EHNRI - Profile and role in the National Nutrition Programme

This article is based on a meeting between Carmel Dolan, ENN and Dr Cherinet, Director, Food Science and Nutrition Research Directorate.

Entrance to EHNRI compound

Dr Cherinet began working for the ENI, predecessor to the EHNRI, in 1988 and has been Director of the Food Science and Nutrition Research Directorate at EHNRI since 2009. Previously he held various positions within the institution including assistant researcher, senior researcher and team leader. He holds a PhD in Public Health (Nutritional Epidemiology) and an MSc in Applied Nutrition.

Dr Cherinet would like to thank the following staff for their contributions to this article: Dr. Tsehaynesh Messele (EHNRI Director General), Dr. Amha Kebede (EHNRI Deputy Director General), Ms. Aregash Samuel (Food Science and Dietetics Research Case Team Leader), Ms. Lakech Goitom (Associate Researcher - Food Science and Dietetics), Ms. Tsehay Assefa (Associate Researcher - Nutrition), Mr. Habtamu Fafa (Nutrition Research Case Team Leader).

Historical overview

The Ethiopian Health and Nutrition Research Institute (EHNRI) is the result of a merger in April 1995 between the former National Research Institute of Health (NRIH), the Ethiopian Nutrition Institute (ENI), and the Department of Traditional Medicine (DTM) of the Ministry of Health. The EHNRI, as a government organisation, is the primary body in Ethiopia for carrying out research, training and providing services for the public and organisations in the areas of health and nutrition.

National Research Institute of Health (NRIH)

The NRIH was the oldest of the three units and began life as the Medical Research Institute in 1942. In the late 1950's, it became the Pasteur Institute of Ethiopia, following an agreement with the Pasteur Institute of Paris and named after the French chemist Louis Pasteur (1822- 1895) who invented the first vaccine for rabies. In the early 1970's, it was agreed that the Ethiopian Government would take over the running of the Pasteur Institute and it was renamed the Central Laboratory and Research Institute. Towards the end of the twentieth century, it evolved into the National Research Institute of Health (NRIH), which focused its energy on making significant contributions towards improving the health of the country.

Ethiopian Nutrition Institute (ENI)

The Children's Nutrition Unit (CNU) was founded in 1962 as a joint Ethio-Swedish project. It became the ENI in 1968, when the Ethiopian Government took over responsibility for and increased the scope of the nutrition programmes to include pregnant and lactating women, school-age children and other adult groups. It carried out nutrition and food science related research and interventions, as well as providing nutrition training and laboratory services to the public, universities and other organisations. This was realised by specialist teams working on medical nutrition, community nutrition, food production, training and information, and through its well-equipped Food Science and Nutrition laboratories.

National Nutrition baseline survey dissemination workshop - Dr Amha giving the opening speech

Major achievements of the ENI include the development of a National Food Composition Table, development and production of a supplementary food for infants and children called FAFFA (meaning 'to grow big and strong'), as well as other types of complementary and therapeutic foods. It also developed a strong presence in local communities through establishing field stations to carry out surveys and research on aspects of nutrition, the production, storage and preparation of locally available foods, and through the dissemination of educational materials and information to the public.

Department of Traditional Medicine (DTM)

The DTM was established in 1979 under the Ministry of Health to undertake research, and promote the production and use of traditionally used medicines. This was at a time when almost 80% of the Ethiopian population relied on traditional medicines to treat various ailments. Major research was undertaken to develop safe, effective drugs from selected medicinal plants being used and to identify those that could have a potentially harmful effect on the population. Hundreds of medicinal plant species were identified and their uses determined for various types of ailments.

The mandate of the EHNRI

The NRIH/ENI/DTM merger allowed the bringing together of complementary expertise and laboratory facilities to allow for maximum utilisation of available resources and create an atmosphere conducive to research. More recently, the Institute implemented 'Business Process Re-engineering' to facilitate a restructuring of the organisation and its activities so that it can more effectively discharge its responsibilities in line with the Ethiopia Health Sector Development Plan (HSDP III/IV (HSDP IV covers the period 2010-2015). HSDP IV is geared towards protecting and promoting the health and wellbeing of the nation.

