Synopsis Accelerating Progress In Improving Diets And Nutrition In Ethiopia

Ethiopia has witnessed significant reductions in child mortality, undernutrition and communicable diseases, but more substantial and faster progress is still needed. The rise in overweight and obesity and in non-communicable diseases, particularly in urban areas, is alarming and requires urgent policy and programmatic attention. Unhealthy diets are the drivers of both forms of malnutrition and are the underlying cause of significant proportion of communicable and non-communicable diseases. Maintaining the relatively high breastfeeding practices and increasing the diversity of diets will be critical. Implementation of effective nutrition messaging that shapes consumer behavior to adopt healthy dietary patterns, while bridging gaps in reach and quality of nutrition messaging is warranted. The health extension program that is the cornerstone of the health sector transformation may need to be redesigned in a way that improves reach, quality, and minimize the risk of burnout of frontline health workers. Interventions focusing on making healthy diets affordable, accessible and available are urgently needed.

Ethiopia has witnessed significant reductions in child mortality, undernutrition, and communicable diseases, but more substantial and faster progress is still needed. The rise in obesity and in noncommunicable diseases, particularly in urban areas, is alarming and requires urgent policy and programmatic attention. Unhealthy diets drive both undernutrition and obesity and are the underlying cause of significant proportion of both communicable and non-communicable diseases. Maintaining the relatively high breastfeeding practices and increasing the diversity of diets will be critical to improving nutrition in Ethiopia. Implementation of effective nutrition messaging that shapes consumer behavior to adopt healthy dietary patterns, while bridging gaps in both the reach and the quality of such messaging is warranted. The health extension program, which is the cornerstone of the transformation of the health sector, may need to be redesigned in a way that improves its reach and the quality of the services it provides and minimizes the risk of burnout of frontline health workers. Interventions focusing on making healthy diets available, affordable, and accessible are urgently needed.

Given the high prevalence of undernutrition among children in low income countries and the associated high human and eco-nomic costs (Hoddinott et al. 2013), improving nutritional out-comes must be an urgent priority. Improving nutrition is high on the policy agenda of the government of Ethiopia, as stated in the Growth and Transformation Plan II, which aims to reduce young child stunting levels from 40 percent in 2014/15 to 26 percent in 2019/2020. Lack of access to diverse diets is one of the underlying factors contributing to chronic undernutrition (Arimond and Ruel 2004, UNICEF 1998). Despite recent improvements, child stunting in Ethiopia remains widespread (CSA and ICF International 2017). Moreover, Ethiopian children consume one of the least diverse diets in sub-Saharan Africa (Hirvonen 2016). At the household level, food consumption baskets are dominated by cereals and pulses, while the consumption of animal-source foods and fruits and Vitamin A-rich vegetables is rare, especially in rural areas.1 Such monotonous diets are regarded as a major contributor to non-communicable diseases in Ethiopia (Melaku et al. 2016). Recent research suggests that the poor dietary diversity in ru-ral areas can be explained, at least partly, both by limited knowledge about the health benefits of diverse diets and by poor access to food markets. Households in areas in which food crop production is not very diverse but which have good access to mar-kets are found to have more diverse diets than do households in such areas but which have poor access to markets and, so, de-pend primarily on own-production for the food they consume.2 Yet, even with sufficient access to markets and knowledge on the benefits of diverse diets, poor households may simply be un-able to afford nutritionally rich foods (Warren and Frongillo 2017). Indeed, prices and affordability of nutritious foods remains a neglected area of research in efforts to understand poor dietary diversity in Ethiopia and elsewhere.3 In the analysis described here, we explore how prices and, consequently, the affordability of nutritious food have changed over the last decade in Ethiopia.

Many development programs that aim to alleviate poverty and improve investments in human capital consider women’s empowerment a key pathway by which to achieve impact and often target women as their main beneficiaries. Despite this, women’s empowerment dimensions are often not rigorously measured and are at times merely assumed. This paper starts by reflecting on the concept and measurement of women’s empowerment and then reviews some of the structural interventions that aim to influence underlying gender norms in society and eradicate gender discrimination. It then proceeds to review the evidence of the impact of three types of interventions—cash transfer programs, agricultural interventions, and microfinance programs—on women’s empowerment, nutrition, or both. Qualitative evidence on conditional cash transfer (CCT) programs generally points to positive impacts on women’s empowerment, although quantitative research findings are more heterogenous. CCT programs produce mixed results on long-term nutritional status, and very limited evidence exists of their impacts on micronutrient status. The little evidence available on unconditional cash transters (UCT) indicates mixed impacts on women’s empowerment and positive impacts on nutrition; however, recent reviews comparing CCT and UCT programs have found little difference in terms of their effects on stunting and they have found that conditionality is less important than other factors, such as access to healthcare and child age and sex. Evidence of cash transfer program impacts depending on the gender of the transfer recipient or on the conditionality is also mixed, although CCTs with non-health conditionalities seem to have negative impacts on nutritional status. The impacts of programs based on the gender of the transfer recipient show mixed results, but almost no experimental evidence exists of testing gender-differentiated impacts of a single program. Agricultural interventions—specifically home gardening and dairy projects—show mixed impacts on women’s empowerment measures such as time, workload, and control over income; but they demonstrate very little impact on nutrition. Implementation modalities are shown to determine differential impacts in terms of empowerment and nutrition outcomes. With regard to the impact of microfinance on women’s empowerment, evidence is also mixed, although more recent reviews do not find any impact on women’s empowerment. The impact of microfinance on nutritional status is mixed, with no evidence of impact on micronutrient status. Across all three types of programs (cash transfer programs, agricultural interventions, and microfinance programs), very little evidence exists on pathways of impact, and evidence is often biased toward a particular region. The paper ends with a discussion of the findings and remaining evidence gaps and an outline of recommendations for research.

