NUTRITIONAL IMPROVEMENTS IN ETHIOPIA: WHERE AND WHAT NEXT ?

Paper Presented at the

International Conference “ Putting Children First: Identifying Solutions and

taking Action to Tackle Child Poverty and Inequality in Africa”

24, October 2017

Addis Ababa, Ethiopia

Kalkidan Assefa and Adrian Gauci

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OUTLINE

Background

Methodology and tools

Result

Key messages

BACKGROUND

Why investing on nutrition and Why now ?

Nutrition is one of the foundations of human health and development and malnutrition is one of the major causes of childhood illness and mortality (World Bank 2006)

Moreover, the impact of undernutrition is observed on social and economic development of countries in Africa (3 to 16.5 % of annual GDP loss, COHA,2014)

Ethiopia Cost of Hunger study 2009: Results 16 % GDP impact of child stunting, 46 percent of children were stunted

Investing in nutrition is also economically sound and has been identified as a ‘best’ investment . (Copenhagen Consensus 2012); investing in nutrition can increase a country’s GDP by at least 3 percent annually (World Bank 2006); every US$1 spent on reducing malnutrition has at least a US$30 return on investment (World Bank 2006;Copenhagen Consensus 2012).

In addition, nutrition was an essential building block to achieving at least 5 of the 8 Millennium Development Goals and a key aspect of the development agenda both Africa 2063 and Agenda 2030 for Sustainable Development.

What about the recent trend?

Government introduced National Nutrition Programme (NNP) with specific targets and timelines

02

Methodology and tools

COHA Model-based on the Life Cycle Approach

Using national data provided for COHA-Ethiopia

study we use both the national and continental

scenarios to compute progress.

Formula:

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Probability differences (DP): is the difference between

the probability that a consequence (i) happens

between undernourished (PU) and non-

undernourished (PNU).

TCU = f (HCU, ECU, PCU)

Health Cost: HCU = f (HSCU, IHCU)

Education Cost: ECU = f (ESCU, IECU)

Productivity Cost: PCU= f (ELCU, MMCU)

RESULTS AND FINDINGS

Status of Nutrition in Ethiopia

Three phase of progress have been observed in theprocess of reducing undernourished people in Ethiopia(increase, significant decline and moderate decline)

Ethiopia has been making progress towards improvednutrition security over the past one and half decades(13 percentage point for Stunting-0.8/yr and 23.6percentage point for underweight-1.4/yr between 2000-2016

Considering the high rates of hunger several decadesago, Ethiopia has placed policy priority and notableprogress has been observed in improving the state ofboth food and nutrition security.

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1992

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2009

2010

2011

2012

2013

2014

2015

2016

In m

illi

on

s

Number of people undernourished (millions) (3-year average)

4.3

Percentage

Increase 14.4

Percentage

Decrease

3.4

Percentage

Decrease

Source: FAOSTAT, 2016

RESULTS AND FINDINGS

51.5

10.5

47.246.5

10.5

38.4

44.4

9.7

28.7

40.4

8.7

25.2

38.4

9.9

23.6

0

10

20

30

40

50

60

Stunting (-2SD) Wasting (-2SD) Underweight (-2SD)

Per

cen

tag

e

Trends in Nutritional Status of Children under Age 5, 2000-2016

2000 2005 2011 2014 2016

Status of Nutrition in Ethiopia contd….

The actual number of children under five currentlyaffected by malnutrition are still significant, meaningthe reduction of malnutrition is not keeping pace withpopulation growth

The total burden of Stunting is still far greater than theburden of underweight (4.2 million and 2.5 million)children.

Significant nutritional differences exists across wealthquintile and location (rural-urban)..avg.15% point

This reflects nutritional deficiencies, illness andincreased morbidity, cognitive development andlearning capacities that occur during the most crucialperiods (early life) of growth and development stillpersists in the country

CSA and DHS (Various yrs)

Year

Under five

Children in

2015

Prevalence of

Stunting in

2016 %

Number of under

five Children who

were Stunted

Percentage of

stunted # of

Children by region

National 10,797,022 38.4 4,146,057 100

Tigray 630,862 39.3 247,929 5.98

Affar 142,377 41.1 58,517 1.41

Amhara 2,337,923 46.3 1,082,458 26.11

Oromiya 4,451,317 36.5 1,624,731 39.19

Somalia 449,699 27.4 123,218 2.97

Bensihangul-

Gumuz 126,430 42.7 53,986 1.30

SNNP 2,341,255 38.6 903,724 21.80

Gambela 42,044 23.5 9,880 0.24

Harari 23,736 32.0 7,596 0.18

Addis Ababa 197,976 14.6 28,905 0.70

Dire Dawa 41,767 40.2 16,790 0.40

Source: CSA population data (2015) and DHS 2016

Progress at sub-national level

Highest rates of stunting were observed in Amhara, BG andAffar regions

However, high absolute number of children affected withstunting were observed in Oromiya (1.6 mil), Amhara (1.1mil), and SNNP (0.9 mil)-all three accounting 87 % of thenational burden.

