What did Ethiopia do?
- Ethiopia’s government has consistently surpassed the African target for agricultural spending, training 70,000 agricultural extension workers who bring farmers fertilizer, improved seeds, and up-to-date knowledge.
- Ethiopia’s sizable education investments have gone primarily to building schools and hiring teachers to staff them.1 Since the early 1990s, the number of schools has tripled and enrollment in primary school has quadrupled.
- The government trained 40,000 community members to serve as health extension workers providing basic care in every village in the country.2 At the same time, the government continued to expand the network of clinics and hospitals and train more midwives, nurses, and doctors to staff them.
- The health extension workers educated communities about the dangers of open defecation, and the percentage of the population defecating in the open dropped precipitously.
AGRICULTURAL DEVELOPMENT LED INDUSTRIALIZATION
Historically, agricultural productivity in Ethiopia has been exceptionally low. In 1993, for example, the composite crop production index was 30 percent lower than the regional average, which in turn was 15 percent lower than the global average. Since the early 1990s, however, productivity has skyrocketed. The cereal output increased from 974 kg per hectare in 1993 to 2,538 kg per hectare in 2017. Between 1993 and 2016, the crop production index more than tripled.3
Crop and livestock production in Ethiopia
In low-income countries with large rural populations, agricultural growth is usually associated with poverty reduction, and Ethiopia is no exception.4 Between 1995 and 2015, while farmers were doubling their yields, extreme poverty fell by more than half, from 71 to 31 percent.5 One interviewee explained how this change is visible in the landscape:
"The farmer who used to live in a small hut is now living in a house made of tin and bricks."- Agriculture expert, Southern Nations, Nationalities, and People’s Region (SNNPR), April/May 2019
The Ethiopian government designed its investments in agricultural productivity not only to reduce poverty, but also to transform the economy. In 1994, the government issued the Agricultural Development-Led Industrialization (ADLI) strategy, the core tenets of which still guide the country’s economic development strategy today through the Growth and Transformation Plan.
The government’s theory of agriculture-led development held that growth in the agriculture sector could, if properly managed, stimulate growth in the industrial sector. Theoretically, a more productive agricultural sector would raise living standards, increase aggregate demand, boost exports, generate tax revenue, and supply raw materials for agro-processing and other fledgling industries such as leather goods. Ultimately, according to the theory, these processes would result in the emergence of Ethiopia as a modern, mixed economy.
According to a United Nations working paper in 2017, ADLI “did not lead to agricultural based industrialization as initially anticipated.”6 Although the gross domestic product (GDP) has grown and the sectoral contributions to GDP have changed, the service sector has seen the largest gains, not the industrial sector. Industry’s share of GDP has mostly stagnated since the mid-1990s, with many economists suggesting that constraints on the private sector need to be loosened to meet the goal of significant growth in industry and manufacturing. Nevertheless, “ADLI is credited for improved agricultural productivity and poverty reduction in rural areas.”6
AGRICULTURE EXTENSION SERVICES
By 2003, when delegates to the African Union issued the Maputo Declaration and pledged to spend at least 10 percent of their budgets on agriculture, Ethiopia was already a decade into its agriculture-first development strategy. Only a handful of countries that made the commitment in 2003 have ever spent 10 percent of their budget on agriculture. Ethiopia does so consistently.7
Ethiopia’s main investment has come in the form of extension services. In the early 1990s, the Japanese-led Sasakawa Africa Association and Global 2000 (an initiative of the Carter Center) piloted a new approach to agricultural demonstration in selected woredas (districts). Extension agents, known as development agents in Ethiopia, worked with farmers to grow various crops on small plots according to the best practices available, thus demonstrating both the potential for large yield improvements and training local farmers in modern agricultural techniques. The government eventually used this methodology as the basis of its national agricultural extension system.8 In recent years, the government has built 15,000 farmer training centers, roughly one per kebele (village), where demonstrations and trainings are available to every farmer. Each farmer training center has three development agents—one each specializing in plant science, animal science, and natural resources management. Furthermore, every three to five farmer training centers share a development agent trained in animal health and cooperative management.
Development agents offer farmers “packages” of fertilizer, improved seeds, and pesticides—all of which can be bought on credit—and best practices for a variety of crops and livestock. The scale of the system is noteworthy. In 1995, there were just 2,500 development agents. Between 1996 and 2006, the network of Agricultural and Technical Vocational Education and Training colleges expanded from 17 to 388, leading to a massive increase in the number of extension agents.9 In 2017, there were 72,000 development agents, giving Ethiopia the densest agricultural extension system in the world, with an agent-to-farmer ratio of 1 to 230.10
This system—along with complementary investments in infrastructure, which helps the development agents cover more ground, and education, which increases literacy rates in rural areas—has increased the use of improved agricultural inputs to a level far higher than in most other countries in sub-Saharan Africa.11 Between 2004 and 2014, the number of cereal farmers using fertilizer more than doubled, from 4.7 to 10.1 million farmers; during the same period, the fertilized area almost doubled, from 2.7 to 5.2 million hectares. The average amount of fertilizer per hectare used also increased by 30 percent. In short, more farmers used more fertilizer on more land.12 These increases in fertilizer use are widely regarded as the driving force behind cereal yield gains.
