Rapid impact on malnutrition through a multi-faceted programme in Wolayita, Southern Ethiopia

By Kate Sadler

Kate Sadler undertook her MSc in Public Health and Nutrition at LSHTM. She has spent over 3 years working for Concern Worldwide in Burundi, Rwanda and Ethiopia. Currently in Ethiopia, she is supporting ongoing emergency feeding programmes as well as developing community health and nutrition programmes for the post-emergency recovery phase.

Background

Damot Woyde Woreda is located in North Omo Zone, Southern Nations, Nationalities and Peoples Regional Government (SNNPRG). It is 385 km South of Addis Ababa. The Woreda is characterised by a rugged, mountainous topography with valleys and gorges and is divided into 48 kebeles. It has a population of 172,877 (Woreda Council 2000) and has a high population density, with between 125 - 742 people per square kilometre in the mid- and highland areas.

The region of Wolayita has been identified for a number of years as a food insecure area. This is caused by a combination of factors - high population density with higher than average family size (7-8 per household), small land holdings and serious soil erosion. Furthermore, a reliance on rain fed agriculture by the majority of farmers in an area which receives erratic rainfall, adds to an already fragile situation.

Concern Worldwide has worked in Damot Woyde since 1984, both in emergency relief and integrated rural development, although left the area in 1998 in line with government policy. In 2000 on the request of regional authorities, Concern once again began emergency assessments to identify needs arising from the most recent drought.

Nutrition and Food Security: April 2000.

Following three successive poor harvests including the complete failure of the main Belge harvest (Jun/Jul 99), acute food insecurity was once again becoming a reality in Damot Woyde. In April 2000 the Belge rain was already 2 months late and the prospect for a harvest looked poor. The sweet potato crop, which is traditionally used to mitigate the effects of the hungry season, had failed for the third consecutive season and maize, usually harvested green in June/July, had not been planted at all. Although much of the land had been tilled there was nothing visibly planted, as the soil was completely dry. Even the coffee trees were burnt from the extreme heat. Most of the ensette¹ in the fields seemed to be harvested. In normal circumstances only matured ensette is harvested when it has been growing for 6-7 years. The early harvest of this crop reduces further the value of an already nutritionally poor food. People reported that they were on one meal a day and this was mainly ensette. They were very worried that their children were also only getting ensette to eat. In addition, the availability of water and pasture for livestock was severely reduced. Many households reported recent animal deaths and that they were unable to sell livestock as demand was so low.

A two-stage 30 cluster nutrition survey conducted by Concern between the 14th and 19th April 2000 identified worrying levels of both global and severe acute malnutrition at 25.6% (<-2 z-score and/or oedema) and 4.3% (<-3 z-score and/or oedema) respectively.

Response

In order to address this situation Concern became operational with the following objectives:

Programme Goal

To prevent the deterioration of the nutritional status of the under 5 population and pregnant/lactating mothers in Damot Woyde Woreda and to contribute towards the nutritional recovery of any in this target group found to be moderately or severely malnourished.

1. To treat current high levels of malnutrition.

By the middle of May Concern had opened 3 therapeutic feeding centres which gave 24-hour nutritional and medical care² for all severely malnourished children. A team of 5 experienced expatriates (including 3 nurses, 1 nutritionist and 1 paediatrician) and approximately 320 national staff, many of whom had worked for Concern previously, ran the centres. By the end of September 874 children had been treated with the results presented in table 1.

Table 1
Averaged across 3 centres	June	July	August	Sept	TFC Target*
Recovery rate (as % of exits)	91	96	99	100	> 75
Mortality rate (as % of exits)	3	4	1	0	< 10
Default rate (as % of exits)	6	0	0	0	< 15
Average weight gain (g/kg/d) Marasmic	- **	-	14.6	16.0	> 8
Average weight gain (g/kg/d) Kwashiorkor	-	-	10.7	8.2	> 8

* Humanitarian Charter and Minimum Standards in Disaster Response. (Sphere, 2000)
** Reporting did not include this information at the start of the programme.

Targeted supplementary feeding was started simultaneously for all moderately malnourished children less than 5 years old and pregnant and lactating mothers. This involved a fortnightly mobile distribution to 10 separate decentralised sites across the Woreda. Treatment included a 3.5kg ration of CSB (approximately 900 kcal/beneficiary/day) as well as basic medicines including vitamin A, folic acid and mebendazole.

By the end of September 5,407 children and 2,272 pregnant/lactating women³ had passed through or were still being treated in this programme. Monthly monitoring statistics gave the results shown in table 2.

