Total country population (2006): 77 million

Project population and area: direct presence in 64 focus districts of ESHE bi-lateral in 3 regions covering 15 million and indirect presence across country through work with partners

Project Duration: 2003 to 2006

• Visit LINKAGES/Ethiopia website
• Download a complete copy of World LINKAGES/Ethiopia
• Download LINKAGES Ethiopia Final Report
• Download Community Assessment in Amhara, Oromia, and SNNP Regions
• Download materials (in English) developed by LINKAGES and its country program partners
• Key Messages Booklet on the Essential Nutrition Actions
• Job Aids for Health Workers at Six Contact Points
• Counseling Cards for Fathers on Infant and Maternal Nutrition
• Counseling Tool on Complementary Feeding
• Complementary Feeding Recipe Book
• Counseling Tool on Infant Feeding Options for PMTCT Sites
• Staying Strong with HIV Desk Flipchart
• Staying Strong with HIV Brochure
• Staying Strong with HIV Posters

Country Profile

Women and children in Ethiopia face enormous and complex nutrition problems. One-fourth of Ethiopian women are malnourished, and approximately one-half of children less than five years old are moderately or severely stunted (EDHS 2005). These levels of malnutrition contribute to the country’s high under-five mortality (more than 472,000 deaths each year). Analyses show that malnutrition, even in its milder forms, accounts directly or indirectly for 53 percent of under-five deaths in Ethiopia (Profiles 2006).

Another challenge facing Ethiopia is HIV and AIDS. Approximately 1.5 million people—96,000 under the age of five years—are living with HIV or AIDS. Of particular concern is maintaining optimal infant feeding practices and ensuring the nutrition and care of HIV-positive individuals, particularly women and young children.

Program Design and Partners

The United States Agency for International Development (USAID) in Ethiopia invited the LINKAGES Project to support the government and its partners to address malnutrition through support to child survival programs and HIV/AIDS programs. LINKAGES introduced the government and other partners to a set of concrete actions to improve nutrition, referred to as the Essential Nutrition Actions (ENA). The ENA approach comprises an integrated package of seven scientifically proven nutrition actions including the promotion of optimal breastfeeding (especially exclusive breastfeeding in the first six months), optimal complementary feeding, nutritional care of the sick child, women’s nutrition, and the control of anemia, vitamin A deficiency, and iodine deficiency disorders. In 2004 the Federal Ministry of Health (Fed-MOH) adopted the ENA approach.

The primary partners were the Nutrition Department of the Fed-MOH, the Regional Health Bureaus, international and local non-governmental organizations (NGOs), donor agencies, USAID cooperating agencies, and pre-service training institutions.

Program Strategies and Activities

The program aimed to ensure that nutrition actions were harmonized across ongoing relevant health and non-health programs, including activities related to HIV, and to extend this type of nutrition support beyond the facility level to the community and family. The comprehensive approach outlined for preventing malnutrition and improving nutritional status involved four key components:

1. Policy and Advocacy: LINKAGES provided assistance for the review of policies and the development and dissemination of nutrition strategies, protocols, and guidelines. Outcomes included the “National Strategy for Infant and Young Child Feeding,” the “National Guideline for Control and Prevention of Micronutrient Deficiencies,” “National Guidelines for HIV/AIDS and Nutrition,” a draft Code of Marketing of Breastmilk Substitutes, and a draft national nutrition policy

2. Capacity Building: More than 150 trainings were held between July 2003 and October 2006. Seven basic courses were offered: 1) ENA Technical, 2) ENA for Counselors, 3) ENA for Community Promoters, 4) ENA in the Context of HIV/AIDS, 5) Baby-Friendly Hospital Initiative, 6) Lactation Management, and 7) Lactational Amenorrhea Method (LAM).

LINKAGES worked with seven universities to strengthen their pre-service programs through technical and skills training, lesson planning, and tools to monitor the quality of teaching and to measure outcomes. Involvement in activities to improve the universities’ practicum sites led to efforts to implement the Baby-Friendly Hospital Initiative in hospitals affiliated with the universities. In-service training and assistance were provided to staff of government agencies, PMTCT sites, donors, and NGOs.

3. Community Involvement: At the community level, LINKAGES worked closely with the USAID-funded Essential Services for Health in Ethiopia (ESHE) project. Formal and non-formal extension workers were trained to promote the Essential Nutrition Actions during their interactions with women and young children. The ENA Course for Community Promoters, developed for illiterate workers, applied counseling and negotiation skills to the promotion of the Essential Nutrition Actions.

4. Behavior Change Communication (BCC): Three formative research studies identified existing practices and obstacles to better feeding and dietary practices. The findings were used to design appropriate messages and tools: a booklet on key ENA messages, an illustrated family health booklet, 6 job aids for health providers and health extension workers, IYCF counseling cards and a desktop flip chart, a complementary feeding counseling tool and recipe book, posters, a video on breastfeeding positioning and attachment, and nutrition and HIV/AIDS materials.

Monitoring and Evaluation

In May/June 2006 LINKAGES and the ESHE Project collaborated in a community assessment of behavior change. The assessment targeted 2,200 households each in three regions among communities where community health promoters had been active for at least six months. Initiation of breastfeeding within one hour of birth increased significantly in project sites in Amhara and Oromia but showed no statistically significant change in SNNPR. Exclusive breastfeeding for the first six months showed large increases in Oromia (from 39 percent to 62 percent) but no statistically significant change in Amhara and SNNPR. For all three regions, the exclusive breastfeeding rate in 2006, which ranged from 62 percent to 81 percent, was considerably higher than the national rate (49 percent) reported in the 2005 Demographic Health Survey.