From the editor

Ethiopia is a diverse country where a significant proportion of the population live on or below the poverty line, where food insecurity is widespread and rates of acute malnutrition are often at or above the international threshold that defines an emergency situation. Levels of chronic malnutrition are also high. Food and nutrition crises arising from the effects of drought, floods, market fluctuations and, at times, political instability are frequently faced. The challenges today are enormous but over the past 25 years, the Government of Ethiopia (GoE), with the technical support and budgetary assistance of many donors, UN agencies, non-governmental organisations and institutions has developed an impressive array of national nutrition, food security, livelihoods and health related policies, programmes and systems. These are driving nutrition and food security improvements and should ensure that the massive loss of lives and livelihoods seen at the height of the famine in the mid-1980s, doesn't arise again.

This 40th issue of Field Exchange (FEX) shines a spotlight on this immense progress in Ethiopia, 25 years on from the mid-1980s crisis. It contains six agency/programming profiles and twenty field articles written by national and international actors about nutrition and food security related programming. The profiles and articles provide insights into some of the key nutrition and food security/livelihoods related structures and programmes in Ethiopia, covering early warning, response, recovery and longer-term programming.

Government agencies and structures

The first profile is on the government's Early Warning System (EWS). Written by Kassahun Bedada Beyi, it plots the EWS evolution from an ad-hoc system in the 1970s, to a highly centralised, somewhat cumbersome system with minimal community involvement in the 1980s to the current system which is highly decentralised and takes account of local early warning knowledge. Ethiopia's EWS, as with many emergency prone country experiences, is not without its problems. It will no doubt continue to evolve as it manages complex data and strives to strengthen its communication channels and to ensure timely and appropriate responses in areas of the country exposed to acute food and nutrition insecurity.

Institutionally linked to the government's EWS is the well-established Emergency Nutrition Coordination Unit (ENCU). Isaack Manyama and colleagues describe the unit's growing mandate since its inception in 2000, at which time the quality and coordination of nutrition surveys in Ethiopia was severely constrained and links to the EWS were minimal. The ENCU has seen considerable expansion since 2005 and today, it is mandated to coordinate, quality assure and disseminate emergency nutrition assessments as well as to coordinate nutrition cluster activities, strengthen EWS capacity and related operational research in Ethiopia.

The ENCU is possibly one of a very few dedicated units of its type in sub-Saharan Africa and has a considerable wealth of experience and knowledge of coordinating many agencies concerned with nutrition assessment and response. Interestingly, since its inception, over 600 nutrition surveys have been carried out in Ethiopia, which, when the logistics and related costs are taken into account, raises questions about the relative merits of cross-sectional surveys in contrast to a nutrition surveillance system.

Another key national structure is the Ethiopian Health and Nutrition Research Institute (EHNRI) which has considerable experience of working at the 'coal face' of nutrition related problems in Ethiopia. With over 450 staff, the EHNRI has (among many responsibilities), the mandate to support the government with implementation of the National Nutrition Programme (NNP) providing analysis of the magnitude and determinants of malnutrition in Ethiopia, capacity mapping for implementing the NNP and undertaking operational research. It's most recent national survey work confirms the need to focus on the determinants of undernutrition in the under 2 year age group, the target group for the NNP, along with women of reproductive age.

The existence of the EHNRI gives Ethiopia a unique 'home grown' capacity to drive the NNP and, arguably, enables government to have a self-determined dialogue with the myriad of donors and agencies that operate in Ethiopia. This is not to suggest that Ethiopia has all the nutrition capacity it needs to implement its programmes. As the article written by Aweke Yilma from Hawassa University highlights, the need for teaching/faculty staff to be trained in nutrition so that they in turn can expand the existing nurse and midwifery undergraduate training curricula to include nutrition is highlighted as a significant need. The need for pre-service training on nutrition is likely to be an issue in many of Ethiopia's universities and training institutions and, where efforts are made to upgrade faculty staff knowledge and skills. As described in the article written by Kate Sadler and Elizabeth N Bontrager from Tufts University, this offers a clear way forward for building capacity in nutrition among Ethiopia's key graduates.

