Ethiopia Operational Plan Report FY 2012 Custom Page 1 of 410 FACTS Info v3.8.8.16 2013-05-24 12:58 EDT Operating Unit Overview OU Executive Summary Executive Summary Country Context With a population of 82 million, Ethiopia is the second most populous country in Sub-Saharan Africa. Despite impressive economic growth, Ethiopia remains a low-income country with a real per capita income of US $351 and 39% of the population living below the international poverty line of $1.25/day. According to the UN Human Development Index, 2011, Ethiopia ranks 174 out of 187 countries on both the overall index and the per capita GNI (Gross National Income). It is also one of the least urbanized countries with 82% of the population living in rural areas. In 2010, Ethiopia launched a five-year Growth and Transformation Plan (GTP) which envisages an annual Gross Domestic Product (GDP) base growth case scenario of 11% and a high growth case scenario of 14.9%. Improving the quality of social services and infrastructure, ensuring macroeconomic stability, and enhancing productivity in agriculture and manufacturing are major objectives of the plan. The high growth rate has been offset by high inflation in recent years. Year-on-year inflation peaked at 64% in July 2008 - the second highest in Sub-Saharan Africa after Zimbabwe. As of December 2011, the year-on-year inflation rate remained high at 36%, driven by loose monetary policy and with it commodity price increases. The Government of Ethiopia (GOE) has taken several measures to combat rising prices, including importing wheat and edible oil and selling at subsidized prices through government corporations; however these measures have not been effective in the short-term in reducing prices. The Health Sector Development Plan IV (HSDPIV) and the Strategic Plan for Intensifying Multisectoral HIV and AIDS Response (SPMII) outline their contributions towards the GTP. In 2008, government expenditure on health was 9.1% of total country budget. The HIV/AIDS epidemic in Ethiopia is characterized by a mixed epidemic with significant heterogeneity across geographic areas and population groups. The official single point estimate based on 2005 DHS and 2005 ANC surveillance data projects HIV prevalence at 2.4 in 2010 with marked regional differences. Urban ANC data from 2009 indicates ranges from 2.4% in the Somali region to 9.9%, 10.7% and 10.8% in the Amhara, Tigray and Afar regions respectively. Updated information will be available with the release of the 2011 DHS+ data in March 2012. Additionally, Ethiopia has one of the widest urban: rural differences in prevalence, with urban prevalence 8 times higher than rural (7.7% vs. 0.9%, respectively) and with transmission thought to be driven primarily by most at risk populations (MARPs). Small towns are considered to be hot spots potentially forming a bridge for the extension of infection into rural areas. Addis Ababa, Amhara, Oromia and SNNPR account for 93.4% of the total PLWHA population in the Custom Page 2 of 410 FACTS Info v3.8.8.16 2013-05-24 12:58 EDT country and with a high urban prevalence: 60% of PLWHA are living in cities/towns. The inflation mentioned above, increases household hardships and could set the stage for people to utilize higher risk livelihood coping strategies, especially in urban areas. Women face almost 50% higher risk of infection than men (2.8% and 1.8%, respectively). The single point estimate projected a total of 137,494 new HIV infections occurred in Ethiopia in 2011. Half would have happened in the Amhara and Oromia regions, while Addis Ababa would have contributed approximately 17% (23,000 new infections). Limited data suggest that HIV transmission is high among MARPs, including a 2008 study in Amhara region that reported HIV prevalence ranging from 11% to 37% among the study population, which included female sex workers (FSW), long distance truck drivers, day laborers, and mobile merchants. The “contributions” of the various MARPs and other vulnerable populations to overall HIV incidence are not well known. There is an upcoming national survey on MARPS quantifying FSWs in regional capitols and major transit corridors and estimating HIV prevalence among FSWs and truck drivers which will add further information. Currently no HIV prevalence data is available among men who have sex with men (MSM), although there is an ongoing study; MSM are highly stigmatized. Of Ethiopia’s estimated 5.4 million orphans, 855,720 were orphaned due to AIDS. According to a 2010 Ministry of Labor and Social Affairs (MOLSA) report, approximately 150,000 children live on the streets, and 60,000 of these children live in the capital putting them at greater risk. Promisingly, the latest ANC surveillance report (2009) indicates a steady decline in HIV prevalence among pregnant women attending ANC clinics. Between 2001 and 2009, prevalence in urban sites decreased from 14.3% to 