The document summarizes two studies conducted in Ethiopia using the Link NCA methodology to understand the causal pathways of undernutrition. The studies were conducted in 2014 in East Harargue zone and Sidama zone. In East Harargue, acute malnutrition (GAM) was found to be 12% among boys aged 6-17 months. Main risk factors identified included poor access to health services, water and sanitation, inadequate infant and young child feeding practices, and food insecurity. In Sidama zone, GAM was 5.6% among boys aged 18-29 months. Main risk factors there were also found to be preventable childhood illnesses, poor access to health services and water, inadequate feeding practices, and poverty.

1. Nutrition Causal Analysis in Ethiopia - The cases of
East Harargue and Sidama
ACF developed the Link NCA methodology to better
understand the causal pathways of undernutrition. In
2014, ACF conducted 2 NCAs in East Harargue (Fedis
and Kersa woredas) and in Sidama (Aleta Wondo and
Aleta Chuko woreda).
• In East Harargue zone (Misraq woreda), bi-annual
nutrition surveys (ENCU data) show little changes in
GAM (11% in Midhaga Tola in 2013) and SAM (0,5%)
rates. In the livelihood zones here-considered in Kersa
and Fedis woredas, the main source of income is
agriculture especially khat) and staple food purchase is
significant.
• Sidama zone, in SNNP Region of Ethiopia, is marked
by the paradox of the so called “green hunger”, and is
chronically affected by food insecurity despite fertile
lands, extended rains and a good diversity of crops
(inset, maize, barley, vegetable, etc.).
In both zones, the Link NCA studies took into account a
homogenous population (with different vulnerable
groups selected) sharing similar livelihood zones, to
extrapolate results and compare similar underling
causes. Indeed, in a local context - causes of under-
nutrition are often different from one location to
another. The purpose of the methodology is to go
beyond generic interventions by identifying really
context specific causes in order to propose adequate
solutions.
Main Objective: to identify main causes of child under-
nutrition, in particular wasting of children age 6-59
months in East Hararghe and Sidama
Among the Specific Objectives
• Estimate the prevalence and severity of wasting,
stunting and underweight among children age 6-59
months in the selected livelihood zones
• Estimate the prevalence of known risk factors for
under-nutrition among the population and key ‘nutrition
vulnerable groups’
• Understand how the community prioritizes risk factors
according to: a) which factors are believed to cause
under-nutrition, b) which causes are believed to be most
prevalent, c) which causes are believed to have the most
serious effects
• Identify seasonal and historical trends
• Determine which causal pathways of malnourishment
are likely to explain most under-nutrition cases
These studies were highly supported by the National Early
Warning Response Core Work Process, Regional Health Bureaus,
Health Research and Technology Transfer Support Core Work
Process, Regional Health Bureau Disease Prevention and Control
Core Work Process, Regional, Zonal and Woreda Health
Authority, Regional, Zonal and Agriculture Authority, Sidama
Zone Water, Mines and Energy Department, Regional / zonal
and woredas DPPO. In addition, technical experts from Hawassa
University, and NGO partners including UNICEF, WFP, World
Vision, CRS, IMC, Goal Ethiopia, Plan International, RIPPLE,
and People in Need, provided key inputs through the NCA
preliminary and final workshops. DRMFSS and ENCU were
supporting the full process of the NCA.
Background
• ACF Link NCA methodology – http://linknca.org
• ACF Nutrition security policy
• NCA Final Report – East Harargue zone, Fedis and Kersa
woredas, June 2014
• Nutrition Causal Analysis, Aleta Chuko and Aleta Wondo
Woredas, Sidama Zone, SNNPR, Ethiopia ; Final Report
Resources to Learn More
Aurelie Carmeille, dcdp@et.missions-acf.org,
Deputy Country Director, ACF Ethiopia.
