Challenges

While Ethiopia has substantially reduced neonatal and maternal mortality in recent decades, certain obstacles remain that will impact these trends in the coming years. In order to continue advancing through the integrated maternal, neonatal, and stillbirth mortality transition framework, accounting for these challenges will be crucial.

Out-of-pocket spending

From 2000 to 2020, out-of-pocket spending comprised a generally consistent portion of total health expenditure in Ethiopia, at 36% in 2000 and 33% in 2020.¹ An assessment in Ethiopia from 2015-2016 indicated that 2.1% of Ethiopian households were estimated to face catastrophic health expenditures every year.² Susceptibility to catastrophic health expenditure was highest in Afar and Benishangul-Gumuz where 5.8% and 4.0% were estimated to face this burden annually.² Within Ethiopia’s broader health financing system, 33% of total health expenditure in 2020 was from external aid – more than double the proportion of any other Exemplar country in neonatal and maternal mortality reduction.¹

Recent Conflict

War in the Tigray region of Ethiopia began in November of 2020 and has had a severe impact on the local health system. Assessments of Tigray’s health system in June 2020 as compared to June 2021 reveal that only 27.5% of hospitals, 17.5% of health centers, and 11% of ambulances that had been functional in months before the war were still functional months after the onset of conflict.³ Additionally, the population in need of emergency food assistance is estimated to have grown by over 500% during this year long span.³ In addition to the acute crisis faced by populations in need, this conflict is likely to undo substantial progress that has accumulated over recent years and decades, having a long-term detrimental effect.

Subnational Variation

Ethiopia is heterogeneous in its contexts – often grouped as urban, agrarian, and pastoralist – with each environment posing widely different challenges. Despite Ethiopia’s efforts to make health facilities more accessible in rural areas via the Health Extension Program, agrarian and pastoralist communities generally have lower utilization of health services and higher mortality levels.⁴ In particular, sizeable nomadic populations in regions that are largely pastoralist may be difficult to reach using interventions that are templatized based on successes in other regions within Ethiopia. This variation requires subnational approaches to problem solving that account for the wide range of realities present in-country.