IRT
MoYWA
GoE
HDA
HEP
HEW
HMIS
INGO
IMNCI
IYCF
KAP
List of acronyms
AGP
APDA
AR
CBN
CBNC
Agriculture Growth Programme
Afar Pastoralist
Association
Annual Review
NGO
Development
NNCB
NNTC
Community-Based
Programme
Nutrition
Community-Based New Born Care
NNP
OTP
CHD
CMAM
DFID
DHS
Community Health Days PFSA
Community Management of Acute
Malnutrition
Department
Development for International
Demographic and Health Survey
PHCU
PLW
PSNP
EOS
EPHI
FMoH
GMP
Extended Outreach Strategy
Ethiopian Public Health Association
Federal Ministry of Health
Growth Monitoring and Promotion
RHB
RNCB
RNTC
RUTF
Government of Ethiopia SAM
Health Development Army
Health Extension Programme
SBCC
SNNPR
Health Extension Worker
Health Information Management
System
International
Organization
Non-Governmental
Integrated Management of Neonatal and Childhood Ilness
SUN
TFP
UNDRS
UK
Infant and Young Child Feeding UNICEF
Knowledge Attitude and Practice VAS
MDG
HACT
Millennium Development Goals VfM
Harmonised Approach to Cash
Transfer
WASH
Integrated Refresher Training ZNTC
Ministry of Youth and Women Affairs
Non-Governmental Organization
National Nutrtion Coordination Body
National Nutrition Technical Committee
National Nutrition Programme
Outpatient Therapeutic Program
Pharmaceutical Fund and Supplies Agency
Primary Health Care Unit
Pregnant and Lactating Women
Productive Safety Net Program
Regional Health Bureau
Regional Nutrition Coordinating Bodies
Regional Nutrition Technical Committees
Ready to Use Therapeutic Food
Severe Acute Malnutrition
Social Behaviour Change Communication
Southern Nations, Nationalities and People's
Region
Scaling Up Nutrition
Therapeutic Feeding Programme
United Nation Developing Regional States
United Kingdom
United Nations Children’s Fund
Vitamin A supplementation
Value for Money
Water, Sanitation, and Hygiene
Zonal Nutrition Coordinating Body
1

Annual Review - Summary Sheet
Title: Accelerating Reductions in Undernutrition in Ethiopia
Programme Value: £39,300,000 Review Date: March, 2015
Programme Code: SC130737
Summary of Programme Performance
Year
Programme Score
Risk Rating
2013
B
Low
Start Date: January,
2014
2014
A
Low
End Date: 31 December 2017
Summary of progress and lessons learnt since last review
Poor nutritional status of women and children continues to be a significant public health problem in
Ethiopia, despite recent trends showing a decline in all the three nutritional status indices (height-for-age, weight-for-height, and weight-for-age) since 2000. The national level of chronic malnutrition, as measured by stunting, was at 44 per cent in 2010, making Ethiopia the 7 th highest in the world for rates of stunting and contributing 3.5 per cent to the global total of stunted children. Likewise, Ethiopia is also one of the ten countries that account for 60 per cent of the global burden of wasting (acute malnutrition) in children under 5 years old. While wasting rates are high even during ‘normal’ years, in times of stress wasting rates rise to alarmingly high levels and regularly exceed emergency thresholds.
During 2014, most of the high impact nutrition interventions of this programme remarkably exceeded expectations and millions of children have already been reached.
For instance,
3,214,432 children under five years old in the four programme regions with high stunting rates were reached with Vitamin A Supplementation (VAS), while a further 2.4 million children two to five years old were dewormed. Additionally, 417,389 pregnant and lactating women (PLW) were screened for malnutrition, while the project has also delivered effective services to treat severe acute malnutrition for
72,467 severely malnourished children under five years old (Jan-Dec). Infant and Young Child
Feeding (IYCF) behaviour change messages were provided in Afar and Benishangul Gumuz through mother-to-mother support groups, and though the provision of support with Growth Monitoring and
Promotion (GMP) in Amhara and Tigray. The bi-annual nutrition surveys continue to be successfully implemented - providing timely nutrition trends. Multi-sectoral Nutrition Coordinating Bodies and
Technical Committees have been established at federal and regional levels, with capacity building sessions carried out. Less progress has been made to implement effective approaches to improve infant and young child feeding, and development of IYCF communication strategy has been delayed due to delays in field implementation of Knowledge, Attitude and Practice (KAP) assessments,
DFID provided an additional tranche of funds (GBP three million) to UNICEF in December 2014. This has been used to purchase zinc supplements for use in diarrhea treatment in the programme regions, and to purchase additional Ready to Use Therapeutic Food (RUTF) in non-programme regions. The supplies have been ordered with delivery expected to take place early to mid-2015. The zinc will cover the estimated population of 3.5 million children at 60 per cent coverage for approximately three diarrheal episodes over two years. The additional RUTF will be used to treat severe acute malnutrition benefiting an approximate 27,000 children nationally.
The main lesson learnt is that the absence of multi-sector nutrition sensitive programmes to address the underlying and root causes of under nutrition could undermine the impact of nutrition specific interventions of the project in reducing undernutrition, especially stunting. There is high need for DFID and other development partners to be more coherent in mainstreaming explicit nutrition activities, considerations and indicators in the five year and annual work plans of key sectors (e.g. Agriculture,
Education, Industry, Trade etc...) that could address these causes among at-risk populations. Some development partners have already started supporting efforts to mainstream nutrition in the PSNP and
AGP2. DFID should accelerate its support to this approach.
2

The Federal Ministry of Health (FMoH) has mandated that all VAS should be transited into the routine health service delivery, which is different from when the Business Case was developed. There is concern that a decrease in service coverage could result in woredas where this transition has occurred.
Therefore, the second lesson learnt is that the nutrition specific interventions now need to be brought more closely within the overall routine health service delivery system and that nutrition actors should collaborate with health counterparts to achieve health system strengthening for health including nutrition.
UNICEF has been discussing with the FMoH on how to best mitigate the risk of a drop in coverage and
DFID is closely following on the outcomes of further discussions and possible mitigating actions. The final lesson this year is that advocacy for the development of a strong accountability mechanism for nutrition that will integrate with already existing frameworks of the key sectors that signed the National
Nutrition Program (NNP) should be considered as a high priority. This can be highly effective to make key sector programs more nutrition sensitive. Efforts are underway to make PSNP, AGP2 and education programs more nutrition sensitive.
Summary of recommendations for the next year

The high impact nutrition interventions need to continue to be supported and maintained.
UNICEF must work closely with health sector to ensure any planning, capacity development and reporting for nutrition is coordinated with routine health service delivery system. UNICEF and
DFID should also seize all opportunities to integrate the nutrition programme with their existing health and water, sanitation and hygiene programmes to promote synergy on the impact of their respective programmes.

There is a need for continued advocacy with FMoH on how to mitigate the risk of a service coverage drop for VAS when transited from CHD to routine while using the transition process as an opportunity for a more sustainable and cost effective programming.

The KAP assessments need to be accelerated in order to complete field work prior to the 2015
Ethiopian elections.

The planned intervention to produce community level Complementary Food could not be started as the pilot of this intervention (not DFID supported), which was supposed to provide lessons learned and inform on the implementation under the DFID project, has faced delays in implementation. There is still a lack of adequate evidence to justify moving ahead with this activity and investing resources. UNICEF should submit a proposal to DFID by early 2015 to reprogramme the Complementary Food funds, along with funds for Albendazole and iron, since
FMoH has taken over the procurement.

Operational research topics need to be discussed, prioritzed and supported in partnership with the Ethiopian Public Health Institute (EPHI) in early 2015. Existing nutritional status data such as the results from the periodic nutrition surveys in hot spot areas could serve to inform the operational research to look into the factors behind variations in nutritional status.

There is also a need for continued scale-up of Outpatient Therapeutic Programme (OTP) and
Stabilisation Centres (SC) in Afar and Benishangul Gumuz (BG), as well as continued provision of supportive supervision in these regions with a poorly developed Health Extension Program
(HEP).

The transition of the supply chain management to the Pharmaceutical Fund and Supply Agency
(PFSA) needs to continue to be supported, particularly for RUTF, without compromising VfM.

The revision of the National Nutrition Programme (NNP) needs to be fully supported along with a clear plan for multi-sectoral actions.

There is high need for continued support and advocacy for a clear governance and accountability mechanism for nutrition, especially at regional and woreda levels.

There is also a need the NNP to establish a strong accountability mechanism that will integrate with already existing frameworks at regional and woreda levels.

Efforts need to continue to ensure that explicit nutrition activities and Government resources are included in annual work plans of key nutrition sensitive sectors other than health (e.g.
Agriculture, Education, Industry, Trade etc...).

Some milestones for output indicators in the existing logframe need to be updated to more realistic targets.
3

A. Introduction and Context (1 page)
DevTracker Link to Business Case: http://devtracker.dfid.gov.uk/projects/GB-
1-202890/documents/
DevTracker Link to Log frame: http://devtracker.dfid.gov.uk/projects/GB-
1-202890/documents/
Outline of the programme
Key expected outputs at the end of four years include:

Reduced under 5 mortality rate from 68/1000 live births to 50/1000 live births

Reduced neonatal mortality from 29/1000 to 19/1000 live births

Reduced stunting from 44.4% to 38%

Reduced wasting from 9.7% to 5%

Reduced underweight from 28.7% to 23%
The two main outcomes of the programme are to 1) increase the coverage and uptake of high impact nutrition and childcare interventions so as to prevent and treat malnutrition in the programme regions, and 2) strengthen an evidence based multi-sectoral response to under nutrition in Ethiopia.
Key outputs by the end of 2014 included:

3,051,700 children aged 6 - 59 months received Vitamin A supplementation in programme regions.