Marie Sardier, msardier@actioncontrelafaim.org,
Link NCA project coordinator, ACF France
Contact Information
Methodology of the Link NCA
Figure Title Findings
East Harargue :
• GAM (w for h z-score) = 12% (95% C.I:8.9 - 16.1%); SAM
= 1.3% (95% C.I: 0.5 - 3.2%)
• Boy (6-17 months old) more at risk of malnutrition
Main risk factors
Sidama :
• GAM = 5.6% (95%CI: 3.5 – 8.9%), SAM = 0.6% (95% CI:
0.0 - 1.9%)
• Boy (18-29 months old) more at risk of malnutrition
Main risk factors :
• High rates of preventable infections and childhood illness in U5,
• Poor health service access and utilisation,
• lack of access to safe water supply,
• Poor hygiene practices,
• Poor utilisation of improved sanitation facilities,
• Poor nutritional status of pregnant and lactating mothers,
• Low status of Women,
• Inadequate complementary feeding practices for children age 6-23
months, & sub optimal breastfeeding practices of children age 0-6
months, chronic poverty
• The outcomes of the Link NCA aims at supporting
stakeholders for better addressing the immediate and
underlying causes of malnutrition  significance of
engagement of authorities  still needs follow-up and
response analysis and implementation
• Ranking risk factors does not bring a ready to use formula
for addressing malnutrition, as factors are various, but
provides orientations on how to prioritize them
• Malnutrition prevention encompasses several factors and
therefore requires a multi-sectoral response
• Plan of Action based on the Link NCA findings is a key
way forward ; ACF (jointly with partners in East Harargue
case) is developing strategy based on Link NCA
recommendations
• ACF is planning to conduct other Link NCAs in its area of
intervention in 2015 and 2016 (in Borena and WagHimra
zones)
Lessons Learned/ Conclusion/ Way forward
Jennifer Holden, Yibeltal Jembru, Carine Magen, Merce Herrero
The SMART survey report, part of the Link NCA study, has
been revised and approved by DRMFSS/Federal ENCU, and
ACF would like to appreciate their collaboration and
feedback.
Acknowledgements
Data from Kersa and Fedis, East Hararghe
A Link NCA is a structured, participatory, holistic, multi-
sectoral study, based on the UNICEF causal framework,
which aims to build a case for nutrition causality in a local
context.
The study is cross-sectional with the following major steps:
Results from Aleta Chucko & Aleta Wondo, Sidama
« We call it ‘hanqina nyaataa’ which means
lack of adequate food. The child becomes
edematous and has a lack of interest to eat
food, including eggs and milk ». Mother of
MN child
« It is true that mothers have a high work load. We
leave our children behind at home and let other
children who are even young to take care of the small
ones. Some might go out to trade khat leaving behind
infants as small as 1 month. During ou mothers’ time,
they didn’t leave their children behind at home but
now everything is getting difficult and we are getting
poor compared to previous times ». Mothers
H 1 – Care givers
work load
84,4% if care takers are mothers only
2,28 hrs/day = average time spent with child by care takers
H 2 – Short birth
spacing
2,35 years is the average age difference between children
(attempts for next pregnancy less than 24 months)
H 3 – Feeding
habits
Anorexia of pregnant women
60,3% children only given colostrum
Father’s pre-emptive right to choose and eat first – food
passes from the oldest to the youngest
H 7 – low use of
health services
Only 40,3% know of availability of OTP and SC
Traditional medicine: uvulectomy; burns on the chest, bell,
lower back; extraction of bad tooth; more rarely ‘hudurof ’
H 12 – Envn.
sanitation pbs
21% have a toilet + 10,3% boil water before drinking
Main source of water is pond water
H 14 – pbs w/
food quality &
quantity
58,5% report not having enough food
32,6% report events of no food to eat
Very low diversity (Vegetables, fruits and meat available only
for between 25 and 26%)
H 15 – Khat
consumption
Extension of khat production to the detriment of food
production
Use of khat cause loss of appetite
Sale of khat on the market = women – takes several hrs/day