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A critical review of rural development policy of Ethiopia: access, utilization and coverage

• Diriba Welteji   ORCID: orcid.org/0000-0003-0857-3885 1  

Agriculture & Food Security volume  7 , Article number:  55 ( 2018 ) Cite this article

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Agriculture is the mainstay of Ethiopian economy involving major source of employment and gross national product. By African, standard rural development programme has long history in Ethiopia. It has also enjoyed a considerable attention by the government. However, the expected level was not achieved. The main objective of this review is to indicate the policy gaps in terms of access, utilization and coverage of rural development policy programme packages by different segments of people in rural areas. The programme packages of rural development policy of the country were reviewed over the past three regimes. It was indicated that there were significant gaps in access, utilization and coverage due to wrong policy priority, institutional and technological variables.

When many African countries have shown limited commitment to supporting smallholder agriculture and when many neglected agricultural extension services in particular, the government of Ethiopia invested in both. On average, the share of national budget devoted to agriculture in the sub-Saharan Africa fell from 5.5% in 1993 to 3.8% in 2000. However, due to the commitment of heads of states in Maputo in 2003 to allocate 10% of their budget to agriculture and a recovery of attention to agriculture, Ethiopia is one of the eight countries to meet the target allocating 15% of the budget over the decade of 2003/2004–2012/2013 [ 1 ].

Agriculture is the backbone of the Ethiopian economy. This particular sector determines the growth of all other sectors and consequently the whole national economy. It constitutes over 50% of the gross domestic product (GDP), accounts for over 85% of the labour force and earns over 90% of the foreign exchange [ 2 ]. On average, crop production makes up 60% of the sector’s outputs, whereas livestock accounts for 27% and other areas contribute 13% of the total agricultural value added. The sector is dominated by small-scale farmers who practice rain-fed mixed farming by employing traditional technology, adopting a low-input and low-output production system. The land tilled by the Ethiopian small-scale farmer accounts for 95% of the total area under agricultural use, and these farmers are responsible for more than 90% of the total agricultural output [ 3 ].

According to Roling [ 4 ], rural development policies and programmes are usually developed to suit the condition of progressive farmers. Knowledge and awareness about the relative importance of each package component to overall yield give farmers room for flexibility in stepwise adoption of the technology, according to their conditions and resources. Development agents, extension professionals, subject matter specialists, farmers’ representatives, politicians and researchers tend to contact only them. Policy makers and donor agencies have so far been emphasized the use of modem farm technologies as a sole source of agricultural growth in Ethiopia. However, the cost of modern technologies is so prohibitive that few farmers in limited areas of the country are so far reached. Therefore, it is high time to explore possibilities for identifying approaches that could complement existing strategies of growth [ 5 ].

The country has varied agro-climatic zones. The government extension programme lists these as: areas of adequate rainfall; areas of moisture stress; and pastoral areas. Farmers traditionally classify them as dega (cool), woina dega (temperate) and qolla (low land; warm climate). This diversity makes it a favourable region for growing a variety of crops [ 6 ].

The rural development in Ethiopia has a relatively longer history than many sub-Saharan African countries. It has also enjoyed increasing government support over years, though not to be in the level expected. Review of the evolution of the Ethiopian rural development policy under different political systems reveals the significance of prevailing policies and development strategies on the contribution to agricultural development [ 7 ].

Under the Imperial Era, development policies favoured industrial development, neglecting the agricultural sector and worked mainly with the better-off and commercial farmers in and around major project areas. During the 1974–1991 periods, however, the political environment favoured collective and state farms at the expense of individual farmers. Distorted macroeconomic policies, political unrest and massive villagization and settlement programmes undermined the contribution that the rural development policies could have made. The post-1991 period is also marked with the most prominent and enduring economy-wide strategies as Agricultural-Led Industrialization (ADLI), the Sustainable Development and Poverty Reduction Program (SDPRP), Participatory and Accelerated Sustainable Development to Eradicate poverty (PASDEP) and successive growth and transformation plans (GTP I and II). These strategies intend, among others, to attain food self-sufficiency at national level by increasing productivity of smallholders through research-generated information and technologies, increasing the supply of industrial and export crops and ensuring the rehabilitation and conservation of natural resource base with special consideration of package approach [ 8 , 9 , 10 , 11 ].

Ethiopian agriculture has been suffering from various external and internal problems. It has been stagnant due to poor performance as a result of factors such as low resource utilization; low-tech farming techniques (e.g. wooden plough by oxen and sickles); over-reliance on fertilizers and underutilized techniques for soil and water conservation; inappropriate agrarian policy; inappropriate land tenure policy; ecological degradation of potential arable lands; and increases in the unemployment rate due to increases in the population [ 12 ].

Agriculture progresses technologically as farmers adopt innovations. The extent to which farmers adopt available innovations and the speed by which they do so determine the impact of innovations in terms of productivity growth. It is a common phenomenon that farmers like any other kind of entrepreneurs do not adopt innovations simultaneously as they appear on the market. Diffusion typically takes a number of years, seldom reaches a level of 100% of the potential adopters population and mostly follows some sort of S-shaped curve in time. Apparently, some farmers choose to be innovators (first users), while others prefer to be early adopters, late adopters or non-adopters [ 13 ].

Despite the fact that many areas of the economy have made progress, the livelihoods of small-scale farmers are still constrained by many impeding factors. The salient constraints include: small and diminishing farm lands due to large family sizes and rapid population growth; soil infertility with decreasing yield-per-hectare ratios; on-field and post-harvest crop pests; unpredictable patterns of rain; input scarcity and outdated technologies leading to low outputs; shortage of capital; reduced market access; lack of market information; outbreaks of animal diseases and shortages of animal feed; and declining price structures [ 6 ].

The methodology followed in this work is time frame critical review of rural development policy of Ethiopia implemented over a long periods of time by different regimes and the achievements compared among the regimes based on the policy instruments adopted accordingly and the total sum of gaps over a long period since its inception in terms of access, utilization and coverage. The objective of this paper is to assess success stories, lessons learnt and loopholes of the past rural development policy of Ethiopia in terms of access, utilization and coverage.

The possible questions of this review are:

Were the rural development policy packages of the country accessible to different segments of society?

Was there any gap of utilization and coverage of the technologies?

What were the rural development models implemented so far in the country?

Were the implemented rural development models in the country appropriate?

Literature review

Theories of agricultural development policies.

Following Ruttan [ 14 ], and Hayami and Ruttan [ 15 ], the literature on agricultural development can be characterized according to the following models: the frontier; the urban industrial impact; the diffusion; the high pay-off; the induced innovation; and the conservation. In what follows, we will review only those models which are more relevant to the conditions of Ethiopian agriculture.

The frontier model or the resource exploitation model involves an approach to agricultural growth through the expansion of the area cultivated or grazed. The southward movement of population throughout most of Ethiopian history demonstrates the importance of the frontier model in that country. However, there are few remaining areas in Ethiopia today where development along the lines of the frontier model would represent an efficient source of growth. The importance of the frontier model in Ethiopia is reduced mainly by limitations in physical availability of land in the temperate highlands. However, it is possible that government policies and institutions are contributing factors, as the World Bank noted in its recent country report on Ethiopia [ 5 , 16 ]. Besides, the ever-growing population pressure over land may not allow the average size of the operational holding to expand in the highlands where more than 80% of crop production takes place.

The high pay-off model, which is also known as “the transformation approach” or “the quick-fix approach”, is based upon investment designed to expand the diffusion and adoption of the high-yielding varieties. In Ethiopia, an attempt was made to partially introduce this model (along with the diffusion model) in the Comprehensive Package Project areas, where it had a strong impact, in particular in Chilalo district of Arsi region. However, the large-scale adoption of this model has been constrained by factors such as: the inability of the public and private sector research institutions to produce new and location-specific technical knowledge; the inability of the industrial sector to develop and produce new technical inputs; the weakness of the extension facilities and related institutions to diffuse the new techniques; the inadequacy of the infrastructure to facilitate the diffusion of the new inputs; the inability of peasant farmers to acquire new knowledge and use new inputs effectively; and lack of complementary inputs such as irrigation facilities which are needed to make fertilizers and modern varieties more effective [ 5 ].

The conservation model of agricultural development, according to Ruttan [ 14 ], “evolved from advances in crop and livestock husbandry associated with the English agricultural revolution and the notions of soil exhaustion suggested by the early German chemists and soil scientists. It was reinforced by the application to land of the concept, developed in the English classical school of economics, of diminishing returns to labour and capital”. The essence of this model is explained by the evolution of a sequence of increasingly complex land- and labour-intensive cropping systems, the production and use of organic manures, and labour-intensive capital formation in the form of drainage, irrigation and other physical facilities to more effectively utilize land and water resources [ 14 ].

