Since then, UNICEF has provided nutrition-related technical support focused on dry supplementary food targeting and monitoring mechanisms in some 13 zones not otherwise "covered" by other agencies. UNICEF also seeks to contribute to overall nutrition-related data collection and analysis working in collaboration with DPPC, UN agencies and NGOs.

Based on available data collected by UNICEF emergency field nutritionists, from NGOs (in particular SCF-UK nutrition monitoring teams), UNEU-E and Government Departments, the following trends emerge:

In the UN/DPPC assessment mission undertaken in June, indications of serious malnutrition were identified in all regions. The report stated:

Of significance is that these reports covered only several of the then worst affected areas, since then, the geographic area of concern has progressively expanded to include additional zones (see footnote 2).

Some four months later, malnutrition rates remain high: children under five in 17 out of 48 kebele/ PAs in Northeast Amhara region had a high prevalence of acute malnutrition using the cut-off point of below 80% weight for length (WFL). In East Hararge, six out of 16 kebele/PAs also had a high prevalence of malnutrition using the same indicator. Worse conditions exist in Konso area where 20.2% of children under five were found to be below the accepted WFL cut off point (minus 2 standard deviation unit) WFL as per a recent MSF-Holland survey carried out in collaboration with DPPC and woreda health authorities. Beyond these specific surveys, rapid assessment and observation reports indicate additional pockets of malnutrition existing in most of the other drought affected areas.

The high prevalence of clinical malnutrition gives evidence of the seriousness of the present situation that requires an accelerated, more concerted response. Yet the impact of the drought on child health is not due solely to lack of food but has aggravated pre-existing marginal health conditions where the net consequence of weak immunization services, lack of safe drinking water and poor sanitation often prevail. Quite possibly, given the conditions in many areas and the various constraints cited, child mortality rates have increased though no specific mortality data is being collected.

Almost immediately, following the recommended framework for targeted nutrition response (UN/GOE appeal of 12 July), it became apparent that a harmonized strategy in responding to the drought at central, regional and sub-regional levels was needed. In an August meeting with DPPC, prior to deploying its field nutrition monitors, UNICEF was informed that though the principle of prioritized targeting remained there were problems at the field level in the form of pressures to meet the additional needs of other and newly identified drought affected populations. It became clear that this was exacerbated by problems in communications both within the regions and among differing government bureaux involved in coordinating drought response, i.e. DPPB and Social Affairs. In Amhara region, the distribution of urgently needed SCF/UK famix was delayed for four weeks while targeting processes were worked out between the region, zones and woredas. SCF-UK was informed that, given inadequate overall food and supplementary food stocks in the face of major needs, the previously agreed target amount of 150g per beneficiary or 4.5 kg per month was not possible due to needs exceeding supply.

As a result, instead of a targeting action aimed at a percentage of the overall affected vulnerable, a blanket distribution was chosen for all vulnerable populations (pregnant and lactating women and children <5 years) registered for food relief. The 1,116 Mts of WFP famix/CSB was allocated on a proportional basis to the regions identified by DPPC as drought affected, recognizing the actual per beneficiary amounts received would be below the planned figure of 150g per beneficiary per day. In the context of food aid, it also bears notice that in many areas, targeted allocations of 12.5 kgs per beneficiary were in fact being allocated for families and often at lesser amounts, as little as 6-7 kgs for a family for one month. As inputs (until very recently, only cereals) were distributed to the Kebele/PA level they were spread too thin. Such was the effect of undocumented and/or unofficial needs, genuine that they were and remain to be.

In the present circumstances, a theoretical emphasis on "targeting" bears little resemblance to conditions on the ground. However, given the various constraints cited and recognizing that community traditions call for sharing among all needy populations, targeting concepts need to be shifted from a per beneficiary focus to that of a geographic area--targeting of worst affected communities at PA and sub-PA levels.

