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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