The document discusses experiences integrating therapeutic care as a routine part of Ministry of Health services in Ethiopia, including examples from Jimma, Oromiya Region where 210 children have been treated through outpatient therapeutic programs at health centers. It emphasizes that therapeutic care can successfully be implemented as part of routine health services with minimum external support if the Ministry of Health demonstrates ownership and all stakeholders share an understanding of malnutrition treatment. Current challenges like high defaulter rates are being addressed through tracing patients and additional research.

2. 2
Cover photo credits
Front (left to right from top): J. Pudlowski, IMC; Valid International; V. Forsythe, Concern; Concern USA;
Concern USA; Linkages; Concern USA,; Concern Ethiopia.
Back (left to right from top): J. Pudlowski, IMC; Concern USA; J. Spector, Valid International; J. Spector,
Valid International.

3. 1
TABLE OF CONTENTS
Acknowledgments............................................................................................................2
List of Acronyms ..............................................................................................................2
1. Introduction .................................................................................................................4
2. Therapeutic care principles, strategy and current status in Ethiopia ....................................4
3. Therapeutic care as a routine part of the MoH service ......................................................6
3.1 Jimma, Oromiya Region .........................................................................................6
3.2 Buee, Butajira, Soddo Woreda, Gurage Zone, SNNPR...............................................7
3.3 SNNPR Regional Health Bureau .............................................................................8
3.4 Current challenges faced by the MoH and suggested solutions ...................................9
3.5. Integrating CTC within MoH structures - Awassa Zuria Woreda.................................11
4. Implementation of CTC – special points of interest .........................................................13
4.1 CTC in an emergency context (Somali Region) .......................................................13
4.2 Health & Nutrition interventions to strengthen CTC: addressing moderate malnutrition .14
4.3 CTC in an urban setting........................................................................................15
4.4 Social development / Community mobilisation .........................................................16
4.5 Therapeutic care and HIV .....................................................................................17
4.6 Ready to Use Therapeutic Food (RUTF) production in Ethiopia.................................18
4.7 Current challenges in CTC programmes and suggested solutions..............................19
5. Appendix...................................................................................................................22
Appendix 1. Counselling on infant feeding....................................................................22
Appendix 2. Summary of background information on community-based programmes
implemented in Ethiopia..............................................................................................23
Appendix 3. Summary of feedback ..............................................................................27
Appendix 4. List of participants ...................................................................................28

4. 2
Acknowledgments
The workshop on Therapeutic Care in Ethiopia, funded by the Office of US Foreign Disaster
Assistance (OFDA), was co-hosted by Concern Ethiopia and Valid International. We would
like to thank the Ethiopian Ministry of Health (MoH) for their ongoing advice and support. This
event was very successful thanks to the presenters and the numerous participants who
shared their experiences and gave constructive suggestions on how to move therapeutic care
forward in Ethiopia.
List of Acronyms
CHP Community Health Promoter
CTC Community-based Therapeutic Care
CV Community volunteers
DPPC Disaster Prevention and Preparedness Commission
ENA Essential Nutrition Actions
ENCU Emergency Nutrition Coordination Unit
EOS Enhanced Outreached Strategy for child survival
EPI Expanded Programme of Immunisations
ESHE Essential Services for Health in Ethiopia
HEP Health Extension Package
HEW Health Extension Worker
HSDP Health Sector Development Programme
IMC International Medical Corps
IMNCI Integrated Management of Neo-natal and Childhood Illness
MDGs Millennium Development Goals
M&E Monitoring and evaluation
MoA Ministry of Agriculture
MoH Ministry of Health
MTCT Mother to child transition
MUAC Mid upper arm circumference
NGO Non governmental organisation
OFDA Office of US Foreign Disaster Assistance
OTP Out-patient Therapeutic Programme
PLWHA People living with HIV/AIDS
PSNP Productive Safety Net Programme
RUTF Ready-to-use therapeutic food
SAM Severe acute malnutrition
SC-US Save the Children – US
SFP Supplementary feeding programme
SMART Standardised Monitoring and Assessment in Relief and Transitions
SNNPR Southern Nations and Nationalities People’s Region
TFC Therapeutic feeding centre
TFP Therapeutic feeding programmes
TFU Therapeutic feeding unit
TSFP Targeted Supplementary Feeding Programme
UN United Nations
VCT Voluntary counselling and testing
WFP World Food Programme
W/H Weight for height % of the median

5. 3
Executive Summary
A two day meeting was held in Addis Ababa between the 27th
and 28th
June 2006,
“to bring together the Ministry of Health (MoH), United Nations (UN) agencies, donors
and non-governmental organisations (NGO) with experience of CTC or other home
based/outpatient therapeutic care programmes in Ethiopia, to share experiences and
discuss plans for the future.”
Over a third of the 112 participants represented various levels of the MoH,
government departments or Academic Institutions while others were from the UN,
NGO’s, donors and technical/research organisations.
This was a follow-on meeting from the last national CTC workshop held in June 2004
and was hosted by Concern Ethiopia and Valid International. Funding was provided
through a grant from the Office of Foreign Disaster Assistance (OFDA).
The first day focused on the provision of therapeutic care as a routine part of the
service in Ministry of Health facilities. An introductory presentation outlined the
progress made by the Ministry of Health in providing therapeutic care (both in-patient
and out-patient) in different areas. This was given by UNICEF and CONCERN, who
have been assisting the MoH through technical support Further presentations were
given by MoH representatives from three different areas: Jimma, Butajira and
SNNPR. It was clearly demonstrated that despite the many challenges that they
face, the MoH has made significant steps forward in treating severe malnutrition and
can successfully implement therapeutic care programmes in a range of conditions.
Five working groups then discussed a specific theme relating to the integration of
therapeutic care within MoH services. The five themes were: logistics, community
participation in the MoH setting, health extension package and institutional structure,
capacity of the MoH, and training and academic institutions. The current challenges
were widely discussed and many suggested solutions were forthcoming.
The second day concentrated more on NGO experiences of therapeutic care as well
as particular topical issues. Presentations were given by GOAL, IMC, the ESHE
project and CARE. This was followed by presentations on social development issues
related to therapeutic care (given by Valid International), Therapeutic care and HIV
(given by LINKAGES) and local production of ready to use therapeutic food (RUTF)
given by the ENCU.
Following on from the presentations, participants were again divided into five working
groups and specific points of interest related to therapeutic care were discussed.
The five themes were: methods and implications of integration with the MoH,
moderate and chronic malnutrition, integration between various aid programmes,
coordination of surveys and assessments, and MUAC and coverage issues. Many
suggestions of how to resolve current challenges were put forward.
Feedback forms form the participants indicated that the workshop was well received
with the majority of the respondents describing it as ‘good’ or ‘excellent’.
Suggestions for improvement in the future included: provision of a manual of how to
implement OTP, allocate more time for all of the interesting questions and
discussions, reduce the number of participants, and to conduct such meetings on a
regular basis.

6. 4
1. Introduction
The workshop on therapeutic care in Ethiopia took place in Addis Ababa on 27th and 28th
June 2006, gathering representatives from the MoH, Academic Institutions, United Nations
(UN) agencies, donors and numerous non governmental organisations (NGOs). This event
followed a previous workshop on Community-based Therapeutic Care (CTC) in Ethiopia held
on 22nd and 23rd June 2004 in Addis Ababa.
The objective was to bring together the MoH, UN agencies, donors and NGOs with
experience in therapeutic care or other home based/out-patient therapeutic care
programmes to share experiences and discuss plans for the future. The workshop
included a series of presentations, question and answer sessions and group discussions.
2. Therapeutic care principles, strategy and current
status in Ethiopia
Presentation by Sylvie Chamois, UNICEF Ethiopia and Emily Mates, Concern Ethiopia
Therapeutic care is a
general term describing
the treatment of severe
acute malnutrition, while
more specific terms are
used to describe the
nature of the
intervention, e.g. thera-
peutic feeding units
(TFUs) or out-patient
therapeutic programme
(OTP).
Outpatient care for
severe malnutrition is a
relatively new way of
treating children with
severe malnutrition,
enabling the majority of
beneficiaries to be
treated at home with a
take home ration of therapeutic food. NGO programmes in Ethiopia have successfully treated
over 18,000 severely malnourished children at home since 2003.
There are strong justifications for establishing community-based rehabilitation for severe
malnutrition within routine health systems. It facilitates early discharge from hospital and
provides continuity of care, and offers an alternative to in-patient care for severely
malnourished children who are clinically well and have a good appetite. It can benefit children
by reducing exposure to hospital-acquired infections. It can benefit families by reducing the
time carers spend away from home and the risk of possible neglect of siblings, and by
reducing opportunity costs. It can benefit the health system through capacity building and can
be the catalyst for strengthening nutrition activities within clinics in relation to both treatment
and prevention of malnutrition. Integration of such programmes as part of the routine health
system is likely to have a major public health impact and contribute to the achievements of
the Millennium Development Goals (MDGs). This can be accomplished by mainstreaming the
management of severe malnutrition into national and local health and development agendas.
Care can thus be given through either in-patient or out-patient services. In-patient care is
normally provided through specialised TFUs based in a local hospital or health centre, and is
usually only required for those severely malnourished children and adults with medical
complications (thus, units are sometimes called stabilisation centres). When the health
condition has stabilised and good appetite is present, patients leave the TFU (or stabilisation
centre) and continue treatment at home, through the OTP until full recovery. However, in-
Source: V. Forsythe, Concern
Picture 1: Clinic delivering OTP services