The strength of this model emanates primarily from the fact that “the inputs used in this conservation system of farming (the plant nutrients, animal power, land improvements, physical capital and agricultural labour force) were largely produced or supplied by the agricultural sector itself” [ 14 ]. The importance of this point in poor countries such as Ethiopia is obvious. As underlined by Ruttan [ 14 ], “the Conservation Model remains an important source of productivity growth in most poor countries and an inspiration to agrarian fundamentalists and the organic farming movement in the developed countries”.

The major factors which make this model highly relevant to Ethiopian agriculture are: the fact that Ethiopia is unable to make widespread use of existing technological backlog due to, mainly, the high costs of generation and diffusion of new techniques of production; the possibility that the improvement approach involves cost-effective techniques of production and capital formation as it is based upon the use of the relatively abundant and that it could delay the operations of the law of diminishing returns as land is saved through labour intensification; and the fact that soil conservation programmes need special attention as the resource base of the agricultural sector is being depleted at an alarming rate due to the fact that the soil erosion and desertification process continue almost unabated [ 17 , 18 ].

Practices and history of rural development policies in Ethiopia

Development Plan has been documented since the 1950s in Ethiopia. During the period 1950–1974, the political arena was characterized by absolute monarchism. In the economic sphere, markets were the driving forces in resource allocation. Overall, GDP increased on average by 4% per year. The rate was higher than the 2.6% of growth in population [ 2 ].

According to Dejene Aredo [ 5 ], agriculture was also discriminated against by sectoral policies. The First Five-Year Development Plan placed emphasis on raising foreign exchange earnings by improving coffee cultivation, accounting for over 70% of foreign exchange earnings. Similarly, the Second Five-Year Development plan added to its priorities the establishment of large-scale commercial farms and neglected cereal production from subsistence farmers which accounted more than 80% of the cultivated area in the 1950s and 1960s. However, shortages of food in the late 1960s shifted the attention of policy makers to agriculture and priority was given in the Third Five-Year Plan without modifications to the overall growth strategy.

During the 1974–1991 periods, however, the political environment favoured collective and state farms at the expense of individual farmers. Distorted macroeconomic policies, political unrest and massive villagization and settlement programmes undermined the contribution that the rural development policies could have made. The post-1991 period is also marked with expansion of the development programmes [ 11 ]. The most prominent and enduring economy-wide strategy to guide development effort has been Agricultural-Led Industrialization (ADLI), the Sustainable Development and Poverty Reduction Program (SDPRP), Participatory and Accelerated Sustainable Development to Eradicate poverty (PASDEP) and successive growth and transformation plans (GTP I and II). These strategies intend, among others, to attain food self-sufficiency at national level by increasing productivity of smallholders through research-generated information and technologies, increasing the supply of industrial and export crops and ensuring the rehabilitation and conservation of natural resource base with special consideration of package approach [ 8 , 9 , 10 ] (Table  1 ).

As indicated in Table  1 throughout the phases, the interventions are not accessed by all segments of the society, limited to certain geographical areas in terms of coverage and constrained by different institutional factors.

During the imperial regime, emphasis was placed on raising foreign exchange earnings by cash crops and the establishment of large-scale commercial farms and neglected cereal production from subsistence farmers which accounted more than 80% of the cultivated area. During the 1974–1991 periods, however, the political environment favoured collective and state farms at the expense of individual farmers. Distorted macroeconomic policies, political unrest and massive villagization and settlement programmes undermined the contribution that the rural development policies could have made. Moreover, concerns shifted by large towards increasing productivity of smallholders to attain food self-sufficiency at national level through research-generated information and technologies, increasing the supply of industrial and export crops and ensuring the rehabilitation and conservation of natural resource base. However, population growth, environmental degradation, climate-related decline of yield, low level of farm input innovation, capital constraints are among the pressing constraints.

Compared to other sub-Saharan Africa, Ethiopia has an admirable record of supporting agriculture; the continued state-led policies to boost agricultural production, but understanding of the complex issues involved, evidence-based analysis and policy recommendations, and continuous debate on the pros and cons of alternatives options are required. Continued public engagement in input markets and extension services, and participation of private investment in providing goods and services for smallholders in a potentially efficient manner should be encouraged. Overall assessment of the access, utilization and coverage of the technological packages of rural development in the country was not realized although there were significant attentions across regimes.

Abbreviations

Agricultural Marketing Corporation

Agricultural Input Supply Corporation

Agricultural Input Supply Enterprise

Ministry of Agriculture

Minimum Package Program

Peasant Agricultural Development Program

Participatory Demonstration and Training Extension System

National Agricultural Extension Intervention Program

Transitional Government of Ethiopia

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Welteji, D. A critical review of rural development policy of Ethiopia: access, utilization and coverage. Agric & Food Secur 7 , 55 (2018). https://doi.org/10.1186/s40066-018-0208-y

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A review on One Health approach in Ethiopia

Gashaw adane erkyihun.

1 Ministry of Agriculture, Federal Democratic Republic of Ethiopia, P.O. Box 62347, Addis Ababa, Ethiopia

2 College of Veterinary Medicine, Addis Ababa University, P.O. Box 34, Bishoftu, Ethiopia

Fikru Regassa Gari

Bedaso mammo edao, gezahegne mamo kassa, associated data.

All reviewed data and materials during the period of review are included in this article.

The risk of spreading emerging and reemerging diseases has been increasing by the interactions of human – animal – ecosystems and increases account for more than one billion cases, a million deaths and caused hundreds of billions of US dollars of economic damage per year in the world. Countries in which their household income is dependent on livestock are characterized by a strong correlation between a high burden of zoonotic disease and poverty. The One Health approach is critical for solutions to prevent, prepare for, and respond to these complex threats. As part of the implementation of the Global Health Security Agenda, Ethiopia has embraced the One Health approach to respond to the existing and emerging threats. Several developments have been made to pioneer One Health schemes in Ethiopia which includes establishment of the National One Health Steering Committee and Technical Working Groups, prioritization of zoonotic diseases based on their impact on human and livestock, the development of prevention and control working documents for prioritized zoonotic diseases, joint disease surveillance and outbreak investigation, prioritization of zoonotic diseases , capacity building and other One Health promotions. Nevertheless, there are still so many challenges which need to be addressed. Poor integration among sectors in data sharing and communication, institutionalization of One Health, lack of continuous advocacy among the community, lack of financial funds from the government, limited research fund and activities on One Health, etc. are among many challenges. Hence, it is critical to continue raising awareness of One Health approach and foster leaders to work across disciplines and sectors. Therefore, continuous review on available global and national one health information and achievements to provide compiled information for more understanding is very important.

Zoonotic diseases account for more than one billion cases and a million deaths per year with the high costs responsible for emerging and pandemic ones [ 1 ]. Now a days, the risk of spreading these diseases has been increasing by the interactions of human – animal – ecosystem due to the exponential growth in human and livestock populations, rapid urbanization, rapidly changing farming systems, closer integration between livestock and wildlife with forest encroachment, destruction of habitat, changes in ecosystems, and the globalization of trade [ 2 ]. Nearly two-thirds of humans infectious diseases arise from pathogens shared with wild or domestic animals. However, ecological, evolutionary, social, economic, and epidemiological mechanisms affecting zoonoses persistence and emergence are not well understood. Multi-sectoral collaboration, including public health scientists, ecologists, veterinarians, economists, and others, is necessary for effective management of such diseases [ 3 ]. Health threats aggravators such as war, nutrition insecurity, pollution, loss of biodiversity, degraded ecosystem and climate change are becoming common factors [ 4 ]. A One Health approach is not only critical for solutions to respond to these threats but also an effective platform to address challenges, coordination mechanisms and global development goals [ 5 ]. Countries in which their household income depends on livestock are characterized by a strong correlation between a high burden of zoonotic disease and poverty ( 6 ). Ethiopia has the largest livestock, second largest human population and considerable wildlife species in Africa. About 80% of her citizens are dependent on agriculture and have direct contact with domestic animals. This could cause a high risk of zoonotic disease transmission and emerging and reemerging pandemic threats and the country is believed to be on a high burden of zoonotic disease [ 7 ]. The country is also near to East African countries which are frequently prone to emerging and epidemic diseases (such as avian influenza and Ebola). For instance, Ebola Virus Disease (EVD) outbreak has occurred more than 13 times, 6 times and 3 times in Democratic Republic Congo, Sudan and Uganda respectively [ 8 ]. On the other hand, a highly pathogenic avian influenza outbreak was reported from Uganda in 2017 and Zambia in 2019 [ 9 ]. In addition to these, the presence of endemic zoonotic diseases (like rabies, anthrax, brucellosis etc.) coupled with limited animal and human health care is also cause a significant impact on the national economy.Thus, reducing the zoonotic disease burden through One Health approach will improve the overall health of populations and contribute to the alleviation of poverty [ 10 ].

