Despite recent progress, malnutrition remains a severe problem in Ethiopia, especially among young children. Many of them suffer lifelong consequences in terms of higher risk of mortality and future illness, impaired cognitive ability (including lower IQ) and educational attainment, and overall productivity loss. This report provides the findings from an in-depth data-based analysis of malnutrition in Ethiopia and its causes. It assesses various aspects of current nutrition programming in the country, noting the importance of Ethiopia's first National Nutrition Strategy and National Nutrition Program established in 2008. The report also examines key details including costs and benefits of a range of interventions against malnutrition in the country, including some that are not yet being implemented but could potentially be introduced. The analysis draws on data from household surveys, detailed program data and data from various sources on costs, impacts and potential coverage, among others. The report finds that contrary to what is commonly believed and traditionally used to guide policymaking, a substantial amount of the malnutrition in Ethiopia is due to factors other than food insecurity, pointing to the need for a multi-sectoral approach. Nutrition interventions in general are found to have high benefit-to-cost ratios - sometimes in the double or triple digits - with these ratios being especially high for micronutrient interventions, insecticide-treated bednets, deworming and community-based interventions. Among others, the report recommends the introduction of deworming for pregnant women in Ethiopia - which has the highest benefit-to-cost ratio among the interventions analyzed - and scaling up community-based interventions. These include the Community-Based Nutrition program which shows impressive results in Ethiopia after just over two years of implementation. The report also recommends various ways of improving the effectiveness of nutrition programming including by improving program targeting, enhancing coordination and linkages among programs, and establishing an effective nutrition information and surveillance system.

Ethiopia’s model for delivering basic services appears to be succeeding and to confirm that services improve when service providers are more accountable to citizens. As discussed in the World Development Report 2004, accountability for delivering basic services can take an indirect, long route, in which citizens influence service providers through government, or a more direct, short route between service providers and citizens. When the long, indirect route of accountability is ineffective, service delivery can suffer, especially among poor or marginalized citizens who find it challenging to express their views to policymakers. In Ethiopia, the indirect route of accountability works well precisely because of decentralization. Service providers are strictly accountable to local governments for producing results, but in turn, the local authorities are held accountable by the regional and federal governments. A degree of local competition for power and influence helps to induce local authorities and service provides to remain open to feedback from citizens and take responsibility for results. The direct route of accountability has been reinforced by measures to strengthen financial transparency and accountability (educating citizens on local budgets and publicly providing information on budgets and service delivery goals), social accountability (improving citizens’ opportunities to provide feedback directly to local administrators and service providers), and impartial procedures to redress grievances. Woreda-level (district) spending has been a very effective strategy for Ethiopia to attain its Millennium Development Goals (MDGs). Woreda health and education goes to pay for health extension workers (HEWs) and teachers. This study finds evidence that woreda-level spending in health and education is effective. Owing to the intervention of HEWs, the use of health services has increased, especially among the poorest quintiles. Finally, the effect of woreda-level spending on agricultural extension workers is associated with higher yields for major crops. Spending on agricultural extension workers increases the probability that farmers, regardless of the size of their plots, will use improved farming techniques. Education, health, and agriculture account for 97 percent of woreda spending. This is complemented by support for capacity building and citizen voice. Clearly, spending efficiency is improved through better capacity, more transparency, and greater accountability to citizens.