Enhanced Outreach Strategy/ Targeted Supplementary Feeding for Child Survival in Ethiopia (EOS/ TSF)

By Selamawit Negash, Nutrition Specialist, UNICEF Ethiopia

Selamawit Negash (MPH) has been working as a Nutrition Specialist with UNICEF Ethiopia since April 2007. From December 2005 to March 2007 she worked with WHO Ethiopia as a Supplemental Immunisation Activities (SIA) officer. She was a Nutrition Team Leader in Federal Ministry of Health, Ethiopia from January 2002 to November 2005.

The author would like to acknowledge Sylvie Chamois and Orla O'Neill for their valuable inputs for this article. The author would also like to acknowledge all others who have kindly commented on the draft article.

Disclaimer: the findings, interpretations, and conclusions in this article are those of the author. They do not necessarily represent the views of UNICEF, its Executive Directors, or the countries that they represent and should not be attributed to them.

Ethiopia has one of the highest under five mortality rates of all developing countries, due largely to the combined effect of a high incidence of infectious diseases and inadequate infant and young child nutrition. Results from the 2005 Demographic & Health Survey (DHS) reported the chronic malnutrition rate among children under 5 years (stunting) to be 46% and acute malnutrition (wasting) 11%¹. About 27% of women are malnourished (Body Mass Index (BMI) < 18.5²). Vitamin A deficiency (VAD) is a severe public health problem affecting 30-95% of children 6-59 months of age in all 11 regions of the country³. In addition, food insecurity and poverty remains a threat, as Ethiopia has been exposed to repeated droughts, resulting in chronic food insecurity for the last four decades. Periodic episodes of acute food shortage still occur in many parts of the country and continue to jeopardise the nutritional status of the most vulnerable, especially children. The situation has been described as a constant state of chronic emergency and therefore effective health and nutrition interventions need to address the long-term and periodic emergency needs underlying this complex situation.

A child receiving vitamin A supplements during EOS in Tigray region, Adwa District

Rationale and programme design

The Enhanced Outreach Strategy/Targeted Supplementary Feeding (EOS/TSF) is the first national programme in Ethiopia to link community-based preventive health services with a ration of supplementary food for women and children who are identified as malnourished⁴. It is one of the leading approaches to address child survival and malnutrition and yet its establishment in 2004 was triggered as a response to the acute famine that affected many parts of the country in 2003. It was also introduced as a transition strategy towards the establishment of the Ministry of Health (MOH)'s Health Extension Programme (HEP), which aims to extend primary health care services to meet the population's long term health and nutrition needs at community level.

In 2001/2002, progress had been made to increase the Vitamin A supplementation (VAS) coverage using the opportunity of polio and measles National Immunisation Days. However, coverage was not more than 64% and it included only one dose. The primary objective of EOS was to increase twice yearly VAS coverage that was extremely low. The opportunity was also taken to include deworming to promote normal growth and prevent malnutrition among children under the age of five. Before 2003, moderate acute malnutrition (MAM) was addressed only through blanket supplementary feeding distributed together with food aid in drought affected districts. The introduction of the EOS was seen as an opportunity to target MAM for TSF in a much wider coverage than seen before. However, due to capacity/resources issues, screening for acute malnutrition and TSF were started in 325 drought prone districts only⁵.

Partnership was developed between UNICEF, WFP and the Government of Ethiopia (GoE) under the United Nations Development Assistance Framework (UNDAF, 2007-2011). A memorandum of understanding, signed by Disaster Risk Management and Food Security Sector (DRMFSS), MOH, UNICEF and WFP, outlined the roles and responsibilities of each party. Whilst UNICEF and WFP provide financial resources and technical support, coordination, implementation and management of the EOS/TSF were and remain under the responsibility of the MOH and DRMFSS both at federal and regional levels. See Figure 1 for an illustration of how the EOS/TSF is organised.