Ethiopia has achieved considerable One Health approach activities to push forward the Global Health Security Agenda (GHSA) commitments and to prevent, detect, and respond to existing and emerging threats since the 2000s. It has already established a National One Health Steering Committee (NOHSC) and Technical Working Groups (TWG) with a five-year strategic plan for the period 2018–2022. In Ethiopia, several achievements have been recorded so far (such as extension of one health schemes to the regional governments, joint disease surveillance and outbreak investigation activities, joint vaccination activities against zoonotic diseases, prioritization of zoonotic diseases, development of control and prevention strategic documents for different prioritized zoonotic diseases [ 11 ], one health and world rabies day celebration. However, awareness creation about One Health principles and importance, for the community and responsible bodies is limited. Little or no review (to provide compiled information) has been conducted regarding One Health in Ethiopia. Therefore, there is a need to strengthen One Health approach by reviewing available achievements, initiatives, activities and challenges. So, this review is believed to highlight potential areas of collaboration between the Ethiopian medical, veterinary sector and other scientific communities. A semi-quantitative method of review on available literature and consultations with selected One Health stakeholders was conducted. Specifically, all available information on One Health related to Ethiopia was searched for in global peer-reviewed databases using relevant search terms related to One Health. References are reviewed from retrieved articles to identify relevant publications. In addition to literature found via PubMed, data publicly available on websites of the World Health Organization (WHO), the United Nations Food and Agriculture Organization (FAO), United States Centre of Disease Communication (US CDC), International Livestock Research Institute (ILRI), Ethiopia’s One Health responsible Ministries and other websites were also included.

General perspective of One Health

Definition of one health.

The terms ‘One Medicine’ and ‘One Health’ have been used to describe the concept of an integrated approach to animal, human and environmental health and to acknowledge that we are all part of ‘One World’ in which animals, people and the environment are interdependent and must rely on each other for basic survival [ 12 ].One Health is collaborative approach for strengthening systems to prevent, prepare, detect, respond to, and recover from infectious diseases and related issues such as antimicrobial resistance that threatens human -animal—environmental health collectively [ 1 ]. It is an approach as ‘a collaborative and all-encompassing way to address animal and public health globally not only at international level, but must be translated as a new paradigm at national levels’[ 13 ]. One Health approach is described as either a narrow approach primarily combining public health and veterinary medicine or as a wide approach as in the wide-spread ‘umbrella’ depiction (Fig.  1 ) including both scientific fields and interdisciplinary research areas [ 14 ], 15 . The One Health concept is a worldwide strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans, animals and the environment. The synergism achieved will advance health care for the twenty-first century and beyond by accelerating biomedical research discoveries, enhancing public health efficacy, expanding scientific knowledge, and improving medical education and clinical care. When properly implemented, it will help protect and save untold millions of lives in our present and future generations [ 16 ].

The ‘One Health Umbrella’ developed by the networks ‘One Health Sweden’ and ‘One Health Initiative’ to illustrate the scope of the ‘One Health concept’ [ 17 ]

One Health is a collaborative, multi-sectoral, and trans-disciplinary approach (Fig.  2 )—working at the local, regional, national, and global levels—with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment [ 18 ].

Typical example of one health coordination, Lilongwe Wildlife Trust, Clinical Project in One Health, Malawi [ 19 ]

The rise of One Health concept

Rudolf Virchow (1821–1902) considered as the father of comparative medicine, cellular biology and veterinary pathology for his contribution to medicine, incorporating veterinary medicine in human health care and effectively launched the One Health concept in the nineteenth century. He asserted that there is no dividing line nor should there be between animal and human medicine. He also coined the term “zoonosis” for a disease transmissible from animals to humans. This founding concept is a worldwide paradigm shift strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans and animals [ 20 ]. The building concept of “ One World, One Health ” was also formulated by the Wildlife Conservation Society in 2004 by establishing an interdisciplinary and cross-sectoral approach to prevent epidemic or epizootic disease and for maintaining ecosystem integrity [ 21 ]. In 2008, the importance of this concept is further strengthened by the FAO, OIE,WHO, United Nations Children’s Fund), the World Bank and United Nations System of Influenza Coordinator and produced a document entitled ‘contributing to One World, One Health’, a strategic framework for reducing risks of infectious diseases at the animal-human-ecosystems interface [ 22 ]. The World Medical Association (WMA) in its resolution on the collaboration between Human and Veterinary Medicine, adopted in October 2008, recommends the collaboration between human and veterinary medicine and supports the concept of joint educational efforts between human and veterinary medical schools [ 21 ]. Since then the One Health concept has become more important and in recent years its initiatives have been rapidly gaining ground [ 23 ]. Another important action, which increased the platform of One Health, is the Global Conference on One Health (held in Spain, May 2015) by the World Veterinary Association (WVA) and the World Medical Association (WMA),. The conference has recommended the need to increase cross-disciplinary collaboration between the veterinary and medical professionals in order to improve human and animal well-being [ 24 ].

Global One Health initiatives

The importance and interventions of One Health are fundamentally linked in food systems, health impact of zoonotic diseases, drug resistance, economic losses and many other health impacts [ 5 ]. The risk of spreading emerging and reemerging diseases has been increasing by the interactions of human– animal–ecosystem increases due to the exponential growth in human and livestock populations, rapid urbanization, rapidly changing farming systems, integration between livestock and wildlife, forest encroachment, destruction of habitat, changes in ecosystems, and the globalization of trade [ 2 ]. Due to this, there is a need for interconnections among the health of humans, animals, and the environment for effective prevention and control measures through collaboration approach [ 25 ]. Hence, several institutions are formally supporting One Health approaches in the country and at global level [ 24 ]. With national, transnational or global partnerships, various One Health collaboration actions have achieved so far, such as controlling rabies in Bali, Indonesia; controlling Q fever outbreaks in the Netherlands; the Human Animal Infections and Risk Surveillance (HAIRS) group in the United Kingdom; control of food borne Salmonella in the European Union [ 26 ]. The WHO, OIE, and FAO also formed the tripartite agreement in 2010 to work together on AMR, rabies, zoonotic influenza, zoonotic tuberculosis and Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) [ 27 ]. A One Health Operational Framework published by the World Bank in 2018 also provides an overview and compendium of work with key initiatives and entities, implementation guidance, and an annex of resources [ 1 ]. Several agencies in various countries have One Health webpages with a variety of resources, including US CDC [ 28 ]. The WHO, FAO and OIE, as well as the United Nations Environmental Programme (UNEP) are working together to facilitate cross-sectoral collaboration at the global level to manage health risks and improve global health security [ 29 ].

Currently, FAO and WHO through the Global Health Security Agenda’s Zoonotic Diseases and Animal Health in Africa (GHSA-ZDAH) has been supporting many One Health interventions through policy documents, control strategies, protocols, evaluations, national veterinary laboratories strengthening, epidemio-surveillance capacity and workforce development [ 30 ]. The One Health approach has been adopted by various countries as the core driver of the Global Health Security Agenda (GHSA) [ 31 ]. The Global Health Security Agenda (GHSA), an alliance of over 70 governments and international partners, was launched in February 2014 with the aims of driving and advocating for a world safe and secure from infectious disease threats; bringing together nations from all over the world to make new, concrete commitments, and elevating global health security as a national leaders-level priority [ 32 ]. Due to its urgency and various importance, One Health approach has increasingly been adopted in national and international plans and strategies of many countries [ 33 ].

One Health frameworks in Ethiopia

Ethiopia is a GHSA member country and many of its One Health activities are supported within the framework of improving global health security. While emerging and epidemic-prone diseases such as avian influenza and Ebola present a global threat, endemic zoonotic diseases, such as rabies and anthrax, affect the health of animals and humans and are a major source of economic loss [ 10 ]. In recognition of the intrinsic relationship between humans, animals, and their environment, and as part of the implementation of the GHSA, the country increasingly has embraced the One Health approach to prevent, detect, and respond to existing and emerging threats and there is a strong political commitment by the government [ 34 ], 14 .

The establishment of One Health platform

In 2015, the first One Health Zoonotic Disease Prioritization workshop, in Ethiopia, was held and brought multiple ministries and partners together to develop a list of zoonotic diseases of the greatest national concern. Key national government stakeholders involved and implemented joint zoonotic disease surveillance, control and outbreak response activities such as such as MOH, MOA) and the EWCA were involved in the implementation of joint zoonotic disease surveillance, control and outbreak response activities [ 34 ]. Within the MOH, the EPHI leads human outbreak investigations, surveillance, and laboratory diagnostics for humans, as well as diagnostics for rabies in animals. Within the MOA, the Veterinary Public Health Directorate, the Disease Prevention and Control Directorate, and the Epidemiology Directorate are primarily responsible for surveillance and response activities in livestock, in partnership with NAHDIC), where most animal disease diagnostics are performed. The EWCA is responsible for the conservation and management of wildlife and its habitats in collaboration with MOA. In line with this, One Health collaborations have continued and the National One Health Steering Committee (NOHSC) was established and got momentumin its effort to create a sustainable national One Health Platform [ 10 ].

