The Emergency Nutrition Coordination Unit of Ethiopia roles, responsibilities and achievements

By Isaack B. Manyama, Gugsa Abate and Mathewos Tamiru

Isaack B. Manyama is ENCU Team Leader and Nutrition Cluster Coordinator for Ethiopia

Gugsa Abate is Nutrition Specialist at the ENCU

Mathewos Tamiru is Information Analyst at the ENCU

The Emergency Nutrition Coordination Unit (ENCU) is located in the Disaster Risk Management and Food Security Sector (DRMFSS), Ministry of Agriculture and Rural Development, Ethiopia.

The history of the Emergency Nutrition Coordination Unit (ENCU) can be divided into two five-year phases: Phase One, the inception phase (2000- 2005) and Phase Two, the expansion phase (2005-2010).

Inception Phase (2000-2005)

Recurrent drought has been a key feature of Ethiopian life for several decades leading to widespread crop and pasture failure and periodic severe humanitarian crises. In response, Ethiopia has carried out numerous seasonal needs and nutrition assessments and programme activities. Initially, the nutrition assessments were characterised by a lack of national level standardisation and coordination, leading to duplication and misguided allocation of resources. In the year 2000, for example, a study into the quality of nutrition surveys in Ethiopia¹ found that only five percent of the 200 nutrition surveys conducted over a 7 year period were of acceptable quality. As a result, the ENCU was established in November 2000 within the Early Warning Department (EWD) of the then DPPA (Disaster Preparedness and Prevention Agency now Disaster Risk Management and Food Security Sector (DRMFSS) under the Ministry of Agriculture. At its inception, the ENCU was funded by WFP and later by UNICEF. Since then, ENCU's routine activities continue to be funded by UNICEF, while staff costs have interchangeably been funded by both agencies.

At the time of inception, the ENCU was charged with fulfilling three major functions:

1. Coordination of emergency nutrition assessments, quality assurance and responses. A total of 266 surveys were coordinated by the ENCU during the first phase.
2. Establishment of a Multi-Agency Nutrition Task Force (MANTF) for coordination, information sharing and discussion of technical issues among nutrition partners working in Ethiopia. The MANTF forum was established and is operational to date.
3. Collection and collation of reports and results of nutrition surveys conducted throughout the country and nutrition information database. The Nutrition data base was established in 2005 and regularly updated since then.

Standardisation and harmonisation of emergency assessments and response was not among the major functions of the ENCU at inception. However the ENCU coordinated the development of the National Emergency Nutrition Assessment guideline in 2002, which aimed to standardise emergency nutrition assessments in Ethiopia. In 2004, emergency nutrition intervention guidelines were developed to harmonise and standardise implementation and management of nutrition programmes.

Expansion Phase (2005-2010)

By 2005, it was evident amongst partners and government that ENCU had played a significant role in coordination of emergency nutrition assessments and response and therefore, its mandate and functions at federal level were expanded. In order to fulfil its extended role, staffing also increased from one to four staff (one team leader, one nutrition specialist, one information analyst and one administrative assistant). In the second half of 2006, regional level ENCUs (R-ENCU) were established in five drought-prone regions (SNNP, Tigray, Amhara, Oromia and Somali) as part of strengthening the early warning system and coordination of emergency nutrition response. Each R-ENCU is integrated within the Food Security, Disaster Prevention and Preparedness (FSDPP) of the respective region. All the five RENCUs are fully operational, with two staff: an information analyst and nutrition expert. The expansion of the ENCU at regional level was supported by UNICEF with funding from the European Commission until 2009, when UNICEF took over. The establishment of a RENCU in Afar region is currently in progress.

Following the roll out of the Nutrition Cluster approach at national level in 2007, the ENCU mandate again expanded to include coordination of Nutrition Cluster activities. In addition, to its previous roles on coordination and quality assurance of emergency nutrition assessments, information management and dissemination, and coordination amongst partners, the ENCU has assumed three new functions:

• Capacity strengthening of early warning system at federal and regional levels
• Coordination of Nutrition Cluster activities
• Coordination of operational research on emergency nutrition assessments.

