Ethiopia Country Office

Form I

TRIP REPORT
Note: This trip report does not substitute existing data collection tools such as supply checklist, rapid assessment
checklist and end-user monitoring checklist.

THIS REPORT TO BE SHARED WITH:

ETH Trip report Database, Amhara
RHB, Amhara APST Nutrition Team

DATES AND SIGNATURE OF TRAVELLER

SUPERVISOR COMMENTS AND SIGNATURE:

Part I - Overall Information

NAME: Wondayferam Gemeda

DIVISION/OFFICE:
NFS/Amhara APSO

PURPOSE/s OF TRAVEL:
Field monitoring
Meeting
Workshop/ Conferences
Training (program)
Training (self)
Emergency / assessment
Others (specify)
DCT liquidation

ITINERARY ( sites visited)

Names / Titles of persons / Partners whom

traveled with (UNICEF and Non-UNICEF):

Names, Titles and Contact of Persons Met:

1. Ato :Leulseged, Head, S.Wollo ZHO, 0914718233
2. Ato Kassahun Abebe, Head, Dessie Zuriya W.H.O
3. Ato Eshetu, Nutrition Focal, Dessie Zuriya W.H.O
4. Seid Mohammed, Head, Gelsha Health Center,
Dessie Zuriya W.H.O, 0914070656
5. Sr. Fana Getachew, Clinical Nurse, Gelsha Health
Center, Dessie Zuriya W.H.O, 0913089556
6. Abdo Seid, Acting head and nutrition focal, Borena
W.H.O
7. Sintayehu Mekasha, Acting nutrition focal, Leagambo
W.H.O, 0914063675
8. Firezer Tesfa, Head, Genete Health Center, Legambo
Woreda, 0921269644
9. Mare Matebe, Clinical Nurse, Genete HC, Legambo
Woreda, 0925044903
10. Melkamu Seyoum, Hidar 11 Hospital, 0920761059
11. Getachew Wale, Deputy head, Dessie T health office,
0913065287
12. Ansha Seid, Acting nutrition focal, Dessie T Health
Office, 0913065287
13. Abateneh Meknoen, Nurse, Boru Meda Hospital,

Start date: 01/12/13

From: (city/town)
Bahir Dar
Dessie zuriya,
Borena, Legambo

TA No:

End date: 07/12/13

To: (city/town)
Dessie zuriya,
Borena, Legambo
Bahir Dar

Date
01/12/13
07/12/13

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0913415525
14. Dawit Kidane, Administrator, Boru Meda Hospital,
0913453163

Part II Scope of travel and main findings

II. 1. Objectives of the travel
Monitor Nutrition Programme implementation in Selected woredas of S. Wollo zone
N.B. - If the trip target was for AWP monitoring and supervision, skip II.2. and II.3. below and
move to part III and IV

II. 2. Key results

II. 3. Constraints, challenges, opportunities and any other comments

Part III Follow up, recommendations and planned actions

Follow up action
Start CBN implementation in Tehuledere woreda

South Wollo ZHO has to encourage W.H.Os to give

nutrition due attention and include basic nutrition
indicators as performance evaluation indicators for HC
staffs and HEWs. Basic indicators shall be shared to
head of ZHO by APST nutrition officer
South wollo ZHO has to encourage Kutaber and
Tehuleder W.H.Os to strengthen their OTP services in all
kebeles so that children can get the service in nearby
HPs

By who
Tehuledere
W.H.O, ZHO,
APST Nutrition
officer
South Wollo
ZHO, APST
Nutrition Officer

By when
December 2013

South Wollo
ZHO, Kutaber,
Tehuledere and
Dessie Town
woredas.

Ongoing

December 2013.

