Early Childhood Development- Investing in the seeds of tomorrow’s fruits

Gillian Mellsop, UNICEF Representative to Ethiopia

‘Children are today’s flowers and tomorrow’s fruit’ is a saying in Ethiopia and there is no better investment that cultivates the fruit and speaks to the ‘right in principle and right in practice’ mantra more than early childhood development.

Parents and communities want the best for their children and understand that the early years of a child’s life are crucial. However, they may not have the means or the knowledge on how to ensure their next generation best thrives.

Last week, the latest offering from the world-renowned Lancet, Advancing Early Childhood Development: from Science to Scale, showed that almost one in two – 43 per cent – of children under five in low-and middle-income countries are at risk of not achieving their cognitive potential. No country can risk losing nearly half of the brain potential of its youngest citizens – low- and middle-income countries least of all.

Advances in neuroscience show that experiences in early childhood have a profound impact on brain development and on subsequent learning and health. Children who are poorly nourished and nurtured, or those who do not receive early stimulation, are likely to learn less in school and go on to earn less as adults.

In Ethiopia, over 5 million children are stunted which has a serious impact on human development and economic growth. And currently, the most disadvantaged children in rural and hard to reach communities are either coming to grade 1 without having the necessary preparation or are enrolling late – under 40 per cent of children in Ethiopia have access to pre-school provision. Once in primary education, many are at risk of dropping out of school too early.

The good news is that early childhood development interventions, including parenting and care programmes, cost as little as 50 cents (US$) per child per year, when combined with existing services such as health – according to the Lancet Series. And much of what needs to be done at the community level can be achieved by mothers and fathers, grandparents, siblings and caregivers.

The findings in the Series underscore the importance of increased global dedication to early childhood development. Earlier this year, World Bank Group President Jim Yong Kim and UNICEF Executive Director Anthony Lake signalled a renewed commitment to prioritizing investments in the youngest children when they announced a new alliance urging global and national leaders to step up and accelerate action and funding for nutrition and early childhood development (ECD) programmes. The Lancet estimates that individuals who suffer a loss of about a quarter of average adult income per year, while countries may forfeit up to as much as two times their current GDP expenditures on health or education. Consequences of inaction impact not only present but future generations.

Drought response in Afar - UK AID
Zebiba Meher feeds her son Ready to Use Therapeutic Food (RUTF) for the past four months. Now the nutritional status of eleven-month-old Bedru has improved from severe to moderate acute malnutrition. He is a much healthier and happier child now. Dubti health center, Afar region, Ethiopia. 25-August-2016 ©UNICEF Ethiopia/2016/Ayene

When children have the opportunity to develop their cognitive capacity, they will pass similar or even better opportunities to their children when they grow up.  Increasing investment in Ethiopia’s young children can break the vicious cycle of intergenerational poverty.

Therefore, prioritizing ECD at the national level is a way for governments to stimulate economic growth. Evidence suggests that every dollar invested in quality ECD programmes brings a return of between US$6 and US$17. Moreover, research by

Nobel Laureate James Heckman found that the rate of return for investments in quality early childhood development for disadvantaged children is 7-10 per cent per annum through better outcomes in education, health, sociability, economic productivity and reduced crime.

This year, the importance of interventions in early childhood was also recognized by the inclusion of an ECD target in the Sustainable Development Goals – indeed, this is the first time ECD has been explicitly included in global development goals. SDG Target 4.2 aims to increase the percentage of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being.

For many children, lack of educational support at home is one of the biggest obstacles to reaching their full potential. In light of differing needs of families, a range of early childhood education services are offered in Ethiopia, including kindergarten, pre-primary class (‘O-class’) and several school readiness programmes. Parenting education programmes are also provided so families can learn about the importance of early nutrition, hygiene, care and stimulation.

The evidence presented this past week, combined with the current momentum globally, speaks for itself. We are well versed in the elements that affect the development of children’s brains – good nourishment, stimulated minds, and protection from violence. It is now vital that we use this growing body of evidence to effect real changes for children, at both the community and policy levels.

Early child development has to be put on the agenda for children’s rights. In Ethiopia, UNICEF, with the support from partners, takes an integrated approach to addressing early childhood development within Ethiopia’s Early Childhood Care Education Policy.