The intended effect of targeted supplementary food distribution: to provide deficient calorie and protein intake as a supplement to dry ration (mostly cereal), targeting most vulnerable population cohorts, has not been achieved thus far. This is compounded by the fact that in most affected areas that have received deliveries of supplementary ration, actual distributions to beneficiaries are only now beginning.

The last serious nutrition emergency on a large scale in Ethiopia was in 1994, though the current situation is believed as bad if not worse. In Ethiopia, the average citizen receives daily caloric intake below the WFP minimum standard (2,100 calories per day) with one of the highest average stunting and wasting figures for children under five in the world.

Over the last five years, resources and capacities in early warning systems have been strengthened at national and regional levels drawing on bilateral aid, UN and NGO institutional support in this area. However, the present crisis demonstrates that emergency nutrition surveillance and emergency response is below the required capacity in the following areas:

• Centralized collection of nutrition surveillance, supported by effective mapping and dissemination systems.

• Adequate regional, and sub-regional nutrition surveillance mechanisms designed to back-up and strengthen existing community-based growth monitoring programs.

• Emergency nutrition management, regional and zonal and criteria for activation.

One of the main constraints affecting overall response to the upsurge in child malnutrition caused by the drought has been the absence at the central level, of a dedicated capacity to plot the global picture of malnutrition and to coordinate and monitor required interventions. Although, the DPPC Early Warning Department, generates regular reports providing data gathered from select drought prone woredas, this information is focused largely on production indicators including rainfall patterns, animal health and other environmental phenomenon such as flooding, hailstorms, etc. While this provides useful regional and woreda-level analysis of general food security trends, in the present situation early warning data does not sufficiently monitor food security indicators at the household level including child nutrition and coping mechanisms.

The SCF-UK Nutrition Surveillance Project (NSP) and more recently, special emergency nutrition monitoring teams (NMTs) composed of SCF and DPPC staff, conduct monthly nutrition surveys in the worst drought affected woredas of North and South Wollo, Wag Hamra Zones of Amhara region. Survey findings are distributed among major Government, UN, donor and NGO actors. However, whereas the purpose of the NSP is to provide early warning of acute food insecurity through a long term monitoring strategy, the aim of NMT activity has been to inform specific relief operations in the short term.

NSP represents data on a zonal level (based on sentinel site woredas/FAs) with a sample drawn randomly, whereas the NMT assessments purposely select the worst drought affected FAs in the worst drought affected woredas. No other comprehensive nutritional surveillance mechanisms are in place dedicated to the drought-affected areas. In some cases, individual NGOs, such as MSF-Holland in Konso, have also conducted local nutrition surveys in coordination with local health and relief departments. However, in many areas, including those visited by UNICEF teams, lack of zonal and woreda capacity in nutrition surveillance has been a constraint in mobilizing the necessary assessment and monitoring mechanisms. Beyond the SCF-UK NSP, no nutrition surveillance and monitoring system has been in place for several years. Moreover, the NSP has been limited in scope--until the effects of the drought expanded considerably--to North and South Wollo zones.

The present crisis has demonstrated the lack of a centrally coordinated, nutritional surveillance capacity. More importantly, nutrition surveillance is meaningless unless it is used purposefully to guide appropriate response in both short term and longer-term food security activities.

For lack of adequate quantities of supplementary food based on the original targeting plan of 150g per beneficiary per day, WFP supplementary food allocations have been made to the affected Woredas on a DPPC established proportional basis (See Annex-4). The selection of zones and woredas was based on an agreed division of geographic coverage involving other agencies such as SCF-UK and CRS. Although supplementary distributions are getting underway in most of the affected areas, the amounts available fall well short of the overall need which, under the present circumstances, would range from a maximum of 4,100 - 5,175 MTs of famix or CSB per month if a formulaic strategy were to be applied (see first and second scenarios below). However, what is also clear is that these interventions are not expected to demonstrate significant impact for many of the reasons cited.

