A variety of initiatives – from counseling to engaging religious leaders to cooking demonstrations to community awareness raising – are supporting health services across Ethiopia to address gaps in nutrition services thanks to a small grants program initiated by Alive & Thrive.
Regional health bureaus in Afar, Amhara, Oromia, Somali, and SNNPR are implementing the activities. A grant to support community awareness activities on child health and nutrition is a good example.
The community awareness activities reached 7,500 residents of the West Gojjam Zone of the Amhara Region. Health workers held community discussions using a variety of printed materials to spark conversations regarding exclusive breastfeeding, the importance of IFA tablets, colostrum feeding, and the need to reduce pre-lacteal feeding practices and improve the overall nutrition status of children.
“This program has been critical to revitalizing optimal infant and young child feeding practices in our community,” said Semahegn Nigussie, Head of Seqela Woreda Health Center in West Gojjam Zone of the Amhara Region. He said the support has led to fewer cases of child malnutrition.
Click on the pushpins in the map below to read short summaries of the initiatives supported by small grants. Click on the lighter shaded pins to read about the key themes identified.
The small grants program was launched after an Alive & Thrive organizational capacity assessment identified gaps in services. Stakeholders in the assessment identified a key theme for each region targeted for focused support, including Afar, Amhara, Oromia, Somali, and SNNPR, explained Tadele Yitaferu, Deputy Project Director of Alive & Thrive in Ethiopia.
“The themes were determined based on a potential for collaborative efforts between the regional health bureaus and Alive & Thrive. This resulted in increased impact of successfully tested innovations that benefited more people through expansion and replication of successful practices, and fostered program developments on a lasting basis through institutionalization,” he said.
The stories below illustrate a selection of the initiatives.
Utilizing EPI platforms for MIYCN services delivery
During her latest pregnancy, Aysha Aden, 25 and a mother of three, received antenatal care services in the local health facility in Woderage, a small village in Dewe Woreda of the Afar Region in Ethiopia. She has found the nutrition counseling during her ANC attendance critically important as it helped her adopt optimal practices on diversified diet consumption, weight gain, iron folate acid (IFA) supplementation and adherence.
It has been four months now since she gave birth to her new baby, Hanferi, whom she started breastfeeding within an hour of his birth. Aysha has continued receiving nutrition counseling services integrated in other platforms including the Expanded Program on Immunization (EPI).
When she visited Woderage Health Center for the third immunization of her new baby, Aysha said the health worker used the platform to counsel her on a range of “nutrition issues including monitoring the growth of her baby, importance of exclusive breastfeeding for the first six months, and hygienic practices.”
As Aysha needs to start complementary feeding for Hanferi in two months, she said, “the health worker also advised me on how to prepare diversified food,” a message she said she will take seriously. The nutrition counseling gave Aysha more insight into how important a healthy and diversified diet is for Hanferi’s further development, after exclusively breastfeeding him for the first six months.
Cooking demonstrations introduce nutrient-rich dishes
At cooking demonstration sessions at Kidamaja Health Center in Banja Woreda in Amhara Region, Zewditu Birhanu has seen firsthand how to prepare nutrient-rich porridge for her nine-month-old baby boy.
“Just like they show us at the health center, I make my baby’s porridge with flour I prepared mixing grains and legumes in the right proportion,” she said. “I then enrich it with mashed vegetables such as kale, carrot and mashed potatoes, as well as milk and minced meat.”
Bezanesh Amare, a health development army leader in the community, regularly updates and receives guidance from Meselech Nega, a health extension worker at Kidamaja Health Center on ways to support mothers to practice optimal complementary feeding to their children between six and 24 months of age. She also recruits new mothers for attending the food cooking demonstration sessions at the health center.
