Why is Ethiopia an Exemplar?

Ethiopia, the second most populous country in Africa, has achieved remarkable declines in U5M. Following consistent but slow progress, U5M dropped from 146 deaths per 1,000 live births in 2000 to 64 in 2015.¹

This improvement spanned income categories, and the formerly large gap in under-five mortality between the wealthiest Ethiopians and the rest of the country narrowed significantly during this period.²

U5M decreased across all regions, though geographic variances remain. The U5M rate in Addis Ababa, the country’s capital and largest city, was 39 deaths per 1,000 live births as of 2016. For the same year, the U5M rate in the northeastern region of Afar was 125 per 1,000.^3,4

During the 2000–2015 study period, Ethiopia achieved a steep downturn in mortality for the largest U5M causes of death. For example, the rate of respiratory infection deaths per 100,000 children under age five decreased by 64 percent and diarrhea-related deaths by 52 percent.¹

Although Ethiopia has not yet achieved full coverage of essential public health measures such as vaccinations, antenatal care, and facility-based childbirth, it has made notable gains on all three of these measures – and many others – which have been instrumental in driving overall reductions in U5M.⁵

Ethiopia has also shown impressive declines in its neonatal mortality rate, though as with many other U5M exemplar countries, progress toward reducing neonatal mortality has come more slowly. As with overall U5M, decreases in neonatal mortality have occurred across geographic regions and wealth quintiles but geographic differences remain.⁶

Ethiopia clearly stands out as an exemplar of U5M reduction, though challenges remain to continue making progress. That one of the world’s poorest countries could achieve this reduction across such a large and diverse population, and throughout a vast geographic area, makes it a promising model for a wide range of low- and middle-income countries in sub-Saharan Africa and beyond.

The country’s successes resulted from the effective implementation of evidence-based interventions to reduce child mortality. Its success also reflects broader contextual factors that both facilitated interventions and indirectly reduced child mortality, particularly through improved overall health status and resiliency of children and families.

Together, these implementation strategies and contextual elements suggest five primary drivers that contributed to Ethiopia’s success in reducing U5M:

• Strengthening the national primary health care system and infrastructure.
• Creating a strong, comprehensive community health system, centered on a highly successful Health Extension Program.
• Availability of significant donor and partner resources, and the government’s ability to coordinate these resources effectively.
• Commitment to data collection and use, pilot testing, and rapid scale-up of interventions.
• Attentiveness to the social and economic factors that affect U5M.