Together for Nutrition

1. An examination of the dynamics of nutrition
program implementation in Ethiopia: Facilitators
and Constraints at National and Sub National
Level
Eileen Kennedy3 Masresha Tessema1, Tesfaye Hailu1, Dilnesaw Zerfu1, Adamu Belay1, Girmay Ayana1,
Desalegn Kuche1, Tibebu Moges1, Tsehai Assefa1, Aregash Samuel1, Tarik Kassaye3, Habtamu
Fekadu4, Joan Van Wassenhove
1Ethiopian Public Health Institute (EPHI), 2 Federal Ministry of Health
3Tufts University and 4Save the Children
Masresha Tessema
Addis Ababa, Ethiopia, June 15/2015

2. Outline of Presentation
• Background
• Objectives
• Method and Analysis
• Results and Discussion
• Recommendation
• Limitation of study
• Application of the research recommendation
(Utilization)

3. Background
• National Nutrition Strategy – 2008
• National Nutrition Program – 2008
• Revised National Nutrition Program – 2013

4. Objectives
• To assess facilitators and constraints in the
implementation of NNP
• To examine cross sector coordination at the federal
and regional level in the context of NNP
• To assess how programs get translated from the design
phase (on paper) to the implementation phase (in
practice).

5. Method
• Semi-quantitative study and key informants
interviewed from Jan-July, 2013
– National/ Federal level – 24 interviewees (Gov’t, donor and
partners)
– Sub-national/Regional level – 307 interviewees
• 4 Regions
• 11 Zones
• 18 Woredas
• Semi-structured tool was used
• Analysis: The analysis was done by clustering the questions into four
domains and sub-analysis was done by clustering into four sectors

6. …Analysis
Domains
1. Nature of the nutrition
problem
2. Decision making and
ownership
3. Program Design and
Implementation
4. Challenges in
implementation
Sectors
– Health sectors
– Economic sectors: Agriculture,
Trade and Industry, Finance and
Economic Development, Small
scale enterprise, Cooperative
Union, Water and energy
– Social-sectors: Administrative,
Education, Women and child affair,
civil service and good governance ,
early warning and food security
– Development Partners:

7. Results and discussion

8. 1. Nature of Nutrition Problem
• Consensus at all levels :
• Food Insecurity
• Undernutrition (particularly stunting)
• Micronutrient deficiency and DD
• Low awareness
• Sub-national level:
– Economic and Social sectors identified food insecurity as major
problem as compared to health sector
– Most health sector and partners identified undernutrition and
micronutrient deficiencies where as they were less likely to be
identified by economic and social sectors

9. Nature of nutritional Problem by Sector
0
10
20
30
40
50
60
70
Health
Economic
Social
Partners

10. Two interviewees from surplus producing areas:
“Our area is one of surplus producing zone in the region
but we give less focus for dietary quality and diversity
rather worried about selling quality to make more
money”, Tigray Region, Health sector
“Nutritional problem is related with lack of knowledge and food
insecurity. The problem is not only observed in food insecure
area but also existed in food secured area due to lack of
knowledge and awareness”, Amhara Region, economic
sector.

11. 2. Decision making and ownership
• Consultation during development of NNP
– The formulation of NNP 2013 was more inclusive than the NNP 2008
– At federal level most of sectors and partners were involved in the
designing of NNP and a spirit of collaboration and active
involvement was reflected
– Most (more than 70%) of the interviewees at regional, zonal and
district level of the health sector were consulted on nutrition and it
was lower participation for social and economic sectors (below 25%)
– Role of global initiatives and movements (Nutrition 1000 days,
SUN,REACH) and partners were instrumental.

12. …..Decision making and ownership
• Attention given on nutrition
– All of the interviewees from health sector’s said that sufficient attention
and resources was given for nutrition whereas most from economic and
social sectors believe other wise
• Knowledge on NNS and NNP
– At national/federal level all sectors know about the NNS/NNP
– A wider gap was observed in social and economic sector:
• Health sector and partners at the sub-national level are aware of NNP
and NNS as compared to economic and social sector
• Push-Back for decision making and ownership
– Considering nutrition as role of health only,
– Social and economic sectors couldn’t clearly see their role
– Absence of a nutrition focal point or unit in each sector.