67,950 of children accesed CMAM services.

1,919,210 children aged 2-5 years received deworming in programme regions.

339,200 pregnant and lactating women (PLW) screened for malnutrition.

35% of women attending antenatal care - Amhara and Tigray (one visit as proxy for receiving iron tablets).

25% of children under 5 years of age received zinc for diarrhoea treatment (Amhara and Tigray).

80% of children 6-59 months screened for acute malnutrition.

115,000 children under 2 years participated in monthly Growth monitoring and Promotion (Amhara and Tigray).

70% of districts from programme regions submitted timely data and reports on nutrition interventions.

21 nutrition surveys implemented on seasonal calander.
4

B: PERFORMANCE AND CONCLUSIONS (1-2 pages)
Annual outcome assessment
The full list of outcome indicators and milestones for this programme is given in Annex 1. It is estimated that the overall outcome of the programme will be reached by the end of 2017. Though it is difficult to measure the effectiveness at this point there is a high achievement of programme outputs, as measured by the indicators. It is also evident that beneficiaries reached with this intervention are from the most disadvantaged areas, as well as those with the highest stunting rates, particularly in Afar and
Benishangul Gumuz. Government systems and staff have been capacitated to deliver with more quality and coverage because of this programme, who otherwise were constrained to dealing with emergency cases previously.
Overall output score and description:
Overall the programme scored an A.
Most of the high impact nutrition interventions of this programme remarkably exceeded expectations, meriting an A+ scoring. However , t he programme score results from of a reporting gap in 2014 from the Tigray Regional Health Bureau on the number of children under two years of age participating in monthly Growth monitoring and Promotion Program (output 2 indicator 3). As we have not received this report, we cannot score this component.
Key lessons
Under nutrition,especially stunting, will only be reduced if there is investment in programmes to address the underlying causes of the problem. The nutrition specific interventions on their own, even if delivered at scale, will have limited impact. Therefore, efforts need to continue to ensure that explicit nutrition activities are embedded in Government annual work plans of key nutrition sensitive sectors other than health (e.g. Agriculture, Education, Industry, Water, Finance Trade etc...). The DFID-supported nutrition project is intended primarily to reduce mortality and undernutrition among vulnureble groups. Based on recent survey data, mortality rates and undernutrition have shown improvments in Ethiopia. Although it is impossible to attribute this to delivery of the nutrition-specific interventions it is plausible that consistent availability of treatment of severe acute malnutrition and other nutrition specific interventions is contributing to keeping mortality under control and reducing undernutrition. Whilst improved infant and young child feeding practices (which is one element of the nutrition specific interventions) could help reduce undernutrition, the potential impact of these components of the nutrition specific interventions could be undermined by high rate of infection, inadequate availability and access to good quality preventative and curative health services, inadequate maternal, neonatal and child health care and problems with water, sanitation and hygiene. This programme has provided a package of high impact nutrition and newborn interventions in the four worst-affected regions of Ethiopia which will obviously improve the nutritional status of women and children under five years old and contribute to reduction in child mortality. However, to maximize the reduction in undernutrition and mortality, it needs to be complemented with a multi-sectoral package of nutrition-sensitive interventions targeted at those at risk.
Although the NNP sets initiatives, indicators, targets and recommendations for nutrition sensitive sectors, there is no actual mechanism to measure performance at various levels. It is now becoming evident that the NNP lacks a strong accountability mechanism that will integrate with already existing frameworks of key nutrition-sensitive sectors (e.g. Agriculture, Education, Industry, Water, Finance Trade etc...).
The routine health delivery system has been able to accommodate the delivery of effective treatment for severe acute malnutrition and most other nutrition-specific interventions. However, it needs further support to fully integrate VAS, screening and IYCF into the routine health service delivery. The Federal
Ministry of Health (FMoH) has mandated that all VAS is to be transited into the routine health service delivery, which is a different situation to when the Business Case was developed. There is concern that in woredas where this transition has occurred a decrease in service coverage could result. Therefore, the key lesson learnt is that the nutrition specific interventions such as VAS now need to be brought more closely within the overall routine health service delivery system and that nutrition actors should collaborate with health counterparts to achieve health system strengthening for health including nutrition.
5

Has the log frame been updated since the last review?
The log-frame was mainly developed by consultants that were recruited to draft the Business Case . The last annual review identified gaps and errors in the previous logframe and the need to revise the log frame was mentioned as one of the key recommendations. Hence, the log frame was revised in 2014 based on available information systems in Ethiopia, without creating new systems and indicators, which accurately reflect progress towards achievement of the outcomes and outputs. The revised log frame was approved by UNICEF and DFID (including through the Operational Excellence team) and is reflected within this annual review reporting – this has allowed improved reporting and understanding of the situation and progress.
Unfortunately, there are some remaining errors on the revised log frame such as 0 milestones for 2014 output indicators 3.1, 4.3, 5.1, and 5.3. Therefore, these output milestones in the logframe need to be updated after this AR to provide more realistic and suitably ambitious targets.
C: DETAILED OUTPUT SCORING (1 page per output)
Output Title
Output number per LF
Risk:
1
Low
Improved nutrient intake of under 5 children and
PLW
Output Score A+
Risk revised since last
AR?
N
Impact weighting (%): 40
Impact weighting % revised since last AR?
Y
Progress of output 1 against expected milestones:
Indicator(s)
Percentage of children aged 6-59 months who received Vitamin A supplementation in programme regions
Milestones (2014)
Amhara CHD: 90% (1,800,000),
Amhara routine: 55% (286,000),
Tigray: 90% (594,000), Afar: 90%
(239,400),
(132,300)
B/Gumuz: 90%
Total= 3,051,700
Percentage of children aged 2-5 years who received deworming in programme regions
Percentage of Pregnant and
Lactating Women (PLW) who were screened for malnutrition
Percentage of women attending
ANC - Amhara and Tigray (one visit as proxy for receiving iron tablets)
Proportion of children under 5 years of age who received zinc for diarrhoea treatment
Percentage of health posts in programme area that have
Gentamicin Injection (CBNC)
Percentage of health posts in programme area that have at least one HEW trained on CBNC
Amhara: 90% (1,186,200),
Amhara routine: 55% (188,650),
Tigray: 90% (423,000), Afar: 90%
(39,600), B/Gumuz: 90% (81,760)
Total = 1,919,210
Amhara: 40% (209,000), Amhara routine: 40% (51,200), Tigray:
40% (69,400), Afar: 40% (9,600)
Total = 339,200
35%
Amhara and Tigray: 25%, Afar and B/Gumuz: 0%
0%
0%
Progress
Amhara CHD: 93.4% (1,866,318),
Amhara routine: 58% (299,832),
Tigray: 97% (646,230), Afar: 97%
(257,417),
(144,635).
9.4%
9.4%
B/Gumuz: 98.4%
Total round 1 (Jan-
Jun): 3,214,432 ; Total round 2
(Jul – Dec, not complete): 257,417
Amhara: 99% (1,303,588), Amhara routine: 61% (208,435,), Tigray:
101% (413,974), Afar: 96%
(167,893), B/Gumuz: 105%
(99,886). Total round 1 (Jan-Jun):
2,193,776 ; Total round 2 (Jul –
Dec, not complete): 169,081
Amhara: 39% (201,793), Amhara routine:
66% (84,825), Tigray: 60% (97,622), Afar:
94% (33,149). Total round 1 (Jan-Jun):
417,389 ; Total round 2: 265,267 (Jul –
Dec, not complete): Amhara: 232,118 and
Afar: 33,149
35%
Amhara and Tigray: 27%
6

