WFP Targeted Supplementary Feeding in Ethiopia

Breastfeeding class in progress at 2006 Child Survival SFP site

Summary of evaluation¹

In October 2004, the Executive Board of the United Nations (UN) World Food Programme (WFP) approved Protracted Relief and Recovery Operation (PRRO) 10362.0 for Ethiopia. This intervention aimed to address the food needs of 3.8 million beneficiaries (relief 1.7 million, recovery 2.1 million) over the period 1 Jan 2005 to 31 December 2007.

PRRO 10362.0 comprises four main programme components including targeted supplementary feeding (TSF) for vulnerable children and women, working within the Government of Ethiopia's framework of Enhanced Outreach Strategy (EOS).

The EOS/TSF programme delivers a combination of key child and maternal health interventions including Vitamin A supplementation, measles vaccination, provision of insecticide treated bed nets and de-worming on a six-monthly basis. Screening of pregnant women, women with infants under six months of age and children under five years of age² using midupper arm circumference (MUAC)³ also takes place, in conjunction with delivery of the health inputs. Those women and children who are found to have a MUAC below the cut-off point of 21.0cm and 12.0cm respectively are given a ration card and referred to the TSF programme. Those with a MUAC below 11.0cm and/or with oedema are referred for treatment of severe malnutrition where available. The TSF beneficiaries receive two 3 monthly food supplements that comprises 25 kg of micronutrient fortified Corn or Wheat Soya Blend (CSB/WSB) and 3 litres of fortified vegetable oil. This provides 1,690 kilocalories, 55g of protein and 15g of fat per day. At the end of 6 months, beneficiaries automatically leave the programme.

The MUAC screening and TSF referral takes place every six months at designated EOS sites. The TSF distribution takes place every three months at TSF designated sites. The FMOH/UNICEF are responsible for the EOS component while the Disaster Preparedness and Prevention Bureau (DPPB)/WFP are responsible for the TSF component.

The overall aim of the combined components of the EOS/TSF is to "reduce morbidity and mortality in children under five". The TSF objectives are nutritional and are as follows:

• To prevent the nutritional deterioration of children under five and pregnant and lactating women.
• To prevent those moderately malnourished becoming severely malnourished.
• To rehabilitate moderately malnourished children and pregnant and lactating women through the provision of fortified supplementary food.
• To promote key nutrition messages.

It should be noted that while the objectives of the TSF are typical of traditional supplementary feeding (SFP) programmes, the TSF is not a standard SFP. The TSF operates on the basis of a three-monthly food distribution without a general ration, absence of facilities for treatment of severe acute malnutrition (SAM)) and no follow up of a child or women's weight gain during their enrolment in the programme. (Ed).

In December 2006, WFP conducted an evaluation⁴ of the TSF/EOS component of the PRRO as part of a larger evaluation of the whole programme. Interviews were conducted with key stakeholders in Addis Ababa and the evaluation team visited five regions of Ethiopia where the TSF was being implemented. Interviews were conducted in regional capitals and at field level. The following were the main findings of the evaluation team.

• The achievements of the TSF in a relatively short space of time have been impressive.
• Over a one and a half year period, the TSF has expanded from just one region and 10 woredas in April 2005 to 264 woredas in 10 regions by the end of 2006.
• In 2005, only 62.2% of planned TSF beneficiaries were reached. This was due to start up problems related to capacity constraints in government, including a lack of training and coordination, under-achievement in terms of nutritional screening targets and delays in secondary transport of food delivery. By November 2006, approximately 400,000 children and 190,000 pregnant and lactating women received two distributions of the food supplement i.e. a total of six months of supplementary food. Furthermore, 4,000 food distribution agents had been trained.
• Considerable resources have been invested in TSF staff training at all levels. In addition, the programme provided a 'minimum package' for the regions that included cars, motorbikes and computers. In 2006, an estimated 54% of all TSF woredas received the minimum package.
• Another significant achievement has been the substantial network of highly capable trained local women (Food Distribution Agents (FDAs)) created for overseeing all aspects of the food distribution and for providing nutrition education. In addition, WFP has made considerable efforts to strengthen programme implementation - largely through operational research/pilot studies. WFP have also developed a monitoring system especially for the TSF.

