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The Targeted Supplementary Feeding Programme (TSF)

By Jutta Neitzel

Jutta Neitzel is the Head of the Nutrition and Education Section at WFP Ethiopia. She has worked for the programme since 1997. Previously she worked for WFP in Italy and Yemen. She holds a Masters in Economics.

The author acknowledges the contributions of Gloria Kusemererwa, Targeted Supplementary Food (TSF) team leader, her deputy Tayech Yimar and the entire TSF team for their wisdom and input to this article and their continued dedication to backstop the intervention and to identify creative ways to improve the response the nutritional needs of young children in Ethiopia.

The findings, interpretations, and conclusions in this article are those of the author. They do not necessarily represent the views of WFP or the country they represent and should not be attributed to them.

The Enhanced Outreach Strategy (EOS)/Targeted Supplementary Food (TSF) for Child Survival is a joint programme under the United Nation Development Assistance Framework (UNDAF, 2007-2011) with the Government of Ethiopia. UNICEF is supporting the Ministry of Health (MoH) to conduct twice yearly campaigns of vitamin A supplementation and deworming to every child under five in the country¹. In TSF selected districts, the EOS is also screening malnutrition of all children under five years and pregnant and lactating women.² WFP is supporting the Disaster Risk Management and Food Security Sector (DRMFSS) of the Ministry of Agriculture and Rural Development (MOARD) to deliver two supplementary rations of Corn Soya Blend (CSB) and oil to children and women identified with acute malnutrition during the screening.³

Overview of EOS/TSF

The Targeted Supplementary Feeding programme aims to rehabilitate children under five years old as well as pregnant and lactating women (PLW) identified as acutely malnourished during EOS screenings in TSF selected districts. The programme also aims to reduce the risk of child mortality and through an awareness-raising component, aspires to enhance the basic nutrition knowledge of mothers and other women in communities targeted by EOS/TSF.

Ethiopia is currently among the countries with the highest rates of child mortality and malnutrition in the world. The various long-term strategies initiated by the Government of Ethiopia, such as the Productive Safety Net Programme (PSNP) or the Child Survival Strategy among others, started in 2004/5. It is anticipated that these programmes will take at least 5to 10 years to have significant impact. The EOS/TSF was developed in 2004 as a 'stop-gap' measure to avoid additional millions of Ethiopian children from dying or becoming malnourished in the meantime. It was carefully designed to create a 'bridge' to the more sustainable and longer-term interventions like PSNP.

The TSF replaced the provision of blanket supplementary food rations alongside the general relief food distribution. The rationale for a more targeted approach was to better respond to the needs of malnourished individuals at a critical physical and mental development stage in their lives and to ensure better targeting than a blanket distribution.

More recently (2008), the National Nutrition Programme (NNP) was approved and provides the broader framework for developing communitybased nutrition capacity in Ethiopia. The EOS is now being gradually phased-out and replaced by quarterly Community Health Days (CHDs) organised and managed by the Health Extension Workers at kebele level. The TSF will be continued at kebele level until the rates of acute malnutrition are low enough to end the programme (i.e. until impact of preventive programmes such as communitybased nutrition (CBN) is effective).

The EOS provides key Child Survival interventions to over 11 million children and 700,000 pregnant and lactating women every 6 months. The annual funding is US$14 million.

The annual requirements of the TSF component, with its present coverage, are currently estimated at about US$53 million, equivalent to 53,000 metric tonnes of fortified blended food and vegetable oil. These quantities respond to the needs of around one million individuals in 168 woredas in Afar, Amhara, Gambella, Oromia, Somali, SNNPR and Tigray regions. Initially, the programme covered 325 woredas, but due to soaring food prices as well as diminished donor support in early 2008, the programme had to be downscaled. The initial 325 woredas were the chronically food insecure woredas identified by the Government of Ethiopia during the 2002/3 emergency. The criteria used to select the current 168 TSF woredas were:

• prevalence of moderate acute malnutrition (MAM) >10%
• classification as emergency hotspot woredas in 2006/7
• identification as a food insecure woreda during the December 2007 meher assessment to be a relief recipient in 2007
• not a PSNP woreda in 2007 and, for Oromia and SNNPR, whether the woreda was rolling out the national nutrition programme's CBN or not.

