LINKAGES REPORT

[Final Draft]

By Patrizia Fracassi

and Lioul Berhanu

2010

Edited by

Simon Rolph

ii

TABLEOFCONTENTS

EXECUTIVESUMMARY i

ACKNOWLEDGEMENTS ix

LISTOFACRONYMS x

1. INTRODUCTION1.1BackgroundInformation 1

1.2ObjectivesofthePilot 4

1.3PilotPhases 5

1.4ReportStructure 5

2. PREPARATORYSTUDY(PHASEI)2.1Introduction 6

2.2StudyObjectives 9

2.3StudyMethodology 9

2.4Analysis,FindingsandResults 13

2.5IdentifiedLinkagesOpportunitiesataGlance 22

3. PLANNING,IMPLEMENTATIONANDMONITORING(PHASEII)

3.1PlanningthroughConsensus‐Building 24

3.2CapacityBuildingonNutritionSecurity 27

3.3BehaviouralChangeCommunicationusingEntertainmentEducation 31

3.4FocusedAttentiononPSNPPregnant‐LactatingWomen 34

4. EVALUATIONOF‘LINKAGES’(PHASEIII) 42

5. CONCLUSIONSANDRECOMMENDATIONSFORSCALING‐UP 45

REFERENCES 50

APPENDICES 52

NOTE: Additional material such as Regional documents, Training Manuals, data‐analysis tools,

participantlistsandaudio‐visualreportsavailableonrequest.

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EXECUTIVESUMMARY

This Pilot Project focuses on identifying, implementing and eventually scaling‐up

opportunities to link two nation‐wide programs in Ethiopia ‐ the Productive Safety Net

Program(PSNP)andtheNationalNutritionProgram(NNP).

TheGeographicSelectionofthepilotworedawithineachregionwasbasedonthepresence

of PSNP and NNP (specifically on availability of Community Based Nutrition, CBN). The

further selection of one kebele in each woreda was based on its typical agro‐ecological

signifiersandarelistedbyRegionasfollows:

TigrayRegion–HintaloWajirat,FikreAlemkebele

AmharaRegion–LayGayint,Sheshokebele

SNNPRegion–DomotSore,Shiambakebele

OromiaRegion–Gamechesworeda,Kokuriftu,Agemti,SreKeloGeto

andHomichokebeles

APreparatoryStudywasconductedfromregionaltocommunitylevelsfrom21stJulyto22nd

August 2009. Primary datawere collected from 39 PSNP/NNP stakeholders through Key‐

InformantInterviews(KIIs).Inaddition,atotalofeightFocus‐GroupDiscussions(FGDs)were

conductedinfourpilotkebelesinvolving28femaleand23malePSNPbeneficiaries.Findings

indicatedadegreeofconvergenceamongallstakeholdersoverperspectiveofmalnutrition,

causes and solutions. While all interviewed people recognized that pregnant‐lactating

women (PLW) and children are the most nutritionally vulnerable groups, their answers

indicatedanarrowfocuson:

‐ Quantity of food rather than quality and appropriateness of diet for PLW and young

children.

‐ Productivityandmarketabilityoffoodsratherthantheirnutritionalcontentforimproved

householddiet.

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‐ Dietary intake and food security with limited attention given to other well known

contributingfactorstomalnutritionlikediseases,childcare,accesstohealthservicesand

environmentalconditions.

Withregardsto‘coordination’,themosteffectiveinstitutionalarrangementappearedtobe

theFoodSecurityTaskForces(FSTF)atworedaandkebelelevels.AccordingtoKIIsfindings,

the active involvement of multiple‐sector partners was the result of continuous working

relationships strengthened through shared objectives and basic compatibility of interests.

Butthecontrarywasapparentatregionallevelwiththeexistenceoftoomanycoordination

platformswithoverlappingfunctionsresultinginincreasedfragmentation.

With regards to ‘cooperation’, primary data from KIIs revealed a number of inter‐sectoral

experiencesatkebelelevelalthoughnotstrictlylinkedwithaddressingmalnutrition.Findings

fromFGDshighlighted thatagenuinecommunity involvement requiredunderstandingand

takingintoaccounteconomical,practicalandculturalmotivesthatinfluencefoodproduction

andaccessaswellasconsumptiondecisionsathouseholdlevel.

Findings from the preparatory study are in line with recommendations by Maxwell and

Conway(2000)to‘planmulti‐sectorallybutcontinuetoimplementsectorally’. Manyofthe

institutional barriers for improved inter‐organizational relationships first reflect

administrative organization in sectors/programs and, second, nutrition, as a cross‐cutting

issue,hardlyfittingatallwithinthisframework.Workinginanincrementalandopportunistic

mannerappearslikelytosucceedwiththecurrentinstitutionalstructure.‘Coordination’and

‘cooperation’ over specific issues like quality of dietary intake for children and pregnant‐

lactatingwomen,forexample,seemstobeapromisingfocusofexchangebetweenPSNPand

NNPstakeholders.

Mainstreaming of nutrition into PSNP is expected tomaximize the impact of the program

among beneficiaries. This is in line with the PSNP 2009 document where the log‐frame

indicates ‘decreasedmalnutritionamongchildrenundertwoyearsofage’ is foreseenasan

impactindicator (PSNPdocument,2009,p.73)and‘improvedaccessandutilizationofhealth

services’isforeseenasanoutcomeindicator(PSNPdocument,2009,p.74).

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Findings from the preparatory study together with a general overview of the PSNP/NNP

policy frameworkwere used to inform theConsensus BuildingWorkshops conducted in all

four pilot woredas and kebeles from 28th September to 16th October 2009. Three major

‘linkage’ opportunities between PSNP and NNP were agreed upon for implementation at

institutionalandcommunitylevel:

1. CapacityBuildingonNutritionSecurity forkeymembersoftheFSTFatworeda,kebele

andcommunitylevels.

2. BehavioralChangeCommunicationusingEducationEntertainment(BCC‐EE)duringpay‐

daysessionsandotherpublicgatheringstoencouragePSNPbeneficiariestooptimizeuse

ofbothlocalandtransferredresourcesforimprovedNutritionSecurity.

3. FocusedattentiontoPSNPPLWtoprotectandenhancetheirnutritionalstatusandthat

oftheirchildrenundertwoyearsofage1.

ExperiencesfromSNNPandOromiashowthat,atinstitutionallevel,nutritionsecuritycanbe

incorporatedintheCapacityBuildingProcessofFoodSecurityTaskForces(FSTF)comprising

multi‐sector members from agriculture, water, health, education, Youth and Women’s

Affairs. Half‐day sessionswere included inWatershedManagementTraining (DomotSore,

SNNP) and in the PSNP review meeting (Oromia, Gameches) targeting over 100 people

including70DAs.BasicsonnutritionwereprovidedduringConsensus‐BuildingWorkshopsto

increase understanding of the nutritional value of different types of foods and on specific

dietary requirements for PLW and young children. Improved awareness on nutrition

outcomes to which PSNP can contribute may result in food security and agriculture

stakeholdersconsideringmorerigorouslywhobenefits fromtheir interventions. Practically

this means, besides agro‐ecological suitability, productivity and profitability, the nutrition

value of selected crop varieties should be included and accounted for in any equation.

Similarly, activities with a direct nutritional benefit, like poultry‐management schemes,

improved post‐harvest storage and food processing techniques or home gardening can be

1Thefocusfromconceptiontoagetwenty‐fourmonthsrepresenta‘windowofopportunity’tobreaktheinter‐generationalcycleofmalnutrition. By the time children reach their second birthday, if undernourished, they could suffer irreversiblephysicalandcognitivedamage.

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promoted in ‘household business or investment plans’ for increased food and nutrition

security2.

ExperiencesfromTigray,AmharaandSNNPshowthatBehaviouralChangeCommunication

usingEntertainmentEducation(BCC‐EE)canbemainstreamedwithinPSNPpay‐daysessions

and/or public gatherings to promote feasible changes within the households and the

community. Nutrition and care‐related behavioural problemswere initially identified by a

Technical Team composed of volunteermembers from the kebele FSTF. Technical Teams

chose drama as the media and set the agenda following the life‐cycle sequence from

pregnancy, lactation, to young child feeding from six to twenty‐four months. PSNP

beneficiariesinvolvedasperformersreceivedanorientationondramaandrehearsedunder

the guidance of a professional theatre performer. Key people at kebele level, such as the

Chairman, the Manager, the DAs and HEWs facilitated events. Woreda level PSNP/NNP

stakeholders attended the events in all regions while Regional and Zonal FS stakeholders

participated in SNNP. For the latter, the drama content addressed family planning and

childbirthspacing,reflectingacommonconcernofboththefoodsecurityandhealthsectors

aswellasthecommunity.

DespitePSNP/NNPstakeholderscontinuouslystatingtheimportanceofFocusedAttentionto

PSNPPLW,theimplementationofthis‘linkage’opportunityhasprovedtobechallengingin

allregions.ForthemonitoringofhealthandnutritionservicesutilizationbyPSNPPLW,on‐

the‐job orientation sessions were organized with HEWs and DAs in all pilot kebeles to

examine key indicators using registers and records from available routine services and

nutrition programs. Additional behavioral indicators related to dietary habits of PLW and

young children were also included in the Checklist. The initial PLW identification was

expected to happen during the annual PSNP registration but so far, this has been either

impossibleor,wherefiguresareavailable,thenumbersaredoubtful.3

2Development Agents andHealth ExtensionWorkers arewell placed to engagewithmale and femalePSNP farmers fordesigning interventions and developing/adopting technologies that take into account local agricultural and nutritionconsiderations.3 Kebele registration lists reviewed in Lay Gayint woreda (Amhara) indicated 12% PLW out of the total PSNP beneficiarypopulationwhilethecommonlyestimatedpercentageofPLWoutofthetotalpopulationisaround3.5%.

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TheestablishmentofWorkTeamsamongPSNPPLWwasalsodiscussedwiththekebeleFSTF

to promote their involvement in ‘light’ works during the non‐exemption time from public

work (e.g. before four months of pregnancy and after ten months from delivery). Work

Teams were foreseen to be the basis for the formation of Interest Groups among PSNP

women/PLWtoengageinproductionactivitieswithnutritionalbenefits. Furtherlinkswere

expectedwithexistingdevelopmentprogramslikeHouseholdAssetBuildingProgram(HABP)

or community‐based services such as micro‐finance and technical assistance. While

interviewedPSNP‐HABPstakeholdersaresayingtheywanttobeopentodiversifyproduction

investments they point out that other partners like the Women’s Affairs, NGOs or Youth

Affairsshouldbeinvolvedinformingandsupportingthesegroups.This‘linkage’opportunity

goesbeyondPSNPandrequiresmuchmoretimeandinputsfromdifferentpartnerstoreally

becomeoperational.

InterviewedPSNPstakeholdersemphasizedthepotentialcontributionofthehealthsectorin

‘Monitoring’thePSNPkeyindicatorsbutacknowledgedlimitedinformationsharingbetween

thetwosectors.Monitoringofdecreasedmalnutritionamongchildrenbelowtwoyearscan

be systematically ensured through the dissemination of Community‐Based Nutrition (CBN)

monthlydata4andCommunityHealthDays(CHD)quarterlydata5.Inaddition,monitoringof

access and utilization of essential health and nutrition services by PSNP PLW can allow

generationofcommunaldatafor jointplanningamongmembersoftheFoodSecurityTask

Forces.Furtherworkisrequiredondatacollectionandusetoshowsomeevidence.

‘LinkagesEvaluation’wasconductedinformallywithkeyPSNPandNNPstakeholdersfocusing

on their view over feasibility and scalability of identified and implemented ‘linkage’

opportunities. So far, all feedback and comments have been positive. None of the

stakeholders seem to believe that scaling‐up should be a challenge, especially for capacity

buildingorfortheBCC‐EE.Whenitcomesto‘monitoringaccessandutilizationofhealthand

nutrition services by PSNP PLW’ no institutional barrier could be identified, especially

becausePSNP/NNPstakeholdersrepeatedlystatedtheirinterestinthecollectionandsharing

4CBNprovidesdataonunderweightandsevereunderweightamongchildrenU2.5CHDprovidesdataonproxyGAM(<12MUAC)andproxySAM(<11MUACorbilateraloedema)amongchildren6‐59monthsandproxyGAM(<21MUAC)amongPLW.

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ofthesedata.Withregardstothe‘establishmentandsupporttoPSNPPLW/WomenInterest

Groups’,themainremarkswereontheneedtoworkmorewiththecommunityuntilsome

experiencecanbegained.

Recommendations:

Forimmediatescale‐upofidentified‘Linkages’atinstitutionallevel:

‐ NNPCoordinationBodyandPSNPJSOCworktogethertoensurethatidentified‘Linkages’

are mainstreamed in their respective programs. On this regard, the NNP document

(2008), the PSNP document (2009) and the revised PSNP Planning Implementation

Manual(PIM;2010)alreadyprovidethepolicyframeworktojustifytheneedforamulti‐

sectoralapproach.

‐ NNP/PSNPregionalandfederalcoordinationbodiesendorseandensuretheinclusionof

‘Linkages’ in respective sector plans, enforce implementation throughmutually agreed

monitoringmechanismsandevaluateperformancejointly.

‐ NutritionalobjectivesandoutputsassociatedwithPSNP impactandoutcome indicators

such as ‘reducedmalnutrition’ (PSNPdocument, 2009, p.73) and ‘increased access and

use of health services’ (PSNP document, 2009, p.74) are incorporated in PSNP annual

plansatcommunity,kebeleandworedalevelssothatresourceallocations,incentivesand

systems of accountability are managed around them. In line with the NNP Sub‐

Component2(d),theNNPensuresthatyoungchildrenandpregnantandlactatingwomen

in families receiving aid are being nutritionally monitored and that the nutritional

anthropometryisincludedintheevaluationofthePSNP(NNPdocument,2008,p.55)

‐ NNP and PSNP stakeholders at federal and regional levels work together on how to

mainstreamNutritionSecuritywithintheexistingtrainingcurriculum.Thelinksbetween

food production and consumption should become part of the discussion on how to

incorporateagricultural andnutritional considerations from theoutset. On this regard,

the Training Manual, already developed and translated, could be an obvious starting

point. In line with the NNP Sub‐Component 2(d), theMOH could support these joint

training so that keymembers of the FSTF at different levels become change agents to

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promoteadequateanddiversifieddietforpregnant‐lactatingwomenandchildrenunder

twoyears(NNPdocument,2008,p.55).