We owe it to our future generations to prioritize and invest in young children. It is our moral, economic, and social imperative to enable all children to reach their full potential.

Nearly 385 million children living in extreme poverty, says joint World Bank Group – UNICEF study

NEW YORK/ADDIS ABABA04 October 2016 – Children are more than twice as likely as adults to live in extreme poverty, according to a new analysis from the World Bank Group and UNICEF. Ending Extreme Poverty: A Focus on Children finds that in 2013 19.5 per cent of children in developing countries were living in households that survived on an average of US$1.90 a day or less per person, compared to just 9.2 per cent of adults.  Globally, almost 385 million children were living in extreme poverty.

Children are disproportionately affected, as they make up around a third of the population studied, but half of the extreme poor. The youngest children are the most at risk – with more than one-fifth of children under the age of five in the developing world living in extremely poor households.

“Children are not only more likely to be living in extreme poverty; the effects of poverty are most damaging to children.  They are the worst off of the worst off – and the youngest children are the worst off of all, because the deprivations they suffer affect the development of their bodies and their minds,” said UNICEF Executive Director Anthony Lake. “It is shocking that half of all children in sub-Saharan Africa and one in five children in developing countries are growing up in extreme poverty.  This not only limits their futures, it drags down their societies.”

The new analysis comes on the heels of the release of the World Bank Group’s new flagship study, Poverty and Shared Prosperity 2016: Taking on Inequality, which found that some 767 million people globally were living on less than $1.90 per day in 2013, half of them under the age of 18. 

“The sheer number of children in extreme poverty points to a real need to invest specifically in the early years—in services such as pre-natal care for pregnant mothers, early childhood development programs, quality schooling, clean water, good sanitation, and universal health care,” said Ana Revenga, Senior Director, Poverty and Equity at the World Bank Group. “Improving these services, and ensuring that today’s children can access quality job opportunities when the time comes, is the only way to break the cycle of intergenerational poverty that is so widespread today.”

The global estimate of extreme child poverty is based on data from 89 countries, representing 83 per cent of the developing world’s population.

Sub-Saharan Africa has both the highest rates of children living in extreme poverty at just under 50 per cent, and the largest share of the world’s extremely poor children, at just over 50 per cent.  South Asia has the second highest share at nearly 36 per cent—with over 30 per cent of extremely poor children living in India alone. More than four out of five children in extreme poverty live in rural areas.   

In addition, the report reveals that even at higher thresholds, poverty also affects children disproportionately.  About 45 per cent of children are living in households subsisting on less than $3.10 a day per person, compared with nearly 27 per cent of adults.

UNICEF and the World Bank Group are calling on governments to:

  • Routinely measure child poverty at the national and subnational level and focus on children in national poverty reduction plans as part of efforts to end extreme poverty by 2030.
  • Strengthen child-sensitive social protection systems, including cash transfer programs that directly help poor families to pay for food, health care, education and other services that protect children from the impact of poverty and improve their chances of breaking the cycle in their own lives.  
  • Prioritize investments in education, health, clean water, sanitation and infrastructure that benefit the poorest children, as well as those that help prevent people from falling back into poverty after setbacks like droughts, disease or economic instability.   
  • Shape policy decisions so that economic growth benefits the poorest children. 
  • UNICEF and the World Bank Group are working with partners to interrupt cycles of poverty and to promote early childhood development – with programs ranging from cash transfers, to nutrition, healthcare and education.

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 Ethiopia specific information:

  • There are 13 million Ethiopian children who live in poor households, 2 million of whom live in extreme poverty.
  • Children are more severely affected by poverty (32.4 per cent) and extreme poverty (5.2 per cent) than adults (29.6 per cent and 4.5 per cent, respectively).
  • The poorest children are found in households whose head is employed in the informal sector. 13.1 per cent of these children live in extreme poverty.

Abducted as a child, returned an adult after 18 years

By Wossen Mulatu

 

GAMBELLA, Ethiopia,  25 May 2016 – Eighteen years after he was kidnapped as a child by raiders, Paul Tok*, 19, came home to his native village of Dima to a warm welcome.

In the long years of his captivity by the Murle tribesmen in neighbouring South Sudan, where he was attached to a local family, forced to learn the language and help raise their cattle and farm their land, he never forgot who he was.

