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Women and children await the distribution of food aid in Adi Mehameday, in the Western Tigray region of Ethiopia, on May 28, 2022.

Ethiopia is among the eight countries in the world where more than half of the world’s population growth will be concentrated between 2022 and 2050, shows the latest UN World Population Report, released on July 11. The nation of the Horn of Africa, on the other hand, distinguished itself more than a quarter of a century ago as a pioneer on the African continent in terms of declining fertility thanks to an elaborate family planning policy, even in the rural areas of this country still in slow urbanization.

The country may be the second most populous in Africa, but it doesn’t know the true size of its population. The last census in Ethiopia dates back to 2007. Since then, the Ethiopian authorities have relied on simple projections. The United Nations estimates the population at 122 million. Despite a steadily declining fertility rate, Ethiopia is expected to have a population of 213 million by 2050, making it the ninth most populous country in the world.

“We have one of the most progressive family planning policies in Africa”, says Dr Mengistu Asnake, director of the NGO Pathfinder in Ethiopia. In Addis Ababa, the capital, women have an average fertility rate of less than two children – a rarity on the continent.

Away from authoritarian methods

A sexual and reproductive health specialist for three decades, the doctor has followed the evolution of the Ethiopian approach. It is in 1993 that the challenges of the demographic transition appear in national policies. The Ethiopian government has therefore set its national demographic policy in stone. Its priority is already “reduce the fertility rate from 7.7 in 1993 to 4 in 2015”.

The goal will not be fully achieved – the national fertility rate is still 4.2 today – but the program will have made it possible to coordinate and spread family planning in this still deeply rural country. “It was not a question of repressive birth control but of aligning the growth of our population with that of our economy, and doing it on a voluntary basis”, says Mengistu Asnake.

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In 1993, Ethiopia slowly emerged from fifteen years of civil war under the Communist military dictatorship of the Derg. Institutions are lifeless, no public institution allows access to family planning. Only a private clinic offered this privilege in the capital. Only 4% of women therefore use contraceptive methods. A hole. The arrival of many international donors and NGOs coincides with the flourishing of clinics.

Far from Chinese authoritarian methods, Addis Ababa is betting on education. A primary school is built in each qebele (“District”), increasing girls’ school enrollment rate from 21% in 1995 to 95% today. This student pool promotes family planning techniques. “From 2005, a flagship health extension program will train high school girls to become reproductive health activists,” explains Dr. Mengistu Asnake. Thousands of young women undergo a year of training before being deployed to their home regions.

“Regional and socio-demographic inequalities”

Ethiopia now has around 40,000 of these ambassadors in the four corners of its territory, responsible for spreading knowledge about contraception. Five modes are proposed: pill, injection, condom, implant and IUD. One in four women use it. “It was an innovation on the continent, to directly mobilize women volunteers from local communities”, adds Mengistu Asnake. Public health experts then flock to Nigeria, Tanzania, Mozambique or Uganda to study the Ethiopian model.

But is this approach satisfactory in a country where 60% of women still do not use contraception? Can we talk about fairness when more than 50% of women in Addis Ababa use a form of contraception compared to 3.5% in the Somali region? And that the fertility rate is more than three times higher in the Oromia region (the largest Ethiopian region) than in the capital?

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Health Minister Lia Tadesse points the finger “Regional and socio-demographic inequalities” and “the poor quality of the distribution of public services” as obstacles to controlling the fertility rate in Ethiopia. In fact, the government budget would have to be tripled to meet the needs of all Ethiopian women. In fact, more than 20% of them, who wish to benefit from family planning, currently do not have access to it.

The ambitions of the Ethiopian authorities could collide with a critical political context. The civil war in Tigray and the drought in the east of the country caused the displacement of more than 5 million Ethiopians in 2021 – a world record. In addition, the conflict has destroyed more than two thousand health centers in northern Ethiopia, as well as hundreds of schools.

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