Ethiopia

With a population of 53 million, Ethiopia is the second most populous country in Sub-Saharan Africa; some 3 million people live in Eritrea, now independent after a protracted civil war. There are 76 various ethnic groups with 286 different languages in Ethiopia, and a split of 40% Christian and 45% Muslim. A large part of the population is concentrated in the highland areas in central and northern regions. The limited data available up to around 1987 were described in the ACC/SCN's Update on the Nutrition Situation (1989, p.48-51).

Recent Trends in Nutrition

Trends can be assessed from two national nutrition surveys, in 1983 and in 1992. Both of these were carried out during the post-harvest season, and the results are considered comparable. An analysis done by the Central Statistical Authority (with assistance from Cornell University) comparing 11 regions of the country indicates that the nutrition situation in 1992 was significantly worse than 1983. For all 11 regions combined, the prevalence of underweight in children (6-59 months, <-2 SDs NCHS in both surveys) increased from 37.3% in 1983 to 46.9% in 1992. This prevalence in 1992 of nearly 50% underweight is likely to be (with Mozambique) the highest in Africa. Projected to the entire 0-4 year population, this implies that the number of underweight children rose from 2.7 million in 1982 to about 4.6 million in 1992, or nearly doubled.

The regional trends have also been estimated by comparing the 1983 and 1992 surveys: the prevalence of underweight children increased in all 11 regions surveyed. This is shown in Figure 1. The regions of Gonder, Gojam, Sidamo, and Welega had an underweight prevalence between 50% to 60% in 1992. These levels are among the highest prevalences reported in Africa, outside of refugee/displaced camp populations.

Stunting (low height-for-age) and wasting (thinness -low weight-for-height) have also been estimated. The mean prevalence of stunting for all the regions in 1992 was 64%. The regions with the highest rates (above 66% stunting) include South Gonder, East and West Gojam, North Welo, Tigray, Sidamo, Ilubador, North Gonder, and South Shewa. South Omo has the highest stunting, with 75% of its preschool children. Such levels of stunting are among the highest in the world, and almost certainly the worst in Africa. Stunting is already prevalent at early ages (6-11 months old infants), although the incidence of low birth weight (12-15%) is not especially high.

Figure 1. Trends in Underweight Children 1983-1992, by Region

Sources: Central Statistical Authority (1993) and Pelletier et al, (1994).

Analysis of the 1992 survey looked into certain factors associated with child growth failure (stunting or underweight). While some associations were found, these varied (including in direction) widely by regions, and more impressive were the variations due to other, non-income factors.

For example children in Gonder, who were observed to have relatively higher prevalences of underweight, were reported also to have very high morbidity rates-50% of children reported to be ill in the immediate two weeks prior to the interview. North Shewa on the other hand showed the least prevalence of underweight and among the lowest in terms of morbidity among the regions.

Breastfeeding Weaning Practices and Child Nutrition. Data on breastfeeding and child weaning practices in the 1992 Nutrition Survey indicate that the problem of early stunting in Ethiopia is due in part to delayed introduction of complementary foods in the first year of life. Associations could be shown between age of introduction of such foods and stunting prevalences. While the recommended age for introducing weaning foods is 4-6 months, the national median was about 7.1 months, with some regions such as North Gonder and Tigray with averages of 12.1 months.

Factors Affecting Trends in Nutrition

Incomes and Poverty. With a GNP per capita in 1993 estimated at U.S.$100, Ethiopia is one of the poorest countries in Sub-Saharan Africa. Per capita GDP declined at an annual rate of -2.5% between 1986 and 1993.

More than 51% of the population is considered to be below the poverty line, or 27 million people. These people live mostly in rural areas. A substantial number are in transit camps as displaced persons due to recent civil disturbances. The main groups identified as belonging to the poor included those coming from self-employed groups in remote rural areas in the central regions, returnees following the civil war, displaced persons, demobilized soldiers, the poor nomadic populations, the female-headed households in both rural and urban areas, and the low level government workers.