Ethiopia's gains in agricultural productivity a product of both increased arable land and efficiency in yield
Improved seeds tell the same story. Only 12 percent of maize farmers used improved seeds in 2004, increasing to 28 percent by 2013. Other crops showed the same trend, but with smaller initial percentages, suggesting the potential for even more increased productivity gains. For example, over the same period, the number of farmers using improved teff seeds quintupled, from 1 to 5 percent.12
In addition to adopting these technologies, farmers increasingly complement them with best practices. According to a farmer in SNNPR, they used to:
". . . just plant the crops by scattering . . . [but now they] . . . plant them in a more organized way using the methods that the agriculture sector person shows [them]."- Mother, focus group discussion (FGD), Bonga, SNNPR, April/May 2019
ADDITIONAL AGRICULTURE AND FOOD SECURITY INVESTMENTS
Despite these productivity gains, millions of Ethiopians, especially those in drought-prone areas, still struggle with food insecurity. By 2000, donors spent US$265 million annually on humanitarian food aid, which saved lives but did not offer a sustainable solution. Donors and the government agreed that something had to be done to help provide a lasting safety net, and in 2003 they created an ad hoc organization called the New Coalition for Food Insecurity to recommend solutions.
The idea of a cash transfer program became a top priority. The US Agency for International Development provided US$4.4 million to nongovernmental organizations (NGOs) in 17 woredas to pilot cash transfer programs. After two years of positive results, the government launched the Productive Safety Net Program in 2005 with support from seven donors.13
PSNP provides two kinds of social protection: (1) For those who cannot work, unconditional cash transfers indexed to the cost of an adequate diet in a given region. (2) For those who can work, cash transfers in exchange for work on public works projects, especially those that increase climate resilience. Targeted to between 8 and 10 million beneficiaries in 290 woredas (of 710 woredas total), PSNP is currently the largest social protection program in sub-Saharan Africa outside of South Africa.
Ethiopia has continued to innovate in the area of agricultural development. In 2010, with support from the Bill & Melinda Gates Foundation, the government launched the Agricultural Transformation Authority (ATA), which focuses on system-wide innovations such as mapping soil and water resources, scaling up seed production, and running the well-regarded 8028 Hotline. This hotline initially provided farmers who called in with up-to-date advice in their local language and tailored to their agroecological circumstances. The ATA has continued to make changes to the services the hotline offers; now it also sends SMS messages to farmers with urgent warnings and gathers survey information to improve the quality of the advice. By mid-2018, 3.6 million users had placed more than 30 million calls to the service.14
The effect that education has on stunting prevalence is complex. Better-educated parents tend to earn more and know more about health and nutrition, which enables them to have more resources to devote to their children and a better understanding of how to use those resources. Educated mothers are more likely to make decisions about how the family will spend money and rear children, and educated fathers are more likely to accept women in decision-making roles. Children are also able to educate their parents.
According to a health worker:
"School children pass messages regarding health to their mothers in the home."- Health worker, Somali Region
Additionally, girls who stay in school longer tend to have fewer children later in life, which also contributes to reductions in stunting. Secondary school enrollment for both boys and girls is still very low, at 28 percent in 2015. It is therefore unlikely that girls’ education was the only driver of delayed marriage and childbearing, but it almost certainly played a role. The adolescent fertility rate declined from 118 births per 1,000 women ages 15 to 19 in 1993 to 67 per 1,000 in 2017.15 During the same period, the total fertility rate declined from 7.1 children per woman to 4.4 children per woman.16
Reduction in total fertility rate and teen fertility rates, Ethiopia
Education was the government’s top priority as early as 1992. Immediately after the fall of the Derg, the government launched the Basic Education, Technical, and Vocational Project as part of the Emergency Recovery and Reconstruction Program. The program ran from 1992 to 1999 and met 96 percent of its new school construction targets.17 The Education Sector Development Program, launched in 1997, focused similarly on building new schools and hiring new teachers.
Today, the government invests more in education than in any other sector – between 2008 and 2018, one-quarter of the national budget has gone to education1 – and the result has been a remarkable increase in the number of schools, enrollment, and literacy.
Government statistics report that the number of primary schools tripled from 11,000 in 1996 to 32,048 in 2014.18 The net enrollment rate in primary school education more than quadrupled from only 19 percent in 1994 to 85 percent in 2015,19 and the youth literacy rate more than doubled from 34 percent in 1994 to 73 percent 2017.20 These increases benefited both girls and boys; gender parity in enrollment rose from 0.63 to 0.91,21 and in literacy from 0.72 to 0.98.22
Improvement of Gender Parity Index over time in Ethiopia
According to one mother:
"Our view of girls’ education has changed between then and now. We used to think a girl who went out early to learn was a bad girl. Now that we have seen the results of education, we educate both genders equally."- Mother, FGD, Somali Region, April/May 2019
In the 1990s, Ethiopia’s tiny health system was unable to meet even a fraction of the needs of its population of more than 50 million. By the late 2000s, the health system was comprehensive – it was available to nearly every community – although the care available was basic.
