In Ethiopia, Community-Based Approaches Help to Improve Nutrition among Women and Children

By Victor Chinyama and Tiguaded Fentahun

South Gondar Zone, Ethiopia: Enalem Asnakew (40) had no idea why her one-year-old son Misganaw Asmare would not stop vomiting. His arms, legs, and abdomen were swollen and his appetite was failing. After about a month, she had had enough and decided to bring him to the local hospital.

“He was put on blood transfusion for three days,” she says in a barely audible voice.Then, they administered [therapeutic] milk through his nostrils in addition to [intravenous] medicine. The nurses frequently visited my child and now, after nine days, the swelling has disappeared, the vomiting is almost gone, and my child takes therapeutic milk orally.”

Misganaw was diagnosed with severe acute malnutrition, a serious but entirely preventable and treatable condition which the WHO estimates accounts for 35 per cent of deaths among children under five globally. Typically, severe acute malnutrition is treated in a hospital but the advent of ready-to-use therapeutic foods has enabled children like Misganaw to be treated at home if they have no underlying medical complication requiring hospitalization.

In general, Ethiopia has made strides in reducing undernutrition in children, with stunting in particular dropping from 58 per cent in 2000 to 38 per cent in 2016. However, the number of children with severe acute malnutrition spikes up during the ‘lean’ season between June and August, the period when most households will have exhausted their food stocks as they await the next harvest beginning September. Prolonged and chronic humanitarian crises, such as droughts and floods, also contribute to increased malnutrition in children.

Inadequate food however is not the only cause of malnutrition. Multiple factors, such as the child’s size at birth and the mother’s weight, predispose a child to malnutrition. Acute illnesses and poor feeding practices are other contributing factors. The key to preventing malnutrition therefore lies in improving the nutritional status of the mother, ensuring the child has access to an improved and diverse diet, providing safe water and sanitation, improving hygiene, and building a strong and supportive system at community level.

In 2011, with a US$ 50 million grant from the Government of Canada, UNICEF embarked on a project to improve nutrition in children and women in 100 food insecure districts in the Amhara, Oromia, and SNNP regions of Ethiopia. The six-year project, later extended for another year, was to improve the use of health and nutrition services by children, adolescent girls, and breastfeeding mothers, and increase the availability of water and sanitation services. The project focused on the community level, where efforts were made to increase the scope and coverage of nutrition activities. These included multi-media campaigns, education of mothers and caregivers on nutrition, promotion of breastfeeding, and increasing production of local complementary foods. Wells were drilled to supply safe water to communities and households were encouraged to construct their own improved latrines.

To improve service delivery, 2,000 community-based health extension workers responsible for mobilizing people and agriculture development agents were trained in nutrition. Water was supplied to health posts and committees to oversee water, sanitation, and hygiene activities were established at kebele level (smallest administrative unit in Ethiopia).

Students line up to receive deworming tablets at Gurumu Koysha Primary and Secondary School in the SNNP Region of Ethiopia. Deworming of adolescents became a national programme after being introduced through the Canada-funded project.
© UNICEF Ethiopia/ 2016/ Meklit Mersha

In total, the number of community-based nutrition activities doubled and 24 per cent more households cultivated a garden (the largest increase was observed among the poorest households). Nutrition knowledge among health workers and health extension workers increased from 51 to 80 per cent while exclusive breastfeeding increased from 71 to 80 per cent. The proportion of mothers stating that water should not be given to babies under six months of age increased from 61 to 78 per cent.

The project also marked a milestone as the first ever in Ethiopia to target nutrition for adolescents (children aged between 10-18 years). Deworming of adolescents was first introduced under the project as a pilot but was subsequently scaled up to national school deworming campaigns, reaching 3.9 million school children.

These results were achieved against a backdrop of unforeseen challenges, such as the civil unrest of 2016 which limited travel and access and the El Nino drought in 2016 which shifted attention and resources.  Notwithstanding, a survey at the end of the project showed that stunting among children had declined from 40 per cent to 35 per cent and the prevalence of underweight children from 22 per cent to 17 per cent. Put differently, the odds of children in the 100 districts being stunted or underweight had been reduced by 19 per cent and 20 per cent respectively.

The education, mobilization, and support given to the 100 districts in Amhara and the other two regions will ensure that mothers like Enalem will never have to wonder again why their children are vomiting, or why their abdomen and limbs are swollen. They will also ensure that children like Misganaw can grow up healthy and strong, free from dangerous yet preventable conditions like malnutrition.