However, a more realistic approach based on the present complexity and magnitude of the problem would be the following:

This would take into account multiple constraints at all levels and more effectively meet needs. It is suggested as the most realistic strategy based on the present complexity and magnitude of the crisis. However, it would require a strongly coordinated approach between woreda, zonal and regional administrations as well as the national level. This would include a rational (though rapid) resource quantification exercise linked to an analysis of deliveries and distributions to date. It would likely require the support of the UN agencies including WFP and UNICEF, major NGOs and ultimately, the donor community.

The 15 October DPPC report expressed need for only 4,400 MTs supplementary food for three months based on 50g per child <5 years per day with no apparent provisions for pregnant and lactating women. Intended necessarily, to supplement grain ration distribution (which varies from 200 - 315g per person per day), the added nutritional value for the laborious and uncertain effort of reaching such a huge number of beneficiaries is probably questionable.

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1. WFP 5,623 MTs CSB/Famix 1,116 MTs Report pending

2. CRS 1,050 MTs CSB 390 MTs 390.00 MTs

3. SCF-UK 1,596 MTs Famix 1,064 532.00

4. MSF-Holland 250 MTs Famix 40 10.00

5. GTZ/IFSP 16.50 MTs Famix 65.10 16.50

6. IFRCS-ERCS 678.50 MT Famix 435.00 435.00

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TOTAL 9,214 MTs 2,642.10 MTs 1,383.5 MTs

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Based on the above figures, the gap between needs and available resources is tremendous; deliveries to date meeting not even a one-month requirement.

In conclusion, it is evident that monthly targets of supplementary food assistance have not been met–even based on the original prioritized (July) framework of 39 woredas requiring a total 651 Mts famix/CSB per month. Although food need figures shift over time (five DPPC revisions in national relief requirements since November last year), even in projecting needs by December which, according to DPPC will stand at roughly 4.5 million (on the assumption of a decent Meher harvest), a substantial strengthening of supplementary food assistance preceded by simultaneous provision of general ration and targeting worst affected PAs is urgently needed in order to:

• Stabilize deteriorating levels of child nutrition across a vast area; reduce morbidity and provide the basis for tentative physical rehabilitation.
• Minimize further deterioration of at-risk populations including those obligated in 1999 to reduce meals, consume "famine foods" in some part of Northern Ethiopia often with toxic side effect, sell off household economic assets, migrate, withdraw children from school and resort to begging.

In addition to famix and CSB (comprising cereals, pulses, sugar and micro-nutrients), other foodstuffs are planned or in the pipeline including 1,620 Mts of WFP pulses, allocated for beneficiaries in North and South Wello, and North and South Gonder. It is essential that in addition to the urgent need of ensuring rational allocation and distribution of blended supplementary foods, more analysis of the nutritional effects of an expanded food basket is done to maximize the widest effective coverage of food aid and to reduce geographic disparities in response.

In support of its commitment to facilitate targeting and monitoring of supplementary food inputs as reflected in the UNCT appeal and working with DPPB/D at zonal and woreda levels, UNICEF has recruited 17 field enumerators to gather data and report on distributions in specific areas (see ANNEX 2). Thus far, the effectiveness of this system has yet to be demonstrated as supplementary food deliveries have only recently taken place.

DPPC does not have an established nutrition monitoring structure that extends to the Woreda level. Moreover, reports of food dispatches and distributions are sent by Social Development Sector of the Woreda Council to the DPPB and then to DPPC. Such structures do not enhance efficient communications and rather, tend to hinder timely information flow on emergency needs. As mentioned above, the SCF-UK NSP/NMT mechanism, while demonstrating its effectiveness, is limited to only some of the affected areas. It tends to be either wide ranging and short term (NMT), or more geographically fixed and long-term (NSP). A more sustained, yet mobile capacity is urgently required.