7. 5
patient care may be used under other circumstances, e.g. mothers and their severely
malnourished children could choose to stay in the TFU for the whole duration of their
treatment. Out-patient care is for cases of severe malnutrition without medical complications.
Severely malnourished children and adults are treated in their home, receiving take-home
food and medicines every week or every two weeks from OTP sites (normally located in a
health facility) until they recover.
CTC empowers mothers, families and communities in addressing malnutrition with an
emphasis on outreach and community-based support as well as home treatment. The
coverage of out-patient therapeutic programmes is usually higher than in-patient programmes
as it promotes decentralised access to services (see graph 1).
Despite an increasing number of therapeutic care programmes in Ethiopia (see graph 2), the
capacity to treat malnourished children does not yet meet the needs of the population (see
table 1).
Graph 2: Evolution of the number of TFP, 2003-2006, Table 1: Treatment capacity
Ethiopia (Source: Unicef Ethiopia) versus needs (Source: Unicef Ethiopia)
(Source: Unicef Ethiopia)
TFU in hospital
or health centre OTP in health
centre
OTP in
health centre
OTP in health
centre
OTP in health
centre
TFU in hospital
or health centre OTP in health
centre
OTP in
health centre
OTP in health
centre
OTP in health
centre
TFU in hospital
or health centre OTP in health
centre
OTP in
health centre
OTP in health
centre
OTP in health
centre
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
J
a
n
-
0
3
M
a
r
-
0
3
M
a
y
-
0
3
J
u
l
-
0
3
S
e
p
-
0
3
N
o
v
-
0
3
J
a
n
-
0
4
M
a
r
-
0
4
M
a
y
-
0
4
J
u
l
-
0
4
S
e
p
-
0
4
N
o
v
-
0
4
J
a
n
-
0
5
M
a
r
-
0
5
M
a
y
-
0
5
J
u
l
-
0
5
S
e
p
-
0
5
N
o
v
-
0
5
J
a
n
-
0
6
M
a
r
-
0
6
M
a
y
-
0
6
Treatment
capacity
0
10
20
30
40
50
60
70
80
90
100
Number
of
TFU/OTP
AVERAGE TREATMENT CAPACITY TFU AVERAGE TREATMENT CAPACITY OTP
Number of TFU Number of OTP
Graph 1: Therapeutic care - access to treatment and coverage
of the population – an example (source: Concern Ethiopia)
The World Health
Organisation says that
therapeutic care or
‘community-based
rehabilitation of severe
malnutrition’:
…. refers to treatment
that is implemented at
home with some
external input, for
example from a health
worker, or treatment
that occurs at a primary
health clinic, or in a
community day-care or
residential centre, in
order to achieve catch-
up growth.
YEAR
Range of SAM
rates in food
insecure areas
SAM
treatment
capacity
(monthly)
Number
of TFP
2003
1 to 3%
(70 to 210,000)
3,500 44
2004
0.8 to 2%
(56 to 140,000)
4,300 44
2005
0.5 to 1.5%
(35 to 105,000)
10,000 101
2006
1 to 2.5%
(70 to 175,000)
18,480 145

8. 6
On a positive note, many major changes were achieved in Ethiopia from 2003 to 2006, which
created a favourable environment for increasing treatment capacity of therapeutic care in the
country. The Ethiopian government has increasingly recognised nutrition not only as a food-
related problem, but also as an overall public health problem:
• Adoption of the MDGs by the Ethiopian government and endorsement of the National
Child Survival Strategy
• Introduction of the Enhanced Outreached Strategy for child survival (EOS)1
which has
increased demand for therapeutic feeding programmes (TFP)
• Development of national guidelines for the prevention/control of micronutrient
deficiencies as well as for infant and young child feeding
• Development of the Management of severe acute malnutrition (SAM) guidelines
• Development of the National Nutrition Strategy
• Introduction of the management of SAM into the Health Sector Development Plan
and the Package of Essential Health services
• Development of an updated version of the Management of SAM guidelines
• Development of the Nutrition and HIV/AIDS guidelines
3. Therapeutic care as a routine part of the MoH
service
3.1 Jimma, Oromiya Region
Presentation by Dr Tsinuel Girma, Medical Director of Jimma University Hospital
The MoH in Jimma started
integrating therapeutic care as a
routine part of its services in
December 2005. As of June 2006,
OTP treatment is offered from five
teaching health centres (including
Jimma University Hospital TFU)
within a 50-60 km radius of Jimma
town. Children can be admitted to
OTP on any day of the week, while
registered children are requested
to come for follow-up visits once a
week on a specific day.
A “minimum package” approach
was adopted to integrate
therapeutic care within existing
MoH services:
• Health workers from health centres and Woreda/Zonal health offices as well as community
volunteers were trained in OTP with the support of Concern Ethiopia and Valid
International
• The Zonal health office took the responsibility to order basic supplies from UNICEF -
ready-to-use therapeutic food (RUTF), weight scales, height boards, etc.
During the seven months of operation, 210 children were admitted to the OTP programme. A
major issue for the OTP programme in Jimma is its high defaulter rate; well above Sphere
standards recommendations. This issue will be addressed through Health Extension Workers
(HEWs) tracing defaulters and operational research into the causes of default. Additional
health centres will start OTP in order to reduce the distance that carers have to travel to
access the service.
1
EOS includes screening children, pregnant & lactating women and referral of malnourished cases to
Targeted Supplementary Feeding Programmes (TSFP) – (MoH, UNICEF and World Food Programme)
2004
2005
2006
Source: Concern Ethiopia
Picture 2: Parents with their child at a health centre in Jimma

9. 7
The following lessons can be learned from the experience in Jimma so far:
• It is possible to integrate therapeutic care as a routine part of MoH services with minimum
external support
• Ownership and enthusiasm from MoH staff is essential
• Existing services need to be continuously evaluated and re-engineered to reach
performance targets
• All stakeholders participating in OTP need to share the same understanding of malnutrition
and how the programme can offer treatment
• The role that community volunteers play in OTP is crucial. To maintain their commitment
and enthusiasm for the programme, an incentive scheme should be in place until there is a
good level of community awareness and cases come through self-referral
• Referrals from out-patient to in-patient and vice versa need to be strengthened.
3.2 Buee, Butajira, Soddo Woreda, Gurage Zone, SNNPR
Presentation by Ato Adenew Yirga, Head of Buee Health Centre
Since April 2006, therapeutic care has been
functioning at the Buee health centre as a routine part
of its under-five clinic. Four health professionals
screen newly referred children every day and follow up
with children admitted to OTP once a week.
The number of children admitted to OTP progressively
increased from April to June 2006 to reach a total of
57. Among these children, 19 recovered, 10
defaulted, 1 died and 4 were transferred to the
stabilisation centre for in-patient care.
The child who died was due to the refusal of the
mother to transfer him to in-patient care. The number
of defaulters was high since many children and their
carers come from outside the catchment area and had
to walk long distances to get OTP services. To
address this issue, carers will be asked to bring their
child to the health centre on a fortnightly rather than
weekly basis.
Prior to the set up of OTP
activities in Buee,
discussions were held
between Soddo Woreda
representatives and Buee
Health Centre staff to agree
on the nature of the
programme to implement.
Once a decision had been
reached, both MoH and
health centre staff received
training in OTP principles
and protocols. Discussions
were also held with
community based sur-
veillance workers and HEWs
on a suitable community mobilisation strategy. Training was given on how to screen
malnourished children during home visits and to trace OTP defaulters.
Despite some challenges, such as a shortage of drugs due to a long MoH ordering chain and
the inability of some parents to pay for additional drugs and lab examinations that may be
required, the overall OTP experience has been positive, due to the following reasons:
Source: Valid International
Picture 3: Mother and child eating RUTF
Graph 3: Admissions to OTP, April to June 2006, Buee, Ethiopia
(Source: Buee Health Centre)

10. 8
• The OTP protocol is simple and easy to follow
• Cards to record children’s health status and reporting are easy to use
• The health centre staff are motivated as children recover quickly and visibly
• The community’s opinion about OTP seems positive, as reflected by the number of self-
referred cases coming to OTP
• The number of children admitted to OTP has so far been manageable for the health
centre.
3.3 Southern Nations and Nationalities People’s Region
(SNNPR) Regional Health Bureau
Presentation by Dr Ephrem Teferi, Regional Health Bureau
Although SNNPR is fertile,
malnutrition is recurrent due to
population explosion, feeding
habits and a lack of food surplus.
During 2002/2003, 1.5 million
people, mostly children and
mothers, were affected by
widespread food shortages as
crops failed. The nutrition
emergency was complicated by
malaria epidemics.
TFC and CTC
From April 2003, 26 feeding
centres were set up across the
region to respond to the food
emergency. At that time,
Concern piloted a CTC programme in Wolayita as an alternative approach to treating severe
malnutrition. From August 2003, Save the Children - US (SC-US) implemented CTC on a
wider scale in Sidama Zone.
CTC and home-based care (HBC)
Following governmental guidelines, TFCs were closed in the region at the beginning of 2005.
Since then, severely malnourished people have received support through CTC, HBC and
supplementary feeding programmes (SFP).
Table 2: Severely malnourished people treated though TFC, CTC and HBC, 2003 to 2005, SNNPR
2003 2004 2005 Total
TFC 12,592 1,251 closed 13,843
CTC 1,540 1,985 8,791 12,316
HBC - - 474 474
(Source: SNNPR Regional Health Bureau)
EOS
To address moderate malnutrition, the MoH together with UNICEF and the World Food
Programme (WFP) began implementing a child survival programme in 54 Woredas through
the EOS programme in 2004. EOS activities include health education, measles vaccination,
Vitamin A supplementation, de-worming, screening for malnutrition (for therapeutic and
supplementary programmes) and distribution of supplementary food for moderately
malnourished children and pregnant and lactating mothers. Cases of severe malnutrition are
referred to local health facilities. The region has also implemented the health extension
package (HEP) which aims to strengthen the structure that provides EOS services.
SFP
SFP is an integral part of the EOS programme. Identified through the EOS screening
process, moderately malnourished children and pregnant and lactating mothers receive
supplementary food and oil as well as health education. In the region, food is distributed from
613 sites with the support of the community.
Source: SNNPR Regional Health Bureau
Picture 4: Vitamin A supplementation