Table 2
Averaged across 10 centres (for all children < 5 years)	June*	July	Aug	Sept	SFP Target **
Recovery rate (as % of exits)	48	64	88	84	> 70
Default rate (as % of exits)	23	36	12	16	< 15
Average length of stay (weeks)	-	10.5	10.8	12.8	-

* At this stage many direct referrals to the TFCs were being included in SFC statistics. These cases account for the remaining 29% of exits. Additionally a significant number of children found to be "cheaters" e.g. registered twice at the same SFP site, were being counted as defaulters - some centres therefore had relatively high default rates in June and July.
** Concern Worldwide "Nutrition in Emergencies" 1996

 

The programme for pregnant and lactating women was not evaluated. Criteria for admission was MUAC < 210 mm and discharge was at 230 mm. The combination of these two criteria resulted in a slow recovery rate and high non-recovery rate, i.e. many women were discharged after 3 months or when the baby reached 6 months without the mother reaching the target MUAC.

2. To increase food available to the most vulnerable households.

In January 2000 official figures released by the Government of Ethiopia indicated that 54,000 people in Damot Woyde Woreda were in need of monthly food assistance. This figure was said to be rising rapidly and by April of the same year was generally thought to be an under-estimation. For many reasons⁴ the Woreda Administration did not have the capacity nor the resources to respond to the food needs in the area. Only 325 tonnes of grain had been delivered to Damot Woyde by April 2000 (enough only for a one off distribution to 26,000 people) and much of this remained in warehouses.

In order for Concern's targeted feeding programmes to be effective, to prevent many more people becoming malnourished and to minimise readmissions to targeted feeding programmes, a general food ration was essential for those in need. Concern assisted the Woreda Council with this objective by:

• Local purchase⁵ and distribution of general food (12.5kg of grain per person per month)⁶ to 54,000 of the most vulnerable people in the Woreda for four months (June to September). Beneficiary lists were drawn up by the Woreda authorities and subsequently verified by a Concern team to ensure all recipients fulfilled the criteria for vulnerability
• Providing a small quantity of fuel and repairing the Woreda truck.
• Providing training on food aid targeting to the Woreda Council and assisting in post distribution monitoring.

3. To improve prospects for household food security.

Some of the most important seeds required by farmers, including teff, sweet potato, wheat, maize and beans, were distributed to 11,000 of the most vulnerable households. Seeds were purchased locally. This enabled many impoverished farmers to plant in July for the Meher season.

Co-ordination & Advocacy

In addition to identifying the acute need for intervention in this area, the survey results gave Concern the necessary information to highlight the area of Wolayita as one that required urgent attention. Up until this time Wolayita had not been considered a priority area by either the Government of Ethiopia or by international donors. Whilst getting programmes established Concern lobbied at the federal level for more food aid for Wolayita and for a more balanced ration. This resulted in Damot Woyde and other Woredas in the area being included among the first priority Woredas on WFP's 'Priority Areas for Pre- Positioning' of general food and in an increase in the number of people listed as requiring food assistance.

A Wolayita region co-ordination group was also initiated which, as well as acting as a forum for information exchange also added weight to the lobbying at federal and donor level. This group highlighted to other NGOs, areas in Wolayita where there was little information on nutrition and food security status. This resulted in OXFAM GB and MSF Spain becoming involved in the neighbouring Woreda of Bolosso Sore and MSF Switzerland starting emergency programmes in Damot Gale Woreda.

Nutrition and Food Security: July & October 2000 - measuring programme impact.

Acute Malnutrition Measured by Weight for Height
6 - 59 Months	April 2000 (C. I.)	July 2000 (C. I.)	Oct 2000 (C. I.)
Global Malnutrition Z score < -2 and/or oedema	25.6% (22.9-28.5)	6.4% (4.3-9.2)	7.2% (5.0-10.1)
Severe Malnutrition Z score < -3 and/or oedema	4.3% (3.2-5.9)	1.0% (0.3-2.6)	1.0% (0.3-2.6)

 

A second survey was undertaken three months after the first. This survey identified a dramatic improvement in the rate of both global and acute malnutrition in Damot Woyde Woreda. The third survey in October showed a stabilisation in the rate of malnutrition as well as identifying a relatively more positive food security environment. By October, malnutrition accounted for only 6% of all deaths recorded during the survey. This compared with 32% in July. The major causes of death had changed from malnutrition and malaria to malaria and cough/respiratory disease (43% and 29% of all deaths respectively).

This improvement in the nutritional status of the population was generally thought to be attributed to two main factors: Concern's nutrition interventions and improved food security.

Nutrition Intervention

Since April 2000 Concern had implemented therapeutic and supplementary feeding, community outreach in all kebeles to identify and refer all at risk individuals and general food distribution to 54,000 of the most needy individuals.

By October, Concern had closed the last of its therapeutic feeding centres and children identified as severely malnourished are now referred to the nutritional rehabilitation unit in nearby Sodo hospital. Concern's supplementary feeding programme is ongoing⁷ although the proportion of those discharged who fully recovered is increasing. This is thought to reflect the overall improvement in the food security situation of the Woreda.