Key Points
CHD/EOS - For the Child Health Days (CHD) and Expanded Outreach Support (EOS), which support vitamin A supplementation for children 6-59 months, deworming for children 2-5 years, and nutritional screening for pregnant and lactating women, January to June implementation was performed as per the plan and targets have been achieved. July to December performance lacks Tigray quarter 3 report. In quarter 4, Amhara, Benishangul Gumuz and Tigray will conduct VAS in December, so reports are not yet available. UNICEF has indicated that Vitamin A implementation coverage in the agrarian regions of
Amhara and Tigray is declining as these regions have transited from the CHD implementation modality to routine implementation through the HEP. In Amhara, 27 woredas have transited from CHD to routine in 2013/2014 and the Government has envisaged transiting more - to 67 woredas in 2014/2015. In
Tigray, the CHD have been transited fully to routine VAS implementation in all the 46 woredas. This has adversely affected the VAS implementation coverage. Another challenge raised by UNICEF (in the third quarter review meeting) is that funds from DFID allocated for the purchase of Albendazole cannot be used, as the Government has purchased Albendazole for three years.
CBNC -Community-Based Newborn Care (CBNC) zonal level project launching was conducted in West
Gojam and North Shewa zones of Amhara and South Eastern zone of Tigray Region. Representatives from the regional health bureaus, zonal administration offices, zonal health department, woreda health offices and primary health care units have attended the events with a total of 286 participants. The events were used as a great opportunity to create a shared responsibility to implement and promote good understanding of the CBNC project, project goals, objectives, activities, roles, and responsibilities.
Moreover, a discussion has been held on how to accelerate the implementation to save more newborns and children.
To produce a pool of CBNC training facilitators, two Training of Trainer’s trainings were organized in
North Shewa and West Gojam zones of Amhara Region. Through this training, 60 training facilitators were equipped with the necessary skills to roll out CBNC trainings to HEWs.
To date, trainings have been rolled out through four sessions to equip 155 HEWs (500 more are planned to be trained in December) with the necessary skills to identify and treat sick newborns. The trainees are from 77 HPs (250 more are planned to be reached in December) drawn from North Shewa and West
Gojam zones of Amhara Region. The HEWs have collected their registers and supplies so that they will start providing CBNC services as soon as they return to their respective health posts.
UNICEF has printed the training materials, guidelines and job aids, and distributed them to the project sites. The necessary supplies and medicines have also been procured and distributed; these include
Gentamycin injectable, Amoxicillin dispersible tablets, syringes, slings for hanging baby scales, timers and thermometers.
UNICEF has also pointed out recent challenges that were faced in Tigray, as the region prioritized the implementation of polio campaigns and integrated supportive supervision – not giving enough time to start the HEWs training in the region.
The CBNC milestones for the end of 2014 were 0% as it was envisaged that the time necessary to plan, sensitize, establish contracts and begin implementation would take more than one year. However, the project was able to make the above achievement.
Zinc for diarrhea treatment - UNICEF is in the process of procuring 1,330,000 packs (13,300,000 doses) of Zinc dispersible tablets based on the quantification done by FMoH. As the shelf life of Zinc DT is shorter (two years), the shipment will arrive in batches. The first batch is expected to arrive at the end of the first quarter of next year.
Iron folate has been procured by FMoH/PFSA for 2014 and 2015 through other sources; thus, UNICEF was asked not to procure. The indicator can still be tracked to see performance, but note that there have been no inputs provided from UNICEF/DFID for 2014, nor will there be in 2015. It has been suggested to
7

look to reprogramme this fund into nutrition-sensitive programmes such as social protection and agriculture.
Recommendations
EOS/CHD – UNICEF should continue advocacy with the FMoH on how to mitigate the risk of a service coverage drop for Vitamin A supplementation when transited from CHD to routine. UNICEF should become more involved in health system strengthening analysis and support taking on board the specific challenges that nutrition-specific interventions (including VAS and screening) present. UNICEF has agreed to regularly communicate with DFID on the progress of the transition and discussions held with
FMoH on ways to strengthen routine service delivery.
UNICEF should draft a proposal for the reprogramming of the funds allocated for the procurement of albendazol into nutrition-sensitive programmes/ investments, especially in the agriculture sector .
CBNC –UNICEF should ensure that CBNC is prioritized in Tigray region and activites such as completing HEWs training in all zones, training HEP supervisors and Primary Health Care Unit (PHCU) staff on Integrated Management of Neonatal and Childhood Ilness (IMNCI) and supervisory skills, conducting post-training supportive supervision and joint supportive supervision, conducting performance reviews and clinical mentoring meetings and monitoring of the implementation by using agreed upon indicators are implemented in the first six months of 2015.
8

Output Title Improved knowledge of PLW and improved infant and young children feeding practices
Output number per LF 2
Risk:
Risk revised since last
Medium
N
Output Score B
Impact weighting (%): 20
Impact weighting % Y/N
AR? revised since last AR?
Progress of output 2 against expected milestones
Indicator(s)
Number of women's support groups established (Afar 32 rural woredas,
B/Gumuz 20 rural woredas)
Milestones
0
Progress
Afar: 90 support groups established (Megelle
8, Amibara 20, Asyieta 28 and kori 26)
BG 129 support groups established (Assosa
41, Yaso 28, Maokomo 60)
Number of women’s support group IYCF sessions conducted (one meeting per month per group)
Number of U2 children participating in monthly Growth monitoring and
Promotion (Amhara and Tigray)
0
Tigray: 35,000
(52%),
Amhara:
80,000 (36%)
Total =
115,000
Afar: 1080, BG: 1548 (inclusive of December,
2014)
Amhara monthly average is 88,000 children per month, but the highest month was June, with 110,000 children. Tigray RHB has not submitted reports in 2014 due to conflict with
Health Management Information System
(HMIS). How to resolve this was discussed with FMOH; they agreed to address it internally. The estimated number based on the last reported data is around 30-32,000 per month. Total estimated = 118,000
Key Points
Technical Assistance – It has been reported that UNICEF has recruited two technical assistants to support the scale up of DFID supported activities, one each in BG and Afar. Additionally, UNICEF is in discussion with Save the Children to develop a partnership agreement to support the scale up of IYCF practices in 11 woredas in Afar, and to build upon the capacity of the Government in order to sustain efforts being made.
IYCF - A National Training of Master Trainers on community IYCF counselling was conducted in
February 2014, with 29 participants drawn from all the programme regions. In BG, two follow up ToTs were held, with around 60 woreda health office and health center staff trained. The training was then cascaded to 20 woredas with 651 HEWs and 555 Health Workers trained on community IYCF. With these trainings, the assumption is that the woreda health staff have now the skills and knowledge to pass on to HEWs in order to scale up implementation of the mother-to-mother support groups. The planned
KAP study will ascertain if the trainings will actually translate into improved practices.
Additionally in BG, establishment and training of the HDA in all woredas was supported by DFID funds.
Regional and zonal level advocacy workshops were held for high-level officials and health professionals.
Then trainings were conducted for woreda administrators, HW and HEWs, with around 3,900 (1,300 female) participants. The cumulative results show that 207,500 (103,500 female) community members were mobilized in all woredas. 25,650 one-to-five structures and 5,760 health development groups were established. These structures will help to enhance the health development system at the grass root level and play a critical role in implementing the community-based nutrition programs.
In Afar, the mother-to-mother support groups in four woredas have been continuing their monthly regular meetings to discuss IYCF practices. These were established as part of the joint UN DRS programme, but are now supported under this programme. Around 52 per cent (51.8%) (i.e. 29 kebeles in four DRS woredas) have a total of 90 mother-to-mother support group meetings monthly. For BG, 129 mother-tomother groups have been formed in 30 kebeles in three woredas. It was envisaged that the time
9

necessary to plan, sensitize, establish contracts and begin implementation would take more than one year, paraticularly given the context of these regions, with less developed systems. Based on this, the milestone for the end of 2014 was 0. As noted in the text, this activity was under establishment with a different funding source in four woredas. However, the funding source expired. Support for the activities was assumed under this project. Because of this, there were results which could be reported in 2014.
Therefore, this project cannot claim all the results related to the mother-to-mother support groups indicated on the above table.
Community-based nutrition (CBN) - UNICEF’s annual report indicated that 40 woredas (30 in Amhara and 10 in Tigray) are currently being supported for CBN. CBN consists of child growth monitoring and counselling for children who are growth faltering. This is a strong community mechanism for delivery of messages on the promotion of appropriate feeding practices . The CBN package offered at community level consists of GMP, IYCF counseling and Community Conversation. The CBN program has been in operation since 2008 (non-DFID funding) and is currently being implemented in more than 300 woredas in Oromia, Amhara, SNNPR and Tigray. The under-2 children Growth Monitoring and Promotion (GMP) participation rates have remained low, between 30 and 40%, both in Amhara and Tigray. Monthly GMP data collected by Health Extension Workers, and delivered to the Woreda, Zonal, and Regional Health offices is used to monitor CBN implementation and yield information to further shape the programme.
Key indicators from monthly programme data used to assess progress include: Participation rate,
Underweight and Severe Underweight Prevalence of programme participants, and Kebele and Woreda level reporting rates. Analysis on these indicators using programme data is stored in the Excel-based
CBN Database for all regions. UNICEF mentioned that Tigray RHB is not currently reporting the CBN monthly data due to an issue with the regional HMIS. There has been a discussion with FMoH on how to resolve this and agreement has been reached to manage it internally. DFID will be updated as events unfold.
The CBN impact assessment study, completed in May 2012 by Tulane University, indicated early success in reducing under-2 stunting prevalence by 4 to 5 percent per annum in the project area, compared to a nation-wide 1.3 percent per annum decline between 2000 and 2011 (DHS data). The programme has shown a consistent downward trend in underweight prevalence over time, with 1.8% reduction in CBN implementing woredas.
Complementary Feeding - Community level production of complementary food was one proposed activity in support of improving complementary feeding practices for children aged 6-23 months under this programme. However, the pilot of this intervention (not DFID supported), which was supposed to provide lessons learned and inform on the implementation under the DFID project has faced delays in implementation. Because of this, there is still a lack of adequate programme implementation for lessons learned to justify moving ahead with this activity and investing resources when the activity is still untested. This was discussed at the joint quarterly review meeting, and, in order to mitigate the risk of this activity, UNICEF agreed to submit a proposal for the reprogramming of these funds. It was suggested that alternative options could be implemented regarding the promotion of appropriate child feeding practices, using the same platform i.e. women’s groups, such as demonstration, home production accompanied by behaviour change communication on IYCF and hygiene.
KAP – KAP surveys, which will provide a foundation to understand the barriers and solutions to improving child care practices and develop a comprehensive communication strategy, are still in the planning phase but are progressing. UNICEF reported that it had repeated poor experiences with poor performance of local contractors for nutrition data collection and analysis. UNICEF reported that Tulane
University has now been contracted to develop the methodology for a qualitative and quantitative assessment. They will also develop the training material, questionnaires, oversee the data collection and carry out the analysis and report writing. Additionally, UNICEF is contracting Save the Children to facilitate the data collection, as they have teams of data collectors on permanent hire and have a good reputation for survey field work. The two survey protocols have been developed, but the contractual arrangement with Save the Children has not yet been finalized. The contractual process encountered significant delays, resulting in delayed field implementation. This will lead to a delay in developing the
IYCF communication strategy. The original timeframe was that the KAP assessments would be completed in 2014, but this is now pushed to the first half of 2015 due to the delays. For future
10

