POLICY BRIEF EXECUTIVE SUMMARY UNICEF Ethiopia/2014/Sewunet Situation Analysis of the Nutrition Sector in Ethiopia 2000-2015 UNICEF has carried out a situational analysis of Ethiopia s nutrition sector to contribute to the process of the EU+ Joint programming on nutrition which aims at developing a coherent and cohesive response to the new National Nutrition Plan (2015-2020). Ethiopia has experienced a rapid improvement in child nutrition in the last 10-15 years, fuelled by economic growth, which has boosted food consumption and the accumulation of assets. There has also been the expansion of health and nutrition services through community-based health extension workers. The policies and programmes developed to support these efforts have been effective, but now need fine tuning to ensure a more equitable impact and have to be expanded in terms of 1) coverage and participation, 2) the human and financial resources involved and 3) the links and coordination between humanitarian and longer term nutritional programmes. Gaps in coverage identified by maps should be used to target the populations most in need. INTRODUCTION Early in 2013, the European Union Commission (EU) along with the 20 EU Member States in Ethiopia plus Norway The Federal Democratic Republic of Ethiopia Ministry of Health
endorsed the EU+ Joint Cooperation Strategy for Ethiopia to ensure a coherent response to Ethiopia s development challenges. The EU in 2014 put forward the Roadmap for EU+ joint programming on nutrition to support the second national nutrition programme. To carry out the situational analysis, UNICEF sought technical assistance from Professor John Mason and his team at Tulane University and from independent consultant Bjorn Ljungqvist. A committee chaired by the Federal Ministry of Health provided guidance. CONTEXT AND IMPORTANCE OF THE PROBLEM The Federal Democratic Republic of Ethiopia is undergoing rapid growth and transformation and has already made great progress in improving the nutrition situation over the last decade, with very significant contributions and support from development partners. However, there is still a long way to go. Too many women of child-bearing age are undernourished (thinness) and anaemic. Forty per cent of children under five are still stunted, while the number with acute malnutrition remains high. Efforts must continue to free the country from malnutrition a critical prerequisite for development and the progress so far should serve as a foundation. APPROACHES AND RESULTS The study involved four main tasks: analysis of nutrition trends and risk factors; mapping of nutrition interventions; assessment of current programmes and resources; and analysis of gaps and opportunities. A variety of data sources were used in the study 1. A) NATIONAL AND REGIONAL TRENDS IN CHILD UNDERNUTRITION Ethiopia has seen a steady reduction in stunting (1.2-1.5 percentage points a year) in the last decade the fastest rate of improvement in Africa 2 and similar to those of other countries successful at eliminating undernutrition 3. The rate of improvement was consistent across the country, except for the pastoral areas of Afar and the Somali region, possibly due to previous drought episodes. 60 55 50 45 40 35 30 2000 2005 2011 2014 Figure 1. National trends in stunting prevalence in children 0-5 years, 2000-2014 There is little variation in stunting levels between livelihood groups such as agriculturalists and pastoralists, however wasting acute undernutrition is highest in the pastoral areas, particularly in Somali and Afar regional states. UNICEF/NYHQ2014-3627/Nesbitt B) NATIONAL TRENDS IN NUTRITIONAL STATUS OF WOMEN Uncorrected Corrected DHS In contrast to child undernutrition, women s nutritional status (body mass index, BMI) has improved very little (0.2 ppts/yr) from 2000-2014 with important regional differences. Considering that the children of malnourished mothers are often malnourished themselves, more needs to be done to boost maternal nutrition. 1 Data sources used: Ethiopia Demographic and Health Survey data; The Community-based Nutrition Programme and evaluation data; The Development Assistance Committee database of resources; 2013 Renewed Efforts Against Child Hunger and undernutrition (REACH)/Federal Ministry of Health database of programme presence; and qualitative project and woreda case studies. 2 Standing Committee on Nutrition, 6th Report on the World Nutrition Situation: Progress in Nutrition., in the World Nutrition Situation, SCN, Editor. 2010, United Nation Systems: Geneva. 3 IFPRI, Global Nutrition 2014: Actions and Accountability to Accelerate the World s Progress on Nutrition 2014, International Food Policy Research Institute: Washington DC.
