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Program Perspectives
For change to occur in how investments are made in children, knowledge, policy, and political will need to come together with community will, suggested Lorraine Sherr, Clinical Psychologist and head of the Health Psychology Unit at University College, London. Community will, in the contemporary Ethiopian context, was highlighted by a series of perspectives on where and how investments are being made in integrated ways across the areas of health, nutrition, education, and social protection not only in young children but also in adolescents and caregivers. Alan Pence, United Nations Educational, Scientific and Cultural Organization Chair for Early Childhood Education, Care and Development at the University of Victoria, pointed out there are many innovative and effective programs across sub-Saharan Africa, but they are largely invisible and unknown. Sherr emphasized the value in these types of perspectives is that they create a process of setting up programs that seem well articulated and possible to implement. The following perspectives highlight interventions in the Ethiopian context.
ETHIOPIAN SCHOOL MEAL INITIATIVE
Frealem Shibabaw, Director of the Ethiopia School Meal Initiative (ESMI), demonstrated the evolution of changing primary schools into community solution centers. Shibabaw unpacked the meaning of investing as a way of framing the ESMI. She deemed that investments could be quantified across time, energy, and resources—or across more intangibles
in the hope that future benefits actualize within a specified time period. Shibabaw’s inspiration for the ESMI was grounded in the realities of children in primary school in Ethiopia and the realization that while schools may be providing in some ways for the country’s children, there were other needs not being met—nutrition being one of these needs.
The ESMI was founded on the premise that Ethiopia is not financially equipped to feed all of its children, where stunting occurs in 40 percent of children who attend school (Central Statistical Agency, 2014). Shibabaw charted the progression from critical issues on child investments to policies, systems, and programs and mapped this progression back to the fundamental values of the community and how communities specifically value children. Within this larger framework, she focused on nutrition. To reduce the number of children who attend school while hungry, and because of high costs associated with buying milk, Shibabaw explained that the ESMI brought cows to primary schools.
The initiative was designed to be responsive to the larger philosophical question Shibabaw posed: What are the values of the community and country? To best articulate how the ESMI addressed the value that every child should have proper nutrition in the country, she used the acronym SSM—simple, sustainable, manageable. Shibabaw maintained that the ESMI had to be simple in its process and delivery in the communities; sustainable in that the model had to be both understood and affordable to the local people; and manageable by individuals in the communities without requiring any external expertise.
At the onset, only two cows were brought to the first participating school, because it was not known how the cows would affect the school environment. Shibabaw reflected that the original pilot school proved overwhelmingly successful insofar as both the community and the children responded positively to the presence of the cows. Today, a total of 3,000 primary school children across Ethiopia drink milk and eat bread every day at school as a result of the ESMI.
The model provides 10 cows to each participating school, with a production rate of 200 milliliters of milk to 500 children per day. The project is sustainable on the premise that the cows multiply themselves by giving birth annually. Also, the school keeps half of the milk produced daily for children and sells the rest to the surrounding community to cover the administrative costs. Additional services have now been integrated into the model and managed by the school personnel. These include local kitchens that bake bread daily, which is produced from the income generated from the school’s milk sales and given to the children alongside their daily milk intake. With the income generation, the schools are also able to afford purchasing feed to sustain the cows.
The impacts of the program were seen almost immediately, reflected
Shibabaw, with increases in school enrollment and attendance. Additionally, the program supports a school milk forum to engage school communities around the importance of milk so that they can support each other, create awareness, and build the capacity of schools. Shibabaw escalated the issue to the Ministry of Education (MOE) level, capturing its attention with the argument that nutrition should be at the top of the national education agenda, on the premise of nutrition before education—that is, children should not come to school without breakfast. She argued that education cannot be separated from nutrition.
By transforming schools into community solution centers, using the dairy farm as a training center for the local farmers, and having an ongoing dialogue with parents and particularly mothers, Shibabaw is shifting the country’s focus from solely crop production to now include dairy and its potential for communities’ economic growth and development. Shibabaw pointed out initial investments need to involve communities to make the changes that can be long lasting. To do this necessitates a contextualized understanding of what is important to communities in order for them to in turn invest in their own children in sustainable and engaging ways.
ECONOMIC AND HEALTH IMPROVEMENTS FOR ETHIOPIA’S EVER-MARRIED ADOLESCENT GIRLS
Jeffrey Edmeades, Senior Social Demographer at the International Center for Research on Women, spoke about the evaluation of the Toward Improved Economic and Sexual/Reproductive Health Outcomes for Adolescent Girls (TESFA) project (implemented by CARE Ethiopia), which targets ever-married adolescent girls in Ethiopia. Edmeades defined ever-married within the Ethiopian context as both females who are currently married and those who were formerly married.
