Access to basic services such as water and sanitation is limited and its distribution is biased towards urban areas. Thirty percent of Ethiopians (80.5% urban and 21.5% rural) have access to improved sanitation, while access to clean drinking water is slightly higher at 35 percent (90% urban and 25% rural). Sixty four percent of the adult population is illiterate; with higher rate of illiteracy among women than men.
The overall current contraceptives prevalence rate among married women in Ethiopia is 14.7%, and among all women of reproductive age group is 10.3%. Thirty four percent of currently married women of reproductive age group have an unmet need for family planning (WHO, 2010). Family planning (FP) services are delivered through facility-based reproductive health (RH) services including government health facilities and health services run by NGOs and private for profit organizations including pharmacies selling socially marketed pills, condoms and Depo-Provera; and by community based reproductive health (CBRH) agents supported by a variety of international and national NGOs.
Family planning services can significantly contribute to limiting the family size efforts. Strengthening contraceptive services has been shown to be effective in reducing maternal mortality. Specifically there is a role for increased access to long term and permanent contraceptive methods. Although 60% of the methods used in Ethiopia are injectables, 32% of users of injectables discontinue in the first year of use, usually because of health concerns or other issues with the method. Also 42% of women want to limit childbearing, thus they are potential clients for LTPMs. Efforts are needed to increase access to LTPM for women who do not want any more children (DHS, 2005).
The Ethiopian government has been undertaking various policy reform measures and making substantial progresses towards achieving the millennium development goals. Improved policy environment and shift in government priorities towards the social sector have significantly improved access to and quality of health services. Potential health service coverage has increased from 45% in 1997 to 90 percent in 2010 (FMOH, 2010). The health policy gives primary focus on preventive and promotive health care to address the major health problems and to provide access to health services for the majority of Ethiopians. In this regard, the health service extension program (HEP) is the biggest venture of the government and flagship program of the ministry by which two female health extension workers who are government paid are being assigned at kebele level ( the lowest administrative level with 5000 population). The government has been engaged into improving health service delivery through enhancing coverage, quality and equity aiming at improving the overall health status of citizens. The various studies and routine information sources showed that the health outcomes are exhibiting encouraging results in terms of reducing child and maternal mortality.
Increasingly, the government of Ethiopia is giving greater attention to address the issue of rapid population growth and associated demographic factors in designing and implementing different development strategies, and has recognised the rapid population growth and high fertility rate as one of the main challenges to poverty reduction. different strategic documents were formulated and being implemented like “accelerated and sustained development to end poverty” (PASDEP), which includes reducing the total fertility rate (TFR) and closing the gap between boys and girls education and also the “health sector development program”.
Overview of the health sector
Health status and access
The government with continues support and collaboration from the development partners as well as the effort of the general public on its health has achieved a lot towards improving the health status of its citizens. However the health status of Ethiopians still remains low compared to worldwide benchmarks. In 2010, life expectancy was 58 years, maternal mortality ratio was 673 per 100, 000 live births, infant mortality rate was 69 per 1000 live births and the under-five mortality rate was 109 per 1000 live births (WHO, 2010). Ethiopia’s health problems are largely attributed to preventable infections ailments and nutritional deficiencies (FMOH, 2010).
Health Service delivery
The public sector is the major health service provider for Ethiopians. As a result of significant decentralization reforms, Ethiopia’s federal structure is comprised of nine regional states and two city administrations, each responsible for managing its own public health sector services. To promote decentralization and meaningful participation of the population in local development activities, decision making process in the development and implementation of the health system are shared between the federal ministry of health (FMOH) (policy guidance), the regional health bureau (RHB) policy and technical support, and the woreda or district health services (coordination of primary health care services).
In order to realize the goals of the health sector strategic plan, the health service delivery was introduced in a four-tier referral system, characterised by a first line primary health care unit (PHCU), comprised of one health centre and five satellite health posts, and then the second line district hospital and specialised hospital. A PHCU is designed to serve 25, 000 people, while a district and a zonal hospital are each expected to serve 250, 000 and 1, 000, 000 people respectively.
The public sector remains the major provider of health services accounting for about 67% of total health services, followed by the private sector which provides 31% of the services, and facilities owned by business enterprises accounts for the remaining 2%. The increasing number of private for profit health sector and not-for-profit, offers an opportunity to enhance health service coverage (FMOH, 2010).