programmes, discussions with possible contractors and establishment of Long Term Agreements should take place prior to programme implementation, which may lead to shorter contractual periods.
Recommendations
IYCF – UNICEF has to continue support to target Regional Health Bureaus(RHBs), especially in Afar and BG to scale-up on the mother-to-mother support groups and IYCF trainings. In 2015, UNICEF should finalize the development of a comprehensive communication strategy considering the context in each region.
Community-based nutrition (CBN) - UNICEF should focus on increasing CBN participation rates. All regions should be consistently reporting participation rates over 50%, since high coverage is key to maximizing the impact of CBN. As regards the reporting gap of the CBN monthly data, UNICEF needs to ensure that agreement is reached with the Tigray RHB and organise reporting in early 2015. This is significant as this problem has brought down the overall score under this output, and indeed the overall
AR score.
Complementary feeding – UNICEF should submit a proposal for reprogramming of the funds that were meant to support local production of complementary food early in 2015.
KAP - UNICEF should work to finalize the partnership agreement with Save the Children for the data collection aspect of the KAP qualitative/quantitative assessment so that the Communication Strategy can be developed and implemented, particularly in Afar and BG, where little is known of IYCF practices and barriers. UNICEF has to ensure that data collection is completed before the 2015 Ethiopian election in
May, which could potentially cause disruption in fieldwork. UNICEF, together with Tulane and Save the
Children, should take actions in order to meet this target, such as recruiting more field staff to lower the number of days in the field. UNICEF has to accelelerate implementation of the KAP assessments.
11

Output Title Improved access of children under 5 years to
Community Management of Acute Malnutrition
(CMAM)
Output number per LF
Risk:
3 Output Score A+
Impact weighting (%): 25
Risk revised since last
AR?
Low
N
Progress of output 3 against expected milestones: revised since last AR?
Y
Indicator(s)
Number of children accessing CMAM services
Milestones
67,950 (in the 4 target regions)
Progress
(Data available from Jan-Dec)
72,467* in the 4 target regions)
Percent of children cured or recovered after receiving CMAM treatment
80% 88%
Percent of children 6-59 months screened for acute malnutrition
*Tigray reporting has been low in 2014 (74%), so actual numbers of children treated for SAM should be more than the reported figure.
80% First round, 88%, second round 82%
Key Points
In 2014, a total of 72,467 severely malnourished children under five years old were treated with a cure rate of 88%. In 2014 (Jan-Nov), the number of CMAM sites increased from 3920 to 4229 in the four target regions. The increase in the number of CMAM sites was remarkable in BG which was 182. The achievement has already exceeded the 2014 milestone of treating 67,950 severely malnourished children under five years old.
Community management of SAM in Ethiopia is now integrated into the HEP, and thus continuous and predictable supply support is needed, particularly since UNICEF remains the sole provider of RUTF.
Previous funding was only available through humanitarian channels and thus short-term in duration, causing unnecessary pipeline breaks. The support from DFID under this project is the first predictable multi-year funding source that has ever been secured by UNICEF for the procurement of RUTF and related SAM supplies. In 2014, 73,621 cartons of RUTF which will treat approximately 80,000 children for SAM were secured. Total reported cases of SAM treated were 72,467.
In the coming three years, the CMAM services are expected to be expanded and integrated as a routine service in every health post for uncomplicated cases of SAM, and at least one Stabilisation Centre (SC) per woreda (district) will address complicated cases of SAM. This means CMAM will be fully integrated into the public health system of Ethiopia where a severely malnourished child can access treatment in any health facility in the same way as a child with another disease such as malaria.
The current National Nutrition Program (NNP), considers CMAM as an integral aspect, not only of emergency response but of the overall resilience strategy of MoH. However, ensuring continuous access to quality CMAM services and securing procurement of therapeutic food for CMAM through multi-year and predictable funding is still a concern for the sustainability of the intervention.
12

The project intends to strengthen the government supply chain and logistics management through progressively transitioning the CMAM supply chain management into the government’s Pharmaceutical
Fund and Supplies Agency (PFSA) of the MOH. UNICEF is well placed to work with MOH to enable smooth and progressive transition of management of CMAM supplies from UNICEF to PFSA.
The CMAM data, which consists of monthly routine SAM data (admission and performance), is currently used for situation monitoring purposes. Instead of waiting for nutrition survey results, partners can easily identify the progress or deterioration of a given nutrition situation and prepare for early action through having this data in time. Additionally, the data is used during the woreda prioritization exercises (multistakeholder) which identify the woredas at risk.
According to UNICEF’s own annual review, in Afar, 87 HWs were trained on SAM case management, with plans to train an additional 600 HWs in December. In BG, 65 HWs were trained, strengthening the facility level treatment capability for SAM, as well as strengthening the capability of HWs to provide supportive supervision to HEWs. Amhara Region has a plan to train 170 HWs as master trainers in the second quarter of EFY, with subsequent cascade trainings to 460 HWs.
UNICEF reported that the number of OTP sites in Afar has increased by 54 in 2014 (Jan-Nov), while the number of SC for complicated cases of SAM has increased by nine. For BG, OTP sites increased by 182 in 2014, while SCs increased by five. Increased numbers of OTP and SC sites allow greater access for malnourished children, increase awareness about programme availability, and reduce travel time.
Additional technical support is being provided to Afar Region through a Project Cooperation Agreement which was established between UNICEF and Afar Pastoralist Development Association (APDA).
Together, UNICEF and APDA are expected to strengthen CMAM support to the hard-to-reach populations of Elidaar, Afdera and Teru. Technical support is being provided to strengthen screening and treatment in all health centres and health posts; with a view to establishing a mobile out-patient therapeutic programme for populations who cannot reach government facilities, thus strengthening monitoring.
UNICEF’s annual report indicated that CMAM monitors have been deployed to both Afar and BG, with the objective to review and assess service provision and quality and to provide on-the-job mentoring as needed. In 2014, 24 woredas in BG and 57 woredas in Afar were covered.
Recommendations
CMAM is now a well-functioning system, incorporated into HEP, throughout the agrarian regions.
However, due to the poor capacity of the HEP in Afar and BG, efforts need to continue so as to strengthen and expand CMAM in these regions. The two technical assistants, in addition to APDA for
Afar, should provide support to the RHBs in order to strengthen their capacity with SAM management.
This includes the continued roll-out of the Integrated Refresher Training (IRT), and expansion of sites.
In addition to improving expansion of CMAM in Afar and BG, more effort is required to improve service quality as well as improve upon the proper utilization of supplies. To this end, UNICEF should continue supporting the CMAM monitors in these regions as they conduct regular visits to health facilities.
Even though CMAM is rolled o ut at national level, the Government’s capacity should also be strengthened to take over the supply management at all levels; including procuring and distributing
CMAM supplies. UNICEF has to continue the ongoing discussions and negotiotions with FMoH and
PFSA and gain more momentum. However, UNICEF should be cautious that moving to PFSA should not affect the VfM gains achieved through using the UNICEF procurement system.
13

Output Title Stronger evidence based inter-sectoral response to under nutrition in Ethiopia
Output Score A Output number per
LF
Risk:
Risk revised since last AR?
4
Medium
N
Impact weighting
(%):
Impact weighting % revised since last
AR?
Progress of output 4 against expected milestones:
Indicator(s) Milestones
0 Operational Research (OR) undertaken that aligns to knowledge gaps and strategic priorities of NNP
Examples of change to Ethiopian nutrition policy
/ NNP plan and programmes attributable to OR and lessons learnt
% of districts from programme regions timely submitting data and reports on nutrition interventions
0
0
10
N
Progress
Stunting reduction analysis is in progress
NA, milestone for 2015
86% Proxied by CMAM reporting rate –
Number of surveys implemented on seasonal calendar
Key Points
21 21 for May/June round.
Bi-annual surveys - The bi-annual survey continues to function well and provide relevant nutrition prevalence trend data. During May/June 2014, bi-annual nutrition surveys were conducted in 21 woredas; Oromia (4), SNNPR (4), Amhara (4), Afar (3), Somali (3) and Tigray (3). The information will continue to establish the trend in nutrition prevalence data for the surveyed highly vulnerable woredas and provide an indication of the severity of the situation, analysed jointly with other multi-sectoral data.
The second round of bi-annual surveys for 2014 is currently underway, with all regions expected to implement during December 2014.
Technical Assistance - Support was provided to ENCU staff who have been actively engaged in the nutrition cluster coordination, i.e. nutrition information system support, situation monitoring and response coordination. Five TAs in four regional ENCUs (one per region for Afar, Somali, SNNPR and two for
Oromia) were provided with technical support to strengthen the regional early warning and response and nutrition cluster coordination capacity. The Government has now recognized the importance of the
ENCU and as of the beginning of 2014, all regional ENCU staff have been recruited on government contracts, although the financial support is still being provided by DFID.
Operational Research – UNICEF reported that a high level consultancy firm has been contracted to analyse the available data for Ethiopia, principally DHS, to look at the potential determinates/reasons for the reduction in stunting that was seen from 2000 to 2011. To date, the literature review, indicator mapping, analysis and a first draft report have been produced. Based on further data needs for a planned National Nutrition Situation Analysis, it was determined that a different methodological approach, including further models of analysis need to be developed for regional level analyses, as well as expanding on the agrio-ecological zone analysis. Tulane University will be working on the further analyses in order to contribute to the causal analysis section of the Situation Analysis. This is expected to guide the next revision of the NNP in 2015. Identification and implementation of other operational research through EPHI has not yet started.
The two 2014 milestones in the above table were set at zero, as research activities would only take place after programme implementation, and take multiple years to complete. The third 0 milestone was
14

an error on the logframe , as the system for submitting data and reports has been in place over the last couple of years.
Recommendations
As part of Tulane University support to the IYCF and establishing an ongoing monitoring system, it is envisaged that implementation research will be ongoing to identify operational modalities for programme delivery in “challenging environments”, namely pastoral areas. In addition, EPHI should be consulted in early 2015 to identify the NNP operational research requirements and potential support through UNICEF and DFID. The results from the periodic nutrition surveys in hot spot areas could serve to inform the operational research to look into the factors behind variations in nutritional status.
15

