Consultancy to conduct a Rapid Assessment on the effectiveness of Nutrition International (NI’s) Capacity-Building Support to Primary Healthcare Providers in Ethiopia for the Management of Childhood Diarrhea

1. Background and Rationale

Diarrheal diseases are among the top causes of illness and death in children under five in Ethiopia. The combined use of Zinc (Zn) tablet and Oral Rehydration Salts (ORS) are the nationally recommended first-line treatment for diarrhea, yet their consistent use across public and private sectors remains a challenge. The national Integrated Management of Newborn and Childhood Illness (IMNCI) protocol is a holistic approach that focuses on the well-being of children under the age of 5. IMNCI and programs are delivered across hospitals and health centers while its community-based variant Integrated Community Case Management (iCCM) program is delivered at health posts by health extension workers (HEWs).

Over the past 6 years (2019 to 2025) NI, with funding from Global Affairs Canada (GAC), has made significant investments to revitalize IMNCI/iCCM implementation with a specific focus on diarrhea management. Using a Collaborative Quality Improvement (CQI) approach, NI has supported MoH and health facilities to systematically identify coverage and quality gaps and implement local solutions that enhance quality of diarrhea management services. The key investments include i) support to MoH to revise and disseminate of national IMNCI guidelines to selected universities and health facilities, ii) universities and health science colleges supported to provide pre-service IMNCI training to graduating health science and medical students, iii) basic QI training provided to PHCU directors and QI teams to design and implement improvement plans iv) financial support provided to Health Bureaus to manage collaborative learning session and finance coaching expenses of Woreda Health offices (WoHO), v) deployed technical assistances and provided hands-on coaching and supervision support to PHCUs focusing on IMNCI and diarrhea management.

Despite the efforts, the project endline survey (2025) found that several key indicators had decreased compared to the baseline. Specifically, of those who sought care from the public sector, only 27% received the recommended course of treatment compared to 37.5% at baseline. Stock data indicates supplies are not the issue; among the facilities sampled (n=180) only 4% of facilities were stocked out of zinc and/or ORS on the day of data collection and ~12% had experienced stock outs of either in the previous 12 months. A closer look at provider knowledge data indicates that while knowledge of correct dosage and duration of treatment is good (>80%), only 1 in 3 could name three benefits for both zinc and ORS in the treatment of childhood diarrhea. Without this knowledge, providers may not be motivated to prescribe zinc and ORS as a first line of treatment translating in poor compliance to national guidelines. In addition, only 25% of caregivers could correctly describe diarrhea treatment using Zn and ORS-a decline from 27% at baseline and only 4.3% of care givers could state all the steps for proper diarrhea care-down from 8.5% at baseline.

Hence, NI intends to hire an individual consultant to conduct a rapid assessment to understand the reasons despite extensive support to improve case management of childhood diarrhea, health provider knowledge and practices remain sub-optimal; and to further inform the design of ISG-2 program.

2. Purpose of the assessment

The assessment aims to understand the key drivers and underlying factors that have limited the impact of Nutrition International’s (NI) technical assistance and capacity-building support for childhood diarrhea management, particularly in improving health worker knowledge, motivation and the quality-of-service delivery. The findings will be used to generate actionable recommendations to inform design of the new project.

3. Specific objectives

1. Identify key drivers and root causes for continued gaps in health care providers practices, attitudes and knowledge on Zinc and ORS use for childhood diarrhea treatment, despite NI’s past investments including technical support through CQI approach (training, coaching/mentoring, supportive supervision).
2. Assess the appropriateness of NI capacity building support over the last 5 years e.g. the extent to which methods, approaches and tools used were adequate and appropriate with the expected changes NI capacity building support aimed to achieve…
3. Examine health system factors that affect providers’ ability to retain knowledge and manage childhood diarrhea effectively.
4. Generate evidence/recommendations to inform the design of the next phase of Zinc and ORS programme in Ethiopia, ensuring future investments more effectively address provider knowledge and attitude gaps and improve diarrhea case management.