Forimmediatescale‐upofidentified‘Linkages’atcommunitylevel:

‐ Capacity Building on Nutrition Security rolled out to kebele and community FSTF

members. DAs, HEWs, CHWs, women’s and youth representatives are well placed to

engage with male and female PSNP farmers for designing interventions and

developing/adopting technologies. Interventions and technologies should take into

accountagro‐ecology,householdeconomy,livelihoodstrategiesandculturalnormsthat

influencehouseholddecisionsoverfoodproduction,accessanduse.

‐ Kebele FSTF should integrate Behavioural Change Communication using Entertainment

Education (BCC‐EE) during pay‐day sessions and public gatherings. Experiences from

implementationshowthatthisactivitycanbemanagedatcommunitylevelprovidedthe

quality of the technical content is supervised by theHEWs. DAs andHEWs can play a

significant role in facilitating the dialogue with the community to influence intra‐

householddynamicsthataffectnutritionallyvitaldecisionswithregardstoallocationof

differentquantitiesandtypesoffoodtoPLWandyoungchildren.

Forimplementationofidentified‘Linkages’atinstitutionalandcommunitylevel:

‐ It isrecommendedtostartthecomponent‘focusedattentiontoPSNPPLW’inonepilot

woredaonlylookingmorecarefullyattherolethatPSNPandNNPkeystakeholderscan

haveonactualoperationaloutput.

‐ With regards to monitoring of PSNP PLW utilization of essential health and nutrition

services,fewindicatorsshouldbeprioritizedbyPSNPandNNPstakeholders.Theinitial

‘windowofopportunity’couldbereducedfrompregnancyuptoelevenmonths instead

oftwenty‐fourmonths(asthiscorrespondsmoreorlesstotheexemptiontimeofPSNP

PLWfromPublicWork).

‐ With regards tomonitoring of nutritional status of children and PLW in PSNP kebeles,

direct linksshouldbeestablishedbetweentheFSTF(particularlytheEWS)andnutrition

program such as CBN and CHD for monthly and quarterly sharing of data. NNP

stakeholders should see it asanopportunity to increasedataqualityandutilization,as

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nutrition information would be shared with multiple sectors and with administrative

cadres.

‐ Theestablishmentof InterestGroupsamongPSNPPLW/womenneedsthe involvement

ofotherpartners liketheWomen’sAffairsand/orYouthAffairstosupportgroundwork.

Product‐value chain assessment and technical assistance will still remain the

responsibilityofagriculturalpartners.

‐ PSNP and NNP stakeholders should optimize the role of home‐economists in SNNP,

OromiaandTigraybylinkingthemwiththeHEWsandCHWstostrengthenpost‐harvest

activitiesasanecessarylinkbetweenfoodproductionandconsumption.

Potential‘Linkages’forfurtherdiscussion:

‐ Protection and enhancement of nutritional status of PSNP Orphan and Vulnerable

Adolescents(OVAs)throughtheirinvolvementin‘HealthyLifeStyle’clubs.

‐ FoodFortification6:i)InclusionofSprinkles7forchildrenundertwoyearsandPLWduring

foodorcashtransfers;ii)FortificationatmillofPSNPfoodtransfer.

‐ Supplementation of PSNP food/cash transfers through local production of ‘special

blendedfood’forchildren6‐11monthsandPLW.Onasmall‐scale,thisactivitycouldbe

linkedwiththeestablishmentofInterestGroupsandwithanincreasedroleoftheHome

Economistsatworedalevel.

‐ Promotionofhigh‐nutrientbio‐fortifiedcrops(e.g.HighProteinMaizeandOrangeFlesh

Sweet Potato) and improved breeds of poultry, small ruminants and cows through

collaborationwithResearchInstitutesfortestingandpromotionofselectedvarieties.

6FoodFortificationisanon‐goingprocesswithacommittedTechnicalWorkingGrouptoensurequalityandsafetystandards7A‘Sprinkle’isasmallpacket(sachet)containingablendofvitaminsandmineralsinpowderform,foreasysprinklingontofood.

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ACKNOWLEDGEMENTS

Wewould particularly like to thank focal people from regional, woreda and kebele levels,

who have made this project possible by believing in it from the start and by creating a

friendlyandsupportiveenvironment.

Wecannotthankenoughallthepeoplewhohavebeeninterviewedindividuallyoringroups

andwho have participated in the BCC events. Wehave been truly touched and, in some

cases,overwhelmedbytheirinvolvement,commitmentandopenness.

Wealsooweathankyoutooursupervisors,Yuki IsogaiandWoutSoer,whohavebeenof

greatsupportthroughouttheprojectandalwaysavailableforadditionaladvice.

Thankyou.

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LISTOFACRONYMS

CBN

CommunityBasedNutrition

CHV CommunityHealthVolunteer

DA DevelopmentAgent

FAO FoodandAgricultureOrganization

FGD FocusGroupDiscussion

FSTF FoodSecurityTaskForce

HEW HealthExtensionWorker

IOR Inter‐OrganizationalRelationships

JSOC JointStrategicOversightCommittee

KII Key‐InformantInterview

M&E MonitoringandEvaluation

MOARD MinistryofAgricultureandRuralDevelopment

MOE MinistryofEducation

MOFED MinistryofFinanceandEconomicDevelopment

MOH MinistryofHealth

NNP NationalNutritionProgram

NNC NationalNutritionCoordination

PSNP ProductiveSafetyNetProgram

SNNPR SouthernNations,NationalitiesandPeoplesRegion

UNICEF UnitedNationsChildren’sFund

WHO WorldHealthOrganization

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1. INTRODUCTION

1.1BackgroundInformation

Malnutrition is the single biggest contributor to child mortality in Ethiopia. The 2005

DemographicHealthSurvey(DHS)reportsthat47%ofchildrenunderfivearestunted,38%

areunderweightand11%arewasted.Childrenwhodonotreceivetherequireddietintheir

critical early yearsmost likely do not reach their optimum size as adults, their brains are

affectedandtheyareatgreatestriskfrominfection.Scientificevidenceshowsthatbeyond

theageoftwoyears,theeffectsofchronicmalnutritionareirreversible.Thismeansthatto

breaktheinter‐generationalcycleofmalnutrition,strategiesmusttargetchildrenduringtheir

firsttwoyearsandwomenduringpregnancyandlactation(Grantham‐McGregor,2007).

Ethiopia is characterized by persistent food insecurity with almost half of the farming

population not producing enough food and income to meet families’ nutritional

requirements. Coupledwith lowproductivity, seasonal variations inmarketpricesofmain

commoditiesseriouslyaffectthecashflowofpoorhouseholdsunabletoaffordtheminimum

requireddietthroughouttheyear. Childrenandpregnant‐lactatingwomenareparticularly

vulnerable.

Policycontext:

Accordingtothe1996WorldFoodSummitdefinition‘Foodsecurityexistswhenallpeople,at

all times,havephysicalandeconomicaccesstosufficient,safeandnutritiousfoodtomeet

theirdietaryneedsandfoodpreferencesforanactiveandhealthylife’.Theemploymentof

acomprehensivedefinitionof‘foodsecurity’requiresthespecialnutritionalrequirementsof

most vulnerable groups to be taken into accountwhen planning for food production and

food/cash transfers. This calls for improved ‘Linkages’ between agriculture and health

sectors to cover the three pillars of ‘food security’: Availability (physical supply), Access

(ability to acquire food) and Utilization (the capacity to transform food into the desired

nutritionaloutcomes).

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In2005,theEthiopianGovernmentlaunchedtheProductiveSafetyNetProgramme(PSNP)as

an attempt to provide a predictable response to persistent hunger through food/cash

transferstosevenmillionchronicallyfood‐insecurepeople.Dependingonlabouravailability

at household level, PSNPbeneficiaries receive payment through direct support or through

participationinpublicworksaimedatcreatingsustainableassetsforthecommunity.In2008,

theNationalNutritionProgramme(NNP)wasstartedtotacklenutritionissuesusingamulti‐

sectoral approach. Both programs expect to contribute to the achievement of the

Millennium Development Goal 1 by reducing the number of Ethiopians suffering from

extremehunger,povertyandmalnutrition.PSNPismanagedbytheMinistryofAgriculture

andRuralDevelopment (MOARD),whileNNP is under theMinistry ofHealth (MOH). The

latterisformallyresponsiblefornutritionsecuritybuttheformerhasthemandateoverfood

availabilityandaccess.

The PSNP (2005, 2006 and 2009) and NNP (2008) documents were used to build an

understandingofthe institutionaldiscoursebeyondtheprograms,withparticularattention

towards identifying formal statements of intent to address cross‐sectoral issues around

nutrition. The2008NNPstrategydocument states theneed foramulti‐sectoral approach

and provides recommendations in the implementation manual on how to mainstream

nutritionbeyondthehealthsector.OneNNPcomponentindicates‘Linkages’betweenPSNP

andNNPasoneintermediateresultwithidentifiedindicatorsandactivities.Thelog‐framein

the2009PSNPdocumentindicates‘reducedmalnutritionamongchildrenundertwoyearsof

age’asthe impact indicator (PSNPdocument,2009,p.73)and ‘improvedaccessanduseof

healthservices’asoutcomeindicators(PSNPdocument,2009,p.74).

The association between agriculture and human nutrition provides a complex picture that

relates food supply with demand and production with consumption. Analyzing how

agricultureandfoodsecurity influencenutritionaloutcomeshighlightstheway institutional

structures influence this relationship. Given the high prevalence of food insecure

households,NNPalonecannothaveasubstantialimpactonnutritionsecurity.Thenumber

of nutrition based emergencies occurring annually throughout the country calls for PSNP

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stakeholders to carefully consider the extent towhich their programaddresses the special

requirementsoftheirmostvulnerablebeneficiaries.

PSNPandNNPinstitutionalarrangementsformulti‐sectoralcoordination:

The2008NNPstrategydocumentrecommendstheestablishmentofoneNationalNutrition

Coordinating (NNC) body at federal level and one corresponding body at regional level. It

suggestsusingthealreadyexistingDevelopmentCommitteeworedaandkebelelevels.

The2009PSNPstrategydocumentprovidesadetailedaccountofcoordinatingmechanisms

at all administrative levels that include members from different sectors expected to

participate in decisions concerning targeting, planning of public works, monitoring and

evaluation.Thefollowinginstitutionalarrangementsareidentified:

Federal level: i) Joint Strategic Oversight Committee (JSOC) comprised of donors and

stateministries8and; ii)SpecificTechnicalCommittees(STC)comprisedofdevelopment

partnersandlineministries9.

Regional level: i) Food Security Coordination Office (FSCO) and; ii) Regional Technical

Coordinating Committee (RTCC)10 responsible for coordination with other line bureaus

anddevelopmentpartners.

Woreda level: Food Security Task Force (WFSTF) including representatives from line

ministriesanddevelopmentpartners.

Kebele level: Food Security Task Force (KFSTF) including Kebele Administration,

Development Agents (DAs), Health Extension Workers (HEWs), Teachers and Youth

representatives.

Community level: Food Security Task Force (CFSTF) including one Development Agent

(DA),oneHealthExtensionWorker (HEW),twoorthreeelected female representatives

8TherevisedPIM2010indicatesthePSNPDonorWorkingGroup(DWG)andtheDonorCoordinationTeam(DCT)9TherevisedPIM2010 indicatesthree TechnicalCommittees: JointTC1 (GeneralManagementandTransfers), JointTC2(PW/CCI)andJointTC3(HABP).10TherevisedPIM2010indicatestwoTechnicalCommittees:JointTC1(GeneralManagementandTransfers)andJointTC2(PW/CCI).

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and male representatives, one elected youth representative and one elder

representative.

The environment comprises many types of public institutions including different line

ministries,donors,UNagencies,researchinstitutes,NGOs,communitiesandpoliticalentities,

likecouncilsandcabinetswithdecision‐makingpowers.

Diagram1:PSNPandNNPMulti‐sectoralCoordinationMechanismsSystemsMap

1.2ObjectivesofthePilot

TheaimofthisPilotistoidentify,implementandeventuallyscale‐up‘Linkages’betweenthe

ProductiveSafetyNetProgram(PSNP)andtheNationalNutritionProgram(NNP)toimprove

thenutritionalsecurityofchildrenandpregnant‐lactatingwomeninacontextcharacterized

bystakeholdersbelongingtodifferentsectorsandadministrativelevels.

ThespecificobjectivesofthePilotareto:

• Identifypotential‘linkage’opportunitiesbetweenPSNPandNNPatcommunitylevel.

• DesignapilotprojectinfourRegions.

• IdentifyappropriateM&Emechanismsandindicators.

• Evaluatethe‘linkage’opportunities.

• Providerecommendationstoscale‐up‘linkage’opportunities.

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While theory acknowledges the importance of a ‘multiple‐stakeholder approach’ to tackle

malnutrition,thereislittleempiricalevidenceonhowthistranslatesintoaction.Oneofthe

main lessons learnt fromthisPilot is thatanypolicyneedstobeseenasa ‘process’where

practicesandrelationshipsatmultiplelevelsshapetheactionandtheoutcomes.Therefore,

thereisaconstantinterplaybetweenthe‘bestlaidpolicy’andwhatisactuallyhappeningon

thegroundinanygivencontext.

1.3PilotPhases

PhaseI:PreparatoryStudyandFeedbacktoregionalandworedastakeholders.

PhaseII:Planning,ImplementationandMonitoringof‘linkage’opportunities:

‐PlanningthroughConsensus‐BuildingWorkshops.

‐Implementationstart‐upthroughCapacity‐Building,mostlyon‐the‐job.

‐Monitoringthroughfieldvisitsandreports.