Source: UNICEF Ethiopia.
ENCU: Emergency Nutrition Coordination Unit; EOS/TSF: Enhanced Outreach Strategy Targeted Supplementary Feeding; MOH: Ministry of Health; DRMFSS: Disaster Risk Managment and Food Security Sector

Initially, the EOS/TSF target was to cover more than 90% of the 6.8 million children aged 6-59 months old and 1.5 million pregnant and lactating women (PLW) living in 325 drought prone districts. However, there remained an additional 6.4 million children in 299 'non-EOS districts'. These were not covered by EOS/TSF interventions because the districts were not considered as the most vulnerable and 'drought prone'. In 2005, the MOH and partners decided to extend its cover to reach these additional 6.4 million children in the 299 'non-EOS' districts with a package of biannual vitamin A supplementation and deworming only. Nutritional screening and TSF were not included due to resource limitations.

Objectives

The overall objective of the EOS is to reduce mortality and morbidity in children under five by providing low cost, high impact child survival interventions at community level. The specific objectives are:

• In all districts of Ethiopia except Addis Ababa and every 6 months:
  - > 90% of children 6-59 months old are supplemented with high dose vitamin A.
  - > 90% of children 2-5 years old are dewormed.
• In all districts of Ethiopia except Addis Ababa and once a year:
  - > 90% of children 9-23 months old are vaccinated against measles if they have missed routine vaccination.
• In TSF selected districts:
  - > 90% of children 6-59 months old and PLW are screened for malnutrition and referred to TSF when acutely malnourished.

EOS is also used as an opportunity to integrate other interventions, such as measles catch up and follow-up campaigns, tetanus toxoid and polio supplemental immunisation activities, long-lasting insecticide treated nets (ITN) distribution and iodine supplementation. Some of the districts are also using the opportunity to conduct routine Expanded Programme of Immunisation (EPI) outreaches.

EOS activities are part of the Ethiopian government Health Sector Development Plan and one of the sub components in the National Nutrition Programme (NNP)⁶. UNICEF is supporting EOS as per its Country Programme Action Plan (2007-2011) under the output "eighty percent of children and mothers in drought-prone districts receiving high-impact, community health and nutrition services every six months through the EOS". It is also part of the UNDAF Humanitarian Response and Recovery and Food Security sub-component for "improved health and nutrition status of 90% of children and PLW in chronically food-insecure areas through outreach activities".

Modalities of EOS service delivery

Every six months and with UNICEF support, Regional Health Bureaus organise the EOS. Each district that is not a TSF district has one EOS team per sub-district, composed of one health worker and one HEW. These staff mobilise the community to come to the nearest health post on a specific day, the EOS day. On EOS day, the EOS team deworms and supplements with vitamin A all children under five years. In many instances, the Regional Health Bureaus take the opportunity to deliver other essential services, such as measles vaccination, tetanus vaccination, mosquito net distribution, HIV/AIDS prevention, iodine capsules distribution, etc.

In TSF districts, the EOS team is expanded with an additional two health staff, generally one HEW and one support staff, to undertake the screening of children and PLW. Screeners measure the mid-upper arm circumference (MUAC) and check for bilateral oedema. Children and women eligible for TSF are registered in a book and given a TSF ration card. In addition to receiving the TSF ration, children identified with severe acute malnutrition⁷ are also referred to the nearest Therapeutic Feeding Programme (TFP).

Comprehensive social mobilisation is conducted to ensure all eligible children and mothers come to the health post. One team supervisor is assigned to support 3-6 teams. The team supervisors provide all-round support, including management and logistic support, technical support and identify problems and constraints and plan for better performance of next the day.

Two months before the implementation of EOS, training of trainers is given to district/ zonal health managers (coordinators and supervisors) by regional and central facilitators. At the same time, district level micro-plans are prepared. Training of trainers and micro-plans are completed once every year. Two standard formats are provided for easy calculation of the needs, both in terms of operational costs and supplies. One to two weeks before the implementation, service providers (supervisors, health workers, HEWs and support staff) are trained for two days by the district trainers. Training of service providers is given on every round, i.e. every six months. The training is based on the national guideline⁸.

Results

After the introduction of EOS, the service coverage has consistently increased, providing key proven child survival interventions (low cost, high impact interventions) to children and PLW every 6 months. Since the start of the programme, the number of children reached by EOS services has progressively increased (see Figure 2 and Table 1). The EOS programme reached its peak activity level in 2006/2007. Using the EOS approach the programme is now covering the entire country, except Addis Ababa city administration, reaching more than 11 million children every six months.

