Why is Ethiopia an Exemplar?

Key Points

Executive Summary

From 1992 to 2016, Ethiopia cut its stunting rate from 67 to 38 percent.

Progress in four key sectors played a pivotal role in reducing stunting. Since the early 1990s, agricultural productivity has more than doubled, enrollment in primary school has quadrupled, immunization rates have more than doubled, and open defecation has declined by almost three quarters. In each sector, massive community-based systems created by Ethiopia’s government to deliver services at scale were instrumental in this success.

Agriculture

In a country that was almost 90 percent rural (and is still approximately 80 percent rural), investments in agricultural productivity were essential for food security and poverty reduction. ¹

The 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.² As a result, adoption rates of these inputs are much higher in Ethiopia than in most neighboring countries.

Since the early 1990s, productivity has skyrocketed. 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

Education

Education was the new government’s top priority as early as 1992, with one quarter of the national budget routinely going to expand access.

Ethiopia’s sizable investments have gone primarily to building schools and hiring teachers to staff them.⁴ Since the early 1990s, the number of schools has tripled, enrollment in primary school has quadrupled, and literacy has more than doubled. Girls, who used to be underrepresented at all school levels, have achieved parity in primary school enrollment.

Like many other sectors, the education sector is turning its attention to the issue of quality. Specifically, its priorities are ensuring that students learn what they are supposed to learn in each grade and that they continue on from primary to secondary school.

Health

Maternal and newborn health care improved significantly over the course of the 2000s and 2010s due to the massive expansion of the community health system and significant investment in health facilities and medical education.

In 1992, given the severe shortage of medically trained personnel and the sheer size of the country, health care was effectively unavailable to most Ethiopians. Taking a cue from the agriculture sector, the Ministry of Health in the early 2000s trained 40,000 community members to serve as health extension workers and provide preventive care— and eventually basic curative care—in every village in the country.⁵ 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.

Ethiopia achieved most 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.⁶

Water, sanitation, and hygiene

Ethiopia’s community health workers prioritized raising awareness about the dangers of open defecation, leading to the largest decline in the practice in the world.

One of the jobs assigned to health extension workers was persuading people to stop practicing open defecation. Between 2000 and 2017, the percentage of people defecating in the open dropped from 79 to 22 percent, the largest decline in the world.⁷ At the same time, the number of people with access to “improved” water sources doubled.

However, these improved water sources and the low-quality toilets constructed in many communities do not guarantee that fecal contamination is reduced to zero. The next priority is to meet the more stringent global standard of “safely managed” sanitation.

Implementation

Ethiopia’s pro-poor policymaking and budgeting has helped government programs reach a large number of the most vulnerable citizens with services. Starting in the early 1990s, the government methodically created and implemented policies and programs in key development sectors, including landmark health and education sector development programs. Regional and local officials are held accountable to the targets laid out in these policies and programs. Ethiopia’s government has also effectively garnered support from donors. It has been especially skillful about getting those donors on board with its policies and programs, instead of the other way around. Using the motto “One Plan, One Budget, One Report,” the government strongly encourages donors to contribute to pooled funds instead of running their own parallel programs.

Challenges

Because Ethiopia started at such a low level of development in the early 1990s, it still has a lot of progress to make in reducing stunting, notwithstanding decades of success. After creating large community-based systems to boost agriculture, education, health, and WASH, the government is now fine-tuning those systems to improve the quality of services they provide. Recent reforms to these systems are promising, but the advent of climate change is making progress harder to achieve.