11. 9
Difficulties encountered
The MoH in SNNPR faces recurrent difficulties in implementing CTC, HBC, EOS, SFP and
HEP, including:
• Shortage of manpower, storage space, transportation and therapeutic products
• Misunderstanding about the nature of malnutrition (‘malnutrition is not a disease, it must
be addressed by NGOs’)
• Late distribution of supplementary food (for EOS)
• Inaccurate targeting (some people who should not receive food receive it, while some
people who are entitled to food do not receive it).
Opportunities
Other major opportunities contribute to the response to malnutrition in the region, including:
• HEP focuses on building the capacity of the MoH (training, resources, and coordination
such as for referrals)
• Some colleges now include management of malnutrition in their curriculum
• CTC, which is now widely accessible in the region, follows a well-structured process
(identification, treatment, follow up)
• Through various programmes, special attention is given to health education and
immunisation.
Overall, emergency and development programmes should be combined to maximise efforts to
reduce nutritional problems, ensure sustainable programmes within the MoH and support
health workers when treating malnutrition (see graph 4).
Graph 4: Towards an integration of development and emergency programmes
(Source: SNNPR Regional Health Bureau)
3.4 Current challenges faced by the MoH and suggested
solutions
Outcomes of group discussions
Participants were divided in five working groups and were asked to discuss specific themes
relating to the integration of therapeutic care within MoH services. The aims of the working
groups were to:
Development
Response
- Immunization
- Proper feeding
- Growth monitoring &
promotion
- Family Planning
- Sanitation & Hygiene
- Safe Water
- Prevention &
management of sick
children
Integrated Emergency and
Development Responses
HEALTH
SYSTEM
Emergency
Response
- Screening children
for malnutrition
- Providing nutritional
products for severely
malnourished children
- Monitoring of nutritional
status
HEALTH SYSTEM
Development
Response
- Immunization
- Proper feeding
- Growth monitoring &
promotion
- Family Planning
- Sanitation & Hygiene
- Safe Water
- Prevention &
management of sick
children
Integrated Emergency and
Development Responses
HEALTH
SYSTEM
Emergency
Response
- Screening children
for malnutrition
- Providing nutritional
products for severely
malnourished children
- Monitoring of nutritional
status
HEALTH SYSTEM
Source: SNNPR Regional Health Bureau
Picture 5: Child education

12. 10
• Give time to participants to air their views and discuss issues encountered
• Suggest some realistic measures that implementing agencies and government
departments can take regarding logistics, community participation, HEP, the capacity of
the MoH and training to move the integration of therapeutic care forward.
The main action points suggested by each working group are summarised as follows.
1. Logistics
• Advocate at all levels for the treatment of malnutrition to be a routine part of the health
service (e.g. RUTF as routine medical supply)
• Define roles and responsibilities regarding logistics at all levels of the MoH
• Train all levels of staff in logistics so that the MoH can handle therapeutic care without
external support
• Debate the creation of two systems (one for the logistics of development programmes
and the other for the logistics of emergency needs) to speed up services and introduce
some flexibility in transport and warehousing.
2. Community participation in the MoH setting
At the community level:
• Select volunteers using a Bottom to
Top approach to ensure
commitment
• Clearly define the roles and
responsibilities of volunteers
• Nominate a focal person in each
Kebele to coordinate community
participation
• Motivate volunteers and HEWs
through recognition and integration
in MoH campaigns.
At the health facility level:
• Motivate health staff to embrace
therapeutic care
• Link outreach and preventive
activities
• Provide technical support and
supervision (with a checklist)
regarding community mobilisation
• Strengthen referral systems.
At the Woreda level:
• NGOs and Government bodies should jointly plan and implement community
mobilisation
• Organise a partners forum to harmonise and coordinate community participation
• Involve the community in decision making
• Build the capacity of the Woreda in community participation (supervision and follow-
up).
3. HEP and institutional structure
• HEWs should identify severe malnutrition as part of their routine work (training is
needed)
• Motivated volunteers should be recruited to support and work under HEWs, e.g.
community health promoters
• Provide incentives to volunteers to ensure continued motivation and therefore
sustainability. Suggestions for incentives included: refresher training, priority for health
centre treatments, regular monitoring & supervision
• Give routine refresher training to HEWs and volunteers (every 3-6 months)
• Provide more practical training
• Follow-up, monitor, supervise and provide institutional support to HEWs
• Analyse the institutional structure to identify weaknesses and gaps.
Source: Concern USA
Picture 6: Checking MUAC

13. 11
4. Capacity of the MoH
• Allocate sufficient resources for the
management/supervision of malnu-
trition
• Reduce the workload of individuals by
hiring more staff
• Provide incentives to MoH staff
working in hardship areas to ensure
retention
• Regular supervision of activities at all
levels
• Make treatment of malnutrition a
routine activity of the MoH and fight the
bias that ‘treatment of malnutrition is
NGO work’
• Address the fear of health
professionals that therapeutic care will
increase admission rates in their facility
• Simplify protocols
• Where NGOs are directly implementing
programmes, ensure the involvement
of MoH staff at the design phase of
programmes and clearly define exit
strategies
• NGOs to better link emergency and
development programmes.
5. Training, academic institutions
• Allocate more resources for training and academic institutions
• Build the capacity of academic institutions (curriculum, in-service training, monitoring
and evaluation) and promote initiatives and responsibilities
• Conduct indigenous research and support publications on nutrition using an
interdisciplinary approach
• Incorporate new findings in guidelines and training curricula
• Include management of malnutrition in guidelines and training curricula
• Develop teaching materials for nutrition
• Shift the paradigm in teaching to be more practical
• Do nutrition courses need to become elective?
• Advocate for a recognition of nutrition problems among officials by sharing good
experiences.
3.5. Integrating CTC within MoH structures - Awassa Zuria
Woreda
Presentation by Alem Hadera Abay, GOAL Ethiopia
GOAL Ethiopia has implemented an OTP/CTC programme in Awassa Zuria Woreda with the
view of integrating the service within the MoH structure.
In addition to managing severe acute malnutrition through 9 health centres and 15 health
posts, the Awassa Zuria CTC programme built the capacity of the MoH staff at the Woreda
level to respond to future emergencies. On-the-job training, supervision, mentoring and
monitoring were key activities in the programme, as 70 health professionals and 29 support
staff received training. Except for average weight gain, outcome indicators before and after
the phasing out of the programme are within Sphere standards, which seems to indicate that
the MoH successfully integrated CTC within its services.
For GOAL, CTC is considered to be integrated when the MoH have the capacity to manage
severe acute malnutrition at the health centre and health post level with minimal external
support. To reach this point, key activities (or ‘phases’) were progressively handed over to
MoH staff (see table 3 below). While phases 1 to 5 did not present any difficulty, the
Source: Concern USA
Picture 7: Measuring weight

14. 12
integration of logistic and supply management (P6) as well as the overall programme
management (P7) were challenging, as the MoH had to commit clear resources (budget,
manpower) to these activities.
Table 3: Phases followed by GOAL to integrate CTC within the MoH, July 2005-April 2006, Awassa Zuria
(Source: GOAL Ethiopia)
The main lessons that GOAL learned regarding integration were:
1. The CTC programme in Awassa Zuria used a minimum amount of external input for its
implementation. Programmes using a ‘minimal approach’ are less intimidating for MoH
staff than resource intensive emergency programmes and prove to be more sustainable
2. At the start of the programme, GOAL approached the Woreda health bureau and
discussed the programme with the management team. The mid-term review showed that
MoH staff understood the programme transition/phasing out as an end to the programme
rather than a continuation through the MoH. This experience shows that not only the
management team but all the Woreda/Zonal MoH staff have to be involved in the start-up
planning phase to ensure consistent and comprehensive understanding of the programme
3. GOAL experienced some challenges in handing over the logistics and supply management
as well as channel supply (for RUTF and drugs) to the MoH. Therefore, it is vital that
capacity building activities should concentrate on these areas of expertise
4. GOAL progressively phased out from the CTC programme taking into account the regular
capacity assessments of each health centre/post. Progressively phasing out using set
criteria can allow for a smooth transition of the programme activities from the NGO to the
MoH. Regular monitoring is vital to allow for scale-up or down of additional support.
Source: GOAL Ethiopia
Picture 8: Communication is an important part of the phasing out
process
??
P-7: Overall management of the OTP/CTC programme
-Planning, budgeting & managing the programme at all levels
?
?
?
?
P-6: Logistic and Supply management
- Capacity to request, transport, control supplies & its movements
P-5: Monitoring
-Capacity to monitor all OTP/SC activities at the Woreda level
created.
P-4: Supervision
- Capacity to supervise all OTP/SC activities at the site level created
P-3: Reporting
- Compile tally sheets and Monthly reports by hand
P-2: Opening new OTP sites in the Highland
P-1: Training including on the job
-Technical know how capacity created:
Ap
r
Ma
r
F
e
b
J
A
n
D
e
c
N
o
v
O
ct
S
e
p
A
u
g
J
ul
Phases
??
P-7: Overall management of the OTP/CTC programme
-Planning, budgeting & managing the programme at all levels
?
?
?
?
P-6: Logistic and Supply management
- Capacity to request, transport, control supplies & its movements
P-5: Monitoring
-Capacity to monitor all OTP/SC activities at the Woreda level
created.
P-4: Supervision
- Capacity to supervise all OTP/SC activities at the site level created
P-3: Reporting
- Compile tally sheets and Monthly reports by hand
P-2: Opening new OTP sites in the Highland
P-1: Training including on the job
-Technical know how capacity created:
Ap
r
Ma
r
F
e
b
J
A
n
D
e
c
N
o
v
O
ct
S
e
p
A
u
g
J
ul
Phases