C) IMPROVING NUTRITION AND THE MAIN OBSTACLES 1As in most other countries, in Ethiopia there is an association between relative poverty and stunting with large disparities seen between the richest quintile the top 20 per cent and the rest. However, with regards to absolute poverty (defined as the degree of ownership of critical assets), stunting has improved at the same rate, regardless of the assets owned. The proportion of the population in the poorest, non-asset, group has also decreased significantly from 2000 to 2011. POVERTY The rise in income by more than 10 per cent per year partly accounts for the rapid improvement in child nutritional status over 2000-2011. The other main driver is the success of pro-poor and pro-equity policies, such as the Productive Safety Net Programme (PSNP), which gives short-term nutrition security in food insecure woredas. EDUCATION 2 Educating mothers is also a key method of improving nutrition. While undernutrition dropped at the same rate in families with uneducated and educated mothers, in absolute terms maternal education is associated with improved child nutrition so education of girls and women should be supported. WATER, SANITATION 3 AND HYGIENE Poor water supply and sanitation are risk factors for child stunting, but interestingly in Ethiopia, poor sanitation has a greater effect among children less than 24 months of age, while poor water supply is more of a factor among children 24 to 59 months of age. The type of water source is also important, as child stunting does not improve until public tap or piped water supply is introduced. Furthermore, children of mothers with some education benefit more from improved water supply and sanitation than those without, so an educational/behaviour change component should be included with water supply and sanitation interventions. 4 Improvement in infant and young child feeding practices showed an effect on stunting, however the report indicates that the feeding practices have to be targeted carefully by age group particularly for children 0-24 months. INFANT AND YOUNG CHILD FEEDING (IYCF) 5 ACCESS TO HEALTH SERVICES 6 Access to health services, especially for institutional delivery and antenatal care, are associated with improved child growth, however there is only an impact on child nutrition if it is paired with improved sanitation at the household and behavioural education to mothers. COMMUNITY EFFECT Reduction in risk factors (poverty, WASH, education) at household level alone is not enough to reduce stunting. Both the household and community as a whole must have reduced risk factors for accelerated reduction in stunting. As such, programmes that reduce risk factors for the community as a whole, combined with individual interventions are more likely to reduce stunting in children. 7The vital role of the Agriculture sector is to ensure that diverse, nutritious foods are available and accessible at all times, either from the market or from farmers own production. To this effect, the sector needs to re-orient itself at all levels to effectively recognize its critical role in establishing sustainable household food and nutrition security through improving production diversity, nutrition knowledge and women s empowerment. AGRICULTURE
GAPS AND OPPORTUNITIES Existing programmes The Community-based Nutrition programme There are existing nutrition programmes to improve undernutrition, but these need to be expanded in the developing regional states with increased resources and improved targeting. There are also programs or projects implemented by several partners that offer important opportunities for lessons learnt which should be incorporated into national programming. The most encouraging evidence of a successful nutrition specific intervention in Ethiopia is the community-based nutrition (CBN) programme which shows significant reduction in undernutrition. There are also other nutrition specific interventions through the health extension program supported by different partners. These programmes, however, vary from location to location and their approaches should be harmonized in a National Integrated Community Based Nutrition Protocol. UNICEF Ethiopia/2015/Bizuwerk UNICEF/NYHQ2014-3670/Nesbitt Link humanitarian interventions with longer-term nutrition interventions An important aspect of improving child stunting is mitigating the risks from shocks that exacerbate poor nutrition. Programmes such as PSNP that ensure short-term nutrition security must be linked with programmes supporting longterm nutrition security in non-emergenc situations. Mapping Interventions Maps can be useful in identifying priority areas for programmes by clearly presenting areas of coverage, undernutrition and risk factors However, maps are only useful with current information, and so a governmentled system for updating the maps is necessary to guide any expansion.