If your travel was for field monitoring & assessment, fill Part IV

Part IV - Status of AWP implementation & field monitoring information

IV. 1. Activity Description and Ref No. ( to be filled as per AWP):
Conduct monthly GMP targeting under 2 children
Conduct nutrition review meeting at woreda and zone level
Conduct regular supportive supervision at woreda and zone level.
IV. 2. Progress made towards achievement of Activity Result ( to be filled based on observations /
findings from the field including DCT and supply issues ):
The plan was to conduct the supervision in one Hospital/Health center and one health post in
each of the four woredas. However as the HEWs were busy on other competing priority, the
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effort to supervise health post in Legambo and Dessie zuriya woredas was not successful. The
below table depicts the supervised health facilities in each woreda.
Visited Woreda
Hospital
Health Center
Health Post
Dessie Zuriya
Gelsha
Borena
Mekaneselam
Mehal Denbi
Legambo
Hidar 11
Genete
Dessie Town
Boru Meda
Tehuledere
Feedback was provided on spot and to the heads, deputy heads or acting heads and nutrition
focals at all levels.
The below are the major findings drawn from the supervision
CBN
HC staffs Training
During the previous field monitoring, it was noticed that CBN programme was not commenced
in Tehuledere woreda of South Wollo zone as HC staffs couldnt support HEWs on nutrition
activities as their capacity was limited to do so. After a thorough discussion had been made with
the deputy head and nutrition focal of the W.H.O, the W.H.O requested our support to conduct
an orientation meeting to enhance the capacity of HC staffs on CBN.
Accordingly a half day orientation on CBN implementation provided to 10 Health workers
(9male and 1 female) from 4 health centers (Sekela HC 3, Hara 3, Sulula 2 and Haik 2) and
nutrition focal of W.H.O.
The orientation focused on what does under nutrition mean, causes of under nutrition, types of
under nutrition (Acute Vs Chronic), invisibility of malnutrition and importance of anthropometric
assessment focusing on GMP to easily identify the problem, window of opportunity to address
under nutrition (the first 1000 days), IYCF and how to counsel caregivers based on age
tailored messages in the FHC.
Participants appreciated the orientation and pledged to translate the orientation to the actual
implementation. The below action points have been drawn at the end of the orientation.
1. Provide the orientation to the remaining health workers in their respective health
centers so that they can support HEWs equally during the regular supervision.
2. Support HEWs in identifying under 2 children in their respective kebeles. Curretly
recording of under five children is ongoing to identify targets for polio campaign.
Hence the under 2 children acan easily be extracted from the registration for the
campaign.
3. Support HEWs during the actual GMP session.
4. Amend their checklist to incorporate CBN indicators like GMP participation rate.
5. Incorporate CBN indicators in their monthly PHCU meeting to evaluate the
performance of HEWs
Supervision finding
Very good data recording, compilation and reporting was observed in Borena and Dessie Zuriya
woredas.
As per the transferred budget to train health center staffs on CBN/CMNCH to support HEWs,
the training was conducted in Dessie zuriya and Leagambo woredas. It was noticed that the
trained HWs have better understanding of CBN particularly on GMP (Plotting, identification of
nutritional status and provide counseling). In Borena woreda where the training was not given,
the HC staffs lacked the basic knowledge of CBN.
HEWs still have basic skill gap on GMP especially on providing counseling adhering to the age
tailored messages in the FHC.
There is well established HC-HP linkage whereby the head of HCs are evaluating the HEWs on
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some important indicators. However from the documented minute and from health workers
opinion, it was observed that nutrition activities were overlooked or never evaluated as major
performance indicators for the HEWs. The HC staffs explained that they are often evaluated by
other activities than nutrition and didnt give the attention it deserves. (In Genete cluster health
center of Legambo woreda, only one out of the five HPs supported by the HC reported CBN in
the month of October 2013. Besides only small number of under 2 children identified (43) in the
reporting kebele and less than a third (13) children attended GMP in the month. These
problems were not identified, analyzed and action taken during the monthly meeting)
Regular review meetings and supportive supervisions were not conducted as per the
recommendation despite the HC staffs and HEWs observed have major gaps in the
implementation of the programme.
The new version FHC (with 64 messages) was not found in Borena woreda. HEWs are using
the old version FHCs. Zonal health office need to identify woredas which didnt receive the
updated edition of FHC and communicate RHB to effect the distribution as early as possible.