Local NGOs and church-based agencies

The article by the REST Mekelle Team from Ethiopia's largest home-grown NGO, the Relief Society of Tigray (REST) provides an insight into the evolution of a relatively small organisation, which started out in the 1970s working with drought affected Tigrayan's, to the organisation it is today - 700 staff strong, commanding a multi-million dollar budget and working in both emergency and long-term programming. This article describes REST's approach to the implementation of the large-scale Productive Safety Nets Programme (PSNP) and the impact of the PSNP on levels of wasting and stunting, on dietary diversity and on household food security - all of which reportedly showed improvement over a 3 year period. Whilst nutrition is not a specific technical competence of REST staff, it is interesting to note the concerted efforts made to try and capture nutrition impact in their work.

Two profiles reflect the work of two of the largest church based organisations in Ethiopia - the Ethiopian Orthodox Church Development and Inter- Church Aid Commission by Gebreselassie Atsbahha and the Ethiopian Evangelical Church Mekane Yesus, by Deed Jaldessa and Debela Kenea. Both highlight the considerable community reach and resources of the Church in mounting emergency responses and in longer term programming. What is interesting, is how these Church groups have formed dedicated departments for overseeing their humanitarian and development programming. They are increasingly closely aligned to government policies and priorities and are able to help fill gaps in responding to food security crises, largely through food aid distributions. A gap identified by both groups in these articles is their lack of nutrition capacity, which they are aiming to address in the future.

Ethiopia's history of large scale emergencies has meant that many international agencies have worked in Ethiopia for 20 to 30 years or more. These agencies have therefore been afforded the opportunity to implement numerous relief and/or development programmes and to refine approaches as lessons have been learnt. Many of the articles in this issue of Field Exchange therefore reflect lesson learning amongst agencies over a significant period of time.

Emergency assessments

There are three articles on emergency assessment. The first, by Zeine Muzeiyn and Ewnetu Yohannes describes the work undertaken in Goal's Early Warning Department involving field based assessments in so called 'hot spot' woredas (districts) identified by the GoE's ENCU and how this information fits into decision making and response. Between August 2005 and June 2010, GOAL Ethiopia conducted 60 nutrition surveys and intervened in approximately 95% of woreda's with an identified need. GOAL's nutrition survey staff carry out surveys with government staff at woreda and regional level in order to build their capacity in planning and conducting surveys, analysing data and report writing.

Aldei Yimam (male, 20 months) has been in and out of SFP and OTP on five occasions (Gelsha kebele)

The second article dealing with assessment is by Patrizia Fracassi. This article provides a personal view of the strengths and weaknesses of the country's nutrition information system, as well as a vision for the future.

The third article by Alison Oman from UNHCR describes the agency's joint assessment mission (JAM) process with WFP for refugees and how this has evolved since the mid-1990s. This article draws heavily on the experiences of implementing JAM's in Ethiopian refugee camps and shows the wide range of information gathered in an assessment, e.g. food security and coping strategies, logistics, non-food items, market prices, health, nutrition and the environment. The process of consensus building is key as it not only encourages assessment from a multisectoral viewpoint, but also ensures that the recommendations reflect the capacities and expertise of the agencies involved.

Addressing moderate acute malnutrition

Supplementary feeding programmes (SFPs) are the subject of three articles. The first article by Jutta Neitzel from WFP describes the national targeted supplementary feeding (TSF) programme implemented by the GoE and WFP which is part of the government's Extended Outreach Strategy (EOS). Initially, the TSF covered 325 woredas when established in 2004, but due to soaring food prices as well as diminished donor support in early 2008, the programme had to be downscaled so that today, it only covers 168 priority woredas and approximately one million children. The TSF has a fairly unique design for the TSF in that food distributions only take place every three months and there are no anthropometric measurements of children between distributions. A TSF evaluation study conducted in 2008 found limited impact (on mid-upper arm circumference (MUAC)), largely due to food sharing at home and high inclusion error. The programme also encountered a number of challenges including logistical problems in more inaccessible areas of the country, delayed communication of screening results and weak linkages with other programmes.