In East Hararge, in affected woredas of South Tigray, or Konso or any one of a thousand other areas impacted by drought, health services are inevitably under-equipped and understaffed, water supply schemes fall into disrepair for lack of parts. Children suffer repeated episodes of malaria, diarrhoea and are vulnerable to vaccine-preventable diseases including measles. Sanitation as a practice, barely exists. As a result, food shortages aggravate already poor health conditions of children. In many chronic food deficit areas, under nutrition is a fact of life and the effects of stunting and wasting are severe (15% levels of wasting and 65% of stunting on average nation-wide, as per a 1996 MOH study). Families are hard pressed to meet even subsidized costs of basic drugs; in the face of hard economic choices they often forego treatment.

In these circumstances, the drought has taken an even greater toll. As a result, lack of food at home places inordinate strains on the daily burdens of children already walking long distances to attend school, tending fields and livestock, commonly playing a direct role in the family economy. For mothers, the burdens have been excessive as well, deepening the cycle of morbidity, poverty and despair.

Against this backdrop UNICEF has sought to mitigate the worst effects of the drought by addressing related non-food needs. Through its own internal allocations and a USAID contribution UNICEF is providing $335,000 worth of cold chain equipment and supplemental vaccine stocks for the four regions with the objective of increasing EPI coverage prioritizing the worst affected and least capacitated health facilities at zonal and woreda levels. WHO is seeking to improve health information systems to facilitate the effectiveness of disease prevention, monitoring and control measures. However, it remains of critical importance to link up a cohesive health component response to the on-going relief food and nutrition response.

UNICEF is also supporting drought water supply interventions in the repair of hand pumps and water yards and select installation of boreholes in worst affected woredas of East Hararge, North and South Wollo and North Omo. This includes support to urban sanitation in a number of towns. Over 12,000 large blankets are being procured for distribution to the most needy, drought affected areas. These will be targeted to families with malnourished children.

UNICEF is collaborating with UN agencies and counterparts in a planned joint school feeding project, intended to target up primary school children in drought affected areas not already covered under the WFP/MoE nation-wide school feeding program.

1.1 Accelerate and expand relief food deliveries to provide current DPPC needs-based allocations of 12.5 kgs per identified beneficiary taking into account updated needs and supported by coherent targeting and monitoring structures at central, regional and sub-regional levels. Depending on availability of resources, the general food ration should be delivered as a package of cereals plus blended foods to targeted population.

1.2 Linked to expanded, full general food distributions, rapidly expand the coverage and increase the ration size of supplementary feeding assistance from 100g to 150g based on geographic targeting at sub-woreda levels. Conversely, in the absence of adequate general food ration, postpone the provision of supplementary food to avoid wastage.

3. To prevent immediate death, strengthen the management of

2.1 Integrate an expanded food/nutrition response with other non-food drought related interventions including immunization, safe water supply, environmental sanitation and basic education.

2.2 Strengthen the capacities of local NGOs that reach the grass root level to handle food distribution and monitoring while the food targeting is outlined jointly with the donor, the DPPC and the local NGO.

2.3 Undertake initiatives to expand nutrition surveillance activities to objectively guide ongoing food and nutrition response including effective area targeting. Specific areas to be addressed include:

1. Concentrate on the build up of the existing regional, and sub-regional nutrition surveillance mechanisms including DPPB early warning systems.

In May this year, DPPD announced that 4.6 million people were in need of food assistance primarily due to successive failed rains across many of the Belg producing areas of the country. In June, following a joint UN/DPPC assessment of non-food needs in these affected areas, 39 woredas in four regions (Amhara, Tigray, SNNPR and Oromia) were identified as requiring immediate supplementary food assistance, linked to the provision of general food ration. It was agreed that this was a preliminary statement of needs that would be broadened as further information on new areas of need became available. A UNICEF/WFP/DPPC working group further divided this figure into two categories comprising the 24 worst affected and 15 lesser-affected woredas. On 12 July, a UN Country Team appeal for non-food needs arising from these assessments, coordinated with and approved by the Government, was launched, totaling $7.4 million to cover related health, nutrition, water and sanitation and relief needs. In the 39 target woredas, 30% of all pregnant and lactating women and children under five in the worst affected and 15% in the lesser-affected were to be assisted with 200g supplementary food per person per day for an initial three months period. For this, a total of 1,954 MTs of supplementary food was required for 153,000 beneficiaries.