Output Title
Output number per LF 5
Risk: Low
Improved knowledge and capacity of national partners for planning, implementation and management of nutrition sensitive interventions
Output Score A
Impact weighting (%): 5
Risk revised since last
AR?
N Impact weighting % revised since last AR?
N
Progress of output 5 against expected milestones:
Indicator(s)
Professionals from NNP implementing sectors trained on multi-sectoral coordination and integration
Annual nutrition performance review conducted
Reach and SUN multi-sectoral coordination meetings held and documented
Milestones
0 yes
0
Progress
9 Federal, 55 Amhara, Oromia 75, Tigray
90
Conducted
National and Regional nutrition teams trained on current nutrition information and skills
0
11 Nutrition Development Partner meetings (SUN coordination), SUN focal point attended the ICN 2 and SUN Global
Gathering.
Comprehensive triangulated nutrition information database currently under development for FMOH. Training plans on data bases included in every regional
AWP.
Key Points
During 2014, much progress has been made towards better multi-sectoral coordination. Support has been provided to FMoH in identifying appropriate focal points in each of the nine implementing sectors.
Appropriate members of the sectoral working groups at the national and regional levels have been identified. The RNTC and RNCBs have been formed at regional level.
UNICE F’s annual report indicated that the current multisectoral activities are mainly focused on capacity building of the nutrition technical committees at the national, regional and zonal level. At the regional level, the project has supported the capacity building and NNP action-planning workshops for the members of the multi-sectoral nutrition committees at the national, regional and zonal level in the four agrarian regions (NNTC, RNTC, and Zonal Nutrition Technical Committee (ZNTC)). Afar and BG have carried out the NNP launching workshops. To date, BG has established the Zonal Nutrition Coordinating
Body (ZNCB) and ZNTC in two zones.
Nine focal persons from the National Nutrition Technical Committee (NNTC) in all implementing sectors received capacity building training; 55 people from 9 zones of Amhara received capacity building training on RNTC and (ZNTC) - the training was cascaded to eight other zones and three woredas. Training was provided to 120 individuals (parliamentarians, sector bureau heads, regional and zonal administrators) from Tigray region. Additionally, 75 participants (heads of health, agriculture and other sector bureaus) from 18 zones of Oromia received the training. These capacity building trainings are expected to strengthen the coordination mechanism; and develop technical and administrative capacity to plan, budget and implement nutrition-specific and nutrition-sensitive actions within and across the nine implementing sectors at regional and zonal level. A technical assistance staff member is currently under recruitment for multi-sectoral support to be seconded to FMOH.
The SUN focal person was also supported in attending and representing Ethiopia at the International
Conference on Nutrition 2 and the SUN Global Gathering in Rome, Italy.
16

Please note that the first two 0 milestones were errors for 2014 within the logframe, as plans to establish the NNCB and coordinating bodies were in place for 2014, along with trainings. Additionally, the REACH and SUN mechanimss were also already in place and functioning. A revision of the logframe is recommended to adjust these milestones The last 2014 milestone in the above table was set at zero, as training would only take place after the development of a database which takes years to complete.
Despite all the above capacity building efforts, the NNP lacks a strong accountability mechanism that will integrate with already existing frameworks. Although the NNP sets initiatives, indicators, targets and recommendations, they are not necessarily measurable or time-bound. Moreover, absence of explicit nutrition activities in annual work plans of key sectors other than Health (e.g. Agriculture, Education,
WASH, Industry, Trade etc.) as well as lack of Government resources in annual plans allocated for nutrition related activities are some of the gaps of the NNP.
The nutrition project has apparently enhanced the process of developing an NNP Monitoring Tool, which is a nutrition database that will store all routine sources of nutrition data (CHD/EOS, CBN, CMAM), as well as nutrition survey data. Information from PSNP, hotspot areas etc. will also be included, which will allow data to be presented by these different factors, allowing for a triangulated analysis. The strategic objectives and multi-sectoral NNP indicators have also been added so that NNP progress can be tracked. The concept is that it will be available online with access allowed to partners. A business case is also being prepared by UNICEF for FMoH. There will also be linkages with HMIS to ensure that there is no duplication or discrepancy in data being reported.The national nutrition database will also need to be clearly reflected in the NNP Phase II document which will span the period 2016-2025 in two
5-year plans.
Other development partners such as EU and NGOs are also working on establishing a similar national and multisectoral nutrition data base with the purpose of using it as the NNP monitoring tool.
Recommendations
In the final year of NNP, Ethiopia needs to lay the ground work for creating an effective multisectoral nutrition system that reduces stunting in a sustained manner. A strong cascading plan for the next phase of NNP is required. This plan will be guided by the current NNP multisectoral activities. A strong implementation team is required at federal and regional levels. This team should be supported by a strong partner-supported financing plan engaging all donors and ministries.
There is high need for continued support and advocacy for a clear governance and accountability mechanism for nutrition, especially at regional and wereda levels. Development partners including DFID and UNICEF should strongly advocate for the NNP to establish a strong accountability mechanism that will integrate with already existing frameworks at regional and woreda levels.
The most important next step is to get the national nutrition database and other key nutrition issues on the agenda of the next NNCB meeting. High-level representatives from the development partners, including DFID, UNICEF, EU and USAID, are well positioned to facilitate bringing key gaps in the implementation of the NNP to NNCB leadership.
DFID and UNICEF should take the lead and need to communicate and work together with the other development partners such as EU and NGOs who are also working on establishing a similar national and multisectoral nutrition data base in order to harmonise initiatives into one process.
UNICEF and DFID need to sieze all opportunities to integrate the nutrition programme with their existing health and water, sanitation and hygiene programmes to accelerate the impact on nutritional status.
Summary of responses to issues raised in previous annual review
The last Annual Review was conducted at a very early stage of the programme, in fact just four months into the implementation phase. Preliminary activities were underway but no implementation milestones under any of the outputs were scheduled to have been achieved at that point in time. No major changes were recommended to programme design in the last annual review. However, both DFID and UNICEF have realized that there was a need to review the existing log frame, work plan and MOU. The logframe,
17

work plan and MOU were revised based on the recommendation. Base line KAP surveys are still in the planning phase as the contractual process took a long time to complete. UNICEF has not still completed partnership agreements with NGOs which was expected before the end of May 2014.
UNICEF has finalized most of the recruitment process to fill federal and regional level positions in order to fully undertake implementation of the programme in 2014. UNICEF is working towards achieving the transition of management of CMAM supplies from UNICEF to PFSA before the end of the project in
2016/17.
18