His brother, five years older and taken with him, repeatedly told him that they were different. “We are Anuak, we will never be Murle.”

The Murle have long raided their neighbours for cattle and children. In the last decade, 50 children have been taken from the Anuak parts of Ethiopia in Gambella State in yearly raids.

Those raids, however, sprang to international prominence when the Murle launched a massive cross border operation against 13 Nuer villages in mid-April, killing more than 200 people and carting off 146 children and thousands of cattle.

As the Ethiopian Government works to release these children, the experience of others kidnapped by the Murle has come under renewed scrutiny.

Dawn raid and captivity

Paul Tok, 19, Ongogi Kebele, Jor woreda, Gambella region.
When Paul Tok, 19, returned to his own village in Dima, everyone was filled with joy and there was a big fiesta by the community. ©UNICEF Ethiopia/2016/Mersha

Paul and his older brother were kidnapped in 1997 in a violent attack on their village. His mother fought to keep her sons and was slashed with a knife that left her weak and she died of illness four years later. Her husband followed her into the grave two years afterwards following a prolonged period of depression.

Paul would only find out about his parents death on his return years later. He and his brother were taken to the village of Lelot in South Sudan and attached to a family who already had 10 other children and was put to work.

Paul said he never liked his life with the Murle.

“I didn’t like the food, the language and the fact that we didn’t wear any clothes,” he said. “Since the Murle take pride in having lots of cattle, they gave us a lot of milk. They also gave us blood from the oxen to drink but I never dared to try it.”

“They taught us to hunt wild animals and when we failed, they would tell us we were not man enough and beat us,” he recalled. They were also beaten when they refused to join the deadly cattle raid attacks against the Anuak. ”I never collaborated with them – how could I steal from my community?”

Paul and his brother were allowed to attend school and Paul studied up to 9th grade.

Escape and reunification

When fighting wracked South Sudan as rival tribes battled each other in a civil war during the past few years, Paul decided to join the flow of refugees into Ethiopia and make his way back to Dima.

“I told them my story in Anuak language when I was in the camp. They were so happy and they hid me and gave me food and clothing. My aunt was looking for me tirelessly and she heard about my return and came to take me,” he said with pride.

Though Paul is thrilled to be reunited with his family, he misses his brother who is still in South Sudan. “He is now in 11th grade in Juba and he wants to finish school. We would have come together. I don’t think he will waste a day to return after he finishes school,” Paul said.

Paul is now receiving lots of affection from his own community. Along with his aunt and relatives, he gets support from the woreda (district) including clothing and school materials and has now re-enrolled. He still lives in fear, however, that the Murle will come back and take him away. “They know me as their child and I will be considered a traitor if found,” he said.

There has been a steady increase in cross-border child abduction over the past decade. The civil war in South Sudan and the easy availability of weapons has exacerbated the rate of these abductions both in terms of the numbers of children abducted and adults killed each year.

Deng Chol, 5 years old boy from Nipnip Kebele (sub-district), with his mother
Deng Chol, 5 years old boy from Nipnip Kebele (sub-district), with his mother Nyapuk Kang at a temporary residence of abducted children © UNICEF Ethiopia/2016/Tesfaye

However, after the April 15 attack, the Ethiopian Government made a statement that the Ethiopian forces will follow the Murle armed men into their territories in South Sudan to rescue the abducted children.

UNICEF is working in close collaboration with the Government of Ethiopia and partners on a response plan which includes reintegration, psychological support, basic health care and nutrition services as well as providing items such as tents for their accommodation and clothing for each child.

UNICEF has called for the children’s swift and unconditional return.

“I hope they will stop abducting our children,” says Okew Owar, head of the Jor Woreda. “For the Murle, the more children they steal from us, the richer and powerful they become since children are sold and exchanged for cattle.”

After the reunification with his community, Paul wants to improve his Anuak since he has forgotten some words apart from what his brother taught him when they were children. He can now speak the Murle language fluently as well as a little Arabic.

“I would like to become a teacher and teach my community,” he said.

 

*Name of subject has been changed to protect privacy

 

Return, recovery and reunification of the abducted children in Gambella

By Wossen Mulatu

Nyatayin Both, 25, Kuanyluaalthoan kebele, Lare woreda, Gambella Region.
25-year-old Nyatayin with her one year old daughter Nyakoch Gatdet at a temporary shelter for returned children in Gambella. ©UNICEF Ethiopia/2016/Mersha

GAMBELLA, Ethiopia, 25 May 2016 – When the attack on the village came, 25-year-old Nyatayin Both held tightly to two of her children, but the raiders still managed to kidnap the two others amidst the panic and commotion.

