Mapping evidence of national-nutrition-relevant policies and programmes in Ethiopia to address multiple burdens of malnutrition

EVIDENCE BRIEF DECEMBER 2025 MAPPING EVIDENCE OF NATIONAL NUTRITIONRELEVANT POLICIES AND PROGRAMMES IN ETHIOPIA TO ADDRESS MULTIPLE BURDENS OF MALNUTRITION © iStock.com/Hadynyah Deploying research Sharing science Transforming the future Deploying research Sharing science Transforming the future       Contributing authors Pradeilles Rebecca1,2*; Worku Meron3,4*; Holdsworth Michelle1, Baye Kaleab3,5; Tessema Masresha6; Samuel Aregash6; Bricas Nicolas1; Ruel Marie2 *joint first authors 1 UMR MoISA (Montpellier Interdisciplinary Centre on Sustainable Agri-Food Systems), (Univ Montpellier, CIRAD, CIHEAM-IAMM, INRAE, Institut Agro, IRD), Montpellier, France 2 Nutrition, Diets and Health Unit, International Food Policy Research Institute, Washington DC, USA 3 Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia 4 Menelik II Medical and Health Science College, Addis Ababa, Ethiopia 5 Nutrition and food systems division, Research center for Inclusive Development in Africa (RIDA), Addis Ababa, Ethiopia 6 Ethiopian Public Health Institute, Addis Ababa, Ethiopia Citation recommendation Pradeilles, R.; Worku, M.; Holdsworth, M.; Baye, K.; Tessema, M.; Samuel, A.; Bricas, N.; Ruel, M. (2025). Mapping evidence of national nutrition-relevant policies and programmes in Ethiopia to address multiple burdens of malnutrition. https://doi.org/10.5281/zenodo.17788723 Acknowledgements The authors of this evidence brief gratefully acknowledge the stakeholders from the Ministry of Agriculture, Ministry of Education, Ministry of Health, Ministry of Women and Social Affairs, Ethiopian Public Health Institute, and Ethiopian Institute of Agricultural Research for their valuable participation in the validation of the evidence collated in the brief. We also thank Karine Perrin, graphic designer, for her expert contribution to the design of this report. Funding RP received funding from the European Union’s Horizon 2021 research and innovation programme under the Marie Skłodowska Curie grant agreement No [101067718]. The funders had no role in the collection, analysis, interpretation of data or writing of the report. TABLE OF CONTENTS I ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 / ETHIOPIA NUTRITION SITUATION ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.1. Nutrition situation analysis amongst children under five . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2. Nutrition situation analysis amongst school-aged children, adolescents and adults . . . . . . . . . . . . . . . . . . . . . . . . 4 2 / BACKGROUND, AIM AND METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.2. Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.3. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3 / RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3.1. Summary of included documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3.2. Double-duty actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3.3. Infrastructure support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4 / SUMMARY OF POLICY GAPS AND RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 5 / APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Appendix 1. Summary of double-duty actions, infrastructure support, and recommended actions . . . . . . 13 Appendix 2. List of included policy and programme documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Appendix 3. Summary of evidence identified for double-duty actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Appendix 4. Summary of evidence identified for infrastructure support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 CONTACT DETAILS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 ACRONYMS AAU Addis Ababa University AGRA Alliance for a Green Revolution in Africa BMI Body Mass Index CIRAD French Agricultural Research Centre for International Development DD Double-Duty DDA Double-Duty Action EBF Exclusive Breastfeeding EDHS Ethiopia Demographic and Health Survey EPHI Ethiopian Public Health Institute FAO Food and Agriculture Organization GMP Growth Monitoring and Promotion Hb Haemoglobin IFPRI International Food Policy Research Institute IRD French National Research Institute for Sustainable Development IS Infrastructure Support IYC Infants and Young Children (6-23 months) IYCF Infants and Young Child Feeding practices MAM Moderate Acute Malnutrition MDD Minimum Dietary Diversity MN Micronutrient deficiency NCDs Noncommunicable diseases ORS Oral Rehydration Solution SAM Severe Acute Malnutrition SD Standard Deviation U5 Children under five (0-59 months) UN Undernutrition UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children’s Fund WASH Water, Sanitation, and Hygiene WHO World Health Organization WRA Women of Reproductive Age (15-49 years) II TABLE OF CONTENTS Anaemia Action Plan Adult fruit and vegetable consumption Double Burden of Malnutrition Early initiation of breastfeeding within one hour of birth Egg and/or flesh food consumption Introduction of solid, semi-solid or soft foods Malnutrition Exclusive breastfeeding under six months Food environment Infrastructure support Minimum Dietary Diversity Evidence Double-Duty Actions Continued breastfeeding WHO defines anaemia in children U5 and pregnant women as a Hb concentration <11.0 g/dL at sea level, and anaemia in non-pregnant women as a Hb concentration <12.0 g/dL. An action plan arises from policy and contains detailed operational plans, including budgets, and goals and targets that are specific, measurable, attainable, relevant and time bound. Daily consumption of at least 400g (equivalent to 5 servings) of fruit and vegetables, as recommended by WHO. The coexistence of undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, within individuals, households, and populations, and across the life course. Percentage of children born in the last 24 months who were put to the breast within one hour of birth. Percentage of children 6-23 months of age who consumed egg and/or flesh food during the previous day. Percentage of infants 6-8 months of age who consumed solid, semi-solid or soft foods during the previous day. Malnutrition refers to both undernutrition (including stunting, wasting, underweight and micronutrient deficiencies) and overweight, obesity. Percentage of infants 0-5 months of age who were fed exclusively with breastmilk during the previous day. The physical, economic, political and sociocultural contexts that affect accessibility, availability, affordability and cultural/sensory perceptions of food. This in turn influences people’s food choices, such as in acquiring, preparing and eating food, and their nutritional status. Findings from research and other knowledge that may serve as a useful basis for decision-making in public health and healthcare. The infrastructure support component (or enabling environment), refers to a set of domains that facilitates policy development and implementation. Percentage of children 6-23 months of age who consumed foods and beverages from at least four out of seven defined food groups during the previous day. (note: the pre-2021 definition was used in this report) Actions that aim to simultaneously tackle undernutrition and problems of overweight, obesity, and diet-related