Information meetings on the Enhanced outreach Strategy (EOS) and Increased

Supervision of the Screening Quality in Ethiopia.
Client: UNICEF-Ethiopia

Objective of the study: The main objective of the spot supervision is to improve the quality of nutrition screening data taken by health extension workers and community volunteers during the Enhanced Outreach Strategy (EOS) or Community Health Day (CHD) through supportive supervision and informationmeetings. The EOS or CHD is a twice-a-year event carried out in a campaign style. This is in addition to the routine health services regularly provided by health centers.  

The Enhanced Outreach Strategy (EOS) or the Community Health Day (CHD) and the Targeted Supplementary Feeding Programme (TSFP) or Therapeutic Feeding Programme (TFP) are interim  programmes of the Ethiopian government designed to temporarily mitigate the effects of chronic malnutrition and to save the lives of millions of children. Children and pregnant/lactating women are screened by health workers and community volunteers and categorized as nutritionally normal, moderately malnutritioned or severely malnutritioned. The moderately malnutritioned children and pregnant/ lactating women are referred to Targeted Supplementary Feeding Programmme (TSF) while those categorized as severely malnutritioned are referred to a Therapeutic Feeding Programme (TFP).

BDS-CDR’s task in this project was to help improve the quality of the screening data through supportive supervision and information meetings. This task was successfully accomplished by recruiting field supervisors with rich experience in nutritional screening. The supervisors were thoroughly oriented on the objective of the assignment, the screening process and the material needed to carry out the screening.


Methodology: To achieve the objective of the spot supervision, BDS- CDR recruited field supervisors with rich experience in nutritional screening. The field supervisors were given a thorough training in the general objective of the assignment and on a checklist of activities to be performed on the field.  They were also provided with the necessary materials that they would need to use in the field.  The supervisors used observation and their checklist as their data collection tools. The check list included activities such as campaign organization, Vitamin A administration, de-worming, nutritional screening, post-campaign activities and

The programme is a joint initiative between the Ministry of Health and the Disaster Risk Management and Food Security Sector and supported by UNICEF, WFP and other development partners. This project was conducted in a total of 93 targeted woredas, 2448 kebeles and 778 sampled posts in the Amhara, Oromiya, SNNPR and Tigray regions. checking on data quality, during the EOS/CHD campaign. Once in the field, the supervisors organized information meetings in collaboration with woreda officials. Then they observed screening campaigns and made careful recordings. After the observations, they held information meetings with the health workers and volunteers who conducted the screening campaign. During these meetings, the main issues discussed were: areas covered by the campaign, challenges, constraints, data quality and management problems, inclusion and exclusion errors, timely reporting, the importance of social mobilization, the role of BDS-CDR (as a provider of technical assistance), lessons learned and ways of improving future campaigns.


Major challenges and limitations : The study of the screening campaigns in the Amhara, Oromiya, SNNPR and Tigray regions reveals the following aggregate of challenges and limitations observed in one of the regions or the other:

•Low performance: the campaign coverage, i.e. the number of persons screened is much lower when compared with the micro-plan held for the year. This shows low performance.
•Failure to adhere to recommended measurement
techniques in identifying nutritional defects such as bilateral edema.
• Lack of quality in data maintenance.
• Lack of regular and reliable flow of information from regional to zonal and woreda focal persons usually due to poor roads and limited network coverage.
• The scattered location of sampled woredas making it difficult for efficient performance.
• Lack of adequate staffing.
• Lack of incentives for people who considered the screening campaign as not part of their regular duty.
• Lack of coordination/synchronization among Regional Health Bureaus and other stakeholders in arranging screening campaign schedules thus resulting in overlaps of programs.


Conclusion and recommendation : The study shows that EOS/CHD screening activities such as site organization, crowd management and anthropometric measurement techniques have shown marked improvement compared with performances during
the previous year. However, there are still gaps that need to be filled to bring about further improvement. The following recommendations are forwarded:

• The EOS/CHD campaigns must be strengthened and maintained as they have the potential of providing rich data on the nutritional status of children under 5 and on pregnant/lactating women vital for national planning on nutrition.
• The community should be involved more in the planning, implementing and evaluating EOS/CHD campaigns.
•UNICEF and other development partners should continue to support the national campaign to improve the nutritional status particularly of children under 5 and pregnant/lactating women.
• Performance-based incentives must be provided to solve the manpower shortage chronically facing EOS/ CHD campaigns.
•There should be better coordination among regional, zonal and woreda officials to avoid clashes of activities that are contributing to the delay and low performance in the EOS/CHD campaign coverage.
•There should be rigorous insistence on using only measurement techniques recommended by the official guideline rather than norms.
•The shortage of supplies essential for the screening process should be solved through advance planning, as the problem observed is not so much due to lack of materials but due to lack of advance preparation.  
• Special attention should be given to building the capacity of local personnel that could supervise the screening campaigns in a reliable and sustained manner