Engaging religious leaders on nutrition
Religious leaders carry great influence in communities across Ethiopia. Members of the Ethiopian Orthodox Church fast for as much as half of the year, which can pose a risk to the health of infants and young children. At a church in Kidamaja Town of Banja Woreda in the Amhara region, Priest Girma Alene has used his position to encourage parents to prepare non-fasting foods for their children even during fasting seasons. The health facility sees him as one of the religious fathers who consistently supports the promotion of complementary feeding through his discussions with parents during cooking demonstration sessions in the health center.
“Making non-fasting foods for children does not contradict with our Christian teachings,” Priest Girma said.
Working with the local health facility as he does, and further making his points during religious and other community gatherings, Priest Girma said, “I and fellow religious fathers are clearing parents’ doubts and assuring them to keep feeding their children what they need for their healthy growth including when it is a fasting season for adult Christians.”
Improving implementation of systems to distribute Iron Folic Acid tablets
In the Ejere Woreda of the Oromia Region, the integrated pharmaceuticals logistics system (IPLS) ensures that Iron Folic Acid (IFA) tablets reach health centers – and then pregnant women during ANC visits. But knowledge and skill gaps led the Oromia Regional Health Bureau and Ethiopian Pharmaceutical Supply Agency to utilize an Alive & Thrive small grant to orient health workers, facility leadership and pharmacists to the system; the orientation was followed by several months of technical support.
The supply system was “managed in haphazard manner without utilizing the IPLS protocol, and our health office considered this an area that was not easy to change for the last four years,” explained Ajema Negasa, coordinator of the Reproductive, Maternal, Neonatal, Child, Adolescent & Youth Health and Nutrition Unit in Ejere Woreda Health Office. He was initially skeptical the initiative could improve the system. But the small grant learning project, Ajema said, “has proved us wrong.”
“No supply is now provided to health facilities without using the reporting and forecasting tools,” he said, citing the Reporting and Resupply Form and Health Post Report and Resupply Form. The small grant support has strengthened the IPLS “by improving the forecasting, distribution, reporting, management of supplies of these and Ejere Woreda Health Office through initiating, reactivating, and updating existing mechanisms and creating stronger linkage among health facilities,” Ajema said.
Haregewoin Solomon, a druggist at the Ejere Health Center in Oromia’s West Shoa Zone, participated in an orientation funded by a small grant initiative. Prior to the orientation, “we had a weak system in IFA tablet forecasting, supplementation and reporting practices,” she said. In fact, the template she used to report stock to the Ethiopian Pharmaceutical Supply Agency Hanamariam Hub did not include IFA tablets on the list of items. Following the launch of Alive & Thrive’s small grant support, Haregewoin started to use the updated template for her EPSA reporting, and her facility also initiated the inter-facility report and resupply, and the request and resupply form (RRF) to make timely requests for medical supplies including IFA tablets. The initiative has “strengthened our IFA tablet supply, and the reporting and requesting mechanisms.”
The small grant to the Oromia RHB ultimately reached the staffs of 12 health facilities (four health centers and eight catchment health posts) to improve IFA tablet supplementation practices. Askale Mengistu, a senior midwife, said the orientation and subsequent support was “a game changer.”
Before the orientation, “counseling and follow-up of mothers for IFA tablet consumption was not part of our workplan,” Askale said. The health center did not have a proper follow-up mechanism on refill, and its previous reporting did not clearly distinguish between mothers with complete and incomplete IFA tablet refill practice, she added. With small grant support, the center has put that follow-up mechanism in place by creating strong linkages between health centers and health posts that facilitate proper refill of IFA tablets, counseling, and documentation as part of ANC and PNC routines.
“Most pregnant mothers attend their first ANC at a health facility and then are referred to health posts for their second and third ANC attendance with all details of their situation reported,” Askale said. “That now includes IFA tablet provided to them.”
When mothers come back to the health center for their fourth ANC service appointment, the health post provides similar follow-up details. Mothers are more aware of the importance of consuming IFA tablets regularly over the course of their pregnancy and beyond because “… the joint support provided by Oromia RHB and Alive & Thrive helped us to make optimal IFA tablet consumption part of our nutrition counseling to mothers,” she said.