PhaseIII:EvaluationandrecommendationsforScaling‐Up

Documentationhasbeenintegratedthroughouttheprocess.

1.4ReportStructure

Part1comprisesthisintroduction.

Part 2 comprises the Preparatory Study including a brief description of the problem

statement, questions, objectives,methodology, results and recommendations. Amore

comprehensiveoverviewoffindingsperRegioncanbeprovideduponrequest.

Part3comprisesadescriptionofthePlanning,ImplementationandMonitoringprocess.

FollowingtheConsensusBuilding,threemain‘Linkage’opportunitieswereidentifiedfor

implementation at institutional and community level. Each of these ‘Linkages’ is

presented separately highlighting the expected outcomes, methodology and the

experiencefromimplementationandmonitoring.

Part4comprisesanEvaluationincludingfeedbackfromkeyPSNPandNNPstakeholders.

Part5presentsconclusionsandrecommendationsforScaling‐Up.

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2. PREPARATORYSTUDY(PHASEI)

2.1Introduction

The UNICEF malnutrition framework (Appendix 1) was applied to reveal convergent

perspectives among PSNP/NNP institutional stakeholders over understanding on

malnutrition, its causes and solutions as a first step toward finding a common ground for

multi‐sectorallinkages.

‘Linkages’ were expected to take place at community level because of the cross‐cutting

natureofnutrition.Thisimpliespublicrecognitionofnutritionsecurityasanissuerequiring

complementary efforts beyond food relief. Understanding the perspectives of PSNP

beneficiaries on malnutrition, its causes and solutions was regarded as a priority for the

feasibilityandsustainabilityofpotentialinterventions.

Definingtheproblem:

Theinitialproblemdefinitionfocusedonthefollowingquestions:

• CanasharedvisionbetweenPSNPandNNPstakeholdersonmalnutrition,itscausesand

solutions,bebuiltuponasapre‐conditionfor‘Linkages’?

• InwhatwayscanPSNPstakeholdersbecomemotivatedto‘link’withNNPstakeholdersto

addressissuesaroundmalnutrition?

Duringtheproblemdefinition,federalrepresentativesofMOARDandMOHreferredmatters

of ‘Linkages’betweenPSNPandNNPtotheregionalandworeda levels inaccordancewith

the decentralized government structure that gives them extensive mandate over local

developmentanddeliveryofbasicservices.

Theproblemanditscharacteristics:

The preparatory study builds from a scientific‐based theory that definesmalnutrition as a

‘cross‐sectoral issue’ affected by a range of contributing factors like dietary intake, health

status,carepractices,foodinsecurity,etc.(MaxwellS.2001,Levittetal.2008).Inthecaseof

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PSNPandNNPfieldofpolicy, this impliesbuildingandmaintainingrelationshipsbetweena

great variety of stakeholders. Understanding inter‐organizational relationships and the

politics that influence these interactions are crucial to appreciate how the ‘multi‐sectoral

approach’islikelytobeinfluencedinitsimplementationbycontext‐specificdynamics.

The rationale for improved ‘Linkages’betweenPSNPandNNP is to increase the impacton

nutritionsecurity.Thetypesofinter‐organizationalrelationshipsthatbetterdefine‘Linkages’

are‘coordination’and‘cooperation’.

According to PSNP and NNP documents, ‘coordination’ is associated to institutional

arrangementsestablished to facilitate the inter‐sectoral responsecapacity. Coordination is

meant as participation in decision‐making, sharing of objectives and basic compatibility of

interests.Coordinationisexpectedtoreflectcapacities,legitimacyandexpertiseofmultiple

partiesratherthancentralizedcontrolandauthority.Thisisinlinewithavailableliterature

that emphasize that the rationale behind ‘coordination’ is to ‘minimize duplication and

wastageofresources’(Robinsonetal,2000,p.215).Whilethisisperfectlyjustifiablefroma

programmaticpointofview,practicallythereshouldberecognitiononhowthismightaffect

interestsofdifferentstakeholders,whicharecompetingforlimitedfundingaccess.Thus,the

comparative advantage of ‘coordinating’ needs to be clearly weighed up against possible

losses.

AccordingtoPSNPandNNPdocuments,‘cooperation’isforeseenatcommunitylevelamong

differentsectorsaswellasbetweeninstitutionsandthepopulation.Initialdiscussionswith

key federal and regional members have brought to light the assumption that physical

‘proximity’ofstakeholdersatcommunitylevelcanpromotetrustandinfluencehowpeople

worktogether. WhileHarris (2000) indicatestrustasbeingcrucial tobuildingcooperation,

healsoemphasizesthatreachingacommongroundisaprocessofincrementallearningand

self‐transformation that requires time. The rationale behind ‘cooperation’ is ‘to ensure

effectiveallocationof resourcesand improved impact’ (Robinsonetal,2000,p.271). This

impliespublicrecognitionofnutritionsecurityasanissuerequiringcomplementaryeffortsof

multiple stakeholders, involving household and community participation. Understanding

8

motivesandconstraintsthatinfluencefoodproduction,accessandconsumptiondecisionsat

householdandcommunitylevelappearstobeapre‐requisiteforbuilding‘cooperation’.

Theproblemasidentifiedwithinpublishedworks:

An internet literature searchwas carried out by setting a periodic time from1999 and by

usingthefollowingkeywords:Linkages,cooperation,coordination,PSNP,NNP,foodsecurity,

nutrition security, malnutrition framework and Ethiopia to generate relevant material. In

their report commissioned by the World Bank, Garret & El‐Tahir (2008) point out that,

despiteaconsensusonmulti‐sectoralapproachtonutrition,thereisalackofasolidevidence

toguidestakeholdersonitsimplementation.

On theotherhand, theacademicarticleby Levitt,PelletierandPell (2008)emphasizes the

importanceoffindingcommongroundamongmultiplestakeholdersrequiringanincremental

‘process’ including consciousness raising, confrontation, collaboration and complementary

activities. Articles by Maxwell (2001) and Bouis & Hunt (1999) provide insights on the

discussion about food and nutrition security, issues and challenges. They acknowledge

extensivelythat improvingnutritionsecurityrequiresamulti‐sectoralapproachbutarenot

abletofindevidenceonhowthisconceptcanorhasbeentranslatedintopractice.

In addition, case studies reviewed in a World Bank Study (2007) refer to agricultural

interventionswhereanutritioneducationcomponentwasaddedtoimprovethehousehold

consumptionofhigh‐nutrientproducts.Inmostcases,theintegrationofnutritioneducation

wasdirectlymanagedbytheagriculturesectorwiththeexceptionofonlyoneinterventionin

SouthAfricawherethehealthsectorwastheinstitutionalpartner.

Inthisfragmentedcontext,managementofmeanings(Robinsonetal,2000)isessentialfor

increased communication between different stakeholders due to the diversity of their

languages and perceptions. From the literature review, the nutrition security language

remainsconfinedwithinthehealthdomainwithanalmostexclusiveemphasisonpromotion

of appropriatematernal and child feeding practices. There is limited acknowledgment of

development opportunities that could come from integration between food and nutrition

9

securityandthatcouldcallforanincreasedroleoftheagriculturesector(Garret&El‐Tahir,

2008).

2.2StudyObjectives

• Identifyingoverlaps inconceptualareasamongthefood‐security,agricultureandhealth

stakeholdersatdifferentlevelsbyusingtheUNICEFmalnutritionframework.

• Identifyingcomplementaryeffortsbythetwosectorstoimprovenutritionsecurity.

• Pointingoutopportunitiesfor‘Linkages’betweenPSNPandNNP.

2.3StudyMethodology

2.3.1Design

Keyprinciples:

TheUNICEFmalnutritionframeworkwasusedasacommunicationtooltoidentifyoverlapsin

conceptual areas among different stakeholders. Continuous feedback was required at

multiple levelsaspartof theconsensus‐buildingprocess throughdevelopmentofa shared

vision.Inthepreparatorystudy,usingpeopleasinformantsimpliedrecognisingtheirroleas

‘stakeholders’aswellasconsideringissuesofpowerrelationsamongthem.

Theaimofthestudywastoexploreopportunitiesfor‘Linkages’betweenthePSNPandthe

NNP context characterized by stakeholders belonging to different sectors, programs and

administrativelevels.Theaimwasreflectedinthekeyquestiononhow‘Linkages’between

PSNPandNNPcanbebuiltforimprovednutritionsecurity.

The sub‐question on ‘who should be involved in the preparatory study at different

administrative levels’was answered through a ‘mapping exercise’ that identified key PSNP

andNNPmulti‐sectoralcoordinationmechanisms. The‘people’stree’wasusedtoidentify

theindividualscoveringrelevantpositionsatdifferentadministrativelevels.

10

Thesub‐questionon‘howdoperspectivesonmalnutrition,underlyingcausesandsolutions

varybetweenPSNPandNNPstakeholdersatdifferentlevels’wasbrokendown intofurther

sub‐questions, which were applied in Key‐Informant Interviews (KIIs) and Focus Group

Discussions(FGD).Therewasanassumptionthatacommongroundcouldbefoundamidst

the different perspectives as long as these were clearly revealed and compared. This

question was also aimed at challenging the belief of policy makers that ‘multi‐sectoral

approach’couldmaterializeonlybecauseitwasrecognizedintheory.

The sub‐questionon ‘what conditionsaremost likely topromote ‘Linkages’betweenPSNP

and NNP stakeholders at different levels’ looked at the recognition and functionality of

institutional arrangements that could steer and advance inter‐organizational relationships.

Thisinformationwasgeneratedthroughprimaryandsecondarydata.

Thesub‐questionon‘whatmightmotivatestakeholderstopromote‘Linkages’betweenPSNP

andNNPstakeholdersatdifferentlevels’lookedatinstitutionalbarriersderivedfrominternal

bureaucracy but also at values and power relations informingmultiple stakeholders in the

publicarena. Itwas important tounderstandwhatwere thepotential gainsand lossesof

differentstakeholders inrelationtogettinginvolvedina‘multiple‐sectoral’approach.Sub‐

questions asked stakeholders about previous experiences of inter‐organizational

relationshipsincludinglessons‐learnedandchallenges.

The finalizedmethodology included a secondary research, a stakeholdermapping exercise

and a primary research through KIIs and FGDs. The research team consisted of the two

consultants(PatriziaFracassiandLioulBerhanu)andadditionalfieldsupportprovidedbykey

PSNP/NNPpeoplefromagricultureandhealthsectorsatworedaandkebelelevels.

2.3.2DataCollection

Collection of secondary data started in June with the desk‐review of PSNP and NNP

documents,Internetarticlesandacademicmaterial.Theformerhighlightedtheinstitutional

discourse behind the twoprograms. Internet articles and academicmaterials provided an

overviewonthelatestconsensusonfoodandnutritionsecurity.

11

The geographic selection of the woreda within each region was based on PSNP/NNP

presence. The further selection of one kebele in eachworedawas based on typical agro‐

ecological signifiers. Primary data were collected from 21st July to 22nd August from the

followinglocations:

OromiaRegion–Gamechesworeda,SreKeloHaroTatekebele

TigrayRegion–HintaloWajirat,Weltaneykebele

AmharaRegion–LayGayint,Sheshokebele

SNNPRegion–DomotSore,Shiambakebele

The stakeholder mapping exercise was done before the field‐work based on PSNP/NNP

documents to identifymulti‐sectoral coordinatingmechanismsat federal, regional,woreda

andkebelelevels.Keyinformantsfromagricultureandhealthsectorswerefirstidentifiedat

regionallevelaccordingtotheirposition.Theyindicatedtheappropriatepersonstospeakto

atlowerlevels(people’stree).Alistofthoseinterviewedisavailableonrequest.

ThefieldworkconsistedofKIIsof60‐90minutesandFGDsoftwo‐threehoursusingasemi‐

structuredmethod.InterviewsstartedatregionallevelwithPSNPandNNPcoordinatorsand

ended at kebele level with frontline practitioners such as Development Agents (DAs) and

HealthExtensionWorkers (HEWs). Atotalof39peoplewere interviewed fromhealthand

agriculture sectors at different administrative levels. The questions (Appendix 2) were

conducted on a face‐to‐face basis allowing for flexibility and the opportunity to explore

answersandqualifythemimmediately.Thefirsthalfoftheinterviewwasstructuredwhile

thesecondhalfwasleftopenforamorefree‐rangingconversationtocoverissuesemerging

frompreviousanswersinmoredetail. Additionalquestionswereaskedtotechnicalpeople

likeagronomists,HomeEconomists,Community‐BasedNutrition(CBN)focalpeople,market

experts and research experts for a better understanding of local production, market and

consumptionpatterns.InterviewswereconductedinAmharicandEnglish.

AtotalofeightFGDswereconductedinfourkebelesinvolving28femaleparticipantsand23

male participants. The sampling criteria required that they were PSNP beneficiaries and

12

belongtohouseholdswithyoungchildrenand/orpregnant‐lactatingwomen(NNPtarget).In

additiontokeyquestions,techniqueslikethe‘affinitydiagram’and‘problemtree’wereused

to summarize and organize participants’ answers to facilitate the discussion on relevant

issues(Appendix3).FGDswereconductedinAmharicandlocallanguages.

2.3.3Qualityofmethodology

The main strength of the applied methodology was its capture of key stakeholders’

perspectivesatdifferent levels, includingbeneficiaries. AkeyadvantageofconductingKIIs

and FGDs was the opportunity to provide immediate feedback to participants. This was

found to be useful in clarifying technical issues like nutritional requirements of the most

vulnerable groups or nutritional value of different foods. It also highlighted differences

betweenPSNPpolicyandpractices, forexample, lengthofexemptionfrompublicworkfor

pregnant‐lactating women or issues surrounding the full family targeting namely the

practicedexclusionofchildrenlessthanoneortwoyears.

