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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
01
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:
04
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
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
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.
12
Public expenditure trends on agriculture, education and health sectors….
-
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
98
0
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81
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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.
05
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$
06
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
11
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
18