The development of National One Health Steering Committee and signing of memorandum of understanding

In 2016, four key Ethiopian Ministries joined together to establish the NOHSC with the support of the government of Ethiopia and other partners [ 35 ]. The members of the NOHSC were constituted from the MOH, MOA, EWCA, MCT and Universities such as Addis Ababa, Jimma and Mekelle representing OHCEA. In addition, International Organizations and Partners participated in NOHSC include: US CDC, FAO, USAID, WHO, Emerging Pandemic Threat (EPT-2) Partners, and OSU-GOHI). Only government stakeholders had a voting right during the period of the establishment. The Steering Committee has an operational framework of a chair, co-chair and secretary nominated from core government sectors. The committee would hold a meeting on a monthly basis. It shall also adopt a formal system of recording its business in line with relevant rules and guidelines from the government of Ethiopia [ 10 ]. One of the NOHSC’s primary goals is to strengthen zoonotic disease prevention, detection and response through a long-term and collaboration at the national and sub-national level. The responsibilities of the Committee’s leadership are to ensure balance and overcome previous problems with multi-sectoral coordination as well as promoting one health goal. The Steering Committee received financial and technical support from partners, local non-governmental organizations (NGOs); and Ethiopian universities [ 36 ]. The NOHSC has laid many critical milestones since its inception. For example, the four Ethiopian Ministries signed the memorandum of understanding (MOU) (Fig.  3 ) in 2018 which was believed to formalize the commitment between the parties to work together on joint disease surveillance, data sharing, preparedness and communication planning, outbreak investigation and response, and related activities. It has also drafted a National One Health Strategic Plan for 2018–2022. This strategic plan included an organizational framework with detailed guidance on how the National Steering Committee would address One Health engagement across disciplines and sectors in its task to prevent, detect and respond to endemic, emerging and re-emerging infectious disease threats at the human–animal–environment interface [ 34 ].

The founding members of Ethiopian National One Health Steering Committee and the Signed Memorandum of Understanding (obtained from NOHSC with permission)

Initiatives which encourage ethiopian One Health approach

There are various Partner One Health Initiatives in the country which have been working in collaborations with government and other institutions, such as universities/research institutions, Non-Governmental Organizations (NGOs) and donor organizations with three main purposes: the prevention of new zoonotic disease emergence, early detection of new threats, and timely and effective response to them [ 35 ]. According to Onyango et al. [ 36 ] and Fasina and Fasanmi [ 14 ]some of them include:

• Jigjiga One Health Initiative (JOHI) is funded by the Swiss Agency for Development and Cooperation (SDC) and run by Jigjiga University, the Armauer Hansen Research Institute (AHR) and the Swiss Tropical and Public Health Institute in Basel. It was aimed at building the capacity of Jigjiga University to become a center of excellence for One Health studies and creating innovative systems for the improvement of health and wellbeing of pastoral communities.
• The Ohio Global One Health Initiative by the Ohio State University Health Sciences which focused on improving the capacity of pre-service health professionals in Ethiopia and established the African regional office in Addis Ababa in 2017.
• One Health Regional Network For the Horn Of Africa is a multidisciplinary, international partnership led by the University of Liverpool in partnership with Liverpool School of Tropical Medicine, United Kingdom; University of Nairobi, and International Livestock Research Institute, Kenya; University of Addis Ababa, and the International Livestock Research Institute, Ethiopia; Sheikh Technical Veterinary School, Somaliland; Hamelmalo Agricultural College, Eritrea; and other national and international organizations. The project was funded by the Biotechnology and Biological Sciences Research Council Fund and aims at improving the research capacities of individuals and institutions particularly on human and animal health issues and creating a One Health Regional Network for knowledge and information sharing [ 14 ].
• One Health Central and East African (OHCEA) University Network is a network of 21 public health and veterinary universities from 8 countries in the East, Central and West Africa regions. In Ethiopia, 3 universities, Jimma, Mekelle and Addis Ababa are members of this network that aims at cultivating the culture of multi-sectoral collaboration through field attachment, experiential learning, training and research.
• Moreover, international organizations such as USAID, WHO, CDC, FAO and others have been aggressively supporting one health issues and working on advocacy and awareness on antimicrobial resistance.

One Health approach achievements in Ethiopia

The establishment of different technical working groups.

The National One Health Steering Committee has established different national Technical Working Groups (TWGs) including Rabies, Anthrax, Brucellosis, Emerging Pandemic Threats (EPT), Antimicrobial Resistance (AMR) and National One Health Communication Task Force to promote multi-sectoral coordination and collaboration on One Health related activities. Each TWG represents a specific zoonotic disease with particular emphasis on prioritized ones (such as anthrax, rabies and brucellosis) and main pandemic threats like highly pathogenic avian influenza, Rift Valley Fever (RVF). The technical working groups are composed of veterinary and medical experts in virology, bacteriology, microbiology and epidemiology and provide a platform for strategic discussions. The working group members include government and non-government stakeholders and are officially nominated from line ministries to the National One Health Steering Committee [ 10 ].

Extension of One Health schemes to the regional governments

So far, the national One Health coordination structures have already been extended to 7 Regions (Amhara, Oromia, Southern Nations Nationalities People Region (SNNPR), Tigray, Somali, Benishangul-Gumuz, and Gambella). In addition to this, the structure has further extended to 7 Zones, and 17 districts in different regions of the country [ 37 ].

The development of national One Health strategic plan (2018 -2022)

The NOHSC developed a National One Health Strategic Plan (2018–2022) for the overall guidance of one health approach in Ethiopia (Fig.  4 ). The strategic plan is the roadmap for the country to achieve the long-term goal of prevention, detection and response to “negligible risks and impacts of endemic, emerging and re-emerging health threats at the animal-environment-human interface". Moreover, the strategic plan includes an organizational framework with detailed guidance on how the NOHSC will address One Health engagement across disciplines and sectors in its tasks [ 38 ]. Ethiopia aims to achieve this goal through the five key pillars and objectives which include: coordination and collaboration to ensure effective one health schemes, preparedness and response to emerging and re-emerging priority threats, multi-sectoral surveillance and reporting system, advocacy and communication as well as research and capacity building. The National One Health Steering Committee has also developed and been implemented a Risk Communication and Community Engagement (RCCE) strategy document (Fig.  4 ) which provide a comprehensive guidance for response zoonotic disease including COVID-19 outbreak and to mitigate the impact of emerging and reemerging diseases,

The National One Health Strategic Plan and Its Communication Message Guide taken from NOHSC with permission)

The development of control and prevention strategic documents for different prioritized zoonotic diseases

Several strategic documents for prioritized zoonotic diseases have also been developed and validated by each National Technical Working Groups together with partners and other stakeholders and finally endorsed by the National One Health Steering Committee. With the overall leadership of the members of each National Technical Working Group in drafting their strategic document, key responsible ministries, regional health and livestock and/or animal health bureaus, research institutions, universities and development partners have engaged during the development of the document. Each strategic document is a joint plan of key ministries ( Ministry of Health, Ministry of Agriculture, Ministry of Culture and Tourism and Ministry of Environment, Forest and Climate Change which has been endorsed by NOHSC. International partners and other stalk holders were also represented and actively participated during the development and validation of the documents. Each strategic document has its own framework (developed based on OIE, WHO, FAO principles), stepwise approach and implementation phases.

The first national control and prevention strategy document which has been endorsed to be implemented from 2018–2030 and currently under enactment is the National Rabies Control and Elimination Strategic Document. It was developed with the goal to eliminate all human rabies deaths by 2030 through a strategic vaccination campaign that achieves and maintains a vaccination rate of at least 70% of the domestic dog population in the country (Fig.  5 ). The second strategic document which was endorsed to be implemented from 2018 – 2030 is Anthrax Prevention and Control Strategic Plan. The overall mission of this plan is to significantly reduce and ultimately control the public health impact of anthrax in humans and animals, in Ethiopia, through sustained surveillance, laboratory diagnosis, prevention and control systems and community awareness (Fig.  4 ).The other strategy document is the National Brucellosis Prevention and Control Strategic Plan (2020–2030). This has the mission of reducing the impact of brucellosis in livestock and humans in Ethiopia by 2030 through multi-sectoral and community engagement at all levels.