Another coverage survey was conducted in 2008 to validate EOS coverage data collected through routine administrative systems. This involve gathering household level data on selected indicators such as VAS, deworming and nutritional screening¹¹. It was a cross sectional survey conducted in 42 districts in Oromia, Amhara, SNNPR, Tigray, Somali, Afar and Benishangul Gumuz regions. Six districts from each region were randomly selected and in each district, nine sub-districts were assessed using a 30 by 30 cluster methodology. A total of 900 households with children under five years were assessed.

The results showed that the overall coverage of the EOS campaign was very high and above 80%. It also confirmed that the post-campaign coverage estimates for VAS, deworming, and nutritional screening were not necessarily the same as those found in routine administrative EOS reports (Figure 3).

In addition to achieving high coverage, EOS has been found to be a cost effective strategy for child survival¹². The 'EOS costing study' conducted in 2006 has estimated that the cost per life saved is equivalent to only $58 for Vitamin A, and $228 for integrated interventions including measles. In conclusion, the study found that EOS interventions are extremely cost-effective and a good investment for Ethiopia¹³.

Despite the favourable unit costs of delivering life saving interventions such as VAS and deworming, there is no direct evidence that the EOS/TSF is having a positive impact on mortality reduction and improving the nutritional status of children enrolled in the programme. A meta-analysis of the effectiveness of VAS to control young child morbidity and mortality in developing countries showed that improving the vitamin A status reduces mortality rates by some 23%¹⁴. However, in Ethiopia it is not possible to quantify the impact of EOS because there is no baseline data or case-control study for comparison. A formula developed by Pelletier et al¹⁵ was used to estimate the life saving impact of EOS. Based on this method, it is estimated that 171,000 under five children's death are prevented through the EOS/TSF every year.

Factors contributing to high coverage in the EOS programme

Factors contributing to high coverage in the EOS programme include:

• The specialised training conducted before every round of EOS for health service providers to strengthen capacity. This helps to overcome the high staff turnover in the health system.
• Social mobilisation has been the key effort to get people to attend the EOS centres, and it was central to achieving 90% coverage¹⁶. High community participation, created by public announcement and mobilisation during the screening time, promoted EOS service uptake, which has a knock-on effect in promoting general health service uptake at sub-district level.
• It creates community demand whereby mothers/caregivers appreciate deworming because of a visible immediate effect.
• The EOS programme benefits from the participation of a large number of public health institutions at all administrative levels and of non-governmental organisations (NGOs).
• Its cost effectiveness is proven and a number of donors have been supporting the programme since the start.
• Added EOS services like measles vaccination, ITN distribution and iodine supplementation have contributed to lowering the average cost per person served.
• Successful community mobilisation and demand for the service is attributable to the financial incentives (outreach allowances) provided for the local HEWs and volunteers. About 68% of the total costs of EOS are for outreach allowances¹⁷.

Challenges

Health extension worker assessing the nutritional status of a child using MUAC measurement during EOS in Tigray region, Adwa District

During the course of its implementation, EOS has also encountered some significant challenges:

Poor nutritional screening data quality has been an issue. The Outcome Evaluation Study of the TSF programme in Ethiopia¹⁸ conducted by WFP in 2008 highlighted a very high inclusion error of the TSF beneficiaries screened during the EOS (46% mistakenly admitted into the TSF). Efforts made since to improve the quality of nutrition screening measurements include providing training before every round of EOS, simplification of the screening methodology to reduce risks of error (from a two-stage screening comprising of MUAC and weightfor- height to MUAC only), wide-spread dissemination of posters in local languages, and use of a new MUAC tape with a colour code to both help HEWs understand screening procedures and to increase the beneficiary's awareness of their entitlement. While noting the continuous improvement of screening data quality¹⁹, the Emergency Nutrition Coordination Unit²⁰ still encounters problems with the data retrieved from systematic checks.

Due to poor quality, the EOS screening data cannot be used for trend analysis in the context of nutrition surveillance. While reporting is part of every six monthly EOS refresher training, late data compilation and reporting still occurs.

