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The Evolution of Adaptive Health & Nutrition Service
Delivery Systems: Disaster Resilience
Strengthening in Ethiopia
dr. bob alexander(funded by UNICEF Eastern & Southern Africa Regional
Office)
• Problem & frameworks: - Joint FSN Resilience
Initiative - Adaptive BSS study
• Context: Ethiopia health & nutrition
• Adaptive health & nutrition services:
- Evolution of the HEP- Special arrangements for
remote areas (iMHNT)
• Conclusions
What are we gonna do differently?
Problem: Parallel Dichotomous System
Stronger to
address ‘everyda
y’ stresses
Less impacts during &
after ‘extensive’ &
‘intensive’ shocks
Risk-based Development
mechanisms for shocks
contiguum
‘Development’: strengthen regular local clinic management
+‘Emergency’: strengthen parallel external shock response
system =
Service access? Resource use? Context appropriate? Do no harm?
+Crowd out mechanisms for local resilience potential
Resilience Capacities
Category Capacity
Absorb Resist stress & shock impacts entirely & respond to quickly recover
AdaptIdentify temporary changes to stresses & shocks in the system & modify activities temporarily
Transform Identify permanent changes to stresses & shocks & change the system permanently
Key: minimize disruptions of accessto food, income, & services
Role of Adaptive BSS
Predictable Safety Net Transfers
Adaptive Basic Social Services
Sustainable Livelihoods
Protection from Shocks
Resilient SystemStrengthening
Activities
SYSTEM LINKAGES
IMPACTS
ETHIOPIA COUNTRY CONTEXT…
ETHIOPIA AT A GLANCE
Population≈90 million (2nd Africa)• Age: 14% < 4; 3% > 65 • Rural: 80% (highland: mixed;
lowland: more pastoralist)
HDI (2013): 173rd (of 187)
1995 decentralization: • 9 regional states• 2 city administrations• Regions & districts (woredas) have
own constitution (executive, legislative, & judiciary)
HEALTH & NUTRITION ISSUES Access to health services: 45%
High child & PLW SAM rates (double in rural areas)
Chronic food insecure 10.4%
Antenatal care from 28% to 34% from skilled provider; postnatal care low (only 7% within recommended 2 days)
Main diseases: Prenatal & maternal conditions, ARI (acute respiratory infection), malaria, undernutrition, AWD, AIDS
Under 5 (33% of deaths): ARI, AWD, undernutrition, malaria
FACTORS AFFECTING HEALTH:Drought (insufficient/ erratic rain) & migration
Other hazardsRemote areas lack access, education & skills (especially women)
Population Poverty, low income Low access: clean water, sanitation & health facilitiesMillions affected by
drought:
KEY CONSIDERATIONS ↓ chronic & acute Health & Nutrition problems:
both preventive & curative procedures Preventive: local = fast identify problems
(woreda health centres too far) BSS Problem: pastoralists migrate –
static facilities can’t help when they move Biggest migration reason: water for livestock Adaptive BSS strategies must be integrated with
sustainable livelihoods strategies (water access: households, service facilities, crops, & livestock):
- Reduce migration out of necessity - Determine strategies for mobile service access for when people choose to migrate
3-Tier Health System
NUTRITION & HEALTH SERVICESHealth Extension Program (HEP): Replace Health
Centre emergency-focused reactive relief & curative paradigm with local Health Post preventive paradigm (15,000 HPs)
Health Extension Workers (35,000): evolving roles under disease prevention/control, family health, hygiene & environmental sanitation, & health education & communication
Health Development Army: Model households (5:1) take on preventive/ sensitization roles so HEW roles can evolve
Evolution: More adaptive through early identification/action
NUTRITION:FEEDING SERVICES
NUTRITION: DEWORMING, Vitamin A, OEDEMA, SCREENING
NUTRITION: DEWORMING, Vitamin A, OEDEMA, SCREENING
SUCCESS?: 2005-11 ↓ kid stunting (52% to 44%) & underweight (35% to 29%)
HEALTH: MNCH
SUCCESS?
HEALTH: DELIVERIES
SUCCESS? = Infant mortality rates ↓ from 121/1000 in 1990 to 47/1000 in 2013
ADAPTABILITY IMPACTS- - integrated in fixed HCs to improve mobile coverage - can replenish supplies, vaccines, fuel, & spare parts to facilities
UNDISRUPTED SERVICE-Mobile teams can move to affected areas for repairs & supplies
KNOWLEDGE ENHANCEMENT-Strengthens training of lower capacity staff in pastoralist HEW program EQUITABILITY -By providing services to people in remote areas
SUSTAINABILITY - ?????????????????????????????????????????????
Key finding: although expensive, iMHNTs can help improve adaptable access for remote and migrating populations
Integrated Mobile Health & Nutrition Teams (iMHNT) Case Study (Remote/Low Capacity)
Conclusions Long-term investment in training of local capacity through evolution steps of
increasing adaptiveness
Local HEWs/HDA coordinate identification, diagnosis, & basic treatment or referral (e.g., CMAM, CBN, ICCM) = adaptive:
- system adapts to local conditions & capacities
- quicker through decision-making & action closer to the problems
Flexibility to determine which services are better done at HC level (e.g., safe deliveries)
Acknowledge that different areas will evolve differently
Some may need special arrangements (e.g., remote, low capacity): innovative & cost-effective/sustainable?
HEWs accountable to HC; HC accountable for HEW training, supervision, & performance
Integration with other sectors key to overall health & nutrition: HEWs & HDA leaders part of intersectoral community development body (e.g., WASH, Education, Social Protection, Livestock, Crops)
[CF] What (are) we gonna do differently in this opportunity?[CG] What (are) we gonna do differently - before & after big events?[CF] What (are) we gonna do differently to help strengthen capacities [CGC] for everyday & extreme resilience?[FC]: (We need) a platform for coordination – for field level implementation to think & act with one mentality [FC]: Resource & target integration – plans to avoid duplication – in partnerships with implementing partners & community [AmG]: We need to find what complements through an approach - that builds on synergies - to address sustainable, adaptable access in joint solution stories
[FC]: (We need to) embrace how things are changing & build systems that are integrated - in a way to minimize both chronic & acute[FC]: (It’s gotta) expand & contract in surge – to resist, adapt, & bounce forward - for both recurrent problems & those shock-induced [AmG]: It’s gotta build on what’s known already & good M&E – & document lessons for upscaling & advocacy
[AmG]: ask why – then where, what - how & who & when – then budget based on how much we can spend
The Ethiopia Joint Resilience Initiative Song