End-line Survey of the Project for Improving maternal and Child nutrition Status in oromiya Region

Client: Japan International Cooperation Agency(JICA)

Objective of the study: The Oromiya Region Health Bureau and Japan International Cooperation Agency (JICA) launched a joint 5-year programme known as the Community-Based Nutrition Approach (COBANA) and aimed at reducing malnutrition. The main objective of this survey was to assess the nutritional status and other project indicators for the purpose of evaluating the effectiveness of the COBANA project in meeting its purpose.  The specific objectives were: 1) to estimate the prevalence of malnutrition in terms of stunting, underweight and wasting in children under 5 in the targeted area; 2) to estimate the key Infant and Young Child Feeding (IYCF) indicators for children under 5 years in the project site; 3) to estimate the prevalence of Protein Energy Malnutrition (PEM) in mothers of children less that 5 years in the project site; 4) to estimate pregnancy care of the last child among the mothers of children 0.24 months; 5) to draw appropriate recommendations. The study was conducted in 10 weredas within 3 zones of the Oromiya Region, namely: East Shewa, Arsi and Bale.


Methodology Used : BDS-CDR’s primary concern in this study, as in all of its other studies, was to collect high quality data through rigorous methodology and with close expert supervision during data collection, processing and consolidation. To generate the high quality data, BDS-CDR used a combination of methods, namely: document review, interviews, taking anthropometric measurements and direct field visits of 1,189 households in 10 woredas distributed among 3 zones (East Showa, Arsi and Bale) of the Oromiya Region.   The collected data was manually verified and put into the computer for processing and rigorous analysis.

Findings : The study showed that, as a result of the programmed intervention sponsored by JICA in collaboration with the Oromiya Regional Health Bureau and the frequent visits by Health Extension Workers, people in the targeted woredas have developed greater awareness on health and nutrition matters and become beneficiaries of basic health services. Health centers are within a walking distance— an average distance of 1.8 km from where they live. As a result, households are able to obtain healthcare services from trained personnel. A large majority of pregnant mothers receive antenatal health services on essential matters including weighing, blood testing, blood pressure follow up, maternal counseling, breastfeeding, balanced complementary feeding and family planning. As revealed by the study, the level of stunting (40.3% in 2013) in the intervention areas, is lower than that in Oromiya (41.4%) and of the national prevalence (48.4%). The decrease of stunting in the intervention area is well over 8%. The level of underweight in the intervention area (21.7%) was far below the national average (29%) as well as the regional average (26.9%). 


-The integrated approach of health, nutrition, food security and WASH in tackling both the immediate and underlying causes of malnutrition should be strengthened and scaled up.
-There should be continued and more intensive health and nutrition interventions on:
-The importance of proper sanitation and hygiene especially using latrines,
-The appropriate IYCF feeding practices  with a special focus on the value and duration of exclusive breastfeeding and the importance of timely introduction of complementary feeding,
-The dietary diversity and appropriate frequency of feeding especially during the pregnancy and lactation period
-The integrated child health day strategy should also be used for delivering immunization for measles as well as for other additional health and nutrition services.


monitoring and Implementing Strategies to Improve the Quality of the management of Severe Acute malnutrition and Community- Based nutrition in oromiya Region

Client: UNICEF-Ethiopia


Objective of the study: The general objective of this consultancy service is to assess the quality of service in In- and Out-patient therapeutic services (OTPs and SCs) and to strengthen the current reporting, supervision and supplies management systems within the Regional Health Bureaus and to improve the performance of the management of severe acute malnutrition.


Specific objectives:  To assess the quality of service in the SCs and OTPs using the standardised score card (tool already existing) and methodology;• To provide mentoring and on-the-job trainings to health workers and health extension workers to strengthen and immediately fix the area for improvement identified during the assessments as per the national protocol and quick reference materials developed for health extension workers;

•To build the capacity of the regional, zonal and woreda health offices to provide supportive supervision and on-the-job mentoring of health workers and health extension workers providing SC and OTP services;
•To build the capacity of the regional, zonal and woreda health offices to manage and utilise CMAM data to monitor trends, performance and trigger response needs.
•To assess the correct distribution/requests and use of the Ready-to-Use Therapeutic Food (RUTF);
•To ensure a healthy supply pipeline through close collaboration with UNICEF regional logistics officers and CMAM logistics at the national level; and
•To monitor the implementation of community-based nutrition programme.


Implementation plan : As stated in the objective, the focus in this project is on assessing and strengthening the current reporting, supervision and supplies management systems regarding the performance of the management of severe acute malnutrition in the Oromiya Region. Therefore, the works to be done had to be structured around tasks that had to be done. Accordingly, six competent and highly experienced professional monitors were recruited. An ICCM-tailored training was given to all monitors for five days, in consultation with the regional health bureau. This training was designed to bring all monitors on the same board with the region’s functional health policy implementation system, including ICCM.