ARE AVAILABLE RESOURCES SUFFICIENT? This study found that the budgetary allocations 4 for nutrition specific activities 5 are modest but sufficient. On the other hand, disbursements to nutrition sensitive 6 social sectors are substantial if not necessarily nutrition-focused. If these resources could be directed into activities focusing on nutrition, improvements are likely to be accelerated. A dedicated funding mechanism could greatly help in allocating resources. CONCLUSIONS AND RECOMMENDATIONS The policies and programmes that have resulted in the rapid improvement in child nutrition over the last 10-15 years, including economic growth and the extension of health services, now need to be fine-tuned to expand coverage and participation. Gaps in coverage identified by maps should be used to target those most in need. UNICEF /NYHQ2014-3678/Nesbitt UNICEF Ethiopia/2014/Sewunet POLICY RECOMMENDATIONS Current policies should be kept and strengthened as they have reduced malnutrition among young children and women in Ethiopia over the past 14 years. Policies increasing household income should be reinforced. Policies improving the situation of women, such as with better education, health, nutrition, water, hygiene, sanitation, should be reinforced. The government should grant more resources to improve access to quality health and nutrition services, with an equity focus, and explore a financial mechanism to better allocate funds to nutritionsensitive social sectors. Agricultural policies should be made more nutrition sensitive with a clear result framework. 4 Based on 2013 budgetary data 5 Nutrition specific activities are activities that have a direct impact on maternal and child nutrition status, 6 Nutrition sensitive social sectors are sectors that contribute to the underlying causes of malnutrition such as agriculture, WASH, education, poverty etc.
PROGRAMME RECOMMENDATIONS Ensure that all critical healthbased nutrition services are maintained as high priority. Increase coverage of nutrition specific programmes, particularly in developing regional states and reaching those with high risk factor especially households with low socio-economic status. Increasing participation in community-based nutrition programmes within covered programme areas must be prioritised. A National Community-Based Nutrition Protocol should be established to unify and coordinate actions with improved participation and supervision of the health development army. Mapping should identify populations with high risk factors and undernutrition to be targeted with additional resources. Create capacity for maintaining a comprehensive mapping of stakeholders, their intervention and geographic coverage of their programmes. Prioritize improving undernutrition among women by targeting adolescent girls and pregnant and lactating women and designing appropriate economic, ag-nut and nutrition intervention packages and approaches. Prioritize water, sanitation and hygiene (WASH) programmes to improve child undernutrition, including hygiene behaviour change component focusing on poorly educated women and access to public tap or piped water supply. Enhance women s access to education and strengthen initiatives to change their health seeking behaviour. Promote age appropriate and timely feeding counselling for children 0-24 months For nutrition sensitive agriculture activities include: Agriculture based solutions, such as production of nutrient dense crops, livestock/livestock products, agroprocessing/storage skills, Increasing on-farm or off-farm income for vulnerable households and women need to be further established in order to increase the production and access to diverse, safe, and nutrient dense foods. Ensure implementation of gender components in nutrition-sensitive programmes like AGP and PSNP. Strengthen institutional capacity for nutrition sensitive agriculture at all levels through development of standardized nutrition sensitive training manual for policy makers/implementers and revising existing materials with a nutrition lens as well. Harmonize and reinforce synergies between Health-and Agriculture Extension Workers regarding food and nutrition security through creating common forums and facilitate experience-sharing sessions. Agricultural interventions need to go along with a behavioural education component to avoid potential, unintended negative effects of interventions such as poultry faecal exposure and selling of diverse foods rather than own-consumption. FURTHER READING For access to all the materials of this situational analysis please visit the following websites: http://www.unicef.org/ethiopia/nutrition.html (under the Nutrition Resources section) http://www.eeas.europa.eu/delegations/ethiopia/index_en.htm