05 Mar 2019

Case study: Improving nutrition outcomes for adolescent girls in Ethiopia

Nutrition International

To what extent is malnutrition among adolescent girls prioritised in Ethiopia?

Through the Seqota Declaration, Ethiopia committed to ending undernutrition by 2030. The 2016 document specifies the engagement of several ministries, including Health and Education, for improving adolescent nutrition.

According to the Ethiopia Demographic and Health Survey (2016), an estimated 23% of adolescent girls aged 15–19 and women aged 20–49 in Ethiopia are anaemic, with a higher prevalence in rural areas (25%) than in urban areas (16%). There are striking regional differences, with prevalence ranging from 16% in Amhara and Addis Ababa regions, to 59% in Somali Region.

In Ethiopia’s National Nutrition Programme II, the government specifically endorses providing weekly iron and folic acid supplementation for adolescent girls to reduce anaemia, and promotes using schools and health facility platforms to ensure adolescents’ access to micronutrient supplements. Additionally, the Ethiopia Federal Ministry of Health (FMoH) includes Weekly Iron and Folic Acid Supplementation (WIFAS) as one of the key interventions for adolescents in the FMoH’s Comprehensive Integrated Nutrition Services. A National Adolescent Girls Nutrition Technical Working Group was established in February 2017 and is being instituted under the National Nutrition Technical Committee.

What did Nutrition International’s project set out to achieve?

Nutrition International’s adolescent nutrition programme in Ethiopia sets out to reduce anaemia in adolescent girls, and improve the knowledge, awareness and agency of adolescent girls and boys around their own nutritional needs for growth, health and development. The adolescent nutrition intervention has a demonstration phase (completed in November 2017) and an ongoing scale-up phase to deliver WIFAS and counseling to adolescent girls in school and out of school (the latter is one of the most vulnerable groups in Ethiopia). Additionally, the adolescent nutrition programme delivers gender-sensitive nutrition education to both boys and girls in school.

What are the results of the project so far?

In 2017, the demonstration project for in- and out-of-school adolescent girls reached over 58,000 girls through 113 health posts and 229 schools in the six project woredas (districts). Since September 2018, an additional 62 scale-up woredas in four agrarian regions (Amhara, Oromia, Tigray and Southern Nations Nationalities and People Region) and one pastoralist region (Afar).

In 2018, 80,411 in-school and 3,819 out-of-school girls were reached through 221 schools and 435 health posts, averting approximately 5,300 cases of anaemia. Weekly nutrition education sessions were provided in schools for both girls and boys. As part of this, more than 7,000 Motivator Girls were sensitised on adolescent girls’ nutrition to deliver peer-to-peer education and support. In 2019, 28 additional woredas will be covered by the project and it will reach nearly 600,000 adolescents (385,231 girls and 212,111 boys) with gender-sensitive nutrition education.

Could the project be scalable?

The results and key lessons of the 2017 demonstration projects in six woredas have informed the scale-up plans for an additional 90 woredas in 2018 and 2019. They also provide guidance on how the Comprehensive, Integrated Nutrition Services’ recommended adolescent nutrition activities can be implemented jointly with the Ministry of Health and Ministry of Education.

There are early signs of commitment: in 2017/2018, all six project woredas included WIFAS for adolescent girls in their annual health sector plans for the fiscal year (after having received the supplements for the demonstration phase without cost from the FMoH).

In 2019, Nutrition International will continue to implement both WIFAS and nutrition education for nearly one million in-school and out-of-school adolescent girls across 100 woredas. Service delivery points will include 2,801 schools, 1,624 health posts, and 149 Alternative Basic Education (ABE) centres (in the Afar region only).

How would better data improve the impact of the project?

Data for younger adolescent girls and boys aged 10–14 years and boys 15–19 years is partially lacking, and data for adolescent girls aged 15–19 years of age is collected only as part of the larger age group of 15–49 women of reproductive age.

Having sex-disaggregated nutrition and health data, including anaemia data, would enable decision makers and programmers across Ethiopia’s ministries to understand the extent of malnutrition in adolescence, as well as to identify any gender inequalities. In addition to having comprehensive sex-disaggregated anaemia data, having school attendance data, health services access by adolescents, early marriage and adolescent pregnancy data would help decision makers understand how different platforms are more or less effective at reaching adolescent girls, and would also help identify vulnerable groups, such as out-of-school girls and pregnant adolescents.

What is preventing you from having an even greater impact on malnutrition?

Adolescents are a relatively new priority group for preventative health interventions, and are often marginalised by the health system. Schools are among the most cost-effective delivery platforms, and education is an important partner in addressing adolescent nutrition. However, school attendance rates among girls (often much lower than enrollment rates) continues to be a challenge for the project. Gendered barriers to school attendance include menstrual hygiene management, early marriage, adolescent pregnancy, safety, stigma and financial constraints. The project tracks attendance and is gaining additional insights from girls on gender barriers, and will highlight this issue with relevant partners. Reaching out-of-school girls has been more challenging than anticipated, but we are increasing our efforts to improve nutrition among this most vulnerable demographic.