Therewasa concern thatpeoplealready familiarwith theUNICEFmalnutrition framework

wouldsimplyrepeatalltheforeseen‘domains’ratherthanexpressingwhatshe/hethought

tobethemaincausesofmalnutritionandpossiblesolutionsforreducingit.Resultsshowed

anarrowfocusonfew‘domains’thatseemedtoreflectmorepeoples’realperspectivesthan

a mere replication of the overall theory behind malnutrition. Despite overlooking key

contributing factors likewater‐borne diseases and environmental hygiene, we did not use

prompts to lead the interviewees in that direction. Instead, we mentioned the ignored

factorsinfeedbackprovidedattheendoftheKIIsandFGDs.

Thebiggest concern for the studywas simplemisunderstandingof the question oranswer

becauseofthe languagebarrier. Forthisreason,asetofquestionsand internalguidelines

weredevelopedinthebeginningincludinganumberofpromptsandprobestoallowfollow‐

upquestioning ifanswerswerenotclearorseemedambiguous. FortheFGD,weusedthe

localDAsand/orHEWstocommunicatewiththepopulationbecauseoftherangeofethnic

languages existing in rural areas. No particular translation difficulties were experienced

13

during the study but there was recognition of a degree of interpretation in the way the

informationwascommunicatedbytheDAsandHEWs.

2.4Analysis,FindingsandResults

2.4.1Analyticalframeworkandtechniques

The research questionswere used as a frameworkwithinwhich to order and analyze the

data.Answerswerelookedatsystematicallythroughtherecordingtallysheets(Availableon

request)andextractedtobuildevidence‐basedargumentstothekeyquestions.

Thesecondaryresearchwasusefultogetbackgroundinformationandalsotoidentifythegap

between the theory underpinning institutional discourse and the reality. Statistical and

monitoring data on nutrition, production, market prices, PSNP and NNP provided context

informationandwereusedfortriangulationpurposestocrosscheckanswersprovidedduring

KIIsandFGDs.

Theprimaryresearchwasconcernedwithgeneratingqualitativedata.The informationwas

summarizedintotallysheetscontainingdetailed,mutuallyexclusivecategories.TheUNICEF

malnutritionframeworkwasusedtogroupanswerstothequestiononperspectives,causes,

factors and solutions tomalnutrition around ‘domains’ commonly known in the food and

nutritionsecurityfield.

Because of their institutional position, each key‐informant represented a ‘stakeholder’,

hereby defined as any organized group or sub‐unit whose resources, authority, status,

influenceor survival is influencedbyapolicyor program (Milio,1990). Participants in the

FGDswere selected because of their status as PSNP/NNPbeneficiaries. Answers received

from male and female participants were grouped and tallied in the summary sheets as

separatestakeholders.

Qualitative analysis implied looking for shared meanings between informants, while being

awareofmultipleperspectivesheld.Similarviewswerematchedwithinthesamecategory

14

anddifferent viewswere recorded separately. For the reporting of findings, the following

definitionswereapplied:

‘Allstakeholders’:100%ofanswersinagreement.

‘Moststakeholders’:atleast75%ofanswersinagreement.

‘Manystakeholders’:atleast50%ofanswersinagreement.

‘Fewstakeholders’:lessthan50%ofanswersinagreement.

‘Singlestakeholders’:allanswerslistedseparatelybecauseofdifferences.

2.4.2Mainfindingsfromprimarydata

Perspectives on malnutrition, underlying causes and solutions among PSNP and NNP

stakeholders:

All PSNP and NNP stakeholders noted malnutrition as a priority concern with a focus on

childrenasthemostaffectedgroupfollowedbypregnant‐lactatingwomen.

Allstakeholdersmentionedfoodinsecurityasthekeycauseofmalnutritionlinkedmostlyto

drought and limited access towater. Other factorswere specific by regions and included

small‐land size in SNNP and Amhara, land degradation in Tigray and Amhara and lack of

improvedseedsandbreedsinOromiaandSNNP.ManyPSNPandNNPstakeholdersnoted

poor dietary intake focusing on food shortage. Only few stakeholders, mostly from the

healthsector,mentionedlimitedvarietyandappropriatenessofdietforyoungchildrenand

pregnant‐lactatingwomen.

MostNNPstakeholdersmentionedpoorfeedingpracticesasacauseofmalnutrition.Specific

cultural practiceswere noted as being particularly resistant to change. Examples included

therefusalbyhighlanderpopulationstousegoatmilkbecauseofthefearofbecomingdeaf

orthelimitedconsumptionofbutterinthelocaldietduetoitsmainpurposeasacosmeticto

indicatewealthstatus. MostmaleandfemaleFGDparticipantsspokeaboutseasonalityof

resources as the key constraint affecting the household diet. While the majority of FGD

participantsnoted lowproductivityand storing technologiesasmainbarriers, fewof them

15

mentioned the burden of food gifts linked to social obligations and special events in post‐

harvesttime.

MostPSNPandNNPstakeholders, includingFGDparticipants,prioritized solutions focusing

onaccess toproductionwaterand improvedagricultural technologies throughprovisionof

better crop varieties and animal breeds. Nutrition education was mostly noted by NNP

stakeholders.FewPSNPandNNPstakeholdersatdifferentlevelmentionedfamilyplanning

asasolutiontoreducepopulationpressureonlandandenvironment.Significantlydivergent

perspectivesonsolutionstomalnutritioncamemostlyfromregionalPSNPstakeholdersand

includedemergency‐basedinterventionslikefoodaidandresettlementprogramsforlandless

population.

‘Linkages’amongPSNPandNNPstakeholders:

Many PSNP and NNP stakeholders provided a clear distinction between agriculture and

healthsectorresponsibilitiesmakingtheformerresponsible for foodsupplyandavailability

andthelatterresponsiblefornutritionsecurity.However,theroleplayedbytheagriculture

sectortotacklemalnutritioncameoutmuchstrongerthanthatofthehealthsectorbecause

of the almost exclusive food‐security focus by both PSNP and NNP stakeholders. Few

stakeholders mentioned the involvement of other ministries like Water, Education and

Women’sAffairsaswellasNGOs,donors,cooperativesandresearchinstitutes.Stakeholders

whodidmention other sectors beyond agriculture and healthwere those that provided a

broaderoverviewoncausesofandsolutionstomalnutrition.

Answers from KIIs with regards to inter‐sectoral coordination mechanisms were quite

divergent among stakeholders and included disparate bodies like Regional Food Security

CoordinationOffices, theRegionalEmergencyCoordinationUnit, theWoredaDevelopment

Committees, theWoreda and Kebele Food Security Task Forces (FSTF), and the Regional,

Woreda and Kebele Cabinets and Councils. The last twobodies do not have coordinating

functionsbuttheydotakedecisionsfortheallocationof financial resources. The lackofa

commonidentificationofmulti‐sectoralcoordinatingbodieswassignificantlypronouncedat

16

regionallevelwhereeachstakeholdermentionedadifferentinstitutionalarrangement.The

FSTFwasmentionedbymoststakeholdersatworedaandkebelelevel.

Answers from KIIs regarding inter‐sectoral experienceswere significantly divergent among

stakeholders.AhighnumberofPSNP/NNPstakeholdersmentionedemergencyinterventions

followed by infrastructure construction, joint activities by DAs and HEWs andmulti‐sector

donor‐driven programmes like the Belgium‐Survival‐Fund Food Security & Nutrition

ProgrammeandtheWorldBank‐supportedGrowthMonitoringProgramme.Singleanswers

includedjointplanning,HIVeducationatpublicworksites,schoolgardeningandpresenceof

home‐economists(nowdiscontinued).

MotivationalfactorsamongPSNPandNNPstakeholderstopromote‘Linkages’:

Answers from KIIs with regards to motivational factors were quite divergent among

stakeholders but a significant number of them mentioned joint planning and the related

monitoring and evaluation. Visibility of common grounds for collaboration like shared

problems,objectivesandresultswerehighlightedbymanystakeholdersasbothachallenge

andmotivational factor. Some PSNP/NNP stakeholders brought up technical support and

joint‐activities, especially at community level, as motivational factors. Other suggestions

included, for example, sharing of experience, stronger involvement of decision‐makers,

clarityoverrolesandresponsibilities,provisionofadditionalresourcesandre‐establishment

ofhome‐economists.

2.4.3Results

Analyzeddatahasbeendivided into twocategories, theybeing ‘Enablers for Linkages’and

‘InstitutionalBarriersforLinkages’lookingatbothprimaryandsecondarydata.

Enablersfor‘Linkages’

Multi‐sectorapproachaspolicypriority:

Multi‐sector approach is part of NNP development objectives, which mentions ‘Linkages’

between PSNP and NNP as an intermediate result (NNP, 2008). It provides a broad

17

frameworkwithactivitiesandindicatorstomeasureprogress.Thisgivesasenseofdirection,

open enough to allow flexibility and opportunism on how to implement the ‘Linkages’

betweenPSNPandNNP.Reductionofmalnutritionisrecognizedas impactindicator inthe

PSNPdocument(2009)andthePilotinfourRegionsisspecificallymentioned(page40)asa

wayto increasePSNP impact. Inaddition,somenutrition inputshavebeen included inthe

revised PIM (2010) and might provide a favorable policy framework for the PSNP

stakeholders.

Multi‐sectorcoordinatingmechanisms:

TherecommendedNNPmulti‐sectorcoordinatingmechanismswerenotinplaceduringthe

timeofthestudybuthavebeenrecentlyestablishedatregionallevel(2010).MostofPSNP

institutionalarrangements, like theFoodSecurityTaskForces,havebeen functioning since

2005asdemonstratedbyanactivemembership,regularmeetingscheduleandinvolvement

injointactivitiesliketraining,monitoringandevaluation.

Many health sector stakeholders found it difficult to name coordinating mechanisms at

regional levelbuttheycouldeasilyrecognizethePSNPFoodSecurityTaskForceatworeda

andkebelelevel.Thelatteriscurrentlyusedasthelowest‐levellinkbetweenthecommunity

and government programs and services like the Water and Sanitation Program, the

HouseholdAsset Building Program, the Emergency Relief Programand so on. There is no

other platform in the community that includes such an extended membership although

DevelopmentCommittees(DCs)arenowintheprocessofbeingrolledoutinTigray(1for30

households).

Despite their focus on food security, PSNP institutional arrangements do represent an

opportunityforincreasedcoordinationwithNNP,especiallyatkebelelevelwhereHEWsare

membersof theFSTF. Their involvement shouldbe strengthenedas itwas reported tobe

mostlylimitedtoplanningandmonitoringofconstructionofhealthposts.

18

Presenceofhomeeconomistsintheagriculturesector:

HomeeconomistsinSNNPRareundertheRuralWomen’sExtensionOffice,which ispartof

theAgricultureExtensionService.ThereisasimilarpositioninTigrayandOromiabutnotin

Amhara. They are responsible for empowering women economically through income

generating activities. They address both production and consumption, including nutrition

education,byintroducingtime‐savingtechnologiesandworkingonpost‐harvestmethodslike

processing and preparation of food. Previously the homeeconomistswere in charge of a

networkofhome‐agentsatkebelelevel. Nowthefunctionofhomeagentshasbeentaken

over by the HEWs and Community Health Volunteers (CHVs) but no link has been yet

establishedwiththehomeeconomists.

InstitutionalBarriersfor‘Linkages’

Narrowperspectiveonmalnutrition,causesandsolutions:

AlthoughtherewasaconsensusamongPSNPandNNPstakeholdersthatchildandmaternal

malnutritionarepriorityconcerns,causesandsolutionsremainedwithinthepathwaydietary

intakeandfoodinsecurity.Whenlookingatdietaryintake,thefocuswasalmostexclusively

onfoodquantityratherthanaddressingotherimportantnutritiondeterminantslikevariety

andappropriatenessofdiet. KIIswithPSNPstakeholders revealeda limitedunderstanding

onnutritionalrequirementsofyoungchildrenandpregnant‐lactatingwomenandsignificant

misconceptions on the nutritional value of specific foods to be included in the household

basket. 2008‐2009PSNPmonitoringdataconfirmedthat foodtransfersweremostlygrains

andthattheamountwascalculatedbasedonenergyrequirementsofoneadult(1800‐2100

kcal/day)multipliedbyafixquotaoffamilymembers(averagefour‐fivepeople)11.

BasedontechnicalrecommendationsfromtheWorldHealthOrganization(WHO)andFood

andAgricultureOrganization(FAO),youngchildrendohave increasedneeds intermsof fat

(30‐40%)andprotein(11‐13%),whichcanonlybecoveredbyadequatesupplementationof

11Theissueoffull‐familysizetargetinghasbeenclearlyaddressedintherevisedPIM(2010)withaclearstatementonthenecessitytoincludeinfants.

19

pulsesandoil inadditiontocereals.Ontheotherhand,pregnant‐lactatingwomenrequire

an increasedamountofenergy(2400‐2600kcal/day)andfat (at least20%),whichcanonly

be compensated by provision of additional amounts of cereals, pulses and oils. The PSNP

food transfer is15kgof cerealperhouseholdmember for fivedaysworkedpermonthper

householdmember. Thecashwagerateshouldequatetothefoodtransfer.12Considering

childrenbetween6‐11monthsand12‐24monthswouldconsumebetween100grto150grof

cerealaday,themonthlyconsumptionofthesetwoage‐categorieswillvarybetween3and

4.5kgof cereal.13 Pregnant‐lactatingwomen, instead,wouldneedabove15kgof cerealsa

month(estimatedaround16‐17kgamonth).WhenthePSNPtransferisincash,partofthe

cashshouldbeusedbythehouseholdtopurchaseotherrequiredfoods inthechild’sdiet,

likeoil(estimatedmonthlyconsumptionfrom0.4to0.8litresforchildrenfrom06‐11to12‐

23months),pulses(estimatedmonthlyconsumptionfrom0.6to0.8kgforchildrenfrom06‐

11to12‐23months),animalproductsandfruits/vegetables.Whenthetransferisincereal,

the household would be able to save PSNP grains from the child allocation and invest

something inpurchasingoil,pulsesandotherrequiredfoodsbythechild. Thismeansthat

increased emphasis is needed in promoting adequate intra‐household distribution of PSNP

transferred resources to ensure the quality and appropriateness of the diet for young

childrenandpregnant‐lactatingwomen.