The second article by Selamawit Negash from UNICEF describes the national Enhanced Outreach Strategy (EOS) programme, which links health extension services and staff (HEW's) and services with the TSF. The GoE and implementing partners have achieved extraordinary coverage with the EOS. During the second round 2009 EOS activity, 11.5 million children aged 6-59 months were supplemented with Vitamin A and 7 million children between 24-59 months were de-wormed. In addition, 3.9 million children and 820,000 pregnant and lactating women (PLW) were screened for acute malnutrition. Out of these, 318,000 children and 150,000 PLW were found to be malnourished and referred to TSF and out-patient therapeutic feeding (OTP) respectively A number of factors that have contributed to the high coverage of the EOS are described: the frequent specialised training of HEW's to strengthen their capacity for social mobilisation, the participation of a large number of public health institutions and participation of NGOs. Successful community mobilisation and demand for EOS services are partly attributed to the financial incentives (per diems) provided for the local HEWs and volunteers. Almost 70% of the total EOS budget is expended on per diems.

Hayat Seid, female, 29 months, has been in and out of OTP and SFP five times

The third article on SFP's has been written by Sarah Style from Concern Worldwide. In 2008, an area classified as a 'hot spot' due to failure of the short belg rains, resulted in Concern Ethiopia initiating a TSF programme which has been continuously operational since then. However, rates of wasting in the woreda have remained relatively un-changed. The TSF programme, although well implemented as evidenced by high coverage rates, has poor recovery rates and high re-admission rates, (2009 recovery rate 27%, non-recovery rate 59%, re-admission rate 57%). Investigations suggest that an inadequate general ration, lack of access to the PSNP as well as climatic and topographical constraints, the health environment and poor caring practices, are key factors limiting effectiveness. Linkages with the general food distribution (GFD) is limited and the impossibility of registering the whole population for the PSNP and GFD means that sharing of the supplementary food amongst non-beneficiary children is commonplace. The author concludes that improvements in rates of wasting in this context might be beyond the scope and capacity of nutrition interventions such as SFP's. Such limitations with traditional approaches to the prevention and treatment of moderate acute malnutrition are the subject of considerable work internationally.

Addressing severe acute malnutrition

There are three articles on the implementation of programmes to treat severe acute malnutrition (SAM), a research piece sharing work on the impact of emotional stimulation on SAM outcomes, and a further article on the challenges of securing affordable ready to use therapeutic foods (RUTF). Sylvie Chamois from UNICEF Ethiopia describes the impressive scale up of the GoE OTP to over 6,400 health posts (at the time of writing) in 691 woredas. The article describes how scale up was achieved and key challenges faced. The enabling factors identified for scale up included advocacy and coordination, donor support, development of regional action plans, technical assistance for training and follow up, provision of supply and logistics support and enhanced programme monitoring and quality assurance. Ensuring good programme monitoring and quality proved to be particularly challenging with the rapid multiplication of OTP sites.

The vast majority of OTP sites are achieving SPHERE standards and UNICEF considers that there have been a number of important contributory factors to the success of this programme. Particularly noteworthy are the GoE's commitment to develop policies and guidelines on decentralised treatment of SAM and to integrate services into the wider decentralised health programme, advocacy by agencies such as UNICEF, high educational levels, technical skills and commitment amongst programme staff working within the health sector and enhanced coordination between the key actors.

Another article written by Sisay Sinamo describes the World Vision Ethiopia (WVE) programme for treatment of SAM (called Community Therapeutic Care (CTC) at the time), between 2005 and 2007. Lessons learnt were then used to inform the design of a subsequent programme in 2009 with h had a more 'hands-off' approach. In the 2009 programme, WVE staff focused on capacity building of partners rather than direct implementation. This was described as a 'minimum support' approach. In addition, WVE supplied a protection ration for children discharged from the OTP, as it could not be assumed that these children would be enrolled on the TSF programme.