15. 13
4. Implementation of CTC – special points of interest
4.1 CTC in an emergency context (Somali Region)
Presentation by Angela Stene, International Medical Corps (IMC)
IMC is currently implementing CTC (including SFP) in 3 Regions of Ethiopia, SNNP, Oromiya
and Somali. IMC responded to the recent drought in Somali Region by commencing CTC in 2
Zones: Liben and Afder.
Liben is the most populated of the two areas with 545,000 people, while Afder has a smaller
population of 85,000 but a higher number of people in need of food (according to an
estimation conducted between August and December 2005). Therefore, IMC implements
OTP and SFP in Afder and only OTP in Liben.
Table 4: OTP implemented by IMC, Somali region, June 2006 (Source: IMC)
Liden Afder
Children targeted by
OTP
1,800 230
MoH resources 13 formal MoH sites
96 MoH staff *
2 health posts
4 MoH staff
OTP sites 10 11
SCs 2 2
Training and Health
Education
CV: 61
MoH: 7
CV: 200
MoH: 0
* Among the 96 people working in the health sector, 28 are service providers for patients.
CV = community volunteers
IMC uses a ‘mobile approach’ to implement OTP in the Somali region, whereby distribution
points are set up across Kebeles. These mobile meeting points work well for the pastoralist
people of Somali.
Community mobilisation is critical for the success of the programme as infrastructure is very
limited in Somali region. High volunteerism rates have proven to be an excellent asset in the
region.
Setting up OTP programmes in Somali region raises a
unique set of challenges:
1. Households’ vulnerability to food crisis varies according
to seasons and rains. For example, the months after
June are critical as camels run out of milk and pastures
decrease
2. Infrastructure is limited (roads, communication)
3. Health facilities, availability of MoH staff, and general
access to health care are also limited
4. Links between emergency food and development
programmes are missing
Despite expectations to the contrary, security was not an
issue in the areas where IMC works.
In spite of these challenges, IMC underlined the fact that
OTP can be used as an entry point for other programmes.
In Afder and Liben, Integrated Management of Childhood
Illness (IMCI), mobile clinics and provision of reproductive
health kits complemented the OTP programme. Source: J. Pudlowski, IMC
Picture 9

16. 14
4.2 Health & Nutrition interventions to strengthen CTC –
addressing moderate malnutrition
Presentation by Dr. Hailemariam Legesse, Essential Services for Health in Ethiopia (ESHE)
While OTP treats severely malnourished people, SFP provides supplementary food to a
larger group who are moderately malnourished. But food alone can not address the needs of
the moderately malnourished. Children still die from pneumonia, malaria, diarrhoea, etc.
In Bolosso Sore Woreda (Wolayita
Zone, SNNPR) ESHE promotes health
and nutrition interventions to
strengthen the CTC programme set up
by IMC through:
• Integrated Management of Neo-
natal and Childhood Illness (IMNCI)
- screening for major diseases,
immunisation status, improving
Vitamin A status for the moderately
malnourished
• Essential Nutrition Actions (ENA) -
nutritional counselling of caretakers
at six contact points
• Expanded Programme of
Immunisations (EPI) – encouraging
the completion of the full series of
immunisations by one year of age.
The main agents to implement these initiatives have been:
• HEWs - for health and nutrition interventions, community-level coordination and referral
• Community Health Promoters (CHPs) - 1 per 30-50 households – for nutritional
counselling on ENAs as well as for follow-up with caretakers, prevention and home
management of diarrhoea, and recognition of danger signs in childhood illness.
The experience to date demonstrated a number of positive outcomes:
• Nutrition messages are more harmonised among the different agents
• Activities of partners are coordinated at Woreda and Kebele levels
• HEWs support and coordinate community volunteers
• CHPs refer severely malnourished children to CTC
sites
• CHPs counsel caretakers on how to follow-up
severely/moderately malnourished children
• CHPs mobilise caretakers for immunisation of their
children.
Based on the experience in Bolosso Sore Woreda, ESHE
recommends:
• Ensuring nutritional counselling and health screening
for the moderately malnourished at OTP sites
• Coordinating activities in communities through HEWs
• Improving caretaker feeding practices and follow-up of
malnourished children through CHPs
• Coordinating activities of partners at the Woreda and
community levels to harmonise approaches through a
partner forum.
Picture 10: Mother showing her children’s
immunisation certificates, Bolosso Sore
Woreda
Source: ESHE
Picture 11
Source: ESHE

17. 15
4.3 CTC in an urban setting
Presentation by Yohannes Shimelis, Care Ethiopia
From October 2005, Care Ethiopia has run a CTC programme in Dire Dawa where poverty is
soaring and HIV/AIDS prevalence is high. This is the first urban programme since CTC was
adopted in Ethiopia.
From October 2005 to June 2006, a total of 974 children were admitted to OTP with 46%
coming from the poorest sub-Kebeles of Dire Dawa and 54% coming from the urban
periphery (see graph 5).
The strategies that Care Ethiopia used to give access to CTC services in Dire Dawa include:
• Volunteers screen children using a measuring stick (65-110 cm). Children with mid upper
arm circumference (MUAC) <11.5% are admitted to OTP. Children who are not admitted
to OTP are referred to the EOS as well as health and education programmes
• HBC providers work as nutrition volunteers and participate in other related tasks (EOS,
polio campaign)
• People whose HIV/AIDS status is positive are referred to a health facility that offers Anti-
Retroviral Therapy (ART) and people living with HIV/AIDS (PLWHA) associations
• Key people from the community are sensitised about CTC (Kebele political leaders,
religious leaders, representatives from health institutions, women’s affairs sector and
PLWHA associations)
• Health committee representatives, health workers and volunteers participate in regular
review workshops for monitoring, coordination and problem solving
• Women volunteers serve as role models for anti-malarial practices.
During the programme, operational challenges included:
• Care Ethiopia mobilised volunteers using well-established systems (Kebele Health
committees, HBC, HEP) which raised some issues regarding overlap: operational
similarities, targeting similarities, coverage and networking
• There is no clear-cut procedure to follow when HIV/AIDS is suspected as the underlying
cause of malnutrition. As most children are out-patient, the decision to go to voluntary
counselling and testing (VCT) centres can be taken only by the caretakers themselves.
Graph 5: Number of admissions to OTP, October 2005 to
May 2006, Dire Dawa (source Care Ethiopia)
With a recovery rate of 95%, a
death rate of 2% and a defaulter
rate of 0.3%, the performance of
the Dire Dawa CTC programme is
well within the Sphere standards.
Compared to CTC programmes in
rural areas, the main cause of
death is suspected to be HIV/AIDS,
which may also explain a higher
than average length of stay in the
programme and a lower than
average rate of weight gain.
• 10% of urban children admitted
to OTP are suspected to have
HIV/AIDS (2% confirmed) and
50% of urban deaths were
thought to be due to HIV/AIDS
• Length of stay: 50-70 days
• Weight gain: 3-4 g/kg/day.

18. 16
The lessons to be learned include:
• Volunteers need to work within their own area (e.g. sub Kebele) as transport costs are
high
• Volunteers need close support from outreach workers to reduce attrition rate and sustain
performance
• Not only mothers, but also families or secondary caretakers should be part of the
treatment as mothers often spend little time at home
• Integration of CTC with well established systems is essential:
o to gain support from the community, political figures and sectors
o to gain access to needy people
o to increase access of services to special groups, e.g. HBC providers can mobilise
PLWHA and provide comprehensive care.
4.4 Social development / Community mobilisation
Presentation by Jane Keylock, Valid International
‘Community mobilisation’ or ‘social development’ implies a range of non-clinical activities that
aim to ensure that cases of severe malnutrition can access the service. It also serves to
further increase the coverage of CTC programmes, i.e. services can reach a higher proportion
of the targeted/needy population.
Typical activities implemented in an NGO-context normally include:
• Active case-finding and tracing defaulters or absentees
o Volunteers who work either for free or outreach workers who work for an amount of
money, screen for cases or visit defaulters at home
o Volunteers/outreach workers are either fixed (e.g. people come to them to be
screened) or are mobile and travel in specific areas to screen for cases and trace
defaulters.
• Awareness raising activities to build the community’s ownership of the CTC programme
and to strengthen the referral mechanism
o Formal and informal channels of communication are used to convey information
o Events are organised for community groups and key community representatives.
• Research to understand local cultures which help shape the programme according to
cultural specificities.
As demonstrated by Concern/Valid International’s experience in Malawi (see graph 6), large
scale community mobilisation helps increase the number of people admitted to CTC
programmes even during emergencies. Early engagement with the community allows the
programme to reach optimal coverage which is the aim of NGO programmes.
Source: V. Forsythe, Concern
Picture 12: Community meeting

