The GNR roundtable event in Addis Ababa was hosted by the Government of Ethiopia’s Ministry of Health and attended by over 100 people.
Ferew Lemma (far left of picture) and Augustin Flory are the new
co-chairs of the GNR’s Stakeholder Group (taking over from Edith Mkawa and Jane
Edmonson who did a great job for 2014) and it was fitting that Ferew was the
key shaper of the event.
The roundtable celebrated Ethiopia’s successes in driving
down stunting rates. We noted the commitment
of the Government to nutrition as evidenced by its membership of SUN, its
commitments at the N4G summit in 2013 and its support for the GNR process.
In prepping for the roundtable I used the GNR
Ethiopia Nutrition Country Profile which notes that:
* Only 10% of births have skilled attendants while
antenatal care rates are low at 19%.
Exclusive breastfeeding is just above the WHA 2025 target of 50%. But
more is better, and the rate of exclusive breastfeeding has not increased for
the past 11 years. But the real
vulnerability is the state of infant and young child feeding, with both
indicators at 5% or less suggesting that 95% of children 6-23 months of age do
not eat enough food of the right quantity or quality.
* At the underlying level—i.e. drivers that are
not interventions or practices per se, but are known to be strongly linked to
nutrition status—estimates of hunger have declined significantly in the past 14
years (from 56% to 35%). But female secondary enrollment rates for the most
recent year are only at 11% in 2000 (compared to over 30% for Africa) and Ethiopia
ranks 121 (out of 151) in the UNDP Gender Inequality Index. On access to improved water and sanitation
progress is rapid but the levels of improved sanitation (37%) and improved
water (52%) remain low. Strong and
positive trends in government spending on social protection and education suggest
the improvements in underlying determinants will improve.
* The opportunities for action seem clear: improve
infant and young child feeding through complementary feeding programmes, dramatically
improve secondary enrollment rates of girls and try to make social protection
and education investments more nutrition sensitive. Other opportunities for action relate to
policy and legislation: few provisions of the international code of marketing
of breast milk substitutes are enshrined in law; nutrition does not feature as
much in national development plans and economic policies as it does in many
other countries (68th out of 83), wheat fortification legislation is
rated as in the planning phase, and maternity protection, so crucial for child
feeding of working mothers is still “partial”.
The roundtable touched on several of these issues. What struck me from the presentations on the
day was the ambition of the Ethiopian Government on nutrition targets and its
use of analysis.
On ambition, Ferew Lemma a senior official in the Ministry
of Health and the SUN focal point, outlined the target for 2020 on stunting:
26%. Remember, the latest mini DHS
suggests a stunting rate of 40% in 2014.
That is a decline of 14 percentage points in 5 years. This is about what Maharashtra achieved. The targets are tied to the projections of
Ethiopia becoming a middle income country by 2020 (based on GNP per capita).
On analysis, we were told of the remarkable story of the
Productive Safety Net Programme (PSNP)
which has been going for about 10 years now.
The new PSNP4 will be more nutrition sensitive than the current
PSNP3. Noting that it is not easy to design
or deliver nutrition sensitive programmes at scale (PSNP reaches 10 million
people) I asked about the process of change.
How was the Minister of Agriculture persuaded to adopt nutrition
sensitivity? I was told it was analysis, persistence over 3 years, and an
influencing strategy that embraced pressure from within the Ministry of
agriculture and from elsewhere in the government, as well as persuasion from
outside (UN agencies and noting that all the donors who fund PSNP also fund
The embrace of analysis was interesting: an evaluation (by John Hoddinott at IFPRI) from
2013 showed that while PSNP3 was improving diet diversity and food security at
the household level it was not having any impact at the under 2 level. This helped support the drive for the nutrition-sensitive
changes. The ambition of PSNP4 is so
striking that Tom Arnold said (and I agree with him) that global leadership on
innovation for safety nets and nutrition may well be shifting to Ethiopia away
from places like Mexico and Brazil.
Clearly the commitment to improving nutrition is high from
all Ethiopian stakeholders. While the
iron is hot there are 2 things I would like the government to consider. First, consult
more about how to tackle wasting rates (perhaps linked to relatively low
coverage of improved sanitation and water?).
Wasting rates are still high at 9-10% and they are stuck. Second, pay as
much attention to child growth as it does to economic growth. The new 5 year Growth and Transformation Plan
(current one here)
will come into effect later in 2015. In
the Plan the Government of Ethiopia should give nutrition the same prominence
as it will give to things such as hard infrastructure and macroeconomic policy
stability. Human infrastructure is vital
Middle income status is a hollow victory if low
income malnutrition rates persist. For
that to be avoided Ethiopia needs to have a middle income nutrition plan for
development and a middle income development plan for nutrition.