The functions of the ENCU are described in greater detail below.

Coordination and quality assurance of emergency nutrition assessments and response

Analysis of the nutrition situation

The nutrition situation in Ethiopia is monitored by analysing admission trends of new severe acute malnutrition cases in Therapeutic Feeding Programme (TFP), analysing nutrition related early warning data and information systems received from woreda (district), regional and national level. Depending on the situation, emergency nutrition surveys (baseline, monitoring or end-line) are conducted based on the existing national guidelines to ascertain the situation and recommend appropriate responses. The nutrition situation is also monitored through updating the woredas identified as 'hotspot woredas' based on pre-agreed criteria. The 'hotspot woreda' update is undertaken as a consultative process carried out at the regional and federal level. A guideline has been developed to standardise the classification/ update process, which enables key actors to prioritise areas requiring particular focus. The ENCU plays a key role in provision of nutrition information used during the classification process as well as coordination and sharing of the hotspot list with nutrition cluster partners after approval of the DRMFSS.

The Government also conducts bi-annual food security assessments, and monthly new TFP admissions are summarised in addition to the routine TFP admission trend analysis outlined above. Unusual increases in TFP admissions in March to May period informs the DRMFSS EWS and partners of a likely worsening nutrition situation in the forthcoming 'hunger period' (from June to August in agrarian communities²). The DRMFSS/ENCU triangulates the TFP data and survey results with other food security information and provides an estimate of the anticipated prevalence of malnutrition in the respective assessment period. This level of prevalence is applied to the estimated total number of rural under-five children (usually 14.5%³ of the rural population) Table 1: Number of nutrition surveys conducted in Ethiopia by region, 2000-2010 from the woredas requiring humanitarian assistance. Based on this analysis, beneficiaries needing either therapeutic or supplementary feeding are estimated for the period covered by the Humanitarian Requirement Document (HRD) issued by the Ethiopian Government.

Quality assurance of standard surveys

All nutrition survey proposals are approved by the ENCU before they are undertaken. Partners planning to conduct emergency nutrition assessment are required to prepare a survey proposal and submit this for review and validation. The proposal is reviewed in terms of objective/rationale, methodology, planned analysis and how the survey will be organised in the field. In the process, partners' capacity is assessed and if deemed to be low, consideration is given for alternative or additional partners to conduct the assessment. After the review is complete, written feedback is provided to the respective partner. Since March 2006, all surveys have been planned, implemented and analyzed using SMART methodology and Emergency Nutrition Assessment (ENA) software (2007 version).

Upon completion of the survey, partners are required to submit the raw data to Federal ENCU for quality checks. The data is scrutinised according to agreed criteria along with respective preliminary reports before the report is shared with government and partners. A total of 237 nutrition surveys were carried out based on the SMART⁴ methodology between 2006 and 2010 and checked by ENCU. So far, only 10 surveys have been rejected because of poor data quality. The remaining 227 surveys' findings have been published in the ENCU quarterly bulletin of emergency nutrition and posted in the DRMFSS web site: www.dppc.gov.et/ pages/ENCU.htm. Preliminary reports of the respective surveys are reviewed in terms of content and interpretation and are cross-checked with recommended reporting format. They are also checked to ensure that conclusions, recommendations and classification of the nutrition situation are coherent and consistent with information based on anthropometric and contextual factors (for example, water and sanitation, food security and health related indicators).

Feedback is provided to the respective partner on the quality status of their survey. It is important to note that the quality of surveys and the accompanying reports depend very much on the existing human resources at that particular point in time within the agency/partner. Where there is high staff turnover among partners, sustaining high quality surveys cannot always be guaranteed. In the case of poor quality surveys, bilateral discussions and clarifications are conducted and in most cases, partners accept the ENCU's feedback and recommendations. The surveys classified as 'acceptable' are submitted to the DRMFSS with a note on the data quality and report for information and approval. After the DRMFSS approval, the respective partner is informed and requested to organise a feedback at regional/woreda level where the assessment was conducted, including planning for appropriate response.