Ethiopia inaugurates model water supply and waste management project

26 May 2018, WUKRO, Tigray region – Today marks another major milestone in the Water Supply, Sanitation and Hygiene (WASH) sector in Ethiopia with the inauguration of a model water supply, sanitation and waste management system in Wukro Town, Tigray Region. Part of the One WASH Plus programme, the system integrates innovative and resilient solutions to provide WASH services to 73,000 people, including 35,000 children under the age of 15, residing in the town and its satellite villages.

Attending the inauguration were His Excellency Dr. Negash Wagasho, State Minister of Water Irrigation and Electricity, Dr Christian Rogg, Head of the UK’s Department for International Development (DFID) in Ethiopia, Ms. Gillian Mellsop, UNICEF Representative in Ethiopia, officials from the Tigray Regional Government and Wukro Town administration officials.

“Ethiopia’s rapid urbanization and population growth has resulted in increased water stress,” said Dr. Negash Wagasho. “The development of adequate, resilient, sustainable and inclusive WASH services is therefore a must to ensure sustainable development of rapidly growing towns. Thus, what we are seeing today is what can be achieved when we put our concerted efforts together.”

“The UK is the largest bilateral donor in the Ethiopian WASH sector and we are proud to fund the excellent work taking place in Wukro, which is supplying vital water and sanitation services to the town and its surroundings,” said Dr Rogg. “I hope the progress in Wukro can serve as an example to be emulated on a national scale.”

UNICEF Representative Gillian Mellsop said the project was one of the greatest achievements of the One WaSH Plus programme and stands as a testament to the tremendous good that can be achieved when everyone pools their resources together towards one common purpose.

“Investments of this nature, both in Wukro and elsewhere in Ethiopia, are not just improving access to essential services but are changing entire lives,” said Dr. Samuel Godfrey, Chief of WASH at UNICEF. “Women and girls no longer have to walk long distances and spend many hours fetching water. Girls can go to school and attend to their schoolwork while mothers have enough time to spend with their children and engage in other productive activities. For communities, a safe and clean environment means fewer disease outbreaks.”

The Wukro project involved expanding the capacity of the town’s existing system to supply water to the town and five satellite villages, integrating it with a “full chain” system for managing liquid sludge and waste (from containment to recycling), improving water and sanitation in institutions such as schools and health facilities, and establishing a business model for managing the facility comprising the local administration and private operators. The low-cost technology deployed in treating domestic liquid waste in selected social housing developments in the town was sourced through a partnership with the Government of Brazil.

The One WASH Plus programme, fully funded by DFID, is implemented by UNICEF in collaboration with the Ministry of Water, Irrigation and Electricity, regional sector bureaus, and the Water Resource Development Fund. The programme also works with the Ministry of Health, the Ministry of Urban Development and Construction, and respective Sector Regional Bureaus, as well as town administrations and town water supply and sewerage utilities.

The programme, which began in 2013, will benefit 250,000 people in eight small towns and surrounding rural villages in Amhara, Oromia, Somali and Tigray regions with a total investment of some US $36 million by targeting communities living in towns and in peri-urban areas. Models such as the one in Wukro, some large and others medium sized, are now a key component of the One WaSH programme across more than 1,000 towns in the four regions in Ethiopia.

Ethiopia’s rapid urbanization and urban development has resulted in increased water stress and high potential for disease outbreaks. The development of adequate, resilient, sustainable and inclusive WASH services is therefore a must to ensure sustainable development of the rapidly growing towns to meet the targets set in the SDGs.

Sweden contributes US$ 3 million to UNICEF’s 2018 humanitarian appeal for children in Ethiopia

30 April 2018, Addis Ababa: The Government of Sweden has provided US$3 million to UNICEF Ethiopia’s 2018 Humanitarian Action for Children. The funds will be used to meet the needs of internally displaced populations in the Oromia and Somali regions of Ethiopia.

“We are grateful to the Government of Sweden for this contribution, which confirms Sweden’s continued commitment to supporting populations affected by humanitarian emergencies,” said UNICEF Representative Gillian Mellsop. “This is the first such significant contribution to our funding appeal in 2018. It will enable us to alleviate the hardships currently faced by populations living in IDP sites where access to basic services remains low and where conditions, especially for children, are simply unbearable.”

Current estimates place the number of persons internally displaced by climatic and conflict factors at around 1.7 million. The displaced are settled in 916 sites across the country.

The contribution from Sweden will enable UNICEF to provide critical and much-needed water and sanitation, nutrition, and health services to displaced populations in the two regions. Other services will include education and child protection.

