Ethiopia:

Although Ethiopia is a low-income country, recent rapid economic growth has done a great deal to reduce the share of Ethiopians living in poverty. In fact, with GDP growth averaging 10.3 percent a year between 2005/2006 and 2015/2016 (World Bank 2018c), Ethiopia has been one of the world’s fastest-growing economies in recent times (Gebru, Remans, and Brouwer 2018). From 1999 to 2015, its poverty rate fell from 55.5 percent to 26.7 percent (World Bank 2018b). Still, in 2017 GDP per capita was just $768 (World Bank 2018b).

The country’s recent economic growth has been driven largely by growth in agriculture, which plays a prominent role in Ethiopia’s economy and has been the focus of recent government investments and policies (FAO 2018b). About 85 percent of the population engages in smallholder farming, with agriculture accounting for 37 percent of GDP in 2016 (FAO 2018b; World Bank 2018b). The bulk of agricultural land is used to grow cereal crops including teff (a local grain), wheat, maize, sorghum, and barley (Taffesse, Dorosh, and Asrat 2012). The rapidly growing service sector is also playing an expanding role in the overall economy (World Bank 2015).

With the decline in poverty, income inequality has also fallen. Regional disparities in poverty rates have narrowed since 1996, when some regions had much higher poverty rates than others. Yet at a finer level of detail, disparities remain: marginalized groups and people with limited access to roads, markets, health services, and other institutions face the highest levels of poverty (World Bank 2015).

Like poverty, hunger and undernutrition among Ethiopians have decreased in recent decades but remain problematically high. Ethiopia’s 2000 Global Hunger Index (GHI) score was 55.9 - considered extremely alarming - whereas its 2018 GHI score is 29.1, which is at the upper end of the serious category (see About section for a guide to interpreting GHI scores). Each of the GHI indicators has also declined since 2000 (Figure 4.4). Yet serious threats remain.

An El Niño–induced drought worsened the food security situation in Ethiopia in 2016–2017 (FAO GIEWS 2017b). Furthermore, a flare-up of conflict in the Oromia and Somali regions in 2017 has led to the displacement of nearly 1 million people, threatening their agricultural activities, livelihoods, and food security (FEWS NET 2018a). Most Ethiopians consume a poor-quality diet that lacks a diverse range of foods; provides inadequate amounts of key nutrients including protein, vitamin A, and zinc as well as micronutrient-rich foods such as fruits and vegetables; and exposes consumers to food-borne pathogens (Gebru, Remans, and Brouwer 2018).

Of particular concern is the nutrition situation of children, given that poor nutrition during gestation and in the first two years of life has lifelong consequences. At 38.4 percent, Ethiopia’s child stunting level for children under five is considered “high” verging on “very high,” and at 9.9 percent its child wasting level for this age group is considered “poor” verging on “serious” according to World Health Organization guidelines (WHO 2010). These rates vary from region to region within Ethiopia, and in some cases the regional rates are substantially higher than the national averages (Table 4.2).

Poor feeding practices for infants and children seem to be a major factor behind these troubling numbers. Sixty-seven percent of children under the age of 24 months receive age-appropriate breastfeeding, but just 7.3 percent of children aged 6–23 months are fed the minimum acceptable diet. Even in Addis Ababa, which has the country’s largest share of children in this age group consuming the minimum acceptable diet, the rate is still low at just 27.1 percent (CSA and ICF 2016). Many other recent studies have documented the inadequacy of infant and young child feeding practices in various parts of Ethiopia, including Abiy Addi town, Tigray region (Mekbib et al. 2014), and Sidama Zone, Southern Nations, Nationalities, and Peoples’ Regional State (SNNP) (Tessema, Belachew, and Ersino 2013; Gibson et al. 2009). In many of these studies, the authors conclude that inadequate infant and young child feeding practices are a primary cause of child stunting. Even in an area with surplus food production (West Gojjam Zone, Amhara region), child stunting was found to be high in past research, and inappropriate feeding practices were the principal risk factor for nutritional deprivation among children under the age of five (Teshome et al. 2009).

The overall health of children also plays a role in their nutrition. Studies have shown that diarrheal disease is associated with child stunting, wasting, and underweight (Asfaw et al. 2015). In Haramaya woreda, Oromia region, diarrhea is associated with underweight, and fever is associated with wasting (Yisak, Gobena, and Mesfin 2015). The nutritional status of women is also important to consider, both for the sake of women themselves and for their children. Women with low levels of empowerment and decision-making power are about 50 percent more likely to experience undernutrition than other women (Tebekaw 2011). Approximately one-quarter of women of childbearing age in Ethiopia have a low body mass index (BMI), which puts their children’s nutritional status at risk (Negash et al. 2015; Tigga and Sen 2016). Early childbearing is common, with 27.7 percent of women giving birth before the age of 19, which places strain on the nutritional status of women and infants (USAID 2018a). In Debub Misraqawi Zone, Tigray region, breastfeeding women had inadequate dietary intake and poor anthropometric measures—factors that have negative implications for the nutrition of their children (Haileslassie, Mulugeta, and Girma 2013).