noncommunicable diseases. Percentage of children 12-23 months of age who were fed breastmilk during the previous day. III GLOSSARY Term Definition TABLE OF CONTENTS Term Definition Noncommunicable diseases Overweight/ Obesity Policy Stunting Underweight Wasting Zero vegetable or fruit consumption Triple burden of malnutrition Programme Noncommunicable diseases, also known as chronic diseases, are non-transmissible diseases of often long duration. Examples of NCDs include mental health conditions, stroke, heart disease, cancer, diabetes and chronic lung disease. In children U5 (0-59 months), overweight/obesity is defined as a weight-for-length or -height z-score > +2SD of the WHO Child Growth Standards. In school-aged children and adolescents (5-19 years), overweight/obesity is defined as a BMIfor-age > +1SD of the WHO growth reference. Obesity only is defined as a BMI-for-age > +2SD. In adulthood (≥18 years), overweight/obesity is defined as a BMI ≥25 kg/m2. Obesity only is defined as a BMI ≥30 kg/m2. A broad set of written principles that commit a government to action regarding a specific subject. In children U5 (0-59 months), stunting (moderate or severe) is defined as a lengthor heightfor-age z-score < -2SD of the WHO Child Growth Standards. In children U5 (0-59 months), underweight is defined as a weight-for-age z-score <-2SD of the WHO Child Growth Standards. In school-aged children and adolescents (5-19 years), underweight or thinness is defined as BMI-for-age < -2SD of the WHO growth reference. In adulthood (≥18 years), underweight is defined as a BMI <18.5 kg/m2. In children U5 (0-59 months), wasting is defined as a weight-for-length or –height z-score < -2SD of the WHO Child Growth Standards. Percentage of children 6-23 months of age who did not consume any vegetables or fruits during the previous day. The coexistence of undernutrition— including stunting, wasting, underweight—alongside micronutrient deficiencies, as well as overweight/obesity. A programme provides details for the implementation of an action plan; specific projects are defined within a programme. IV GLOSSARY TABLE OF CONTENTS EXECUTIVE SUMMARY Background Despite remarkable progress in reducing undernutrition, Ethiopia still has one of the highest rates of undernutrition amongst children under five years of age (U5) and women of reproductive age (WRA) globally. The country’s stubborn problem of undernutrition coexists with a rising challenge of overweight/obesity and diet-related noncommunicable diseases (NCDs), particularly amongst WRA in urban areas. Both undernutrition and overweight/obesity share common causes, including poor diet quality. Yet, undernutrition and overweight/obesity have traditionally been considered as distinct problems requiring different solutions. The need to reshape public health nutrition to address multiple forms of malnutrition simultaneously through double-duty actions (DDA) has been recently highlighted1. Shifting policies and programmes to address multiple forms of malnutrition requires a deep understanding of the problem and of stakeholders’ views, a conducive policy/programme environment, and a careful analysis of the problems and potential ways of addressing them. Aim The study aimed to: i. assess whether existing national nutrition-relevant policies and programmes align with recommended DDAs, and if they do not, explore how they could be reshaped to tackle multiple burdens of malnutrition, and ii. determine how the enabling environment could be strengthened to enhance implementation of the recommended DDAs. Methods We conducted a qualitative policy mapping review to synthesise the evidence on nutrition-relevant policies and programmes that address different forms of malnutrition in Ethiopia amongst children U5, school-aged children/adolescents, WRA and adults between 2010-2023. For this, evidence was collated to assess action on ten proposed DDAs1 across four sectors (agriculture and food systems, education, health, social protection) and six measures of the enabling environment (leadership, governance, monitoring and evaluation, platforms and interactions, funding, and health in all policies2). Recommended actions (n=66) were included to assess ten DDAs (n=46) and infrastructure support (n=20). The evidence was compiled into an evidence brief and shared with six key experts from government institutions and research organisations for validation. Results - Description of included documents Overall, 80 policy documents were included. There was good evidence of policy activity to improve nutrition across all four sectors and for all population groups (children U5, school-aged children and adolescents, WRA and other adults). Policy documents, however, focused primarily on undernutrition (wasting, stunting, underweight) and micronutrient deficiencies. Overweight/obesity and NCDs were recognised as important outcomes only in documents from the health sector. Overall, only 15 documents (18.8%) specifically addressed the issue of multiple forms of malnutrition in an integrated way. - Double-duty actions There was good evidence of policy activity that aims to improve diets and nutritional status across the 10 DDAS in all four sectors. Within the health sector: • There was good evidence of policy activity for maternal nutrition during pregnancy (i.e. nutrition counselling, and antenatal care) and IYC nutrition (i.e. early initiation of breastfeeding, vitamin A supplementation and monitoring/ management of malnutrition). • There was some evidence on the promotion of healthy and diverse diets and the need to limit the consumption of unhealthy foods and beverages in WRA and children U5. • There was also moderate evidence of policy activity on preventing potential harm from the regular and extended consumption of energy-dense and micronutrient fortified foods and ready-to-use supplements in infants and young children. • In women during pregnancy, gaps existed around energy/protein supplementation for at risk women, anaemia testing, and delayed cord clamping. • After pregnancy, there are gaps in promoting healthy postpartum weight management and encouraging healthy dietary and physical activity behaviours. Within the social protection sector: • There was some evidence of policy activity related to social protection programmes that include behaviour change communication strategy, especially for the promotion of dietary diversity and optimal IYCF practices but not for prevention of overweight/obesity in women or children. 1 Hawkes, C., Ruel, M.T., Salm, L., Sinclair, B., Branca, F., 2020. Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. The Lancet 395, 142–155. https://doi.org/10.1016/S0140-6736(19)32506-1 2 Swinburn B, Vandevijvere S, Kraak V, Sacks G, Snowdon W, Hawkes C, Barquera S, Friel S, Kelly B, Kumanyika S, L’ Abbé M, Lee A, Lobstein T, Ma J, Macmullan J, Mohan S, Monteiro C, Neal B, Rayner M, Sanders D, Walker C; INFORMAS, 2023. Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index. Obesity Reviews 14 Suppl 1:24-37. https://doi.org/10.1111/obr.12073 1 TABLE OF CONTENTS EXECUTIVE SUMMARY 2 Results (continued) • There was a lower level of evidence of policy activity for programmes that link subsidies or food vouchers to nutritious foods, or cash transfers that incorporate counselling on healthy diets. Within the education sector: • There was good evidence of policy activity around nutrition and health counselling and water, sanitation and hygiene programmes. • Gaps existed around the provision of healthy meals and affordable nutritious foods in/ around schools; and in education on healthy diets and physical activity. • Finally, there was insufficient evidence of action on the regulations of sale and promotion of unhealthy foods in/around schools. Within the agriculture and food systems sector: • There was good evidence of efforts to empower women in agriculture. • There was some evidence of policy activity related to increasing the production of nutritious foods to enhance their availability, access, and affordability; implementing taxes on unhealthy foods and subsidies for nutritious foods; and restricting the marketing and health claims of unhealthy foods. • Gaps existed in regulations concerning the healthiness of foods sold by retailers. Infrastructure support (enabling environment) There is good evidence of policy activity that aims to improve and sustain a positive enabling environment for nutrition policy making and implementation. • There is strong evidence for three of the six infrastructure components - Governance, Monitoring and Evaluation, and Funding. • There is strong leadership support for improving population nutrition. However, the lack of implementation and evaluation of the food-based dietary guidelines developed and published in 2022 remains a challenge. • The government has structures in place to ensure transparency and accountability in the formulation and implementation of policies, with procedures in place to limit commercial influences when developing policies aimed at improving food environments. • Systems are in place to monitor food environments, nutrition, and health. • Investment exists to improve population nutrition. • There are platforms, both within government and between the government and commercial food sector, but coordination platforms and opportunities for synergies between government and civil society are lacking. • There is no evidence that policymaking integrates a health-in-all-policies approach. Recommendations for action Given the multiple forms of malnutrition that now coexist in Ethiopia, there is a need to reshape and adapt current nutrition policies and programmes so that they can serve as double-duty actions and address the country’s new nutrition reality. New ways of thinking, designing, and implementing policies and programmes are needed to address multiple forms of malnutrition. The current lack of integration presents a missed opportunity that hinders optimal utilisation of resources (fiscal, human, and time) for prevention. There is a need to promote the consumption of diverse and nutrient-rich diets and to limit the consumption of unhealthy foods and beverages. However, further research is needed on the extent of unhealthy food and beverage consumption and poor quality diets across different population groups in Ethiopia. Adaptations are needed to retrofit and strengthen current policies and programmes into DDAs. Diet is a key shared driver of all forms of malnutrition and represents an important pathway to improve diet, nutrition, and health outcomes. Policies and programmes should therefore include healthy diets as a key outcome of food system transformation and focus on making nutritious foods more accessible and affordable whilst limiting the availability, purchase and consumption of unhealthy foods and beverages by improving the food environment and investing in behavior change communication strategies to promote healthy diets, nutrition, and health for all. TABLE OF CONTENTS Multiple forms of malnutrition coexist at population level in Ethiopia • Despite remarkable progress in reducing stunting, Ethiopia still has a very high level of stunting amongst children U5 (26.2% urban vs. 40.2% rural). The national average (36.8%) is higher than the regional one for Africa, estimated at 30.0%. • Anaemia is widespread, affecting approximately 1 in 2 children U5 (49.3% urban vs. 57.8% rural) and 1 in 4 WRA (29.0% pregnant vs. 23.5% non-pregnant). • The prevalence of overweight/obesity in children U5 is very low (2.5%). However, it increases significantly in school-aged children and adolescents (5-19y), reaching 14% in girls, suggesting that the rise occurs during these stages. In adulthood, the prevalence increases further and more than 1 in 4 women experience overweight/obesity. Infant and Young Child Feeding practices and diets need attention • Slightly more than 1 in 2 women with a child < 23mo practice exclusive breastfeeding (57.6%), with a very high proportion of women continuing to breastfeed between 12-23 m (81.1%). • In urban areas, only half of women (52.1%) introduced foods at the optimal time – when their infant was 6-8 mo old. • Diets lack diversity as only 13.4% of IYC meet the minimum dietary diversity. Furthermore, only 27% of IYC consumed animal-sourced foods in the previous day. • The prevalence of fruit and/or vegetable consumption is low in both IYC (32%) and adults (26.4%). Only 4.9% of adults consumed the recommended 5 servings or more of fruit and/or vegetable in the previous day. • Anecdotal observations suggest that the consumption of unhealthy foods and beverages is increasing amongst IYC, adolescents and adults but data are lacking on the types, frequency and amounts of consumption in these groups. Highlights Figure 1. Children’s nutritional status (0-5 y) Stunting Children 0-59 mo who are stunted (height-for-age < -2SD) Urban Rural Overweight/obesity Children 0-59 mo who are overweight or obese (weight-for-height > +2SD) Urban Rural Wasting Children 0-59 mo who are wasted (weight-for-height < -2SD) Urban Rural Anaemia* Children 6-59 mo who are anaemic (Hb levels < 11.0 g/dL) Urban Rural %100 80 60 40 20 0 2000 2005 2011 2016 2019 * No data available for 2000 and 2019 1.1. Nutrition situation analysis amongst children under five ETHIOPIA NUTRITION SITUATION ANALYSIS3 1 3 3 Data sources: Data on nutrition and food consumption displayed in the Ethiopian Nutrition Situation Analysis section were sourced from the most recent nationally representative surveys conducted between 2000 and 2019, and extracted from multiple databases including the Ethiopia Demographic and Health Surveys; Global Nutrition Report; Food Systems Dashboard; NCD STEPS report; and UNICEF/WHO/World Bank Joint Child Malnutrition Estimates. TABLE OF CONTENTS Highlights 3.3. Infrastructure support (enabling environment) Design new agricultural and food system policies to support healthy diets DDA9 Implement policies to improve food environments from the perspective of malnutrition in all its forms DDA10 Agriculture/food systems Agriculture/Food systems DD - double-duty MN - micronutrient deficiency UN - undernutrition A high proportion of recommended actions (17 out of 20) across five of the six infrastructure support domains had some evidence of policy activity. (see Appendix 4 for full summary of evidence). We found that: • Leadership had good evidence of support for improving population nutrition. However, the lack of implementation and evaluation of the food-based dietary guidelines developed and published in 2022 remains a concern. • For Governance, governments have structures in place to ensure transparency and