Specifically, Sweden’s support will go towards:

  • Trucking of water to IDP sites and construction or expansion of water supply systems;
  • Diarrhoea treatment, vaccination of children against measles, and distribution of mosquito nets;
  • Treatment of children with acute malnutrition and provision of high protein biscuits to prevent malnutrition in children and pregnant and lactating women;
  • Provision of emergency education, including early childhood development;
  • Reunification of separated and unaccompanied children with their families and preventing and mitigating risks faced by children, especially girls.

While the Government continues to prioritize the return and resettlement of the IDPs, thousands of displaced people are still in need of urgent life-saving assistance. UNICEF’s US$ 112 million humanitarian appeal for children targets 3.1 million people with support, out of which 1.5 million are children. Presently, the appeal has a shortfall of US$ 86 million, with nutrition, health, and education having the most significant gaps.

EU and UNICEF launch a photo book on the success story of reducing malnutrition in Ethiopia

25 April 2018, HAWASSA – Today, the European Union (EU) and UNICEF launched a photo book entitled “Ending malnutrition in Ethiopia – A SUCCESS STORY” which illustrates Ethiopia’s success story in ending malnutrition, through the voices, stories and images of Ethiopians.

The nutrition photo book launch and photo exhibition held in the presence of Dr Abreham Alano, Head of the SNNP Regional Health Bureau, H.E Ambassador Johan Borgstam, Head of the European Union Delegation to Ethiopia, Ms Gillian Mellsop, UNICEF Representative to Ethiopia and other key stakeholders from the Government and other partners is a celebration of the success achieved so far in the reduction of malnutrition in Ethiopia while advocating for continued multi-sectoral efforts since malnutrition among children and women in Ethiopia remains a major concern.

It is also a celebration of how Ethiopia has managed to sustain improvements in nutrition, yet also a reminder of all the work that needs to be done to ensure everyone enjoys optimal nutrition.

On the occasion, Dr Abreham Alano, Head of the SNNP Regional Health Bureau thanked the EU and UNICEF for their support in results gained thus far in reducing stunting and  malnutrition, on the health care utilization as well as maternal and child mortality reduction and urged them to continue their support until the targeted results are achieved.

Ambassador Johan Borgstam, Head of EU delegation to Ethiopia on his part said, “It is an honour for me to open this photo book and exhibition launching event today on a topic of malnutrition which is a priority of both the Government of Ethiopia and of the EU’s development cooperation policy. Malnutrition is not only a major health problem affecting children and adults in partner countries, it also has important economic and social dimensions challenging their development by deteriorating the well-being of their entire population.”

Ethiopia has experienced rapid and sustained improvements in nutrition during the past 15 years. For instance, the country has seen a steady reduction in stunting – the fastest rate of improvement in Africa – as well as a significant decline in the percentage of underweight and wasted children. Yet, Ethiopia remains in a precarious situation, with large absolute numbers of affected children: 5 million children are stunted and 1.3 million children under five suffer wasting.

“I would like to highlight the importance of long-term investments to ensure that progress is sustained in ending malnutrition in Ethiopia. While the achievements we recognize today are indeed a success story, we cannot afford to rest on our laurels. Undernutrition still remains a challenge and it requires us all to redouble our efforts to ensure that every child enjoys better health and nutrition,” said Ms Gillian Mellsop, UNICEF Representative to Ethiopia. With the Government’s leadership and the strong commitment of partners, this goal is achievable. Let’s walk together with the same single-minded determination, zeal, and focus to end undernutrition in Ethiopia.”

To further reduce these numbers, the EU has provided €10,000,000 to support vulnerable populations in 17 woredas (districts) in Oromia, SNNP and Amhara regions of Ethiopia through a project entitled “Multi-sectoral interventions to improve nutrition security and strengthen resilience.” This joint action plan which is being implemented by UNICEF and FAO aims to contribute to the improvement of nutritional status of children, adolescents, pregnant and lactating women using the life cycle approach.

Survivors of FGM facilitate discussions to end the practice

By Martha Tadesse

Fatuma learned about the impacts of FGM/C after her first delivery and refused to have her daughters go through the same procedure.

Chifra, Afar, 23 January 2018 – “I had severe period pain, and my labour was a life and death situation,” says Fatuma Abdu, 28, who had undergone Type III FGM/C as a child. Fatuma has two daughters, a 4–year-old and a 20-months-old.

She recalls her first pregnancy experience saying, “I was very weak during my first pregnancy. I was in labour for 24 hours before they took me to the hospital. I gave birth at the hospital. However, because of our tradition, I have stitched again. My menstrual cycle pain was agonizing. I got pregnant again, and it was worse than my first experience. I was in labour for three days until I was unconscious and found myself at Mille Maternity hospital.

