Nutrition in Ethiopia: An emerging success story?

Derek D. Headey

Senior Research Fellow,

Poverty Health & Nutrition Division, IFPRI, Washington DC

June 15th, 2015Addis Ababa, Ethiopiad.headey@cigar.org

Introduction

• Undernutrition is a complex multidimensional problem• Requires changes in diets, care practices, sanitation & health, and all

the underlying factors that affect these different pathways• But from a policy point of view we would like to identify:

Which factors are driving nutrition improvements over time?Which factors can be sources of future progress?

• As part of TRANSFORM and Stories of Change we are looking at understanding nutritional successes in different countries

• Approach is 90% quantitative; dynamic focus on changes over time

T1. The 5 fastest reductions in pre-schooler stunting in the 2000s at the global level

Rank Country Start & end dates

Start & end stunting ()

Speed of change (points per year)

1st Nepal 2001 57.1 2011 40.5 -1.66 points per year

2nd Bangladesh 1997 56.7 2007 43.2 -1.42 points per year

3rd Lesotho 2000 53 2010 39 -1.40 points per year

4th Vietnam 2000 42.7 2010 29.3 -1.34 points per year

5th Ethiopia 2000 57.4 2011 44.2 -1.20 points per year

Table 2: Trends in prevalence of stunted children in Ethiopia, 2000 to 2011,

2000 2011 Change changeAll Ethiopia 55.7 43.4 -12.3 -22.1 Rural 56.8 45.3 -11.5 -20.2 Urban 46.6 30.2 -16.4 -35.2 Boys 57.2 45.5 -11.7 -20.5 Girls 54.3 41.3 -13.0 -23.9 Oromia 53.0 40.5 -12.5 -23.6 SNNP 56.5 42.9 -13.6 -24.1 Amhara 61.0 50.6 -10.4 -17.0 Tigray 60.0 50.9 -9.1 -15.2 Somali 46.6 32.0 -14.6 -31.3 Afar 50.8 48.8 -2.0 -3.9 Gambela 41.5 27.2 -14.3 -34.5 Addis Ababa 34.5 21.1 -13.4 -38.8 Dire Dawa & Harar 37.9 31.8 -6.1 -16.1

F1—Trends in child HAZ scores by children’s age … or changes in nutrition in the first 1000 days

-2.5

-2-1

.5-1

-.5

0

Pre

dict

ed H

AZ

sco

res

0 20 40 60

Child's age (months)

95% CI 2000 2010

A large & significant improvement in birth size!

Postnatal growth falteringstill very steep; little change

F2 … same graph – rural areas only

-2.5

-2-1

.5-1

-.5

0

Pre

dict

ed

HA

Z s

core

s

0 20 40 60

Child's age (months)

2000 2011

F3….Urban areas only

-2-1

.5-1

-.5

0.5

Pre

dic

ted H

AZ

score

s

0 20 40 60

Child's age (months)

2000 2011

Substantial improvement in postnatal growth faltering after 16 months

Investigating improvements in birth size…

• In rural areas almost all the improvements stems from birth size & hence maternal nutrition: -macro & micronutrient intake? -improved maternal health?

• In urban areas the improvement happens much later:

-improved feeding practices? -improved health/sanitation?

Table 3—Proportion of children reported by their mothers to be below average size at birthRural Urban

2000 42.2 28.2

2011 33.8 29.4

T4: Explaining small birth sizes in rural areas

Variation Marginal effects (%)

Average 2000

Average2010

Predicted change in small birth size

Asset index (1-10) -1.4** 1.0 1.5 -0.68%

Father’s education (years) -1.1*** 1.5 2.3 -0.81%

4+ ANC visits dummy (0/1) -3.3* 8.0% 15.1% -0.23%

Open defecation (0-1) 7.0** 91.5% 46.3% -3.16%

Maternal age>40 years (0/1) 5.7* 7.7% 6.5% -0.07%

Maternal height (cm) -0.1 0.00

Female dummy (0/1) 8.0*** 0.00

Year 2010 dummy (0/1) 1.5 0.00

Number of children 5,635 (children 0-24 months)

F4. Links between open defecation, maternal anemia and small birth size

.25

.3.3

5.4

.45

An

emia

/Sm

all b

irth

siz

e (

0-1

)

0 .2 .4 .6 .8 1Open defecation (0-1)

Maternal anemia Small birth size

Important thresholdgf about 60%

F5. Comparing experiences across three major success stories

Stunting in Nepal: 2000-2011

Stunting in Bangladesh: 1997-2011

Small birth size in Ethiopia: 2000-2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

18.5% 12.7% 14.5%

20.7%

14.1%

24.5%

9.1%

4.9%

11.6%

7.5%

67.3%

5.1%

6.6%

18.7%

43.9%

6.2%

8.5%

Wealth accumulation Mother's human capital Father's human capital Health services

Sanitation & water Demographic change Unexplained

Tota

l cha

nge

in n

utriti

on (%

)

Conclusions

• Ethiopia’s rapid progress stems from improved birth sizes and hence improved maternal nutrition

• However, most of the improvement in maternal nutrition seems related to improvements in sanitation (but caveats …..)

• Further analysis needed, but DHS suggests rapid expansion of simple pit toilets, not hard infrastructure (community led total sanitation?)

• Improvements in urban areas more enigmatic – model doesn’t perform well, but does suggest asset accumulation is the main factor

• Still more work to be done!

Conclusions

On the policy front, Ethiopia shares some similarities:Strong economic growthMajor improvements in sanitation (All three countries use CLTS)Community-based health workersAll saw significant fertility decline (Ethiopia on its way)

But also differences: Bangladesh made huge gains in girls’ secondary education Nepal achieved much more success in innovative health extension:

e.g. used transport subsidies to reach remote areas

Case studies available on the IFPRI website:

We sincerely hope that this work promotes some cross-country and within-country learning on achieving and sustaining success against undernutrition

*Ethiopia (still a work in progress….)http://www.ifpri.org/sites/default/files/publications/esspwp70.pdf

*Bangladesh: http://www.ifpri.org/sites/default/files/publications/ifpridp01358.pdf

*Nepal: http://www.ifpri.org/sites/default/files/publications/ifpridp01384.pdf