An assessment of the causes of malnutrition in Ethiopia: A ...

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2.1. Introduction In the early 1960s, the then Imperial Ethiopian Government recognized the importance of identifying the nutritional status of the Ethiopian people by inviting Swedish nutritionists to advise on the problem of nutrition in Ethiopia and to establish the Ethio- Swedish Pediatrics Clinic of which the Children Nutrition Unit (CNU) was the most important research and application department. The CNU focused on the development and preparation of weaning foods for infants and children less than 5 years of age, strengthening of laboratory food analysis, and the preparation of balanced food recipes from local staple ingredients. Field stations were established at sites representing the food habits of Ethiopians living in different localities of rural and urban areas. The findings and result of the activities of the CNU were documented in a number of publications and monographs. The Pediatric Clinic was incorporated into the Ethiopian Nutrition Institute (ENI) when ENI was established under the Ministry of Health in 1968. However, studies conducted in the late 1950’s and 1960s confirmed that the physical status of the population, in relation to the energy required to accomplish different tasks, was at a low level. The average body weight of adults at the national level was about 18 percent below the standard at that time (ONCCP 1982). Thus, the establishment of ENI was a milestone in pursuit of knowledge for dealing with the serious problems of malnutrition in Ethiopia through training and research by collecting and disseminating data and information on nutritional status among various groups. Although limited in coverage, surveys were conducted on the nutritional status of various socio-economic groups (semi-pastoralists, enset-growing farmers, cereal-based farming households, and urban dwellers) between 1963 to 1968 that include both direct (clinical, laboratory, anthropometrics) and indirect (production, mortality rate, disease burden) measurements. The results showed that the population faced serious shortages in energy, protein, and micronutrients as compared to international standards (ibid, 9). Understanding the problem of nutrition in a developing country like Ethiopia and arriving at a consensus on the synergies and the integration of various causes of malnutrition are deemed essential as a background for the development of a National Nutrition Strategy (NNS). Three clusters of causes of malnutrition are identified as key sets of determinants for the process of developing the NNS. These include the immediate causes, the underlying causes, and the basic or root causes. This report focuses on the basic causes or basic determinants of malnutrition. This report consists of the following sections. After this introduction, a definition of malnutrition and a conceptual framework on the causes of malnutrition, the global framework, along with historical background on past scientific investigations of malnutrition and its basic causes are presented. In section 2.2, a description of the major identifying characteristics of the malnourished in Ethiopia and trends in malnutrition are presented. Section 2.3 identifies and describes in detail the basic causes of malnutrition in Ethiopia, examining the macro and structural characteristics of the socio-economic, political, cultural, and institutional structures as they relate to malnutrition. Key implications of the assessment of the basic determinants of malnutrition are presented in section 2.4, while section 2.5 presents a summary of the findings and recommendations for future directions in formulating a sustainable National Nutrition Strategy. 2.1.1. Defining Malnutrition The concept of nutrition and its manifestation as malnutrition (both under and over nutrition), involves complex processes at multiple levels, from indiv idual to the household to the community to the national and international levels. A UNICEF Policy Review paper states that, from the perspective of developing countries, “malnutrition results from inadequate intake of nutrients and/or from disease factors that affect digestion” among which protein- 10
energy malnutrition (PEM), nutritional anemia, vitamin A deficiency, and iodine deficiency disorders (IDD) are the most serious nutritional problems (UNICEF 1990). It has been shown through various studies that children and women are the primary victims of malnutrition who suffer the most lasting consequences. Although closely related, nutrition security is sometimes confused with the related concept of food security. Food security refers to physical and economic access to food items for a healthy and productive life of individuals at a household level, while the concept of nutrition includes access to health and care, as well as food, for individuals at the household level. Nutrition is seen from a security point of view in line with food security. Thus, we may define nutrition security as a situation when a household attains secure access to food coupled with a sanitary environment, adequate health services, and knowledgeable care (Benson & Shekar 2005). It is important to recognize that the primary focus of this paper will be on chronic malnutrition and on the basic causes of malnutrition. However, acute malnutrition emergencies resulting from natural, man-made, and market shocks will be considered within the National Nutrition Strategy as an integral component. 2.1.2. Conceptual Framework of the Causes of Malnutrition—The Global Framework As a result of UNICEF’s child nutrition interventions in Africa and other parts of the world in 1980s and particularly based on the experiences of the Joint Nutrition Support Program (JNSP) in Iringa, Tanzania and elsewhere, UNICEF developed a comprehensive nutrition strategy in 1990 (UNICEF 1989). The objective of the strategy was “to empower families, communities, and government to improve nutrition of women and children on the basis of adequate information and sound analysis” (UNICEF 1990, 12). The main elements of the strategy include (a) a method of assessment, analysis, and action (Triple A) and (b) a conceptual framework for the analysis of the causes of malnutrition. Triple A involves the iterative process of dealing and responding to problems associated with malnutrition, while the conceptual framework helps to identify and clarify the causes of malnutrition (ibid, 17). The global conceptual framework developed by UNICEF identifies malnutrition and death in children and women as the result (final outcome) of a long sequence of interconnected events. (See Figure 1.2 in previous chapter.) These events can be classified as components of three major groups of causes: the basic, the underlying, and the immediate determinants of malnutrition. First, inadequate dietary intake and disease are considered the most significant immediate causes of malnutrition of children and women. Secondly, the underlying causes for inadequate dietary intake and diseases can be numerous. These are context-specific and the most important fall within the three interrelated groupings of insufficient food availability and access, inadequate care for children and mothers, and insufficient health services and inadequate provision of a healthy environment (e.g. clean water and sanitation). Finally, the major basic or structural causes of malnutrition in the hierarchy include economic, technological, political, cultural, and institutional structures and processes, the means of control of physical resources, and the level of human development. This paper examines the various sub-components of the basic causes of malnutrition in Ethiopia as presented in detail in section 2.3 below. In order to capture the distinctive roles of the basic causes or determinants, they are presented in three groups or levels, the international, national, and sub-national or household/ community levels. The three categories of causes of malnutrition function synergistically with each other. It is also important to recognize that there are horizontal cause and effect relationships at all levels, although these linkages are somewhat more obvious for the underlying causes – the food—care—health trio. Figure 1.2 in the previous chapter shows the interrelationships of the global framework as originally envisaged. Other versions of the framework, without 11