The doctor told me I would have suffered from fistula had I stayed home longer than that. I had a stillbirth.  I was physically and emotionally hurt. My third pregnancy was much better because of the surgery at the hospital.”

Zahara Mohammod, 28 discusses about FGM/C with “Unmarried Adolescent Girls’ Club” at Mille Woreda, Afar. © UNICEF Ethiopia /2018/Tadesse

Fatuma learned about the impacts of FGM/C after her first delivery and refused to have her daughters go through the same procedure. She explains how it was difficult to convince her husband on her decision saying, because “The day I went through all that because of my FGM/C procedure was the same day I made that decision. My husband disagreed because we had always thought we were right to practice FGM/C. Mind you, even though he knew how much I have suffered, he still could not make up his mind. I told him I would sue anyone who would touch my daughters and that was it.”

The UNFPA-UNICEF Joint Programme has been working in collaboration with Bureau of Women and Children Affairs (BoWCA) to accelerate the abandonment of FGM/C in Afar region since November 2008. During the implementation of its first phase that ended in 2013, the programme targeted six districts out of the 32 districts in the region, which have declared abandonment of FGM/C presently.

According to the assessment made at the end of this first phase, the programme has resulted in substantial changes in belief and practice of FGM/C in target districts, with a practice decline from 90 per cent in 2008 to 39 per cent after five years of intervention. The second phase of the programme is currently implementing social mobilization interventions in three districts with the aim of improving community knowledge, attitude and practice. The programme heavily focuses on the engagement of community and religious leaders who are the most influential persons in the community. Additionally, the programme promotes community conversations through various discussion groups to create awareness and empower community members for a lasting change.

Fatuma is among the trainers who have been selected to facilitate discussion groups in their communities. The UNFPA-UNICEF Joint Programme has trained 176 facilitators for community conversation and dialogue from 3 districts on FGM/C and early marriage. This community conversation and dialogue on FGM/C is inclusive of girls, boys, men, women, and the youth in the community.

“I hope everyone listens to our suffering and refuses to undergo the FGM/C procedure.”

Sharing her experiences with the training, Fatuma states, “The training was such an eye-opener. I was challenged regarding my wrong beliefs, and it helped me speak up for others.”

According to Sheikh Mohammod Dersa, President of the Islamic Affairs Supreme Council in Afar, the FGM/C intervention by UNFPA-UNICEF has brought a behavioural change in the community.

He states, “We are grateful for what UNFPA and UNICEF have done in our region. We have been working with them hand in hand. But, we still need to work harder, because the issue is deeply rooted in social and religious norms. Social norms are powerful. We need to know that this is a generational issue, as well. It takes a lot of effort and collaboration to challenge communities and achieve the goal of ending FGM/C. We are always ready to teach our community, and we hope the programme continues and expands to other districts.”

Canada partners with UNICEF to improve reproductive health and nutrition among adolescent girls in Ethiopia

8 March 2018, ADDIS ABABA – On the occasion of International Women’s Day, the Government of Canada is pleased to provide CDN$ 14.8 million (US$ 12 million) to UNICEF Ethiopia to improve the reproductive health and nutritional status of adolescent girls. The initiative will reach over four million girls in districts with high food insecurity and a high prevalence of child marriage. It will be implemented between 2018 and 2022.

“As part of our feminist approach, Canada is committed to advancing sexual and reproductive health and rights in order to empower women and adolescent girls in Ethiopia and around the world,” says Ivan Roberts, Head of Cooperation at the Embassy of Canada in Ethiopia.

In Ethiopia, 25 per cent of the population is made up of adolescents (aged 10 to 19 years), of which 11 million are girls.  Adolescent girls experience numerous barriers that hinder them from fully realizing their potential. A significant portion of these barriers is related to their sexual and reproductive health and to their nutrition.

Canada’s contribution will help girls access adolescent-friendly sexual and reproductive health services and nutrition facilities by training health workers to clearly understand the physiological and psychological needs of adolescent girls. This initiative will also leverage gender clubs in schools to provide life skills and sexual and reproductive health knowledge to young people. In addition, adolescent-friendly spaces will be created to ensure out-of-school children freely discuss nutrition and sexual and reproductive health issues and practices including family planning.

To improve personal hygiene, the programme will support the local production and supply of sanitary pads, education of girls on pre- and post menstruation, improve sanitary facilities through upgrading and rehabilitation, provide spaces in schools for menstruating girls to rest, enhance counselling and peer-to-peer support, and promote informal discussions among girls on issues that concern them.