For the last decade or so, the economy has been characterized by decay and stagnation with per capita real incomes declining consistently since 1987. This appears, however, to have reversed in 1992/93 with the economy registering a growth of about 7.6%, generally coming from growth in agriculture, with improved rainfall and some effects from reforms, which boosted output via improved producer prices and market access. Since 80% of the labour force depended on agriculture, the trends in incomes and poverty depended to a large degree on that sector's performance. Nearly all of its export earnings come from coffee, and some from skins and hides of animals.

Transitory problems have compounded the chronic poverty situation in the country. Ethiopia's Relief and Rehabilitation Commission estimated that in 1992, a total of 6.2 million people required food aid. This was reduced to about 4.2 million in 1993. Intermittent drought particularly in the north and northeast, and civil war, which disrupted large areas of the country, are major causes. It is estimated that 1.7 million people of the 6.2 million in need of food aid in 1992 were refugees and displaced persons caused by the civil disturbance.

Food Security. Ethiopia's food security has been constantly eroded by progressive soil exhaustion, and overcrowding of land, which has caused declining food production per capita since 1960s. As a consequence, Ethiopia's production of the main cereals (barley, maize, sorghum, and teff) fell short and the country depended on imports averaging 100,000 MT per year in the 1980s, increasing to 1 million MT in 1990 and 1991/92. Food supply per capita has been deteriorating, and this has resulted in a low calorie supply per capita of less than 1700 kcals, one of the lowest in the world. The regions of Sidamo, Hararghe, Gamo Gofa, and Wollo experience more food security problems and are prone to crisis situations.

Health and Other Factors. The level of health service support has been rising, but by 1991, only 37% of infants had been immunized against DPT-still lower than most areas on the continent. Governmental health service provision is estimated at about $1.44 per capita and around 3% of the national budget expenditures. Attendance in primary schools is very low, at 36%, and fiscal data indicate that the proportion of government expenditures for education has been declining.

ETHIOPIA

(Estimates in 1993)

Population	: 53 million
Population Density	: 43 per sq. km.
Population Growth Rate	: 3.4% per annum
Urban Population	: 13%
IMR	: 120
GNP US$ (Per Capita) (WB Atlas Methodology)	: 100
PPP estimates of GDP ($ Per Capita, in 1991)	: 370

CHILD GROWTH AND SURVIVAL

Underweight preschool children (Percent below -2 s.d. weight for age)

Infant mortality rate (Per 1,000 live births)

ECONOMICS

GDP per capita (1987 Mkt. prices, Birr / capita)

Debt service ratio (Debt service/exports)

FOOD

Food production index (Per caput, 1979-81=100)

Dietary energy supply (Kcals/caput/day)

Consumer price index (1980=100)

FPI/CPI ratio (1980=100)

HEALTH

Immunization coverage (Percent)

Access to local health care (Percent)

PUBLIC EXPENDITURES

Education and health expenditures (US $ per capita)

Education and health expenditures (Percent of government expenditures)

With its large population of 53 million in 1993, and with 4.6 million of its 9.7 million preschool children underweight, malnutrition remains one of the biggest socio-economic problems in Ethiopia.

Further Analysis¹

1. Text of this section was contributed by D. Pelletier, Cornell University

The national survey and a large number of local surveys reveal that infant feeding practices, including late initiation of breastfeeding, widespread use of purgatives immediately after birth, use of liquids throughout infancy, and late introduction of complementary foods should be considered intervention priorities. Rates of infection are very high and typical of those found in other countries, and coverage of improved water and sanitation facilities is very low.

Demands on women's time have been shown to be considerable and this is likely to be a major factor constraining efforts to improve infant and child feeding practices. The design of agricultural, food security and rural development programs should avoid increasing demands on women's time and, if possible, attempt to reduce such demands so as to enhance the ability of households and communities to implement improved child feeding and caring practices. This is especially relevant at the present time, in light of the extensive use of labor-intensive public works being discussed in country.