The current TSF woredas do not cover all the hotspot districts in the country. Therefore a special mechanism has been developed to undertake 'ad hoc' TSF distribution in hotspot woredas that are not TSF woredas.

Implementation and design

Every six months and with UNICEF support, Regional Health Bureaus organise Child Survival campaigns. Each district (woreda) that is not a TSF district forms one EOS team per sub-district (kebele) composed of one health worker and one health extension worker. These mobilise the community to come to the nearest health post on a specific day, called the EOS day. On this day, the EOS team will de-worm and supplement with vitamin A all children under five years. On many occasions, Regional Health Bureaus take the opportunity to deliver other essential services such as measles and tetanus vaccinations, mosquito net distribution, HIV/AIDS prevention, iodine capsules distribution, etc.

In TSF districts, the EOS team is expanded with another two health staff, generally one health extension worker and one support staff, to undertake the screening of children, pregnant and lactating women. Thes- health staff measure the Mid-Upper Arm Circumference (MUAC) of children under five years and check for bilateral oedema. Children and women eligible for TSF are registered in a book and given a TSF ration card. The registration book includes the serial number of the distribution card⁴. There are three carbon copies of the registration book, one for the Food Distribution Agent (FDA), one for the district Health Office and one for the district Disaster Prevention and Preparedness Office (DPPO). The registration book is then kept by the FDAs. The three carbon copies allow supervisors and field monitors to verify that they are identical and were not manipulated. In addition to receiving the TSF ration, children identified with severe acute malnutrition (SAM)⁵ are referred to the nearest Therapeutic Feeding Programme, if available.

Table 1: Achieved coverage 2005-2009 (source: MTE Team)
	PRRO 10362.0		PRRO 10665.0
Coverage	2005	2006	2007	2008	2009
No. regions	7	10	10	7	7
No. woredas	165	260	342	166	202
No. pregnant/ lactating women (millions)	0.173	0.228	0.369	0.289	0.356
No. of children under five (millions)	0.301	0.484	0.783	0.615	0.756
Total no of beneficiaries (millions)	0.474	0.712	1.152	0.904	1.112

PRRO: Protracted Relief and Recovery Operation

During the EOS days, MoH supervisors and UNICEF field monitors undertake spot visits although number of sites visited is limited. In addition, post-EOS coverage surveys are regularly conducted by independent organisations. At Federal level, the Emergency Nutrition Coordination Unit (ENCU) checks screening data and informs the MoH, DRMFSS, UNICEF and WFP of any aberrant data.

The DPPO is responsible for compiling the data from the screening registration book and to request the appropriate amount of TSF food from the regional Disaster Prevention and Preparedness Bureau (DPPB). The DPPB is in charge of transportation and distribution of food to over 1,300 food distribution centres. The food is provided by WFP to all of the regional warehouses. All of the food transportation, distribution and administrative costs incurred by regional government are paid by WFP.

TSF distribution centres are selected through community participation and managed by FDAs (trained and paid females from respective communities)⁶. Once the food is received by the FDAs, the community is informed of the TSF distribution date. Beneficiaries come with a TSF ration card and collect the ration for 3 months. The food basket comprises two 3- monthly rations of 25 kg of Corn Soya Blend (CSB) and 3 litres of oil. The size of the ration has been set to compensate for intra-household sharing. FDAs also pass on four nutrition messages during the distribution. This includes instruction to minimise intra-household sharing and selling of the TSF ration.