The policy framework
Global reproductive health policy context
In 1994 the world came together to create a consensus on what had previously been a deeply divisive issue: the relationship between population growth and other areas of development and was considered a groundbreaking effort for shifting population policy discussions away from simply slowing population growth to enhancing individual health and rights while focusing on social development (ICPD 1994). Since then remarkable achievements has been registered. To move the sexual and reproductive agenda forward, progressive international and regional instruments has been developed among which the most important one include the 1995 Beijing declaration and platform of action, the 2004 ICPD ten review, the 2006 Maputo plan of action on sexual and reproductive health and rights (AU, 2006), and the 2009 UN convection for elimination of all form of discrimination against women. The 2000 millennium summit adopted the United Nations millennium declaration committing their nations to a new global partnership to reduce extreme poverty and setting out a serious of time bound targets with a deadline of 2015-the millennium development goals. To achieve this, UN organizations, governments, associations, private foundations, and other non governmental organizations expressed their commitments (Farina et al. 2008).
National Health policy
The health policy of the country was formulated in 1993 after careful assessment of the nature, magnitude and root causes of the existing health problem of Ethiopia and awareness of newly emerging health problems. Democratization and decentralization of the existing health service system were emphasised stressing on development and prioritization of the preventive and promotive components of health care, development of an equitable and acceptable standard of health service system that will reach all segments of the population maximizing the effective and efficient utilization of existing internal and external resources, promoting and strengthening of multi-sectoral and intersectoral activities, promotion of attitudes and practices conducive to the strengthening of health system development, ascertaining the accessibility of health care for all segments of the population, enriching the concept and intensifying the practice of family planning for optimal family health and planned population dynamics, and intensifying family planning for the optimal health of the mother, child and family (TGE, 1993).
National Population policy (1993)
This major goal of the policy is harmonization of the rate of population growth and the capacity of the country for the development and rational utilization of natural resources thereby creating conditions conducive to the improvement of the level of welfare of the population. The general objective of the policy include: “closing the gap between high population growth and low economic productivity through planned reduction of population growth and increasing economic returns; expediting economic and social development process through holistic integrated development programmes designed to expedite the structural differentiation of the economy and employment; reducing the rate to urban migration; maintaining/improving the carrying capacity of the environment by taking appropriate environmental protection/conservation measures; raising the economic and social status of women by freeing them from the restrictions and drudgeries of traditional life and making it possible for them to participate productively in the larger community; and significantly improving the social and economic status of vulnerable groups (women, youth, children and the elderly)”. The specific objectives include: “reducing the total fertility rate to 4.0 children per women by the year 2015; reducing maternal, infant and child morbidity and mortality rates as well as promoting the level of general welfare of the population; significantly increasing female participation at all levels of the education system; removing all legal customary practices militating against the full enjoyment of economic and social rights by women including the full enjoyment of property rights and access to gainful employment; ensuring spatially balanced population distribution patterns with a view to maintaining environmental productivity in agriculture and introducing off-farm non agricultural activities for the purpose of employment diversification; and mounting an effective country wide population information and education program addressing issues pertaining to family size and its relationship with human welfare and environmental security”.
Some of the major areas requiring priority attentions were “improving the quality and scope of service delivery: expanding the diversity and coverage of family planning service delivery through clinical and community based outreach services; encouraging and supporting the participation of non-governmental organizations in the delivery of population and family planning and related services; and creating conditions that will permit users the widest possible choice of contraceptives by diversifying the method mix available in the country” (TGE, 1993).
Health sector development plan
Ethiopia has been health sector development (HSDP) plan since 1997, every five years it has been evaluated and revised until now. The current HSDP IV is the extension of the previous plans and aims to improve the health status of Ethiopians people through provision of adequate and optimum quality promotive, preventive, basic curative and rehabilitative health services to all segments of the population. The major goals include improving the health of mothers and children by reducing maternal mortality ratio, reducing child mortality rate and reduction of total fertility rate. (FMOH, HSDP III, 2005).