“I wish I’d had four hands to hold them and save all of my four children,” she recalled, describing the horrific day in mid-April in Ethiopia’s Gambella region when she lost her 9-year-old daughter and 4-year-old son.

In a raid of unprecedented scale, some 200 people were killed and 146 children were taken by raiders from neighboring South Sudan, widely described as Murle tribesmen. The Ethiopian military and the local Gambella Government have been negotiating for their slow release ever since.

For Nyatayin, it meant a miracle to see the return of her 9-year-old daughter Nyamuoch.

“At first it was just rumors that some of the children had returned, but later we were told by local officials to come and identify our children,” she said. “I was hoping to see mine, when I spotted my daughter among the many children standing in a circle, I was thrilled and praised the Lord and thanked the government for taking action.”

It was a joy tempered by the fact that her other son was still out there and of course the death of so many relatives that day, including her husband. So far 91 children have been recovered.

UNICEF is working closely with the Government of Ethiopia and partners on a response plan which includes reintegration, psychological support, basic health care and nutrition services as well as providing tents and clothing for each child.

Currently, the children are being cared for at a two-storey guest house of the Gambella Regional Government, where Sarah Nyauony Deng is supervising their care.

“When they arrive here, most of them were so silent and isolated themselves, but after some time, they start to socialize with others, play together and become cheerful,” she said. “Most of them also have injuries on their legs from the long walks.”

Nyamuoch Gatdet, 9 years, 1st grade student, Kuanyluaalthoan kebele, Lare woreda, Gambella region.
Nyamuoch Gatdet, 9 years, was one of the 146 children who were abducted from their communities in the Gambella Region ©UNICEF Ethiopia/2016/Mersha

Flashbacks from the forest
Nyamuoch recalls that terrible day she was taken from her village that began at dawn with the sound of shots.

“I was still asleep and suddenly I heard gunfire and ran out of the house. I was filled with fear and anxiety,” she said. “I started running along with many other children and adults but they caught most of us and took us to a forest. Where I was, most of the abducted children were strangers except a boy I recognized from my village.”

Nyamuoch said they were constantly talking to them but none of the children understood a word. “I think they were trying to teach us their language,” she said. “I am so happy to be back to my family. My mother and I cried for a long time with happiness and now she is with me again, I am not scared anymore.”

Reintegration

Working with the president’s office and the Bureau of Women and Children Affairs, UNICEF has drawn upon a detailed action plan for child protection, including identification, documentation, psycho-social first aid and family assessments to facilitate appropriate rehabilitation services during reunification of the children.

Children in Gambella at the Presidential Guest House
Children in Gambella Presidential Guest House after their recovery from abduction ©UNICEF Ethiopia/2016/Tesfaye

“Currently, we are doing a needs assessment to mobilize resources for the abducted children and their families. Some of the children have lost one or both parents, some their cattle and some their huts as it was burned by the Murle,” said Ocher Ocher Obang of the Bureau of Women and Children’s Affairs in Gambella.

In addition, many in the affected communities are afraid to return to their remote villages for fear of renewed attacks by the Murle.

With the return of the rains, the displaced families need land to till, shelter to live in, as well as additional clothing and health care.

As the Ethiopian and South Sudanese governments strengthen their efforts to recover the remaining abducted children, UNICEF calls for the children’s swift and unconditional return to their families.

“I thought they would lock us in the forest forever,” said Nyamuoch. “When I grow up, I only want to do good things for humanity by becoming a teacher or a doctor – I will never forget this incident.”

 

Sweden responds to El Niño-driven drought in Ethiopia

The Government avails US$ 5.7 million to UNICEF’s drought response activities

Inauguration of new UNICEF warehouse
New cartons of Ready-to-Use Therapeutic Food (RUTF) arrives at a UNICEF warehouse

ADDIS ABABA, 22 June 2016 -The Government of Sweden contributes US$ 5.7 million to UNICEF to save children’s lives and protect children affected by El Niño-driven drought in Ethiopia. This is the single largest crisis contribution of Sweden to UNICEF globally this year. In addition to the grant provided through UNICEF Ethiopia, Sweden has provided US$25 million to the drought response in Ethiopia since September 2015.

