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.

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.

Government of Ethiopia and Humanitarian Partners Release 2017 Humanitarian Response Planning Document

ADDIS ABABA, 11 January 2016 – The Government of Ethiopia has released the Joint Government and Partners’ Humanitarian Document, an initial humanitarian response planning document for 2017 while the comprehensive Humanitarian Requirements Document (HRD) is being finalized. Based on the early warning data and modelling undertaken by partners such as UNICEF, the document reflects the joint humanitarian response planning and provides a shared understanding of the crisis, including the most pressing humanitarian needs.

While Ethiopia battles residual needs from the El Niño-induced drought, below average rains in the southern and eastern parts of the country caused by the negative Indian Ocean Dipole, another climatic phenomena, have led to new symptoms of drought. It is anticipated that 5.6 million people will need emergency food assistance in 2017, in addition to those still suffering from effects of El Niño. Ongoing assessments for the HRD will provide total figures of those in need for 2017.

In 2016, international donors contributed US$894 million toward the humanitarian response efforts and from that figure, UNICEF raised US$108.7 million to support the Government of Ethiopia and partners to reach around seven million people with access to health and nutrition care, education, safe water, sanitation and hygiene services, and protection support. At least 73 per cent of those reached were children.

The total anticipated financial requirements for the 2017 HRD is US$1.1 billion, of which, the UNICEF Humanitarian Action for Children (HAC) appeal for Ethiopia is US$110.5 million. This includes US$13.6 million to respond to the new influx of South Sudanese refugees in the Gambella region. While the funding will be critical to UNICEF’s ability to respond to immediate needs, it will also be used to take appropriate actions to strengthen preparedness, improve early warning systems and reduce vulnerability, contributing to more resilient communities.

Immediate responses have already taken shape from regional governments allocating funds to water trucking and fodder provision in the south and south eastern regions, those most affected by the below average rainfall. In 2016 and years prior, UNICEF has supported such emergency interventions, in addition to child health and nutrition, sustainable water and sanitation, quality education for boys and girls, and the protection of children from violence and exploitation. UNICEF Ethiopia looks forward to continuing this support with the Government of Ethiopia and partners in 2017, for every child and their family.

Five in six children under two not getting enough nutrition for growth and brain development – UNICEF

 NEW YORK/ ADDIS ABABA, 14 October 2016 – Five in six children under two years old are not fed enough nutritious food for their age, depriving them of the energy and nutrients they need at the most critical time in their physical and cognitive development, according to a new UNICEF report.

“Infants and young children have the greatest nutrient needs than at any other time in life. But the bodies and brains of millions of young children do not reach their full potential because they are receiving too little food, too late,” said France Begin, Senior Nutrition Adviser at UNICEF. “Poor nutrition at such a young age causes irreversible mental and physical damage.”

UNICEF data show that poor nutritional practices– including the delayed introduction of solid foods, infrequent meals and lack of food variety – are widespread, depriving children of essential nutrients when their growing brains, bones and bodies need them the most. The findings reveal that: 

  • Young children wait too long for their first bites. One in five babies hasn’t been fed any solid foods by the age of 11 months.
  • Half of children aged six months to two years are not fed the minimum number of meals for their age, increasing their risk of stunting.
  • Less than one-third of children in this age group eat a diverse diet – meaning from four or more food groups daily – causing deficiencies in vitamins and minerals.
  • Almost half of pre-school aged children suffer from anaemia.
  • Only half of children aged six to 11 months receive any foods from animal sources – including fish, meat, eggs and dairy – which are essential to supply zinc and iron.
  • The high cost of foods from animal sources makes it difficult for the poorest families to improve their children’s diet. In Sub-Saharan Africa and South Asia, only one in six children from the poorest households aged six to 11 months eats a minimally diverse diet, compared to one in three from the richest households.
  • Improving nutrition for young children could save 100,000 lives a year.

Making nutritious foods affordable and accessible to the poorest children will require stronger and more targeted investments from governments and the private sector. Cash or in-kind transfers to vulnerable families; crop diversification programmes; and fortification of staple foods are key to improving nutrition for young children. Community-based health services that help caregivers learn better feeding practices, and safe water and sanitation – absolutely critical in preventing diarrhoea among children – are also vital.

“We cannot afford to fail in our fight to improve nutrition for young children. Their ability to grow, learn and contribute to their country’s future depends on it,” Begin said. 