MOH leadership to manage the logistics need and programme information/data management has been limited. Supply and distribution of resources at national scale is a challenge for all programmes without a MOH National Logistics Master Plan that is still not fully functional.

Except for staff salary and overhead cost, there is no budget allocation from government for EOS programme. The programme is supported by international donors through in kind assistance (vitamin A capsules from the Canadian International Development Agency (CIDA) and the Micronutrient Initiative (MI)), and financial contributions for supplies and operational costs (CIDA, MI, Spanish Government, Australian Aid, UNOCHA, USAID, different national committees for UNICEF, etc.). Donor's funding commitment is usually for one or two rounds so that it is difficult to plan for the longer-term.

Future Direction: EOS transition into the HEP

The Health Extension Programme (HEP) is the long term and sustainable strategy for delivering the child survival and maternal packages under EOS. While the EOS will continue to be implemented, its pilot transition to the HEP was started in 39 selected districts from Amhara, Oromia, Tigray and SNNPR.

Two modalities are envisaged to provide EOS services in the HEP package:

• The first and main mode is the Community Health Days (CHDs) that will be organised by the HEWs on a quarterly basis to allow more frequent identification and early treatment of the malnourished cases. The vitamin A and deworming will continue to be delivered every six months. The CHDs are underway since the end of 2008.
• The second mode would be part of the routine activity at the health post and during home visits by the HEWs, in order to maximise the current 'missed' opportunity and enhance coverage (this has not yet started).

The main rationales for the transition are:

• Creating a mechanism for the sustainable delivery of child survival service packages as part of the HEP by maintaining the current EOS coverage of 90%.
• Giving responsibility to the local distric and sub-district to plan, implement and monitor programmes.
• To help the HEWs to organise and execute the services as part of their regular work and ultimately to increase local ownership and service delivery capacity.

As of now, 170 districts have started implementing CHDs. In 2009, more than 1.3 million children 6-59 months have received VAS and about 800,000 children 24-59 months were dewormed through the CHD modality. In addition, 1.3 million children 6-59 months were screened for acute malnutrition. Post-CHD coverage surveys were conducted in October 2009 in three regions²¹. The preliminary report is showing coverage is ranging from 58% to 73% for VAS²².

Lessons

EOS in conjunction with TSF seems to be a highly relevant action for the local environment. This is partly due to the prevailing critical nutrition and health situation in large areas of the country, where on average 47% of children suffer from chronic malnutrition. For sustainability, the GOE has prepared a plan for EOS transition in HEP with phase by phase exit strategy for EOS. The plan is to be implemented within the MOH's Health Sector Development Plan IV (period 2010-2014). It is important to make sure that the transition is smooth and that the HEP will be able to maintain the current gain in EOS.

Availability of financial incentives associated with EOS has played an important role in the success of EOS. However, there are also concerns regarding the sustainability of its high coverage when the financial incentives are withdrawn. For example, it will be difficult to maintain the high level of engagement of Community Health Workers (that are volunteers) if financial incentives are removed. This will have a negative impact on programme coverage. The reliance on pure volunteerism to support community mobilisation remains a challenge to any community-based programme.

The process of screening children using MUAC instead of weight-for-height has helped to identify more severely malnourished children who are at risk of death. In addition, it makes the task much simpler for the HEWs and reduces risks of error attached to conducting two stage screening (i.e. using both MUAC and weight for height).

The EOS screening should ensure that only acutely malnourished children get access to supplementary feeding. However, the current safeguard mechanisms in EOS/TSF are not enough to adequately prevent distortion²³. In addition, there is no formal appeal process for individuals if they feel that they have been unfairly excluded²⁴. EOS/TSF partners are currently working on improving supervision and monitoring during EOS/CHD screening and conducting intensive community awareness and social mobilisation before, during and after the EOS/CHD screening to mitigate the problem in the short-term. Dialogue is ongoing with Ministry officials and donors to discuss the actions necessary to improve the overall management of MAM in the country. A redesign of nutritional screening and management of MAM is required, both to respond to the immediate need to overcome the high inclusion error²⁵ and to strengthen the programme through establishing appropriate safeguard mechanisms. Re-design should also look to secure wider coverage and use of alternative products for management of MAM.