Most identified solutions by key‐informants and FGD participants are closely linked to

agriculture interventions. Nutrition education has been suggestedmainly by heath sector

stakeholdersanddoesnotappear togobeyond improving feeding skills andknowledgeof

mothers.Ontheotherhand,FGDparticipantsdiscussedpracticalconstraintslikeseasonality

ofresourcesandpost‐harvestcapacitiesthatseemedmoresignificantforinitiatingapossible

collaborationbetweenNNPandPSNPstakeholders.

12Thewagerateisamendedannuallybasedonawageratestudy.13Theenergyrequirementforchildren6‐11monthsis820kcalwithbreast‐milkproviding50%ofnutritionalneeds.Theenergyrequirementforchildren12‐23monthsis1,220kcalwithbreast‐milkproviding35‐40%ofnutritionalneeds(Source:WHOManagementofNutritioninmajoremergencies,2000).ThenutritionalvalueofdifferenttypesoffoodhasbeencalculatedusingNutValsoftware2006.Averageintakeofbreastmilkisestimatedat549ml(Source:WHOComplementaryfeedingofyoungchildren,Geneva1998)equivalentto379kcal(Source:NutVal,2006)

20

Differingsectormandatesandpriorities:

Sector mandates and objectives are important organizing mechanisms for bureaucracies

because they help to define course of action and distinguish areas of institutional

specialization.Theaccomplishmentofsector‐specificprioritiesisthebasisbywhicheachline

ministry can make substantive claims on state resources. Attaining nutrition objectives,

instead,requiresarangeofactionsthat islessneatlycircumscribedwithinasingle‐sectoral

responsibility.

KIIs and additional interviews with agronomists, market specialists and home‐economists,

confirmedthattheagriculturemandateistoensureyear‐roundfoodavailability,accessibility

andstability.Themainpriorityisboostingyields.Intensifiedcultivationofhigh‐valuefoods

ispromotedinirrigatedareasformarketpurposeswiththeonlyscopeofincreasingfarmers’

income. Raising agricultural production and income are necessary but not sufficient for

solvingmalnutrition.Increasingfarmingprofitabilitythroughexport‐orientedproduction,for

example, can have negative nutritional outcomes if traditional foods in the household

consumptionbasket,especiallypulses,become locallyunavailableand theirprice increases

asaresult. Effectsonthenutritionalstatusfinallydependonthesubstitutabilityofthese

itemswithothersthatareobtainableatreasonablysimilarcostsbuttherangeofproducts

availableinruralmarketsisalwaysnarrowandunsteady.

Thus, agriculture prioritiesmay affect nutritional security and practically work against the

mandate of the health sector,which is particularly concernedwith ensuring theminimum

food basket – cereals, pulses and oil – for the nutritionally vulnerable groups. Trade‐offs

betweenproductions,market,food/cashtransferandconsumptionpatternsshouldbecome

anareaofdiscussionbetweentheNNPandPSNPstakeholders. TheFSTFcanbethe ideal

platformforthiskindofdiscussionalthoughthenumberofdifferentinterestsatstakemight

constituteachallenge.

21

Sector‐specificresourceallocations,incentivesandsystemofaccountability:

Based on findings from the KIIs and FGDs, the UNICEF conceptual framework of nutrition

determinantsisuseful inmappingtherolesofthehealthandagriculturesectorstoaddress

issues around dietary intake. However, in practice, any harmonized cross‐sector attempt

tendstorunintothebureaucraticbarriersthatdividespheresofresponsibilitiesbetweenline

ministries. Resource allocations, incentives and systems of accountability are managed

around sector goals, functional specialization and obvious lines of authority. Personal

incentivesforindividualcivilservantsrevolvearoundtheircontributiontotheattainmentof

narrow sector‐specific objectives. For example, agriculture practitioners may take into

account nutritional considerations, but increasing crop yields is the principal criterion for

judgingtheirperformance.

Productivity and profitability are the basis by which the agriculture sector can make

substantiveclaimsongovernmentresources.Secondaryproductiondatafromtheselected

researchareasshowthattraditionallyvaluablehigh‐nutrientcropslikepulsesareincreasingly

substitutedbyimprovedandhighlyproductivevarietiesofIrishpotato.Thesamedatashow

newlyirrigatedsitesareentirelyusedforintensivecultivationofcashcropslikeonion,garlic,

chat,coffeeandspiceswithnomajornutritionalvalue. As longastheperformanceofthe

agriculturesectorisnotevaluatedbytheircontributiontowardsnutritionsecurity,significant

changesareunlikelytobeseeninproductionpatterns.

2.4.4Qualityofanalysis:

Thestrengthoftheanalysiswasitsidentificationofacommongroundbetweenthedifferent

stakeholderstobuildasharedvision.Thisisconsideredtobethebasisfor‘coordination’at

institutionalleveland‘cooperation’atcommunitylevel.Similarviewswerematchedwithin

thesamecategoryandindicatedwith‘all’, ‘most’or‘many’stakeholders.Theypointedout

perspectivesthatwere‘widelyheld’withinthesampleofintervieweesandFGDparticipants.

Differentviewswererecordedseparatelyunderthedefinition ‘few’or‘single’stakeholders.

Unexpectedandcontraryfindingswerenotsignificantinnumber.

22

The main weakness of the analysis is that all answers had to be grouped into exclusive

categories, thus partly simplifying a far more complex reality. As highlighted by Diesing

(1972), qualitative analysis carries its own integral notion of contextual validity, which is

formedby assessing each answerwith other replies on the samepoint and by looking for

extremecases. Evidencefromqualitativedatawillnevermeshtogetherexactlybutwillbe

presentedinsuchawaytoprovidesomeformofexplanation.

2.5Identified‘Linkages’OpportunitiesataGlance

(Document04Septemberavailableuponrequest)

Atinstitutionallevel(woredaandkebele):

1. Consensus‐Buildingmeetingsatworedalevel.

2. Consensus‐BuildingWorkshopsatkebelelevel.

3. Capacity‐buildingon foodandnutrition security usingPSNPorNNP training/workshop

opportunities.

Atcommunitylevel(kebele):

1. BehavioralChangeCommunication(BCC)usingpay‐daysessionsandpublicgatherings.

2. Incorporation of nutrition into HABP and other development packages using already

establishedgroupsbyDAs(e.g.DevelopmentGroups,Cooperatives,SavingGroups).

3. ProtectionandenhancementofnutritionalstatusofPSNPPLW.

MonitoringutilizationofhealthandnutritionservicesbyPSNPPLW.

MonitoringandfacilitatingaccesstoHABPorotherdevelopmentpackagesthroughthe

establishment of InterestGroups among PSNPPLW/women to promote activitieswith

directnutritionalvalue.

4. Protection and enhancement of nutritional status of PSNP Orphan and Vulnerable

Adolescents(OVAs)throughtheirinvolvementin‘HealthyLifeStyle’clubs.

23

Otheropportunitiesidentifiedforfurtherdiscussionatfederalandregionallevel:

1. FoodFortification.

InclusionofSprinklesforchildrenundertwoyearsandPLWduringfood‐cashtransfersin

the‘hungerseason’.

FortificationatmillofPSNPfoodtransfer.

2. Supplementation of PSNP food/cash transfers through local production of ‘special

blendedfood’forchildren6‐11monthsandPLW.

3. Promotion of high‐nutrient bio‐fortified crops (e.g. High ProteinMaize, Orange Flesh

Sweet Potato) and improved breeds of poultry, small ruminants and cows through

collaborationwithResearchInstitutesfortesting/promotionofselectedvarieties.

24

3.PLANNING,IMPLEMENTATIONANDMONITORING(PHASEII)

3.1PlanningthroughConsensus‐BuildingWorkshops

Consensus‐BuildingWorkshops took place from 28th September to 16th October 2009 and

wereconductedinallfourRegions.InGemechisworeda,threekebeles–Agemti,Kokuriftu,

Homicho–wereadded to the initialoneof Sre KeloGetodue to concernoveryear‐round

accessibility.

3.1.1ExpectedOutcomeandOutputs

Outcome:

ReachingconsensusforPlanning,ImplementationandMonitoringofanumberof identified

opportunitiesfor‘Linkages’.

During the Preparatory Study a number of opportunities were identified for further

discussionwithFoodSecurityTaskForces(FSTF)atworedaandkebelelevel.Theaimofthe

Consensus‐BuildingWorkshopswastocreateanenablingenvironmentfortheplanningand

consequentimplementationofthePilotproject.

Outputs:

• Consensusreachedonthefeasibilityofanumberofidentifiedopportunities.

• Actionplandevelopedwithdetailedtime‐tableforthefirstthree‐months.

• Agreement reached on the roles and responsibilities of sector‐stakeholders of FSTF at

woredaandkebelelevel.

3.1.2Methodology

Humanresources:

• Endorsers:RegionalFood‐SecuritykeymemberswereinformedaboutConsensusBuilding

Workshops, except Oromia Region where the Food Security Coordinator had just

changed.

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• Organizers:Woreda level FSTF key members like the Food Security Coordinators and

Administratorsmobilized participants atworeda and kebele level and arranged for the

venueandthetime‐schedule.

• Facilitators:WBConsultantsandworedalevelFSTFkeymembers.InTigrayRegion,ENCU

DataAnalystsupportedtranslationofkeydocumentsandfacilitation.

• Participants:MembersoftheworedaandkebeleFSTF.Thelistofparticipantsisavailable

onrequest.

Physicalresources:

• Hand‐outs:

Presentation including: i) Introduction‐PSNPandNNPataglanceandrationalebehind

‘Linkages’;ii)SummaryoffindingsfromthePreparatoryStudy;iii)Briefoverviewon‘why

nutritionmatters?’and;iv)Identifiedopportunitiesataglance.

Tableofopportunitiesfor‘Linkages’betweenPSNPandNNP.

GuidelinesforBehavioralChangeCommunication(BCC).

All documents were translated in Amharic for SNNPR and Amhara Region, in Oromifa for

OromoRegionandTigrignaforTigrayRegion.

• Stationery:Flipcharts,markers,folders,notepads,pens,tapesandscissors.

• RefreshmentswereprovidedtoparticipantsforConsensus‐BuildingWorkshopsatkebele

level.

3.1.3AgreedOpportunitiesfor‘Linkages’

Details of agreed ‘Linkages’ include activities, outputs, indicators and responsible bodies.

Proposals,SummaryTablesandAction‐PlansbypilotWoredasandKebelescanbeprovided

uponrequest.

Three major ‘Linkages’ between PSNP and NNP were agreed upon for implementation at

institutionalandcommunitylevel:

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1. CapacityBuildingonNutritionSecurity forkeymembersoftheFSTFatworeda,kebele

andcommunitylevels.

2. BehavioralChangeCommunicationusingEducationEntertainment(BCC‐EE)duringpay‐

daysessionsandotherpublicgatheringstoencouragePSNPbeneficiariestooptimizeuse

ofbothlocalandtransferredresourcesforimprovedNutritionSecurity.

3. FocusedattentiontoPSNPPLWtoprotectandenhancetheirnutritionalstatusandthose

oftheirchildrenundertwoyearsofage.

3.1.4InstitutionalArrangements(RolesandResponsibilities)

RegionalLevel:

• Endorsingthepilotprojectthroughanofficialletter.

• Assigning a focal person from the regional Food Security Coordination Office to follow

implementationoftheagreeduponactivitiesinthepilotworeda.

• GuidingontheuseofPSNPresourcestocoverimplementationcostsofagreedactivities

suchastrainingmaterial,transportformonitoring,etc.

• Facilitatingexperience‐sharingeventsamongdifferentsafety‐netstakeholdersatregional

andworedaleveltoscale‐upbestpracticesfromthepilotproject.

WoredaLevel:

• Releasing funds for ‘linkage’ activities as planned and agreed upon among the major

stakeholdersoftheworedaFoodSecurityTaskForce(FSTF).

• Assigninga focalpersonfromtheworedaFSTFtofacilitate implementationofthePilot

andtoreporttotheworedaFSTF.

• Monitoringofactivitiesinthemodelkebele/s.

• DocumentingprogressofthePilotforsharingexperiencewithotherPSNPworedasinthe

region.

• Facilitatingexperience‐sharingeventsamongdifferentkebeleFSTF,scaling‐upasagreed

andmonitoringreplicationofpilotactivitiesinotherkebeles.

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KebeleLevel:

• Requesting required resources to the woreda FSTF for implementation of agreed

activities.

• Monitoringimplementationoftheactionplanasperschedule.

• Identifying and using local resources for implementation of activities such as BCC,

education,etc.

• ReportingtotheworedaFSTFontheprogressofthe‘linkage’activities.

• Documentingprocessof implementedactivities forexperience sharingwithotherPSNP

kebelesintheworeda.

3.2CapacityBuildingonNutritionSecurity

3.2.1ExpectedOutcomeandOutputs

Outcome:

FosteringcommonunderstandingontheneedtoaddressandmainstreamNutritionSecurity

withinexistingPSNP‐HABPactivities.

Outputs:

• Improved understanding of and due attention given to nutritional requirements of

childrenundertwoyearsandpregnant‐lactatingwomen.14

• Improved nutritional analysis capacity of FSTF members to: i) Incorporate nutritional

priorities and objectives in the food‐security agenda and; ii) Assess the nutritional

outcomesoftheirfood‐securityandagricultureinterventions.

3.2.2Methodology

Humanresources:

• Organizers:WoredalevelFSTFkeymembersliketheFoodSecurityCoordinatorsbasedon

theexistingPSNPtrainingandreview‐meetingschedule.

14PLW(estimated3.5%)andchildrenundertwoyears(estimated6.4)arearound10%ofthetotalpopulation.

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• Facilitators:WBConsultants.

• Participants:MembersoftheworedaandkebeleFSTF.

Physicalresources:

• TrainingManualandHand‐outsbasedonselectedsessions.

The TrainingManual has been translated into Amharic for SNNPR and Amhara Region, in

OromiffaforOromoRegionandTigrignaforTigrayRegion.

