Task-shifting and task-sharing initiatives to improve community nutrition services, lessons from Ethiopia
Authors: Abebe Yared , Tafesse Zergu , Berhane Solomon , Kemal Muzemil 
Published: February 2023

Abstract
Introduction: The USAID Transform: Primary Health Care project is working on preventing maternal and child deaths in Ethiopia. As part of its effort, the project is supporting the government in its endeavor in improving nutrition service coverage and quality. More than 90% of the communities are accessing nutrition and health services at health posts where trained health extension workers (HEWs) provide services. ‘Workload’ in the HEWs was identified as critical challenge and in response, a small scale task-shifting task-sharing initiative was tested in two selected health posts. Tasks related to monthly acute malnutrition screening, monthly GMP, and cooking demonstration were shifted completely from the HEWs to a voluntary community health workers. The tasks of tracing and linking of targeted children for VAS and deworming were also shared by the CHWs, while the actual provision of the drugs were done by the HEWs. This study focuses on the results of this initiative.
Methodology: A quasi-experimental method with pretest-posttest design is used to measure the outcomes of the initiative. The findings of the house-to-house survey done after eight months of the implementation of the initiative are compared with that of the baseline. This is triangulated with the findings of record reviews and in-depth interviews.
Result: A total of 243 (116 girls) and 219 (112 girls) under-five children were identified at the baseline and at the second round house-to-house surveys respectively. Monthly screening coverage for acute malnutrition has improved from 8% at baseline to 99%. The percentage of children supplemented with vitamin-A during the six months prior to the survey reached 97% from the baseline status of 23%. Growth monitoring and promotion (GMP) participation rate has also improved from 5–96%. Recounting and comparing the coverages reported by the health facilities from source document was not possible at baseline due to incomplete documentation. After the introduction of the initiative, the documentation has improved and the discrepancy between the reported, the recorded and the survey data for the three services narrowed down to a range of 1% difference for VAS, to 6% for acute malnutrition screening.
Conclusion: Nutrition services in Ethiopia heavily depend on the productivity of the health extension program (HEP) which is currently struggling with several challenges with the workload being among the critical bottlenecks. The results of this study shows that coverage and quality of essential nutrition services can be improved if workload challenges are recognized and addressed through carefully designed task-shifting and task-sharing initiatives. The marked discrepancies among the reported, the recorded and the actual coverages shows that monitoring nutrition services through the routine information system could be misleading.
Recommendations: Efforts to improve community nutrition services should recognize heavy workload in the HEP as a critical challenge. This initiative should be scaled up with continuous learning including on its impact on the productivity of HEWs and CHWs. Investigating and addressing nutrition data quality should also be among the top priorities as the current status is often seen to be unacceptable.