D: VALUE FOR MONEY & FINANCIAL PERFORMANCE (1 page)
Key cost drivers and performance
Funds Utilized
Cost Category
CONTRACTUAL SERVICES
1 Jan 2014 –
15 Dec 2014
$1,982,496
EQUIPMENT, VEHICLES AND FURNITURE $99,946
GENERAL OPERATING + OTHER DIRECT
COSTS
INCREMENTAL INDIRECT COST
$320,744
$0
1 Jan 2012 -
31 Dec 2013 Prior to 2012 Total
$0 $0 $1,982,496
$0
$0
$0
$0
$0
$0
$99,946
$320,744
$0
STAFF AND OTHER PERSONNEL COSTS $582,946
SUPPLIES AND COMMODITIES
TRANSFERS AND
COUNTERPARTS
GRANTS
TRAVEL
UNASSIGNED
TO
$10,226,856
$3,294,998
$50,293
-$92,019
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$582,946
$10,226,856
$3,294,998
$50,293
-$92,019
%
12%
1%
2%
4%
62%
20%
0%
-1%
Total $16,466,260 $0 $0 $16,466,260 100%
The key cost driver for 2014 was supply at 62 per cent of the current programme utilization. This was primarily for RUTF, which was US$ 8,247,328, or 50 per cent of all utilization for 2014. UNICEF utilizes both international and local procurement channels. The local channel is more cost efficient, but they lack the capacity to meet the overall quantity as well as to deliver at the right time. While the international procurement cost is higher than local (unit cost US$73 compared to US$56), it is also significantly less than global estimates identified in the BC (unit cost US$200), mostly because UNICEF procures globally and is able to attain best-cost point of service. Using both local and off-shore procurement channels have also proved to be most effective in eliminating pipeline breaks; when one channel is back-logged, the other can be used to fill the gap. This adds VFM by ensuring that there is no supply break for this lifesaving programme commodity and by avoiding emergency air-freighting (high-cost).
Description
Offshore
Qty procured
70,695
Total USD paid
5,154,258.53
Unit cost in USD
72.91
Local
Total
54,398
125,093
3,093,070.28
8,247,328.81
56.86
65.93
The second key cost driver is “transfer and grants to counterparts”. This is principally representative of our mechanism to transfer funds to government counterparts, through the United Nations Executive
Committee (UNEXCOM) Harmonised Approach to Cash Transfer (HACT) which is a risk-based financing system.
1 The funds under this cost support the Government to carry out implementation, such as funds for travel/monitoring, trainings, and daily subsistence allowances (DSAs) for the activities supported under this programme (EOS/CHD, etc.). This is another mechanism for increased VFM, as the cost of implementation is lower by using existing government systems and structures, and it ensures a wider
1
UNEXCOM HACT modalities - UN agencies adhere to the Harmonised Approach to Cash Transfer (HACT) which is a risk based financing system. The principles of this are outlined in the UNEXCOM
–MoFED Programme Implementation Manual
(PIM) December 2013 and include three payment modalities: a) DCT
– Direct Cash Transfer: where funds are advanced to Government based on agreed Annual Work Plan b) DP - Direct Payment : where funds are directly paid for services works or goods delivered by a vendor c) Reimbursement: where partner funds are used and then reimbursed by UNICEF
19

coverage to reach more beneficiaries. CMAM is fully implemented now through the HEP, so is delivered by HEWs. There is no cost to the programme for the HEWs, except for what is indicated above. This is better VFM than in the previous system which utilized NGO partners, in a much more limited coverage.
VfM performance compared to the original VfM proposition in the business case
Economy
As discussed, the key cost driver is RUTF for the CMAM programme. This continues to be able to be delivered at a low-cost, relative to global standards. International procurement has a unit cost, factoring in transport, of around US$73, local procurement has a unit cost of US$57. The estimated global average for unit cost of CMAM is US$200, indicating that delivering this intervention in Ethiopia has a high level of economy and continues to ensure VFM. The reasons for maintaining two channels of procurement to manage risk were discussed previously. It should also be mentioned that for the amount of RUTF that was locally procured, there was a saving to the programme of about US$800,000. There is also ongoing effort by the local production facility to improve upon quality and quantity, so it is possible that in some years, the full amount could be procured locally, but these conditions do not yet exist.
UNICEF’s Evaluation of Community Management of Acute Malnutrition (CMAM): Global Synthesis
Report published in 2013 shows that on average, outpatient treatment for a child with SAM costs an average of $145 in Pakistan, whereas it costs $110 in Ethiopia. The cost is higher in Pakistan as compared to the other countries mainly because government health workers receive salary top-ups.
Combined inpatient and outpatient treatment costs $196 in Chad and $110 in Ethiopia. Cost data were merged in these two countries, and could not be disaggregated. The lower cost in Ethiopia is attributed to more involvement of the MoH in the transportation of RUTF from districts to the health facilities, thus more sharing of the recurrent costs.
Comparison of CMAM cost per child in US $ among countries
Country
Nepal
Outpatient treatment of SAM
$76.8
Pakistan
Ethiopia
Chad
Kenya
$145
$110
$196
$93.9
In the five case study countries, CMAM is generally implemented through three implementation modalities: a) providing funds to international NGOs (INGOs) that in turn support the MoH for implementing the activities in the districts; b) direct support to the government by UNICEF which provides technical assistance to the MoH; and c) providing funds to local NGOs for supporting the government in implementing the intervention. In Nepal the second modality (direct support to the government by UNICEF) is found to be the most cost-efficient because of stronger ownership of the government. Similar to Nepal, in Ethiopia direct support to the government is provided through UNICEF.
In Ethiopia, as much as direct support to the Government could have been the best implementation modality interms of efficiency, absence of explicit funding financial aid modality to channel resources for nutrition interventions makes UNICEF the alternate option.
In Ethiopia, the 2014 average unit cost of CMAM ($71) was significantly less than the $110 reported in the evaluation report in 2013.
This could be explained through the fact that UNICEF’s capital contribution is initially higher through limited contributions and is reduced over time. Cost reductions occur through integration with other interventions, such as IYCF and IMCI, and into the national health system.
UNICEF’s evaluation report indicated that the average cost per woreda in Ethiopia was $51,199 which is also significantly less than implementing through INGOs which is currently estimated by SCI at
$100,000.
The existing capacity of UNICEF to take wider coverage and entrench in the government system added an important value which most prominent INGOs in the nutrition field lack. For example, Save the
20

Children International, the largest INGO in this field, acknowledged during our meeing that its nutrition intervention is led by emergency humanitarian need and financied by non-predicatble resources.
UNICEF currently implements CMAM in more than 500 woredas in collaboration with the government where as SCI’s CMAM implementation is only limited to 4 woredas.
Efficiency
Efficiency has been able to be improved through the programme through two mechanisms. The programme has assisted in 2014 to strengthen government systems for delivery of programmes. HEWs and the HEP structure are already in place. Implementing through these structures, interventions are able to be delivered at a low cost, and efficiency can further be improved by strengthening the capacity of the staff and structure.
The second mechanism which allows for efficiency in programme delivery is the use of UNICEF structures and staff. UNICEF already have in place staff and operational structures both at Addis Ababa and within all the programme regions. VfM through efficiency is ensured by UNICEF contributing high calibre experts with international and broad national experience who are paid by UNICEF Regular
Resources and complemented with Other Resources. The management team in Addis Ababa is comprised of four international nutrition experts and eleven national nutrition experts, with specialities ranging across all programme components: CMAM, IYCF, Micronutrients, Surveillance, Early Warning,
Emergency, communication, gender and M&E. The management team is complemented by at least two nutrition specialists in each programme region, who are instrumental to ensuring programme delivery and monitoring through government and partners. Along with the technical staff, it is the operational support staff who ensure maximum efficiency for things such as procurement, logistics, human resources and financial management. For this level of in-country programme support, the per cent of utilization against the programme funds was only 4 per cent. This greatly contributes to VFM through maximized efficiency of programme technical assistance and delivery.
The cost effectiveness for this project particularly under the main two activities identified in the BC, i.e
CMAM and CBN was well-positioned compared to original assumptions and other similar undertakings.
The total cost for CMAM activities (inclusive of supply, monitoring, transportation, trainings, etc) falls at
£5,678,843 with RUTF supply of reaching 80,000 children that gives a cost per output result of treating a child with acute malnutrition through community management at a cost of £71 per child as compared with
£88 per child as presumed in the Business Case. Acivities under CBN normally include Vitamin A supplementation, deworming, screening of pregnant and lactating women, and supplementation of mircro nutrients such as iron and zinc. The total cost allotted for all CBN related activities in this reporting peri od was £3,977,372. Beneficiaries addressed under these interventions are 3.92 million children under 5 years (with new Tigray data: 421,879), 900,000 Pregnant and Lactating women screened and a total of 4,820,000 beneficiaries reached with CBN activities with an aggregated unit cost average of
£0.82 per beneficiary, comparing favourably with the assumption in the BC (£1.28 per beneficiary) and global average (£1.59 per beneficiary).
Effectiveness
It is difficult to measure the effectiveness at this point; the nutrition interventions have been proven effective in reaching the outcomes. What can be commented on is that there is a high achievement of programme outputs, as measured by the indicators. A considerable number of children have been reached with life-saving interventions such as RUTF and VAS. Additionally, these are children in some of the most disadvantaged areas, as well as those with the highest stunting rates, particularly in Afar and
Benishangul Gumuz. Government systems and staff have been capacitated to deliver with more quality, and programme intervention coverage (CMAM) has increased, because of this programme. Prior to the
DFID/UNICEF support and attention to these areas, there were little to no resources and funding (Afar and BG), and what was available was emergency focused, not development. In this respect, VFM through effectiveness has been improved.
Assessment of whether the programme continues to represent value for money
The programme accelerating reductions in under-nutrition in Ethiopia has represented value for money during the first year of implementation. The key cost driver is RUTF, which has been shown to be
21