At the food distribution stage, the DPPB is responsible for conducting regular food monitoring, complemented by WFP monitoring. Unfortunately, DPPB monitoring results are not regularly shared with partners. WFPs monitors and woreda health and DPPO focal points conduct spot check visits to ensure proper implementation and support to the FDAs. In 2009, through regular spot check visits, WFP monitors interviewed 2,369 beneficiaries in 111 woredas and visited 1,245 distribution centres. Nearly 500 centres were visited during distributions. The monitoring visits check on whether the distribution process is following procedures, including proper documentation in the registration books, registration cards, signboards, etc. Monitors also conduct beneficiary interviews 40 days after the food distribution. Beneficiary interviews enquire about food received and how it is used as well as obtain feedback on the distribution, knowledge about entitlement and nutrition awareness. Following each distribution, FDAs attend a post-distribution woreda review meeting to assess the distribution process and to discuss problems encountered with woreda health and DPPO focal points. Review meetings are conducted at district and zonal level to assess the overall EOS campaign performance, including the quality of the screening process.

WFP's approach verifies whether allocated TSF food is reaching beneficiaries identified through the EOS-TSF screening on a timely basis, and enables follow up at higher levels if need be. Commodity tracking will further benefit from the envisaged Food Management Improvement Project (FMIP). As the programme does not regularly check on the improvement of the beneficiaries' nutritional status, WFP conducts an outcome survey once a year including data on recovery and mortality rates.

TSF achievements

The EOS service coverage has been consistently high (>90%) since its inception in 2004. A TSF outcome evaluation study⁷ was conducted in 2008. This study aimed to recruit children for a prospective cohort study in eight districts. Children were to be followed up at 1,2, 3 and 6 months after enrolment in the TSF. At the time of the first follow-up visit, 973 children had received TSF food and were defined as intervention children, and 588 children had not received TSF food and were defined as control children. Overall, at all four follow-up visits, intervention children had greater change in weight-for-height z-scores from baseline than control children (p< or =0.001). Weight gain differed much less between the two study groups and was not statistically significant, with the exception of the fourth follow-up visits. Changes in MUAC also did not differ greatly between the intervention and control group. However, at the first follow-up visit, the difference was marginally statistically significant (p=0.05).

By the end of follow-up at 6 months, 49.2% of children with a low MUAC at baseline had a MUAC greater than or equal to 12 cm and were considered 'recovered', 47.6% had a MUAC less than 12 cm and were considered 'not recovered', 2.9% had died, and 0.3% did not pick up either the first or second distribution and were considered 'defaulted'.⁸ A similar study conducted in 2009 showed much better results, with a 68% recovery rate after three months food consumption.

In 2008, compliance with TSF programme recommendations was generally poor. The majority of children lived in households where the food was consumed faster than expected, ate less than one-half of the TSF food, or shared the food to some extent with other persons in the household. The authors of the study concluded that although the TSF programme has a beneficial effect on enrolled children, the effect seen was smaller than expected. Numerous reasons for this were suggested, including:

• A large proportion of children enrolled were not acutely malnourished.
• Poor compliance, i.e. food sharing (children living in households with increased food sharing tended to have less improvement in nutritional status than children in house holds with less food sharing).
• Increased food insecurity during the followup period so households may have increased TSF sharing.

A number of recommendations to address these findings were made that included: The targeting needed to be improved to exclude more children who do not have acute malnutrition, e.g. ensuring better trained screeners, employing supervisory checks on a portion of EOS screening and implementing two stage screening.

The intra-household food sharing should be minimised by more research into reasons for sharing, better education of mothers and increasing TSF rations. The TSF programme should be linked more closely to health centres to improve the referral of severely malnourished children for more appropriate therapeutic care.

What challenges has the programme faced?

The programme has encountered a number of challenges. The absence of a national nutrition surveillance system and weight gain monitoring in between the six-monthly screenings prevents regular outcome monitoring. Current information on the nutrition situation is provided through woreda-level nutrition surveys, which are mostly conducted by international non-governmental organisations (NGOs) and cannot be extrapolated to regional or national levels. Such surveys are triggered if a serious nutrition problem has been signalled or as follow up to nutritional programmes.

The 2008 TSF outcome evaluation study observed an inclusion of many children who are actually not malnourished (46% of the surveyed group). However, the error of inclusion clustered very closely around the 12 cm cut off point. This error may be due to the poor quality of the screening (poor health extension workers skills/performance in the identification of malnutrition) or to external pressures to get additional or less beneficiaries on the TSF list. The screening methodology initially combined a pre-selection with MUAC measurement followed by the weight-for-height calculation and oedema checking. This method was complicated and highly prone to errors. In 2006, the methodology was simplified and a new MUAC tape, using a colour code and a poster were developed to increase the awareness and understanding of the children's entitlement to TSF and TFP.

