Experience from Ethiopia Improving Women’s and Children’s Nutrition through Targeted Capacity Building Interventions: Experience from Ethiopia Medhin M., Jirga A. and Guyon A IUNS 20th International Congress of Nutrition, Spain September 19, 2013 Presented by: Agnes Guyon MD.MPH. Senior Child Health & Nutrition Advisor – JSI

Presentation Outline Background Achievements Challenges/Lessons Learned Ways forward

Trends in nutritional status of children Based on WHO reference standard Percent of children under age of 5 years

Based on WHO reference standard Trends in nutritional status of women Based on WHO reference standard

Integrated Family Health Project Works in 4 regions serving a population of more than 35 million people Nutrition is one component among a comprehensive mix of maternal and child health interventions. Nutrition, through the Essential Nutrition Actions (ENA) framework, allows an effective implementation of High Impact Nutrition Interventions at scale by using all existing health contacts enhancing community involvement And has BCC as a back bone The goal is to improve nutrition practices, targeting women (pregnancy & lactation) & children under 2 (1000 days – Window of opportunities) Works in 4 regions (Amhara, Oromia, SNNP, Tigray) –more than 35 million people Nutrition is one component among other maternal and child health interventions (EPI, Sanitation, FP, RH, ENC, IMNCI, Community-MNCH), done in partnership with BMGF Alive & Thrive project. Nutrition, through the Essential Nutrition Actions approach, allows an effective implementation of High Impact Nutrition Interventions, at scale by using all existing health contacts enhancing community involvement And has BCC as back bone The goal is to improve nutrition practices, targeting women (pregnancy & lactation) & children under 2 (1000 days – Window of opportunities) 5

Nutrition Program Components Adapted from previous success (USAID-ESHE-LINKAGES projects) PO 0717 & in partnership with BMGF Alive & Thrive project Advocacy for health managers Sensitization workshop on “why stunting/nutrition matters?” Training for health providers. ENA/MIYCN (BCC +SAM) BCC special focused on CF Integrated Refresher Training (IRT) Post-training review meetings Integrated Supportive Supervision (ISS) & Post ISS review meeting - This 4 key elements were presented before and are summarized on this slide: # The first one forming partnerships at all levels, from the community up to the national level, so a united front is promoting nutritional improvements, - The second. carrying out skills-based training, both in-service as well as pre-service. - The third, promoting community action to disseminate messages and based on negotiation with mothers and family members to adopt new improved practices, and - Fourth, using Behaviors change communication approach using support and mass media to reinforce those messages and actions Community mobilization by Mobile Vans 6

Radio spots Family Health Card To assist health providers & families to adopt small do-able actions, through counseling & negotiation Complementary feeding tool Radio spots To assist health providers in counseling & negotiation Food demonstration MCH job aides To improve quality of basic health services at each contact To re-enforce messages 7 Mobile vans 7

Ultimate goal: saturate the environment with improved MNCH-ENA practices Enroll a large number of actors across sectors HW-HEW support mothers Community volunteers assist at health facilities Community volunteer make home visits Here some example of community activities in Ethiopia 1) 2) 3) 4) 5) # Community volunteers support women at chance encounters (market, fields, collecting firewood) Community health festivals Agricultural extension workers support mothers 8

Background Achievements Challenges/Lessons Learned Ways forward

Major Achievements 2010 2011 2012 2013 Total Advocacy “why stunting/nutrition matters?” (ENA Technical) 31 30 229 171 416 Health workers trained on ENA/MIYCN 864 1,744 2,878 2,380 7,866 Health work trained on IRT - 1,824 Post training review meetings 2,712 Integrated Supportive Supervision 84 167 200 231 682 The expansion of MNH activities will be tailored to each region’s context and request for assistance in specific sites and in accordance with each RHB and IFHP’s resources. The program sticks to its principles of working within the existing public health system framework, the primary health care unit approach, comprehensive intervention, stepwise activity implementation, engagement of the local community and partnership with other implementing agencies. The main objective remains to be promoting the health center (HC) as the best place to provide delivery services and Basic Emergency Obstetric Care (BEmONC) and the primary hospital to provide Comprehensive Emergency Obstetric Care (CEmONC). Additionally, the health extension workers (HEWs) (either in rural or semi-urban areas) are the entry point for pregnant women and their newborns to access services.

Breastfeeding practices Monthly randomized “Follow-up Surveys” among 2560 Households All results significantly higher in intervention area % As you can see on the left of this graph, in the original program on which this present study was based, exclusive breastfeeding went from a baseline level of 46% to 68% in the first 10 months, then thereafter to a peak level of 83% after 22 months. This original program covered a population of over 6 million people living in 10 districts located in two highland regions of the country. The present study, shown on the right side, showed increases from 29 to 52% in exclusive breastfeeding levels over a period of 9 months. As mentioned before, one reason for the quickness of our Study’s results was that the field approach existed and just needed fine-tuning before being used in the two new coastal regions. TIBF: Timely Initiation of breastfeeding EBF: Exclusive breastfeeding 0-5 months *** p<0.001

Complementary feeding practices & Vitamin A supplementation Monthly randomized “Follow-up Surveys” among 2560 Households All results significantly higher in intervention area % As you can see on the left of this graph, in the original program on which this present study was based, exclusive breastfeeding went from a baseline level of 46% to 68% in the first 10 months, then thereafter to a peak level of 83% after 22 months. This original program covered a population of over 6 million people living in 10 districts located in two highland regions of the country. The present study, shown on the right side, showed increases from 29 to 52% in exclusive breastfeeding levels over a period of 9 months. As mentioned before, one reason for the quickness of our Study’s results was that the field approach existed and just needed fine-tuning before being used in the two new coastal regions. ICF: Introduction of Complementary Foods Frq: Frequency of feeding VAS: Vitamin A supplementation

Women’s micronutrient supplementation Monthly randomized “Follow-up Surveys” among 2560 Households % As you can see on the left of this graph, in the original program on which this present study was based, exclusive breastfeeding went from a baseline level of 46% to 68% in the first 10 months, then thereafter to a peak level of 83% after 22 months. This original program covered a population of over 6 million people living in 10 districts located in two highland regions of the country. The present study, shown on the right side, showed increases from 29 to 52% in exclusive breastfeeding levels over a period of 9 months. As mentioned before, one reason for the quickness of our Study’s results was that the field approach existed and just needed fine-tuning before being used in the two new coastal regions. IFAS: Iron Foclic Acid Supplementation VAS: Vitamin A Supplementation *** p<0.001 13 13

Background Achievements Challenges/Lessons Learned Ways forward

Challenges Limited resources for nutrition within a broad health project High public sector staff turn over Nutrition competes with other multiple responsibilities of health workers and health extension workers Poor household-level practices, in particular complementary feeding for children and women’s diet

Lessons Learned Delivery of nutrition can be improved through the health system contact points Post-training follow-up visits and regular review meetings were important tools to fill nutrition- related gaps Use of community level opportunities were very important for nutrition implementation Community level complementary feeding demonstration seems to result in improved practices

Ways Forward Support heath system strengthening, including delivery of high-impact nutrition interventions Continue health managers sensitization on stunting and “why nutrition matters” Integrate post-training follow-up and supportive supervision into front-line staff capacity building Standardize and collaborate with partners

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