accountability in the formulation and implementation of policies, with procedures in place to limit commercial influences when developing policies aimed at improving food environments. • For Monitoring and Evaluation, systems are in place to monitor food environments, nutrition, and health. • For Funding, investment exists to improve population nutrition. • With regards to Platform and Interaction, there are platforms both within government and between government and the commercial food sector but coordination platforms and opportunities for synergies between government and civil society are lacking. • There is no evidence that policymaking integrates a health-in-all-policies approach. Scale up nutrition-sensitive agriculture programmes DDA8 Agriculture/food systems Regulations on healthiness of foods sold by retailers Focus agriculture production on affordable nutritious foods DD Restrict nutrition and health claims on unhealthy foods & beverages DD Restrict marketing of unhealthy foods and beverages in all contexts Restrict promotion of infant formula in all media and healthcare settings DD DD DD Taxes on unhealthy foods & subsidies for nutritious foods DD Empower women in agricultural programmes Inputs and training to develop and maintain home gardens with nutrition education to improve diets DD DD 10 3.2. Double-duty actions (continued) 3 - RESULTS Higher level of evidence Some level of evidence No/lower level of evidence Double-duty actions (DDA) Evidence of alignment of policy with recommended actions TABLE OF CONTENTS Leadership Governance Monitoring and Evaluation Funding Platform and Interaction Health in all policies Strong and visible political support to improve population nutrition Restrictions on commercial influences on nutrition policy Systems in place to monitor food environments Population targets for nutrients of concern Evidence informed food policies Monitoring of nutritional status, NCDs and population intakes Government funding to promote healthy eating and healthy food environments Coordination mechanisms across government sectors to ensure policy coherence Food-based dietary guidelines implemented6 Transparency in developing food policies Evaluation of major programmes/policies in relation to nutrition and health Government funded research targeted at improving food environments, reducing obesity, NCDs and/or inequalities Platforms between government/commercial food sector to implement healthy food policies Government-led implementation plan to improve population nutrition Public access to nutrition information Monitoring of progress towards reducing health inequalities Statutory health promotion agency with secured funding stream to improve population nutrition Platforms for interactions between government/civil society on food policies Government policies are sensitive to nutrition, public health and reducing inequalities Government priorities to reduce inequalities 3.3. Infrastructure support (enabling environment) Figure 11. Status on infrastructure support and 20 recommended actions Infrastructure support components Recommended actions Yes, found at least one piece of evidence No evidence found 6 Food-based dietary guidelines were developed and published in 2022 but rigorous implementation, continuous monitoring, promotion, and advocacy remain limited. 11 3 - RESULTS TABLE OF CONTENTS Highlights SUMMARY OF POLICY GAPS AND RECOMMENDATIONS 4 Nutrition situation analysis • Multiple forms of malnutrition coexist in Ethiopia at population level (stunting, anaemia in children U5 and WRA, overweight/obesity and diet-related NCDs in adults). • Diets in Ethiopia lack diversity (low overall diversity and low consumption of animal-sourced foods and fruits and vegetables). Anecdotal evidence suggests that the consumption of unhealthy foods and beverages is increasing amongst IYC, adolescents and adults but data are lacking on types, frequency and amounts across population groups. Double-duty actions Our review showed good evidence of policy activity that aims to improve diets and nutritional status across the 10 DDAS in four sectors (health, social protection, education, and agriculture and food systems). • Emphasis was placed on reducing undernutrition and micronutrient deficiencies, which is logical given the high prevalence of undernutrition that persists in children U5 and WRA. However, there was also recognition from the health sector that overweight/obesity and NCDs need addressing. Only 15 documents (18.8%) targeted multiple forms of malnutrition in an integrated and holistic way. • Within the health sector, there was good evidence of policy activity for maternal nutrition during pregnancy and IYC nutrition. In women during pregnancy, gaps existed around energy/ protein supplementation for at risk women, anaemia testing, and delayed cord clamping. After pregnancy, there are gaps in promoting healthy postpartum weight management and encouraging healthy dietary and physical activity behaviours. • Within the social protection sector, there was evidence of policy activity for programmes that included behaviour change communication for optimal dietary diversity and IYCF practices, but less evidence on subsidies/food vouchers for nutritious foods or cash transfers that incorporate counselling on healthy diets. • Within the education sector, there was good evidence on nutrition, health, and WASH counselling. However, gaps remained around the provision of healthy meals and affordable nutritious foods in and around schools, as well as in education on healthy diets and physical activity, and in the regulation of the sale and promotion of unhealthy foods in and around schools. • Within the agriculture and food systems sector, there was good evidence of efforts to empower women in agriculture. Gaps existed in regulations concerning the healthiness of foods sold by retailers. Infrastructure support Our review also showed good evidence of policy activity that aims to improve and sustain a positive enabling environment for nutrition policy making and implementation. • There is strong leadership support for improving population nutrition. However, the lack of implementation and evaluation of the food-based dietary guidelines developed and published in 2022 remains a challenge. • The government has structures in place to ensure transparency and accountability in the formulation and implementation of policies, with procedures in place to limit commercial influences when developing policies aimed at improving food environments. • Systems are in place to monitor food environments, and population nutrition & health. • Investment exists to improve population nutrition. • There are platforms both within government and between the government, and commercial food sector, but coordination platforms and opportunities for synergies between government and civil society are lacking. • There is no evidence that policymaking integrates a health-in-all-policies approach. Recommendations for action • Given the multiple forms of malnutrition coexisting at the population level, there is a need to reshape and enhance current nutrition policies and programmes to re-focus them as double-duty actions that can address multiple forms of malnutrition simultaneously. New ways of thinking, designing and implementing policies and programmes are needed to address