Building on the Millennium Development Goals, the UN Sustainable Development Goals (SDGs) are the cornerstone of the 2030 Agenda for Sustainable Development, billed by the UN as “an agenda of unprecedented scope and significance.” These seventeen goals are conceived as integrated, indivisible, and as balancing the economic, social and environmental dimensions of sustainable development. To be achieved by 2030, the goals are organized around five core pillars: people, planet, prosperity, peace and partnership. As a member of the SDGs Publishers Compact, Frontiers is committed to advocating the themes represented by the SDGs and accelerating progress to achieve them. Nutrition sits at the heart of the SDGs. In addition to achieving ‘Zero Hunger’ (SDG2), improvements in nutrition are critical to both achieve and reap the benefits of all seventeen global goals. With good nutrition comes improved health and wellbeing (SDG3), enhanced educational and work productivity (SDGs 4 and 8), less poverty (SDG1) and reduced inequalities (SDGs 5 and 10). And with stronger and more sustainable environments, communities, and technologies (SDGs 6, 7, 9, 11-17) improved food security and nutrition will follow. As part of an innovative collection showcasing nutrition in the context of the SDGs, this Research Topic will focus on Sustainable Development Goal 4: Quality Education.

Few challenges facing the global community today match the scale of malnutrition, a condition that directly affects 1 in 3 people. Malnutrition manifests itself in many different ways: as poor child growth and development; as individuals who are skin and bone or prone to infection; as those who are carrying too much weight or whose blood contains too much sugar, salt, fat, or cholesterol; or those who are deficient in important vitamins or minerals. Malnutrition and diet are by far the biggest risk factors for the global burden of disease: every country is facing a serious public health challenge from malnutrition. The economic consequences represent losses of 11 percent of gross domestic product (GDP) every year in Africa and Asia, whereas preventing malnutrion delivers $16 in returns on investment for every $1 spent. The world’s countries have agreed on targets for nutrition, but despite some progress in recent years the world is off track to reach those targets. This third stocktaking of the state of the world’s nutrition points to ways to reverse this trend and end all forms of malnutrition by 2030.

The International Food Policy Research Institute (IFPRI) began research activities in Ethiopia in the 1980s to assess the root causes of drought-related food-production shortages and support adoption of appropriate policy responses. IFPRI’s rigorous empirical research contributed to a broader understanding of economic development processes in Ethiopia and built capacity to conduct such research on a national scale. Working with many long-standing partners, IFPRI evaluated strategies for achieving sustainable agricultural growth, investment in agricultural research, the provision of safety nets to strengthen resilience, prioritization of nutrition interventions for women and children, property rights, and management of natural resources, among other goals. Evidence from this and other work informed programs and initiatives to improve food and nutrition security for vulnerable people.

In recent years, the world has seen unprecedented attention and political commitment to addressing malnutrition. Milestones such as the Scaling Up Nutrition (SUN) Movement, the Lancet Maternal and Child Nutrition Series, and the Second International Conference on Nutrition (ICN2) have marked the rapid rise of nutrition on the global policy and research agenda. These developments reverse years of relative neglect for nutrition. Undernutrition is a global challenge with huge social and economic costs. It kills millions of young children annually, stunts growth, erodes child development, reduces the amount of schooling children attain, and increases the likelihood of their being poor as adults, if they survive. Stunting persists through a lifetime and beyond—underweight mothers are more likely to give birth to underweight children, perpetuating undernutrition across generations. Undernutrition reduces global gross domestic product by US$1.4–$2.1 trillion a year—the size of the total economy of Africa south of the Sahara.

Ethiopia’s Productive Safety Net Programme (PSNP) is a large-scale social protection intervention aimed at improving food security and stabilizing asset levels. The PSNP contains a mix of public works employment and unconditional cash and food transfers. It is a well-targeted program; however, several years passed before payment levels reached the intended amounts. The PSNP has been successful in improving household food security. However, children’s nutritional status in the localities where the PSNP operates is poor, with 48 percent of children stunted in 2012. This leads to the question of whether the PSNP could improve child nutrition. In this paper, we examine the impact of the PSNP on children’s nutritional status over the period 2008–2012. Doing so requires paying particular attention to the targeting of the PSNP and how payment levels have evolved over time. Using inverse-probability-weighted regression-adjustment estimators, we find no evidence that the PSNP reduces either chronic undernutrition (height-for-age z-scores, stunting) or acute undernutrition (weight-for-height z-scores, wasting). While we cannot definitively identify the reason for this non-result, we note that child diet quality is poor. We find no evidence that the PSNP improves child consumption of pulses, oils, fruits, vegetables, dairy products, or animal-source proteins. Most mothers have not had contact with health extension workers nor have they received information on good feeding practices. Water practices, as captured by the likelihood that mothers boil drinking water, are poor. These findings, along with work by other researchers, have informed revisions to the PSNP. Future research will assess whether these revisions have led to improvements in the diets and anthropometric status of preschool children in Ethiopia.