4. Scope of work

The assessment will be conducted at all levels of the MoH. The consultant will carry out an assessment that compares the drivers of provider’s performance in NI-supported and non-supported areas. The goal is to understand both the added value of NI’s involvement and the factors that have limited its effectiveness.

The work will be carried out in collaboration with the Ministry of Health (MoH) and relevant stakeholders at multiple levels of the health system in two regions (Sidama and Central Ethiopia). The assessment will encompass the federal, regional, woreda, health facility, and community levels, drawing perspectives from both NI-supported and non-supported areas in the proposed regions to provide a balanced and comprehensive view.

5. Methodology

The consultant will apply a mixed approach:

A. Desk review of program and policy documents, articles and reports.

• National guidelines for diarrhea management
  • NI Ethiopia’s Program documents for the Zinc program
  • CQI process documents, tools, checklists and Past monitoring reports
  • Guidelines and tools for supportive supervision
  • The content and coverage of in-service and pre-service training (including IMCI integration)

B. Qualitative assessment

• Key Informant Interviews (KIIs): Health managers at national, regional and district levels, service provides and supervisors and HEWs, NI program staff and extenders
• PHCU observation and document review: CQI documents (minute book, charts etc), stock and service delivery records related to Zinc and ORS, supervision checklist and reports, training records (to identify when and how staff were trained) …
• Data Analysis: Thematic analysis of qualitative data from KIIs and document reviews, comparative analysis of findings between NI supported areas and non-NI areas and triangulation of findings across data sources…

6. Expected deliverables

• Inception report: outlining the methodology, data collection tools, and work plan.
• Draft assessment report: detailed analysis of findings from desk review, KIIs and facility observations.
• Final assessment report: comprehensive report incorporating feedback from NI; includes findings, conclusions and actionable recommendations.

7. Tasks and responsibilities of the consultant

The consultant will be responsible for leading and coordinating all aspects of the rapid assessment, in close collaboration with NI CO and HQ child survival team.

Specific tasks and responsibilities will include:

• Conduct an inception discussion with NI to confirm objectives, expectations and work plan.
• Prepare and submit an inception report outlining the methodology. Sampling, tools, and detailed timeline.
• Carry out desk review of key documents (NIMS endline survey, IMNCI guideline, CQI, training and supervision reports).
• Develop and finalize data collection tools in consultation with NI and relevant stakeholders.
• Conduct field data collection through KIIs, facility observations, and document reviews.
• Analyze data, prepare draft and final reports, summarize findings, conclusions, and recommendations.
• Maintain regular communication and progress updates with NI throughout the consultancy.

8. Proposed timeline

The assignment is expected to be completed within approximately 46 working days, spread over three main phases. The exact schedule will be finalized in consultation with Nutrition International (NI) and the Ministry of Health (MoH) during the inception stage.

Phase	Estimated Duration
Phase 1: Inception and tool development	8 days
Phase 2: Desk review and Data collection (Assessments)	22 days
Phase 3: Data analysis and reporting	16 days

9. Qualification and Experience

1. Experience IMNCI/ICCM programs: Assessors should be qualified health professionals (e.g., physicians, nurses, public health specialists) with specific, in-depth training and experience in the IMNCI/iCCM guidelines and case management, planning, supervision and monitoring.
2. Health systems knowledge: A thorough understanding of Ethiopian health system and IMNCI/iCCM programs (policy, human resources, supply chain, information systems, financing, and governance) is necessary to assess how IMCI is integrated within the broader system and identify systemic barriers.
3. Knowledge of quality improvement methodologies: Familiarity with Improvement Collaboratives, Plan-Do-Study-Act (PDSA) cycles, and other Quality Improvement (QI) methods is crucial.
4. Program evaluation experience: Experience in designing and conducting program evaluations, particularly qualitative methods, is needed to determine the effectiveness and gaps of health system strengthening efforts.
5. Policy and planning experience: Knowledge of strategic planning processes is important to assess policy alignment and make recommendations for future implementation.