1. Addressing Acute and Chronic Malnutrition in Ethiopia: Challenges to Finding the Policy Balance Poster Reference Number: PO1426 Background and Objectives Methods Results Conclusions In-depth interviews using semi-structured guides were conducted with key policy stakeholders, including donors, implementing agencies, and the government. A total of 20 participants were interviewed, including 9 program implementers, 7 development partners, 2 government organizations and 2 media agencies. Transcribed interviews were analyzed using a qualitative software package, Nvivo. Code lists were developed based on the interview guide, with new codes added as needed during the analysis process. There is indeed a perceived a shift in the policy discourse in Ethiopia to now include both stunting and wasting. The relative operational simplicity of addressing wasting, however, tilts program activities towards wasting. Continued advocacy, resources and technical inputs are likely needed to ensure that prevention of stunting is kept high on the agenda in a food insecure context like Ethiopia. Keywords Ali D 1, Amare Y 2, Menon P 3 1 International Food Policy Research Institute (IFPRI), Addis Ababa, Ethiopia; 2 The Consultancy for Social Development, Addis Ababa, Ethiopia; 3 IFPRI, New Delhi, India Stakeholders, Policy, Nutrition, Ethiopia Ethiopia has among of the highest rates of child malnutrition in the world with 44 percent stunted (chronic malnutrition) and 10 percent wasted (acute malnutrition). Historically, nutrition programs in Ethiopia have focused on the management of wasting as a response to recurring emergency conditions in the country. Alive & Thrive focuses on infant and young child feeding (IYCF) to prevent stunting and along with other interventions, has also engaged in advocacy around a stronger focus with various stakeholders. This study aims to understand whether the advocacy activities had led to any shifts in perceptions of stakeholders about wasting and stunting and the actions that were being taken to address these problems. Perspectives on Malnutrition Most respondents considered stunting as a major problem in Ethiopia. “One of the challenges we have is stunting is very high. By the WHO cut off point, if it is more than 40%, it is very high even if the stunting rate has gone down from 61 or 62% in 1992 to 44%. There is a marked decrement but we still have the highest prevalence of stunting. So chronic under nutrition is still a major public health problem” [implementing partner] “We should take it as a serious problem because of its implication for development in terms of having an appropriate work force for our development activities. The other thing is, once stunting has occurred, you cannot reverse it. You should act before 2 years of age, as much as possible.” [development partner] Persistent high percentage of wasting baffles program implementers; Still a major issue at 10 percent with pockets of higher rates and not declining. “We are addressing the symptoms of the problem but we really are questioning, are we really addressing the underlying causes because why are we getting all these readmissions; why are we going back after a few months?” [Implementing partner] Current Focus of Nutrition Policy and Programs According to a majority of respondents, historically and continually, the management of wasting has been the primary focus of most programs. “People understand malnutrition mainly in terms of wasting, not stunting. It is understood that way by development partners as well as by the government and donors. More attention and money is given to acute in the form of emergency intervention.” Some noted that the focus of policy and programs has recently shifted to prevention of stunting. “Currently, I think the focus is coming to chronic malnutrition than the acute malnutrition which used to be the focus before 2008 especially. More partners are coming to address chronic under nutrition. Funding for chronic under nutrition is increasing.” Overall, the development community mainly believed that at this point in time, equal attention is being given to both stunting and wasting. Perspectives on the Effectiveness of Current Nutrition Programs Intention and reality appear to deviate when it comes to effectiveness of nutrition programs. Programmatic management of stunting is weaker compared to management of wasting. Implementers have better knowledge, resource and experiences to tackle wasting than to tackle stunting. Coverage of stunting reduction programs is much lower than for emergency nutrition programs. “The coverage for managing acute malnutrition is very high because every health worker has been oriented on it. But coming to the proper management of chronic malnutrition there are lots of challenges starting from the level of awareness of health workers.” Community Based Nutrition (CBN), the most wide-spread program focuses more on growth monitoring than teaching and counseling. Nutrition is often considered a vertical program lacking multi- sectoral approach involving sectors like agriculture, women’s affair, and education. Shift in the Discourse The discourse of nutrition is changing on the part of the government, donors and implementing organizations. The prevention of undernutrition is a priority for the Ministry of Health, in contrast to a few years ago when emergency nutrition and resilience- building were the foci of the National Nutrition Program. Global initiatives such as the Scaling Up Nutrition (SUN) movement and successes in reducing stunting contribute to this change. Clear strategies in the current National Nutrition Program for prevention of stunting reflected the government’s support toward prevention. “When I came in early 2010, a lot of people were talking about treatment, treatment, treatment. But what I have seen is a change, not only from the donor point of view but from the NGOs and the government point of view. They are talking about prevention. I think they know that if they want to achieve their growth and transformation plan, prevention is one of the key things.” Perceived Challenges Competing priorities within the health sector that could reduce the emphasis on nutrition. Insufficient priority to the preventive aspects of nutrition in a country where emergency nutrition has always been a focus; as a result, implementers face resource shortfalls for prevention-focused programs. Potential weaknesses in managerial and technical capacity for managing stunting-focused programs. Lack of receptivity at the community-level to the softer components of prevention-focused programs in preference to more visible inputs of the wasting- focused programs was a serious constraint on the initiation of one program. Complexities related to the causes of stunting is not well understood at the communities. Lack of human resources and infrastructure is also a major challenge. Potentially excessive demands on HEWs within the health system and beyond were seen as likely to weaken their ability to give sufficient attention to issues such as nutrition. “We wanted to do much better particularly at health center level with the intention that it could support the HEWs. That link is very important even for sustainability. It just started but it requires a lot of input. We hope it will improve through time but the progress is not encouraging.”[Government official]