19. 17
With regard to therapeutic care
becoming a routine part of the
health service, the MoH needs to
define its priorities and standards
and the role that community
mobilisation will play, including:
• What is the aim of community
mobilisation and how
important is coverage
compared to not overwhelming
the system? (what level of
coverage is realistic?)
• What is the best catchment
area?
• What is the role of HEWs and
volunteers for community
mobilisation?
• Will the understanding of local
cultures impact on the
programme (e.g. consultation
of local healers)
• What long term approaches
should be adopted? (self-
referrals, identify and address
root causes of defaulting).
4.5 Therapeutic care and HIV
Presentation by Dr Agnes Guyon, Director, Linkages Project
CTC can be a non-threatening entry point for other home-based care programmes. Diets
and protocols can be tailored to HIV/AIDS patients among whom severe malnutrition is a
common condition. CTC is also appropriate for those on anti-retroviral therapy who have
additional nutritional needs as a result of the drugs. Hence, professionals who are involved in
CTC programmes should be familiar with the following messages.
1. Keep HIV positive mothers
healthy and well nourished as this
may be key to preventing post-
natal HIV transmission.
2. Keep the problem of infant
feeding and mother to child
transition (MTCT) in perspective.
The majority of babies will not
contract the virus through
breastfeeding (see graph 7).
3. Promote exclusive breastfeeding
from 0 - 6 month old babies for
HIV negative mothers and those
who do not know their status
• Introduce complementary foods at 6 months
• Encourage breastfeeding up to 24 months
• Promote maternal nutrition and health
• Promote safe sex to avoid becoming HIV infected.
Graph 6: Impact of community mobilisation on the number of
people admitted in a CTC programme, Malawi, August 2002
to March 2003 (source Concern/Valid International)
Graph 7: MTCT in an urban community with a HIV
prevalence of 12%...

20. 18
4. Counsel on optimal infant feeding practices for pregnant women who have been tested
and are HIV positive, so that they can make an informed choice about replacement
feeding or exclusive breastfeeding – see appendix 1 for more details.
5. Improve infant feeding practices, e.g. safer
breastfeeding can reduce transmission rates
(exclusive breastfeeding from 0 - 6 months;
breast health to avoid cracked nipples, mastitis
and abscesses).
6. Focus on the 7 ENAs and integrate them into
ALL contact points with pregnant women and
new mothers. ENAs are a set of key
messages with small do-able actions:
1. Optimal breastfeeding for children
between 0 and 6 months old
2. Adequate complementary feeding with
breastfeeding up to 24 months
3. Nutritional care of the sick child
4. Women’s nutrition
5. Control of Vitamin A deficiency
6. Control of anaemia
7. Control of iodine deficiency disorders.
4.6 Ready to Use Therapeutic Food (RUTF) production in
Ethiopia
Presentation by Dominique Brunet, Emergency Nutrition Coordination Unit (ENCU)
RUTF is an energy dense mineral/vitamin
enriched food, which is equivalent to
Formula 100. RUTF is oil-based with low
water activity; thus it is microbiologically safe
and can be kept for months in simple
packaging. It is easily made with low-tech
methods and is an ideal vehicle to deliver
many micronutrients as well as desired
levels of protein, fat and carbohydrates. As
it is eaten uncooked, there is no need for
other preparation and it therefore has low
labour requirements.
Ethiopia imports Plumpy’nut
®
, the RUTF made by NUTRISET
in France. Plumpy’nut
®
is recognised for its good quality, but is
very expensive (cost per MT: USD 3722.972
+ transport costs +
taxation) and there have been considerable problems with the
importation and taxation process.
Since November 2004, ‘Shalkan’, a private company in Addis
Ababa, has produced BEZA, i.e. locally produced RUTF, with
technical support from Concern/Valid International. BEZA is
recognised as a good quality product as all quality control tests have
been within normal ranges. To produce BEZA, milk still needs to be
imported from abroad, which has generated considerable delays in
the manufacturing process and maintains BEZA’s high cost (similar
cost to Plumpy’nut®
but transport costs are minimised).
2
This is an average price, source NUTRISET.
Source: Linkages
Picture 13
Source: Valid International
Picture 14: Ingredients to make RUFT, i.e. peanut
butter, sugar, dried skimmed milk, oil and a
vitamin/mineral complex
Source: Concern Ethiopia
Picture 15: Sample of Plumpy’nut
®
Picture 16: Sample of Beza

21. 19
Currently both NUTRISET and Valid Nutrition are supporting producers in Ethiopia to start
local production of RUTF.
NUTRISET Valid Nutrition
NUTRISET, a French company who
developed Plumpy’nut
®
in 1996.
Valid Nutrition are supporting a number of
producers to develop a range of quality
assured RUTF. Valid Nutrition focuses on
product research and development, e.g.
alternative recipes eliminating the use of milk
(expensive) and peanuts (risk of aflatoxin
contamination).
Use the franchising system, based on the
transfer of NUTRISET know-how to a local
independent producer. This includes
manufacturing process, quality assurance
and control, specifications of raw materials,
management tools, use of the patent license
and of the registered trade name.
Valid Nutrition provides technical support,
advice, supervision, training as well as
appropriate technology to build high quality
local production capacity. Valid Nutrition aim
to produce MT 170 RUTF in Ethiopia by the
end of December 2006.
To date, NUTRISET has 3 franchised
producers in Niger, Malawi and DRC.
NUTRISET has identified a potential
producer in Ethiopia which is expected to
start local production in October 2006.
Two local producers have been identified.
Additional local producers will be identified as
and when demand increases.
4.7 Current challenges in CTC programmes and suggested
solutions
Outcomes of group discussions
Participants were divided in five working groups and
were asked to discuss specific points of interest
regarding CTC. The aims of the working groups were
to:
• Allow time for discussion for participants to share
experiences
• Suggest some realistic measures that implementing
agencies and government departments can take in
order to move CTC forward.
Methods and implications of integrating with MoH
Participants from one group were asked to discuss
methods and implications of integration with MoH and
came up with the following suggestions:
• Ensure good communication at all levels - from a
participatory pre-planning phase, the NGO should be
recognised as a partner not as a programme owner
• Establish a nutrition policy and nominate bodies at
all levels responsible for coordinating activities
related to the integration of the treatment of
malnutrition
• Integrate various sectors to address the multifaceted
causes of malnutrition.
Source: Concern USA
Picture 17

22. 20
Moderate and chronic malnutrition
The group observed that, although chronic malnutrition
is a major public health concern in Ethiopia,
stakeholders have tended to give little attention to
moderate malnutrition. Moreover, despite the many
causes of malnutrition (such as poor health, little care
for mothers, cultural and nutritional practices, food
insecurity at household level), sectors are not
integrated to address this problem.
Therefore, the group made the following
recommendations to help tackle moderate and chronic
malnutrition:
At the national and regional levels:
• Identify which fora exist at national and regional
levels in various sectors (MoH, the DPPA,
Agriculture department, Water department, donors,
etc…) and define their objectives and roles to
improve overall effectiveness in addressing moderate malnutrition. The MoH could
coordinate the fora’s actions.
At the Woreda/District level:
• Raise the profile of and advocate for the treatment of moderate malnutrition at all levels
and address issues of prevention of malnutrition at the Woreda/District level
• Link existing aid programmes (livelihood programmes, Productive Safety Net Programme
i.e. PSNP, NGOs, MoH services) to combat moderate malnutrition
• Conduct operational research that examines the underlying causes of malnutrition.
At the community level:
• Promote ENAs in the community at different contact points – prevention of malnutrition
should be incorporated into all community based programmes
• Communicate and counsel on malnutrition to change behaviours:
o Promotion of optimal feeding practices at household level
o Information for caretakers about the consequences of malnutrition
o Promotion of prevention and home-based care practices for illnesses.
Integration between various aid programmes
To move CTC forward, the group suggested that aid programmes (such as CTC, SFP, Child
Growth Programme, EOS, EPI and PSNP) could be integrated in 4 areas:
1. Existing fora
Existing fora (e.g. multi-agency nutrition task force (MANT), emergency health and nutrition
task force (EHNTF)) need to improve their monitoring and evaluation (M&E) and reporting
systems. Above all, such fora need to be empowered to assist the integration of existing aid
programmes.
2. Protocols
Protocols should be harmonised across agencies (WFP, DPPC, UNICEF, MoH, NGOs) and
incorporate enough detail to facilitate their application in the field. These protocols should
incorporate lessons learnt from regional integration experiences and best practices.
3. Logistics Systems
By sharing information on Regional/Woreda decisions and agreements, logistics systems
from various stakeholders could be integrated for:
• vaccination logistics (EPI as part of EOS, Health Extension, and other programmes)
• food distribution and transport (PSNP, EOS, NGOs, etc)
• targeting of beneficiaries.
Source: Concern Ethiopia
Picture 18