By 2000, the design of Ethiopia’s health system, which was based on doctors and nurses providing care in health centers, was clearly inadequate for a vast, overwhelmingly rural country with a severe shortage of trained health workers. The country had only 400 health centers, mostly concentrated in urban areas, despite that more than half of Ethiopians lived 10 kilometers or more from any health care. Fewer than 2,000 doctors existed in the entire country, creating a doctor-patient ratio five times lower than the sub-Saharan African regional average – and more than 60 times lower than the global average.23
Around the turn of the millennium, community-based systems staffed by frontline health workers began to receive funding from the development community. Ethiopia benefited from this global trend. In addition to several community health pilot programs run by NGOs, officials in the Tigray Region, from which President Meles hailed, launched a program of their own in 1998.24
When President Meles and the Ministry of Health started looking for solutions to the health crisis, they turned to the pilot programs in Tigray, which already had four years of results. The government launched a national version of Tigray’s Health Extension Program in 2003. The program trained 40,000 local women, called health extension workers (HEWs), to provide basic preventive care in every community across the country.2
Improvements in health coverage over time
By 2015, the Health Extension Program, alongside a steady expansion of more highly trained health workers in primary health facilities, enabled Ethiopia to achieve almost all of the health-related Millennium Development Goals, including a 67 percent reduction in mortality among children under age five, a 71 percent reduction in maternal mortality, a 90 percent reduction in new HIV infections, a 73 percent reduction in malaria deaths, and a more than 50 percent reduction in tuberculosis deaths.25
The importance of improved road infrastructure on the effectiveness of the Health Extension Program is worth noting. Over the past two decades, Ethiopia invested US$11 billion in roads; between 1990 and 2015, the total length of roads increased from 19,000 to 100,000 kilometers.26 A health worker described the effect of roads on her work:
"It used to be a three-day trek, but now it’s a half-day trek. You can imagine the difference. Now there are many roads that connect [us] to different parts of the region and anyone can move from one place to another without fear or military escort. This has helped us reach more malnourished children who would otherwise die."- Health worker, Somali Region, April/May 2019
At the same time, with the Health Extension Program firmly established, the government has continued building other parts of the health system, namely by investing heavily in more clinics and doctors. To address the problem of many Ethiopian doctors leaving the country to practice in countries where salaries are higher, the Ministry of Health adopted a policy of “deliberately overproducing” doctors. “Even if you lose 100 or 200,” said the minister of health, “everybody doesn’t leave.” In 2012, 13 new medical schools opened, more than doubling the country’s total. As of 2016, there were 33 medical schools,27 and those schools graduated approximately 3,000 new doctors.28
Child mortality reduction, Ethiopia
Overall, gains in strengthening the health sector have been impressive. One health worker captured the dramatic change over the past generation:
"We only had one health center in this woreda back in the day, but now we have three or four. There was also a health post that has changed to health center and a health center that has changed to hospital. There was no hospital in Tepi; we have one hospital there now. Overall, there have been great improvements in relation to health facilities."- Health worker, SNNPR, May/June 2019
Water, sanitation, and hygiene
The reduction in open defecation in Ethiopia was the largest in the world during the same period; from 79 percent of the total population practicing open defecation in 2000 to 22 percent in 2017. 29 Those who continue to practice open defecation are concentrated in the pastoralist regions, including Afar, Somali, parts of Oromia, and SNNPR.
The sharp decline in open defecation began in 2006 when Ethiopia introduced the community-led total sanitation (CLTS) approach. CLTS was developed in 2000 in Bangladesh by Kamal Kar, an Indian development consultant, together with a local NGO. Kar knew from experience that simply providing toilets would not solve any sanitation problems, because many villagers would not use them. He experimented with a more participatory approach that could generate demand instead of sinking more money into supply.
The process of CLTS is straightforward. Facilitators try to demonstrate the danger of open defecation, encourage people to build latrines, and motivate early adopters to persuade other villagers to use them. By 2009, after three years of pilot programs, the Ministry of Health adopted CLTS as its official policy.30 Conveniently, it had the necessary infrastructure in place – 40,000 HEWs were already trained in behavior change.
Reduction in open defecation rates in Ethiopia
In 2011, the government created the WASH Implementation Framework to provide guidance to all those working collectively on WASH to achieve SDG water and sanitation targets. The framework was followed by the creation of the One WASH National Program in 2013,31 which brought together donors, NGOs, and four different government ministries to ensure that targets are achieved.32 The program’s motto, borrowed from the health sector, is “One Program, One Budget, One Report.” All funds are pooled in what is known as the Consolidated WASH Account, which gives the government more control over where funding goes and reduces gaps and redundancies. Given the newness of these policies and programs, it is not yet possible to evaluate their effectiveness.
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