multiple forms of malnutrition. The current lack of integration presents a missed opportunity that hinders optimal utilisation of resources (fiscal, human, and time) for prevention. • The situation analysis highlights the need to promote the consumption of diverse and nutrient-rich diets and to limit the consumption of unhealthy foods and beverages. However, further research is needed to assess the consumption of unhealthy foods and beverages and poor quality diets’ in different population groups. • Adaptations are needed to retrofit and strengthen current policies and programmes into DDAs. Diet is a shared driver of all forms of malnutrition and represents an important pathway to improve diet, nutrition, and health outcomes. Policies and programmes should therefore include healthy diets as a key outcome of food system transformation and focus on making nutritious foods more accessible and affordable whilst limiting the availability, purchasing, and consumption of unhealthy foods and beverages by improving the food environment and investing in behavior change communication strategies to promote healthy diets, nutrition, and health for all. 12 TABLE OF CONTENTS Appendix 1. Summary of double-duty actions, infrastructure support, and recommended actions APPENDICES 5 Scale up new WHO antenatal care and maternal nutrition recommendations for all WRA ANC1 - Counselling on healthy eating, physical activity, weight gain management ANC2 - Energy/protein supplementation for at risk women ANC3 - Iron/folic acid supplementation (adolescents/WRA) ANC4 - Multiple micronutrient supplementation ANC5 - Anaemia testing ANC6 - Antihelminthic treatment (in high-risk areas; and where anaemia>40%) ANC7 - Antenatal care (8 contacts +) ANC8 - Delayed cord clamping Scale up programmes to protect, promote and support breastfeeding BF1 - Early initiation of breastfeeding, 6 mo exclusive; continued up to 24 mo BF2 - 10 steps to successful breastfeeding in hospitals BF3 - Maternity protection policies including workplace BF4 - Eliminate breastmilk substitutes marketing Redesign guidance for complementary feeding practices and related indicators CF1 - Complementary feeding counselling (incorporation of double duty messages) CF2 - Vitamin A supplementation (children) CF3 - Multiple micronutrient powders to prevent anaemia (where anaemia > 20%) CF4 - Infant feeding guidelines with recommendations to promote healthy and diverse diets and to avoid consumption of unhealthy foods/snacks/beverages CF5 - Nutrition counselling training for primary healthcare workers (incorporation of double duty messages) Redesign existing monitoring of anthropometric measures (including underweight and overweight) for WRA and children under five (U5) and management of different forms of malnutrition AMP1 - Assess risk for all forms of malnutrition for WRA & U5 AMP2 - Referral for counselling on healthy diets for WRA & U5 (double duty messages) AMP3 - Referral for diet & physical activity counselling for healthy weight postpartum AMP4 - Manage SAM & MAM in U5 AMP5 - Zinc supplementation with ORS for U5 Prevent undue harm from energy-dense and micronutrient-fortified foods and ready to use supplements UH1 - Promote healthy nutrient-rich diets to prevent undernutrition UH2 - Nutritional criteria for the distribution of fortified foods/ready to use supplements targeted to WRA and U5 & counselling on healthy diets and snacks UH3 - Energy-dense fortified foods provided for SAM/MAM with dietary counselling Redesign cash and food transfers, subsidies, and vouchers CASH1 - Cash/food transfers, subsidies and voucher programmes with behaviour change communication focused on healthy diets CASH2 - Link subsidies or food vouchers to nutritious foods Redesign pre-school (i.e., early childhood education), school and high school feeding programmes and devise new nutritional guidelines for food in and around educational institutions EDUC1 - Nutritional guidelines for school’s healthy food provision EDUC2 - Eliminate promotion and sale of unhealthy foods, in/around schools EDUC3 - Nutrition education in schools for healthy diets EDUC4 - Daily iron suppplementation for children in schools EDUC5 - Deworming prophylaxis for children/adolescents in schools EDUC6 - Training caterers in schools to provide healthy food EDUC7 - Free/subsidised fruit and vegetables in schools EDUC8 - Price manipulation to make unhealthy foods more expensive in schools EDUC9 - Menu labelling in schools with nudges for healthy options EDUC10 - Toilets and handwashing facilities in schools EDUC11 - Free, accessible and safe drinking water in schools Scale up nutrition-sensitive agriculture programmes AGRI1 - Empower women in agricultural programmes AGRI2 - Inputs and training to develop and maintain home gardens with nutrition education Design new agricultural and food system policies to support healthy diets FOODSYS1 - Focus agriculture production on affordable nutritious foods Implement policies to improve food environments from the perspective of malnutrition in all its forms FOODENV1 - Restrict marketing of unhealthy foods and beverages in all contexts FOODENV2 - Restrict nutrition and health claims on unhealthy foods & beverages FOODENV3 - Taxes on unhealthy foods & subsidies for nutritious foods FOODENV4 - Restrict promotion of infant formula in all media and healthcare settings FOODENV5 - Regulations on healthiness of foods sold by retailers Proposed good practice in each domain2 Recommended actions DDA1 DDA2 DDA3 DDA6 DDA10 DDA7 DDA4 DDA5 DDA8 DDA9 Domain (policy) Maternal nutrition Breastfeeding Complementary feeding Anthropometric monitoring Energy-dense fortified foods Social safety nets School feeding Nutritionsensitive agriculture Agriculture and food system Food environment 1 Hawkes, C., Ruel, M.T., Salm, L., Sinclair, B., Branca, F., 2020. Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. The Lancet 395, 142–155. https://doi.org/10.1016/S0140-6736(19)32506-1 13 TABLE OF CONTENTS 5 - APPENDICES Appendix 1. Summary of double-duty actions, infrastructure support, and recommended actions (continued) The political leadership ensures that there is strong support for the vision, planning, communication, implementation and evaluation of policies and actions LEAD1 - There is strong visible, political support (at the Head of Government/ Cabinet level) for improving food environments, population nutrition, diet-related inequalities LEAD2 - Clear population intake targets has been established by the government for the nutrients of concern to meet WHO and national recommended dietary intake levels LEAD3 - Clear, interpretative, evidence-informed food-based dietary guidelines have been established and implemented LEAD4 - There is a comprehensive, transparent, up-to-date and government-owned implementation plan (linked to national needs and priorities) to improve food environments, reduce the intake of the nutrients of concern to meet WHO and national recommended dietary intake levels, and reduce diet-related NCDs LEAD5 - Government priorities have been established to reduce inequalities or protect vulnerable populations in relation to diet, nutrition, obesity and NCDs Governments have structures in place to ensure transparency and accountability, and encourage broad community participation and inclusion when formulating and implementing