The Swedish support comes at a critical time when Ethiopia is currently facing the worst drought in decades leaving 10.2 million people, including 6 million children, in need of emergency assistance. It also created critical water shortages in Somali, Afar, parts of SNNP, eastern Oromia, Amhara and Tigray regions.  Poor sanitation and hygiene conditions, resulting from water shortage, are also contributing to an increase in disease outbreaks. 

In addition, the number of severely malnourished children who need therapeutic feeding treatment continues to increase. UNICEF, together with the Government of Ethiopia and humanitarian partners, is stepping up efforts to address the needs of 458,000 children under five with Severe Acute Malnutrition and 2.5 million children, pregnant and lactating women with Moderate Acute Malnutrition.[1]

“Sweden has been a strong humanitarian and development partner to Ethiopia over the years. We are very committed to support the country in the struggle to combat and prevent the effects of the worst drought Ethiopia has seen in over 50 years,” said H.E. Jan Sadek, Ambassador of Sweden to Ethiopia. “Sweden is determined to continue to work for a deeper integration between humanitarian relief and long term development objectives. The partners in Ethiopia have come quite far in this integration but more needs to be done. We believe that in this regard, UNICEF, which has a mandate in both ‘spheres’, is playing a key role.”

Together with other donors, Sweden’s support enabled UNICEF to make the largest global purchase of Therapeutic Food for children in drought-stricken Ethiopia. With this new funding, UNICEF will work towards improving the capacity of health extension workers on Severe Acute Malnutrition management.

In addition, new stabilization centres will be established in existing health centres to cater to the increasing number of children with severe acute malnutrition.  The contribution will also strengthen Mobile Health and Nutrition Teams which provide lifesaving primary health care, nutrition, hygiene and sanitation promotion services in hard hit drought areas of the Afar and Somali regions. Furthermore, water will be provided to primary schools for drinking as well as for routine handwashing in the Oromia Region.

“UNICEF appreciates the Government of Sweden’s generous contribution of life saving interventions for children and their families whose lives have been affected by the El-Niño driven drought emergency,” said Ms Gillian Mellsop, UNICEF Representative to Ethiopia. “UNICEF, together with the Government of Ethiopia and partners, continues to play an important role in scaling up its interventions in terms of nutrition, health, water sanitation and hygiene, child protection and education to mitigate the worst impact of this crisis.”

 

Baby WASH – the missing piece of the puzzle? 

By Samuel Godfrey

Mustapha and his one year old daughter Meia-Teza Wota Health Center Clinic
Mustapha and his one year old daughter Meia at Teza Wota Health Center ©UNICEF Ethiopia/2012/Getachew

The January 2016 Huffington Post article entitled Why are Indian kids smaller than Africa kids: hint its not race authored by Sanjay Wikesekera, UNICEF Global WASH Chief and Werner Shultink, UNICEF Global  Nutrition Chief, highlighted the link between child stunting[1] and lack of access to toilets. Children growing up in an environment where people are defecating in the open will result in kids crawling around on dirty floors, putting feacally contaminated material and objects in their mouths and ultimately will results in children having high rates of diarrhea which will result in their stunted physical and mental development.

To understand this better, UNICEF Ethiopia WASH team and John Hopkins University undertook a systematic review of more than 1000 peer reviewed academic articles with the aim of identifying interventions that health and WASH professionals can take or promote to reduce the contact of children with feacally contaminated material. The review identified strong evidence on the linkage between open defecation, stunting and early child development (See figure below from Ngure et al (2014).

Picture1

The review also notes good knowledge of how to do hygiene and sanitation promotion to safe disposal of adult feaces but limited evidence on safe disposal of baby feaces.

UNICEF Ethiopia is using the review to design specific Baby WASH interventions that can complement our current Infant Young Child Feeding programmes. Ethiopia has substantially reduced Open Defecation during the last 25 years. In 1990, an estimated 9 out of 10 people were “pooing” in the open and by 2015, this had reduced by 64 per cent to less than 1 in 3 people. However, despite this progress, almost half of children were recorded as ‘stunted’ or not achieving their full physical and mental growth by 2015. The literature suggests that Baby WASH, as we have termed it, may be one of the key “missing pieces” in reducing stunting. Baby WASH comprises of a ‘menu’ of physical and promotions activities which will reduce the exposure of the BABY to ingestion of feaces and ultimately reduce stunting and improve Early Childhood Development.