Under the new structure, a Director General and two Deputy Director Generals head the EHNRI. One of the deputies heads the Research and Technology Transfer wing of the Institute, which is tasked with tackling priority public health and nutrition problems through problem focused research in order to improve the health of the country. The other deputy heads the Public Health Emergency Management division of the Institute, which works to anticipate, prevent, prepare for, detect, and respond to public health threats so that negative health and socio-economic impacts are minimised.

The Institute also has the mandate to establish and maintain a high quality, sustainable laboratory system throughout Ethiopia. This delivers quality and accessible laboratory services relating to the occurrence, causes, prevention and diagnosis of major diseases of public health importance and to establish and support National Laboratory Quality Assurance programmes and systems.

The Institute is well placed to carry out all of its tasks, with almost 200 research and technical staff, 250 support staff and well-equipped laboratories. It also benefits from the generous support of the Government of Ethiopia and various national and international organisations, with total funds of around 25 million birr and $20 million USD per year (in cash and in kind) received.

Organisations that support the Institute include WHO, UNICEF, World Bank, Centre for Disease Control (CDC) Atlanta, Japan International Cooperation Agency (JICA), the Food and Agriculture Organisation (FAO) and various non-governmental organisations through joint research projects. Also, collaborative research projects are carried out with local universities, as well as with international partners, research institutes and institutions of higher learning.

Current major programmes include joint cooperation with CDC for a national surveillance study of HIV/AIDS, sexually transmitted infections, malaria, and tuberculosis and strengthening of laboratories at central and regional level. Also, there is significant collaboration with JICA, WHO, and local and international Rotarians for polio surveillance. In collaboration with WHO and the Foundation for Innovative New Diagnostics (FIND), EHNRI has set up a lot testing centre for malaria with the objective of providing this service for the whole of Africa. This centre is one of only three globally, the other two being in Cambodia and The Philippines. A Rapid Test Kit has also been established at EHNRI. At present there is also strong collaboration with the governments of China and South Korea on research into traditional medicines.

Support for the National Nutrition Programme

One of the most significant programmes that the Institute is currently involved in is the National Nutrition Programme (NNP). The NNP is an ambitious nutrition programme, developed by the Ministry of Health with partners, in order to implement the country's first National Nutrition Strategy endorsed in February 2008. It is designed to not only address emergency interventions and food insecurity but also focus on preventive interventions, as well as address the fragmented nature of past interventions by taking into account the multi-sectoral nature of nutrition. The overall aim is to reduce the magnitude of malnutrition in Ethiopia, particularly amongst the most vulnerable groups of children under five, pregnant and lactating women, and people living with HIV (PLHIV).

The Food Science and Nutrition Research Directorate (FSNRD), part of the Research and Technology Transfer wing of the Institute, is carrying out NNP activities as part of its regular operations. The mandate of the directorate is, firstly, to determine and monitor the magnitude, distribution and determinants of malnutrition in the country and, secondly, to carry out effective research to develop an evidence base that offers innovative solutions to reduce and eradicate malnutrition. Research includes the development of new food products and processing and preservation technologies. The directorate also offers laboratory services to the public and organisations, supports curriculum development and teaching at universities, and carries out demand based 'on-the-job' training for various organisations on health and nutrition related topics.

This Directorate has been responsible for many innovative nutrition interventions in Ethiopia since its inception, including the development of food composition tables, menu development for chronic health problems and micronutrient research. Currently, with the advent of the NNP, nutrition is once again in the spotlight in Ethiopia at a time when the economy has been enjoying steady growth. However, this has not been matched by a corresponding fall in the level of malnutrition that development can bring.