Ethiopia has experienced rapid, sustained improvement in under-nutrition during the past 15 years. For example, the country has seen a steady reduction in stunting – the fastest rate of improvement in Africa – and a decline in the percentage of underweight and wasted children. Yet, Ethiopia remains in a precarious situation, with large absolute numbers of affected children: 5.3 million children are stunted and 1.2 million children suffer wasting. UNICEF’s nutrition programme collaborates with the Government of Ethiopia to reduce these numbers further, working on multi-sectoral coordination to improve the nutrition of all children, pregnant and lactating women and their families

The Government of Ethiopia recognizes that addressing malnutrition is essential to achieving sustainable development. It therefore has issued the Seqota Declaration to end child malnutrition by 2030. The Declaration lays out a plan to stop the cycle of under-nutrition by bringing together all sectors of the Government, paying particular attention to the importance of nutrition during pregnancy and in the first years of a child’s life. 

Over the past decade, Ethiopia has seen a steady reduction in stunting from 58 per cent in 2000 to 40 per cent 2014, in the percentage of underweight children from 41 per cent to 25 per cent, and in wasting from 12 per cent to 9 percent (Mini EDHS: 2014) 

These trends indicate an improvement in chronic malnutrition over the past 15 years. Yet, 28 per cent of child deaths in Ethiopia is associated with under-nutrition. In addition to this high contribution to the under-five mortality rate, high prevalence of various forms of malnutrition among vulnerable groups in Ethiopia has serious implications for social development and economic growth. In a study conducted in 2009, the total annual cost of under-nutrition was estimated at US$2,775,000, equivalent to 17 per cent of the country’s GDP in 2009.

UNICEF’s strategies for nutrition ensure the achievements of results in four areas: 1) upstream nutrition policy support and multi-sectoral engagement; 2) improved nutrition knowledge and caring behaviours; 3) strengthening of systems for nutrition service delivery; and 4) strengthening partner capacities to respond to nutrition in humanitarian crises.

To accelerate the reduction of chronic and acute malnutrition, UNICEF is working in partnership with sectoral government counterparts, including in health, agriculture, education, social protection, trade and industry, and women, children and youth affairs.

UNICEF also works with United Nations agencies such as the Food and Agriculture Organization (FAO), United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), World Food Programme (WFP) and World Health Organization (WHO); UNICEF National Committees; donors such as the aid agencies of Canada, Ireland, Japan, the Netherlands, Spain, the United Kingdom and the United States, as well as the European Union; civil society organizations; and local and international academic institutions.

Baby WASH – the missing piece of the puzzle? 

By Samuel Godfrey

Mustapha and his one year old daughter Meia-Teza Wota Health Center Clinic
Mustapha and his one year old daughter Meia at Teza Wota Health Center ©UNICEF Ethiopia/2012/Getachew

The January 2016 Huffington Post article entitled Why are Indian kids smaller than Africa kids: hint its not race authored by Sanjay Wikesekera, UNICEF Global WASH Chief and Werner Shultink, UNICEF Global  Nutrition Chief, highlighted the link between child stunting[1] and lack of access to toilets. Children growing up in an environment where people are defecating in the open will result in kids crawling around on dirty floors, putting feacally contaminated material and objects in their mouths and ultimately will results in children having high rates of diarrhea which will result in their stunted physical and mental development.

To understand this better, UNICEF Ethiopia WASH team and John Hopkins University undertook a systematic review of more than 1000 peer reviewed academic articles with the aim of identifying interventions that health and WASH professionals can take or promote to reduce the contact of children with feacally contaminated material. The review identified strong evidence on the linkage between open defecation, stunting and early child development (See figure below from Ngure et al (2014).

Picture1

The review also notes good knowledge of how to do hygiene and sanitation promotion to safe disposal of adult feaces but limited evidence on safe disposal of baby feaces.

UNICEF Ethiopia is using the review to design specific Baby WASH interventions that can complement our current Infant Young Child Feeding programmes. Ethiopia has substantially reduced Open Defecation during the last 25 years. In 1990, an estimated 9 out of 10 people were “pooing” in the open and by 2015, this had reduced by 64 per cent to less than 1 in 3 people. However, despite this progress, almost half of children were recorded as ‘stunted’ or not achieving their full physical and mental growth by 2015. The literature suggests that Baby WASH, as we have termed it, may be one of the key “missing pieces” in reducing stunting. Baby WASH comprises of a ‘menu’ of physical and promotions activities which will reduce the exposure of the BABY to ingestion of feaces and ultimately reduce stunting and improve Early Childhood Development.

Watch this space for more details on field evidence on Baby WASH from UNICEF Ethiopia as we work closely with the Government of Ethiopia and development partners to expand this intervention throughout Ethiopia in our new Country Programme of Cooperation between 2016 and 2020. For the time being, UNICEF Ethiopia is using its own financial core resources. Interested development partners are welcome to join this groundbreaking initiative.