Some of validated One Health approach strategic documents (obtained from Ministry of Agriculture with permission)

The fourth important strategic documents, prepared by the key ministries having a role in the one health activities, are a Multi-sectoral Preparedness and Response Plan for Highly Pathogenic Avian Influenza. It was prepared with financial support of Partners. The purpose of the preparedness and response plan is to prevent and/or mitigate transmission of pandemic Avian Influenza virus strain and protect the health, social and economic wellbeing of the population. Rift Valley Fever Multi-sectoral Preparedness and Response Plan is also among the strategic documents. The plan is thought to address prevention and control of Rift Valley Fever in humans and animals through professionals and relevant institutions through involvement of professionals in the surveillance, detection and response to RVF outbreaks. The scope could extend to bilateral agreements with neighboring countries to jointly prevent and control the threat. Another important strategic document is Prevention and Containment of Antimicrobial Resistance. Its goal is to prevent, slow down, and contain the spread of antimicrobial resistance through the continuous availability of safe, effective, and quality-assured antimicrobials and their effective use thereof. This can only be achieved through collaborative actions among partners in human health, animal health, the environment, agriculture, the food industry, teaching and research institutes, civil societies and associations, the pharmaceutical industry, and global stakeholders to synergize efforts and resources (Fig.  5 ).

Joint disease surveillance and outbreak investigation activities

The country with the Technical Working Groups (TWGs) has been coordinating and conducting joint disease surveillance and outbreak investigations activities following reports received from various locations in the territory of the country. It has conducted joint anthrax disease outbreak investigations in 2018 for suspected animal and human cases. The investigation team consisted of regional veterinarians, medical workers and national-level laboratory and epidemiology experts were deployed for the investigation. Safe sample collection and transportation training was completed only days before the outbreak investigation mentioned above. As a result, the responders were better prepared and equipped to collect samples from both animal and human suspected cases (Fig.  6 ). A joint investigation team composed of community animal and human health experts, local representatives and faculty members of College of Health sciences of Jimma University were engaged on another anthrax outbreak investigation in Oromia Regional State in 2018. In the same year, Rabies joint outbreak investigation was led by the Ministry of Health and Ministry of Agriculture after having trained on animal sample collection and transportation. Furthermore, in the mid-2018, Rift Valley Fever outbreak was reported across an extensive geographic range in East Africa, including areas bordering Ethiopia. Thus, in preparation for its possible spread to Ethiopia, the Ministry of Agriculture worked with the NOHSC to organize One Health preparedness planning, coordinating teams to conduct enhanced surveillance activities in at-risk border zones [ 10 ].

CDC and Ethiopian animal rabies surveillance officers in Ethiopia, 2016 [ 39 ]

A multidisciplinary and multi-sectoral team (Fig.  7 ). was also organized and deployed by the Emergency Pandemic Threat-Technical Working Group for joint survey and potential outbreak investigation was conducted in the Borena zone of Oromia region. This was conducted following the Rift Valley Fever outbreak report in northern Kenya and mass wild birds (pigeons) mortality in the South Omo zone of Southern Nations Nationalities People Region. This multidisciplinary team also conducted anthrax outbreak investigation in Wag Himra and North Gondar zones of Amhara Region and Assosa zone of Benishangul-Gumuz region.

Joint outbreak field investigation team discussing while anthrax outbreak investigation and Laboratory workers collect samples from the bone remains of a suspected anthrax case [ 10 ]

Vaccination activities against zoonotic diseases

The Ministry of Health represented by the Ethiopian Public Health Institute (EPHI) and Ministry of Agriculture with the support of global partners US CDC, Ohio State University Global One Health Initiative (GoHi) and the Global Alliance for Rabies Control, and the European Union-Health of Ethiopian Animal for Rural Development (HEARD) project have been conducting mass dog vaccination campaign(MDVC) in collaboration with regional and city administrations. Since 2016, more than 50,000 dogs have been vaccinated. The campaigns were achieved after providing training for veterinary, medical and public health staff regarding animal handling, vaccine safety, vaccination evaluation and dog population estimation methods. The vaccination activities were a reflection of how successful One Health collaborations among government partners were. It also showed how strategic support and mentoring from global experts can help in materialising and sustaining the goals of the TWGs and workforce [ 10 ].

Prioritization of zoonotic diseases in Ethiopia

There are three strategies — predict, respond, and prevent — and eleven packages which were developed to achieve the strategies by GHSA. One of the main packages is addressing the burden of zoonotic diseases [ 40 ]. In Ethiopia, there are large numbers of zoonotic diseases which are endemic. Hence, prioritization of zoonotic diseases based on impacts on both human and animal is of paramount importance so as to jointly address experts from both animal health agencies and public health authorities. Accordingly, two prioritization processes of zoonotic diseases were conducted; in 2016 and 2019.

The first prioritization of zoonotic diseases in Ethiopia

The first zoonotic diseases prioritization workshop in Ethiopia was held in 2015 by participating organizations form Federal Ministry of Health represented by Ethiopian Public Health Institute, the Ministry of Livestock and Fishery Resources, the Ministry of Environment and Forestry, WHO, United States Centres for Disease Control and Prevention, Defence Threat Reduction Agency/Cooperative Biological Engagement Program, the Ohio State University, Food and Agriculture Organization of the United Nations, and Armauer Hansen Research Institute/Swiss Tropical and Public Health Institute using a in Addis Ababa [ 7 ]. The workshop participants identified five criteria for ranking among 43 zoonotic diseases through group discussion. The criteria used to select the final five prioritized zoonotic diseases are unique to Ethiopia and includes: Severity of human disease in Ethiopia (diseases having the highest number of deaths rates per population in humans were deemed to have priority), proportion of human disease attributed to animal exposure, burden of animal disease (priority was given to diseases that have negative impacts at the household level in Ethiopia by causing production losses in Livestock), availability of interventions (vaccines targeting diseases in animal and medical intervention available for people), and existing inter-sectoral collaboration ( disease which has focus of inter-sectoral collaboration gained full credit). Finally, five top zoonotic diseases (rabies, anthrax, brucellosis, leptospirosis, and echinococcosis) were selected and ranked for inter-sectoral engagement by human and animal health agencies [ 39 ].

Re-prioritization of zoonotic diseases in Ethiopia

Ethiopia is the first country in Africa to utilize the One Health Zoonotic Disease Prioritization Process (OHZDP) for the second time to update the priority zoonotic disease list. Because of the request from Ministry of Agriculture and other relevant stakeholders for the reprioritization of current country’s public health and economic importance of diseases, the National One Health Steering Committee in collaboration with US CDC and Human Resource for Health -2030 (HRH2-030) organized national level zoonotic diseases re-prioritization workshop from September 24–25, 2019 in Addis Ababa. Experts from national and regional level and key stakeholders of the National One Health Steering Committee (Ministry of Health; Ministry of Agriculture; Environment, Forestry, and Climate Change Commission; and the Ethiopian Wildlife Conservation Authority and partners such as USAID, CDC, FAO, WHO, Veterinary Sans Frontiers -Suisse, etc.…) were participated on the workshop (Fig.  8 ).. Accordingly, 41 Zoonotic diseases were considered for prioritization and criteria utilized to determine the ranked outcomes of the One Health Zoonotic Disease Reprioritization process are epidemic or pandemic potential, availability of prevention and control strategies, severity in humans, socioeconomic impact and presence of disease in Ethiopia. After the two days exercise, a list of five top zoonotic diseases of greatest national concern was agreed upon by voting members. These are: Anthrax, Rabies, Brucellosis, Rift valley fever, and Zoonotic Avian Influenza which are identified as the five national priority zoonotic diseases in Ethiopia [ 41 ].

Participants of One Health zoonotic disease re-prioritization workshop in Ethiopia, Photo taken from the workshop by the first author

Awareness creation

The NOHSC established National One Health Communication Taskforce (OHCTF) in 2019 to facilitate planning and implementation of advocacy and communication interventions for One Health program in the country. The task force has been working aggressively since its establishment. The communication taskforce has developed One Health website and telegram channel, prepared, printed and distributed many copies of national zoonotic diseases message guide and National Rabies Control and Elimination Strategic Documents (Fig.  4 ). At the global level, the World Health Organization WHO), OIE, FAO and the Global Alliance for Rabies Control (GARC) have launched 'World Rabies Day' (WRD) campaign in 2007 as a response to the call to raise global awareness and mobilize resources for rabies prevention and control and it has been celebrating annually every September 28 which is the largest unifying initiative on the prevention of the disease [ 42 ]. Based on this, celebration of the World Rabies Day in Ethiopia promoting One Health has begun since 2017. The 2021 celebration day workshop was held on 28 September (Fig.  9 ).

Moment of World Rabies Day Celebration in Ethiopian, 2021 September 28(Ministry of Agriculture)

Opportunities, challenges and solutions of One Health approach in Ethiopia

Opportunities and challenges.