Initially, screening was undertaken by community volunteers that were new and unqualified. The screening is now the responsibility of the health extension workers that are qualified and regularly trained on measuring techniques. Where ENCU cannot confirm the validity of screening data, WFP reduces the ration in line with the previously served numbers or individuals or withholds the food distribution till such a time as a field verification exercise can be undertaken. The withholding of food has however, only happened in a few instances.

ENCU's most recent guidance notes on the EOS screening data quality underscores the need to present credible screening results for effective TSF targeting with limited inclusion and exclusion errors. The note suggests more community mobilisation and sensitisation on EOS/TSF, training of anthropometric measurers, the reduction of the number of children to be screened per HEW per day (from 200-250 to 100 per day), more supervision, better quality data compilation at kebele, woredas and regional level, application of data quality check criteria including plausible maximum levels for moderate acute malnutrition (MAM) (15% of children screened) and SAM (3.2%) and a maximum ratio between SAM and MAM.

WFP has also piloted a programme using the 'gatekeeper concept' aimed at a reduction in targeting errors. In this approach, a second screening done by WFP-employed nurses is undertaken. The gatekeeper concept was piloted in Afar and SNNPR as those regions were known to suffer from high numbers of false positive inclusions. The strong commitment to the initiative from the side of high-level regional administration officials was a main factor for the success of the pilot in SNNPR. Another round of secondary screening is currently underway by WFP for comparison with MoH screening. Furthermore, UNICEF has developed a funding proposal for more training and supervision so that screening can be improved.

A Knowledge, Awareness and Practice (KAP) study conducted in 2009 compared child feeding and care practices of mother/caregivers of children less than three years of age (n = 1525) with their immediate neighbourhood non-beneficiaries (n= 1531) in five regions (Tigray, Afar, Amhara, Oromia and SNNPR). The study found that overall, a large proportion of the beneficiary mothers had good knowledge, positive attitude and appropriate practices related to child feeding compared to the control group. Significant differences were observed in their knowledge about optimal time of initiation of breastfeeding, duration of exclusive breastfeeding and optimal time for the introduction of complementary foods compared to their non-beneficiary counterparts (P=<0.05).

FDA nutrition education sessions were not implemented at all food distributions and some mothers missed nutrition education as husbands were sent to collect food, especially in Amhara region.

The conduct of nutrition education only at distribution session sites was considered to be inadequate in terms of bringing behavioural change in child care practices. This implies the need for additional follow up nutrition education sessions and monitoring in-between distributions.

There was clear evidence that the nutrition education made a significant difference in the knowledge of mothers on the preparation of the TSF food. Although the majority of mothers had shared the TSF food with other people in the household, the problem was most common in Tigray and Afar region (P= <0.001). This indicated the need for strict monitoring of compliance and strengthening of the nutrition education given at the food distribution centres in these areas. From focus group discussions it was observed that nutrition education messages passed by the FDA are not given due attention by the community and hence not implemented in Tigray and Afar regions. In Afar region, there is a strong need for the involvement of traditional clan and kebele leaders while in Tigray involvement of health extension workers is going to be important. Key recommendations from this study included the need to integrate FDAs nutrition education with activities of Health Extension workers, reducing the distance travelled for collection of TSF food, making mothers attendance of nutrition education a necessary precondition for TSF distribution, distributing smaller amounts of TSF food at a time, and more frequent distributions to prevent sharing. These recommendations are still being discussed with partners.

As a consequence of inadequate regional food transport tendering processes and delayed communication on screening results, targets for timely food delivery after the identification of acute malnutrition are regularly not met. These difficulties are exacerbated by poor infrastructure, e.g. in Somali and Afar regions and difficult terrain in Amhara region. WFP continue to try to address these problems and have had success with the prepositioning of food within Somali region. The programme benefitted from the 'Hubs and Spokes system' which was introduced for the relief programme and resulted in setting up numerous logistic hubs. WFP are now looking more closely at introducing an adaptation of the same system into Oromia by increased prepositioning at secondary warehouses. In addition, the tendering process has improved in many regions with tendering now for a one year period.

