An examination of the dynamics of nutrition program implementation in Ethiopia: Facilitators and Constraints at National and Sub National Level  

Eileen Kennedy3 Masresha Tessema1, Tesfaye Hailu1, Dilnesaw Zerfu1, Adamu Belay1, Girmay Ayana1, Desalegn Kuche1, Tibebu Moges1, Tsehai Assefa1, Aregash Samuel1, Tarik Kassaye3, Habtamu Fekadu4, Joan Van

Wassenhove

1Ethiopian Public Health Institute (EPHI),  2 Federal Ministry of Health3Tufts University and 4Save the Children

Masresha TessemaAddis Ababa, Ethiopia, June 15/2015

Outline of Presentation • Background• Objectives• Method and Analysis• Results and Discussion• Recommendation• Limitation of study• Application of the research recommendation

(Utilization)

Background

• National Nutrition Strategy – 2008

• National Nutrition Program – 2008

• Revised National Nutrition Program – 2013

Objectives• To  assess  facilitators  and  constraints  in  the implementation  of NNP

• To  examine  cross  sector  coordination  at  the  federal and regional level in the context of NNP

• To assess how programs get translated from the design phase  (on  paper)  to  the  implementation  phase  (in practice).

Method• Semi-quantitative study and key informants interviewed

from Jan-July, 2013– National/ Federal level – 24 interviewees (Gov’t, donor and partners)

– Sub-national/Regional level – 307 interviewees• 4 Regions • 11 Zones• 18 Woredas 

• Semi-structured tool was used

• Analysis: The analysis was done by clustering the questions into four domains  and sub-analysis was done by clustering into four sectors

…Analysis

Domains

1. Nature of the nutrition problem               

2. Decision making and ownership 

3. Program Design and Implementation          

4. Challenges in implementation

Sectors– Health sectors

– Economic sectors: Agriculture, Trade and Industry, Finance and Economic Development, Small scale enterprise, Cooperative Union, Water and energy

– Social-sectors: Administrative, Education,  Women  and  child  affair, civil  service  and  good  governance  , early warning and food security

– Development Partners:

Results and discussion

1. Nature of Nutrition Problem• Consensus at all levels :

•  Food Insecurity

•  Undernutrition (particularly stunting)

•  Micronutrient deficiency and DD• Low awareness

• Sub-national level:– Economic and Social sectors identified food insecurity as major problem as compared to health sector 

– Most health sector and partners identified undernutrition and micronutrient   deficiencies where as they were less likely to be identified by economic and social sectors

Nature of nutritional Problem by Sector

0

10

20

30

40

50

60

70

Health

Economic

Social

Partners

Two interviewees from surplus producing areas:

          “Our area is one of surplus producing zone in the region but we give less focus for dietary quality and diversity rather worried about selling quality to make more money”, Tigray Region, Health sector

“Nutritional problem is related with lack of knowledge and food insecurity. The problem is not only observed in food insecure area but also existed in food secured area due to lack of knowledge and awareness”, Amhara Region, economic sector.

2. Decision making and ownership• Consultation during development of NNP

– The formulation of NNP 2013 was more inclusive than the NNP 2008

– At federal level most of sectors and partners were involved in the designing  of NNP and a spirit of collaboration and active involvement was reflected 

– Most (more than 70%) of the interviewees at regional, zonal and district level of the health sector were consulted on nutrition and it was lower participation for social and economic sectors (below 25%)

– Role of global initiatives and movements (Nutrition 1000 days, SUN,REACH) and partners were instrumental.

…..Decision making and ownership

• Attention given on nutrition – All of the interviewees from  health sector’s said that sufficient attention 

and resources was  given for nutrition whereas most from economic and social sectors believe other wise 

• Knowledge on NNS and NNP– At national/federal level all sectors know about the NNS/NNP– A wider gap was observed in social and economic sector: 

• Health sector and partners at the sub-national level are aware of NNP and NNS as compared to economic and social sector

• Push-Back for decision making and ownership– Considering nutrition as role of health only,– Social and economic sectors couldn’t clearly see their role – Absence of a nutrition focal point or unit in each sector.  