Apart from surveys, quality assurance has been expanded to cover Community Based Nutrition (CBN), Community Health Day (CHD) and Enhanced Outreach Strategy (EOS) community based bi- annual screening data. ENCU have also developed the EOS screening quality checks guideline currently being integrated into the EOS implementation guideline.

Table 1 shows the number of nutrition surveys conducted in Ethiopia since the inception of the ENCU.

Coordination of Emergency Nutrition Responses

Emergency nutrition responses/interventions are usually triggered by acute malnutrition prevalence threshold levels, as per 2004 emergency nutrition intervention guideline. Since it is not possible to conduct standard assessments in all hotspots, woredas classified as priority 1 are given preference for implementation and/or strengthening the existing nutrition interventions.

The relevant federal and R-ENCU contact capable and willing partners to initiate emergency nutrition interventions in the identified woredas, through monthly, ad hoc or bilateral meetings. During the meetings, consensus is reached with regard to who, what where and how (i.e. process to be followed in engagement of the regional and woreda authorities). This averts duplication of coordination efforts and overlaps among partners. However, sometimes partners engage with the regional authorities directly and therefore the above mentioned processes are not necessary.

Coverage of emergency nutrition interventions in hotspot woredas is monitored on a monthly basis based on national and Sphere standard indictors and shared among partners. The ENCU also uses the information to advocate for expansion of interventions in hotspot woredas, particularly priority 1 that may not yet be covered, or in new emerging hotspot areas. Overall, the performance of emergency interventions has been impressive and consistently above national and Sphere standards thresholds in recent years.

Information management and dissemination

A nutrition database has been created to store survey results as well as other data from large scale programmes such as the EOS and Productive Safety Net Programme (PSNP). Over the last 10 years, 592 nutrition surveys have been conducted in hotspot woredas and the raw data and summary reports of these surveys are posted on the DRMFSS web site (see Table 1). The survey results are used for information sharing and for triggering nutrition interventions, which have saved many lives.

The nutrition information available is regularly analysed and shared electronically and with nutrition cluster partners through monthly MANTF meetings. ENCU also disseminates the information through its emergency nutrition bulletin (available at www.dppc.gov.et/pages/ENCU.htm), which provides detailed analysis and presentation of the survey results and TFP monthly admissions and other performance indicators on a quarterly basis. Moreover, monthly nutrition situation updates are prepared and shared with key government departments and agencies. In addition, ENCU hosts many consultation meetings with missions, consultants from partners, and donors inside and outside the country who wish to learn how the ENCU works and to engage in information sharing. There has been also improved analysis, knowledge and utilisation of nutrition information for planning, decision making and for monitoring the evolving nutrition situation at national and regional levels.

Capacity strengthening

The ENCU has focused on four main areas to support capacity strengthening:

1. Capacity mapping
2. Training on emergency nutrition assessments
3. Database development and information management
4. Revision/development of guidelines

1. Capacity mapping

The ENCU in collaboration with partners has developed a food and nutrition '3W's' matrix of who is doing what and where. This tool contains a wealth of information for each of the woredas, such as hotspot ranking, survey results, and nutrition interventions being implemented and by respective partners. It also provides information on food aid allocation, dispatch information and challenges experienced, provided by the WFP country office. This tool is updated on a monthly basis. The ENCU use the tools to monitor the intervention coverage in terms of availability of TFP and TSF services in the hotspot woredas and in woredas where needs are not being met. The ENCU also maps the technical capacities of the nutrition cluster partners in terms of conducting standard assessment and emergency nutrition interventions. This matrix is completed through meetings and bilateral discussions and feedback with respective partners.