UNICEF Ethiopia is collaborating with the US based Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Global Disease Epidemiology and Control. A researcher from the school was an intern in the UNICEF Ethiopia WASH section in 2015 and has collaborated with the WASH section on producing a paper entitled Evidence on Interventions Targeted at Reducing Unsafe Disposal of Child Feaces: A Systematic Review.

UNICEF Ethiopia’s rural wash activities are supported by the UK Department for International Development (DFID), the Government of Netherlands, the Government of Canada and the UNICEF National Committees from Germany, UK and New Zealand.

Dr. Samuel Godfrey is Chief of WASH for UNICEF Ethiopia, and has a PhD and MSc in Civil Engineering and Water and Waste Engineering.

[1] Stunting is a sign of ‘shortness’ and develops over a long period of time. In children and adults, it is measured through the height-for-age nutritional index. In Ethiopia approximately 40 per cent of children are stunted.

UNICEF’s largest global purchase of Therapeutic Food for children in drought-stricken Ethiopia through donor support

Drought in Ethiopia
A mother feeds a her malnourished child a Ready-to-Use Therapeutic Food (RUTF), a high protein and high energy peanut-based paste, in Arsi zone, Oromia, Ethiopia. In Ethiopia, after two years of erratic rainfall and drought, one of the most powerful El Niño weather events for 50 years is wreaking havoc on lives and livelihoods. ©UNICEF Ethiopia/2016/Ayene

ADDIS ABABA, 22 April 2016 – Today, UNICEF thanked donors for their generous contributions and the Government for its strong leadership, which together have enabled a concerted response to the current El Niño driven drought in Ethiopia, particularly in treating children with severe malnutrition.

With support from donors, UNICEF has procured 543,631 cartons of Ready-to-Use Therapeutic Food (RUTF), which represents 22 per cent of the global order for 2015 and is one of the largest single purchases in UNICEF’s history. The donors include the Governments of Canada, Germany, Japan, Sweden, United Kingdom and United States and partners including ECHO and the Bill & Melinda Gates Foundation.

To date in 2016, UNICEF procured in 2015 a further 73,344 cartons of RUTF out of a global procurement estimated at 565,623 cartons, which corresponds to 13 per cent of the global supply. In addition to RUTF, other supplies including therapeutic milk, routine drugs and hygiene and sanitation commodities have been procured as part of the drought response. To accommodate this large volume of supplies and enhance preparedness for the drought response, UNICEF rented a new warehouse in the Gerji area of Addis Ababa, earlier this year.

“On behalf of the Government of Ethiopia and UNICEF, I would like to express my sincere appreciation to the humanitarian donors for their timely and generous financial contributions to purchase Ready-to-Use Therapeutic Food that will save the lives of millions of children diagnosed with severe malnutrition,” said Ms Gillian Mellsop, UNICEF Representative to Ethiopia. “I would also like to especially thank the Ethiopian Customs Authority, the Ethiopian Food Medicine and Health Care Administration and Akakas Logistics, this enormous supply chain operation would not have been possible without their active support. By accelerating our joint nutrition interventions, we can transform the lives of millions of children to become healthy citizens and reach their full potential.”

Ethiopia is experiencing one of the worst droughts in decades due to El Niño weather condition which continues to wreak havoc on the lives of children and their families’ livelihoods. According to the latest Humanitarian Requirement Document issued this year, 6 million children are at risk from hunger, disease and lack of water. Malnutrition rates have greatly increased – 450,000 children are expected to be treated for severe acute malnutrition (SAM) this year.

Inauguration of new UNICEF warehouse
Inauguration of new UNICEF warehouse (L-R) Ms Gillian Mellsop, UNICEF Representative to Ethiopia, Dr Kebede Worku, State Minister of the Federal Ministry of Health, and Ms. Emma William, Deputy Head, DFID Ethiopia ©UNICEf Ethiopia/2016/Tsegaye

As part of the joint drought response coordinated by the Government, UNICEF is leading the Nutrition, Water Sanitation Hygiene, Education (together with Save the Children) clusters and the Child Protection sub-cluster. Together with other partners, UNICEF implements life-saving humanitarian responses including procurement and supply of therapeutic food and milk, drugs, other medical supplies, plus water/sanitation and education and child protection supplies.

UNICEF also supports the treatment of severely malnourished children through the community-based management of acute malnutrition, with training, quality assurance and coordination with other partners. Regular nutrition screening helps ensure that malnutrition in children is diagnosed and treated early, thereby reducing cases of severe acute malnutrition and life-threatening complications.

The supply of RUTF procured by UNICEF to date to respond to the current emergency is worth US$28 million including freight and in-country distribution. With the continued effort of the Government and support from humanitarian actors, 350,451 children were treated for severe acute malnutrition in 2015.

