,A 4O*LD WANK COUNTRY STUDY Public Disclosure Authorized AusustIqc Ethiopia Socaa/Sector Report Public Disclosure Authorized .,_ . r _ . _~ ~ ,\X- Public Disclosure Authorized - _ --~~144*C "1Qy%}] Public Disclosure Authorized A WORLD BANK COUNTRY STUDY Ethiopia SocialSector Report TheWorld Bank Washington,D.C. Copyright © 1998 The Intemational Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433,U.S.A. All rights reserved Manufactured in the United States of America First printing August 1998 World Bank Country Studies are among the many reports originally prepared for intemal use as part of the continuing analysis by the Bank of the economic and related conditions of its developing member countries and of its dialogues with the govemments. Some of the reports are published in this series with the least possible delay for the use of govemments and the academic, business and financial, and development communities. The typescript of this paper therefore has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility for any consequence of their use. The boundaries, colors, denominations, and other information shown on any map in this volume do not imply on the part of the World Bank Group any judgment on the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to the Office of the Publisher at the address shown in the copyright notice above. The World Bank encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for noncommercial purposes, without asking a fee. Permission to copy portions for classroom use is granted through the Copyright Clearance Center, Inc., Suite 910, 222 Rosewood Drive, Danvers, Massachusetts 01923,U.S.A. Cover photo: "Ethiopia: Mother, child, coffee. Coffee was boiled in a clay pot over coals and ceremoni- ally poured into small china cups." Photo taken by Ian Newport, chief counsel for the Europe and Central Asia Region of the World Bank, during his one week in Afgol Kebele in Tigray,Ethiopia, in May 1998,as part of the Grassroots Immersion Program under the World Bank Executive Development Program. ISSN: 0253-2123 Libraryof Congress Cataloging-in-PublicationData Ethiopia: social sector report. p. cm.- (A World Bank country study) ISBN 0-8213-4314-9 1. Ethiopia-Social conditions-1974- 2. Ethiopia-Social policy. 3. Education-Ethiopia. I. World Bank. II. Series. HN789.A8E87 1998 306'.0963-dc2l 98-34326 CIP CONTENTS ABSTRACT ............................................. x PREFACE......................................... xi ACKNOWLEDGMENTS................................. xii ACRONYMSAND ABBREVIATIONS........................ xiv EXECUTIVESUMMARY ................................ xv BACKGROUND...................................... 1 Objectives of This Report ...................................... 1 Using a Life Cycle Approach to Social Sector Strategy Formulation .............. 2 Data Sources ............................................... 3 2 CONTEXTUALFACTORS INFLUENCING ETHIOPIA'S SOCIALSECTORS ................................... 7 Social Sector Performance and the Economy ............................ 7 Policy and Economic Environment ................................. 9 Economic Growth ....................................... 10 Fiscal Policy Reform ..................................... 11 Institutional Context ......................................... 12 Regionalization ......................................... 12 Private Sector Role ...................................... 13 Community Involvement .................................... 14 Population Projections and Implications .............................. 14 3 THE ETHIOPIANHOUSEHOLD .19 Income and Sources of Income .19 Household Expenditure Patterns .20 Impact of Community Level Infrastructure and Services .21 iii iv CONTENTS 4 HEALTH .......................................... 23 Indicators of Health Status .................................. 23 Burden of Disease.. ................................ 24 Demand for Health.. ................................ 26 Incidence and Duration of Illness ........................ ..... 26 Utilization Rates.. ................................. 27 Choice of Provider. ................................. 29 Health Expenditure at the Household Level ............ ... .. .. ... .. 30 Supply of Health Services .................................. 32 Health Services and Utilization ............................... 