MARCH 2025

Country context: Taking stock of family planning and reproductive health

Ethiopia, with a population of nearly 130 million in 2024, is the second most populous country in Africa, after Nigeria, and the 11th most populous globally. It has a high total fertility rate of 4.1 births per woman as of 2022, and its population is projected to double to 225 million by 2050. Classified as low-income as of 2024, the landlocked country faces a multitude of crises, including conflict in the northern region, drought in the eastern and northern regions, and landslides and flooding in the southern and central regions. Despite these challenges, Ethiopia has seen a stable decline in unmet need for modern methods of contraception over the past decade, from 18.2 percent of women in 2012 down to 16.1 percent in 2023 due to an enabling policy environment for rights-based family planning and reproductive health services, and an institutionalized network of community health workers. Meeting family planning targets, however, continues to be a challenge amid Ethiopia’s humanitarian crisis, which has displaced an estimated 4.5 million people and disrupted their access to family planning and reproductive health services.

Expanding modern contraceptive prevalence

Reflecting Ethiopia’s progress in reducing unmet need for family planning, the modern contraceptive prevalence rate (mCPR) among Ethiopian women increased from 20.5 percent in 2012 to 27.3 percent in 2023. Ethiopia’s mCPR was higher than the average for sub-Saharan Africa at 23.4 percent as of 2023 but lower than the world average of 35.2 percent. However, wide disparities exist in mCPR across the country’s 11 regions, from as low as zero usage in Somali in the east, 2.2 percent in Afar in the northeast, to as high as 38.9 percent in the Sidama region in the south. There was no published mCPR in 2021 for Tigray, likely due to the conflict in the region making it difficult to conduct data collection. In 2021, about half of women (49.5 percent) who used contraceptives opted for injectables, followed by implants (33 percent), the pill (6 percent), emergency contraceptives (1.8 percent), sterilization (1.7 percent), and condoms (1 percent).

In a 2024 qualitative survey of 12 Ethiopian women aged 18 to 49 years from the Oroma region, respondents indicated a preference for injectables over other contraceptive methods because of the short-term nature of injectables, suitable for women planning to conceive soon. Respondents also perceived injectables as more aligned with religious teachings than long-term methods and found them to have minimal side effects as compared to other methods. While this qualitative survey had a very limited number of participants, the findings underscore that promoting informed choice through education and counseling can empower women to select contraceptive methods that best suit their needs and preferences, especially as knowledge of less-popular methods such as IUDs was found to be lower than that of injectables and pills. Increasing informed choice would also help generate demand for family planning and reproductive health services, thereby contributing not only to increasing family planning but also reducing maternal and child health risks.

Strengthening maternal and newborn care

Alongside steady progress in reducing unmet need for family planning and increasing mCPR, Ethiopia has reduced maternal deaths by a third from 952.8 deaths per 100,000 live births in 2000 down to 266.7 deaths per 100,000 live births in 2020. However, the country still missed its 2019/2020 target of 199 deaths per 100,000 live births due to a number of reasons, including limited health service coverage in remote regions, shortages of supplies and equipment at health care facilities, low provider-to-population ratios, insufficient health-seeking behavior within the community, and service disruptions due to the COVID-19 pandemic. Moreover, the number of unintended pregnancies in Ethiopia is estimated to have climbed from 1.6 million in 2012 to 1.9 million in 2023, which stems from a range of factors contributing to unmet need for family planning.

Child marriage continues to be a challenge in Ethiopia and contributes to the high prevalence of adolescent pregnancy. As of 2020, 40 percent of women ages 20 through 24 were married or in a union before turning 18, while the adolescent pregnancy rate was 67 girls per 1,000. Moreover, the sub-national picture is complex as large regional disparities exist, from a 3 percent adolescent pregnancy rate in Addis Ababa to 23.4 percent in Afar as of 2016. This disparity underscores the need to ensure that affordable and easy access to modern contraceptives is extended to remote and rural regions, especially in the aftermath of COVID-19. The pandemic disrupted adolescents’ access to family planning and reproductive health services in Ethiopia, with one estimate showing that between 2019 and 2020, there were 8,884 unintended adolescent pregnancies, 14 adolescent maternal deaths, and over USD 250,000 in costs related to adolescent pregnancy and newborn care. The impacts of crises such as COVID-19 demonstrate how hard-won gains can be quickly reversed.

Ensuring access to family planning and reproductive care

Aside from challenges in servicing key segments of the population such as youth, the most urgent family planning and reproductive health challenge facing Ethiopia is service delivery disruption in certain geographic locations embattled by conflict, disease outbreaks, drought, and other natural disasters. An expert practitioner from the multilateral sector described in an interview with FP Analytics the impacts of the conflict in the northern region: “We are facing situations where some workers have been abducted, and even some of our health workers have been impacted by the crisis, not only being displaced but also caught up in the violence that has been going on. It’s been quite challenging in some regions of the country, but there are also areas in the country which have remained fairly stable.” The humanitarian situation in Ethiopia highlights the critical roles of grassroots initiatives, multilateral relief organizations, and international NGOs in delivering health care to communities. As part of humanitarian aid efforts, it is important to prioritize family planning and reproductive health in the immediate aftermath of an emergency as well as throughout the duration of a prolonged crisis to reduce unmet need.