5.3%; rural prevalence decreased from a high in 2003 at 4.1% to 1.9% in 2009. Prevalence among 15-24 years has also significantly declined from 12.4% in 2001 to 2.6% in 2009. Preliminary findings from the 2011 DHS indicate that HIV/AIDS awareness is universal. Knowledge about HIV prevention methods has increased from 2005, especially among women. Forty three percent of women in 2011 knew that HIV can be prevented by using condoms and limiting sexual partners, up from 35%; among men this increased from 57% in 2005 to 64% in 2011. Overall, 4% of men aged 15-49 reported that they had 2 or more partners in the past 12 months with men aged 40-49 eight times more likely than their younger counterparts aged 15-24 years to have had two or more partners. Less that 1% of women reported they had two or more partners in the preceding 12 months of the survey. There have been other encouraging preliminary results from the 2011 DHS+ in comparison to figures from 2005. Child mortality decreased by 28% from 128 to 99 per 1,000 births and infant mortality from 77 to 59 deaths per 1,000. The total fertility rate (TFR) has declined from 5.4 births per women to 4.8 and modern contraceptive use among married women increased from 15% to 29%, although a quarter of married women still had an unmet need for family planning. These gains are not shown in maternal mortality ratio which remains at 676/100,000 births and neonatal mortality has also remained stagnant. Custom Page 3 of 410 FACTS Info v3.8.8.16 2013-05-24 12:58 EDT These latter results are not surprising when only 34% of women access antenatal care and only 10% of deliveries were attended by a health professional. There are severe cultural and social barriers impeding women from accessing antenatal care and seeking institutional delivery. Gender based violence remains a pervasive social problem. The 2005 DHS reported 81% of women believed that their husbands had a right to beat their wives and societal abuse of young girls continues to be a problem. Harmful practices include FGM, early marriage, marriage by abduction, and food and work prohibitions. Forced sexual relationships accompany most marriages by abduction, and women often experience physical abuse during the abduction. Abductions lead to conflicts among families, communities, and ethnic groups. Female Genital Mutilation (FGM) remains widespread, with areas in Eastern Ethiopia where 60-80% of women underwent infibulations, although a 2008 review reported a 24% national reduction in FGM cases over the previous 10 years, due in part to a strong anti-FGM campaign and legislation. In urban areas, women have fewer employment opportunities than men, and the jobs available do not provide equal pay for equal work. Women's access to gainful employment, credit, and the opportunity to own and/or manage a business is further limited by their low level of education and training, and by traditional attitudes. Although there has been a marked increase in the number of girls attending school, dropout rates among girls are higher and many fewer girls reach tertiary educational facilities. Even for those reaching university, there is currently a 44% average dropout rate for females and 19% for men in the first and second years. There has been a major expansion in the coverage of HIV/AIDS services. Facilities offering counseling and testing have more than quadrupled from 658 in 2005 to 2,309 in 2011. As a result of provider initiated counseling and testing (PICT) in health facilities and community mobilization, the number of people tested for HIV increased from 436,854 (2004/5) to 9.45 million (2010/11). The number of hospitals and health centers has increased fourfold from 645 in 2004 to 2,884 by 2009; over the same period the number of health posts increased almost five-fold. In 2003/2004 only 32 facilities offered PMTCT services; this has now reached 1,445. In 2005, only 3 facilities were offering ART; these services are now available in 743 facilities. From a baseline of 8,226 persons ever started on ART in 2005, 333,434 people had been started on ART by 2009 (62% of estimated need). As of September 2011, 247,805 people were currently on ART, the difference including patients that died, stopped treatment, and the 7% who are “true” lost to follow-up. These encouraging results reflect the combined efforts of high-level GOE political commitment and a supportive donor community, including support from both the PEPFAR and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) who together contribute almost 90% of total donor input to HIV. Although prevalence is lower than many other Sub-Saharan countries, there are still an estimated 1.2 million people living with HIV in Ethiopia, the fourth highest burden of PLWHA to care and treat in East Custom Page 4 of 410 FACTS Info v3.8.8.16 2013-05-24 12:58 EDT Africa, placing substantial demand on the country’s already strained resources.