Ethiopia has achieved encouraging progress in recent years in detecting and managing acute malnutrition through EOS and the expansion of the national TFP. At the same time, there is a growing understanding that it is time to invest in a more comprehensive approach at household and community level to prevent and manage all causes of malnutrition. The Community Based Nutrition programme (CBN) is the first compressive nutrition programme to address some of the immediate, underlining and basic cause of malnutrition in Ethiopia. Started at the end of 2008, CBN is being implemented in 170 districts so far. CBN activities are centred on the Triple-A (assess, analyse, act) approach, which helps parents/caregivers and community members to assess the situation of children and women, analyse causes of the problems and take feasible actions at family and community level. Monthly growth monitoring and promotion is conducted for children under two years, which is the most vulnerable period and when the impact of early childhood malnutrition can be reversed. In all of the CBN districts, services under the EOS package are being delivered as quarterly CHDs. The CBN has established effective referral linkages to the management of acute malnutrition.

In many countries, social security has reduced poverty and inequality by half and more²⁶. There is evidence that social protection in a form of cash transfer has improved the nutritional status of children^27,28,29. While most of the EOS/TSF districts are chronically food insecure, the current management of MAM is not adequately linked with existing food assistance/ food security programmes. Food sharing has been noted in TSF outcome evaluation study conducted by WFP³⁰. It is one of the cultural mechanisms to cope with food insecurity. Therefore, targeting a malnourished child in poor family will not be enough to get the required programme effectiveness. Poor families/ communities need to be targeted for social security programming. One possible way to improve programme effectiveness lies with the possibility of changing the targeting mechanism to include not just anthropometry, but also targeting families of vulnerable children for basic social protection.

For more information, contact: Selamawit Negash, email: snegash@unicef.org

¹Ethiopia Demographic and Health Survey, 2005

²ibid

³National Vitamin A Deficiency Survey Report, Ethiopian Health and Nutrition Research Institute, 2006

⁴Mission Report, Enhanced Outreach Strategy/Targeted Supplementary Food for Child Survival Interventions, Ethiopia, Andrew Hall and Tanya Khara, November- December 2006

⁵In 2008, the number of TSF districts reduced from 325 to 167 due to resource constraints.

⁶The NNP is a long-term programme that will be imple mented in two phases for the next 10 years, each phase lasting five years. The current NNP phase I spanning from July 2008 to June 2013. The NNP targets the most vulnerable i.e. under 5 year children, particularly those under 2 years, PLW, and adolescents. The objective of the NNP is to halve malnutrition from 1990 levels (underweight in children under 5y) by 2015 that constitutes the non-income target of the MDG 1. It also explicitly aims to reduce child stunting, wasting, and low birth weight rates by half by 2010, to which the NNP will contribute as an integral part of the HEP.

⁷Eligibility for TFP: children with MUAC < 11 cm and/or bilateral oedema.

⁸Guidelines, Enhanced Outreach Strategy for Child Survival Interventions, Ethiopia, Federal Ministry of Health, March 2006

⁹Bale, Borena, Guji, East Showa and Arsi zones of Oromia region, North Wollo, SouthWollo and Waghimra zones of Amhara region, all districts of Tigray region, all districts of B. Gumuz region, all districts of Somali region and Gurage, Wolayita, Dauro, Siltie, Hadiya, Kembata Tembaro zones and Konta, Alaba districts, and Awassa, SNNPR.

¹⁰Coverage Survey Report on Integrated Child Survival Interventions In Oromia, Amhara, SNNPR, Tigray, Somali and Benishangul Gumuz National Regional States of Ethiopia, UNICEF Addis Ababa, December 2006

¹¹Post campaign Evaluation Survey of round 1 2008 Enhanced Outreach Strategy in Ethiopia, Addis .Continental Institute of Public Health, October 2008

¹²Feedler, J. and Chuko, T. 2006. Enhanced Outreach Strategy Costing Study. Micronutrient Initiative, A2Z, World Bank, UNICEF

¹³The Macroeconomic Commission on Health classifies all health interventions that have a cost per life saved that is the equivalent of less than per capita GDP as "highly costeffective".