“We appreciate the timely support from the Government of Canada which will allow us to address the challenges that Ethiopian adolescent girls face today,” says Gillian Mellsop, UNICEF Representative in Ethiopia. “We believe that this contribution will help adolescent girls break out of discriminatory social and gender norms that hamper their education and hinder their ability to meaningfully contribute to their nation’s development.”

UNICEF will use its strong monitoring and evaluation tools to ensure the success of this programme and invest in regular compilation of health and nutrition data to better understand trends and uptake of services by adolescent girls.

FGM/C survivors teach communities to end the practice in Ethiopia

By Martha Tadesse

“I used to believe 12 years ago that FGM/C is a mandatory requirement in our religion Islam. I was doing what every mother did back then.”

Mille, Afar, 23 January 2018 – “My labor took two nights and a day. I was in so much pain. It was a very painful experience and most of all, I was a child myself.” says Kedija Mohammod, a mother of three children (ages 12, 8 and 5).

Kedija learned about the harmful effects of FGM/C through community conversations supported by the UNICEF-UNFPA Joint Programme, in partnership with Bureau of Women and Children Affairs (BoWCA), to accelerate the abandonment of FGM/C in the Afar region.

FGM/C or locally known as KetnterKeltti, the removal of some or all of the external female genitalia, is a highly prevalent traditional practice in Ethiopia that has a multi-dimensional impact on the lives of girls and women.

According to Ethiopia and Demographic Health Survey (EDHS) 2016, FGM/C rate in Afar is 91 per cent for ages of 15-49, placing it among the highest prevalent regions in the country next to Somali. Moreover, the region practices Type III infibulation, which is the most severe form of FGM/C characterized by the total elimination of the external female genitalia and stitching, leaving a small opening for urination.

“No one should go through what we Afar women have gone through. I can’t even explain the pain.”

The UNICEF-UNFPA Global Programme, which was launched in November 2008, promotes community-led discussions on harmful practices like FGM/C in which communities are empowered to progress toward collective abandonment.

The programme targets 9 districts (3 in zone 1 and 6 in zone 3) in the Afar region, each having multiple sub-districts. A total of 60 trainers were trained for married and unmarried adolescent girls from these districts and they are trained on harmful practices and menstrual hygiene in order to lead various discussion groups in their communities. These married and unmarried adolescent girls’ clubs aim to facilitate sustained awareness.

FGM/C prevention and care Afar
Zahara Mohammod, 28 discusses about FGM/C with “Unmarried Adolescent Girls’ Club” at Mille Woreda, Afar. © UNICEF Ethiopia /2018/Tadesse

Zahara Mohammod, one of the trainers in Mille Woreda, testifies that the programme has brought a huge difference in the community. She says, “People used to think that FGM/C is required by the Quran, but the programme has raised awareness among the community on the lack of direct link between the practice and religion. People are now listening and most have changed their stance. Women used to give birth in their houses, and we have lost many due to prolonged labor. But now, the Barbra May Maternity Hospital is a few minutes away from our village, so women go to the hospital for delivery and treatment. This is happening because of community conversations and girls’ club discussions in our villages.”

Kedija, an FGM/C survivor herself, regrets having made her daughter go through the same procedure. She says, “I used to think 12 years ago that FGM/C is mandatory and a requirement in my religion Islam. I was doing what every mother did back then.”

However, Kedija is now teaching her community and sharing her experience. “ I have been working with the community for two years now and the change motivates me to do even more. People used to mock me at first because FGM/C is considered as a religious practice, but many have changed their attitude and are thankful for our discussions now. I have never thought FGM/C could have consequences like mental and emotional damage until I had my first intercourse with my husband. No one should go through what we Afar women have gone through. I can’t even explain the pain.”

While talking about her daughter, Kedija says, “I have shared my experience with my daughter. She is aware of the consequences. My daughter is now in grade 7. I will not marry her off to anyone out of her will. She will get married when she finishes her education. I hope she will marry an educated man who can take care of her and take her to the hospital during her labor.”

According to Seada Moahmmod, at BoWCA, these discussions have been increasing awareness and openly challenging community perspectives towards FGM/C. She says, “The community’s awareness has improved a lot, and people discuss openly about the practice. They used to think that exposing stories would lead them to discrimination, but cases are now exposed to local enforcement bodies.  Many households have already rejected FGM/C. It is quite a success.”

While positive outcomes have certainly been observed in the districts, Zahra Humed, Head BoWCA of the region, says, “The outcome of the programme has been very rewarding and the behavioral change we have attained is wonderful. However, we still need to continue working until all districts abandon the practice once and for all. ”