Emily Mates from Concern Worldwide describes the history of Concern's programme that evolved from an innovative emergency intervention, into a longer-term initiative aimed at supporting the Ministry of Health (MoH) to integrate treatment services for SAM within the routine health system - the National CMAM (N-CMAM) programme. The N-CMAM team assisted the MoH in selected areas of four regions (Oromia, Tigray, SNNP and Amhara). The approach used a process of incremental capacity building from the outset to ensure that the ownership of the programme was always firmly in the hands of the MoH. Concern provided a minimal support package of theoretical and practical training in OTP and in-patient SAM case management, as well as joint supportive supervision and follow-up community mobilisation mapping and facilitation of regular dissemination workshops to facilitate sharing of experiences.

A number of key factors promoted an enabling environment within which the N-CMAM programme could achieve its objectives, e.g. continuous and sufficient funding from July 2005, and a strong focus on training of the N-CMAM team in how to support partner staff rather than directly implement programmes. Numerous lessons have been learnt from the experience, e.g. the length of time that the process of integration requires and the importance of using both formal and informal channels of communication and networking to muster influence.

Women work in tree and fodder nurseries as part of the cash for work scheme

An article by Play Therapy Action describes early findings from a study to explore impact of introducing emotional stimulation and good parenting skills, in addition to emergency therapeutic food distribution, for SAM children. Investigated in 47 outreach therapeutic sites and one hospital in the SNNP Region, preliminary results found faster weight gain, less developmental damage of the acute malnutrition 'event', and positive 'knock on' effects of the interventions on care of other children, on the mother's mental well-being and her empowerment, and on family life.

An article by Yuki Isogai from the World Bank (WB) outlines how the cost of treating the severely and moderately malnourished in Ethiopia is 'too high' as a large share of the feeding products, i.e. RUTF and CSB, have to be imported from abroad. She poses the question-'why hasn't the private sector stepped in to fill the local supply gap'? The WB Ethiopian Nutrition Team conducted a thorough review of this question and identified three major issues, which are interlinked with each other: lack of market information, low access to finance; and weak value chain. The author argues that the problems affecting the whole value chain need to be tackled simultaneously if a solution is to be found. To do this will requires a strong public private partnership involving private companies, commercial banks, farms, NGOs, UN agencies and donors.

Reaching pastoralists and livelihood programmes

Two field articles specifically focus on pastoralists, who represent a significant minority in Ethiopia. Dr Abay Bekele writes about Oxfam UK's Somaliland- Ethiopia cross-border programme. At the heart of the programme is a concern to build strong, representative pastoral organisations, through which pastoralists can better understand and claim their rights and manage the development services they need. Principle aims include improved institutional capacity for drought preparedness linked to enhanced community preparedness capacity, and improved integrated natural resource management to ensure increased access to and availability of pasture, fodder and water so that households can preserve their assets. A key lesson from the early phases of the project is that the focus of pastoralist interventions should be to strengthen the community and risk reduction strategies, rather than simply fill material gaps through resource provision.

Save the Children (UK) has been providing support to pastoral communities in Ethiopia for almost 20 years with current programmes in the Somali and Afar regions. The PILLAR project, which is described in the article by Holly Welcome Radice and colleagues, seeks to contribute to community level drought risk reduction focusing on the three pillars of pastoralism - people, livestock and natural resources. The article focuses on the project's impact on the lives of children. Children belonging to families involved in water point construction, small scale irrigation and income generating activity micro-projects reported that they had more time for leisure and more time with their parents. They also spent less time on chores and attended school more regularly.

There are five articles written about programmes aimed at supporting the livelihoods of farmers in Ethiopia, which include market based analyses for high value commodities. The first of these is by Andrew Simmons who writes about the Food for the Hungry (FFH) Market-led Livelihood Recovery and Enhancement Programme (MLREP). This programme aims to improve the food and livelihood security status of smallholders in SNNP region. The programme targets PSNP beneficiaries to help them build assets and graduate from the PSNP programme. The approach involves building upon and integrating livelihood components identified following the results of a value chain analysis (VCA) study. The analysis provides the answer to the question, 'which commodity should be pushed further in terms of ease of access to input and output markets? After the completion of the first year of the MLREP, initial benefits were seen at the household level in terms of income generation. However, there was no obvious evidence that this increased income was being put to use to improve the nutrition and health outcomes of the most vulnerable members of the family.