CMAM
As the below graph depicts, majority (75-90%) of children enrolled in OTP are children in the
age group of 6-24 months. This is in line with the fact that malnutrition in children typically
develops during the period from 6 to 18 months of age, when growth velocity and brain
development are especially high. This can be seen as a good justification for the need of
strengthening CBN programme. I felt its an important finding for our advocacy activities.
I wonder also if the sensitivity of MUAC cut of is decreasing with increasing age of children. It
would be the area of investigation in the future.

There is good documentation of records in Borumeda Hospital. The OTP cards of all children
identified as admitted, discharged cured, Defaulted etc. is kept in separate folder for easy
access.
Boru meda hospital is making follow up for children in OTP every 15 days to align the
appointment with the schedule of beneficiaries under the Food by Prescription programme.
After brief discussion with the nurse in charge based on the guideline for the management of
SAM, it was agreed to make the follow-up on weekly basis.
Boru Meda hospital is providing both Outpatient and inpatient management of SAM. The great
majority of children are treated at OTP level. However as depicted in the below graph only 6 out
of 10 children were discharged cured and nearly a third of children defaulted. Both indicators
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imply suboptimal quality of service delivery as compared to the standard.

It was noted that the main reason for high defaulter rate is children from far kebeles which
should have got the service in their respective kebeles were enrolled. As it can be observed
from the below graph more than a third of children were from one kebele in Kutaber woreda
where the service is supposed to be provided. The Hospital is supposed to provide OTP service
for children from Boru Meda kebele and SC to all children from nearby woredas.
The issue has been reflected well in the discussion with the head of the ZHO (during feedback)
so that the respective woredas could be advised to strengthen the programme in their kebeles
and children would get the service in the nearby health facility.

A good RUTF supply monitoring system is established in Genete Health center of Legambo
woreda. Caregivers are expected to bring the empty aluminum foil and the nurse in charge
counts the number and infer whether the child has consumed the recommended amount. Then
the amount for the week is prescribed and collected from the pharmacy department. The
pharmacy technician receives plumpy nut through the appropriate voucher (model 19) and
responsible for its proper dispensing. The health workers explained the procedure reduced the
misuse of plumpy nut.
IV. 3. Constraints / challenges / opportunities

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Constraints
Challenges
Competing priorities like campaigns are taking the major part of HEWs time which will lead to
under achieving nutrition programme implementation.
In all the three woredas visited, the increasing attrition rate of HEWs was a big concern for the
implementation of the programme. As it can be observed from the below graph, 30-50% of
kebeles in the visited woredas have no or one HEW instead of the required 2 HEWs/HP.

Opportunity
Presence of committed nutrition focal persons at woreda level. If proper attention is given by
the decision makers and nutrition indicators are considered as performance evaluation, great
improvement will be observed.
Presence of nutrition monitors deployed by UNICEF through consulting firm who can support
programe implementation at all level.

Annex 1: CBN orientation meeting participants, Tehuledere woreda, Haik,

December 7/2013
S. No Name
Health Center
Tel
1
Ahmed Kebede
Sulula
0914074417
2
Melkam Workneh
Seglen
0933553063
3
Alemu Tadese
Seglen
0924351332
4
Yimer Endris
Seglen
0921274370
5
Mohammed Seid
Hara
0912914034
6
Tadese Abebe
Hara
0913075728
7
Getenet Asres
Sulula
0921265522
8
Abdu Mohammed
Hara
0912199848
9
Askal Getahun
Haik
0920186414
10
Getahun Diyago
Haik
0920096458
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11

Yusuf Hassen

W.H.O Nutrition Focal

0913504469

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