policies and actions to create healthy food environments, improve population nutrition, and reduce diet-related inequalities GOV1 - There are robust procedures to restrict commercial influences on the development of policies related to food environments where they have conflicts of interest with improving population nutrition GOV2 - Policies and procedures are implemented for using evidence in the development of food policies GOV3 - Policies and procedures are implemented for ensuring transparency in the development of food policies GOV4 - The government ensures access to comprehensive nutrition information and key documents (e.g. budget documents, annual performance reviews and health indicators) for the public The government’s monitoring and intelligence systems (surveillance, evaluation, research and reporting) are comprehensive and regular enough to assess the status of food environments, population nutrition and diet-related NCDs and their inequalities, and to measure progress on achieving the goals of nutrition and health plans MONIT1 - Monitoring systems, implemented by the government, are in place to regularly monitor food environments (especially for food composition for nutrients of concern, food promotion to children, and nutritional quality of food in schools and other public sector settings), against codes/guidelines/standards/targets MONIT2 - There is regular monitoring of adult and childhood nutrition status and population intakes against specified intake targets or recommended daily intake levels. There is regular monitoring of the prevalence of NCD risk factors and occurrence MONIT3 - There is regular monitoring of adult and childhood overweight and obesity prevalence using anthropometric measurements MONIT4 - Progress towards reducing health inequalities or health impacts in vulnerable populations and societal and economic determinants of health are regularly monitored Sufficient funding is invested in ‘Population Nutrition Promotion’ to create healthy food environments, improved population nutrition, reductions in obesity, diet-related NCDs and their related inequalities FUND1 - Government funding for the promotion of healthy eating and healthy food environments, as a proportion of total health spending and/or in relation to the diet-related NCD burden is sufficient to reduce obesity and diet-related NCDs FUND2 - Government funded research is targeted at improving food environments, reducing obesity, NCDs, and/or their related inequalities FUND3 - There is a statutory health promotion agency in place that includes an objective to improve population nutrition, with a secure funding stream There are coordination platforms and opportunities for synergies across government departments, levels of government and other sectors (e.g. NGOs, private sector, academia) such that policies and actions in food and nutrition are coherent, efficient and effective in improving food environments, population nutrition, diet-related NCDs and their related inequalities PLATF1 - There are coordination mechanisms across departments and levels of government (national and local) to ensure policy coherence, alignment, and integration of food, obesity, and diet-related NCD prevention policies across governments PLATF2 - There are formal platforms between government and the commercial food sector to implement healthy food policies PLATF3 - There are formal platforms for regular interactions between government and civil society on food policies and other strategies to improve population nutrition Processes are in place to ensure policy coherence and alignment, and that population health impacts are explicitly considered in the development of government policies HIAP1 - There are processes in place to ensure that development of all government policies relating to food are sensitive to nutrition, public health, and reducing health inequalities in vulnerable populations Proposed good practice in each domain1 Recommended actions (LEAD) (GOV) (MONIT) (FUND) (PLAT) (HIAP) Domain (infrastructure support) Leadership Governance Monitoring and evaluation Platforms for interaction Health in all policies Funding 2 Swinburn B, Vandevijvere S, Kraak V, Sacks G, Snowdon W, Hawkes C, Barquera S, Friel S, Kelly B, Kumanyika S, L’ Abbé M, Lee A, Lobstein T, Ma J, Macmullan J, Mohan S, Monteiro C, Neal B, Rayner M, Sanders D, Walker C; INFORMAS, 2023. Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index. Obesity Reviews 14 Suppl 1:24-37. https://doi.org/10.1111/obr.12073 14 TABLE OF CONTENTS Appendix 2. List of included policy and programme documents 1. The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) 2. National Antenatal Care Guideline (2022) 3. National Guideline for Emergency Nutrition Intervention (2022) 4. Health Sector Transformation Plan II (2021) 5. Ethiopia Food based dietary guideline 2022 (2022) 6. National Food and Nutrition Strategy (2021) 7. Seqota Declaration Roadmap for Expansion and Scaleup Phases 2021 – 2030 (2021) 8. National Health Equity Strategic Plan 2020/21-2024/25 (2020) 9. A Proclamation to provide for food and medicine administration (2019) 10. Excise tax proclamation (2019) 11. National strategic action plan for the prevention and control of non-communicable diseases (2018-2025)(2019) 12. Baby food control directive (2018) 13. Children Daycare Guideline (2018) 14. Food and nutrition policy of Ethiopia (2018) 15. Leadership, management and governance; In-service training modules: Facilitators’ Manual (2018) 16. One WaSH National Programme A Multi-Sectoral SWAp: Phase II Program documents (2018) 17. Baby and Mother WASH Implementation Guideline (2017) 18. Comprehensive, Integrated Nutrition Services (2016) 19. Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) 20. Hygiene and Environmental Health Strategy 2016-2020 (2016) 21. National Adolescent And Youth Health Strategy 2016-2020 (2016) 22. National cancer control plan (2016) 23. National guidelines on adolescent, maternal, infant and young child nutrition (2016) 24. National Health Care Quality Strategy 2016-2020 (2016) 25. National health promotion and communication strategy (2016) 26. National Nutrition Programme (2016) 27. Seqota Implementation Plan (2016-2030) (2016) 28. Family Health Guide (2015) 29. Health Sector Transformation Plan (2015) 30. National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) 31. Federal Negarit Gazette: Food, Medicine and Health Care Administration and Control Council of Ministers Regulation No. 299/2013 (2014) 32. Ethiopia Nutrition Advocacy Plan (2013) 33. National Nutrition Programme (2013) 34. One WaSH National Programme (2013) 35. Infant formula, follow up formula and formulas for special nutritional purpose regulatory directive No. 13/2013 (2012) 36. Community-Led Total Sanitation and Hygiene (CLTSH) Facilitators Training Guide (2011) 37. Integrated Refresher training for Health extension workers: ModuleII (CMNCH) Participants Manual (2011) 38. National Health Policy (2011) 39. Health Sector development programme IV 2010/11-2014/15 (2010) 40. National food fortification monitoring and evaluation framework (2021) 41. National food fortification programme plan of action 2017/18-2021/22 (2017) 42. Ethiopian Women Development Strategy (2017) 43. National Social Protection Strategy of Ethiopia (2016) 44. International Development