Watch this space for more details on field evidence on Baby WASH from UNICEF Ethiopia as we work closely with the Government of Ethiopia and development partners to expand this intervention throughout Ethiopia in our new Country Programme of Cooperation between 2016 and 2020. For the time being, UNICEF Ethiopia is using its own financial core resources. Interested development partners are welcome to join this groundbreaking initiative.

UNICEF Ethiopia is collaborating with the US based Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Global Disease Epidemiology and Control. A researcher from the school was an intern in the UNICEF Ethiopia WASH section in 2015 and has collaborated with the WASH section on producing a paper entitled Evidence on Interventions Targeted at Reducing Unsafe Disposal of Child Feaces: A Systematic Review.

UNICEF Ethiopia’s rural wash activities are supported by the UK Department for International Development (DFID), the Government of Netherlands, the Government of Canada and the UNICEF National Committees from Germany, UK and New Zealand.

Dr. Samuel Godfrey is Chief of WASH for UNICEF Ethiopia, and has a PhD and MSc in Civil Engineering and Water and Waste Engineering.

[1] Stunting is a sign of ‘shortness’ and develops over a long period of time. In children and adults, it is measured through the height-for-age nutritional index. In Ethiopia approximately 40 per cent of children are stunted.

EU gives €3 million to improve the nutritional status of children in Ethiopia

Funds to reach over one million beneficiaries in Ethiopia 

Asmera Bere feeds her son, Amanuel Shibabaw, feeds to her child a nutritious porridge made from locally available products, at the health post as a demonstration to cook at home
Asmera Bere feeds her son, Amanuel Shibabaw, a nutritious porridge made from locally available products, at the health post as a demonstration to cook at home ©UNICEF Ethiopia/2014/Sewunet

ADDIS ABABA, 21 March 2016 – The European Commission today announced a €3 million grant to UNICEF to improve the nutrition for severely malnourished children in the drought affected areas in Ethiopia. 

The EU funding aims to strengthen the current emergency response and reach an estimated 40,000 Severe Acute Malnutrition (SAM) children. It will help provide supplies (40,000 boxes of Ready-to-use Therapeutic Food (RUTF) and 19,700 packs of amoxicillin). The funds will also support one round of Extended Outreach Strategy (EOS) screening which provides biannual vitamin A supplementation and de-worming to children under 5 years of age. Screening for acute malnutrition for children and pregnant and lactating women will also be covered.

“The El Niño phenomenon is impacting entire regions in Africa, notably Ethiopia. The EU support will help UNICEF provide life-saving assistance to the most vulnerable. It will help more than a million children suffering from malnutrition get treatment,” said Jean-Louis De Brouwer, Director of Operations in the European Commission’s Humanitarian and Civil Protection department (ECHO).

“We are grateful to the EU for its continued support for life saving interventions addressing malnutrition in Ethiopia,” said UNICEF Representative to Ethiopia, Ms Gillian Mellsop. “Children are always the most vulnerable group in emergencies but when support is made available, we can change their lives for the better.”

The EU funding targets close to half a million children under the age of five along with nearly 140 000 pregnant and lactating women in the Somali region. UNICEF, at the request of the Government, is responsible for the procurement of supplies for Severe Acute Malnutrition (SAM) management as a key input to the emergency nutrition responses throughout the country. It also provides technical and financial support to ensure programme quality and coverage. 

UNICEF is supporting the Government in responding to the emergency by scaling up and strengthening the treatment of children with severe acute malnutrition, increasing the intensity and frequency of screening of children and pregnant and lactating women, and ensuring key preventative nutrition services are provided to prevent excess morbidity and mortality.

According to the revised Humanitarian Requirement Document (HRD), over 10.2 million people in need of food aid and estimated 435,000 in need of treatment for severe acute malnutrition by the end of 2016. This has significantly devastated livelihoods and greatly compromised the health and wellbeing of children and women, through malnutrition and hygiene-related diseases across Ethiopia with six regions hit particularly hard.