Improved Food Security

With the arrival of rain in May animal health visibly improved in the area and by late June many households began harvesting small quantities of beans and kale from their fields. In October post distribution monitoring indicated that the majority of the seed distributed had been planted and was maturing successfully. In addition, most households were eating two meals a day of maize or wheat, beans, cabbage and coffee and in some cases sweet potato, milk and sorghum. For the majority, the main source of food was the market with income coming from daily labour, credit and the sale of grass, firewood and in some cases agricultural produce such as cotton, green maize, cabbage and milk.

While a large proportion of the dramatic decline in malnutrition between April and July was due to the arrival of rain in May and the general improvement in the food security and animal health situation seen by June, evidence from near-by Woredas indicates a significant impact of the Concern intervention in Wolayita. In neighbouring Bedewacho Woreda, which did not benefit from early assistance from an INGO, a nutrition survey in August found that malnutrition rates remained relatively high at 16.8% GAM and 4.8% severe wasting.

Lessons Learnt

• The programme implemented a number of activities simultaneously which, as well as treating those already sick, attempted to address the wider food problem.
• Activity implementation was generally considered to be timely - feeding began within 2 weeks of the survey, when food access was extremely low.
• The programme was able to use many experienced national staff who had worked previously in nutrition programmes for Concern. With relatively little training and supervision they were able to implement programme protocols effectively.
• Experienced expatriates on the team enabled high quality of service provision from the start of the programme. This was especially true for the therapeutic feeding centres for which the presence of a paediatrician, a nutritionist and 3 nurses almost certainly kept mortality rates low and recovery rates high throughout.
• Dissemination of information and advocacy at a regional level was extremely important to ensure that areas in need received due attention and timely intervention.

Admission criteria for pregnant and lactating women to the supplementary feeding programme were too generous resulting in a slow recovery rate and a high non-recovery rate.

Conclusions

• The stabilisation in the rate of malnutrition is a good indication that Concern's nutrition intervention has achieved its programme goal and that generally short-term household food security status has improved. Future nutrition and food security status however will remain fragile:
• Concern has ceased all general food distributions and pending the end of year harvest, any future food distributions are the responsibility of DPPC/WFP.
• Although the majority of the population are currently harvesting, many farmers are having to use a large proportion of their harvest to recover from the previous food crisis i.e. pay off debt, purchase agricultural seeds and tools.
• Household diet and sources of income remain limited, especially in the poorest households.
• The health, especially vaccination status of much of the population remains very poor.

Future Priorities

• Supplementary feeding should continue in order that the large number of beneficiaries who remain in the programme can reach their target weight. Programme phase-out should begin in Jan 2001 with finalisation of the hand-over strategy to the Ministry of Health.
• The nutritional rehabilitation unit in Sodo Hospital should continue to be the referral facility for severely malnourished children from the Woreda. This unit would benefit from continual support in the form of monitoring visits and training opportunities.
• Continue food security monitoring and implement a fourth survey in 6 months time to ensure that nutritional status has remained stable.
• In order to sustain nutritional recovery a community health and nutrition programme, developed in conjunction with the Woreda Ministry of Health, is now a priority. As well as addressing immediate needs such as low vaccination coverage and poor health centre capacity it should begin to develop strategies which will improve longer-term food and health security.
• Criteria for admission, monitoring and discharge of pregnant and lactating mothers should be reevaluated and developed for this population group. Further research is required in this field.

Concern would like to acknowledge OFDA, Ireland Aid, Fyffes and EthiopiaAid who have generously supported the above programmes.

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¹Ensette is a root crop not dissimilar to cassava which is widely grown in Wolayita and commonly known as false banana.

²All care administered followed standard WHO/MSF/Concern protocols.

³All pregnant women in the third trimester were admitted to the SFP. This was difficult to verify as many were not receiving antenatal care and did not have a card with estimated time of delivery recorded. Many of the women were admitted based on appearing to be in the 3rd trimester.

⁴A country-wide shortage of grain: even though many donors had pledged grain for Ethiopia by April 2000, a gap of at least three months was anticipated before these pledges reached the required destinations. Lack of fuel and transport at Woreda level for grain distribution: Damot Woyde Woreda Council had very little capacity to distribute grain once it arrived in Woreda warehouses.

⁵Shashemane only 2 hours to the north remained a surplus producing area where food was available for local purchase - this contrast in the food security of neighbouring areas is common across Ethiopia and is an important issue to be considered when discussing famine preparedness and prevention.

⁶This ration complied with the National Policy for general food distribution.

⁷Total beneficiaries at the end of October: 2769 children and 1648 mothers