Emergency Assistance for Nutrition Support Provided by Catholic health facilities in Hosanna Diocese Objectives
The project aims to provide support to Catholic health facilities to enable them to continue to provide Therapeutic and Supplementary Feeding Programmes to acutely malnourished children under five, pregnant and lactating women and other vulnerable groups.  
Expected Results
The intended results of the project are that by 30th September 2012
1.	598 children under five will have received care in Therapeutic Feeding Programmes (TFPs); and 619 children under five, 352 pregnant and lactating women (PLW) and 208 other vulnerable people will have received care in Supplementary Feeding Programmes (SFPs).  
2.	Accurate measurement, tracking and recording of cases of malnutrition takes place in Catholic health facilities.
3.	Standards of care in Catholic health facilities will have improved in line with Ethiopian protocols and recognised international standards through the provision of technical support and guidance.
Main Activities
Result 1: Therapeutic and Supplementary Feeding Programmes
All of the six Catholic health facilities run SFPs.  Teza and Wazera Health Centres also provide TFPs, with Teza providing full Stabilisation Centre (SC) services, and Wazera providing short-term (two to three days) in-patient care for children under five with Severe Acute Malnutrition (SAM) with complications.  Only Teza Health Centre and Shallalah Clinic do not provide services to PLW, please see Table 2 on page 4 for a detailed description of services provided.  
Staff at Teza Health Centre recognise that many users of their service travel considerable distances to access TFP/SC services.  In cases where carers from poor families are required to stay away from their homes to care for their child, Teza Health Centre will also provide food for carers while they stay with their children.  If required, carers will also receive funds for the return journey home. 
Result 2: Accurately recording cases of MAM and SAM
It is known that at least one clinic and one health centre that provide nutrition services do not record all, or any of their data on malnutrition cases as part of the centralised government health authority Health Management Information System (HMIS).  While not confirmed, it is expected that this is also the case for other health facilities.  This is either because local authorities do not want to collect the data, because health centres are ordered not to record it, or because providing data would reveal that increased numbers of malnourished children are being treated and lead to pressure to stop treatment.
For this reason, while health centres and clinics are capable of recording SAM and MAM cases they deal with, centralised records are not consistently or accurately maintained.  However, clinics and health centres are prepared to keep accurate records and provide this information as part of the project.  Nutrition cards recording name, home, weight, height, gender, treatment and start and finish dates are currently in use in three health facilities (Teza, Wasera, Madula/Tambaro) and will be introduced into the remaining two health centres and clinic.  Cards will be printed and training will be given in their usage.  These cards will then be used to provide monthly reports showing numbers of SAM and MAM in boys and girls as well as the nature, duration and outcome of their treatment.
Result 3: Raising standards through technical support
The Catholic health facilities are renowned for their high quality care and are well integrated with government services, receiving training and support from local health authorities, as well as providing data for the HMIS (even if not consistently for nutrition).  However it is recognised that some services provided are at variance with standard international protocols, notably in terms of admission criteria and record keeping (see Table 2 and Section 2, Rationale, below for details).  It is proposed that two technical support visits of ten days each are provided by CRS/CST (costs not included in this budget) for the clinics and health centres.  This will provide an opportunity for expert review of the programmes and refresher training and guidance.  It will also provide an opportunity to explore feasibility of expanding and/or improving services, as well as the expertise, human and financial resources and monitoring and supervision systems required.  
The range and nature of activities provided by the clinics is severely circumscribed by the politically sensitive nature of the region.  Nutrition activities and information about malnutrition is highly controlled by the government.  This limits the activities that can be provided as part of this project, notably in two major aspects:
•	Survey: While ideally a nutrition survey would be conducted, agencies are not permitted to conduct any nutrition assessments in the region.  These may only be conducted by government authorities, and agencies would face expulsion should they be found to be conducting informal or unauthorised surveys.
It is hoped that more accurate recording of MAM and SAM cases (Result 3) in health centres and clinics will provide valuable data on levels of malnutrition in the region, though this will be recorded confidentially and kept for internal use only.
•	Scale-up or initiation of new activities: Services provided by the health facilities are approved by the local authorities as part of their five year plan.  For this reason CRS/CST are not required to request permission for a new project, as they are contributing to an existing programme of activities.  However, substantial changes to this programme risks incurring government interference and possible discontinuation of services.  Many of the services described above are outside of formal government nutrition responses and are able to operate by not drawing attention to their activities.  Scale-up, out-reach or significant changes to the way they operate are therefore prohibited, precluding the inclusion of nutrition education, changes to admission criteria or any activities that may involve outreach as part of this project.  
While it is not appropriate to plan for these activities now, it is hoped that technical support visits by CRS/CST will be able to explore opportunities to safely develop and improve nutrition programming in clinics and health centres.
Main intended beneficiaries
The intended beneficiaries of this project are the extremely vulnerable families in SNNPR, specifically children under five and pregnant and lactating women, as well as other vulnerable groups.  Beneficiaries tend to be from families which have extremely small landholdings who are at all times unable to grow enough to eat or sell to provide sufficient income.  This chronically poor group often rely on neighbours to support them in lean times but given widespread and heightened food insecurity this safety net is no longer functioning.
People suffering from the effects of malnutrition may be referred to Health Centres from Health Posts or Clinics, or may self-refer (see page 7 for a description of the hierarchy of health services), and similarly will self-refer to Clinics.  It appears that screening and selection is conducted to the extent that clinical staff may identify children presenting at health services as suffering from malnutrition and will assess them using MUAC, weight for height ratios and oedema testing.  Children under five years old found to be SAM or MAM and PLW will then be admitted into SFPs/TFPs. No record of total screened versus total admitted is conducted, and Catholic health facilities do not conduct any community screening.  
All clinics and health centres also provide nutritional care to people outside of these criteria.  This may include children over five years old who are malnourished, elderly people, people living with HIV/AIDS and people with other diseases such as TB. These groups are not currently disaggregated by type but will be for this project, and are noted as ‘other’ in the table above. 
Given variations in treatment protocols, as described above, it cannot be assumed that all children in SFP are Moderately Acute Malnourished (MAM) as many clinics include SAM cases in their SFP.  However, where TFP is provided for children under five, it is uniquely for SAM cases.  It can therefore be assumed that of the 1,217 malnourished children provided with care at least 598 of those will be SAM cases, but that there are also more receiving treatment in SFP.