In Ethiopia, children born from Amhara, BG, Affar and DDregions (where stunting prevalence rates over 40%) arealmost three times more likely to be stunted than childrenborn in the capital-AA.

Although Oromiya region relatively has lower stuntingprevalence (36.5) than the national average, it has thelargest number of stunted children (39.2 % of the total)due to its large population size.

The actual number of children under five currentlyaffected by malnutrition are still significant, meaning thereduction of malnutrition is not keeping pace withpopulation growth.

Progress at sub-national level

• The nutritional improvement in

most of the regions are marginal

and keeps with in the standard

levels (very high and high

prevalence range)

• As the data indicates, despite

Ethiopia’s progress, continued

emphasis and investment in

nutrition at regional levels is highly

warranted to ensure continues

growth and development.

• Although these trends have

improved (from 2011 to 2015),

prevalence of underweight and

stunting in Ethiopia remain among

the highest across Sub-Saharan

Africa.

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Public expenditure trends on agriculture, education and health sectors….

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1.0

2.0

3.0

4.0

5.0

6.0

7.0

-

0.2

0.4

0.6

0.8

1.0

1.21

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To

tal

Pu

bli

c E

xp

end

itu

re i

n b

illi

on

s o

f U

S$

Sec

tora

l ex

pen

dit

ure

in

bil

lio

ns

of

US

$

Sectoral Public Expenditure in 2005 US$ (in billion)

Agriculture Education Health Social Protection Total Expenditure

• Investment on Education is almost threetimes higher than investment on Healthat national level

• Investment on Health and Educationsectors is Increasing significantly

• Declining trends of nutrition investment

2009 2010 2011 2012 2013

Source of

funding

Productive Safety Net

Program (PSNP) 467,429,087 437,156,335 374,259,292 479,997,322 350,376,861

Different donors

and GoE

Emergency Food Relief 270,283,401 529,439,127 246,471,180 187,921,382 126,912,921 Different donors

Food for Education (School

Feeding) 14,812,700 20,808,762 24,816,294 17,816,218 12,824,977 WFP

Community Based Nutrition - - 7,060,196 8,707,792 17,106,792 UNICEF

Urban HIV AIDS 9,337,255 11,41,1814 10,221,703 3,983,212 6,808,120 WFP

Targeted Supplementary

Feeding - 58,701,348 32,083,795 13,092,225 4,664,160

Pilot Social Cash Transfer

Tigray - - - 602,032 602,032 UNICEF

Total Social Safety Nets 761,862,443 1,057,517,386 694,912,460 714,171,042 521,346,722

Source: World Bank, Public Expenditure Review of Ethiopia, 2016 page 48.

Source: IFPRI-SPEED data, 2016

NNP COMMITTED BUDGET AND FINANCIAL GAP, 2013–2015

*Not easy to access investment trend on nutrition at national and regional levels

Source: Ethiopian National Nutrition Program (NNP) Report, 2013–2015:Page 48 18

List of CountriesOn Health

(Millions of US$)

On Education

(Millions of US$)

On Productivity

(Millions of US$)

Total Costs

in 2015

Percentage of

GDP

1st Phase Base Year 2009 Base Year 2009 Base Year 2009

1 Ethiopia 154.4 7.9 4,538.4 4,700.5 16.54%

Scenarios for

the Year 2025*

S1. The cost of

Inaction (BL)

S2. Cutting by

Half

S3. Goal Scenario

(5 and 10%)

Est.Cost 3,682 2,071 777

% increase 39 -22 -71

Total Projected Savings

(2009-2025) M of US$

Annual Projected Savings

(2009-2025) M of US$**

Cutting by Half Goal Scenario Cutting by Half Goal Scenario

1 Ethiopia 6,010 12,544 376 784

• *Net Present Value of the total cost up to 2025 was estimated, with an annual discount rate of 8 percent

• **To achieve the targeted scenarios, there was almost 16 years since the baseline COHA study in 2009

• Exchange Rate in 2009=11.8 birr/$USD

COST OF UNDERNUTRITION AND ESTIMATED SAVINGS

BY SCENARIO-IN 2009

Scenario # 1-Cost of Inaction (BL)The prevalence of stunted children in2009 remains unchanged• As a result of population growth,

the costs for 2025 increased by 39percent

Scenario # 2- Cutting by HalfAchieving the second objective ofhalving the prevalence of stuntedchildren by 2025.• The cost would decrease by -22

percent from the estimated cost forScenario #1, with potential saving ofUS$ 6 billion.