Preventing and managing reproductive cancers and diseases

Breast cancer had the highest mortality rate among all cancers in Ethiopia, at 24 deaths per 100,000 people, as of 2022, followed by cervical cancer at 16.8 deaths per 100,000 population. Although still a leading cause of cancer deaths, there has been a decline in the mortality and incidence of cervical cancer over the last decade, alongside the introduction of the first National Cancer Control Plan in 2015, which prioritized the expansion of vaccination for human papillomavirus (HPV) and improvement of early detection through increased screening programs. Meanwhile, ovarian cancer incidence has been increasing, with a 61 percent rise in mortality between 2010 and 2019, due to a combination of lifestyle and age-related risk factors. Regarding other reproductive diseases, Ethiopia has achieved significant progress in reducing HIV cases, as new HIV infections in the country have declined by 72 percent, and AIDS-related deaths by 51 percent since 2010. The current HIV prevalence rate is at 0.7 percent, or 660,000 people living with HIV, although the prevalence among sex workers remains high, at 18.3 percent. In recent years, the Ethiopian government and UNAIDS collaborated to develop a national HIV baseline survey in humanitarian settings and an HIV/sexual and reproductive health guiding document to monitor and ensure the needs of the displaced people are met.

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Policies and programs: Assessing multistakeholder efforts

Ethiopia’s 1995 constitution enshrined the right of women to family planning services and forms the basis of a rights-based approach in place today. Article 35.9 of the constitution states: “To prevent harm arising from pregnancy and childbirth and in order to safeguard their health, women have the right to FP education, information, and capacity.” Now in its third edition, Ethiopia’s Reproductive Health Strategic Plan 2021 to 2025 provides a detailed situational analysis of the country’s progress toward its family planning and reproductive health targets as well as revised targets, such as increasing mCPR among married women to 50 percent and increasing the share of health facilities providing youth-friendly services from 45 percent to 80 percent.

Ethiopia also has a separate National Guideline for Family Planning Services, published in 2020, which aims to improve the counseling capacity of health care providers and expand the involvement of the private sector in family planning services, among others. As a priority strategy in the Reproductive Health Strategic Plan, the government developed a Family Planning Service Integration National Implementation Guideline in 2021 to guide policy makers, health managers, and other service providers in facilitating the integration of family planning services into other primary health care services. Building on the efforts to integrate family planning services with maternal health care and HIV/AIDs prevention and treatment, the Ethiopian government plans to integrate family planning services with antenatal care, labor and delivery, postnatal care, abortion care, child health, adolescent and youth health, and other primary care areas. The document also establishes quality assurance measures and includes monitoring and evaluation tools to track progress, which must be implemented to be effective.

As a low-income country with resource constraints, in 2003 Ethiopia launched its Health Extension Program (HEP), which aims to achieve universal health coverage (UHC) through deploying community health workers across the country. The program focuses on primary health care in rural areas, and seeks to involve communities in their own care, particularly by training women as health extension workers (HEWs), thereby promoting community-led development and local ownership. Currently there are about 40,000 HEWs across the country responsible for implementing 18 packages of primary health interventions, including family planning and reproductive health services. The HEP has been credited with contributing to Ethiopia’s progress in various family planning and reproductive health outcomes and progress in the UHC index, which increased from 13.0 in 2000 to 35.0 in 2021. As Dr. James Okara Wanyama, UNFPA Humanitarian Programme Coordinator in Ethiopia, noted in an interview, “Ethiopia is one of the countries that adopted a task-shifting approach.” This entails training community health workers to deliver primary-level care at the household level and reducing the workload of doctors. He explained, “Through this approach, they have managed to build quite an extensive network of community health workers. The penetration of health care to communities is much, much better than most of the other neighboring countries.” This network of community workers has been critical in the provision of services, particularly in areas affected by recent conflict and disasters.

Nevertheless, areas of improvement have been identified by the Reproductive Health Plan with respect to the HEP, as disparities exist in health worker density across regions, from 0.47 health workers per 1,000 people in Somali and 0.49 per 1,000 people in Afar to 2.23 per 1,000 people in Addis Ababa and 2.28 per 1,000 people in Harari. Even where density is higher, coverage remains inadequate for population needs. The Reproductive Health Plan’s situational assessment showed that a high proportion of health care centers, 59 percent, were stocked out of one or more lifesaving maternal and reproductive health commodities. Health care workers need to be trained in the management of commodities, and the country needs to work with international partners to minimize delays in re-supplying maternal and reproductive health medicines.