23. 21
4. Usage and training of volunteers
Various aid programmes could integrate usage and training of volunteers by harmonising
messages and distribution systems. This would decrease the workload of volunteers and
avoid the creation of parallel systems.
Coordination of surveys, assessments, etc
Many surveys and assessments are produced at academic, national (e.g. baseline surveys)
or field levels (e.g. rapid assessment, standard nutrition surveys). The group made the
following suggestions to coordinate all of these surveys and assessments:
• Establish a strong system to ensure continuous nutrition surveillance across the country,
including monitoring of actions taken by programmes and respect of survey protocols. The
government (MoH or Ministry of Agriculture (MoA)), who is responsible for long term
initiatives, could take this responsibility
• Facilitate strong involvement and increased capacity of the Government in the area of
surveys and assessments
• Establish a survey taskforce in all
regions and ensure its permanency
• Conduct operational research to
validate survey methodologies and
avoid bias when identifying critical
areas for intervention
• Every actor should become familiar
with the survey analysis tool called
Standardised Monitoring and
Assessment in Relief and
Transitions (‘SMART’) introduced in
Ethiopia in 2006.
MUAC and coverage issues
The group highlighted the fact that the use of MUAC to measure malnourished children
generates some advantages and disadvantages:
ADVANTAGES DISADVANTAGES
- Children at high risk of malnutrition are
easily identified
- Screening and admission of children does
not use different criteria
- The use of MUAC does not require heavy
logistical support
- CVs can easily use MUAC with minimal
training
- The amount of error is less than for other
measurement techniques, such as weight for
height % of the median (W/H).
- MUAC tapes (with numbers or colours) are
not standardised
- More research is needed for 6-12 month old
children, adolescents and adults
- Discharge criteria are not clearly defined.
Therefore, the group reached the consensus that, taking into account the present situation,
children should be measured using both W/H and MUAC (with numbered and coloured
tapes), with further research conducted.
Regarding coverage, the group agreed that the 30x30 methodology is unsatisfactory. The
current methodology may be appropriate for emergency contexts but a methodology that can
be applied in every context (emergency and development) needs to be developed. Moreover,
additional data about social issues and community mobilisation should be gathered during
surveys to produce meaningful information about coverage that can be translated into actions.
Source: J. Spector, Valid International
Picture 19

24. 22
5. Appendix
Appendix 1. Counselling on infant feeding
(Source: Linkages)

25. 23
Appendix
2.
Summary
of
background
information
on
community-based
programmes
implemented
in
Ethiopia
Agency
GOAL
IMC
SC
-
US
CARE
Concern
Save
the
Children
UK
Area
of
intervention
(Woreda,
Zone,
Region)
•
Awassa
Zuria,
Sidama,
SNNPR
•
Fedis,
East
Hararghe,
Oromiya
•
Silte,
Silte,
SNNPR
Somali
Region
•
Filtu,
Moyale
and
Hudet
woredas,
Liben
Zone;
•
G.Damole,
G.
Baqaqsa
woredas,
Afder
Zone
Oromiya
Region
•
Dire,
Moyale,
Arero
and
Teltele
woredas,
Borena
Zone
•
Tullo,
Mesela
and
Dobba
woredas,
West
Hararghe
Zone
•
Karsa,
Gursum,
Gora
Gutu,
Gola
Oda,
Babile
and
Alemaya
woredas,
East
Hararghe
Zone
SNNPR
•
Boloso
Sorie,
Omo
Sheleko
and
Damot
Gale
(through
October
2006)
woredas,
Woylaitta
Zone
•
Shebedino,
Boricha
and
Hulla
woredas,
and
Konso
special
woreda,
Sidama
Zone,
SNNPR
•
Lanfuro
and
Dalocha
woredas,
Siliti
Zone,
SNNPR
•
Dolo
ado
and
Dolo
bay
woredas,
Somali
Region
(recently)
Dire
Dawa
and
Grawa,
East
Hararghe
Zone,
Oromiya
Region
•
Kalu
and
Dessie
Zuria
woredas,
South
Wollo
Zone,
Amhara
Region
•
Damot
Woyde
and
Offa
woredas
,
Woylaiitta
Zone,
SNNPR
•
Sekota,
Ziquala
and
Dahina
woredas,
Wag
Hamra
Zone,
Amhara
Region
•
Fik,
Segeg,
Duhun
and
Hamero
woredas,
Fik
Zone,
Amhara
Region
Population
(general)
•
Awassa
Zuria:
380,497
•
Fedis:
246,437
•
Silte:
203,367
•
Liben:
544,000
•
Afder:
68,000
•
Borena
Zone:
356,000
•
Woylaitta:
320,000
•
West
Hararghe:
350,000
•
East
Hararghe:
536,000
1,337,620
•
Dire
Dawa:
370,000
•
Grawa:
212,000
•
Kalu:
249,779
•
Dessie
Zuria:
261,012
•
Damot
Woyde:
236,757
•
Offa:
160,507
598,909
Under-5
population
•
Awassa
Zuria:
76,100
•
Fedis:
28,143
•
Silte:
40,670
•
Liben:
109,000
•
Afder:
13,800
•
Borena
Zone:
71,000
•
Woylaitta:
64,000
•
West
Hararghe:
70,000
•
East
Hararghe:
107,200
231,110
•
Dire
Dawa:
74,000
•
Grawa:
42,400
•
Kalu:
44,960
•
Dessie
Zuria:
46,982
•
Damot
Woyde:
47,351
•
Offa:
32,101
119,782
Prevalence
of
GAM
at
the
start
of
CTC
•
Awassa
Zuria:
8.4%
•
Fedis:
19.2%
•
Silte:
12.2%
•
Somali
estimates:
19.7%
•
Borena:
no
survey
•
Woylaitta:
8.7%
•
West
Hararghe:
7.7-12.3%
•
East
Hararghe:
11.8%;
13.9%
•
Sidama
Zone
:
Shebedino:
16%,
others
-
no
survey
•
Siliti
Zone:
no
survey
•
In
Somali
region:
19%
•
Dire
Dawa:
no
survey
•
Grawa:
11.2%
•
Kalu:
16.9
•
Dessie
Zuria:
17.2
•
Damot
Woyde:
10.5
•
Offa:
16.7
16.1%
Prevalence
of
SAM
at
start
of
CTC
•
Awassa
Zuria:
0.4%
•
Fedis:
2.9%
•
Silte:
2.0%
•
Somali
estimates:
1.7%
•
Borena:
no
survey
•
Woylaitta:
0.9%
•
West
Hararghe:
1.3%
•
East
Hararghe:
1.9%;
2%
SAM
:
1.5%
•
Dire
Dawa:
no
survey
•
Grawa:
SAM:1.2%
•
Kalu:
4.0
•
Dessie
Zuria:
3.1
•
Damot
Woyde:
1.4
•
Offa:
4.5
2%

26. 24
Agency
GOAL
IMC
SC
-
US
CARE
Concern
Save
the
Children
UK
Altitude
of
programme
area
•
Awassa
Zuria:
1,500m-2,200m
•
Fedis:
1,700-1,850m
•
Silte:
1,820
–
2,076m
•
Varies
•
Sidama
Zone:
mostly
highland
some
mid
and
low
land;
Konso:
70%
low
land,
30%high
land
•
Siliti
Zone:
low,
mid
and
highland
•
Somali
region:
low
land
•
Dire
Dawa:
<1,500m
•
Grawa:
3,300m
•
Kalu:
57%
lowland,
40%
midland,
3%highland
•
Dessie
Zuria:
53%
midland,
41%highland,
6%
very
highland
•
Damot
Wayde:
65%
lowland,
20%
midland,
15%highland
•
Offa
:
30%
lowland,
55%
midland,
15%highland
high
and
low
altitude
Main
livelihood
activities
•
Awassa
Zuria
:
Agriculture,
livestock
keeping
•
Fedis:
Cash
crop
(chat),
Mixed
Agriculture
with
livestock
keeping
•
Silte:
Agriculture,
livestock
keeping
•
Liben:
Semi-Pastoralist
•
Afder:
Semi-Pastoralist
•
Borena
Zone:
Semi-Pastoralist
•
Woylaitta:
Agriculture
•
West
Hararghe:
Agriculture
•
East
Hararghe:
Agriculture
•
Sidama
zone:
Agriculture,
cash
crop
and
love
stock
•
Konso:
agriculture,
cash
crop
and
livestock
•
Siliti
zone:
Agriculture
and
cash
crop
•
Somali
region:
Agriculture
mainly
livestock
In
all
areas
:
daily
labourers,
food
for
work
•
Dire
Dawa:
Trade,
unskilled
and
skilled
labour
and
employment,
rain
fed
agriculture
(periphery
and
mid
land),
pastoralist
and
agro
pastoralists
(low
land
•
Grawa:
Rain
fed
agriculture,
livestock
in
highland
and
limited
cash
crops
Agriculture
and
livestock
rearing
Pastoralist,
and
agro-
pastoralist
Food
security
situation
(no.
receiving
food
aid,
harvest
prediction…)
•
Awassa
Zuria:
12,700
General
Ration,
11,400
safety
net
&
5,514
EOS
beneficiaries.
•
Fedis:
113,000
on
safety
net
and
relief
assistance
including
10,178
school
feeding
and
3,837
EOS
beneficiaries.
•
Silte:
19,841
Safety
net
and
2,400
EOS.
All
operational
areas
are
food
insecure.
General
Food
Distribution,
EOS.
•
Dire
Dawa:
Rural
areas
rely
on
food
aid
and
safety
net
implemented;
Inadequate
Hagaya
rain
and
poor
harvest
are
expected;
Shortage
of
water
and
grazing
for
pastoralists.
•
Grawa:
Inadequate
Belg
rain
and
depletion
of
meher
harvest;
safety
net
implemented
in
the
woreda.
•
Kalu:
PSNP
distributed
to
63,903
Apr-Dec2006.
•
Dessie
Zuria:
PSNP
distributed
to
73,275
Jan-
June
2006.
•
Damot
Wayde:
PSNP
distributed
to
32,572
•
Offa:
PSNP
distributed
to
12,840.
Not
adequate
in
both
zones.
Health
environment
(major
diseases,
outbreaks…)
•
Awassa
Zuria:
Meningitis
•
Fedis:
Malaria,
diarrhoea
•
Silte:
Malaria
Malaria,
diarrhoea,
Acute
Respiratory
Illness
Malaria,
ARI,
diarrhoea
•
Dire
Dawa:
No
major
disease
outbreak
•
Grawa:
No
major
disease
outbreak
Malaria,
Respiratory
Tract
Infection
(RTI),
pneumonia,
Diarrhoeal
disease
Endemic
malaria,
lack
of
water
and
sanitation
facilities,
high
prevalence
of
diarrhoea
diseases
Start
date
of
CTC
programme
•
Awassa
Zuria:
June
2005
•
Fedis:
September
2005
•
Silte:
May
2006
•
Liben,
Afder:
May
2006
•
Borena
Zone:
January
2005
•
Woylaitta:
June
2004
•
East
Hararghe:
Dec.
2005
•
West
Hararghe:
July
2004
•
Konso,
Lanfuro
and
Dalocha,:
July-August
2004
•
Shebedino:
August:
2005
•
Boricha
and
Hulla:
2005
•
Somali
region:
June
2006
•
Dire
Dawa:
October
2005
•
Grawa:
August
2004
•
Kalu
&
Dessie
Zuria
:
February
2003
•
Damot
Woyde:
July
2005
•
Offa:
August
2003
October
2005
No.
&
location
of
SCs
(or
phase
1
in-patient
centres)
•
Awassa
Zuria:
2
SCs,
•
Fedis:
1
SC
•
Silte:
1
SC
•
Somali:
none
yet
•
Borena
Zone:
1
SC
•
SNNPR:
3
SCs
•
West
Hararghe:
11
SCs
•
East
Hararghe:
5
SCs
1
SC
in
each
health
centre
available
in
the
woreda
•
Dire
Dawa:
3
health
centres
and
1
hospital
•
Grawa:
1
health
centre
•
Kalu
&
Dessie
Zuria
:
1
•
Damot
Woyde
:
1
•
Offa
:
1
Sekota
hospital
and
Fik
health
centres.
Criteria
for
entry
to
in-patient
No
appetite,
+++
,
edema
or
marasmus
kwash,
MUAC
<110mm
or
WFH<70%
or
oedema
with
medical
complications
<70%
WFH
with
complications
(diarrhoea,
fever,
ARI,
or
anorexia)
Oedema
2-3,
WHM<70%,
MUAC<11cm
(Height>65cm)
with
poor
appetite
and/or
aggravating
medical
problem
WH<70%
or
MUAC<11cm
with
no
appetite,
medical
complications,
oedema+++
<6month
children:
WH<70%,
difficulty
on
suckling
irrespective
of
nutritional
status.
+++
oedema,
Poor
appetite,
Severe
anaemia,
Severe
dehydration,
Severe
pneumonia,
High
fever
Complicated
severe
and
moderate
malnourished
children

