Profiles in Nutrition: The Seqota Declaration's Dr. Sisay Sinamo Boltena

In a world where stunting affects about one-third of children in low- and middle-income countries, Ethiopia has become one of the success stories.

In 1992, two out of every three children in the East African nation were stunted and the country had one of the highest rates of stunting prevalence in the world at 67%. Over the next quarter century, as the country embarked on sweeping economic and political reforms that improved agriculture, education, health, and water and sanitation, it made steady progress against the condition, reducing its stunting rate by almost half to 38%. Although this rate was still slightly higher than the African regional average of about 34%, Ethiopia’s rate of improvement greatly exceeded that of its neighbors.

In 2015, the Ethiopian government unveiled the Seqota Declaration, a 15-year commitment divided into three five-year phases – Innovation, Expansion, and Scale-Up – to end stunting in children under 2 by 2030.

For the past six years, Dr. Sisay Sinamo Boltena, the Senior Program Manager for the Seqota Declaration Federal Program Delivery Unit – which is in the Ethiopian Ministry of Health and gets support from Nutrition International – has been at the forefront of efforts to make this commitment a reality. As part of a series to mark the Micronutrient Forum Global Conference in The Hague, Exemplars News spoke with Dr. Sisay, who is also the SUN Focal Person at the Nutrition Coordination Office under the Ministry of Health, about the Seqota Declaration program and what lessons Ethiopia has to share with the other countries.

Could you tell us a bit about your own journey? How did you come to focus on nutrition and why is it so important to you?

Dr. Sisay: After graduating medical school, I was assigned to work as a general practitioner in rural Ethiopia. Along with my day-to-day clinical work at the health facility, I started supporting community-based health and nutrition programs as part of a government program with World Vision Ethiopia. That NGO has multiple projects in the southern region called Micronutrient and Health and they helped to conduct a lot of nutritional screenings, nutritional surveys, and nutritional education. They asked us to support them specifically with goiter grading, vitamin A supplementation, Bitot Spot screening, and nutritional education, especially in preschool and school children. That inspired me to go beyond the clinical work I was doing and start my journey in terms of community nutrition and community public health work.

Could you tell us more about the Seqota Declaration and how it has impacted nutrition and stunting in Ethiopia?

Dr. Sisay: The Seqota Declaration is the Ethiopian government's commitment to end stunting among children under 2 years of age by 2030. It was unveiled in 2015 alongside the Financing for Development Conference held that year in Ethiopia. The government developed a three-phased, 15-year roadmap with an Innovation phase, an Expansion phase, and a Scale-up phase.

During the first phase between 2016 and 2020, the program was implemented in 40 woredas (districts) in the Amhara and Tigray regions, which both have very high stunting prevalence rates. During the Innovation phase, 10 local ministries, the government, and development partners conducted multi-sectoral, nutrition-specific, nutrition-sensitive, and nutrition-smart infrastructure interventions. As a result, households benefited in terms of improved access to nutrient-dense foods, access to nutrition information, and improved water, hygiene, and sanitation.

By the end of the Innovation phase in 2020, we did an impact evaluation and found the annual average rate of reduction of stunting was around 3% and that nearly 110,000 children had avoided becoming stunted. Based on these results, the government decided to expand the program from 40 woredas to 240 woredas across the country. We documented the impact in a study with the Ethiopian Public Health Institute and John Hopkins University.

You help lead Seqota’s program delivery – what lessons have you learned about delivering nutrition programs in Ethiopia?

Dr. Sisay: The first learning is that the government's commitment has been critical for the impact achieved during the Innovation phase. In the case of the Seqota Declaration, the government has shown its commitment at the highest levels by providing leadership through performance reviews and even conducting on-site visits. The (federal) government and regional governments also showed their commitments through budgetary allocations.