National reproductive health strategy, 2006-2015
The national reproductive health strategy was developed in 2006 after comprehensive consultation process with all relevant stakeholders’ including various government agencies, at federal and regional level, local and international partners, and community representatives. The strategy reaffirms the commitment of the government by setting forth a targeted and measurable agenda for the coming decade. It builds upon notable initiatives undertaken like the population policy, followed by the formulation of comprehensive health sector development program (HSDP) in 1998 and the recent health extension program and the current plan for accelerated and sustainable development to end poverty which gives priority to reproductive health and family planning. The goal of the strategy is built on the momentum occasioned by the millennium development goals to garner the multicultural support needed to support the reproductive and sexual health needs of the culturally diverse population (FMOH, 2006).
Adolescent and youth reproductive health strategy (AYRH)
In Ethiopia people less than 15 year age group constitute about 40 percent of the general population. Most of these adolescents are less informed, less experienced and less comfortable to seek access for sexual and reproductive health information and services. Access of reproductive health care information and services targeted for young people contributes to prevent and improve many of their reproductive health problems. To address this issue Ethiopia has launched a national strategy on adolescent and reproductive health that aims “to tackle the problems of early marriages and pregnancies, female circumcision, abduction and rape, and poor access to health care” for 10 to 24 year olds that will be implemented for eight years (FMOH, 2007).
The health extension program
Health Extension Program Packages
Maternal and child health
Adolescent RH health
Disease prevention and control
TB prevention and control
Malaria prevention and control
Hygiene and Environmental health
Solid and liquid waste management
Water supply and safety measures
Food hygiene and safety measures
Healthy home environment
Control of insects and rodents
Health Education and communication
In order to expand health service coverage and improve the delivery of primary health care services to the rural population, the government has introduced an innovative health service delivery system through the implementation of the health extension program (HEP) as part of the 2002-2005 health sector development program II. The HEP moves services out of facilities to the household and village level, and involves 16 packages to be provided at grass roots level focusing on sustained prevention actions and increased awareness. Accelerated expansion of primary health services coverage has also been endorsed as part of facilitating the implementation of the HEP.
The HEP empowers communities to collaborate with the government health sector at the kebele level (the lowest administrate level in a woreda [district]), to identify health problems and root causes, seek solutions, set priorities and formulate local plans of action at the grass roots level.
The HEP consists of promotive and preventive health care services made accessible to all rural kebeles at a kebele health post, the lowest level of the FMOH’s health system. The program includes a cadre of health extension workers (HEW), with each health post staffed by two female health extension workers. Each health post serves a catchment area of approximately 5, 000 people and refers clients to the health centre.
The health extension workers have completed schooling to grade ten or higher and originally come from the communities in which they work and live. Recruiting HEWs from their community ensures a more rapid acceptance of the HEW: she speaks the local language, is respected by the community and in turn respects the local traditions and culture of the community. All HEWs receive training in the essential health promotive and preventive health care services that make up 16 health care packages identified in the HSDP.
HEWs work closely with and supervise the efforts of volunteer community health workers (VCHWs), including community based reproductive health agents (CBRHAs) and community health promoters. VCHWs conduct house to house visits to provide information on family planning, exclusive breast feeding, nutrition and immunization, and refer individuals to the health post. This coordination between the HEWs and VCHWs maximizes the opportunity to obtain the desired outcomes of the HEP, as well as of the HSDP and the millennium development goals (FMOH, 2003).
The World Bank (WBG 2004) has benchmarked a population growth rate of 2 percent per year as a level beyond which it is difficult for a countries institutions and technologies to keep up with expanding population pressures on all sectors, from water, sanitation, and agriculture to health, housing, and education. Ethiopia adds 2 million people every year, and it is the pace and imbalanced distribution of this population growth, rather than the ultimate size of the population, that most give rise to concerns. These concerns are aggravated by degradation of the environment and natural resources, increased climate variability, and market vulnerability. With 83% rural population, population growth in the rural areas adds to the growing number of rural residents who are land-short and landless. In 2009, 4.9 million beneficiaries were identified as requiring emergency food and non food assistance; another 7.5 million with chronic food insecurity receive assistance (DMFSS/MoARD, 2009).
The population trends reported in the nationally representative National NFFS (1990) and Demographic and Health Surveys (DHS) 2000 and 2005 reveal a dynamic society in the early stages of demographic transitions, in which mortality has fallen but fertility remains high (DHS, 2005). With the present imbalance in births and deaths, Ethiopia’s population could double in size in less than 30 years.