27. 25
Agency
GOAL
IMC
SC
-
US
CARE
Concern
Save
the
Children
UK
Criteria
to
move
from
SC
(in
patient)
to
OTP
(outpatient)
Appetite
restored
Oedema
resolving
Medical
complications
controlled
70%
WFH+,
appetite
and
cured
from
other
medical
complications.
Appetite
returned,
Oedema
reducing,
Stable
medical
condition
Return
of
appetite
(Plumpy
Nut
test),
Oedema
reduced
to
++
or
+,
Medical
complications
resolved
Good
appetite,
Improved
complications,
Subsidised
oedema
Uncomplicated
severe
and
moderate
malnourished
children
Criteria
for
entry
to
OTP
(outpatient)
MUAC
<110mm
(age
>11months),
WFH
<70%;
Awassa
Zuria:
Oedema,;
Others:
visibly
wasted,
2
nd
twin
<80%
WFH
or
bilateral
oedema
WHM
<70%,
Oedema
grade
1,
MUAC
<11%
(height
>65cm)
,Good
appetite,
stable
medical
condition
WH<70%,
MUAC<11cm
(from
May
2006
children
>65cm
and
MUAC
<11cm
admitted)
and
no
medical
complication,
Oedema
+
and
++
Oedema,
MUAC<11.0
cm,
ht>65
cm;
MUAC
<11.0
cm,
ht
<65
cm
and
age
>1
year;
Others:
baggy
pant,
WH
<70%,
<4kg>6
months
U
W/H<70%,
MUAC<11cm,
oedema,
twins,
etc
Proportion
admitted
directly
to
OTP
•
Awassa
Zuria:
98%
•
Fedis:
98%
•
Silte:
99%
Data
not
calculated
90%
•
Dire
Dawa:98.5%
•
Girawa:
95.5%
•
Kalu:
86.3%
•
Dessie
Zuria:
91%
•
Damot
Wayde:
88%
•
Offa:
95.3%
85%
Total
no.
of
OTP
sites
•
Awassa
Zuria:
9
•
Fedis:
5
•
Silte:
5
•
Liben:
15
•
Afder:
10
•
Borena
Zone
:
21
•
SNNPR
(Woylaitta)
:
42
•
West
H.:
35+27
handed
over
•
East
Hararghe:
32
48
•
Dire
Dawa:12
•
Girawa:8
•
Kalu:
12
•
Dessie
Zuria:
10
•
Damot
Wayde:
10
•
Offa:
10
35
sites
No
of
OTP
sites
integrated
in
health
facility
•
Awassa
Zuria:
9
•
Fedis:
5
•
Silte:
5
All
OTP
sites
are
open
in
an
existing
health
facility/health
post
except
in
Somali
where
distribution
sites
are
used.
37
•
Dire
Dawa:
12
•
Grawa:
8
•
Kalu:
12
•
Dessie
Zuria:
10
•
Damot
Wayde:
10
•
Offa:
10
19
sites
OTP
attached
to
SFP
•
Awassa
Zuria
0
•
Fedis:
0
•
Silte:
5
IMC
is
ending
its
SFP
programmes
aside
from
OTP
graduate
follow
up
for
3
months;
SFP
recovery
rates
based
on
past
experience.
All
OTP
programmes
are
attached
to
SFP
No
OTP
attached
to
SFP
•
Kalu:
no
•
Dessie
Zuria:
no
•
Damot
Wayde:
no
•
Offa:
no
19
sites
Community
mobilisation/
sensitisation
methods
Initially,
CVs
not
linked
with
health
facility
–
in
Awassa
Zuria.
Now,
for
all
sites:
CVs
integrated
with
MoH
outreach
system.
Through
community
based
organisations.
House-to-house
active
case
finding.
Community
leaders
first
assessed
than
community
volunteers
trained
for
outreach
activities.
Informal
meetings,
through
Traditional
Birth
Attendants,
Community
Health
Agents,
CVs.
Sensitisation
for
key
community
figures;
Volunteers
system
capitalised
on
well
established
mobilisation
systems.
Integrating
with
HEP;
Community
meeting;
Mother
to
mother
networking;
Integration
with
EOS
and
polio
campaign.
-
Community
volunteers
at
village
level
-
Outreach
workers
at
kebele
level
-
HEWs
at
Kebele
level
integrated
in
their
daily
routine
activities.
Active
participation
of
community
volunteers
on
sensitisation,
screening
and
follow-up
of
cases.
Discharge
criteria
Awassa
Zuria:
WFH
>85%
2
weightings
till
later
changed
to
>
80%
when
integrated
with
EOS;
No
oedema;
No
medical
complications
Fedis
&
Silte:
WFH
>80%
2
weightings;
No
oedema;
No
medical
complications
80%
WFH
except
85%
WFH
in
areas
where
there
is
no
SFP.
>80%
WHM
for
two
consecutive
weightings,
free
from
oedema
and
medical
complications
WH>80%
and
absence
of
oedema
in
two
consecutive
weighting;
And
absences
of
infections
NB:
Children
discharged
with
three
month
supplementary
food
ration
>=80%
WHM
for
two
consecutive
follow
up;
Absence
of
oedema
for
two
consecutive
follow
up;
No
medical
complications
W/H
>
85%,
no
oedema,
MUAC
>
11CM
No
of
children
treated
(SC,
OTP,
SFP)
-
Stats
based
on
2006
data
only.
•
Awassa
Zuria:
1489
•
Fedis:
1962
•
Silte:
540
•
Somali:
No
stats
yet
•
Borena:
OTP-102;
SFP-919
•
Woylaitta:
OTP-1926;
SFP-0
•
West
H.:
OTP-497;
SFP-597
•
E.
H.:
OTP-1768;
SFP
-
5237
38,030
(July
2004
to
March
2006)
•
Dire
Dawa:
OTP-823;
SC-14;
•
Grawa:
OTP-2096;
SC-76
•
Kalu:
SC+OTP
-2405
•
Dessie
Zuria:
SC+OTP
-
1910
•
Damot
Wayde:
OTP-455,
SC-62,
SFP-2608
•
Offa:
SC+OTP
-
1201
OTP-1898,
SC-86