Before the learning project, pregnant mothers would take the IFA tablets from the HC’s dispensary unit without proper counseling on consumption, refill and side effects. Now, they obtain them right at the maternal and child health unit where they receive ANC and PNC services and counseling on IFA tablet consumption and ways to deal with side effects.
“The contribution of the small grant support to our health center and other facilities on the program is certainly huge and it helped us improve the demand and supply of IFA tablets as well as our counseling and reporting activities. I would like to recommend its scale-up in all other facilities in our Woreda,” Askale said.
Supporting mothers groups to discourage pre-lacteal feeding practices
According to the 2016 Ethiopian demographic and health survey and other reports, Somali Region has the highest rate of pre-lacteal feeding practices – the giving of any substances other than breastmilk to newborns before breastfeeding initiation – in Ethiopia. Pre-lacteal practices deprive newborns of valuable nutrients and the protection provided by colostrum and expose the newborn to the risk of infection. An Alive & Thrive small grant sought to stimulate behavior change for improved child nutrition practices, focusing on promoting colostrum feeding and reducing pre-lacteal feeding practices in the community.
The initiative focused on supporting community volunteers – groups of mothers and fathers called Umul gar gar and Abo gar gar, respectively. The small grant supported training sessions implemented by the Somali Regional Health Bureau and Abware Woreda Health Office Team and enabled the Umul gar gar community volunteers and Awbare Health Center to provide better nutrition counselling services and household-level support.
One mother, Hodan Abdilahi, 28, said the program had helped her see better nutrition outcomes. She has exclusively breastfed her youngest child for the first six months and has seen “amazing results in the growth and development of my baby girl.” Unlike her older kids, Adan, the youngest born, is growing faster and stronger with “no single experience of diarrhea or any other ailment so far.”
Nimo Abdi, Head of the Umul gar gar team in Awbare town, said the initiative “strengthened us as a team to perform better in helping mothers to obtain health and nutrition services.” The Umul gar gar team in Abware “provides counseling support for women on various nutrition issues including the critical need to feed colostrum to newborns within an hour of birth, abandoning pre-lacteal feeding, which is a common practice in my community and to also link pregnant mothers to the health center for antenatal services.” She confidently noted that the Umul gar gar team she leads has been successful in bringing more mothers to the health center for these services through its use of various community platforms including religious congregations and community gatherings, household visits, and mother-support-group sessions at the health facility for promoting child health and nutrition.
The Umul gar gar team in Abware reached 590 mothers through this intervention and Nimo hopes, post-project, her team will continue to collaborate with the RHB, elders and religious leaders to sustain the success in promoting health and nutrition in her community.
Mentorship program for improved MIYCN services
In SNNPR, the organizational capacity assessment highlighted that a lack of mentorship and coaching for health workers undermined the quality of MIYCN services during ante-natal and post-natal care visits.
In order to address this gap, the Regional Health Bureau used small grant funds to implement a MIYCN mentorship program in Lanfuro Woreda of the region’s Silt'e Zone. Following the mentorship trainings in one hospital and two health centers in the zone, supportive supervision visits and follow-up counseling improved the quality of MIYCN services in the facilities through knowledge and skill transfer.
The mentorship program helped the bureau to coordinate efforts between the bureau, Silte Zonal Health Department, and Lanfuro Woreda Health Office to implement all the components of the project, explained Genet Lakew, Nutrition Case Team Coordinator at the Regional Health Bureau’s Maternal and Child Health and Nutrition Directorate.
“Health facilities were able to create strong health post-health center- primary health care linkages, improving health workers’ knowledge and skills in nutrition services provision and promotion,” Lakew said. A cluster approach – linking a district hospital and a health center in their catchment and supporting them through MIYCN mentorship and coaching – “had been particularly effective to transfer knowledge and skills among staff at rural health facilities over the course of about six months,” she said.
“This led to a great success in improving and integrating nutrition services in the facilities. Now, we will have to sustain the improved services and find ways to scale up.”