemia for women and children
• Prevention of iodine deficiency for all members of the household.
The ENA approach emphasizes contacts at critical stages in the lifecycle to deliver the above
interventions so that growth and micronutrient status of children and women improve. These
contact points are:
• Pregnancy
• Delivery and early neonatal consultations
• Postnatal and family planning contacts
• Immunization contact
• Well child visits, including growth monitoring and promotion
• Sick child visits, especially during and just after illness
The ENA approach is integrated into the health system, from the community to national levels,
and promoted at all appropriate health and non-health contact points to ensure consistent
widespread coverage and quality of services.
In Ethiopia, particular effort was put on harmonizing nutrition messages and promoting
consistent and practical packages of nutrition interventions. This was accomplished through four
complementary strategies:
a. Supporting the FMOH to develop national strategies and guidelines for ENA
implementation;
b. Conducting formative research and developing behavior change messages and materials
to harmonize information across multiple partners, including the FMOH and NGOs;
c. Supporting the FMOH, NGOs and university partners to integrate ENA into their
programs through capacity building; and
d. Strengthening training of health professionals through incorporation of ENA in pre-
service curriculum by the Institute for Curriculum Development and universities.
23
3) Review Questions
Four questions will be addressed by this review:
1. How and to what degree has ENA been incorporated at different levels and by various
partners? Key partners of interest include:
a. ESHE Project in SNNPR, Amhara and Oromia regions
b. NGOs operating in the health/nutrition area, including the Title II NGOs
c. UNICEF and other multilateral organizations
d. Community Nutrition Promoters
e. Universities, particularly those supported by the Carter Center for health
curriculum development
2. Where ENA has been incorporated, how has it evolved and how is it currently being
implemented? Are some components easier to incorporate than others? What factors or
processes have facilitated incorporation of ENA? What have been the challenges to
integration of ENA? What are the lessons learned from these experiences? As part of the
report, the ENA components that have been easily integrated and their facilitating factors
should be identified and explained; and the ENA components that have not been
incorporated and obstacles for their integration should be identified and explained.
3. How has ENA been linked with other activities such as management of severe
malnutrition, including integrated management of childhood illness (IMCI), expanded
program for immunizations (EPI), community therapeutic care (CTC), and HIV care and
support? What are the lessons learned from these experiences?
4. Given the review findings, what can the USAID Mission do to ensure that the use of
ENA is optimized and continues to successfully strengthen nutrition programming in
Ethiopia, as part of bilateral programs and through integration in other USG activities?
4) Specific Activities
The consultant will be responsible for the following tasks:
1) Review background documents (refer to list in annex). LOE: 3 day.

2) In consultation with the local consultant and FANTA technical manager, develop the design
of the review including: aspects of ENA to be reviewed; institutions of focus; review
questions; methods; timeline; and plan for analysis of information collected. LOE: 4 days.
3) In consultation with the local consultant, develop tools for collecting information in Ethiopia
(e.g. interview and observation guides; survey). LOE: 3 days.
4) With the local consultant, meet with USAID Mission personnel in Ethiopia before starting
collection of information to discuss and finalize review design and list of people that will be
interviewed for the review. LOE: 0.5 day.
5) With the local consultant, gather information in Ethiopia through interviews, observation, site
visits and document analysis. LOE: 17 days.
24
6) With the local consultant, write one-page summaries of each contact made for the review
including: contact name and institution; date; location; length of interview or observation;
questions asked or activities observed; key informant responses or description of
observations. LOE: 2 days.
7) With the local consultant, meet with USAID Mission personnel in Ethiopia after finishing
collection of information to discuss preliminary findings. LOE: 0.5 day.
8) Write the final review report including: executive summary (one page); background;
objectives of review; methods; key findings and results; discussion; conclusion; and annexes
(interview/observation guides; interview/observation/document summaries; schedule of
review). LOE: 12 days.
5) Deliverables/Milestones
Proposed Date Deliverable/Milestone Location Days

September 2007 Review design finalized USA 7
September 2007 Institutions/interviews to be USA
included in review identified
October 2007 Interview and observation USA/Ethiopia 3
guides finalized
October 2007 Interviews and site visits Ethiopia 20
scheduled and logistics
arranged
October 2007 Interviews, observation, and Ethiopia
document analysis completed
Contact summaries provided
to FANTA technical manager
via email within 3 days after
each contact
November 2007 Final review report completed USA 12
25
Annex 2. Websites, Documents and Presentations for ENA Review
Websites
FHI 360 Linkages: http://www.linkagesproject.org/
FHI 360 Linkages Ethiopia:

http://www.linkagesproject.org/country/ethiopia.php
USAID Ethiopia Health:

http://www.usaidethiopia.org/pages.asp?PMID=6&CMID=14&SCMID=20
John Snow International, Essential Services for Health in Ethiopia:

http://www.jsi.com/JSIInternet/Projects/ListProjects.cfm?Select=Country&ID=108
Documents
LINKAGES/Ethiopia Final Report 2003-2006.