28. 26
Agency
GOAL
IMC
SC
-
US
CARE
Concern
Save
the
Children
UK
Recovered
%
Stats
based
on
2006
data
only.
•
Awassa
Zuria:
92.3%
•
Fedis:
92.1%
•
Silte:
99.3%3
•
Somali:
No
discharged
to
date
•
Borena:
OTP-80%;
SFP-83.7%
•
Woylaitta:
OTP-92%;
SFP-N/A
•
W.
H.:
OTP-94%;
SFP-87.1%
•
East
H.:
OTP-91%,
SFP-55%
92.2%
•
Dire
Dawa:95%
•
Grawa:
86%
•
Kalu:
84.6%
•
Dessie
Zuria:
78.7%
•
Damot
Wayde:
88%
•
Offa:
92%
79%
Deaths
%
All
stats
based
on
2006
data
only.
•
Awassa
Zuria:
2.3%
•
Fedis:
1.3
%
•
Silte:
0.7%
•
Somali:
no
death
to
date
•
Borena:
OTP-0%;
SFP-0%
•
Woylattia-3%;
SFP-N/A
•
West
H.:
OTP-3%;
SFP-0%
•
East
H.:
OTP-
3%;
SFP-0.5%
1.8%
•
Dire
dawa:1.5%
•
Grawa:2.5%
•
Kalu:
5.1%
•
Dessie
Zuria:
5.3%
•
Damot
Wayde:
4.1%
•
Offa:
2.3%
1.7%
Default
%
Stats
based
on
2006
data
only.
•
Awassa
Zuria:
5.7%
•
Fedis:
6.6
%
•
Silte:
0%
•
Somali:
data
not
available.
•
Borena:
OTP-10%;
SFP-15%
•
Woylaitta:
OTP-2%;
SFP-N/A
•
West
H.:
OTP-3%;
SFP-6.7%
•
East
H.:
OTP-4%;
SFP-23%
3.4%
•
Dire
Dawa:0.3
%
•
Grawa:
3.8%
•
Kalu:
5.4
%
•
Dessie
Zuria:
6.7
%
•
Damot
Wayde:
4.1
%
•
Offa:
5.6
%
17%
Non-recovered
%
Stats
based
on
2006
data
only.
•
Awassa
Zuria:
1.8%
•
Fedis:
0.3%
•
Silte:
0%
•
Somali:
data
not
available
•
Borena
OTP-0%;
SFP-0%
•
Woylaitta:
OTP-1%;
SFP-N/A
•
East
H.:
OTP-
1%;
SFP
12%
•
West
H:
OTP-0%;
SFP-0.8%
2.5%
•
Dire
Dawa:
0.3%
•
Girawa:
0%
•
Kalu:
4.8
%
•
Dessie
Zuria:
9.4
%
•
Damot
Wayde:
3.3
%
•
Offa:
0
%
1.8%
Weight
gain
g/kg/day
Stats
based
on
2006
data
only.
•
Awassa
Zuria:
4.5g/kg/day
•
Fedis:
5.3g/kg/day
•
Silte:
N/A
Average:
4.5
kg/g/day
6
gm/kg/day
N/A
•
Kalu:
3.4
g/kg/day
•
DZ:
3.0
g/kg/day
•
DW:
2.8
g/kg/day
•
Offa:
N/A
5
gm/kg/day
Length
of
stay
for
cured
•
Awassa
Zuria:
47
days
•
Fedis:
37
days
•
Silte:
N/A
Average:
40-50
days
38
days
N/A
Kalu:
79.8
days
Dessie
Zuria:
85.4
days
Damot
Wayde:
82.5
days
Offa:
N
/A
42
days
Coverage
(method
used)
•
Awassa
Zuria:
Results
pending
(CSAS)
•
Fedis:
No
coverage
survey
•
Silte:
N/A
West
Hararghe:
61%
in
December
2004
(Valid);
CSAS
method
currently
on
process
N/A
Kalu
&
Dessie
Zuria:
77.3%
Jan/Feb
2005
period
cover,
66.4%
point
cover
(cross
sectional
survey
using
CSAS
for
strata
definition+
case
finding).
Coverage
survey
result
is
not
yet
ready.

29. 27
Appendix 3. Summary of feedback
Participants were asked to fill in a feedback form to describe how they felt about the workshop
and to make recommendations on how to improve for next time. A total of 49 forms were
completed with the results summarised below:
How the participants rated the workshop:
Description Number %
Excellent 14 29%
Good 32 65%
Average 3 6%
Total 49 100%
Thus the majority of the participants described the workshop as good or excellent. When
asked what were the most interesting aspects, answers given included; active involvement of
all partners, presence of different actors, explanation of OTP as it was a new concept for
many, group discussions.
Suggestions of how to improve the workshop included; provision of a manual of how to
implement OTP, allocate more time for all of the interesting questions and discussions,
reduce the number of participants, and encourage more participation from the Federal MoH.

30. 28
Appendix 4. List of participants
Abayneh Alemayehu MoH - Fedis Woreda
Abel Hailu (Dr) Valid International
Adem Endris MoH - Kalu Woreda Health Office
Adnew Yirga MoH - Buee health centre
Agnes Guyon (Dr) Linkages
Akako Alano MoH - Buee health centre
Akililu Ayenew MoH - Amhara RHB
Alem Greiling SC - US
Alem Hardera Goal
Amy Sink USAID/OFDA
Angle Stene IMC
Antehun Yeneabat IMC - Harar
Anwar Ali UNICEF
Anwar Yibria (Dr) Gondar University
Ashenafi Halefom EOC-DICAC
Assefa Bulcha The Carter Centre
Assefa Seme (Dr) Addis Ababa University
Aster G/Kidan (Sr) MoH - Yekatit 12 Hospital
Awala Equar Mekelle University
Ayele Atlabachew MoH - Debre Birhan Health Office
Ayele Lenja MoH - Offa Woreda
Berhanu Asfaw (Dr) WFP
Berhanu W/Senbet (Dr) DPPB - Somali
Biftu Bitew MoH - Awassa Zuria WHealth Office
Binyam Addis Samaritans Purse
Bogalech Alemu Pathfinder
Brian Mulligan ESHE
Daniel Hadgu IMC - SNNPR
Dawit Teklu MoH - Jimma ZHD
Dejene Benti IMC - Borena
Dereje Below UNICEF
Efrem Teferi (Dr) MoH - SNNPR RHB
Eleni Asmare Linkages
Emily Mates Concern
Fiften Endeg MoH - Shuromeda Health Centre
Fikir Melesse (Dr) MoH - Addis Ababa RHB
Fitsum Teshome World Vision Ethiopia
Frew Tekabe EHNRI
Gebregziabher Dori USAID
Gebrehiwot G/Wahid MoH - Nutrition Unit
Geliue Plitahard USAID/OFDA
Genene Bekele MoH - Borena ZHD
Geremew Tesfaye UNICEF
Gerenew Yadessa World Vision Ethiopia
Getachew Haile UNICEF
Girma Ashenafi MoH - Fiche ZHD
Gobane Dea FMoH Nutrition Unit
Gugsa Abate ENCU
H/Mariam Legesse (Dr) ESHE
Haimanot Bogale MoH - Sitia Woreda Heatlh Office
Jane Keylock Valid International
Jean Luboya UNICEF
Jedor Lubiya UNICEF
Jhuan Carlus UNICEF
John Augsburger USAID/OFDA
Karin Génevaux Concern
Kelbessa Beyene DPPC - Oromiya
Kidane Tsigie MoH - Dessie Zuria Health Office
Lemlem Sinhinel Concern
Lubaba Hussein Concern
Margaret Schuler SC - US
Marshet W/Yohannese MoH - Wolayita ZHD
Martha Bekele (Sr) MoH - Free Methodist health centre
Meaghan Murphy ESHE/DELIVER
Medhanit Wube FHI
Melake Demena Alemayhu University - Dean
Melkamnesh Alemu DFID
Melkamu Debay MSF - Switzerland
Melkie Edris Gondar University
Meron Berhane OCHA
Meron G/Medhin (Sr) MoH - Addis Ketema health centre
Merry G/Medhin MSF - Belgium
Mesfin Andargie Federal DPPA
Mesfin Beyene MoH - SNNPR Offa Woreda
Mesfin Mathewos Tear Fund
Mesfin Mekonnen SC - UK
Mesret Shiferaw (Dr) IMC
Million Belihu USAID
Muhiadin Haji UNICEF
Mulugeta W/Tsadik UNHCR
Orla o'Neill Concern
Rachel Onyiro ACF
Rebka Demelash UNICEF
Rumi Hulst MSF - France
Sadik Taju (Dr) Mekelle University
Samson Desie UNICEF
Seid Tesfaw MoH - South Wollo ZHD
Selamawit Dagnew (Sr) MoH - Tigray RHB
Shimeles Eshite IMC - Somali
Simon Karanja Goal
Sisay Haile MoH - Shuromeda Health Centre
Solomon Fisseha (Dr) World Health Organisation
Solomon Mogiste (Dr) SC - UK
Solomon Shiferaw Addis Ababa University
Svenja Jangjohann WFP
Sylvie Chamois UNICEF
Tayech Yimer SC - UK
Tensai Assefaw OCHA
Teshome Desta UNICEF
Tewoldeberhane Daniel (Dr) UNICEF
Tezeta Gossa (Dr) MoH - Zewditu Memorial Hospital
Tim Mander Care
Tirunesh Bune (Sr) IRC
Tsinuel Girma (Dr) Jimma University
Yacob Loha DPPB - SNNPR
Yemiru Teka MoH - Gurage ZHD
Yengusenesh Tadesse (Sr) MoH - Yekatit 12 Hospital
Yeshareg Wondimu World Vision Ethiopia
Yohannes Badie MoH - Damot Weyde Health Office
Yohannes Shimelis Care
Zelalem Kebede (Dr) Awassa University
Zeline Pritchard USAID
Zemen Abebe SC - US
Zenebu Habtu (Sr) MoH - Zewditu Memorial Hospital
Zewditu Getahun EHNRI

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Organised by Concern and Valid International with a grant from OFDA