The six monitors were assigned to 6 zones in the Oromiya Region. Each monitor was required to develop his own monthly monitoring plan in consultation with zonal health and nutrition focal persons. After deployment, all monitors assessed and identified the current CMAM & CBN performance situation by reviewing the existing reports and through discussion with the zonal health offices and nutrition focal persons.  

The monthly planning was prepared in such a way that each monitor would cover 2-4 woredas every month, with 100% coverage of SCs and 50% coverage of all OTPs. Therefore, for this implementation, each monitor was provided with one vehicle.  In order to cover 2-4 woredas, the monitors spent most of their time in the field and the allocation of days was as follows: every month, 25 days were spent in the field monitoring activities, 2 days supporting the zonal and woreda offices in reporting and 3 days in preparing a monthly report to be submitted to the national coordinator, UNICEF and RHB.

During the monitoring process, based on the performance of the health posts and health centers providing CMAM services and the gaps identified, the monitors provided, besides mentoring, on-the-job training as well as any relevant support needed on the site. However, if, in many of the health facilities, the CMAM performance indicators and reporting rates were low, woreda level refresher trainings were undertaken in consultation with UNICEF, RHB and zonal health offices.


Observations : As was pointed out in the objective, the major task in this project is monitoring and implementing strategies for improving the quality of the management of Severe Acute Malnutrition and Community-Based Nutrition in the Oromiya Region. The project was conducted in six zones for six months.  Monthly reports on the situations observed were compiled. Common problems observed during this period are summarized below.

There is a dramatic difference in service quality among health facilities in the zones. There were very poor sites which were not performing well and also there were sites which were performing well and adhering to the national protocol. About forty-four percent of the visited facilities had good service quality, scoring well above 70%. About forty-two percent of the facilities had poor service quality with a score of 50-70%, while about fifteen percent of the facilities had very poor service quality with a score < 50%.

In principle, the national protocols must be followed scrupulously during the CMAM implementation process. However, during the joint monitoring, it has been observed that for various reasons, this national protocol was not followed as expected. In this regard, during monitoring, the overall gaps in admissions and discharge procedures, proper follow up and treatment, proper recording and reporting, proper supply request and stock management have been observed.


On Admission and Discharge procedures

•Appetite test not systematically done using the weight category table in 53.1% of facilities, •51% of the facilities had problem in referring non-responders.
• Discharging criteria were wrong in 49% of facilities. •Body temperature was not taken in 36.5% of facilities.
•OTP sites with no or with only one trained person was observed in 28.1% of the facilities •Wrong admission criteria were observed in 30.2%5 of facilities


On Follow-up Care and Treatment

• Routine medicines were not being given as per the national protocol in 66.7% monitored facilities.
•Recording about the physical examination findings was not good in 52.1% of the facilities.
• Weight change was poorly monitored in 47.9% of the visited sites.
• Recording of history of cases was poor in 46.9% of the visited sites.
•Appetite testing was not performed weekly in 39.6% of the visited facilities.
•Amount of RUTF given was wrong in 45% of the facilities.


On Recording and Reporting
•Reports were either inaccurate or were not sent on time in 41.2% of the facilities visited. •Recording on OTP card was not correct or not complete in 46% of the facilities.
•The Registration Book was poorly used in 2.6%% of the facilities.
•Monthly reports were not accurate or complete; nor were they sent on time in 23% of facilities.


On logistics
• Folic Acid shortage was observed in 86.5% of the facilities monitored.
• Measles Vaccine was not adequate in 58.8% of the facilities visited.
• Amoxicillin was not found in 58.1% of the visited facilities.
• Plumpy Nut was not adequate in 23% of the facilities where scoring was done.
• Stock balance/control form was not well used in 83.8% facilities where scoring was done


Supervision system and WASH
•Supervision support to sites was very poor with 60.8% of the visited facilitiesnot getting the deserved support.
•Soap and clean water supply was a problem for 60.8% of the visited sites and latrine was a problem in 13.5% of the sites visited


Based on their observations, the monitors have forwarded the following recommendations.
1.The joint operation between HEWs and HDAs should be more strengthened if better performance is to be achieved.
2. More adequate RUTF should be available at the HPs level.
3. All OTP routine medication packages such as Amoxi
4.The WoHO should strengthen the TFP supply management system.
5.The HEWs should be encouraged to prepare and submit complete, accurate and consistent monthly OTP reports as well as document the copies in the HP.
6.Routine, checklist-based supportive supervision by Cluster HEW supervisors and WoHO should be strengthened.
7.The referral systems from/to OTPs must be strengthened and made systematic.
8.The WorHO should provide/print adequate referral slips to all OTP sites.
9.All health facilities have to respect the national protocol when managing SAM cases. 10.Woredas should follow the recording and reporting system of Health facilities regularly.                     
11.Zonal and woreda offices have to give more attention to the WASH programs.



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