Edmeades pointed out the Amhara region of Ethiopia historically had some of the highest rates of child marriage in the world (Bruce and Erulkar, 2015). While the numbers have been declining over the past decade, the region also boasts high rates of divorce (Tilson and Larsen, 2000). Edmeades stated this means there are many adolescent girls who may have children and yet may be in limbo in terms of their marital status.
Edmeades provided figures to further quantify the importance of targeting this particular population. Data point to the fact that there will be an estimated 142 million more married girls over the next 10 years (UNFPA, 2012), given that there are already more than 720 million females who were married as an adolescent (UNICEF, 2014a). Edmeades emphasized that this is a large and important subset of the global population
because they are the primary caregivers for many young children around the world.
According to Edmeades, for an adolescent girl marrying early often means the end of formal education (Stoebenau et al., 2015; UNICEF, 2014b; Warner et al., 2014). In addition, this often marks the beginning of sexual activity and childbearing, as well as the introduction of other physical and mental health issues (Nour, 2009; Plan UK, 2011; UNFPA, 2012). Furthermore, children of very young women comprise a subsequent generation that is susceptible to health, poverty, and developmental challenges (Duvvury et al., 2013; Parsons et al., 2015).
The TESFA program was designed to deliver content to adolescent girls in rural Ethiopia to impact economic empowerment and sexual and reproductive health. Program implementation utilized an innovative group-based peer education model, building off the CARE’s Village Savings and Loan Association model. Groups of girls identified two internally selected facilitators who received the initial training and who were then responsible for passing on the key knowledge of the program (with some external assistance). A representative community-nominated group served as the liaison between the project and the group of girls participating in the project from their community and received a separate training curriculum based on CARE’s Social Analysis and Action approach. This group was pre-identified by CARE to make sure it was representative of all groups in the community, and in doing so the program benefited from key engagement within the communities.
Edmeades stated the objective of the training was to determine if pairing economic empowerment with sexual and reproductive health would result in improvements across both areas of competencies through the synergistic training. Edmeades summarized the objective by stating that a girl who is receiving economic empowerment training would be more empowered economically and potentially have more resources to access sexual and reproductive health facilities and services. When accessing those services, an adolescent girl may then feel that she can invest more in her future and have more confidence in her future.
The program was implemented for 1 year with baseline and endline data collected from approximately 3,000 female adolescent participants. The quasi-experimental design created a comparison group where the same outcomes were compared across all arms to evaluate both areas of training against each other and against the comparison group to yield an estimate of total effect and of relative effect.
Qualitative data were collected using focus group discussions, in-depth discussions with community members and girls who participated, in addition to the use of innovative photo-voice data collection methods where girls were given cameras and sent out into their community with
instructions to take pictures of elements that were illustrative of the effect of the program on their daily lives. Edmeades noted the qualitative data added rich images of men engaging in child care, cooking, and other activities, as well as evidence of savings and income-generating activities, such as animals that had been purchased. The photo-voice in particular provided a powerful tool for allowing the voices of the girls to come through in a way that even the qualitative research did not.
Edmeades indicated the effects of the program were particularly clear for the sexual and reproductive health outcomes, whereas the economic outcomes were clouded by broader macro-economic changes going on in Ethiopia. More specifically, Edmeades pointed out there was a general confidence communicated in the single-intervention groups and the combined intervention groups they felt they could provide for their family during an unexpected time of crisis. In addition, across the three intervention groups there was evidence of a dramatic increase in the proportion of adolescent girls reporting that they had amassed savings of their own.
Edmeades pointed out the key differences between the intervention groups occurred around questions of savings and anticipated uses for money saved. For adolescent girls who were saving for productive investment in the future either in the form of human capital development or actual capital, there was a sharp increase only in the two groups that received the economic training.
There were also significant changes in knowledge, which Edmeades noted is not too surprising given that advancing knowledge is not as challenging as moving behavior. There were dramatic increases in the percentage of adolescent girls communicating that they knew a way to avoid sexually transmitted diseases, in addition to improvements in the percentage who reported being able to use a condom effectively, and increases in accurate knowledge surrounding antenatal care requirements, stated Edmeades. While these significant improvements were observed across all groups, Edmeades argued they were particularly evident in the group receiving the sexual and reproductive health intervention and the group receiving the combined intervention.
Edmeades reflected on the success of the overarching peer group–based model and the community support that emanated from this model, which was instrumental insofar as the groups functioned as key agents of change on their own account. Edmeades commented that outcomes in the combined program did not necessarily reveal synergies, yet for a population of adolescent girls who were largely invisible in health and education systems in their communities and with fundamentally limited mobility, working with them in any way was creating an impetus for change that was also supported by the community. The types of interventions supported by the TESFA program and their intended outcomes are
important to future engagement with this large population of Ethiopia’s ever-married adolescent girls, concluded Edmeades.