32 Availability of Facilities .................................. 33 Staffing and Inputs .............................. 35 Medical Supplies and Pharmaceuticals ........................... 37 Policy and Institutional Framework .............................. 38 Decentralization: Managerial and Institutional Framework .39 Government Agencies .39 Private Sector .40 Community Participation .40 Nongovernmental Organizations .41 Costs and Financing .41 Levels and Composition of Financing .41 Sources of Financing .43 Cost Recovery .44 Adequacy and Sustainability of Financing .46 Future Options for Financing .46 Program Implications for the Health Sector .50 5 NUTIUTIOION.53 Malnutrition in Ethiopia .53 Child Malnutrition .53 Other Nutrition Problems .56 Poverty and Malnutrition .57 Programs and Policies .61 Program Implications for Nutrition .64 6 POPULATION ................................ 65 Outcomes.. ........................ 65 Population Growth and Structure. ......................... 65 Fertility.. ........................ 66 Mortality .............................. 67 STDs and HIV/AIDS .......................... 68 CONTENTS v Demand for Services .............. ... ... ... ... ... ... ... ... 69 Preference for Children ........... .. .. .. .. ... .. .. .. .. .. .. 69 Knowledge and Use of Contraceptives ........ I. .. 70 Other Determinants of Demand ......... .. .. .. .. .. .. .. 72 Programs and Policies .............. ... ... ... ... ... ... ... ... 72 Program Coverage and Finance ......... .. .. .. .. .. .. .. 72 Population Policy .............. .. ... ... ... .. ... .. ... ... 73 Program Implications of Projected Population Changes ...... 74 Projected Population Changes .......... .. .. .. .. .. .. .. .. 74 Integrating Services ............. .. .. ... .. ... .. .. ... .. ... 75 Elimination of Harmful Practices ......... .. .. .. .. .. 76 Improvement in the Socioeconomic Status of the Population, Especially of Women . 76 7 EDUCATION..................................... .77 General Structure and Performance of the Education Sector ...... 78 Primary School ................ ... ... .... ... ... ... .... 78 Urban-Rural Differences ........... .. .. .. .. .. ... .. .. ... .. 79 Regional Differences ............. .. .. ... .. ... .. .. ... .. ... 80 Gender Differences ............. .. ... .. ... .. ... .. ... .. .. 81 Secondary School .............. .. ... ... ... .. ... .. ... ... 81 Tertiary Schooling .............. .. ... ... .. ... ... .. ... ... 82 Technical and Vocational Education ........ .. .. .. 82 Household Demand for Education ......... .. .. .. .. .. .. .. .. 82 Attitudes toward Schooling .......... .. .. .. .. .. .. .. .. .. .. 83 Household Education Expenditures ........ .. .. .. .. .. 84 Opportunity Costs of Schooling ......... .. .. .. .. .. 85 Perceived Returns to Schooling ......... .. .. .. .. .. .. .. 86 Other Factors That Affect Household Demand for Schooling ..... 88 Supply-Side Assessment .............. .. ... ... .. ... ... ... .. ... 88 Provision of Educational Facilities and Services ...... 91 Teaching and Administrative Staff ........ .. .. .. .. .. 92 Cost and Financing of Education .......... .. .. .. .. .. .. .. .. .. 94 Sources and Uses of Funds .......... .. .. .. .. .. .. .. .. .. .. 94 Public Spending on Education ......... .. .. .. .. .. .. .. 95 Stability of Funding Sources .......... .. .. .. .. .. .. .. .. 98 Alternative Domestic Sources of Funding ....... 99 Cost Efficiency ............... ... ... ... ... ... ... ... ... 101 Program Implications in the Education Sector ....... 104 8 IMPLICATIONSOF FINDINGSON THE PROPOSEDHEALTH AND EDUCATIONSECTOR DEVELOPMENTPROGRAMS .... 107 Overall Assessment . ... 108 vi CONTENTS Issues for Education and Health Sector Development Programs ..... 108 Demand Side Constraints ........ .. .. .. .. .. .. 108 Financial and Organizational Sustainability ....................... 110 Flexible Service Delivery ................................. 112 The Social Sector Strategic Vision ............................ 113 Monitoring and Evaluating Progress ........................... 114 ANNEX 1. List of PHRD Social Sector Studies and Authors .... 115 ANNEX 2. Population Projections ...... 117 ANNEX 3. Statistical Appendix ....... 119 BIBLIOGRAPHY ............ 133 TABLES BACKGROUND Table 1.1 Situation of Ethiopians at Various Stages of the Life Cycle .... 4 CONTEXT