Association Project Appraisal Document on Urban Productive Safety Net Project (2015) 45. National Social Protection Policy (2014) (n=41 documents) Health sector Social protection sector (n=4 documents) 15 5 - APPENDICES TABLE OF CONTENTS Appendix 2. List of included policy and programme documents (continued) Multisectoral (n=6 documents) 75. Ten Year Development Plan 2021-2030 (2021) 76. Ethiopia Humanitarian and Disaster Resilience Plan (2018) 77. Humanitarian Response Plan Ethiopia (2017) 78. National Children Policy (2017) 79. Growth and Transformation Plan II (2015/16-2019/20) Volume I (2016) 80. Growth and Transformation Plan I (2011) 46. National Food and Personal Hygiene Protocol For School Feeding Program (2022) 47. National school feeding strategy (2017) 48. National school water, sanitation and hygiene (SWASH) (2017) 49. School health programme (2017) 50. Children Right Mainstream Guidelines (2015) 51. Emergency School Feeding (2016) 52. Education sector development programme V (15/16 - 2019/20) (2015) 53. Home Grown School Feeding Programme Implementation Manual (2015) 54. National school health and nutrition strategy (2012) Education sector (n=9 documents) 55. National Postharvest Management Strategy 2023-2030 (2023) 56. AGRA’s Five-Year Strategy (2023) 57. Ethiopian Food Systems technical synthesis (2021) 58. Agriculture sector investment prioritization (2019/20 – 2024/25) (2019) 59. Lowlands livelihood resilience project appraisal documenton (2019) 60. Ethiopia national pulses strategy 2019-2024 (2018) 61. Oil Production Companies Food Safety and Quality (2018) 62. Postharvest management strategy in grains in Ethiopia (2018) 63. Agricultural extension strategy of Ethiopia (2017) 64. Cereal manufacturing food safety audit guideline (2017) 65. Food Producer Agencies Pre License Guideline No. 37/2010 (2017) 66. Food Exporter, Import and Distribution Control Directive No. 32/2009 (2016) 67. Food supplement directive No. 31/2016 (2016) 68. National nutrition sensitive agriculture strategy (2016) 69. Food Advertisement Control directive (2015) 70. Agricultural growth programme II (2014) 71. Disaster risk management strategic programme and investment framework (2014) 72. Productive safety net programme phase IV (2014) 73. Pastoral community development project III project appraisal (2013) 74. Ethiopia’s agricultural sector policy and investment framework 2010-2020 (2010) Agriculture and food systems sector (n=20 documents) 16 5 - APPENDICES TABLE OF CONTENTS Counselling on healthy eating, physical activity, weight gain management - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - Ethiopia Food based dietary guideline 2022 (2022) - National Antenatal Care Guideline (2022) - National Food and Nutrition Strategy (2021) - Food and nutrition policy of Ethiopia (2018) - School health Programme (2017) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal infant and young child nutrition (2016), National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - Children Right Mainstream Guidelines (2015) - Family Health Guide (2015) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) - National Nutrition Programme (2011) Antenatal care (8 contacts+) - First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - National Antenatal Care Guideline (2022) - National Children Policy (2017) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal infant and young child nutrition (2016) - National Health Care Quality Strategy 2016-2020 (2016) - National health promotion and communication strategy (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - Family Health Guide (2015) - Health Sector Transformation Plan (2015) - The National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - National Social Protection Policy (2014) - Productive safety net programme phase iv (2014) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) Iron/folic acid supplementation (adolescents and WRA) - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - National Antenatal Care Guideline (2022) - National Food and Nutrition Strategy (2021) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - Family Health Guide (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: ModuleII (CMNCH) Participants Manual (2011) - Health Sector development programme IV 2010/11-2014/15 (2010) Multiple micronutrient supplementation - National Food and Nutrition Strategy (2021) - Seqota Declaration Roadmap for Expansion and Scale up Phases 2021 – 2030 (2021) - Humanitarian Response Plan Ethiopia (2017) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Health Sector Transformation Plan (2015) - National Nutrition Programme (2013) Antihelminthic treatment (in high-risk areas; and where anaemia>40%) - National Antenatal Care Guideline (2022) - National Food and Nutrition Strategy (2021) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - Seqota Implementation Plan (2016-2030) (2016) - National Nutrition Programme (2016) - Family Health Guide (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) Energy/protein supplementation for at risk women - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal infant and young child nutrition (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) Anaemia testing - National Antenatal Care Guideline (2022) - Comprehensive, Integrated Nutrition Services (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) Delayed cord clamping - National Food and Nutrition Strategy (2021) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) Indicators Source of evidence Scale up new WHO antenatal care and maternal nutrition recommendations for all WRA DDA1 Health Higher level of evidence Some level of evidence No/lower level of evidence Appendix 3. Summary of evidence identified for double-duty actions 17 5 - APPENDICES TABLE OF CONTENTS Early initiatiation of breastfeeding, 6 mo exclusive; continued up to 24 mo - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - Ethiopia Food based dietary guideline 2022 (2022) - Seqota Declaration Roadmap for Expansion and Scaleup Phases 2021 – 2030 (2021) - Ethiopia Humanitarian and Disaster Resilience Plan (2018) - Food and nutrition policy of Ethiopia (2018) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Health Care Quality Strategy 2016-2020 (2016) - National health promotion and communication strategy (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - Family Health Guide (2015) - Health Sector Transformation Plan (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - Ethiopia Nutrition Advocacy Plan (2013) - Integrated Refresher training for Health extension workers: ModuleII (CMNCH) Participants Manual (2011) - National Nutrition Programme (2013) - Health Sector development programme IV 2010/11-2014/15 (2010) 10 steps to successful breastfeeding in hospitals - Health Sector Transformation Plan II (2021) - National Food and Nutrition Strategy (2021) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Health Sector Transformation Plan (2015) - Productive safety net programme phase iv (2014) - Ethiopia Nutrition Advocacy Plan (2013) Maternity protection policies including workplace - National Food and Nutrition Strategy (2021) - Children Daycare Guideline (2018) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Ethiopia Nutrition Advocacy Plan (2013) - National Nutrition Programme (2013) Eliminate breastmilk