Given the large number of distribution points (over 1300) and the difficult terrain in many areas, the regular monitoring of all sites is a challenge for the government and UN partners. In particular, in Afar and Somali region, security is an additional and serious obstacle as travel of food monitors is restrained. In 2008, WFP were facing challenges in Somali region to ensure that assistance reached intended beneficiaries. Access problems meant that screening could not be implemented in all areas of Somali region while the blanket blended food distribution as part of the general relief ration was not reaching all intended beneficiaries. Therefore in April 2008, WFP started distributing food through a relief/TSF hybrid model, using blended food, normally part of the relief programme, through the dispatch and distribution structure used for TSF, i.e. DPPB dispatched the food which was distributed by the women FDAs. WFP used the TSF structures in 17 woredas in Somali region where no screening had taken place since late 2006. Instead of screening, all children under five years and pregnant/lactating women in the woredas received supplementary food through the TSF distribution centres. The trained FDAs also provided nutrition education to the women receiving the food. This model was expected to contribute to improved targeting of blended food to nutritionally vulnerable groups, as many more delivery points were used than the relief programme. It was also hoped that the model would be used as an alternative in areas with accessibility issues and/or concerns about targeting of blanket blended food assistance through the relief structure. This approach has however not been used since.

In 2009, WFP food monitors concluded that a number of woredas in Afar and Somali regions were not adequately screened and numbers of beneficiaries were consequently not based on reality. In following up with ENCU, the government could also not confirm that screening results were correct. The TSF distribution was then cancelled.

A cost study of the programme conducted in Amhara and Oromia regions in 2007/8 found that excluding food items, the highest cost of the TSF is related to transport which ranges from 75% in Amhara to 79% in Oromia. Next to transport the highest cost is related to personnel (16% in both regions). For a ration of 25 kg of CSB and 3 litres of oil the cost per beneficiary per distribution was found to be $30.30 and $23 with and without considering transport. For a typical food distribution centre with an average number of 239 beneficiaries, the cost per year was $29,988 and $21,988 with and without considering transport respectively. The study concluded that in order to increase cost saving, the major strategic action that needs to be taken is better targeting both in identifying beneficiaries and geographic targeting towards most severely affected woredas.

Conclusions

Since its inception, WFP and Government have worked hard to roll out the TSF and maintain a difficult logistical operation. The programme has undoubtedly had a significant impact on the prevention and treatment of moderate malnutrition. While the programme does not accord with the more traditional supplementary feeding design and has not reached SPHERE targets, many view the TSF as an important bridging programme well suited to a country where up until its inception, there was very little targeted provision for those children suffering or at risk from moderate malnutrition. WFP and Government have grappled with numerous challenges around the TSF. Some of these are outlined above. Other issues have been around how to strengthen linkages between the TSF and treatment of SAM, as well as linkages with the PSNP programme. WFP have written a series of discussion papers on these topics. While the treatment of SAM has made enormous strides in Ethiopia in recent years as OTP roll out has increased, treatment (and prevention) of MAM has made less progress. Numerous mechanism are in place to address MAM, e.g. TSF, blanket distribution of CSB as part of relief programmes, targeted SFPs implemented by international NGOs in woredas affected by acute food insecurity and discharge rations for those graduating from OTP programmes. However, WFP and the Government are highly aware of the need for improved coordination and a more 'joined up' strategy for improving the treatment and prevention of MAM. To this end, WFP in collaboration with Government, have recently convened a meeting between key stakeholder agencies to begin the process of formulating a national strategy for the prevention and treatment of MAM.

For more information, contact: Jutta Neitzel, email: Jutta.Neitzel@wfp.org

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Jutta Neitzel (). The Targeted Supplementary Feeding Programme (TSF). Field Exchange 40, February 2011. p75. www.ennonline.net/fex/40/targeted

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