The Directorate's role in the NNP is based around carrying out critical surveys and research that will create a greater understanding of the current nutrition situation in the country and help to shape the scaling up of the programme. The Directorate also undertakes monitoring and evaluation of various components of the programme as they are implemented, and the NNP as a whole.

Nutrition surveys and understanding factors that cause malnutrition

An integrated national nutrition baseline nutrition survey has already been designed and successfully conducted by EHNRI in June 2009 at the national level. The aim was to collect information on basic indicators of nutritional status such as under-five, adolescent girl and maternal malnutrition and morbidity. Within the household, conditions such as food security, clean water, safe sanitation facilities, hygiene practices, maternal care practices and access to health services can have an impact on the nutritional situation, so data was also collected on these indicators, amongst others.

The survey report, which includes the full results of the survey, can be found at www.ehnri.gov.et. As expected, the findings are mostly in line with the Ethiopia Demographic Health Survey (EDHS) 2005, but serve to highlight the magnitude of the nutrition problems in Ethiopia and the importance of NNP implementation. The NNP particularly focuses on the period from birth to two years of age, which is seen as the 'critical window' for the promotion of good growth, health, and behavioural development through optimal infant and young child feeding. Thus indicators relating to this age group are the most critical to understand since this is where interventions are most needed. Major findings related to this age group are highlighted in the Table 1.

*Based on NCHS/CDC Reference Population 1977.

The nutritional status figures of both the 6-23 months and 6-59 months groups fluctuated. Mothers from rural areas with a low Body Mass Index (BMI) and mothers with low levels of education were at greater risk of having a malnourished child. The nutritional status of the child also depended on their age and the region that they live in. Children between 18-23 months were more likely to be stunted (43%), those between 12-17 months had higher rates of wasting (17.5%) and those between 24-35 months were more commonly underweight (39.3%). Children were more likely to be stunted in Amhara and Afar, wasted in Afar and Somali, and underweight in Afar and Tigray regions.

Key survey results related to breast and complementary feeding are indicated in Table 2. The breastfeeding results particularly varied based on the mother's level of education. Mothers with a higher level of education were more likely to have ever breastfed their child, breastfed within the first hour of life and fed colostrum to their newborn infant.

*Based on WHO indicators and methodology.

Maternal nutrition is critical to ensure the health of the mother during pregnancy and after birth, and to ensure the strong development of the child. If the mother does not receive sufficient nutrition and supplementation during pregnancy, there is a good chance that this may adversely affect the development of the child. Key indicators related to the nutritional status of pregnant and lactating women found in the survey are shown in Table 3.

Increased food consumption and iron-folate supplementation was more likely amongst younger women, those who lived in an urban area and those of higher educational status. Symptoms of night blindness were less likely and vitamin A supplementation higher for women living in urban areas and those with higher levels of education. For iodised salt, a higher percentage of rural households, compared to urban households, were using it.

The little change found in key nutritional indicators since the Ethiopia DHS survey of 2005 shows that many challenges remain. However, the next few years, during which the various components of the NNP will be implemented, is the critical time that interventions will be scaled up. An end line survey, planned to take place during 2013, should show the impact of these interventions.

Assessment of national capacity for implementing the NNP

EHNRI also commissioned a series of studies in order to create a clearer picture of the nutrition professionals available from federal to subdistrict levels to implement the NNP and the capacity of nutrition training institutions to supplement and strengthen this cadre. A further study was conducted to assess current behaviour change communication activities, with a view to developing a comprehensive communication framework that would complement the implementation of the various NNP activities.

Major findings of the two studies on personnel and training for nutrition found that there is a shortage of trained professionals at federal, regional, zonal and district levels to effectively implement the NNP. Recommendations focused on developing a uniform structure at each level with clearly defined roles, placing greater significance on in-service training and developing a new generation of nutrition professionals. This is to be achieved through creating a Technical Advisory Group to support universities to strengthen existing and develop new short and degree courses and strong nutrition curriculum, focusing on university staff development and creating greater linkages between universities.