http://www.linkagesproject.org/publications/Ethiopia_Final_Report_06.pdf
Performance Monitoring Report Selected NGOs and ESHE/RHBs, Essential Nutrition Actions
(ENA) Approach, September 2006.
Community Assessment in selected ESHE focus woredas in Amhara, Oromia & SNNP regions,
Ethiopia 2006.
http://www.linkagesproject.org/publications/Community_Assessment_Ethiopia2006.pdf
Essential Services for Health in Ethiopia, Annual Report, Project Year 3, July 1, 2005 – June 30,
2006. (FANTA Technical Manager has copy of report)
The Essential Nutrition Actions: Findings from the Baseline Surveys of 2003-04 Conducted
ESHE II Project Sites in Amhara, Oromia and SNNPR Regions of Ethiopia, may 2006.
Key Messages on the Essential Nutrition Actions to Improve the Nutrition of Women & Young
Children in Ethiopia, January 2006.
http://www.linkagesproject.org/publications/EthiopiaKeyMessagesBooklet.pdf
National Strategy for Infant and Young Child Feeding. Family Health Department, Federal
Ministry of Health, Ethiopia, April 2004.
Health Sector Strategic Plan (HSDP-III), 2005/6 – 2009/10. Federal Ministry of Health,
Program Planning Department, Ethiopia, 2005. (FANTA Technical Manager has copy of report)
National Strategy for Child Survival in Ethiopia. Family Health Department, Federal Ministry of
Health, Ethiopia, July 2005. (FANTA Technical Manager has copy of report)
26
Framework document for a National Nutrition Strategy for Ethiopia. IFPRI, November 2005.
http://www.ifpri.org/PUBS/wpapers/ethionutrition.asp
Using ‘Essential Nutrition Actions (ENA)’ to Accelerate Coverage with Nutrition Interventions
in High Mortality Settings, June 2004. Basics II.
http://www.basics.org/documents/pdf/Using%20ENA.pdf#search="ena"
Program Review of Essential Nutrition Actions, Checklist for District Health Services. BASICS
II. Revised 2003.
http://www.basics.org/documents/pdf/Program%20review_Checklist.pdf#search="ena"
Presentations
Community Assessment in selected ESHE – RHBs supported woredas in Amhara, Oromia,

SNNP regions. Presented by Dr. Mesfin Beyero, MD MPh, October 12, 2006. (FANTA
Technical Manager has presentation slides)
Using the ‘Essential Nutrition Actions’ Approach to reach broad scale in Ethiopia: Building on
lessons from Madagascar. LINKAGES Final Expo Presentation. (FANTA Technical Manager
has presentation slides)
Essential Nutrition Actions. Presented by Susan Anthony, MPH and Agnès B. Guyon MD,
MPH, June 2004. (FANTA Technical Manager has presentation slides)
Using PROFILES to Build Advocacy Coalitions in Ethiopia and Malawi. Presented by Helen
Stiefel Heymann, FHI 360, April 2007. (FANTA Technical Manager has presentation slides)
27
Annex 3: List of Site Visits and Key Informants21 at National and Regional Levels
NATIONAL LEVEL
F-MOH Nutrition Unit
Nutrition Expert VI
Nutrition Expert seconded by UNICEF
National Level Partners Carter Center Public Health Training Initiative, Program Manager
UNICEF, Nutrition and Food Security, Community Based Nutrition Team (3)
World Bank, Mission team for nutrition (4)
Save the Children-US in Ethiopia
Health and Nutrition Coordinator
sub-office Health and Nutrition Coordinator
GOAL central office Ethiopia, Health Program Coordinator
Non-governmental Concern central office Ethiopia, National CTC Coordinator
Organizations:
Catholic Relief Services
National Level
Country Director (phone)
Health Coordinator (phone)
International Medical Corps in Ethiopia, Health Coordinator (email)
CARE Ethiopia, Health Coordinator (email)
ADDIS ABABA REGION