There are several achievements and opportunities to extend the One Health schemes and philosophies to deal with zoonotic diseases in Ethiopia. The opportunities include strong interest from technical people in the ministries, the establishment of the National One Health Steering Committee and prioritized zoonotic diseases Technical Working Groups and their active engagement, and interest and support from various NGOs. However, there are still considerable challenges which stakeholders and responsible government bodies should be aware of [ 38 ], 30 . According to Fasina and Fasanmi, 2020, some of the challenges include:

• Poor integration among animal and human health sectors in data sharing and lack of awareness and continuous advocacy across the relevant sectors and community members
• Leadership and commitment from higher government officials including budgeting is still not strong
• Weak encouragement and collaboration between regional One health task forces
• Competing priorities among prioritized zoonotic diseases prevention and control strategic plans (Ethiopia has already planned more than three zoonotic diseases to control and eliminate them by 2030).
• Limited laboratory diagnostic capacity, resulted in poor detection of outbreaks/causative agents
• One Health-based course in the curriculum of human medicine, veterinary medicine and other related disciplines in most universities are still not included.
• Lack of clear legislation on the engagement of public–private partnership pertinent to One Health

Possible solutions could be awareness of One Health and foster leaders who are uniquely skilled to work across disciplines and sectors, rapidly Institutionalize the One Health approach. The NOHSC with its TWGs should not only extend the One Health concept to the community level but also begin operation of prioritized zoonotic diseases prevention and control measures based on urgent revision of competing priorities. Universities should include One Health philosophies and principles to academic curricula, including designated degree programs as well as incorporating the One Health research issues into their thematic areas. In addition to these, capacitating diagnostic laboratories, encouraging research activities and advising to increase leadership commitment are very important.

The risk of spreading of emerging and reemerging zoonotic diseases has been increasing by the interactions of human, animal and ecosystem and accounts for more than a billion cases, a million deaths and hundreds of billions of United States dollars of economic damage per year. The One Health approach is critical for solutions to prevent, prepare for, and respond to these complex threats. Countries, like Ethiopia, in which their household income is dependent on livestock, are characterized by strong correlation between a high burden of zoonotic disease and poverty. Thus, reducing the zoonotic disease burden through OH approach is crucial to improve the overall health. In recognition of the intrinsic relationship between humans, animals, and their environment, and as part of the implementation of the GHSA, the country increasingly has embraced the One Health approach to prevent, detect, and respond to existing and emerging threats. Several One Health initiatives and workforces have been developed so far including the establishment of the NOHSC and different prioritized zoonotic diseases Technical Working Groups, the development of control and prevention strategic documents for different prioritized zoonotic diseases, conducting joint disease surveillance and outbreak investigation activities, re-prioritization of zoonotic diseases , beginning of capacity building for diagnostic laboratories and other One Health promotions. Nevertheless, there are still so many challenges which require serious considerations. Poor integration among sectors in data sharing and communication, lack of advocacy, lack of financial support from government, limited research fund and activities etc. are among many challenges. Hence, it is critical to continue to raise awareness of OH and foster leaders who are skilled to work across sectors. Institutionalization of One Health is a vital step in materializing One Health policy. The N OHSC and its different national Technical Working Groups (TWGs) should not only extend the One Health concept to the grassroots level and/or community level but also begin the operation of prioritizing zoonotic diseases prevention and control measures. Universities should include One Health philosophies and governing principles to academic curricula, including designated degree programs as well as incorporating the One Health research issues into their thematic areas.

Acknowledgements

We are grateful to the Ministry of Agriculture of Federal Democratic Republic Ethiopia, Ethiopian Public Health Institute, Ministry of Health, Ethiopian Wildlife Conservation Authority, and Health of Ethiopian Animal for Rural Development, National One Health Steering Committee of Ethiopia, Addis Ababa University College of Veterinary Medicine and Agriculture and Regional Agricultural and Health Bureaus for their data, facilitating, collaboration and other supports during the period of this review.

Abbreviations

Authors’ contributions.

GA collected all the required data, designed the review and drafted the manuscript.GM advised in the designing the review and continuously supported during the review period.FR and BM critically and substantially revised the manuscript. The author(s) read and approved the final manuscript.

This work was achieved by the inspiring by the correspondent author (Zoonotic Disease Prevention and Control Expert in Veterinary Public Health Directorate of Ministry of Agriculture of Ethiopia and a student at Addis Ababa University, College of Veterinary Medicine) and initiatives and/or full commitment of all authors.

Availability of data and materials

Declarations.

Not applicable.

Permission for unreferenced figures is obtained from NOHSC, Ministry of Agriculture and Moment of workshops and they are open to public.

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Determinants of household decision making autonomy among rural married women based on Ethiopian demography health survey: a multilevel analysis

• Desalegn Anmut Bitew 1 ,
• Amare Belete Getahun 2 ,
• Getachew Muluye Gedef 3 ,
• Fantahun Andualem 4 &
• Mihret Getnet 5  

BMC Women's Health volume  24 , Article number:  216 ( 2024 ) Cite this article

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Introduction

Decisions made at the household level have great impact on the welfare of the individual, the local community, as well as the welfare of the nation. Women’s independent decision on reproductive health increases women’s access to health information and utilization of reproductive services. This has great impact on maternal and child health outcomes. However, women in developing or low-income countries often have limited autonomy and control over their household decisions. Therefore the main purpose of this research project is to investigate the potential determinants of rural women’s household decision making autonomy.

A multi level analysis was performed using the fourth Ethiopian Demographic and Health Survey (EDHS) 2016 data set. A weighted sample of 8,565 married rural women was included in the final analysis. Women were considered to be autonomous if they made decisions alone or jointly with their husband in all three household decision components. It was dichotomized as yes = 1 and no = 0. Multico linearity and chi-square tests were checked and variables which did not fulfill the assumptions were excluded from the analysis. Four models were fitted. Variables with p-value ≤ 0.25 in the bi-variable multilevel logistic regression were included in the multivariable multilevel logistic regression. The Adjusted Odds Ratio (AOR) with a 95% confidence interval (95% CI) was computed. Variables with a P-value of less than 0.05 in the multi-variable multilevel logistic regression were declared as statistically significant predictors.

A total of 8,565 weighted participants involved. From the total respondents, 68.55 % (CI: 67.5%, 69.5%) of women had decision making autonomy. wealth index (poor: AOR: 0.84; 95% CI: 0.72, 0.97 and middle: AOR: 0.85; 95% CI 0.73, 0.98), literacy (illiterate: AOR: 0.75; 95% CI: 0.66, 0.86), respondents working status (Not working; AOR 0.68; 95% CI; 0.60, 0.76) ,who decides on marriage (parents: AOR 0.76; 95% CI; 0.67, 0.87), and proportion of early marriage in the community (high proportion of early marriage AOR: 1.35; 95% CI; 1.10, 1.72).

Women decision making autonomy was significantly determined by women economic participation (their wealth and their working status), women’s literacy, proportion of early marriage in the community and women’s involvement in decision of their marriage. Improving women’s economic participation and enhancing women’s participation to decide on their marriage will enhance women’s decision making autonomy.

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Empowering women means capacitating them with any tools they need to have power and control over their own lives. Empowered women have freedom, equal opportunities, and the ability to makes choices in all areas of their lives [ 1 ]. Women’s Empowerment is a process by which individuals get power, develop confidence, increase awareness, improve control over resources, and make decisions [ 2 ].

Women’s decision-making autonomy is women’s ability to decide independently on their concerns [ 3 ]. Women’s independent decision on reproductive health issues is crucial for better maternal and child health outcomes; however, restriction of open discussion and decision limits women’s access to reproductive health services [ 4 ]. Women’s autonomy on the decision regarding health increases women’s access to health information and utilization of reproductive services [ 5 ].

Limited women’s autonomy prevents mothers from using maternal healthcare services such as, ante natal care (ANC), postnatal care (PNC), and delivery at a facility. Thus, Strong women’s decision-making power is essential to reduce maternal and child mortality and morbidity [ 6 ]. Lesser decision-making power of women negatively affect the fertility decision, usage of contraception, and sexual lives of women [ 7 , 8 ]. Decisions made at the household level have great impact on the welfare of the individual, the local community, as well as the welfare of the nation [ 9 , 10 ].

Women’s decision making power was significantly affected by age of respondents [ 11 ], respondent’s educational attainment [ 11 , 12 , 13 ], occupation [ 12 , 13 ], income [ 11 , 12 , 13 ], and gender-based awareness [ 12 , 13 ], and justification of wife-beating [ 13 ].