ETHIOPIA’S SCHOOL READINESS INITIATIVE
Menelik Desta, Chief Operating Officer of the Ethiopian School Readiness Initiative (ESRI), described the program, which was founded in 2007 as a pilot project to demonstrate the importance of preprimary education in the Ethiopian context. Desta drew inspiration from a World Bank report (2005) that proposed if Ethiopians were educated through grade 4, the poverty index could be reduced by 18 percent. Referencing the World Bank report, Desta quickly realized that the existing condition posed significant barriers, given that less than 5 percent of children were enrolled in school, and out of those, 65 percent did not attend school beyond the elementary grades. The evidence suggested to Desta and his colleagues that dropout rates could largely be attributed to insufficient early preparation for children ahead of enrolling in primary school.
Initial conversations with the MOE were challenging, reflected Desta, because preschool programs were not funded by the government. Translating content from the U.S.-based Head Start program and adapting it to the local context, Desta’s group piloted the program for 1 year and delivered the initial results to the Minister of Education. Then, the Government Education Bureau became interested in the program. Working together, and against the national policy that does not support the Treasury to fund preschool education, they developed the ESRI at 10 schools initially with the vision to ensure every child not only stay in school, but also succeed in a holistic manner.
The program works alongside the Government Education Bureau, which provides school infrastructure and teachers’ salaries. The ESRI curriculum utilizes teacher-to-teacher and parent-to-teacher engagement strategies designed to empower the teachers and parents to improve the quality of education being provided. Beginning with 80 children, the program has now been scaled up to serve 10,000 children in 52 government-run preschools in Addis Ababa, mostly serving children from families who cannot afford to send their children to private schools. Furthermore, the government mandated that every government preschool use the guidelines created by the ESRI, which is accompanied by a monitoring and evaluation plan. To date, the Ministry of Health, the MOE, and the Ministry of Women, Children and Youth Affairs in Ethiopia adopted 11 manuals on early child care and education created by the ESRI.
Desta presented a sub-program that supports mental health in schools, which is innovative in that there are few trained professionals in Ethiopia who can provide mental health services for young children. In Ethiopia,
Desta pointed out mental health problems are typically attributed to cultural and preternatural factors. In the program he presented, Desta found that in nearly 90 percent of cases, an individual with behavior or mental problems will seek care through traditional mechanisms. Even in instances when individuals are aware of the medical benefit of seeking mental health care, there are few professionals in the field of mental health, particularly when it comes to childhood mental health challenges.
Desta presented the rationale for the mental health program within the ESRI. It operates on the premise that the school is the most adequate setting to efficiently start addressing the issue of behavior or mental health issues in Ethiopia’s children. With funding from Grand Challenges Canada, the objective of the project is to improve quality services by engaging teachers and parents who are the key actors in the implementation of early childhood care. After implementing a series of empowering activities with parents and teachers specifically addressing mental health in children, assessment takes place at the community, school, and health facility levels to document change. Specific areas of measurement include the magnitude of mental illness in adults and children, public well-being, community well-being, public perceptions of mentally ill individuals, and community practices in child discipline.
Desta stated the study seeks to determine if training parents and teachers helped them identify signs and symptoms of mental illness in children. Follow-up assessment for those individuals diagnosed by teachers who are referred to centers takes place and is also documented. The centers have professionals who assess the referrals and begin administering treatments.
Findings from the study reveal evidence of depression in both the adults and children admitted to treatment. Desta also reported that more than 75 percent of the adult population still uses physically aggressive means to discipline children. Through the program and training, changes in knowledge, attitude, and practice are also reported to be improving, stated Desta. While Desta pointed to the incremental improvements as a result of the overall ESRI and the program targeting mental and behavioral health, he is looking to next steps, which include the ability for teachers to diagnose children with mental illness.
REACTION TO PROGRAM IMPLEMENTATION IN THE ETHIOPIAN CONTEXT
In her research reaction to the series of community-based programs in Ethiopia, Sherr suggested that gathering evaluation data not only provides feedback to the program developers, but it also ushers in the potential to ask much more complex questions. Sherr went on to state that
evaluation provides opportunities as well as imperatives: the opportunity to ask and the imperative to move on and to start designing around the data that have been generated.
By investing in the balance between children and programs in integrated ways, Sherr articulated that integration creates complexity; but it also looks at the intersections, it brings in multiple disciplines, multiple concepts, and multiple visions. Sherr underscored that existing evidence shows education, nutrition, family support, early childhood development, stimulation, and good health all work as program targets. Sherr emphasized that the program perspectives from the Ethiopian context describe the challenges associated with family and community investments in young children and present a way forward. By asking the right questions, growing through diversification, and placing an emphasis on ownership, Sherr stated, scalability is possible.