Livestock ownership—an important part of many Ethiopian households’ livelihoods—can contribute to children’s nutrition, but the link is not always straightforward. Cow ownership raises children’s milk consumption and height-for-age and reduces child stunting, particularly in areas where markets for milk are limited and home consumption is more important (data from Amhara, Oromiya, SNNP, and Tigray regions in Hoddinott, Headey, and Dereje 2015). Qualitative research in the pastoralist Sitti (formerly Shinile) and Liben Zones of Somali region revealed that animal milk plays a large role in the diets of young children, but that milk supply is vulnerable during the dry season and droughts (Sadler and Catley 2009). In Amhara, Oromia, Somali, SNNP, and Tigray regions, a household’s poultry ownership is positively associated with children’s height-for-age, but keeping poultry inside the home overnight is negatively associated with children’s height-for-age, suggesting a trade-off between improved diet and increased exposure to pathogens that can negatively affect nutritional status (Headey and Hirvonen 2016).

Finally, several studies show an association between market access, roads, and nutrition. All else being equal, children whose households are located closer to food markets in East Tigray Zone, Tigray region, have greater weight-for-age and weight-for-height, although proximity to markets is not sufficient to offset poor nutrition in the lean season (Abay and Hirvonen 2016). In Alefa woreda, Amhara region, remote communities have poorer diets than communities that are less remote (Stifel and Minten 2017). Mothers’ nutritional knowledge is positively associated with children’s dietary diversity in Alefa woreda, Amhara region, but only in areas with good access to markets (Hirvonen et al. 2017). Furthermore, children in households that produce a more diverse range of agricultural products tend to have more diverse diets, particularly in areas where there is poor market integration (Hirvonen and Hoddinott 2014).

Ethiopia’s sustained economic growth has contributed to improvements in children’s nutrition, including child stunting, child wasting, and child underweight. These improvements may be due in part to associated increases in household expenditure on food and increased public spending on health, infrastructure, and other areas related to development (Biadgilign, Shumetie, and Yesigat 2016). As described below, much evidence is available on the impact of interventions that have been implemented in Ethiopia to address hunger and undernutrition.

Some of these projects have centered on livestock and other agricultural interventions. Government policies to promote agricultural productivity and food security in Tigray region, including the promotion of fertilizers and improved seeds, are associated with increased food availability and food self-sufficiency (van der Veen and Gebrehiwot 2011). In Holetta town, Oromia region, a project promoting ownership of crossbred cows that can be used for both traction and milk production was associated with higher household income and increased caloric intake (Ahmed, Jabbar, and Ehui 2000). In the Liben and Sitte (formerly Shinile) Zones of Somali region, a project offering livestock feed, vaccinations, and deworming to pastoralist communities during the dry season/drought resulted in increased milk production, raised children’s milk consumption, and stabilized their weight-for-age (Sadler et al. 2012).

Food aid programs also improved recipients’ diets and nutrition. In rural Ethiopia, the Employment Generation Schemes—a food-forwork program—and a free food distribution program known as Gratuitous Relief both raised household food consumption, even after the programs had ended (Gilligan and Hoddinott 2007). Quisumbing (2003) finds that food-for-work and free distribution of food boosted children’s weight-for-height in rural areas. Using nationally representative data, Yamano, Alderman, and Christiaensen (2005) find that food aid increased children’s height relative to that of children in control communities.

An assessment of an Alive & Thrive program, which promotes proper infant and young child feeding practices, in SNNP and Tigray regions showed a positive association between the program and improved breastfeeding and complementary feeding practices (Kim et al. 2016).

Safety net programs can make a difference as well. The Productive Safety Net Programme (PSNP)—a large-scale, government-led safety net program that has reduced poverty in Ethiopia by 2 percentage points (World Bank 2015)—provides food or monetary transfers to food-insecure people. Started in 2005, it has reached more than 1 million participants and their families (Berhane et al. 2014). With data from Tigray, Amhara, Oromiya, and SNNP regions, Berhane et al. (2011) show that the PSNP and associated programs improved food security by reducing the number of months without sufficient food. Using data from the same regions, Gilligan, Hoddinott, and Tafesse (2009) show that the PSNP in combination with the complementary Other Food Security Programme (OFSP) improved household food security. Using data from Tigray region, Debela, Shively, and Holden (2015) find that the PSNP improved weight-for-height in children. In Abiy Addi and Hintalo Wajirat woredas, Tigray region, the Social Cash Transfer Pilot Programme, which was targeted to poor and laborconstrained households, also improved diet quantity and quality (Berhane et al. 2015).

Researchers have evaluated more multifaceted projects as well. The Ibnat-Belessa integrated food security program, which includes environmental rehabilitation, water supply, irrigation, livestock, crop production, fruit and vegetable production, feeder road construction and maintenance, and off-farm activities, increased the calories consumed in beneficiary households in Amhara region (Abebaw, Fentie, and Kassa 2010). A study of the Graduation Programme, which combines temporary consumption support with an asset transfer and other activities, showed that beneficiaries experienced higher per capita food consumption and greater improvements in self-reported food security indicators, such as whether everyone in the household receives enough food relative to controls (Banerjee et al. 2015).

Water, sanitation, and hygiene interventions can potentially improve nutrition by reducing the incidence of infection and disease, which limit the body’s ability to absorb nutrients. A study from South Wollo Zone, Amhara region, compared groups that received water, sanitation, and hygiene interventions; nutrition education; health support; a combination of all interventions; and a control group. Only the water, sanitation, and hygiene group showed a significant reduction in child stunting, possibly through improved hygiene (Fenn et al. 2012). Nutrition; health; and water, sanitation and hygiene interventions have paid off in terms of child survival as well. Nutrition interventions resulting in decreased rates of wasting and stunting; water, sanitation, and hygiene interventions; treatment of diarrhea with oral rehydration solution; and the introduction of the Hib vaccine were determined to be the main factors behind the decline in child mortality between 2000 and 2011 (Doherty et al. 2016).