Efforts are being made by the international community to increase women’s access to decision-making. This is evidenced by one of the Sustainable Development Goals (SDGs), which stated as establishing gender equality and empowering all women and girls [ 14 ]. Ethiopia had the legal frame works that promote, enforce and monitor gender equality under SDG indicators with a focus on violence against [ 15 ] and has implemented affirmative action a constitutional laws and national legislatures that fosters women Empowerment [ 16 ]. However, in practice, women are still second class citizens in which 40.3% of women aged 20–24 years old were married or in union before age 18, the adolescent birth rate was 79.5 per 1,000 women aged 15–19. In 2018, 26.5% of women aged 15–49 years reported that they had been subjected to physical and /or sexual violence by current of former intimate partner [ 15 , 16 ]. Even if women’s participation in a decision making will increase the uptake of healthcare services, facilitate poverty reduction, and enhance household economic growth, evidences suggest that women in developing or low-income countries often have limited autonomy and control over their household decisions [ 9 , 11 , 17 , 18 ]. The UN government speculates the following triple mandates as a priority agenda to empower women both in developed and developing countries [ 19 ].

Promote coordination across the UN system to enhance accountability and results for gender equality and women’s empowerment;

Support UN Member States to strengthen global norms and standards for gender equality and women’s empowerment, and to include a gender perspective when advancing other issues; and.

Undertake operational activities at the country and regional levels, including supporting Member States in developing and implementing gender-responsive laws, policies and strategies that take into account women’s lived realities.

As far as our knowledge, prior researches considering the three main areas of decision making autonomy in the household (decision on the woman’s own health care, major household purchases, and visits to the woman’s family or relatives) among rural women in Ethiopia are limited. It is very crucial to identify the determinants of the decision making autonomy. Because, as directed by UN, developing and implementing gender-responsive laws, policies and strategies that take into account women’s lived realities is a priory agenda [ 19 ]. This study will provide inputs for this action therefore the main purpose of this research project is to investigate potential determinants of rural women’s household decision making autonomy. The finding from this study will provide an input for policy makers, program designers and project managers to design appropriate interventions incorporating the factors affecting the rural women’s participation on household decision making autonomy in the whole process of project design and program implementations.

Study setting, study design, period and sampling

This study was conducted in Ethiopia using the fourth Ethiopian demography and health survey (EDHS).

The sampling procedure in EDHS was a stratified, two stages. Each region was stratified into urban and rural areas. Stratification and proportional allocationwere performed at each lower administrative level by sorting the sampling frame within each sampling stratum. Data collection took place over data collection took place over a 5.5 month period, from January 18, 2016, to June 27, 2016. The detailed sampling method has been explained in the methodology section of EDHS report [ 20 ].

Data source and study population

We have used individual record (IR) data set of EDHS 2016 for this study. The data was accessed from the measure DHS website ( http://www.measuredhs.com ). Interviews were done for 15,683 women of reproductive age across urban and rural strata, of whom, 9,824 were already married (currently living with husband or partner). Of those, 2,491 were urban residents and 7,333 were rural residents. The current study includes only rural married women. After weighting, a total of 8,565 rural married women were included in the final analysis. All the frequencies and percentages in the result section were weighted.

Variables and measurements

The outcome variable in this study was women’s decision making autonomy in the house hold. Women were asked the following three questions.

Who decided on women own health care?

Who decided on major household purchases? and.

Who decided on visits to the woman’s family or relatives?

Women were considered to be autonomous if they made decisions alone or jointly with their husband in all three of the above questions. Other ways they were considered not autonomous [ 20 ]. It was dichotomized as (yes = 1 and no = 0). The final aggregate measure of Women’s decision making autonomy was computed from the three major components of household decision making (decision on visits to family or relatives, decision on respondent’s health care and decision on large household purchases). First, the three components were dichotomized as “Yes” if a woman decides jointly or alone and “No” if a woman didn’t decide. We generate the outcome variable by adding the three components. Finally the intersection of the three was considered as “Yes”.

The independent variables were socio-demographic and husband related characteristics such as age, educational level, wealth index, literacy, religion, media exposure, decision on marriage, age at first sex, respondents working status, husband education, husband working status, sex of household head and age of household head and health insurance coverage. As well as community level variables include community wealth, community education, and community proportion of early marriage, community literacy and community media exposure.

Individual level variables

Educational status of women : This variable was divided into four categories: no education primary, secondary and higher education.

Wealth index

In the dataset, the wealth index was categorized as Poorest, Poorer, Middle, Richer, and Richest. In this study, a new variable was generated with three categories as “Poor”, “Middle” and “Rich” by merging poorest with poorer and richest with richer.

In the data set, religion was categorized as Orthodox, Muslim, Protestant, Catholic, traditional followers and others. In this study, the former three were encoded independently and Catholic and traditional religion followers were merged into the “others” category.

Working status

this has been categorized as “Yes” and “No” in the 2016 EDHS.

Media exposure

Watching television (TV), listening to the radio and reading newspapers both less than once a week and at least once a week were considered to measure exposure to media.

Age at first sex

Was categorized into four as “never had sex, “active before age 15,” “active between ages 15 and 17,” and “active at age 18 and above”.

Community level variables

Community-level variables were computed by aggregating the individual level women’s characteristics into clusters. Then the proportion was calculated by dividing subcategories by the total. Distributions of the proportion of aggregate variables were checked using the Shapiro–Wilk normality test and were not normally distributed. Therefore, these aggregate variables were categorized using the median value. Five community level variables were generated.

Data processing and analysis

Descriptive statistics such as frequencies and percentages were computed once the data had been cleaned. We used Stata soft ware to analyze the data. Sampling weights were used to account for the sample’s non-proportional strata allocation and non-responses. Individuals were nested inside communities in the EDHS data, and the intra-class correlation coefficient (ICC) was 20.50%. Before fitting the model, we tested the chi square assumption. As a result, early marriage, husband working status, husband education and respondents age were failed to fulfill the chi square assumption and were excluded from the model. Multi-co linearity was also checked and variance inflation factor (VIF) for respondent’s educational status was greater than 10 and we excluded it from the regression. To evaluate the independent (fixed) effects of the explanatory variables as well as the community-level random effects on the outcome variable, a two-level mixed-effects logistic regression model was fitted. We fitted four models (Null Model (no factors), Model 1 (0nly individual level factors), Model 2 (only community-level factors), and Model 3 (both individual and community-level factors)). Variables with a p-value of < = 0.25 from the bi-variable multilevel logistic regression analysis were included in the multivariable multilevel logistic regression analysis. The Adjusted Odds Ratio (AOR) with a 95% confidence interval (95% CI) was computed. Variables with a P-value of less than 0.05 in the multi-variable multilevel logistic regression analysis in the final model were declared as statistically significant determinants of women’s decision making autonomy.

Individual level characteristics of respondents

The median age and the mean age of respondents was 30 years and 30.60 (± 8.30) respectively. Totally, 8565 married rural women participated in this study. About 69% of respondents had no formal education. Nearly half (46.18%) of the respondents were from poor socio economic class. About three forth (76.10%) of respondents had early marriage. The decision of marriage was made by parents for 64.68% of respondents (Table  1 ).

Community level characteristics of the respondents

Five thousands and nine hundreds twenty nine (69.23%) of respondents were from a community with low proportion of poorness. Nearly half (49.77%) of respondent were from a community with high proportion of no education (Table  2 ).

Model selection

Multilevel mixed effect logistic regression model was fitted. The measures of variations or random effects were reported using intra-class correlation (ICC), a proportional change in variance (PCV), and Median Odds Ratio (MOR). The ICC was used to show how much the observation within one cluster resembled each other and it was generated directly from each model using “estat ICC “command following regression. PCV was computed using the following formula.

\(PCV=\frac{Vnull -VA}{V null }\) [ 21 ] and MOR was computed to measure unexplained cluster heterogeneity and it was calculated using the formula \(:MOR={e}^{0.95\sqrt{VA}}\) [ 21 ] where “VA” represents the area or cluster level variance for each model. The model comparison was done using Akaike’s information criterion (AIC). The model with smallest AIC was selected. Therefore, model III was the best fit model with AIC 9819.714 (Table  3 ).

Magnitude of Women’s decision making autonomy from the total respondents, 68.55 % (CI: 67.5%, 69.5%) women’s had decision making autonomy. Women’s participation on visits to family or relatives, respondent’s health care and large household purchases were 82.23%, 79.57% and 76.29% respectively (Table  4 ).

Determinants of women decision making autonomy (WDMA)

In this study wealth, working status, literacy and decision on marriage from individual level factors and proportion of early marriage from community level factors were statistically significant predictors of WDMA .

The odds of WDMA among poor women and Middle class women was reduced by 16% (poor: AOR: 0.84; 95% CI: 0.72, 0.97) and 15% (middle: AOR: 0.85; 95% CI 0.73, 0.98) respectively compared to rich women. The odds of WDMA illiterate women was reduced by 25% (Illiterate: AOR: 0.75; 95% CI: 0.66, 0.86) compared to literate women. The odds of WDMA among women who didn’t work was reduced by 32% (Not working; AOR 0.68; 95% CI; 0.60, 0.76) compared to women who were working.