Behaviour Change Communication in the NNP

Systematic behaviour change approaches are extremely important to bring acceptance of nutrition interventions in communities. However, this communication study found that current nutrition behaviour change communication (BCC) activities are fragmented and under-exploited. A framework, under which new BCC activities should be developed, has been produced as part of the study, The BCC framework aims to increase the capacity of each household to use existing food resources to maximum advantage by taking into account Government policy, socio-economic status, culture, and gender issues. The study also outlined the actors that should be involved in planning and implementing new BCC activities and the training necessary for them. All of these studies are available at www.ehnri.gov.et.

Research focus for the NNP

One of EHNRI's strengths is in its research capacity. It was on this basis that it was given the mandate to set up and run the Operational Research Programme (ORP). This programme, as part of the NNP, exists due to the recognition of the complexities inherent in programme implementation. It aims to identify and carry out studies that can ultimately bring about new insights and understanding to improve implementation and shape the scaling-up of the NNP. By doing this, it provides managers and policymakers with the information they need to improve the existing delivery activities and plan future ones.

The programme is ambitious in its size and scope, and potentially one of the largest of its kind ever carried out in nutrition. A lot of the groundwork is already in place. To ensure that high quality studies are carried out that can inform nutrition programme planning and implementation, selection of the research entities to carry out the studies will be done through a competitive-bidding process.

Priority research areas have been identified and agreed upon in consultation with nutrition partners. These include on issues specifically related to Community Based Nutrition (CBN) such as quality of services, data quality, programme scale-up to reach pastoralist communities, and Health Extension Worker skills. Other areas of research focus include the feasibility of local production of micronutrientrich processed foods, using micronutrient powders to improve complementary food quality, effectiveness of the media to deliver BCC messages, and micronutrient interventions, such as pregnant women's compliance to daily iron supplementation.

Listening to the opening speech at the National Nutrition baseline survey dissemination workshop

This research will be carried out and results disseminated over the next two years, so that they will have a direct impact on current and planned programmes being implemented as part of the NNP. Furthermore, each year of the NNP, EHNRI will identify with nutrition partners the most critical operations research that needs to be carried out as part of the ORP in order to improve NNP implementation.

Establishing a national nutrition database

EHNRI also has the responsibility to set up and run a comprehensive nutrition database. Its purpose is not to take over the role of existing sources of nutrition information, such as the database held at the Emergency Nutrition Coordination Unit (ENCU), but rather to gather 'under one roof' all emergency, programmatic and nutrition survey data from existing sources. This will enable the interpretation and use of this data effectively for inputs into management decisions, long term planning, evaluation and related purposes for the CBN and other nutrition- related programmes.

Potential outputs from the database in order to meet these needs include quarterly bulletins containing interpretation of risks to nutrition from early warning and nutritional data, quarterly reports monitoring nutritional outcomes and NNP implementation, and annual publications on the state of nutrition in Ethiopia to estimate long-term nutritional trends and factors determining these. At the same time, stakeholders will be able to request specific data from EHNRI as required.

A positive future

There are exciting times ahead for EHNRI, and particularly the FSNRD, as it continues to play a significant role in implementing the NNP, including the ORP, developing the nutrition database and also carrying out micronutrient surveys and numerous evaluation studies. The Directorate is also advocating for a food fortification agenda and plans to conduct studies on various aspects of fortification at the community and industrial levels. Further studies are planned on the relationship between nutrition and chronic health problems, as well as on food consumption patterns and composition. Furthermore, quality control and quality assurance work will continue on the salt iodisation programme as it continues to be scaled up.

The Directorate has high ambitions to be at the forefront of all nutrition interventions in the country and sees the NNP as a great opportunity to increase the capacity of the young but dedicated staff through their work, with numerous partners and increased opportunities for training. This is indeed a huge opportunity for the Directorate to push forward and continue to make a significant contribution to the success of the NNP, as well as for the country to banish the high rates of malnutrition to the annals of history.

For more information, contact: Dr. Cherinet Abuye, email: cherinetabuye1@yahoo.com