procured and delivered at a unit cost well below global averages ($73/56 compared to $200). Therefore,
VFM has been achieved through maximizing on Economy .
VFM has been achieved with Efficiency, through two mechanisms. Government systems are utilized for programme delivery, which are already in place, functional and mostly supported through government budgets. Efforts under this programme have been successful to strengthen the capacity of these systems to improve upon the delivery, and especially the quality of service. The second mechanism is the programme utilization through UNICEF structures. UNICEF has technical staff and operational structures in place both at Addis Ababa level and within the regions. Additionally, UNICEF has strong financial measures in place for the management of resources. The overall cost of the technical and operational services to this programme are low, indicating VFM through Efficiency .
Finally, this programme is reaching areas with the highest stunting rates as well as the previously neglected regions of Afar and Benishangul Gumuz. While achievement towards outcomes cannot be measured at this time, the fact that the output indicators show that the programme is delivering lifesaving and malnutrition preventative interventions at a high coverage to some of the most marginalized populations is an indication that this programme is achieving VFM through Effectiveness .
Quality of financial management
Total program budget
£39,600,000
YTD transfer
£14,000,000
YTD utilization
£9,822,777
Remaining balance
£4,177,223
Overall programme budget and payment schedule is clearly outlined on project agreement. After having programme review meetings and continuous discussions, DFID Ethiopia and UNICEF have agreed to revise the original MoUs and made some changes on the amount of money to be transferred in each tranche based on a realistic activity plan and utilization rate. Both have also agreed to make our Annual
Review period to be aligned with UNICEF reporting cycle at a time when UNICEF also gets reports from respective government departments.
The programme also benefited from an additional £3million last year with a bid from a central nutrition reserve to augment procurement of zinc and CMAM supplies.
Programme funds are transferred to a dedicated program account in UNICEF that will allow UNICEF to manage overall programme operation. As indicated above, 20% of the resource is transferred to
Government and NGO partners.
Funding flow chart
DFID
UNICEF
CSOs
FMoH
RBoH
UNICEF regularly provides budget utilization reports on a quarterly basis and submits performance and financial utilization reports annually in a form of certified statements of accounts signed off by UNICEF central financial comptroller. Therefore periodic forecasts and subsequent releases are determined based on realtime financial information. For example, a transfer in January 2015 was reduced by 65% from the original forecast based on timely receipt of programme budget information.
Following a due diligence assessment in December 2013, DFID has made a follow up check on recommended action a year later. The assessment generally found that UNICEF has addressed all
22

findings related to financial management that were identified by UN internal audit and the due diligence team. The key issue on this recommendation was linked to challenges faced when UNICEF migrated from its previous Financial Management System (ProMS) to its new VISION/SAP system. It can be said that at this moment, the overall integration of UNICEF’s financial system into VISION has now been fully completed and there were no records of anomalies registered in recent months attributable to the new system. Several measures were taken by UNICEF to address this concern. The key ones are:
 Recruitment of a VISION specialist who is responsible for handling glitches on the system and for providing training at different levels;
 Establishment of a VISION working group to share experiences and to address any difficulties within the network; and
 Involvement of the UNICEF Regional Office to provide feedback on specific VISION related challenges and augment the system with additional modules when necessary.
A global audit report covering accounts as of December 2012 remains unqualified with a general auditors opinion stating the financial statements present fairly, in all material respects, the financial position of UNICEF as at 31 December 2012 and its financial performance and cash flows for the period then ended, in accordance with IPSAS (International Public Sector Accounting Standards).
Despite its overall good performance, the audit indicated weakness on risk management and deficiencies in programme management that were also identified under DFID due diligence. However,
UNICEF Ethiopia country office has demonstrated substantial improvement with these aspects that have been confirmed during follow up checks.
The Office of Internal Audit and Investigation (OIAI) has also audited UNICEF Ethiopia, covering the period from January to October 2012. The OIAI report was subsequently shared with the public following the decision made in mid-2012 by UNICEF HQ to publicize its internal audit reports on all its offices.
Some sections of the report have been redacted where there is particularly sensitive information and
DFID-E was given this version.
UNICEF’s country office subsequently (January and November 2014) shared details of actions taken since issuance of the report which is summarized in the table below:
Finding Priority Status of action at time of follow up
Action taken by the office
No micro or macro assessment carried out on HACT implementation.
High Reported as in progress
-Both micro and macro assessments carried out.
(please refer to Downstream Activity pillar for details)
Delays and inefficiencies in programme cash transfers, inadequate documentation for supporting financial transactions.
High Reported completed
On programme management:
Requests for cash transfers did not correspond to the activities in the
Medium Reported completed as
On governance:
Poor performance on RCSA and slow progress against action plan following a RCSA finalized in 2010.
Medium Reported completed as -
- as Trainings have been given to staff on HACT, specifically related to this issue.
A one stop shop Hub has been set up to review
23

approved workplan.
Delay in raising and authorizing purchase requisitions in programmes.
Medium Reported completed
No systematic way of managing field monitoring trips- reports not submitted or tracked and acted upon.
Medium Reported completed as as all payments before processing.
The Standard Operating Procedure (SOP) has been updated circulate and its implementation monitored.
An online Trip Report and Monitoring System
(TRMS) has been created to manage, monitor and track findings made during field visits.
Operations support:
Challenges subsequent introductions of VISION: to Medium Reported as completed
-
- Delay in finalization of Table of
Authorities and thus formal authorities and rights to VISION;
- Inappropriate assignment of authorities to staff,
- Incomplete TOA;
- Discrepancy between delegation of authority in VISION and the manual TOA;
- Inadequate segregation of duties among finance staff.
Lack of review on the master Vendor record in UNICEF’s old management sysstem (ProMS) prior to their migration into VISION. As a result, the following shortcomings were noted on the master Vendor record system in VISION:
Medium Reported as in progress
The Master Vendor record was reviewed and a
‘cleaning up’ exercise resulted in removal of non-active vendors. Verification of names and bank details were also carried out and a standard operating procedure (SOP) was issued which stipulates that the vendor database should be monitored, updated and cleaned up on regular basis to ensure accuracy of recording.
- Lack of 3 rd party confirmation on validity of vendors’ names and bank details;
- Duplicate cases of implementing partners, suppliers, and contractors;
- Incorrect designation of vendors to account groups.
Inaccuracies in the General Ledger due to inadequate staff capacity in maintaining the accounting records and in coding financial transactions, insufficient supervision and due to changes in systems.
Medium Reported as completed
Further training on VISION was given to staff tasked with this responsibility. The office has also revisited the work processed and issued guidelines to address the gaps identified.
A vision support specialist is now in place complemented by vision support peer groupd at every branch offices.
24

Poor oversight and control on programme supplies and equipment stores/warehouses
Medium Reported as completed
The 2012 end of year physical count was completed and results submitted to the UNICEF
Division of Financial and Administrative
Management (DFAM) on 18 January 2013. There have been following up discussions between
DFAM and the UNICEF Ethiopia Country Office.
DFAM is satisfied with the results.
Programme supplies are monitored regularly at programme and Country Management Team
(CMT) meetings.
Since February 2013, this is being reported monthly at the CMT meetings and continuous follow up discussions are taking place with programme sections.
Progress against the recommended actions in the OIAI report, except on 1 have been assessed to be adequate.
Date of last narrative financial report Dec 9, 2014
Date of last audited annual statement Aug 15, 2013
E: RISK (½ page)
Overall risk rating: Low/Medium/High
Low
Overview of programme risk
The overall programme risk of the project has recently been updated. The review so far has not identified evidence that suggests any major implication of the risks identified in the business case.
However, the risk of decline in coverage for Vitamin A Supplementation, deworming and screening as a result of the transition from the Child Health Days (CHDs) approach to government routine health service delivery system appeared recently due to change in government policy. However UNICEF and DFID are continuously discussing on mitigation measures to minimize its impact. However, the transition of of the nutrition services into the routine health service delivery system will have long lasting benefites in making the interventions more sustainable and cost-effective.
Outstanding actions from risk assessment (from Due Diligence)
DFID conducted a Due Diligence of the UNICEF Ethiopia Country Office from June - August 2013, with the final report being signed off by DFID Ethiopia Head of Office on 13 December 2013. UNICEF was rated as Medium Risk across the reviewed pillars on a scale that spans from Low, Medium, High and
Critical. The DD was subsequently shared with UNICEF ECO and follow up meetings were held to review the status of the recommendations.
The Governance Pillar Risk is considered closed. UNICEF ECO has strengthened its risk management processes and is effectively implementing the UN HACT approach. UNICEF has also recruited an
International Staff member to manage this process from the financial side.
The Ability to Deliver Risk is considered closed. As a UN agency, UNICEF delivers the majority of its programmes in Ethiopia through the Government of Ethiopia. The recommendation further suggested that “UNICEF Ethiopia to systematically assess the capacity of the government at different levels more frequently and design a strategy to influence policy that yields realistic programme targets”, which the
ECO has now put in place. UNICEF conducted both national and project specific risk assessments.
These assessments provide UNICEF with a basis to determine the support modality and the context to score individual risk rating as well as to indicate an optimum level of resources to be transferred.
25