The odds of WDMA among women whose marriage was decided by their parents was reduced by 24% (parents: AOR 0.76; 95% CI; 0.67, 0.87) compared to women who decided by themselves. The odds of WDMA among women from a community with high proportion of early marriage were increased by 35% (high proportion of early marriage; AOR: 1.35; 95% CI; 1.10, 1.72 ) compared to women from a community with low proportion of early marriage (Table  5 ).

We investigated the potential determinants rural women decision making autonomy. As a result, women’s wealth index, their working status, their literacy, their involvement in their marital decision and high proportion of early marriage in the community was found to be significantly associated with WDMA.

Our study showed that women with lower household wealth indexes had lower decision making autonomy. This finding is supported by findings from, Ghana [ 22 ], Burkina Faso [ 23 ] and Nepal [ 4 ], women from wealthier households were more likely to participate in decision-making, either jointly or individually. This may be explained by women in poor household are likely to be uneducated and they may lack the knowledge and skill of negotiating decision. Their economic condition might also limit women’s purchasing power. This is because the ownership and control of property had great impact on minimizing gender gap and enhance economic wellbeing, social status, and empowerment [ 12 , 24 ]. This implies that programs and projects policies and strategies designed to empower should give special attention for women in low socio economic classes.

Literacy was also positively associated with women decision making autonomy. This shows literate mothers had increased odds of decision making autonomy compared to illiterate mothers. This was supported by other findings from Ghana [ 22 ] and Nepal [ 4 ]. Most of literate mothers had at least primary and above educational attainment. In our study, about 92% of literate mothers had primary and above educational attainment. Evidences showed that, Women who had higher educational attainment had higher decision making autonomy. Because, education improve their knowledge, negotiating abilities, and self-confidence [ 25 , 26 , 27 ], improves employment chances [ 27 , 28 , 29 ], and reduces the occurrence gender-based violence [ 22 , 30 , 31 ]. `This implies that increasing women’s literacy through different mechanisms like increasing their enrollment to either traditional or formal education and increasing their attainment to higher level of education should be mainstreamed by ministry of education and other program managers.

This study also revealed that women working status had significant association with their autonomy in decision making. This finding was supported by findings from Burkina Faso [ 23 ] and Nepal [ 4 ] which showed that Women’s participation in household decisions is enhanced while they are working. This is due to the fact that women who are working will have capacity to afford costs related to their own health care as well as other major purchases which in turn improves women’s participation in decision making regarding their own health care, household purchases or visiting family or friends [ 4 , 23 ]. This finding implies that ministry of labor and skills of Ethiopia in collaboration with other stake holders like civil services, Nongovernmental organization and institutions should facilitate job opportunities for women.

Surprisingly, our study revealed that women who were form a community with high proportion of early marriage had increased odds of decision making autonomy. This was supported by one evidence from Bangladesh [ 32 ] which stated that, the autonomy level of women who got married in their earlier age have the highest level of autonomy in all three dimensions of house hold decisions. This may be explained by the fact that, the formation of first marriage brings important changes in a women’s family situation and in thier future expectations and opportunities. Marriage is the time when couples start their own life independent of their family [ 32 ]. However, this finding contradicted with other findings from Ethiopia [ 33 , 34 ] and Indonesia [ 35 ]. This contradiction may be due to the difference in the study population and the difference in the operational definition for the outcome ascertainment as well as the difference the interest of the outcome. For example in our study, the populations were all married rural women where most of the household tasks are given for women. Where as in the previous study, the population were all married women regardless of their residency [ 33 , 34 ]. In the previous study the outcome was decision regarding to contraception and women was considered autonomous if the decide independently [ 33 , 34 ], while in the current study, the outcome was decision making autonomy for the three major household decisions (own health care, household purchase and family visit) and women were considered autonomy if they make decision alone or jointly for all the three components of household decisions. The other possible explanation for this contradiction can be the nature of the outcome variable. It is obvious that decision on contraceptive use is somehow sensitive than decisions on household purchase and family visit. This contradictory finding revealed that researchers should further investigate the reasons using advanced research designs like prospective cohort and qualitative research design.

Another important determinant of women’s decision making autonomy was their power of decision on their marriage. In this study, women whose marriage was decided by their parents had reduced odds of decision making autonomy. This study finding was supported by finding from Pakistan [ 36 ]. This could be explained women who are able to express their opinion and are part of the decision for their own marriage, they might be confident in communicating and negotiating with their husband once married. This implied that, the involvement of women in their marital decision will enhance their decision making autonomy in the household.

Generally women’s decision making autonomy was high (68.55%) compared to other developing countries [ 37 ]. Women decision making autonomy was significantly determined by women economic participation (their wealth and their working status), women’s literacy, proportion of early marriage in the community and their participation in their marriage. Improving women’s economic participation and enhancing women’s participation to decide on their marriage will enhance women’s decision making autonomy. Qualitative researches should also be conducted to explore reasons for the contradictory findings (Does early age marriage positively associated with women’s decision making autonomy? ).

Strengths and limitations

As strength, we used nationwide data which increased the representativeness of the finding and we used advanced statistical model which solved the effect hierarchal nature of the data set. On the other hand, using secondary data limit the researcher to measure all possible factors such as culture and tradition-related factors as well as the individuals perception on the severity of the illness for health care decision. The source of the data was self-report which affect the accuracy of the data by recall bias. The data for this conclusion was from cross-sectional survey and it does not show causality.

Data availability

The dataset supporting the conclusions of this article were accessed through request on the measure DHS website ( http://www.measuredhs.com ) and the extracted data used during the current analysis is available from the corresponding author on reasonable request.

Abbreviations

Akaike’s: Information Criterion: Ante Natal Care

Adjusted Odds Ratio

Bayesian Information Criterion

Confidence interval

Crude Odds ratio

Ethiopia Demographic and Health Survey

Intra Class Correlation

Median Odds Ratio

Proportional Change in Variance and WDMA: Women Decision Making Autonomy

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Acknowledgements

We want to express our heartfelt thanks to the measure DHS program for allowing access to EDHS dataset and authorized us to conduct this research using this data set.

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Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Desalegn Anmut Bitew

Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Amare Belete Getahun

School of midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Getachew Muluye Gedef

Department of psychiatry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Fantahun Andualem

Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

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This study was done in collaboration between all authors. DAB: conceived the idea for this study and design, participated in the analysis and write-up of the manuscript. TBB, DBA and WDN: Participated in the data extraction, data analysis, in interpretation of the result, in the manuscript write up and reviewing of the draft manuscript. All authors participated sufficiently in the work and take responsibility for the appropriate portions of the content.

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Bitew, D.A., Getahun, A.B., Gedef, G.M. et al. Determinants of household decision making autonomy among rural married women based on Ethiopian demography health survey: a multilevel analysis. BMC Women's Health 24 , 216 (2024). https://doi.org/10.1186/s12905-024-03058-3

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DOI : https://doi.org/10.1186/s12905-024-03058-3

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Traditional Healers' Knowledge, Attitudes, and Perceptions About Tuberculosis and Collaboration with the Conventional Health System in the Kereyu Pastoralist Area of Ethiopia: A Cross-Sectional Study

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Background: Traditional Healers (THs) hold significant roles in many developing countries, often sought for ailments like tuberculosis (TB). However, their knowledge, attitude, and practice (KAP) regarding TB, particularly in Ethiopias pastoralist areas, remains unexamined. This study evaluates THs KAP on TB and their perceptions to collaborate with conventional health systems on TB control. Method: A cross-sectional survey was conducted among THs in Kereyu, Ethiopia from September 2014 to January 2015. Using a semi-structured questionnaire, 268 THs were interviewed. Health Extension workers helped identify the THs. Results: Of the 268 participants, 80.6% were male. 97.4% were aware of TB (locally dukubba soombaa), with 80.2% associating its cause to proximity with a TB patient. Coughing for over two weeks was identified as a primary TB symptom by 87.35%. However, 66.4% displayed limited biomedical knowledge on TB. A notable 38.4% associated TB with sadness and hopelessness, while 47.8% utilized plant-based remedies for treatment. Impressively, 86.2% expressed willingness to collaborate with conventional health services for TB control. Conclusion: The THs had limited biomedical knowledge and some misconceptions about TB. Despite providing traditional medicine to treat TB, their readiness to collaborate with established health systems is promising. Thus, Ethiopian TB control initiatives should consider integrating THs via targeted training and health education interventions.

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This was a PhD project and was supported by the single student support program at the University of Oslo.

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1.The Norwegian Social Science Data Service (NSD) and 2. Ethical Review Committee of Jimma University, Jimma Ethiopia and 3. The Oromia Regional Health Office Ethical Review Committee, Addis Ababa, Ethiopia approved this study.

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