Pre-Service Training Institution: Addis Ababa University, Assistant Professor Department of Pediatrics and
Addis Ababa Child Health
AMHARA REGION
Regional Health Bureau: Team Leader Family Health Department
Amhara
Kuyu District Health Office
Head
Environmental Expert/Community Promoter
Libokemkem District Health Office
Acting Head
Vice Head
EPI Clinic nurse
Zonal and/or District Health
Ante-Natal Care nurse
Services: Amhara
Child Health Clinic nurse
Yilmanadensa District Health Office
MCH Expert & Nutrition Coordinator
Sick Child Clinic nurse
EPI Clinic nurse
Ante-Natal Care Clinic nurse
Family Planning Clinic nurse
Pre-Service Training Gondar University, Associate Professor Nutrition Department
Institutions: Amhara
GOAL Sub-office in Awassa town
Non-governmental
Assistant Project Manager
Organizations: Amhara
Health Program Officer
21
Names of key informants are not given in the report as some of those interviewed wished to remain anonymous.
28
Concern sub-office/Field staff in Wolaita District

Sub-office Manager
Program Manager
Program Coordinator
Community Outreach Worker
Libokemkem District
1 Health Extension Worker
Community Health Workers and
2 Community Health Promoters
Volunteers: Amhara
Yilmanadensa District
2 Health Extension Workers
OROMIA REGION
Regional Health Bureau: Head of Family Health Department
Oromia Team Leader Nutrition Section
West Hararghe Zonal Health Office
Zonal and/or District Health
Vice Head
Services: Oromia
Head of Family Health Department
Haromaya University
Vice Dean of Health Sciences College
Former Instructor from Health Sciences College, now doing post-graduate study
in Pediatrics at Addis Ababa University
Jimma University
Pre-Service Training Instructor in Public Health Department
Institutions: Oromia Child Health Outpatient Clinic, Pediatrics intern
Jimma University Hospital
Pediatrics Unit, General Practitioner
2 Labor and Delivery nurses
Nutrition Instructor
Clinical Pediatrics Instructor
Chiro District
Community Health Workers and
Volunteers: Oromia
1 Community Health Promoter
SNNP REGION
Regional Health Bureau: SNNP Child Health and Nutrition Team Leader
Awassa District Health Center
Head
Zonal and/or District Health Family Planning nurse
Services: SNNP Child Health nurse
Labor and Delivery nurse
Damot Woyde Health Office, Head
Hawassa University Hospital
General Practitioner in Pediatrics Unit
Pre-Service Training Institution:
2 Labor and Delivery residents
SNNP
Dean of College of Agriculture
Undergraduate medical student
Wolaita District
5 Community Health Promoters with Concern project
Community Health Workers and 21 Health Extension Workers
Volunteers: SNNP Wondogenet District
3 Community Health Promoters
29
Annex 4. Itinerary of Site Visits
WEEK ONE
Monday 8th Tuesday 9th Wednesday 10 th Thursday 11th Friday 12th Saturday 13th
8:00 – 10:00 am. 8:30 – 9:00 am. 6:30 – 10:30 am. 7:30 –10:00 am. Note day is official Drive back to
Meet with ESHE central Haromaya College of Drive to Awassa Drive to Wolaita holiday: Eid al Fitir Addis Ababa
office: Mr. Eerens, Dr. Health Sciences: Ato
Tesfaye, & Mrs. Senait Nega, Vice Dean 9:00 am. Meet SNNPR
ESHE staff
9:00 – 9:30 am.
SC–USA: Dr. Tedbabe, 9:30 – 10:30 am. Drive
Health & Nutrition to Wondogenet District,
Specialist Fura Kebele
10:30 – 12:00 pm. F- 10:00 – 11:00 am. 11:00 – 12:30 pm. 10:30 – 11:30 am. 10:30 – 12:00 pm.
MOH, Dept. Family Addis Ababa University, SNNPR ESHE regional CONCERN, Wolaita Interview with 2 HEWs
Health, Nutrition Unit: Dept. of Pediatrics: Dr. office: branch office: and 3 CNPs combined
Ms.Gobane, Nutrition Solomon; hospital Dr. Hailemariam Mr. Abraham
Expert VI undergoing renovation Observe HEW
11:30 – 12:30 pm counseling pregnant
11:00 – 11:30 am. Drive to Damot Woyde mother
Dr. Dula Benti, former District
instructor Alemaya U, Visit Health Post and
now post-grad at AAU review materials
2:00 – 3:30 pm. 11:30 – 12:30 pm. 2:00 – 2:45 pm. 1:30 – 2:00 pm. 2:30 – 3:30 pm.