TheTrainingManualataglance

(ThefullManualcanbeprovidedonrequest)

• Session1–Rationalefor‘Linkages’

o WhyNutritionmatters(pg.4):

- Typesofmalnutrition

- Groupsmostvulnerabletomalnutrition

- Causesofmalnutrition(UNICEFconceptualframework)

o NutritionalrequirementsforchildrenandPLW(Insert1):

- Basicexplanationofmacroandmicronutrients

- Highlights:i)Differencesindailykcalrequirementsbetweenanadult,apregnantanda

lactatingwoman;ii)Whydoesachildneedcomplementaryfoodstartingatsixmonths?;

iii)Whydoesthefatcontentmatterinthedietofachild?;

iv)Consumptionrequirementsforhouseholdmembers(daily,monthly)

o PSNPandNNS/NNPPolicyFramework(pg.7).

• Session2–Identified‘Linkages’

o Tableofopportunitiesfor‘Linkages’(Insert2):

‐ Leveloflinkage:InstitutionalandCommunitylevel

‐ Activities

‐ OutputsforeachActivity

‐ IndicatorsforeachActivity

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‐ ResponsiblebodyforeachActivity

• Session3–Workingtowardsimprovingtheabilitytoconsumeadequatefood

(focusinginnutritionalrequirementsofPLWandchildrenunder2years)

o BehavioralChangeCommunication(BCC)toincreaseintakeofnutrient‐richfoodsfor

mostvulnerablegroups(pg.11):

‐ HowtoimplementBCCusingEntertainmentEducation(EE)withafocusonhowto

developandpre‐testdifferenttools.

‐ OperationalinsightsforBCC‐EEimplementation.

o IncorporationofnutritionintoHABPandotherdevelopmentpackages(pg.21):

‐ FromProductiontoConsumption:essentialstepsforunderstandinglocalpatterns.

‐ HABPFramework.SuggesteddiscussiononhowNutritionSecuritycanbemainstreamed

intothedevelopmentofBusinessPlans.

o MonitoringandfacilitatingaccesstoHABPandotherdevelopmentpackagesfor

groupsofPSNPPLW15(pg.24)

‐ WhyPSNPPLWgroups?HowcanPSNPPLWacquireresources?Whatactivitiesofdirect

nutritionalbenefitcantheInterestGroupsworkon?

‐ KeystepsforcreatingandmaintainingInterestGroups.

• Session4–Workingtowardsimprovingaccessanduseofhealthservices(focusingon

nutrition)

o MonitoringaccessandutilizationofhealthandnutritionservicesbyPSNPPLW(pg.

26):

‐ RationaleforfocusedattentiontoPSNPPLWbeneficiaries

‐ HowtofilltheChecklistofkeyindicators(Insert3)

‐ Follow‐upChecklistofkeyindicators(Insert3a)

‐ Howtosummarizedifferenttypesofinformation(one‐offindicators,quarterlyCHD

indicatorsandmonthlyindicators)

‐ Howtoreport

15DuringtheEvaluation,someFSstakeholderssuggestedtonotfocusonlyPLWbuttoexpandtheGroupsofInteresttoallPSNPwomen

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‐ Whatkindofrecognitioncanbegiventomotherspracticingappropriatehealthand

nutritionrecommendations

• Session5–MonitoringandEvaluationof‘Linkages’

3.2.3ImplementationandMonitoring

Amhara: The woreda level agreed to organize a one‐day training session during the

WatershedManagementTraininginNovember.However,thedatewasgivenonshortnotice

andoverlappedwithapreviouslyarrangedvisit. KeyPSNPandNNPstakeholders fromLay

Gayint Woreda, the pilot kebele administrators, DAs and HEWs received an on‐the‐job

orientationfrom28thto29thofJanuary2010.Guidancewasprovidedonimplementationof

BCC‐EEandonmonitoringutilizationofessentialhealthandnutritionservicesbyPSNPPLW.

MostparticipantshadalreadybeeninformedonNutritionSecurityprinciplesandonthelink

betweenproductionandconsumptionduringtheConsensus‐BuildingWorkshop.

Oromia: Gemechis Woreda Food Security Desk (WFSD) organized a workshop for FSTF

members of all kebeles in mid‐January 2010. A half‐day session was added for 21 FSTF

members of the four pilot kebeles. Emphasis wasmade on the actual implementation of

agreed ‘Linkages’. Most participants had already been informed on Nutrition Security

principlesandonthelinkbetweenfoodproductionandconsumptionduringtheConsensus‐

BuildingWorkshop. The focalperson from theWoredaHealthOffice couldnotattend the

trainingduetoothercommitments.

SNNPR: Damot Sore WFSD organized the Watershed Management Training for woreda

experts and DAs form all kebeles. Half‐day training was provided on 1st January 2010

focusing on Nutrition Security principles and how tomainstream nutrition into household

business and investment plans (HABP). Involvement of the focal person from theWoreda

HealthOfficewasminimalduetoothercommitments.

Tigray: HintaloWajiratWFSDorganized one‐day stand‐alone training for FSTFmembers of

FikreAlemkebeleatthebeginningofDecember2009.Unfortunately,thetraininghadtobe

rescheduled due to the national consultant being unable to attend through circumstances

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beyondourcontrol.Asaresulttheone‐daysessionhasnotyetbeenimplemented.Experts

from theWFSD andWrHO have been particularly pro‐active inmainstreaming orientation

sessions on how to implement ‘Linkages’ using review meetings. Both Food Security

Coordinatorswere involved in reviewing the translatedmanualandextractedpartsof it to

developorientationmaterial,especiallyfortheimplementationoftheBCC.

3.3BehaviouralChangeCommunicationusingEntertainmentEducation

3.3.1ExpectedOutcomeandOutputs

Outcome:

Increasingintakeofnutrient‐richfoodsforpregnant‐lactatingwomenandchildrenundertwo

yearsofage.

‘Variousassessmentresultsshowthatintegratednutritioncommunicationhasthepotential

tomakeadifference fornutrition securityand nutritionalwellbeingeven in resource poor

settings.These indicatethatnutritioncommunicationcanbeacrucial linkconnectingfood

security to nutrition security to nutritional wellbeing’ (National Nutrition Communication

Framework,EHNRI2009).

Outputs:

• Key nutritional behavioural gaps are identified and addressed using Education

Entertainment (EE) in the form of songs, drama, storytelling and games followed by

CommunityConversationbyHEWs.

• Multiple audiences, including husbands, youth, elderly and the general community are

targetedduringPSNPpay‐daysessionsandpublicgatheringstoinfluenceintra‐household

decision‐makingdynamics.

3.3.2Methodology

Humanresources:

• Organizers:WoredalevelFSTFkeymembersliketheFoodSecurityCoordinatorsbasedon

theexistingpay‐dayscheduleandotherpublicgatherings.

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• Facilitators:WBConsultants,Community‐DramaExpert,woreda‐levelkeypeoplelikethe

Child Health and Nutrition Officer and kebele‐level key people like the Chairman and

Manager,DAsandHEWs.

• Participants:PSNPbeneficiarieswhovolunteerasperformers.

Physicalresources:

• Hand‐outsonBCC‐EE(Session3oftheTrainingManual).

• BCC‐EEAgenda.

• Dramascripts.

• StagepropsprovidedbyPSNPperformers.

‘Entertainment Education’ uses traditional/folkmedia like drama showing appropriate and

non‐appropriatebehaviorsratherthanjustdescribingthem.Inthiswayitcanreachalarge

audienceandaddressbothliterateandilliteratemembersofthecommunity.

ThesearetheessentialstepsforsuccessfulpreparationandimplementationofBCC‐EE:

• EstablishmentoftheTechnicalTeam includingvolunteermembersfromthekebeleand

thecommunityFSTF.

• EstablishmentofthePerformers’Group includingPSNPbeneficiariesandagreementon

thework‐norms. The DA is responsible to facilitate the communicationwith the PSNP

beneficiaries,theforemenandtheFSTFmembers.

• SettingoftheAgendaanddevelopmentofthescripts (oneforeachevent).TheHEW is

responsibletoensurethetechnicalqualityoftheBCCcontent.

• PreparationandrehearsalbythePerformers’Group.

• Implementation of the event. The HEW is responsible to conduct Community

Conversationsattheendofeachevent(unlesstheDAsaretrained).

• Monitoringanddocumentationbyworedaandkebelefocalpeople.

TheAgendashouldaddressspecificbehaviouralgapsduringeacheventwithoutoverloading

the audience with messages. Current knowledge, beliefs, attitude and practices in the

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communityareavitalsourceofinformationforidentifyingthestagesofBehaviouralChange.

For example, the community might be aware of the recommended ‘additional meal for

pregnantwomen’ but theymight still be disputing the actual necessity for the nutritional

wellbeing of the mother and the future newborn. Therefore, the drama would focus on

negotiating‘good’and‘bad’habitstopromotefeasiblechanges.

Education Entertainment can be mademore action‐oriented by incorporating Community

Conversation (CC) at the end of the each event. TheHEWs and someDAs are trained on

community‐dialogue skills, therefore the CC implementation should not be particularly

challenging.CommunityConversationallowsmoreinsightstotheproblemaddressedinthe

traditional/folk media (drama, storytelling, poem, etc.) and to reach consensus on

recommendedaction‐pointsatcommunitylevel.

3.3.3ImplementationandMonitoring

InallRegions,itwasagreedtoconductBCC‐EEeventsonamonthlybasisin linewithPSNP

pay‐daysessionsandpublicgatherings.Capacitybuildingincorporatedonesessiononhow

toimplementBCCusingEntertainmentEducation.TechnicalTeamswereformedinallpilot

kebelesincludingmembersfromtheFSTF.Motivatedandtalentedperformerswereinvolved

from the start‐up, including identification of key behavioral gaps, agenda setting and

developmentofdramacontent.

Amhara:FirstBCCsessionusingdramatookplaceatapublicgatheringon19thFebruary2010

inSheshoKebeleandwasattendedbymorethan200PSNPbeneficiaries.Theperformance

involvedsixplayersincludingtheHEWandtheDA.Thedramaaddressedcareforpregnant

motherswitha focuson threekeyENA (EssentialNutritionAction)messages including the

needforoneadditionalmeal, restandante‐natalcare. Officers fromtheWFSDandWrHO

attendedtheevent(Reportavailableonrequest). ThenextBCCsessionisplannedformid‐

Aprilduringpay‐day.

Oromia: The four pilot kebeles in GemechisWoreda have established Technical Teams to

organizeBCCeventsusingquizandpoems.Pay‐daysessionshavebeendelayedduetoheavy

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rainandinaccessibilityofkebeles.ThefirstimplementationoftheBCCsessionistentatively

plannedfortheendofApril.

SNNPR:ThefirstBCCsessionusingdramatookplaceduringapay‐dayon26thMarch2010in

ShiambaKebeleandwasattendedbymorethan100PSNPbeneficiaries. Theperformance

involvedsixplayersincludingtheHEWandtheDA.Thedramawasonfamilyplanningwitha

focusontheimpactofshortchildbirthspacingonmaternalandchildnutrition.Theregional

PSNPSocialDevelopmentAdvisor,thezonalandworedaFoodSecurityCoordinatorsandthe

woredaHealthOfficerattendedtheevent(Reportavailableonrequest).

Tigray:ThefirstBCCeventtookplaceduringapay‐dayon31stDecember2009inFikreAlem

Kebele and focused on appropriate use of PSNP resources. The second BCC session was

organizedonFebruary10th2010andinvolvedsevenplayersincludingtheHEWandtheDA.

The drama addressed care for pregnantmotherswith a focus on three key ENA (Essential

NutritionAction)messages including theneed foroneadditionalmeal, restandante‐natal

care.Officers fromtheWFSDandWrHOattendedtheevent(Reportavailableonrequest).

ThethirdBCCeventwasimplementedonApril1st2010.

3.4FocusedAttentiononPSNPPregnant‐LactatingWomen(PLW)

3.4.1ExpectedOutcomeandOutputs

Outcome:

IncreasedprotectionandenhancementofnutritionalstatusofPLWandthatoftheirchildren

undertwoyearsofage.

PSNP supports households who live in the lowest quintile of wealth. Findings from the

DemographicHealthSurvey2005showthatgroups inthe lowestquintileofwealtharethe

least likely topractice recommendedmaternal, infantandyoungchild feedingpracticesas

compared to otherwealthgroups (14.5 compared to theaverageof23.2andmore). Also

utilizationofessentialhealthservicesshowsdifferencesbywealthgroups.

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Outputs:

• Information on access and use of essential health and nutrition services by PSNP PLW

regularlysharedinworedaandkebeleFSTFmeetingsaspartoftheroutinemonitoringof

PSNPoutcomeindicators(2009).

• Informationonnutritional statusofPSNPPLWandchildren regularly shared inworeda

andkebeleFSTFmeetingsaspartofroutinemonitoringofPSNPimpactindicator(2009).

• Interest Groups established among PSNP PLW/women and supported to work on

productionactivitieswithadirectnutritional‐addedvalue.

3.4.2Methodology

MonitoringutilizationofhealthandnutritionservicesbyPSNPPLW:

Humanresources:

• Organizers: Woreda level FSTF key members like the Food Security Coordinators in

collaborationwiththeChildHealthandNutritionOfficers.

• Facilitators:WBConsultants.

• Participants:HEWswiththesupportfromDAsandForementoidentifyPSNPPLWduring

theinitialannualregistrationorthroughouttheyear.

Physicalresources:

• Hand‐outs(Session4oftheTrainingManual).

• Follow‐upChecklists.

• Routineserviceregistersandnutritionprogramrecord/reportforms(alreadyavailablein

healthcentersandhealthposts).

Consideringhealthandnutritionalmilestones, fourgroupsofmothers canbe identifiedfor

follow‐up:

Category1: Pregnantwomenfromthetimeofregistrationuptodelivery

Category2: Mothers of children from 0 to the end of five months. During this period

exclusivebreastfeedingisrecommended.

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Category3a: Motherswithinfantsfromsixtoelevenmonths.Duringthisperiodtheinfant

shouldreceivecomplementaryfoodsinadditiontobreast‐milk.