2. Training on emergency nutrition assessments

The ENCU focuses on planning and conducting capacity building sessions to ensure that partners at national and regional level use the latest knowledge and skills in nutrition assessments. For example, a series of SMART trainings were conducted at federal and regional levels to enhance skills and knowledge of the staff of DRMFSS and its partnering NGO agencies. The training is aimed at harmonising planning, implementation, analysis and reporting of nutrition assessments. As a result, partners' capacities for conducting standard emergency nutrition surveys have significantly improved at both regional and national levels.

The use of the SMART methodology has revolutionised the execution of the standard assessment in Ethiopia. Benefits include improved and shortened planning time for standard surveys, i.e. reduced the challenge of manual calculation of sample size, number of clusters and assigning clusters based on probability proportion to size of the population. The inbuilt plausibility check in the ENA software provides nutritionist and survey teams with the ability to assess the quality of the data collected while the survey is in process. Also, as part of quality assurance at the ENCU, the plausibility check guides whether the survey data and information is worth using for planning and decision making.

3. Database development and information management

The ENCU is currently in the process of strengthening the R- ENCU's capacity with the aim of decentralising expertise for emergency nutrition assessment, quality insurance, and situation analysis and data management. A user friendly TFP database to be used at woreda level is also in the process of development. This will facilitate utilisation of nutrition information for planning, decision making, and monitoring/early warning, and enhance and improve reporting at woreda level.

4. Revision/development of guidelines

The ENCU has coordinated the development and revision of the national emergency assessment and intervention guidelines to ensure that partners implement emergency nutrition activities based on the latest knowledge, skills and best practice in the field. The 2002 emergency assessment guideline, for example, was revised in 2008 in line with SMART and ENA software. The 2004 emergency intervention guideline is in the process of being revised to incorporate the 2008 Global Nutrition Cluster intervention tool kit. A stand alone moderate acute malnutrition (MAM) guideline will also be developed to guide and standardise implementation of supplementary feeding programmes in the country. Also in 2010, ENCU coordinated the development of new methodology for seasonal assessments and timely response focusing on strengthened information and surveillance system in line with the Governments Disaster Risk Management (DRM) policy.

Coordination of the Nutrition Cluster

Alignment of the MANTF with the IASC

When the nutrition cluster approach was introduced globally in 2007, it was not a new approach in Ethiopia. Similar nutrition coordination mechanisms existed through the MANTF. The main objective of the cluster approach at global and national level is to strengthen humanitarian response by demanding high standards of predictable leadership, accountability and partnership in emergency response. In Ethiopia, the Government took the cluster lead through sectoral task forces led by the respective ministries. In view of this, ENCU was mandated to coordinate nutrition cluster activities and the MANTF terms of reference were revised to align with the IASC and national level cluster guidance note. It is important to understand that the emergency nutrition situation in Ethiopia is characterised as slow onset chronic emergency and therefore, largely predictable. This predictability calls for sustained and reliable coordination with capacities to implement the cluster approach integrated within the government structures. UNICEF has created four fixed term positions at the ENCU in 2010 to ensure stable, predictable, effective coordination and leadership of the nutrition cluster activities in Ethiopia. he role of the Nutrition Cluster has been to ensure application of national standards, guidelines and protocols in emergency assessment and response, advocate partners and government for timely assessment and response, undertake data and information , and quality assurance. ENCU liaises closely with UNICEF, the nutrition cluster lead agency, on all the above responsibilities. It also advocates for donor funding among nutrition cluster partners. UNICEF, Nutrition Cluster lead agency also has the role of "provider of last resort" when all other options for emergency related response are exhausted.

Decentralisation of the Cluster Approach

A major development achieved by the ENCU has been the roll out of the nutrition cluster approach to the regions. This has significantly improved awareness of cluster partners' responsibilities, contingency planning/ preparedness, as well as the strengthening of nutrition information analysis and sharing among partners in the five regions with RENCUs. However, plans are under way to strengthen the regional nutrition cluster capacities for coordination of emergency assessments and response where it is weak.