Carter Centre – F-MOH, Nutrition Unit: Awassa (district) Health Damot Woyde District Hawassa University &
Ethiopian Public Health Mr. Teshome, Unicef Center: Mr. Amsalu and Health staff: Mr.Moges associated BFHI hospital
Training Initiative: Mr. consultant health professionals
Assefa, Program during visit of facility 2:00 – 3:30 pm 5:00 – 6:00 pm. Dr.
Manager 2:00 – 3:00 pm. Meet with HEWs and Yewelsew, Dean
Oromia Health Bureau CHPs, separately Hawassa University
/Family Health Dept/ Agriculture College
Nutrition Unit:
Mr. Abera and Dr.
Megersa
4:00 – 5:30 pm. 3:30 – 4:30 pm. 3:00 – 4:30 pm. 4:00 – 7:00 pm. 6:30 – 7:30 pm.
Stop by Guion Hotel; USAID Ethiopia/HAPN GOAL sub-office: Drive back to Awassa Southern Regional
Omo Car Rental Agency Mr. Takito & Mr. Health Bureau:
Shiferaw Dr. Efrem
30
WEEK TWO
Monday 15th Tuesday 16th Wednesday 17th Thursday 18th Friday 19th Saturday 20th
6:30 am – 4:00 pm. 8:00 – 9:30 am. 7:00 – 10:30 am. 7:30 – 9:00 am. 7:30 – 8:30 am
Drive to Bahir Dar Join ESHE staff; Drive to Gondar Drive to Bahir Dar Drive to Fitche
Amhara Regional Health (ESHE staff) then to
Bureau/ Family Health Libokemkem District 8:30 – 9:30 am
Dept: Locate district staff
Mr. Alemu (occupied with EPI
campaign)
continued 11:00 – 12:00 noon 11:00 – 12:30 pm. 9:00 – 11:00 am. 10:00 –11:30 am. Review and
West Gojjam Zone, Gondor University, South Gondor Zone, North Shoa Zone, organize notes,
Yilmanadensa District Nutrition Dept.: Libokemkem District Kuyu Dstrict Health collecting
DHO: Mr. Mulat Mr. Melkie Health Office Office and North plane tickets
Shoa ESHE cluster
Visit of District Health Visit District Health staff
Center Center
continued 2:30 – 3:30 pm (Dean is not available to 11:30 – 1:00 pm Note that HEWs and continued
Mesebo kebele: approve interviews with CHPs are all
2 HEWs (look for 2 students or visit of Agelamantegera Kebele: occupied with the
nearby CHPs but they hospital; time is used to HEW and CHP first day of an
are occupied) discuss findings, review immunization
notes) campaign; lunch with
Head of DHO;
review notes 18 Oct.
with DHO (interview
done in Amharic)
4:30 – 6:00 pm 3:30 – 4:30 pm 4:30 – 5:00 pm 3:00 – 6:30 pm 2:00 – 5:00 pm continued
ESHE Amhara regional Return to Bahir Dar AJJDC office Drive to Debremarkos Drive to Addis Ababa
office: Dr. Anwar, Ms. (talk with CRS by
Selamawit & Mr. Bizuhan phone)
31
WEEK THREE
Monday 22nd Tuesday 23rd Wednesday 24th Thursday 25th Friday 26th Saturday27th
7:00 – 11:00 am. 9:30 – 10:30 am. 7:30 – 9:30 am 7:45 – 9:00 am. 8:00 – 8:45 am. Review and
Drive to West Hararghe Yabdoshambuco Health Discuss key findings Debriefing at USAID Jimma University, organize notes
zone, Asebe town Post, Chiro District, West Basic Nutrition
Hararghe Zone: instructor:
2 HEWs and 1 CHP
continued 10:30 – 11:30 am. 10:00 – 11:30 am 11:00 am – 1:00 pm 9:00 – 9:45 am continued
Visit HP Drive to Addis Ababa Fly to Jimma Jimma University
Head of Pediatrics
Locate 1 CHP
1:30 – 2:30 pm. 1:30 – 3:00 pm 1:30 – 3:00 pm 2:00 – 3:30 pm. 1:30 – 4:30 pm
West Hararghe Zonal Look for Belgium Unicef Nutrition and Jimma University, Fly to Addis Ababa
Health Office Survival Fund but Food Security Section: Nutrition Dept:
(Mr. Abdi and Samuel) program has ended; visit Dr. Iqbal Kabir, Dr. Tesfera
CRS sub-office but they Kyoko Okamura,
state they have just Ababe Hailemariam
opened a new project (CBN Team)
with little training given
yet.
3:00 – 4:00 pm. 3:00 – 6:00 pm. 3:30 – 4:30 pm 3:30 – 4:30 pm continued Joan leaves
West Hararghe ESHE zonal Drive to Nazereth; talk Unicef and World Visit associated BFHI Addis Ababa
cluster: Mr. Dedefo with former Ministry of Bank mission team for hospital and outpatient 10:50 pm
Agriculture nutrition National Nutrition clinics
expert by phone Strategy
Note: Had tried to 5:00 – 8:00 pm 6:30 – 7:00 pm.
schedule a visit to CRS Prepare key findings Meet with Emily Mates,
program near Nazereth for tomorrow’s Concern
but staff had an outside debriefing with
workshop this week. USAID
32
Annex 5. Map of Districts Visited
33