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List of CountriesOn Health

(Millions of US$)

On Education

(Millions of US$)

On Productivity

(Millions of US$)

Total Costs

in 2015

Percentage of

GDP

1st Phase Base Year 2015 Base Year 2015 Base Year 2015

1 Ethiopia 85 5.3 3,745 3,836 11%

Scenarios for

the Year 2025*

S1. The cost

of Inaction

S2. Cutting by

Half

S3. Goal Scenario

(5 and 10%)

4,408 2,479 931

23% -31% -74%

Total Projected Savings

(2015-2025) M of US$

Annual Projected Savings

(2015-2025) M of US$

Cutting by Half Goal Scenario Cutting by Half Goal Scenario

1 Ethiopia 6,696 13,798 669.6 1,380

Cost Of Undernutrition and Estimated Savings by Scenario- in 2015

• *Net Present Value of the total cost up to 2025 was estimated, with an annual discount rate of 8 percent

• **To achieve the targeted scenarios in 2025, there is almost 10 years since the COHA study in 2015

• Exchange Rate in 2015=20.6 birr/$USD

SCENARIO ANALYSIS

Based on 2015 estimated cost borne dueto prevalence of stunting under the age offive, three alternative scenarios areanalysed for 2015

Scenario # 1

• The prevalence of stunted children in 2015remains unchanged.

• As a result of population growth, the costsfor 2025 would increase by 23 percent

Scenario # 2

• Achieving the second objective of halvingthe prevalence of stunted children by2025.

• The cost would decrease by 31 percentfrom the estimated cost for Scenario #1,with potential saving of US$6,7 billion

Scenario # 3

• The eradication of child stunting isachieved by 2025.

• The cost would decrease by 74 percentfrom the estimated for Scenario #1generating a potential savings of up toUS$13.8 billion.

Cost Increased from 43,445 to 90,648 million birr (2.09 times)

Or

Cost increased from 3682 to 4,408 million US$ (1.2 times)

If we invest now, saving increases as well. From 70,918 to 132,571

Or

Saving will increase from 6,010 to 6,696 million US$

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WHERE TO GO FROM HERE?

National Target to reduce stunting to 30 % by 2015-not mate

Malabo declaration on reducing hunger by 2025

Pathways towards 10 % and 5 % target in 2025

Seqota-declaration: a commitment to end child undernutrition by 2030

Agenda 2063

SDG 2030

Other national, regional and continental agenda and targets for monitoring

NNP-II

GTP II

Food and Nutrition Policies, programs and projects

Achievable but requires strong

national commitment and intervention

More relaxed but requires planning and

intervention

10

5%

10%

42%

30% 25%

13%

57%

45%

40%

20%

0%

10%

20%

30%

40%

50%

60%

70%

Underweight-GS Stunting-GS Underweight-Half Stunting-Half

Annual APR Required for

Halving Stunting =2%

APR in reduction of underweight

from 2000 to 2010

1.19% Annually

APR Required for 5% target

2% Annually

APR in reduction of Stunting

from 2000 to 2010

1.21% Annually

Current and Required Progress to Achieve Goal Scenario for 10% and 5% for 2025

APR Required for 10% target

3% Annually

Annual APR required for Halving

Underweight =1.3%

APR=Average Progress Rate

Scenario I /Reduction by Half

Total Saving

70,918 Million Birr

6,010 Million USD

Scenario II (10% & 5% Reduction)

Total Saving

148,023 Million Birr

12,544 Million USD

Scenario I /Reduction by Half

Total Saving

132,571 Million Birr

6,696 Million USD

Scenario II (10% & 5% Reduction)

Total Saving

273,201 Million Birr

13,798 Million USD

APR in reduction of Stunting

from 2010 to 2015

0.98% Annually

APR in reduction of underweight

from 2010 to 2015

0.98% Annually

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Conclusion and Key Messages

In Ethiopia child stunting has dropped from 46 to 40 percent between 2009 and 2015 and economic cost of undernutrition decreased from 16 to 11 percent of GDP

Estimation done in 2015 show that the increase in the cost of action has led to a significant decrease in GDP terms but the cost of inaction has increased.

The variation across regional administrative units on progress towards child stunting indicates transfers and algorithms of fiscal blocks should include level of stunting

The causes of malnutrition in Ethiopia are manifold and requires multifarious actions and therefore nutrition needs to be policy coordinated

In Ethiopia, malnutrition is not decreasing at the required rate and is affecting the majority of the population

Access to consistent and comparable data is a challenge, especially in relation to nutrition investment

Improving caring and feeding practices of children and mothers through Community based Nutrition Interventions should be scaled up

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