Category3b: Motherswithyoungchildrenfromtwelvetotwenty‐threemonths.Duringthis

period the child starts family food and he/she is still highly susceptible to

malnutrition.

PSNPpregnant‐lactatingwomenareexemptedfromPublicWorkswhentheyarebeyondfour

monthsofpregnancyand in the first tenmonthsafterdelivery. During this time theyare

expected to attend recommended health and nutrition services like ANC, facility‐based

delivery, child immunization, family planning, community‐based growth monitoring and

promotion,etc.Aftertenmonthsfromdelivery,whentheyresumePublicWorkduties,they

shouldbestillallowedtoattendrecommendedhealthandnutritionservices.The‘windowof

opportunity’forreducedmalnutritionisconsideredfromconceptiontilltwenty‐fourmonths

after delivery. However, it might be difficult to follow PSNP lactating women after ten

months from delivery. For this reason, a regular follow‐up from pregnancy up to eleven

monthsfromdeliverymightrepresentaconsiderableachievement.

Monitoring of decreased malnutrition among children under two years of age can be

systematically ensured through the sharing of Community‐Based Nutrition (CBN) monthly

data16 and Community Health Days (CHD) quarterly data17. Monitoring of access and

utilization of essential health and nutrition services by PSNP PLW is expected to generate

communal data for joint planning among members of the FSTF. Additional behavioral

indicatorsrelatedtofeedinghabitsofPLWandyoungchildrenhavebeenincorporatedinthe

checklist. Apartfromthebehavioralindicators,allotherdataareexpectedtobeaccessible

fromexistingregisters,recordandreportforms.Thenumberofindicatorscanbereducedto

includeonlythosethatareconsideredrelevantbytheFSTFbasedonlocalpriorities.

16CBNprovidesdataonunderweightandsevereunderweightamongchildrenU2.However,coverageofweightedchildrenisstilllow.17CHDprovidesdataonproxyGAM(<12MUAC)andproxySAM(<11MUACorbilateraloedema)amongchildren6‐59monthsandproxyGAM(<21MUAC)amongPLW.

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Keyindicatorsataglance(Checklist‐Insert3a‐intheTrainingManual)

Accessandutilizationofservices:

‐ ANCattendance

‐ ModernFamilyPlanning

‐ Deliveryatfacility

‐ MonthlyattendanceofCommunityBasedNutrition

‐ QuarterlyattendanceofCommunityHealthDays

Note:Theaboveindicatorsareexpectedtoberegularlyreported.Indicatorsthatarestagnating(do

notshowanychange)overaperiodoftimeshouldbeperiodicallydiscussedwiththeKFSTFto

identifykeybarriersandconstraints.

Malnutritionstatus:

‐ Prevalenceofmalnourishedchildrenamong thoseattendingCBN (No. of underweight

andsevereunderweightchildren/No.ofundertworeported).

‐ Prevalence of malnourished mothers among those attending CHD (No. of pregnant

and/orlactatingwithMUAC<21/No.ofPLWreported).

‐ PrevalenceofmalnourishedchildrenamongthoseattendingCHD(No.ofchildrenwith

MUAC<12/No.ofundertworeported).

‐ PrevalenceofLow‐BirthWeight(No.ofnewbornwithweight<2.5Kg/No.ofnewborn

reported).

Note: Sharp deterioration of nutrition status (especially from monthly growth promotion and

monitoring)shouldbetimelyreportedtotheFSTFatkebeleandworedalevel.

MaternalandInfant,YoungChildFeeding(IYCF)practices:

‐ Maternalintakeofoneadditionalmealduringpregnancy.

‐ Maternalintakeofone‐twoadditionalmealduringlactation(0‐11months).

‐ Exclusivebreastfeedingofinfantfrom0totheendof5months.

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‐ Two‐threetimesdailyservingsofcomplementaryfeedingforchildren6‐11months.

‐ Atleastfourtimesdailyservingsofcomplementaryfeedingforchildren12‐23months.

‐ Densityandvarietyincomplementaryfeedingforchildren12‐23months.

‐ Useofiodizedsaltforchildren6‐23months.

Note: The above indicators are normally included in standard nutrition surveys. However, the

incorporationof feedinghabits intoa routinemonitoringsystemcanshowchanges (ornot)over a

periodoftime.BCCmessagescanbetailoredbasedonthesefindings.

MonitoringandfacilitatingaccesstoHABPorotherdevelopmentprograms:

Humanresources:

• Organizers: Woreda level FSTF key members like Food Security Coordinators in

collaborationwithChildHealthandNutritionOfficersandrepresentativesfromWomen’s

Affairs,YouthAffairsandNGOs(whereavailable).

• Facilitators: WB Consultants in collaboration with DAs, HEWs, women and youth

representativesatkebelelevel.

• Participants:PSNPPLW/women.

Physicalresources:

• Hand‐outs(Session3oftheTrainingManual).

• Micro‐credit.

• Inputsfortrials.

Findings from the Preparatory Study and continuous interaction with food‐security and

agriculture stakeholders show that nutrition is not yetmainstreamed intoHABP and other

development packages. Few shortcomings need to be addressed to influence production

decisionsandmaximizethe impactofagricultural interventionsonthenutritionalstatusof

mostvulnerablegroups:

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• Food quality and appropriateness of diet for PLW and young children should be fully

understoodandtakenintoaccountinadditiontofoodquantity.

• The nutritional value of foods should be added to existing selection criteria of ‘agro‐

ecologicalsuitability’,‘productivity’and‘marketability’oftreeandcropvarieties.

Theassociationbetweenagriculture,foodandnutritionsecurityprovidesacomplexpicture

that relates food supply with demand and production and consumption. It needs to be

discussedandunderstoodwiththelocalcontext.DAsandHEWsareinthebestpositionto

engage with male and female PSNP farmers for designing interventions and

developing/adopting technologies that take into account local agricultural and nutrition

considerations.

The following steps have been piloted during the Preparatory Study and the Consensus‐

BuildingWorkshops at kebele level and can enable understanding and discussion on local

patternsfromproductiontoconsumption:

STEP1Assesslocalproductionpatterns.DAscanprepareandfacilitatethispartastheyhave

all relevant information per hectare (including productivity in q/ha for local or

improved seed with nothing, with compost and/or with fertilizer). Additional

informationcanbeprovidedontheuseofcrop(percentageforconsumptionandfor

market).

STEP2Identify key products in the household food basket and relate them to nutritional

value(energy,protein, fatandmineral&vitamins). HEWscanfacilitatethispartby

gettingparticipantstostartthinkingintermsofbalancedmeals.

STEP3Assess seasonal availability of key food items from the household basket. DAs can

facilitate this partwith the aim to identify seasonal gaps. For food items available

from the market – either seasonally or throughout the year – participants should

discusswhetherPSNPparticipantswillbeabletoaccessthemornot.

STEP4Identify key food items thataremissing from thehousehold basket– seasonallyor

throughouttheyear–thatarenecessaryformostvulnerablegroups(e.g.fat‐richand

protein‐richsources).

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STEP5Discuss possible solutions using existing community structures (e.g. Development

Groups, Cooperatives, Saving Groups, etc.) and services/programs (e.g. HABP,

developmentprograms,financialservices).

TheearlyidentificationofPSNPPLWandtheestablishmentofWorkTeamsamongthemwas

discussedwiththekebeleFSTFasawaytopromotetheirinvolvementin‘light’worksduring

thenon‐exemptiontimefromPublicWorks(e.g.beforefourmonthsofpregnancyandafter

tenmonths from delivery). Work teamswere also expected to become the basis for the

formation of Interest Groups among PSNP PLW/women to engage in production activities

with nutritional benefits like home‐gardening, poultry, production of local complementary

food, post‐harvest improved techniques, etc. These Groups are expected to establish at

watershedorkebeleleveltofacilitatelinkswithtechnicalassistance,creditandmarket.One

InterestGroupcanhavesub‐groupsatvillagelevel.

The involvement of Women’s Affairs is foreseen as crucial for the formation of Interest

Groupsespeciallyfortheinitialgroundworknecessaryfortheestablishmentofself‐support

mechanismslikesavingschemesorrotatingfunds.

This component requires considerable time and effort that go beyond PSNP and build on

HABP and other development packages. Key steps for creating and maintaining Interest

Groupscanbesummarizedasfollows:

1. IdentificationofPLWandinterestedwomen.

2. CreatingawarenessonbenefitsofestablishingInterestGroups.

3. Enquiringformembership(oneInterestGroupmighthave15‐30membersdependingon

productioninterest).

4. Holding initialmeetings to establish rules and responsibilities amongmembers (sort of

‘work‐norms’).

5. Facilitatingregularmeetingsandinitiatingactivitiesofdirectnutritionalimpact.18

18 The product value chain assessment should be part of the business‐plan development including the identification ofhumanresourcesforrequiredtechnicalassistance

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6. Facilitatingself‐supportmechanismsamongmembers.

7. Linking with financial services and/or technical support for production activities

(responsibilityofDAsandworedaexpertsforspecializedskills).19

3.4.3ImplementationandMonitoring

Useof the Checklist formonitoring access and utilization of essential health and nutrition

serviceswasexplainedduringcapacity‐buildingsessionsandon‐the‐joborientationinallpilot

KebelesandWoredas.Itwasemphasizedthatkeyindicatorscouldbeprioritizedaccording

to need and based on available information from services and nutrition programs. The

Checklist was introduced as an aid to facilitate reporting of key indicators. The initial

identification of PSNPPLWwas planned to take place during the annual PSNP registration

withfollow‐upduringpay‐days,publicgatheringsandPSNP‐relatedmeetings.

In all pilot kebeles identification of PSNP PLW is not complete. Where there is some

progress, like insomeKebeles inLayGayintWoreda, forexample, thefiguresof registered

PLW(startingfromfourmonthsofpregnancytotenmonthsafterdelivery)areunrealistic.20

This may be due to mis‐categorization of beneficiaries, especially lactating mothers ten

monthsafterdelivery.

19 Self‐support mechanisms can be concurrently promoted while searching for external financial and technical support.Promotionofsavingsandjoint‐responsibilityforrepaymentshouldgoalongsidecreditdisbursement.20Kebeleregistrationlistsindicated12%PLWoutofthetotalPSNPbeneficiarypopulationwhilethecommonlyestimatedpercentageofPLWoutofthetotalpopulationisaround3.5%(rarelyover5%).

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4.EVALUATIONOF‘LINKAGES’(PHASEIII)

Theevaluationwas conducted informallywithkeyPSNPandNNPstakeholdersat regional,

zoneandworedalevelfocusingontheirviewoverfeasibilityandscalabilityofidentifiedand

implemented‘linkage’opportunities.

4.1CapacityBuildingonNutritionSecurity

Regional (SNNP) and zone stakeholders (SNNP and Amhara Regions) believe that Capacity

Building onNutrition Security is feasible and can be integrated in the schedule of existing

PSNP/NNP training for future scale‐up, preferablywhere all FSTFmembers or at leastDAs

and HEWs are involved. No institutional barriers are foreseen in the incorporation of

Nutrition Security in the annual training plan (one or half‐day sessions) but there is

acknowledgmentthatthisrequiresastrongcollaborationbetweenfood‐securityandhealth

stakeholders,especiallyatworedaandkebelelevel.

The Training Manual has been translated and shared with PSNP/NNP key stakeholders.

Regionaland zonal stakeholdershave suggestedorganizinga separate reviewworkshop to

understandtheuseoftheTrainingManual’sinnovativemodularlayout.

CapacityBuildingofDAsiscloselylinkedwithincorporationofnutritionintoHABPandother

development packages. Increased awareness of DAs on the nutritional value of different

typesoffood isexpectedtoshowinbusinessorinvestmentplans.However,incentivesfor

DAs depend very much on the inclusion of nutritional outcomes in addition to other

establishedcriterialike‘productivity’and‘profitability’ofselectedcrops.

4.2BehaviouralChangeCommunicationusingEntertainmentEducation

Regional (SNNP)and zone stakeholders (SNNPandAmhara Regions)believe thatBCC‐EE is

feasible and can be easily scaled up in all PSNP Woredas and Kebeles. This activity has

received a lot of favourable feedback and visibility from all stakeholders. Woreda

Documentation Officers recorded the events in SNNP and Tigray Regions. A short audio‐

43

visualreport iscurrently inproductionandstakeholdershavealreadyexpressedwillingness

topropagateitusingregionalmedia.

Both PSNP and NNP stakeholders emphasized the crucial role played by the health sector

(HEW) inensuringthequalityoftheEEcontentandappropriatenessofkeymessages. The

importanceofCommunityConversationattheendofeacheventwasacknowledgedbymost

peopletodiscusscausesofbehaviouralgapsandtoreachcommunal consensusonhowto

solvetheraisedproblems.

ForthesustainabilityofBCC‐EE,woredaandregionalstakeholdersneedtoacknowledgethe

efforts put in by Technical Teams in the preparation and implementation of these events.

Time taken for practice/rehearsal by performers, usually not more than a day, should be

consideredasaworkingdaytoavoidrequestforadditionalpaymentasaseparateactivity.

4.3FocusedAttentiontoPSNPPregnant‐LactatingWomen(PLW)

DespitetheinitialagreementduringtheConsensusBuildingandon‐the‐joborientation,this

activitycouldnotbepilotedinanyRegion.Withregardsto‘monitoringaccessandutilization

of health and nutrition services by PSNP PLW’, no specific institutional barrier could be

identified, particularlywhenPSNP/NNPstakeholders repeatedly stated their interest in the

collectionandsharingofthesedata.Inaddition,HEWsbelievethatallserviceandprogram

indicators are already available and can be easily accessed from their registers and report

forms.

AccordingtotheinvolvedPSNP/NNPstakeholders,thisactivityremainsfeasibleandrelevant,

not leastbecauseofthePSNPPLWbeingentitledtodirectsupportbeyond fourmonthsof

pregnancyand inthefirst tenmonthsafterdelivery. ThusHEWandCHWare inasuitable

position to verify inclusion or exclusion errors and even failure to include newborn and

infantsasPSNPclients.