Attachment

Uploaded by

Copyright:

Available Formats

Attachment

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Attachment

Uploaded by

Copyright:

Available Formats

FOOD AND

Review of Incorporation of Essential

Food and Nutrition Technical Assistance Project (FANTA)

EXECUTIVE SUMMARY .........................................................................................................................iii

1. OBJECTIVES OF THE REVIEW............................................................................................................ 1

3. METHODOLOGY OF THE ENA REVIEW ........................................................................................... 7

4. MAIN FINDINGS .................................................................................................................................... 8

5. FACTORS THAT FACILITATED THE INSTITUTIONALIZATION OF ENA ................................ 20

6. FACTORS THAT INHIBITED THE INSTITUTIONALISM OF ENA ............................................... 21

SAM Severe Acute Malnutrition

1. OBJECTIVES OF THE REVIEW

Please refer to the Scope of Work of the Review in Annex 1.

In addition to increasing coverage through the construction or rehabilitation of health facilities, a

2.2 Nutrition in Ethiopia

2.3 Essential Nutrition Actions and Key Contact Points

1. Exclusive breastfeeding for children 0-5 months

Linkages/Ethiopia Final Report 2003-2006, Linkages Project, FHI 360 2007

Linkages/Ethiopia Final Report 2003-2006, Linkages Project, FHI 360 2007

2.4 Activities by LINKAGES to Support Adoption of ENA in Ethiopia

In Ethiopia, the adoption of ENA was facilitated by four complementary actions:

LINKAGES, in coordination with the F-MOH, developed six training courses8:

2.4.4 Strengthening training of health professionals through incorporation of ENA in pre-

2.5 Essential Services for Health in Ethiopia and ENA

3. METHODOLOGY OF THE ENA REVIEW

4.1 Nutrition and ENA at National Level

4.1.2 National Nutrition Strategy

4.1.3 National Strategy for IYCF

4.1.4 Control and Prevention of Micronutrient Deficiencies

4.1.5 Baby Friendly Hospital Initiative

4.1.6 ENA and Health Management Information Systems

4.2 Incorporation of ENA into Health and Nutrition Programming

4.2.1 The Federal Ministry of Health

4.2.2 Essential Services for Health in Ethiopia

4.2.3 MOH Health Services at RHBs and ZHO/DHOs

4.2.4 ENA Counseling at the Community Level

4.2.7 ENA and Management of SAM

4.3 ENA and Pre-service Training of Health Professionals

5. FACTORS THAT FACILITATED THE INSTITUTIONALIZATION OF

6. FACTORS THAT INHIBITED THE INSTITUTIONALIZATION OF ENA

Annex 1. Scope of Work

Food and Nutrition Technical Assistance Project (FANTA)

Review of Incorporation of Essential Nutrition Actions into Public Health Programs in

Technical Manager: Alison Tumilowicz

Period of performance: September – November 2007

Project Number: 2620-63-1-00

Total Number of Days: Up to 42 days

The objectives of the review are to:

The seven Essential Nutrition Actions are:

Four questions will be addressed by this review:

The consultant will be responsible for the following tasks:

1) Review background documents (refer to list in annex). LOE: 3 day.

Proposed Date Deliverable/Milestone Location Days

Annex 2. Websites, Documents and Presentations for ENA Review

FHI 360 Linkages: http://www.linkagesproject.org/

FHI 360 Linkages Ethiopia:

USAID Ethiopia Health:

John Snow International, Essential Services for Health in Ethiopia:

LINKAGES/Ethiopia Final Report 2003-2006.

Community Assessment in selected ESHE – RHBs supported woredas in Amhara, Oromia,