The Financial Stability Risk is considered closed. The key issue on this recommendation was linked to challenges faced when UNICEF migrated from its previous Financial Management System (ProMS) to its new VISION/SAP system. It can be said that at this moment, the overall integration of UNICEF’s financial system into VISION has now been fully completed
Finally, the Downstream Activity Risk is considered closed. The key element here is related to UNICEF’s downstream communication of its anti-fraud policy. UNICEF uses its existing agreement models such as cooperation agreements and other grant agreements to declare its anti-fraud policy. But the sturdy establishment of the HACT system currently demands frequent (based on risk rating of the Micro
Assessment) financial spot checks be conducted on financial transactions to assess their exposure to fraudulent risks. The p artner’s HACT records that were shown to DFID representatives during DD follow up discussions demonstrate how it is being implemented within UNICEF country office. Fortunately, there has not been any occurrence of fraud or any form of corruption reported in the HACT assessments.
F: COMMERCIAL CONSIDERATIONS (½ page)
Delivery against planned timeframe
Some programme components faced initial project start-up delays while other components have been fully implemented from the start of the project. Components that were already operational continue to be operational with DFID support, such as CMAM, CHD/EOS and bi-annual nutrition surveys – which are on-track. New programme components have faced delays, based on a four month inception phase. The
CBNC programme required sufficient time to engage in a Partnership Cooperation Agreement with NGO partners in order to be able to implement on the ground. This is now complete and the project is moving ahead.
As discussed, the community production of complementary food has been delayed because of lack of findings from a pilot study. This delay is necessary so as to manage any potential risk from a project that does not yet have any documented lessons learned. A reprogramming request will be made.
The KAP assessments have also faced delays. This is also due to efforts made in order to manage the risks of poor implementation and loss of funds. In the past, UNICEF encountered obstacles due to poor performance on nutrition assessments and analysis owing to the poor capacity of local firms. Therefore, to minimize the risk of a loss of investment and poor quality products, a high level institution, Tulane
University, has been engaged to develop the methodology, oversee the process and carry out the analysis and report writing. Additionally, Save the Children is being engaged to facilitate the data collection, as they have permanent data collection teams on staff and have a good reputation. The delays for the KAP assessment are from the contractual processes, but should in the long-term result in higher level outputs and documents, such as an IYCF communication strategy for programme areas such as Afar and BG, from which no information is currently available.
Performance of partnership (s)
Aside from the delays mentioned above regarding delays in establishing contractual arrangements for the KAP assessments, the overall performance and partnerships under this project are strong. DFID and
UNICEF maintain a strong and positive relationship with the Government, which continues to be a strategic advantage of the project. Partnerships with NGOs are positive, such as the arrangement with
APDA in Afar to strengthen CMAM services in areas with no access to government services. The relationship between UNICEF and DFID remains strong due to openness, transparency and good communication.
G: CONDITIONALITY (½ page)
DFID management has decided not to conduct a programme level partnership principle assessment for nutrition, taking in to consideration the level and type of government’s engagement in this programme.
However a national assessment carried out in October 2014 found that whilst the Government of
Ethiopia remained committed to the underlying principles of our partnership sufficient to continue
26

financial aid, we had some concerns regarding their commitment to civil and political rights. These concerns have been raised with the Government and we continue to monitor developments. The
October 2014 assessment remains valid for the purposes of this programme.
To obtain beneficiaries impression and feedback on the impact of the program please refer to Annex 1.
H: MONITORING & EVALUATION (½ page)
Evidence and evaluation
The programme is actually in the second year of implementation so no change in evidence that would affect programming is evident at this time. Progress on the KAP assessments has been discussed, with a target of completing data collection prior to the 2015 Ethiopian election. Appropriate sex/age disaggregation will be done.
Modifications to the programme design have been discussed regarding the local community production of complementary food, and consequently a proposal for reprogramming will be submitted to DFID for review and approval. The Government has already purchased adequate Albendazole (deworming) for a period of three years, so a proposal for reprogramming of the funds will be submitted to DFID for review and approval.
Monitoring progress throughout the review period
As the project scored B at the last annual review, a Project Improvement Plan (PIP) was prepared to closely monitor and improve performance before the next annual review. The PIP has drawn on the lessons from the previous year and the recommendations of the last annual review which were based on the review’s assessment of challenges and lessons. Quarterly joint DFID/UNICEF review meetings were held to assess progress against the set targets and follow-up actions from the May 2013 Annual Review.
Emerging challenges, financial management issues, risks and mitigating actions were also discussed at the quarterly meetings. It is very encouraging to note that the PIP made a significant contribution to both the improved achievements of the nutrition project to date.
DFID Ethiopia’s lead nutrition advisor and programme officer conducted a field visit to West Gojam and
North Gondar zones of Amhara region which is one of the the target regions where the project is implemented. The team observed programme implementation at community level in two districts in
West Gojam and one district in North Gondar. The team held discussions with concerned government district health office staff, UNICEF Child and Nutrition focal person in the region, and community based
Health Extension Workers. The team confirmed that DFID funds are being used for the purposes intended in the business case and all the activities supported at the ground level are being implemented towards achieving the project’s outputs and outcomes. Although the strengthening of the health extension system at all levels is essential for the success of the transition of the nutrition interventions into the routine health service delivery mechanism, the field visit has helped the team to realize that commitment of HEWs is also an important factor for the smooth transition. The HEWs in the visited woredas in Amhara were very commited which would be unlikely in the developing regional states, and needs further exploration in further field visits.
Compliance with Gender Equality Act
An increased emphasis on providing services through household visits will help overcome the physical and financial barriers many women face utilising services and should help overcome the husband’s resistance to the women travelling outside of the immediate area.
A stronger multi-sectoral response should increase the likelihood of women and girls ’ needs being better reflected in key sectoral programmes such as AGP2, PSNP, Education etc. With strengthened capacity the FMOH can work together with the Ministry of Youth and Women Affairs (MOYWA) and incorporate gender disaggregation into nutritional data collection. In addition, resources for operational research could provide the opportunity to build the evidence base on the gender dynamics around nutrition and food security and how best to reach women and girls with effective nutritional/food security programming.
27

Activities in the programme that specifically target women include:
 Training women’s groups and the Health Development Army (HDA) /community volunteers who are all women to deliver a Social Behaviour Change and Communication (SBCC) campaign on nutrition during pregnancy, breastfeeding, complementary feeding, diet diversity, hygiene and sanitation and child care.

Additionally, 1.6 million pregnant and lactating women (PLW) were screened for malnutrition and provided with supplementary food if found undernourished.

Iron folate supplementation is delivered to all pregnant women in the target regions.

Health Extension Workers (HEWs) who are women themselves will be trained and supported to track pregnancies, undertake antenatal and postnatal household visits, to promote maternal nutrition and to establish early initiation of exclusive breastfeeding. All the HEWs are paid full time Government employees.

Women are organized into mother-to-mother support groups and appropriate Infant And
Young Child Feeding (IYCF) behaviour change messages are in place.
Annex 1
Summary of beneficiary Feedback from DFID team field visit in Amhara region.
During DFID’s field visit in Amhara region, the field team asked the opinions of some HEWs about the project. They explained that the programme is very vital, as they are able to screen the nutritional status of children in their village, provide counselling for mothers, treat those with under nutrition and refer those who are severely malnourished with complications to health centre for further diagnosis and treatment. They also explained that the programme gave them an opportunity to work at the household level and provide services at village level. They indicated that they are facing challenges particularly when moving alone from village to village carrying all items and materials on their shoulder and suggested to consider providing incentives for community facilitators to move with them and assist them.
As regards the concern that coverage of some nutrition services will decline as a result of the transition of the CHD into routine health service delivery system, they indicated that the coverage might fall as the awareness at the community level to bring their children to health institutions for nutrition services is poor. They feel that some preparatory ground work should be considerd befor the transition is fully implemented.
The DFID team also asked some mothers if they are benefiting from the DFID supported nutrition project. One of the mothers explained that her knowledge and understanding is improving about her child rens’ health and nutrition. She was ableto tell us that vitamin A supplementation will prevent blindness and has other health benefits. She also mentioned that her children who are taking deworming capsules, do not get sick of intestinal parasits and diarrhoea. Her awareness about the importance of breast feeding, complementary feeding and immunization was also very good. We also talked with one of the Women ’s Group Leaders who explained that she is actively leading her fellow women group members to make them seek the nutrition and health services of the project.
Beneficiary feedback on DFID support
1. Feedback collected from Amhara regional Health Bureau Nutrition officer and Maternal & Child
Health case team Leader.
We are getting DFID support through UNICEF to implement different nutrition interventions such as
CBN, CHD & CMAM. CBN is being implemented in Amhara region with DFID support. This has benefited our community mothers to follow-up on the growth status of their children on continuous basis for two years in order to reduce stunting. We are also working on adolescent nutrition.
With the support, we are expanding outpatient therapeutic feeding programs and stabilization centres in health facilities. We receive all the supplies needed such as vitamin A, RUTF, MUAC tapes, etc. through
UNICEF.
2. Feedback collected from East Gojam Zone Health Bureau head
28

In our zone, special focus has now being given for implementing nutrition activities. With support from
DFID through UNICEF all existing nutrition interventions are being implemented and we are seeing the success through improved coverage.
The zonal health office has now strengthened the supportive supervision and review meetings made with the woredas in our zone. The woredas also closely followed for the implementation of CBN, CHD and
CMAM activities. Our growth monitoring participation rate has increased to 74%. The CHD implementation has now transited to routine implementation to be done in integration with other health services. Severely malnourished children are also getting nutritional treatment on time.
Although most of the woredas in the zone have the highest rate of stunting, woreda health bureaus are doing their best in creating awareness of mothers on proper IYCF practices to address the problem. With the support we are getting from DFID, we intend to do more in the future.
The zonal health office very much appreciates the support we are getting from DFID to reduce stunting in the zone.
3. Feedback collected from Machakel Woreda Health Office head
Machakel woreda has given due focus for nutrition activities and is trying to do better than the previous years. We have transited form CHD to routine vitamin A supplementation and have achieved 89.5% vitamin A coverage (July - December 2014).
Our performance on CBN programme is also strengthened and we are conducting growth monitoring and promotion (GMP) for under five children. We are screening for malnutrition on a routine basis and children found to be severely malnourished are being referred to Outpatient Therapeutic care Program
(OTP) and those with complications are referred to Stabilization Centres (SC).
Our HEWs are conducting demonstrations on complementary food preparation for mothers using the health development army 1-5 women group linkages. This we believe will change the practice of the mothers on IYCF practices so that they can learn from one another. In our woreda UNICEF is working with DSW on adolescent nutrition with DFID support.
29