An article by Todd Flower from Mercy Corps describes the Revitalising Agricultural/pastoral Incomes and New markets (RAIN) programme - a multimillion dollar OFDA/USAID funded programme being implemented for three years (2009 to 2012) in zones in the Oromia Region with four bordering zones of the Somali Region. RAIN seeks to protect, promote, and diversify livelihoods as a means of increasing households' resilience to shocks. The RAIN programme focuses on market systems and provides support by creating linkages between various market participants. In the first year of the programme, several value chains were identified and evaluated including live animals, hides and skins, milk, fruits and vegetables, and peanuts. The RAIN programme works to improve access to agricultural input supplies to assist producers in meeting available market demand.

Another article by Shekar Arnand from Oxfam describes the emergency and food security livelihoods (EFSL) project which is part of the Global Agricultural Scale up (GASU) initiative started by Oxfam four years ago. The GSAU programme in Ethiopia has worked with farmers on many crops. It has now been decided to use a scalable model for three commodities, honey, coffee and sesame. These have also been identified by the GoE as high value export crops.

The EFSL component arose out of Oxfam's awareness that their target farmers are often exposed to emergencies caused by drought, flood, market turbulence and climate change. The idea is therefore to embed a humanitarian response programme within the programme to prevent farmers from falling into 'the poverty trap'. The EFSL project aims 'to protect those farmers that are vulnerable to impact of drought and other shocks'. Key lessons learnt so far from the EFSL include the understanding that asset poor households are less able to apply resource management practices and that the onset of natural disasters presents new business opportunities for microfinance institutions (MFI) especially in rural areas.

An article by Antoinette Powell describes Christian Aids (CA's) response to a series of emergencies and subsequent work with implementing partners to rebuild lives and livelihoods and strengthen disaster preparedness. Christian Aid works through a range of implementing partners with some of the most marginalised communities in Ethiopia, including pastoralist communities in the country's south and farmers in SNNP region. Concern about the effects of climate change has recently prompted Christian Aid to fund one of its partners, Citizens Solidarity for the Campaign Against Famine in Ethiopia (CS-CAFÉ),to carry out a study on climate change.

The article written by Mulugeta Wtsadik from UNHCR describes a multi-story gardens (MSG) programme in refugee camps for Eritreans and Somalis. Mulugeta outlines how a pilot MSG programme was established in three camps to address problems of anaemia and to compensate for a WFP ration considered inadequate in terms of micronutrients like iron and zinc. The pilot project began in April 2008 and has had a significant impact on the diversity of foods available to beneficiary households - particularly in terms of fruits and vegetables. Water shortages have been the main problem with the programme, although various methods have been employed to conserve scarce water in the more arid camps.

Large-scale safety net programming

After many years of implementing food relief programmes through the old Employment Generation Scheme (EGS), implementing partners reached a view that there had to be a better way of meeting transient emergency needs. The EGS activities were poorly managed and ultimately unproductive so that recipients rarely graduated to any level of food security and remained dependent on annual food relief packages. The advent of the PSNP in 2005 was a reflection of this learning. The vision for the PSNP, which uses food and/or cash as a resource transfer, was to use resources more imaginatively to help build up productive assets and so enable beneficiaries to graduate out of structural poverty and chronic food insecurity. The multiannual and multi-donor commitment to this programme reflects this vision.

An article on the PSNP by Matt Hobson and Sarah Coll-Black from the World Bank describes how the PSNP has developed over the last 5 years, its achievements and major challenges.

By 2009, the PSNP supported 7.6 million people in 290 chronically food insecure woredas in eight of the country's 10 regions. This demonstrates that large scale cash and/or food transfers are operationally and logistically possible in resource-poor, low-income rural settings. However, between 2007 and 2009, only around 280,000 individuals graduated from the PSNP, which although not insignificant (especially given the adverse events of 2008), falls well short of the national goal. Deficiencies in implementation, due to limited human and physical capacity, undermine the potential impact of the PSNP, while ensuring quality implementation in all programme areas remains a significant challenge for the future.