Figure 1, Population Growth in Ethiopia, 1990 to 2020, Past, Present & Future
When there are more working-age adults relative to children under age 15 and the elderly, those in the working ages (generally ages 15-59) have a lower “dependency burden”- fewer people to support with the same income and assets. Under the right conditions, this can lead to a short term but substantial economic bonus. This “demographic bonus” is a window of opportunity to increase economic output because of the larger workforce; save money on health care and other social services; improve the quality of education; invest more in technology and skills to strengthen the economy; and create the wealth needed to cope with the future aging of the population. As much as one-third of the rapid economic growth among the East Asian “tigers” can be explained by the growth in the labour force as fertility declined and by the increase in savings and accumulation that accompanied this growth. A demographic dividend will not be realised without prior investment. An educated and unskilled youth population can threaten rather than enhance national stability and economic security (Ringheim et al. 2009).
Ethiopia has a great likelihood of capturing a demographic bonus or dividend if manage to slow population growth, if women have fewer children, the altered age structure of the population produces a more favourable ratio of adults in their economically productive years to dependent children and the elderly. With fewer children requiring education and health services, the government has great discretion to invest resources in other critical areas. Greater investment and increased savings create a one time, age structure-related economic growth spurt that is either captured or forever lost.
In Ethiopia, the proportion of all women who are married has declined as a result of a rising age of marriage and an increase in the proportion of women remaining single. This change is responsible for most of the modest decline in fertility in the last decade. While contraceptive use has not yet played a major role, Ethiopia has among highest levels of unmet need for contraception in Africa (Ahmed J and Mengistu G, 2002).
Patterns of family formation are intricately related to the social and cultural norms and practices of society. Marriage is the result of an often extended social process involving the couples, their families and the wider community. The right to found a family is paralleled by the right not to be coerced in marriage. Although information is not readily available about the degree to which this rights are realised in Ethiopia, questions arise in relation to early marriage and limiting number of children a family should have. In Ethiopia, marriage is the destiny of nearly all people. 97% of women in Ethiopia are married at least once in their life (DHS 2000/05). The social pressure to have large families is very strong. The reproductive carrier of women starts early, and one pregnancy follows another with little thought of child spacing. The male oriented structure of the family and the expectation that the women is in charge of all household chores, absorbs her energy, and limits her participation in economic and political activities in the country.
Figure 2, Determinants of High Fertility in Ethiopia
Age of Marriage
High fertility rate
Education discourages high fertility through economic factors in ways that it reduces the economic utility of children. It creates aspirations for upward social mobility and the accumulation of wealth. It also increases the opportunity cost of women’s time and enhances the likelihood of their employment outside home. However the education level women particularly girl’s education is low (40%) in Ethiopia.
Another strong factor underlying large family size preference in Ethiopia is parents’ dependence on children for social security. Children provide economic support in old age and help in emergencies or time of adversity, and take care of their parents by taking them to their homes. This expectation declines with level of increasing education (UNFPA 2008, Desta K and Seyoum G, 1998)
According to the in-depth analysis of the DHS 2005 data, low lifetime fertility is observed among urban residents, those achieving secondary and above education, women who have frequent access to media, employed in the modern sector of the economy, and are getting married after the age of 18. High fertility on the other hand prevailed among those experiencing child loss, and women residing in the regions where values of children are supposed to be high. High fertility is also observed among women experiencing child mortality. Death of a child tends to increase lifetime fertility by 25 percent while the death of two or more children increases it by 45 percent among all women of reproductive age.
Getting married at age 18 and later is also demonstrated to reduce fertility by 24 percent when compared to those entered marital life early. In countries like Ethiopia where contraceptive prevalence rate is low, increasing age at first marriage could reduce lifetime fertility by minimizing the exposure time to the risks of pregnancy (UNFPA 2008).
A survey done in southern Ethiopia also showed important socio demographic determinants of fertility like poor educational status, absence of income, rural place of birth, early marriage, history of child death to be significantly associated with high fertility rate (Geberemdhin and Betre 2009).
Low coverage of family planning service
The service coverage and uptake of modern contraceptives is very low in Ethiopia. The majority of Ethiopian women (78 %) and men (76%) prefer to space or limit the number of their children they have. and have a potential need for family planning, 34% of currently married women have an unmet need for family planning (DHS 2005). If all currently married women who say they want to space or limit the number of children were to use family planning, the contraceptives prevalence rate of Ethiopia would increase from the current 15 to 49 percent.
