1. Integrated WASH and Community Based Nutrition Programs: insights from a five-year UNICEF program in Ethiopia
Authors: Samuel Godfrey, Jane Bevan, Katherine F. Shields, Argaw Ambelu, Ronna Chan, Georgia Kayser, Jamie Bartram

2. Sanitation in Ethiopia
National*
Rural
Urban*
Safely managed - 4
Basic service 7 1 18
Limited service 30
Unimproved 59 62 44
No service 27 32
*No safely managed estimate available
FMoH/UNICEF/EU Situation Analysis of the Nutrition Sector in Ethiopia: Ethiopian Federal Ministry of Health, UNICEF and European Commission Delegation. Addis Ababa, Ethiopia 2016

3. Malnutrition in Ethiopia
Stunting prevalences are 35-45% in most regions, except Somali and Gambela, indicating an extensive problem of malnutrition
The national rate of improvement in stunting was estimated as 1.5 percentage points (ppts)/year, , likely continuing to 2014 ( ppts/yr)
Data from 2016 DHS

4. UNICEF Ethiopia WASH/CBN Program components 2012 to 2017
Rural Water Supply
Rural water supplies in 30 Districts benefiting 1,800 communities
CBN Package
Scaling-up of CBN package in 15 Districts targeting 134,000 children under-two years with GMP, counseling on infant and young child feeding best practices
WASH & MUS
Sanitation & Hygiene
Community Led Total Sanitation and Hygiene resulting in home built toilets, benefiting 280,000 families
Complementary Foods
Supporting local production of complementary foods targeting 60 per cent of children under-two years and promote household garden to improve dietary diversity
WASH in Schools
150 rural primary schools (97,500 school children) with a complete WASH package
Community Health Days
Biannual provision of vitamin A and deworming capsules and quarterly screening of children under 5 and pregnant and lactating mothers for malnutrition and referral to HF
Integrated WASH, MUS and CBN
WASH in Health Centers
150 rural health facilities with complete WASH package
Capacity of health workers
Strengthening the capacity of health workers on nutrition and data management
Schematic of the program
Explanation of MUS
Demonstration of MUS
Establishment of 60 school-managed market gardens to demonstrate the benefits of MUS
CBN
Nutrition Education
Establishing nutrition education in 60 per cent of the schools through nutrition clubs and BCC activities
Enhancing Capacity and Knowledge
Strengthened capacity for communication for behavior and social change in schools and communities
Knowledge generation and dissemination through networks and fora to inform policy and practice
Micronutrient Supplementation
Providing micronutrient supplementation to pregnant and lactating mothers and adolescent girls in and out of school with strong BCC

5. UNICEF Ethiopia WASH/CBN Implementation regions
Tigray
Amhara
Oromia
The program aims to respond to the combined risks of chronic malnutrition and poor access to services for 1.4 million people living in 30 woredas (districts) in 4 regions in Ethiopia, between 2011 and 2015.
SNNPR

6. Outcomes of Interest Stunting Diarrhea
Height for age z-score 2 standard deviations or more below normal.
Baseline: children under the age of five
Midline: children measured at baseline, new children under the age of five
Diarrhea
Self-reported by head of household
Asked for each member of the household
Analyzed for children under the age of five

7. Program groups CBN CBN, CWS CBN, CS&H (CLTSH) CBN, CLTSH, CWS, MUS
Data was collected from four different program groupings (Figure 3). In the control group (red), only CBN is being implemented. The intervention groups are:
CBN programing plus community water supply (CWS) (green),
CBN programing plus hygiene promotion and sanitation (CH&S) (purple)
CBN programing plus multiple use services (MUS), hygiene promotion, sanitation and water supply-related activities (blue).

8. 4 Regions
Intervention
30 woredas
576 kebeles
Control
92 woredas
2,158 kebeles
230 CBN & CWS
kebeles
319 CBN & CLTSH
kebeles
27 CBN & MUS
kebeles
16 CBN & CWS
kebeles
22 CBN & CH&S
kebeles
2 CBN & MUS
kebeles
33-50 households
depending on region
40-44 households
depending on region
36-39 households
depending on region
67% houses with children
< 5
33% houses
without
children
67% houses with children
< 5
33% houses
without
children
67% houses with children
< 5
33% houses
without
children

9. 4 Regions
Intervention
30 woredas
576 kebeles
Control
92 woredas
2,158 kebeles
230 CBN & CWS
kebeles
319 CBN & CLTSH
kebeles
27 CBN & MUS
kebeles
40 control
kebeles
38-42 households
depending on region
67% houses with children
< 5
33% houses
without
children

10. Data collection Baseline conducted June – Aug 2013
Midline: January-March 2017
30 Woredas (Districts)
80 kebeles (sub-districts)
4 surveys
Household
Community
WaSH committee
School

11. Key Results
Stunting reduction across the study is in range of 7-9%, about 2.2% per year
This compares with the national rate of reduction (DHS) of 1.2% per year
No evidence of difference
between CBN and WaSH+CBN
groups from baseline to midline
after controlling for child age,
child gender and region.
Diarrheal disease prevalence
uncommon (2-4%)

12. Diarrheal prevalence by Age Group

13. Mean height-for-age Z-score (HAZ) Stunting
Decline is less rapid after age 2

14. Mean weight-for-age Z-score (WAZ) Underweight
Decline slows after 9-11 months

15. Mean weight-for-height Z-score (WHZ) - Wasting
No clear pattern emerging

16. Stunting: Sanitation Vs Water
Predicted probabilities for likelihood of stunting based on a difference-in-difference analysis of stunting controlling for child age, access to drinking water and sanitation type
Shows differential effect of improved versus unimproved drinking water source by age group, not for sanitation
Sanitation
Drinking water
Child age

17. Practices to reduce diarrhea

18. Conclusions and Way Forward
Stunting reduction across the board higher than national rate despite El Nino drought ( )
CBN is being scaled up across the country to support the continued decline of stunting
Convergence of programmes will continue
No statistically significant change in the primary outcomes (stunting and diarrhea) between the two study groups from baseline to midline
Sanitation marketing is being rolled out to increase and improve existing sanitation coverage
Baby WASH added to programme to focus specifically on child faeces disposal, infant hygiene and safe play areas
Diarrheal prevalence lower than expected based on 2011 DHS results and recent AWD outbreaks
Challenges with access, reduced sample size, seasonal variations to be addressed for endline, planned for 2020
Data analysis suggests higher impact of water quality on stunting than sanitation
Supporting GoE on regulating water safety plans and water quality management
Minimum dietary diversity was found to be very low at baseline and midline, but in-line with the findings from the DHS
While stunting did decrease by 7-9 percentage points, there was no evidence of a statistically significant difference between the CBN and CBN+WaSH arms from baseline to midline for any of the z-score or calculated anthropometric indicators.

19. Acknowledgements and Thanks
With support from:
Government of Ethiopia
Thank you!
And National Partners Plan, SNV, IDE, Ripple