substitutes marketing - Ethiopia Food based dietary guideline 2022 (2022) - National Food and Nutrition Strategy (2021) - Baby food control directive (2018) - Guidelines for The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Food Advertisement Control directive (2015) - Federal Negarit Gazette: Food, Medicine and Health Care Administration and Control Council of Ministers Regulation No. 299/2013 (2014) - Ethiopia Nutrition Advocacy Plan (2013) - National Nutrition Programme (2013) - Infant formula, follow up formula and formulas for special nutritional purpose regulatory directive No. 13/2013 (2012) Vitamin A supplementation (children) - National Guideline for Emergency Nutrition Intervention (2022) - Health Sector Transformation Plan II (2021) - National Food and Nutrition Strategy (2021) - Seqota Declaration Roadmap for Expansion and Scaleup Phases 2021 – 2030 (2021) - Ethiopia Humanitarian and Disaster Resilience Plan (2018) - Comprehensive, Integrated Nutrition Services (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Health Care Quality Strategy 2016-2020 (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - Children Right Mainstream Guidelines (2015) - Family Health Guide (2015) - Health Sector Transformation Plan (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) - Health Sector development programme IV 2010/11-2014/15 (2010) Complementary feeding counselling (incorporation of double duty messages) - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - National guidelines on adolescent, maternal infant and young child nutrition (2016) - National Food and Nutrition Strategy (2021) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Nutrition Programme (2016) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) Indicators Source of evidence Health Health Higher level of evidence Some level of evidence No/lower level of evidence Scale up programmes to protect, promote, and support breastfeeding DDA2 Redesign guidance for complementary feeding practices and related indicators DDA3 Appendix 3. Summary of evidence identified for double-duty actions (continued) 18 5 - APPENDICES TABLE OF CONTENTS Multiple micronutrient powders to prevent anaemia (where anaemia > 20%) - National Food and Nutrition Strategy (2021) - Ethiopia Humanitarian and Disaster Resilience Plan (2018) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - National Nutrition Programme (2013) Nutrition counselling training for primary healthcare workers (incorporation of double duty messages) - National Food and Nutrition Strategy (2021) - Comprehensive, Integrated Nutrition Services (2016) - National Nutrition Programme (2016) - Seqota Implementation Plan (2016-2030) (2016) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) Infant feeding guidelines with recommendations to promote healthy and diverse diets and to avoid consumption of unhealthy foods/ snacks/beverages - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - National Food and Nutrition Strategy (2021) - National guidelines on adolescent, maternal infant and young child nutrition (2016) - National Nutrition Programme (2016) - Family Health Guide (2015) Assess risk for all forms of malnutrition for WRA & U5 - The First 1,000 Days Plus Public Movement for Social and Behavior Change Guideline (2023) - National Antenatal Care Guideline (2022) - Health Sector Transformation Plan II (2021) - National Food and Nutrition Strategy (2021) - Humanitarian Response Plan Ethiopia (2017) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016), - National guidelines on adolescent, maternal, infant and young child nutrition (2016) - National Nutrition Programme (2016), Seqota Implementation Plan (2016-2030) (2016) - Family Health Guide (2015), Health Sector Transformation Plan (2015) - Productive safety net programme phase IV (2014) - National Nutrition Programme (2013), Integrated Refresher training for Health extension workers: Module II (CMNCH) Participants Manual (2011) Manage SAM & MAM in U5 - National Guideline for Emergency Nutrition Intervention (2022) - Health Sector Transformation Plan II (2021) - Seqota Declaration Roadmap for Expansion and Scale up Phases 2021 – 2030 (2021) - National Food and Nutrition Strategy (2021) - Ethiopia Humanitarian and Disaster Resilience Plan (2018) - Humanitarian Response Plan Ethiopia (2017) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Health Care Quality Strategy 2016-2020 (2016) - Children Right Mainstream Guidelines (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015) - Productive safety net programme phase IV (2014) - National Nutrition Programme (2013) - Integrated Refresher training for Health extension workers: ModuleII (CMNCH) Participants Manual (2011) - Health Sector development programme IV 2010/11-2014/15 (2010) Zinc supplementation with ORS for U5 - National Guideline for Emergency Nutrition Intervention (2022) - Health Sector Transformation Plan II (2021) - National Food and Nutrition Strategy (2021) - Seqota Declaration Roadmap for Expansion and Scaleup Phases 2021 – 2030 (2021) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines For The Prevention And Control Of Micronutrient Deficiencies in Ethiopia (2016) - National Nutrition Programme (2016) - National nutrition sensitive agriculture strategy (2016) - Seqota Implementation Plan (2016-2030) (2016) - Family Health Guide (2015) - National Strategy for Newborn and Child Survival in Ethiopia 2015/16-2019/20 (2015), Federal Negarit Gazette: Food, Medicine and Health Care Administration and Control Council of Ministers Regulation No. 299/2013 (2014) - National Social Protection Policy (2014), Health Sector development programme IV 2010/11-2014/15 (2010) Referral for counselling on healthy diets for WRA & U5 (double duty messages) - National Food and Nutrition Strategy (2021) - Humanitarian Response Plan Ethiopia (2017) - Comprehensive , Integrated Nutrition Services (2016) - National Adolescent And Youth Health Strategy 2016-2020 (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) Referral for diet & physical activity counselling for healthy weight postpartum - National Food and Nutrition Strategy (2021) - Comprehensive, Integrated Nutrition Services (2016) - Guidelines for The Prevention and Control of Micronutrient Deficiencies in Ethiopia (2016) - National guidelines on adolescent, maternal, infant and young child nutrition (2016) Indicators Source of evidence Health Health Higher level of evidence Some level of evidence No/lower level of evidence Redesign guidance for complementary feeding practices and related indicators DDA3 (continued) Redesign existing nutrition assessment and management programmes for WRA and children under five (U5) DDA4 Appendix 3. Summary of evidence identified for double-duty actions (continued) 19 5 - APPENDICES TABLE OF CONTENTS Contact details - Dr Rebecca Pradeilles (French National Research Institute for Sustainable Development; International Food Policy Research Institute); Email: [email protected] - Professor Kaleab Baye (Addis Ababa University); Email: kaleab.ba[email protected] - Meron Worku (Addis Ababa University); Email: workumer[email protected] 26 © FreeImages.com/Ncrotty TABLE OF CONTENTS © iStock.com/Hadynyah Deploying research Sharing science Transforming the future Deploying research Sharing science Transforming the future      