Knowledge on NNS/NNP

Health Economic Social Partners0

10

20

30

40

50

60

70

80

90

100

yesNo

3. Program Design and Implementation

• The design of the NNP should consider the diversity of the country and be tailor to local needs. 

• The NNP design considered strengthening existing program  and integration of nutrition into existing sectoral activities and programs 

• Each sector need to have a road map how NNP can be accomplished

“A lot of work has gone into the NNP; we now need an operational plan by sector that provides guidance on what is expected of the key actors.” NGO, Addis Ababa

…..Program Design• Sub-national and sectoral interviewees proposed key issues

that will improve NNP implementation

– Focal point for nutrition in all sectors– Creating more awareness for sub-national – Nutrition education and advocacy at community level – Empowering agriculture development agents  for nutrition activities – Incorporating nutrition in the curriculum

“Unless there is focus at the sub national level on awareness and capacity development, the nutrition plan will fail.” Gov’t Representative AA

4.Challenges in implementation

• The challenges were categorized into four a) Leadershipb) Implementation c) Budgetd) Multi-sectoral coordination and incentives for 

collaboration

…..Challenges

a. Leadership

               Most  reported  (national  and  sub-national  level) NNP need high level  commitment  especially  in  social  and  economic  sector  and coordination.– “We should make a strong recommendation to GOE that we need an autonomous body

that has accountability and authority.. May be an office of nutrition in the PM’s Office.”

b. Operational challenges to implement NNP: 

– Lack of capacity on nutrition at sub-national level

– Poor community awareness and ownership

…..Challenges c. Budget• At the national level, 22% believe that budget is a constraint. 

Government key informants (42%) from all ministries see the budget constraint as more of an issue 

“We can’t do all that is expected in the NNP without more staff and funds. It’s just not realistic.” Government Representative, Addis Ababa.

• At the sub-national level, budget was identified as a constraint by a quarter of the respondents in all region except some interviewees from Oromia region.  

…..Challenges

d. Multi-sectoral coordination– National level coordination is progressing 

– Sub-national coordination was minimal

– At the national level, 35% indicated  there should be incentives for collaboration

– At  sub-national level; HDA, sector mandated activities, good M&E plan, leaders commitment, work satisfaction, joint planning and meetings were identified as main motivational factors for coordination and collaboration. 

Motivation factors to collaborate within and among sectors at regional level

Interface, joint meeting& HAD (1 to 5 link)

Sector mandated activity       

Command post and steering committee  

BPR/ BSC 

No motivation  

0 5 10 15 20 25 30 35 40

% 

Recommendation• Coordination: in the office of the Prime minister 

• Maintain the high level of enthusiasm• Awareness creation at all levels• Capacity building at sub-national level• Establish monitoring and evaluation system • Nutrition focal person at all sectors level• Budget allocation

Limitation of Study:

• The  study  was  conducted  immediately  after NNP  was  revised.  The  result  may  not indicate/show  the  current  status  of  NNP implementation.

Application of the research recommendation (Utilization)

• First lady became ambassador/champion for nutrition.• The revised NNP rolled out to sub-national and economic 

sectors.• Regional and woreda multi-sectoral coordination has been 

established (cascading).• Increased ownership of NNP by economic sectors, e.g. 

Ministry of Industry is leading national food fortification • Some economic and social sectors assigned a nutrition 

focal person or nutrition case team,e.g Ministry of Agriculture and education

• Pending: high level multi-sectoral coordination and accountability to PMO, and budget allocation for nutrition

Acknowledgement

• USAID/ENGINE project• Save the Children• Regional government sectors offices• Interviewees

• The authors of this report acknowledge the support of the United States Agency for International Development (USAID), under the terms of Award No. ENGINE: AID-663-A-11-00017.  The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.