The family planning service was limited to urban facilities for a long time with limited access and coverage. It was practiced as a vertical program and mainly supported by external funding. Long term and permanent methods were limited to hospitals and health centres where trained and skilled health workers are practicing. Currently the contraceptive prevalence rate is 15 percent.
Figure 2, Trend in CPR modern methods, married women: 1990-2005-Ethiopia
Most methods used are injectables (61%) followed by the pill (25%). The use of long term and permanent methods is nearly absent: use of Implant among married women is 0.2 % while IUCD use with same group is 0.1% (DHS, 2005).
Causes of low coverage of family planning service
The causes for the low coverage of the service can be seen from two directions: organizational/institutional and community level causes. From the health service organizations the major factors include limited service outlets (failure to expand), lack of skilled human resources in the facilities which is due to shortage, lack of training, lack of motivation. Erratic supply of contraceptive due to inadequate and inefficient procurement and poor distribution system also needs attention.
With respect to service delivery organization causes include lack of integration of family planning service, permanent assignment of staffs, poor coordination between public and private for profit and for non profit including lack of referral mechanism and inefficient use of available resources.
From the community side, the diversified cultural and traditional practices in the different segments of the population plays role in hindering the use of contraceptives.
Cultural barriers, partners and peer influence lack of adequate knowledge of the contraceptives, accessibility and acceptability, affordability, and perceived attitudes of service providers and rumours about contraceptives also important factors to be addressed for successful program implementation.
Figure 5, Causes of low coverage and uptake of FP depicted in systems framework
Consequences of high fertility
The consequences of high fertility include unwanted pregnancy often leads to unsafe abortion attributable to contraceptive non-use, incorrect use, or method failure. High fertility also affects the well-being of mothers and their children. Maternal mortality and morbidity are strongly associated with high parity and early childbearing.
High population growth will lead to increasing number of children who need schooling which the education sector can’t satisfy.
High parity restricts women’s educational and economical opportunities, thereby limiting their potential for empowerment broadly, as well as their ability to safeguard the health and economic well-being of the family and community at large. Low educational attainment further perpetuates high fertility, as these women tend to have less knowledge of and access to family planning options.
Environmental degradation and impact on health is also one of the long term effects of rapid population growth. It is also seen to strain the capacity of the government and non-governmental organizations to provide important social services such as schools, health care, clean water and sanitation. The growing population demand for land redistribution can’t be satisfied and there will be rural urban migration, household food insecurity, high unemployment rate and other associated problems.
Rapid and unhindered population growth is a significant factor in exacerbating food shortages in Ethiopia. Of the total population an estimated 12 million are facing serious threats from food insecurity and famine. More than the half of the countries under five children are stunted and some 45 percent are underweight (PAI 2005).
Role of health extension workers in family planning service scale up
Analysis of the DHS data
Knowledge of family planning
Adequate Knowledge about contraception among women and men is a major determinant of the use of contraceptive methods. The analysis of the data from the two demographic and health surveys shows that the percentage of women with knowledge of any family planning method showed an increased by 39 percent during the last 15 years, from 62 to 86 percent in 1990 and in 2005 consecutively. As shown in table 1, although knowledge of modern methods of contraceptives increased from 2000 to 2005, knowledge about injectables and condom has increased substantially among both women and men over the same period (MII 2007).
As one of the important task of the health extension workers, they are playing a major role in transmitting knowledge in their specific community abut the different contraceptive methods use, side effect, and other important information. Even though there is no data currently on contraceptive knowledge, in the last five years between 2005 and 2010, there is much progress and increase through the expansion of primary health care coverage and access through health extension workers.
Table 1, Knowledge of specific contraceptive methods among women age 15-49 and men age 15-59
Percentage of Women
Percentage of Men
Any modern method
Any traditional method
Source: DHS data, Ethiopia trend report
Current use of family planning
Trend analysis of current use of contraceptive, provide insight into measuring determinants of fertility and helps to assess the success of family planning program. As shown in figure 6, current use of contraceptive methods among currently married women tripled in the 15 years between 1990 and 2005 from 5 percent to 15 percent. The increase is especially marked for modern methods. Current use of modern methods doubled during the first 10-year period and more than doubled during the last five years from 6 percent in 2000 to
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