Withregardstothe‘establishmentandsupporttoPSNPPLW/WomenInterestGroups’,the

mainremarkswereontheneedtoinvolveotherpartnersliketheWomen’sAffairstosupport

44

in theestablishmentofgroups. PSNPstakeholdershaveexpressedan interest todiversify

investment opportunities. The opinion is that it is feasible butmore efforts and time are

requiredtoshowsomeexperiencefromthecommunity.

45

5.CONCLUSIONSANDRECOMMENDATIONSFORSCALING‐UP

Is thereasharedvisiononmalnutrition,underlyingcausesandsolutionsbetweenPSNPand

NNPstakeholdersatdifferentlevels?

LessonslearnedfromthePriorityStudy,Consensus‐BuildingandCapacityBuildingshowthat

there is consensus regarding malnutrition as a priority concern. Similarly all PSNP/NNP

stakeholders agree that children are the most vulnerable groups followed closely by

pregnant‐lactatingwomen.

When it comes to underlying causes, the focus ismostly on insufficient dietary intake and

food insecurity as the route tomalnutrition. However,most PSNP and NNP stakeholders

prioritize development‐oriented solutions within the agriculture domain as opposed to

emergencyresponses.Anincreasedunderstandingonqualityandappropriatenessofdietary

intake forPLWandyoungchildrenappears tobea feasible commonground forPSNPand

NNP linkage. Having recognized the limitation of PSNP cereal‐based food/cash transfers,

complementaryeffortsarethenrequiredtoensuretheyear‐roundpresenceofthefullfood‐

basket–cereal,pulsesandoil– forthemostnutritionallyvulnerablegroups. Thisrequires

the commitment of agriculture departments like extension services and cooperatives to

ensureavailabilityandaccessofkeycommoditiesaswellasworkingtogetherwiththehealth

sectorforincreasedawarenessofnutritionalbenefits,demandandappropriateuse.

Whatconditionspromote‘Linkages’amongPSNPandNNPstakeholders?

Therecognitionof‘multi‐sector’approachtowardsmalnutritionaspolicypriorityiscrucialin

providing legitimacyto ‘Linkages’betweenPSNPandNNP. TheFSTFatworedaandkebele

level appear to be the most effective institutional arrangement for coordination and

cooperation among different sectors. However, the participation of the health sector

appearstobelimitedandsporadic.

Lessons learned from the Preparatory Study and from the BCC‐EE point to the fact that

malnutritionisrecognizedasanissueofconcerninthecommunity.Yet,thereareanumber

46

of economical, practical and cultural motives and constraints that do influence food

production,accessandconsumptiondecisions.Thus,livelihoodiscentraltoanychange.

Whatmotivatesstakeholderstopromote‘Linkages’betweenPSNPandNNP?

Attention and rewards to the nutrition outcomes to which the agricultural sector can

contributemayresult in itconsideringmorerigorouslywhobenefits fromits interventions.

Practically this means that, besides ‘productivity’ and ‘profitability’, the nutrition value of

foodshouldbeincludedandaccountedforintheequation.

Recommendations:

Forimmediatescale‐upofidentified‘Linkages’atinstitutionallevel:

‐ NNPCoordinationBodyandPSNPJSOCworktogethertoensurethatidentified‘Linkages’

are mainstreamed in their respective programs. On this regard, the NNP document

(2008), the PSNP document (2009) and the revised PSNP Planning Implementation

Manual(PIM;2010)alreadyprovidethepolicyframeworktojustifytheneedforamulti‐

sectoralapproach.

‐ NNP/PSNPregionalandfederalcoordinationbodiesendorseandensuretheinclusionof

‘Linkages’ in respective sector plans, enforce implementation throughmutually agreed

monitoringmechanismsandevaluateperformancejointly.

‐ NutritionalobjectivesandoutputsassociatedwithPSNP impactandoutcome indicators

such as ‘reducedmalnutrition’ (PSNPdocument, 2009, p.73) and ‘increased access and

use of health services’ (PSNP document, 2009, p.74) are incorporated in PSNP annual

plansatcommunity,kebeleandworedalevelssothatresourceallocations,incentivesand

systems of accountability are managed around them. In line with the NNP Sub‐

Component2(d),theNNPensuresthatyoungchildrenandpregnantandlactatingwomen

in families receiving aid are being nutritionally monitored and that the nutritional

anthropometryisincludedintheevaluationofthePSNP(NNPdocument,2008,p.55)

‐ NNP and PSNP stakeholders at federal and regional levels work together on how to

mainstreamNutritionSecuritywithintheexistingtrainingcurriculum.Thelinksbetween

47

food production and consumption should become part of the discussion on how to

incorporateagricultural andnutritional considerations from theoutset. On this regard,

the Training Manual, already developed and translated, could be an obvious starting

point. In line with the NNP Sub‐Component 2(d), theMOH could support these joint

training so that keymembers of the FSTF at different levels become change agents to

promoteadequateanddiversifieddietforpregnant‐lactatingwomenandchildrenunder

twoyears(NNPdocument,2008,p.55).

Forimmediatescale‐upofidentified‘Linkages’atcommunitylevel:

‐ Capacity Building on Nutrition Security should be rolled out to kebele and community

FSTFmembers.DAs,HEWs,CHWs,women’sandyouthrepresentativesarewellplacedto

engage with male and female PSNP farmers for designing interventions and

developing/adopting technologies. Interventions and technologies should take into

accountagro‐ecology,householdeconomy,livelihoodstrategiesandculturalnormsthat

influencehouseholddecisionsoverfoodproduction,accessanduse.

‐ Kebele FSTF should integrate Behavioural Change Communication using Entrainment

Education during pay‐day sessions and public gatherings. Members of the FSTF and

performers have demonstrated that this activity can be managed at community level

providedthatthequalityofthetechnicalcontentissupervisedbytheHEWs.DAs,who

aremostlymen, can contribute significantly in promoting nutrient‐rich foods including

information on production, processing, preservation, preparation, consumption and

commercialization. Intra‐household dynamics can influence nutritionally vital decisions

with regards to allocation of different quantities and types of food tomost vulnerable

members.DAsandHEWscanplayasignificantrole infacilitatingthedialoguewiththe

community.

Forimmediateimplementationofidentified‘Linkages’atinstitutionalandcommunitylevel:

‐ It isrecommendedtostartthecomponent‘focusedattentiontoPSNPPLW’inonepilot

woreda lookingmorecarefullyat the rolePSNPandNNPstakeholders canhaveon the

actualimplementation.

48

‐ With regards to monitoring of PSNP PLW utilization of essential health and nutrition

services, the focus could be on few indicators prioritized by both PSNP and NNP

stakeholderswithaninitial‘windowofopportunity’frompregnancyuptoelevenmonths

(asthiscorrespondsmoreorlesstotheexemptiontimeofPSNPPLWfromPublicWork).

‐ With regards tomonitoring of nutritional status of children and PLW in PSNP kebeles,

directlinkcouldbeestablishedbetweentheFSTFandnutritionprogramsuchasCBNand

CHD formonthly and quarterly sharing of data. NNP stakeholders should see it as an

opportunity to increase data quality and utilization as nutrition information would be

sharedwithmultiplesectorsandwithadministrativecadres.

‐ Theestablishmentof InterestGroupsamongPSNPPLW/womenneedsthe involvement

of additional partners, especially in the beginning to support the groundwork. Closer

collaborationwithWomen’s Affairs and YouthAssociation could be explored given the

timeconstraintsofthefood‐security,agricultureandhealthsectors.However,product‐

value chain assessment and technical assistance will still require the involvement of

agriculturalpartners.

‐ PSNP and NNP stakeholders should optimize the role of home‐economists in SNNP,

OromiaandTigraybylinkingthemwiththeHEWsandCHWstostrengthenpost‐harvest

activitiesasanecessarylinkbetweenfoodproductionandconsumption.

Potential‘Linkages’forfurtherdiscussion:

‐ Protection and enhancement of nutritional status of PSNP Orphan and Vulnerable

Adolescents(OVAs)throughtheirinvolvementin‘HealthyLifeStyle’clubs.

‐ FoodFortification: i) InclusionofSprinkles forchildrenundertwoyearsandPLWduring

foodorcashtransfersinthe‘hungerseason’;ii)FortificationatmillofPSNPfoodtransfer.

‐ Supplementation of PSNP food/cash transfers through local production of ‘special

blendedfood’forchildren6‐11monthsandPLW.Onasmall‐scale,thisactivitycouldbe

linkedwiththeestablishmentofInterestGroupsandwithanincreasedroleoftheHome

Economistsatworedalevel.

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‐ Promotionofhigh‐nutrientbio‐fortifiedcrops(e.g.HighProteinMaizeandOrangeFlesh

Sweet Potato) and improved breeds of poultry, small ruminants and cows through

collaborationwithResearchInstitutesfortestingandpromotionofselectedvarieties.

50

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Malnutrition,WorldBankSeminarSeries:GlobalIssuesFacingHumanity

FederalMinistryofHealth(2008),NationalNutritionStrategy,AddisAbaba,Ethiopia

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Ababa,Ethiopia

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(Eds),FoodSecurityinSub‐SaharanAfrica,IntermediateTechnologyGroup,London,p.350

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APPENDICES

Appendix1:UNICEFConceptualFramework

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Appendix2:SetquestionsforKey‐InformantInterviews(KIIs)

1. Doyouthinkmalnutritionisstillapriorityconcerninthearea?Ifno,why?

2. Ifyes,whattypesofmalnutritionaremostcommoninthearea?

3. Ifyes,whodoyouthinkaremostlyaffectedbymalnutrition?

4. Whatdoyouthinkarethemaincausesofmalnutrition?Listandconfirm

5. (After confirming the ‘domains’ to which their answer belongs to) What are the key

contributingfactorstoyourlistedcauses?Discussfactorsinrelationtoeachlistedcause.

Ifnewfactorsorcausesarementioned,askforclarifications.

6. Howdoyouthinkthesecausesandrelatedfactorscanbeaddressed(solutions)?Discuss

solutionsinrelationtolistedfactorsandcauses.Askforclarificationsifgeneralsolutions

areproposed(forexample,‘Increaseawareness’)

7. Whoshouldberesponsiblefortheproposedsolutions?Linkresponsibilitywithproposed

solutions.Confirmmandateoverresponsibilities.

8. Whichotherstakeholdersshouldgetinvolved?Ifgovernmentismentioned,asktospecify

theadministrativelevel

9. Are theremulti‐sectoral coordinationmechanisms between food security/agriculture,

healthandothersectors?Listthem

10. Canyoumentionany inter‐sectoralexperience between foodsecurity/agricultureand

health?Promptforexperienceswithnutritionalobjectives

11. Ifyes:

a. Aretheseinter‐sectoralexperiencesstillcontinuing?Ifnot,why?

b. Anylessonlearnt?

c. Anychallenges?

d. Allocatedadditionalresources?Ifyes,bywhom?

12. What would be themotivating factors for more involvement in ‘coordination’ and/or

‘cooperation’withPSNP/NNPstakeholders?

13. Keycontactpeople:Whodoyouthinkcanbe interestedor isalready involved inmulti

sectoral‘coordination’and/or‘cooperation’atregional/woreda/kebelelevel?

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Appendix3:SetquestionsforFocusGroupDiscussions(FGDs)andguidelines

Brainstorming: The aim of the first set of questions is to gain an understanding of the

communityinvolvementindevelopmentinterventions.

1. Inthepastsixmonths(useappropriateeventfromlocalcalendar)wasanyofthegroup

involved incommunitydiscussions involvingmapping,planningorproblem‐solving?Ask

toraisehands

2. WherethesecommunitydiscussionslinkedwithPSNP?WithCommunity‐BasedNutrition

(NNP)? With Water and Sanitation Program? With Household Asset Building Program

(HABP)?With other types of programs or local events? List answers and always ask if

anybodyhasanythingtoadd(usetallyforrepeatedanswers)

3. What were the key priority actions that came from the community discussions? List

answersandalwaysaskifanybodyhasanythingtoadd(usetallyforrepeatedanswers).

Linkanswers fromquestion3toquestion2, ifpossible.Group itemsunder ‘domains’of

theUNICEFmalnutritionframework–e.g. foodsecurity,maternalandchildhealthcare,

accesstohealthservices,environmentalhygiene,etc.

4. Do these priorities reflectmost of yourmain concerns or problems? List concerns and

problemsnotaddressedbypriorities

MalnutritionandProblem‐Tree:Theaimofthe secondsetofquestions is togetmaleand

femaleperspectivesonmalnutrition,causesandsolutions

5. Whatisthenutritionalstatusinthecommunity?

6. Howdoesmalnutritionmanifestsitselfinthecommunity?Listallanswers

7. Whoarethemostvulnerabletomalnutritioninthecommunity?Listallanswers

8. Whatarethemaincausesofmalnutrition?Listallanswersandusepromptsandprobes

toidentifykeycontributingfactorsundereachidentifiedcause.Groupsunder‘domains’

of the UNICEF malnutrition framework – e.g. food security, maternal and child health

care,accesstohealthservices,environmentalhygiene,etc.

Discussion: A comparison is made between ‘domains’ identified during the brainstorming

session (question 3) and those identified during the problem‐tree session (question 8).

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Promptsandprobescanbeusedtodiscusswithparticipantsontherelationcauses–factors

–priorities. Forexample,doidentifiedprioritiesforfoodsecurityhaveanutritionalvalue?

Do they address the nutritional requirements of the most vulnerable groups? Do they

stimulateproduction,storageandconsumptionofnutrient‐richfoods?

5WsandH:Agreeanddiscusson1‐3prioritiesthatarewithinthedomainofPSNPandNNP

andthatdemandcooperationbetweenhealthandagriculturesector.Usethe5WsandH‐–

who,what,where,when,whyandhow–tobreakdowneachpriorityintofeasibleactivities.

Discuss with participants on existing links with programmes, services and community

resourceslikeDevelopmentGroups,Cooperatives,Farmers’TrainingCentresandsoon.