An article by Alix Carter from CARE Ethiopia describes the Joint Emergency Operation Plan (JEOP) which has existed in different iterations since 1984. JEOP targets food insecure households who are not covered though the PSNP. It thus provides a complementary intervention to prevent acute food shortages from depleting overall community progress gained through PSNP.The JEOP is activated in close collaboration with the GoE when chronic food insecurity is exacerbated by emergency shocks, requiring additional coverage of emergency food relief. The partnership was re-activated in 2000 under its current form with five member international NGOs. More recently, REST and SC-UK have joined. As a result of recurrent shocks, JEOP has been operational in seven of the last ten years, providing one third of all emergency food relief in Ethiopia to an average of 1.8 million beneficiaries at each round.

A major challenge for the JEOP is delays and changes in allocation of food aid figures to partner agencies' caused, in large measure, by communication and capacity gaps between or at different levels of Government. Another difficulty is the arrival of huge shipments of commodities to ports and warehouses, creating congestion and difficulty for partners to secure enough space for their commodity storage. In addition, secondary transport to distribution sites has proven difficult for some JEOP partners and different strategies have been used to overcome these problems. In the Extended JEOP, partner agencies are considering options for a pooled transport system that could circumvent these logistical issues in the future.

Concluding remarks

The articles in this special issue of Field Exchange show clearly how a range of actors are playing a vital role in testing and developing new and more effective programming approaches, disseminating findings and then advocating for adoption and scale up of evidence based programming to address acute malnutrition, food insecurity and support more sustainable livelihoods in Ethiopia. There is a strong commitment by GoE to invest in scaled up programming. The two best examples are the scale up of the OTP and the PSNP.

The GoE has also proven itself over many years to be 'fiercely independent' of international agencies. Its emergency and development philosophy with respect to external actors is very much along the lines of 'work with us, help us to develop the capacity to implement programming and then leave us alone to do it'. Most international agencies working in Ethiopia have embraced this and invest considerable resources in building national capacity. This can only bode well for Ethiopia and its capacity to prepare, respond and recover from emergencies in the future. There are, however, as highlighted in some the articles in this issue, risks associated with rapid scale up where the demands for implementing 'best-practice' and high quality programmes can outstrip capacity for delivery. This is a challenge facing many countries, not only Ethiopia, and will be the subject of international focus as the international Scaling up Nutrition (SUN) initiative gets underway.

The extent to which programmes are joined up, coherent and integrated to maximise nutritional objectives is a challenge. For example, SFPs will not be effective if general rations or basic food security is inadequate and integrating the TSF with OTP, or PSNP with TSF/OTP households, need to be fully grasped. There are also a number of specific challenges for GoE and its implementing partners. For example, scale up of local production of RUTF for the treatment of SAM and the need to bring prices down so that the current roll out of OTP and TFP can be sustained. Another challenge relates to the large case load of MAM in Ethiopia. It is widely acknowledged both within and outside of Ethiopia that the current TSF is not a panacea and that much work needs to be done to develop an evidenced MAM strategy, underpinned by a clear implementation plan to reach the large number of MAM population affected.

Despite these challenges, Ethiopia appears, with minimal publicity and fuss, to have manoeuvred itself away from being the country which, in many previous years grabbed the international humanitarian spotlight as a result of drought and famine. Sadly, other countries have taken its place. The good news is that famine early warning and response systems in Ethiopia have been considerably strengthened through many years of programme implementation and learning.

This issue of Field Exchange has tried to capture the array of national and international policies, programmes and systems that have been put in place to drive nutrition and food security developments in Ethiopia. Many of these developments have been adapted from international policies and evidencebased good practice in key areas of nutrition, as well as from lessons learnt from within Ethiopia on what does and doesn't work within the country's specific political, socio-economic and cultural context. There is much to learn from this experience and we hope that this special issue of Field Exchange plays some small part in disseminating the many lessons learned by the GoE and the myriad of national and international actors involved in humanitarian work in Ethiopia.

Jeremy Shoham, Editor
Carmel Dolan, Guest editor