Anticipating and targeting demographic change

Ethiopia has a young population, with 39 percent below 15 years of age, which presents demographic opportunities for the country. To realize the future socio-economic gains of a young population, current investments in their health and education are important to ensure that young people will be healthy and become productive members of the society. To this end, Ethiopia developed its National Adolescent and Youth Health Strategy (2021–2025), which includes targets to reduce the teenage pregnancy rate from 12.5 percent to 7 percent by 2025, improve health literacy among adolescents and youth, and increase their access to health services. Ethiopia is one of the 69 countries that pledged their commitment to FP2030, reiterating its goal of reducing teenage pregnancy to 3 percent by 2030.

Beyond targets, for health programs to resonate with youth and be effective, they need to reflect the lived experiences, goals, and priorities of this demographic. Jennifer Pope, Vice President for Sexual and Reproductive Health, HIV, and TB at PSI Global, explained:

When we’re working with youth, we work to understand their challenges, needs, and desires in life. Are there opportunities where SRHR could be helpful, and what components are relevant in terms of their journey in life and throughout their reproductive health cycle? It’s about understanding their individual needs, as well as things like social norms, gender, and power dynamics.

Pope went on to describe PSI’s strategy, explaining that, “Building on individual insights, it is also critical to understand the community context, as well as the market and health systems, including the private sector; access, including self-care options, as well as quality of care. Based on these insights, we co-design different prototypes with youth and key stakeholders to see what might resonate with the users to ensure initiatives resonate with them. We will then iterate and adapt accordingly based on feedback loops and impact.” To unlock the full potential of Ethiopia’s youth and drive sustainable development, the family planning and reproductive health needs of adolescents and young adults will have to be addressed through tailored programs sensitive to community dynamics and the socio-cultural context, especially in a culturally diverse country like Ethiopia.

Funding and coordinating family planning and reproductive health

Government and NGO health facilities generally provide contraceptives to patients free of charge in Ethiopia. The public sector was overwhelmingly the main source of modern contraceptive methods at 87 percent, followed by the private sector at 12 percent, and NGOs at 1 percent, according to the 2019 Ethiopia Mini Demographic and Health Survey. To cater to the needs of more Ethiopians and support the financial sustainability of public health care system, the Ethiopian government engages with the private sector for the delivery of family planning and reproductive health services. With support from USAID, the government published implementation guidelines for strengthening public-private models of delivering reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services. The private sector’s share of family planning and reproductive health care delivery is targeted to increase from 12 percent to 15 percent by 2030, providing additional resources and innovations to meet growing demand for commodities and services.

In terms of financing, the government has committed to reduce its heavy reliance on donor funding by increasing the domestic budget for family planning commodities by 1 percent every year, with support from UNFPA through a Country Compact. Ending reliance on international donor funding is a considerable challenge for Ethiopia, however, as the latest available data indicates that the share of donor funding is 42 percent for sexual and reproductive health services, although this share has declined over the years. Recently, in 2024, the government signed budget agreements with the Bill and Melinda Gates Foundation, the Susan Thompson Buffet Foundation, USAID, and the David and Lucile Packard Foundation to co-finance the procurement of a range of reproductive health commodities, including but not limited to family planning, amounting to USD 36 million, with 31 percent or USD 11.27 million to be financed by the government. Partnerships that drive sustainable service delivery, rather than hindering progress with short-term, fragmented programs, will be critical for Ethiopia to achieve its targets. 

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Looking ahead: Pursuing untapped opportunities and key priorities

In times of humanitarian crises, family planning and reproductive health services are often de-prioritized in favor of addressing immediate needs such as food, shelter, and disease control. This kind of de-prioritization can yield long-term repercussions for a country’s economic development and stability, as family planning and reproductive health services enable sustainable development and economic growth. Multisectoral and international coordination efforts become lifelines in such situations, helping ensure that displaced populations can access lifesaving health services, including family planning and reproductive health services. Ethiopia has taken steps in the right direction by working with organizations like UNAIDS, UNFPA, and the International Red Cross to help supply reproductive health commodities and services. Particularly notable is the government’s initiative with UNAIDS to develop an HIV baseline survey and HIV/SRH Guiding Document in humanitarian settings, which could be replicated and expanded to address other family planning and reproductive health services.

Health care workers in crisis-affected communities need sustained support and protection from the government, with assistance from multilaterals and donors, especially as these workers risk their lives to deliver essential health services. Moreover, as reports indicate that health care workers require upskilling in health systems management to reduce stockouts, the private sector and multilaterals could assist in further developing capacity of the Ethiopian health care workforce, possibly tapping into Ethiopia’s large diaspora community for skills training and knowledge exchange. The private sector can continue to coordinate with the government and seek opportunities as the latter plans to expand private sector involvement in health care systems. As a country where a young population defines its demographic landscape, aligning research agendas and national strategies with the needs of the youth—through multisectoral collaboration and active participation of youth groups from diverse ethnic and cultural backgrounds—could generate long-term socioeconomic returns and support Ethiopia’s transition to middle-income economic status.