Standardisation of emergency nutrition intervention proposals

In order to standardise the preparation of the proposals and assist partners to be focused in proposal preparation, the ENCU prepared a detailed nutrition cluster proposal outline based on the Humanitarian Relief Fund (HRF) format. This was intended to shorten the time for proposal review and facilitate accelerated approval and release of HRF funds to the respective partners, with an overall objective of improving timeliness and coordination of emergency nutrition responses. The ENCU organises a joint nutrition cluster review by sharing the original proposal with a review committee composed of six members (UNOCHA, UNICEF, WFP, UNFPA (gender) and ENCU) and two members normally from NGOs who are not related to the proposal application. All members participate equally in the review process and decision making. Individual reviewers' comments are discussed during a joint review organised by ENCU and a joint feedback note is prepared and shared with HRF based on the consensus from the review committee.

During the review process the committee ensures that the proposal has addressed all the important issues as per national intervention guidelines and format. The application is rated on a four point scale of quality. Based on the level, the proposal is either recommended for HRF board review and funding or re-submitted to the cluster for final consideration for funding or, it is rejected. In situations where the partners are not able to get funds from donors bilaterally or the cluster faces inadequate funding, ENCU communicates with the respective donors directly or through UNICEF and advocates on the importance of funding the proposed interventions. In most cases the advocacy has been successful.

One of the limitations of the cluster review process in Ethiopia is that not all emergency nutrition intervention proposals are reviewed by the nutrition cluster. Partners with adequate funds or funded bilaterally usually do not submit their proposals to the nutrition cluster for review. Despite this, the cluster review process has proven to be an important advance in helping to avert duplication of efforts, maximise resources and increase coverage of nutrition interventions in hotspot woredas.

Operational research on emergency nutrition assessments

ENCU/DRMFSS has been collaborating with national and international bodies in conducting operational research particularly in the area of emergency nutrition assessment. For example, in 2006, with funding from the European Community through UNICEF Ethiopia, ENCU commissioned a study into the relationship between weight-for-height, MUAC and body shape in pastoralist, agro pastoralist and agrarian populations in Ethiopia⁵. The findings helped to shed light on the implications of interpreting nutrition survey results in pastoralist populations and to improve understanding, both within Ethiopia and at a global level, regarding the applicability and appropriateness of MUAC vs. WHZ indicator use to assess the nutrition situation in such communities.

In 2009, ENCU/DRMFSS, in collaboration with Nutrition Works⁶, conducted secondary data analysis of the contextual factors identified during emergency nutrition surveys. The result of the study was presented and discussed by nutrition cluster partners in Ethiopia in September 2009⁷. There were consensuses that the final emergency nutrition assessment guideline should reflect the report/study recommendations and standardise the collection, analysis and reporting of the contextual factors, as in the case of anthropometric and mortality information collected during the surveys. As a result of the recommendation, contextual factors are now included in the 2008 revised national emergency guidelines being funded by UNOCHA-HRF in Ethiopia and the finalisation of the 2008 draft guideline has started.

Future challenges and opportunities for the ENCU

Funding

During the mid-term review of the UNICEF country programme in 2009, it was recommended to incorporate the ENCU as part of the UNICEF structure from mid 2010, with four fixed term positions. This presents an opportunity for establishing effective leadership and in particular, predictable coordination of the nutrition cluster activities as part of UNICEF's Core Commitment for Children in emergencies, while maintaining close coordination with the government. Despite the reinforcement of technical staff, the ENCU's roles and mandate continues to expand and the workload remains a significant challenge. In light of this, UNICEF and DRMFSS have recently agreed to recruit additional staff to focus on strengthening of the ENCU nutrition information systems.