The second learning is that implementation of high-impact nutrition-sensitive, nutrition-specific interventions need to consider gender, especially engaging women to be active participants in the program. Another learning is to engage a wide range of stakeholders, development partners, and donors – that has been very critical to creating ownership and leveraging resources and maximizing impact. Another is the importance of community empowerment and community ownership – we've done a lot of community mobilization through the First 1,000 Days Plus Public Movement, as well as through what we call Community Labs.

Ethiopia faces a number of humanitarian and civil challenges and traditionally has been very focused on wasting – how have you succeeded at addressing other forms of malnutrition, including stunting?

Dr. Sisay: In the case of the Seqota Declaration, the program is multi-sectoral, which means it addresses both the short-term and long-term impacts of stunting. For instance, health sector interventions include interventions that address wasting. Also, with the Seqota Declaration, when you work on long-term goals like stunting, you end up addressing shorter-term challenges as well. For instance, if you have good water access, if you have access to food, if you have nutritional literacy, and you also empower householders to generate their own income, which will really help to address not only the long-term effects of stunting but also, in the short term, will address the immediate causes of wasting, which are inadequate food intake and diseases.

In your experience, what are some of the best ways to promote optimum nutrition practices at household levels and develop strong community-based nutrition promotion activities?

Dr. Sisay: I think to promote optimum nutrition practices at the household level, developing strategies that are locally relevant and owned by the local communities, the local administrations, and the local governments is critical. That is number one. Number two is using locally available resources to maximize the impact. Strengthening the existing systems and building on the existing systems is very important. For instance, in our case, when we do the woreda-based plans, we engage with the local communities to identify their challenges and develop actions that are priority for them, but that also have a high impact on nutrition. I think having that kind of approach really helps to promote nutrition practices at the household level and develop community-based nutrition with impact.

You’ve also helped deliver nutrition programs in fragile contexts across East Africa – what lessons do you have to share about delivering nutrition programs in these settings?

Dr. Sisay: From my experience working in East Africa in nine countries – a number of them in fragile contexts, as you mentioned – I think the most important thing is looking at existing institutions and structures that could deliver nutrition in those contexts. If you look across East Africa, for instance, the community health system varies from country to country. Some have strong community systems where governments finance everything down to the grassroots level, while others are voluntary community systems. So, understanding the community system is critical to deliver nutrition programs in these contexts. That will help you understand the actions you need to take to build up existing systems using existing opportunities, existing structures, and existing resources.

East Africa is also so diverse in terms of socio-cultural diversity. In this regard, understanding socio-cultural differences is very important in promoting nutrition programs because one nutrition activity that has been promoted in one area might not work well in the other area unless we consider the socio-cultural differences.

The policy landscape is also very critical. Even though overall programming approaches can be replicated, different countries have different policy and strategic interests, and you need to understand those policies and other strategic factors to align nutrition programs to specific country contexts.

Training tens of thousands of Health Extension Workers and improvements in WASH – water, sanitation, and hygiene – have also helped Ethiopia reduce its stunting rate. Could you tell us more about how these have helped people?

Dr. Sisay: WASH is one of the critical underlying factors for nutrition, including stunting, so whatever investments Ethiopia is making in WASH could contribute to addressing the underlying causes of malnutrition, including stunting. The Health Extension Workers' role in promoting hygiene, in promoting sanitation, in promoting good WASH practices, could also contribute to addressing the underlying causes of stunting and other diseases that also predispose them to malnutrition, which would help to address the stunting rate. Specifically in the Ethiopian context, Health Extension Workers have massively mobilized the community to build their own latrines, which has been one of their critical contributions in terms of breaking the cycle of infection and malnutrition.

What lessons do you believe Ethiopia can share with other countries facing undernutrition and stunting?

Dr. Sisay: I think Ethiopia can share a number of things. One of the things is the need for a multi-sectoral food and nutrition strategic plan. Ethiopia can also share the importance of having a national commitment – a multi-year roadmap for ending stunting like the Seqota Declaration.