¹⁴Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC, and Harvey B - Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries; ACC/SCN State-ofthe- Art Series, Nutrition Policy Discussion Paper No.13, 1993

¹⁵Pelletier, DL, E.A. Fongillo, Jr., D.G. Schroeder, and J.P. Habitch. 1994. A methodology for estimating the contribution of malnutrition to child mortality in developing countries. Journal of Nutrition 124 (10 SUPPL.): 2106s-2122s

¹⁶Mission Report, Enhanced Outreach Strategy/Targeted Supplementary Food for Child Survival Interventions, Ethiopia, Andrew Hall and Tanya Khara, November- December 2006

¹⁷Feedler, J. and Chuko, T. 2006. Costing Study. Enhanced Outreach Strategy, Micronutrient Initiative, A2Z, World Bank, UNICEF

¹⁸Outcome evaluation study of the Targeted Supplementary Food (TSF) programme in Ethiopia; World Food Programme; Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MD MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH.

¹⁹The ENCU checks show regular decreases in the proportion of districts with unreliable screening data. Those with unreliable data amounted to 48% in 2008 Round 1, 44% in 2008 Round 2, and 47% in 2009 Round 1, 27 % in 2009 Round 2.

²⁰The Emergency Nutrition Coordination Unit (ENCU), which is the technical arm of Disaster Management and Food Security Sector (DMFSS), with the support of UNICEF, was established in 2000 to coordinate emergency nutrition assessments and interventions. ENCU is doing quality check for EOS nutritional screening data.

²¹1,391 children sampled in 1,103 households in Tigray, Oromia and SNNPR less than 2 weeks after the CHD

²²The proportion of VA supplementation was 73.3% in SNNP 51.9% in Tigray 62.9% in Oromia Regions. The proportion of children de-wormed was 65.8% in SNNP, 35.4% Tigray and 52.4% in Oromia regions. The proportion of screened children was higher 89.4% in Tigray, 73.5% in Oromia and 66.6% in SNNP Regions

²³Aid, Accountabilities and Distortion, An exploratory study into possible distortion in donor-supported development programmes in Ethiopia, Productive Safety Nets Programme; Protection of Basic Services Grant; Humanitarian Relief Programme; Enhanced Outreach Strategy - Targeted Supplementary Feeding Programme, Report prepared by DFID on behalf of, and for the consideration of, the Development Assistance Group, Ethiopia, 23rd March 2010

²⁴ibid

²⁵Outcome evaluation study of the Targeted Supplementary Food (TSF) programme in Ethiopia; World Food Programme; Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MD MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH. The ENCU checks show regular decreases in the proportion of districts with unreliable screening data: it was 48 per cent in 2008 Round 1; 44 per cent in 2008 Round 2; 47 per cent in 2009 Round 1 and 27 per cent in 2009 Round 2.

²⁶International Labour Office, 'Can Low income countries afford Basic Social Security?', Social Security Policy Briefing, no.3 ILO, Social Security Department, Geneva, 2008.

²⁷Rutstein S. O, Effects of preceding birth Intervals on neonatal, infants and under five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. International Journal of Gynecology anad Obstetrics, Vol.89, Supplement 1, April 2005, PP S7-S24.

²⁸Erhlich, Isaac and Jinyoung Kim, 'Has Social security Influenced Family Formation and fertility in OECD Countries? An Economic and Econometric analysis'', NBER Working Paper no. 12869, National Bureau of Economic Research, Cambridge, MA, January 2007

²⁹Boldrin Michele, Mariacristina De nardi and Larry Jones, 'Fertility and Social Security', NBER Working Paper no. 11146, National Bureau of Economic Research, Cambridge, MA, February 2005.

³⁰Outcome evaluation study of the Targeted Supplementary Food (TSF) programme in Ethiopia; World Food Programme; Ethiopia; June 2009; Jutta Skau, MSc; Tefera Belachew, MD MSc; Tsinuel Girma, MD; Bradley A. Woodruff, MD MPH.