In view of reports of the severity of the situation in places like Konso, Bugna, East Hararge, and other areas, UN agencies, DPPC and a number of NGOs met almost immediately to begin planning a coordinated nutrition response. Given the magnitude of the problem, the onset of long-rains in most of the target area, and limited resources available, it was agreed in several meetings held at WFP that the framework of first and second priority woredas would be upheld along with a planning figure of 200g per beneficiary per day. Although this issue was questioned by DPPC representatives, it was agreed subsequently by all that this figure would serve as an overall planning framework recognizing the resources would likely fall short of the target. Moreover, as bad as the situation was, there was recognition that it would likely get worse--SCF UK survey data identified 5 woredas in Wollo with a larger proportion of people having <80% malnutrition; in other areas people were afflicted by limb paralysis due to reliance on drought-resistance legumes with dangerous toxic content (see below). Almost immediately, for lack of its availability, edible oil was effectively ruled out as part of the supplementary response.

Practical constraints acknowledged, there was clear readiness of at least the main agencies to coordinate planned supplementary food allocations, in particular SCF-UK and CRS. Smaller NGOs such as MSF Holland, MSF France and others, shared their experiences and concerns. This process facilitated efforts by WFP and UNICEF to concentrate attention on areas not already covered. With concurrence of DPPC this was done and UNICEF and WFP reached agreement in principle on a coordinated plan by which WFP would resource supplementary food commodities, DPPC would be responsible for transport, and UNICEF for supporting overall targeting and monitoring (see ANNEX 1). During the months of August and into early September, little in the form of supplementary food distributions to beneficiaries took place. Despite persistent efforts to attract donor support for the supplementary food component of the UNCT appeal (1,954 MTs), only USAID made a contribution, enabling WFP to resource some 706 MTs of famix/CSB.

Since August, UNICEF has been conducting field visits to some of the worst affected areas for the purposes of planning distribution, targeting and monitoring modalities with regional, zonal and woreda officials, to collect additional data on the overall extent and seriousness of the nutrition crisis and inform a functional and strategic response. Specific tasks were :

• Making contact with DPPBs and briefing them of the strategies and objectives of the supplementary feeding response.

• Review of existing/planned targeting modalities used by DPPBs including who should qualify for limited resources and existing target beneficiaries.

• Preparing DPPB at zonal and woreda levels to receive supplementary foods including review of existing distribution plans, storage capacities, distribution locations and accessibility, review of exiting human resources and critical gaps to be assisted by UNICEF.

• Identification and orientation of woreda and kebele/PA level enumerators.

• Rapid needs assessment including observation, monitoring of migration and destitution levels.

In orienting DPPBs and designated enumerators on essential tasks, a checklist was prepared comprising the following:

Ensuring proper targeting: Who receives supplementary food, random household asset surveys in known hard-hit areas, consideration for overall targeting framework (original 30% - 15% woreda classification), noting overall physical appearance, signs of wasting and edema.

Storage conditions: In the absence of proper storage efforts will be made for immediate distribution of SF.

Access to beneficiaries: Distances target populations are travelling to reach distribution sites--not more than three hours being preferable.

Beneficiaries knowledge of entitlement: Do they know how much supplementary food they are receiving and its purpose?

Road conditions: To be shared with logistics/transport operators to inform them about local conditions.

Knowledge of donor: Who do the beneficiaries think is providing this?

Frequency and timeliness of distribution: When was the last time they received supplementary and general food ration and how frequently?

Receipt of supplementary food: Who actually receives the supplementary food.

Assessment of health status: Rapid assessment of EPI; review existing records at zonal MOH with focus on measles.

Major disease outbreaks: Monitor and report on known conditions

The overall evaluation and progress assessment was to be enhanced by weighing under five children who are legible for SF using equipment provided by health centers. Weight for height (WFH) is one of the best methods used in this respect.