13. Knowledge on NNS/NNP
0
10
20
30
40
50
60
70
80
90
100
Health Economic Social Partners
yes
No

14. 3. Program Design and Implementation
• The design of the NNP should consider the diversity of the
country and be tailor to local needs.
• The NNP design considered strengthening existing program
and integration of nutrition into existing sectoral activities and
programs
• Each sector need to have a road map how NNP can be
accomplished
“A lot of work has gone into the NNP; we now need an operational
plan by sector that provides guidance on what is expected of the key
actors.” NGO, Addis Ababa

15. …..Program Design
• Sub-national and sectoral interviewees proposed key issues
that will improve NNP implementation
– Focal point for nutrition in all sectors
– Creating more awareness for sub-national
– Nutrition education and advocacy at community level
– Empowering agriculture development agents for nutrition activities
– Incorporating nutrition in the curriculum
“Unless there is focus at the sub national level on awareness and
capacity development, the nutrition plan will fail.” Gov’t
Representative AA

16. 4.Challenges in implementation
• The challenges were categorized into four
a) Leadership
b) Implementation
c) Budget
d) Multi-sectoral coordination and incentives for
collaboration

17. …..Challenges
a. Leadership
Most reported (national and sub-national level) NNP need
high level commitment especially in social and economic
sector and coordination.
– “We should make a strong recommendation to GOE that we need an
autonomous body that has accountability and authority.. May be an office of
nutrition in the PM’s Office.”
b. Operational challenges to implement NNP:
– Lack of capacity on nutrition at sub-national level
– Poor community awareness and ownership

18. …..Challenges
c. Budget
• At the national level, 22% believe that budget is a constraint.
Government key informants (42%) from all ministries see the
budget constraint as more of an issue
“We can’t do all that is expected in the NNP without more staff and funds. It’s
just not realistic.” Government Representative, Addis Ababa.
• At the sub-national level, budget was identified as a constraint by
a quarter of the respondents in all region except some
interviewees from Oromia region.

19. …..Challenges
d. Multi-sectoral coordination
– National level coordination is progressing
– Sub-national coordination was minimal
– At the national level, 35% indicated there should be
incentives for collaboration
– At sub-national level; HDA, sector mandated activities, good
M&E plan, leaders commitment, work satisfaction, joint
planning and meetings were identified as main motivational
factors for coordination and collaboration.

20. Motivation factors to collaborate within and
among sectors at regional level
0 5 10 15 20 25 30 35 40
Interface, joint meeting& HAD (1…
Good M&E scheme
Sector mandated activity
GTP
Command post and steering…
Work satisfaction
BPR/ BSC
Leaders commitment
No motivation
%

21. Recommendation
• Coordination: in the office of the Prime
minister
• Maintain the high level of enthusiasm
• Awareness creation at all levels
• Capacity building at sub-national level
• Establish monitoring and evaluation system
• Nutrition focal person at all sectors level
• Budget allocation

22. Limitation of Study:
• The study was conducted immediately after
NNP was revised. The result may not
indicate/show the current status of NNP
implementation.

23. Application of the research recommendation (Utilization)
• First lady became ambassador/champion for nutrition.
• The revised NNP rolled out to sub-national and economic
sectors.
• Regional and woreda multi-sectoral coordination has been
established (cascading).
• Increased ownership of NNP by economic sectors, e.g.
Ministry of Industry is leading national food fortification
• Some economic and social sectors assigned a nutrition
focal person or nutrition case team,e.g Ministry of
Agriculture and education
• Pending: high level multi-sectoral coordination and
accountability to PMO, and budget allocation for nutrition

24. Acknowledgement
• USAID/ENGINE project
• Save the Children
• Regional government sectors offices
• Interviewees

25. • The authors of this report acknowledge the support
of the United States Agency for International
Development (USAID), under the terms of Award No.
ENGINE: AID-663-A-11-00017. The opinions
expressed herein are those of the author(s) and do
not necessarily reflect the views of the U.S. Agency
for International Development.