Challenges

Currently, there is insufficient evidence that the TSF is having a positive impact on nutritional status of children enrolled in the programme. This is a critical gap given the unusual design of this programme and lack of precedent for implementing this type of programme. There are also no population level data (baseline and post-intervention) on prevalence of acute malnutrition in children under five and women or infants and under five mortality rates that could be used to demonstrate an impact of the programme at population level. However, the scale of the food transfer, the coverage and the integration with EOS health inputs would suggest that the programme must have some nutritional and health benefit even though the magnitude of this has as yet to be measured.

There is also a lack of clarity and policy guidance with regard to how the TSF should be adapted where acute nutritional crises occur. This has reportedly led to situations where the EOS/TSF has been viewed as a replacement for traditional SFPs in situations where child wasting levels have substantially increased.

Another challenge is that there are no formal linkages between the TSF and relief/Productive Safety Net Programme (PSNP) components of the PRRO. Although, according to the PRRO document, the TSF programme was meant to serve a subset of the relief/PSNP beneficiary population, no operational linkages have been established. A high proportion of TSF beneficiaries may therefore not be in receipt of an adequate general ration. This will lead to sharing (small scale studies conducted by WFP suggest that over 50% of TSF beneficiaries may be sharing rations with other family members) and consequent dilution of impact of the TSF ration. However, as a significant proportion of those identified as mild and moderately malnourished may not be food insecure but affected by poor health and/or caring practices, it may not be appropriate to formalise a linkage between the TSF and relief/PSNP components of the PRRO. This issue requires follow up study to determine whether a formal linkage between the programmes should be established.

Another issue is that there is no clearly articulated exit strategy for the TSF component, although the overall EOS/TSF programme is expected to phase out as the national Health Extension Programme (HEP) expands. It is unclear how long the planned HEP expansion will take although considerable progress is being made in training Health Extension Workers (HEW) and in constructing health posts. In addition, there is currently no stated role for supplementary food in the HEP documentation. It is therefore unclear how the programme will continue if WFP withdraws from programming in the future.

The evaluation made a number of recommendations that include the following.

In order to demonstrate impact of this novel type of programming, WFP should:

• Conduct a robust nutritional impact and efficacy assessment of the TSF as a priority, with all parties and donors involved in the study design to ensure shared objectives and ownership of the results.
• Ensure the study involves representative samples of cohorts of children to assess nutritional outcome and also include programme coverage indicators to understand what levels of exclusion and inclusion error are occurring.
• Ensure that if impact and efficacy are demonstrated, there are discussions with key stakeholders to determine clear programme targets for the future, including exit criteria.

To strengthen linkages between EOS and create opportunities for FDAs to become a bridge to the HEP, WFP should formalise the role of FDAs in EOS screening.

To ensure that the TSF does not inhibit an appropriate response to acute nutritional crises, WFP should develop clear guidance material on the role of the TSF in acute crisis, especially with regard to emergency targeted SFPs implemented by international non-governmental organisations.

¹Summary Evaluation Report Ethiopia PRRP 0362.0. 10 October 2007. Available at http://www.wfp.org/eb/docs/2007/wfp137560~2.pdf

²The screening actually includes older children who are stunted as the entry to the EOS programme is based on a height less than 110.0cm

³Up until March 2006, MUAC screening was followed by weight for height measurements but this was stopped after agreement among all stakeholders to simplify the system and use only MUAC as a good predictor of mortality risk.

⁴WFP (2007): Summary Evaluation Report Ethiopia 10362.0: Enabling livelihoods protection and promotion. Executive Board 2nd Regular Session, Rome 22nd-26th of October. Agenda Item 6