Leadership matters: The case of community led total sanitation and hygiene

By Araya Mengistu


Ethiopia is a country showing strong progress in achieving global and national goals for WASH services. It has achieved the MDG target 7c for water supply. Although still behind for sanitation targets, considerable progress is made. As of 2012, 37 per cent of communities practiced open defecation, as compared to 92 per cent in 1990[1]

The progress on sanitation is mainly achieved through the national Health Extension Programme (HEP) and the community led total sanitation and hygiene (CLTSH) approach. CLTSH is an approach that helps to mainly rural communities to understand undesirable effects of poor sanitation, and through a process of “triggering” – igniting a change in behaviour – achieve sustained behaviour change leading to spontaneous and long term abandonment of Open Defecation (OD) practices. Since its introduction in 2006/7, CLTSH has remained the only instrument in Ethiopia to induce behaviour change of communities to consider construction of latrines and use them – discouraging the practice of open defecation. Although the achievements in the past decade are significant, the success of the approach varied significantly from place to place.

For example, the Oromia regional state, the largest in the country, consists 265 rural and 39 urban districts or woredas. Out of 6,531 kebeles (sub-districts each with an average population of 5,000) in rural areas, about 16 per cent are open-defecation free (ODF) – meaning no-one, including visitors and passing pedestrians, are openly defecating and all have access to basic latrines with handwashing facilities.

UNICEF supports 24 woredas in Oromia state between 2011 and 2015. Of the supported woredas, 24 per cent (116 of 477 kebeles) have achieved ODF status. Compared to regional average of 16 per cent, this is a huge achievement. Sire, one of the supported woredas, has recently been graduated in 2015 with 100 per cent performance, declaring all 18 rural kebeles ODF. Other woredas are at various stages. 11 woredas are between 20-50 per cent progresses, while the rest 12 woredas are of 0-10 per cent progress. Compared to these, Sire Woreda shows an outstanding performance.

Such exceptional achievement requires successfully overcoming a number of challenges. A key challenge is lack of thorough understanding of the steps involved in CLTSH and their importance. Usually CLTSH is about training facilitators and triggering communities. However, many practitioners agree that this is the easiest part. Rendering adequate supervision after the triggering stage and providing support that is necessary to sustain the momentum is the difficult part. Other challenges include diffusion of information to neighbouring communities that make the approach ineffective, lack of trainers with actual field experience, high staff turnover, poor coordination among stakeholders, weak commitment of staff and trained people and application of CLTSH without adequate or proper organisation and preparation.

Growing over all these challenges and as a result of four years of effort, Sire Woreda celebrated 100 per cent ODF achievement in April 2015, with all rural villages and kebeles free from open defecation.

Even though, some of these kebeles were declared ODF two or more years ago, , they continued to sustain their status despite the usual trend of falling-back to OD practice noticed as time elapses. This demonstrates an effective post-triggering activity by the Woreda that effectively complimented the planning and triggering activity.

How was this achieved? The Woreda administration leveraged existing structures to sensitize the leadership ladder down to village level on CLTSH and built it in to the regular reporting and evaluation process. This has helped to mobilize the largest possible support to the effort of Health Extension Workers (HEWs) and CLTSH facilitators, including teachers and students under the guidance and support of the Woreda Health Office. It has also avoided diversions of focus (including manpower, logistics, and resources) as CLTSH has become an official woreda priority.

Two notable practices can be praised in the woreda for this success.  (a) the technique of triggering one full kebele at a time in contrast to the usual practice of village by village, and (b) use of different post-triggering follow-up technique suited to context. The advantage of the first technique was twofold. It helped to avoid diffusion of information in to neighbouring communities. Since, focusing in one kebele at a time required more trained people, the coordinators called upon trained and experienced facilitators from adjacent woredas to support, which worked really well. On the other hand, the woreda experts consciously applied different post-triggering follow-up methods. In highland areas, they applied the ‘flag system’, where by communities themselves awarded white flags to households who have constructed basic latrines, and red flags to those who did not. In low land areas, students were organized to alert the community when they see any one defecating in the open, who will then ensure the person buries the excreta.

Currently, the Woreda continues to strengthen the community platforms for monitoring progress and pro-actively works with local leaders to provide the necessary guidance and technical support to sustain the achievement. As a result of this, they are expecting at least two kebeles to achieve secondary ODF, which includes upgrading of basic latrines to improved latrines (with washable slab, vent pipe, hole-cover) with hand washing facility by the whole community. The commitment of leaders, and subsequent effective coordination in the Woreda has benefited the wider community to keep children, women and the society at large healthy.

[1] Joint Monitoring Programme 2014.