Moderate acute malnutrition

Over the years, ENCU and cluster partners have faced significant challenges in management, monitoring, evaluation, reporting and coordination of nutrition interventions addressing MAM. The 2004 emergency intervention guideline provides limited guidance on the implementation of MAM interventions, reflecting the lack of guidance at the global level. There are also challenges with the adoption of WHO growth standards and the related implications on the implementation of emergency nutrition interventions. Moreover, TFP interventions are not always linked with supplementary feeding programmes and other related interventions. Recognising these challenges, a proposal for revision of the 2004 guidelines and development of separate MAM guideline has been accepted by the government and the revision process has started. This provides a unique and timely opportunity for addressing MAM and other relevant emergency nutrition interventions based on recent developments in this technical area.

Assessing pastoral populations

The lack of international consensus on how the nutrition situation in pastoralist populations should be assessed and characterised in view of their body shape continues to present challenges. To address this, the ENCU/DRMFSS has initiated development of pastoralist survey method studies in collaboration with Action Contre la Faim (ACF) Ethiopia and nutrition partners in Ethiopia that may lead to separate methods for nutrition assessments in pastoralist populations in the future.

Linking nutrition and food security/livelihoods programmes

Another significant challenge has been the absence of or weak linkages between emergency nutrition interventions and long term food security/livelihood and emergency recovery programmes. Focus is now being placed on articulating alignment of future emergency nutrition interventions with implementation of new government policies in relation to DRM and Public Health Emergency Management (PHEM). This is also likely to be addressed by the proposed guideline revisions. Lack or delayed establishment of a nutrition information/ surveillance system, however, will continue to impair the effectiveness of the envisaged early warning systems, on which preparedness, prevention, mitigation and early response components of the DRM policy are based. The existence of the R-ENCU presents a unique opportunity for improved coordination of emergency nutrition assessments, timely response, monitoring and evaluation, accountability, and quality assurance of emergency nutrition interventions which is currently weak.

Information systems

Over the years, ENCU has built a reservoir of nutrition data and information that can be used as a reference for a future information system that integrates emergency and non-emergency nutrition information. Such a system can provide an important input for development of nutrition data and information for disaster risk mitigation and prevention in line with the government's DRM policy.

The ongoing OTP roll out implemented by the federal Ministry of Health (FMOH) provides a unique opportunity for integration of management of acute malnutrition into longer term nutrition programmes, such as CBN and micronutrient deficiency control programmes.

The Government's National Nutrition Programme (NNP) provides considerable opportunities for the integration of emergency and non-emergency nutrition information systems, as well as integration of the ENCU functions into the government structures. The paradigm shift from crisis management to risk mitigation and prevention requires strengthened and improved early warning systems of all the sectors including nutrition. The integration of ENCU into the government working system includes preparation and implementation of common DRMFSS-ENCU/UNICEF annual work plans supported by UNICEF. This ensures government ownership and presents positive signs for future integration within the government structures. ENCU has also secured government and partners trust in the ENCU's work and strengthened linkages between respective government institutions, UN agencies, donors and NGOs implementing emergency nutrition activities in Ethiopia.

For more information, contact: Isaack B. Manyama, email: isaackm@dppc.gov.et

¹Spiegel et al (2004). Quality of Malnutrition Assessment Surveys Conducted During Famine in Ethiopia JAMA. 2004;292:613-618

²The hungry season is January to February in the pastoralist communities.

³The 14.5 percent is based on the FMOH estimates

⁴Standardised Monitoring and Assessment in relief and Transition

⁵ENCU 2007: Report concerning the analysis of data collected for the MUAC/weight for height/body shape research study. Prepared by Mark Myatt, Institute of Ophthalmology, University College London. See summary in Field Exchange, Issue No 34 (2008). M Myatt et al. Effect of body shape on weight-for-height and MUAC in Ethiopia. October 2008. p12. http://fex.ennonline.net/34/effect.aspx

⁶Nutrition Works (a partnership of international nutritionists based in UK

⁷Nutrition Works, 2009. Analysis of Nutrition Surveys in Ethiopia, Workshop Report September 22-23rd Addis Ababa. See summary in Field Exchange, Issue No 37 (2009). Contextual data collection in nutrition surveys in Ethiopia, November 2009. p14. http://fex.ennonline.net/37/contextual.aspx