Page 1: An assessment of the causes of maln
Page 4 and 5: • Bantirgu Hailemariam coordinate
Page 6 and 7: 3.4. National and Regional Trends:
Page 8 and 9: LIST OF TABLES Table 2.1: Child stu
Page 10: LIST OF ACRONYMS ADLI AGOA AIDS BCC
Page 14 and 15: Figure 1.1: Stunting among children
Page 16 and 17: these underlying determinants of th
Page 18 and 19: experimental body of evidence that
Page 20 and 21: water can have significant impact o
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Page 26 and 27: Table 2.3: Regional profile of stun
Page 28 and 29: A rich food through popularization
Page 30 and 31: key tenet in the process of identif
Page 32 and 33: Basic Causes Major Features High im
Page 34 and 35: commodity trading is the most signi
Page 36 and 37: Table 2.9: Gross primary enrollment
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Page 45 and 46: CHAPTER 3: FOOD SECURITY AND MALNUT
Page 47 and 48: Afar in 2000 was 12.6 percent and 5
Page 49 and 50: 3.1. Introduction The economic grow
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Page 63 and 64: Figure 3.3: Per capita food product
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due to inappropriate land mismanage
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3.6.3.5. HIV/AIDS This disease is w
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coordinates the different implement
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conception through early pregnancy
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households who depend on purchased
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• Improve rural radio infrastruct
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3.7.3.6. Improve rural market infra
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CHAPTER 4: CARE AND MALNUTRITION IN
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household allocation; 5) workload a
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lack of national nutrition strategy
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children between 6 and 24 months. T
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Care was recognized as one of the u
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Figure 4.1: Risk of death in infant
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Table 4.2: Present discount values
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Figure 4.3: Factors that affect the
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Box 4.2: Reasons why PLWHA are vuln
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Figure 4.7: Risk of mother to child
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arely provide this kind of benefit.
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Figure 4.8: The extended model of c
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4.3.1.2. Recognizing symptoms of il
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the direction of the growth curve i
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Figure 4.13: Prevalence of stunting
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from poor exposure of children to l
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4.3.3.4. Response to food security
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4.3.6. Time and energy expenditure
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Table 4.3: Care focused initiatives
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together. This demands an integrate
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In an emergency, therefore, care an
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• Enhance women’s capacity for
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Table 4.4: Analysis of care conside
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Sector/ Office Strength Weakness Op
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International initiative Strengths
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• Rate of continued breastfeeding
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Figure 4.17: Community based nutrit
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There is a strong need for enhancin
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supplies. The available facilities
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5.1. Introduction 5.1.1. Conceptual
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access to a basic package of qualit
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Integrating nutrition interventions
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Although the coverage of ENA traini
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Box 5.1: Household and Community In
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The interventions that make up this
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conferences. To this effect, a nati
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with the engineering aspect of wate
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Table 5.1: Prevalence of diarrhea a
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Figure 5.3: Trends in latrine cover
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Institutional arrangements are also
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ehavior are integrated and supplied
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5.4.2. Programs and projects 5.4.2.
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made by NGOs for the affected child
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CHAPTER 6: INSTITUTIONAL FRAMEWORK
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interventions in Ethiopia, includin
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6.2. Challenges and Lessons Learnt
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Training Post-secondary training is
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Table 6.6: (continued) Agency Inter
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Achievements Challenges Sustainabil
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Berhane G. 1995. Nutrition surveill
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Ethiopian PROFILES Team & AED/Linka
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Middlebrook, P. 2002. Social protec
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Raisin, J. 2001b. Improving food se
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Yamano, T., H. Alderman, & L. Chris
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