[{"bbox": [96, 153, 1133, 205], "category": "Text", "text": "need for rehabilitation of victims with mental health and psychosocial support particularly in conflict affected areas is critical."}, {"bbox": [96, 235, 464, 262], "category": "Section-header", "text": "## Inequalities in health service delivery"}, {"bbox": [96, 276, 1134, 619], "category": "Text", "text": "In Ethiopia, health status variations across regions are dominant, caused by multiple factors such as gender norms and harmful traditional practices, low economic and educational status, low access to basic utilities, etc. The government strategy (HSTP-II) recognises the need for transformation in addressing inequalities with increased attention for hard to reach populations – urban poor, pastoralist and identified poverty areas (often drought affected zones/woredas). Low human development in Ethiopia (as indicated by low outcomes in education and health) has been identified as a binding constraint¹³ to strengthening the livelihoods of the bottom 40 % of the wealth distribution. Recognising this challenge, Ethiopia has improved human capital outcomes as a result of high levels of public investment in education and health. Together, in the past, these sectors have accounted for a third of government expenditure¹⁴, as public spending on primary education and preventative health care is quite progressive and pro-poor. However, despite promising practices being observed to reach out to underserved populations, analysis of progress across regional states and/or zones indicates the need for further investment in addressing inequalities. In addition, these inequalities have been further deepened due to the ongoing conflict."}, {"bbox": [96, 635, 1134, 921], "category": "Text", "text": "National reports¹⁵ also hide stark inequalities across zones/woredas, calling for innovative and context specific interventions within poverty areas. The analysis from regional reports indicate that there are poverty areas that perform far below the regional and/or national average in terms of maternal and child health indicators. For instance, Amhara is amongst the developed regions. They are amongst the best regions when considering maternal health care indicators, and the second region with most use of contraceptives, only behind Addis Ababa¹⁶. Maternal education is negatively associated with immunization rates and is a main driver of inequality in maternal and child health outcomes. However, there are significant inequalities when comparing performance amongst woredas in Amhara: those further away from the regional capital, Bahir Dar, fare worse in almost all performance indicators, some behind the average of better performing regions¹⁷. This inequality is being further deepened due to the conflict, as these woredas (in the border with Tigray) have suffered from intense fighting."}, {"bbox": [96, 948, 598, 974], "category": "Section-header", "text": "## Limited improvement in quality of care at all levels"}, {"bbox": [96, 988, 1134, 1244], "category": "Text", "text": "Improving quality of health services across the continuum of care is one of the pillars of the HSTP-II. However, despite encouraging results in reducing under-five mortality rate (from 222 in 1990 to 49 deaths per 1 000 live births in 2020), still an estimated 173 000 under-five children die from preventable childhood diseases every year mainly due to poor quality of care particularly during the neonatal period¹⁸. Unfortunately, efforts made so far in reducing neonatal mortality rates have not been satisfactory, with conflicting data regarding its progress, but in any case proving it remains very high¹⁹. High numbers of stillbirths occur, representing a “silent epidemic”. Close to half of stillbirths occur during the process of labour and delivery, and over 80% of all newborn deaths are caused by preventable and treatable conditions. Maternal mortality is also unacceptably high in Ethiopia, though it has been reduced from 1,030 in 2000 to 401 deaths per 100,000 live births in 2017²⁰."}, {"bbox": [96, 1263, 1134, 1348], "category": "Text", "text": "These issues are manly attributed to sub-optimal quality of care, low nutritional status of mothers, uneven distribution of health resources, low maternal and child health care seeking behaviour of communities, and shortage of essential health commodities and equipment at service delivery. As an example, among the direct"}, {"bbox": [86, 1377, 274, 1401], "category": "Footnote", "text": "¹³ World Bank (2016)."}, {"bbox": [86, 1401, 577, 1426], "category": "Footnote", "text": "¹⁴ World Bank. 2015. ‘Ethiopia Poverty Assessment 2014.’"}, {"bbox": [86, 1426, 672, 1452], "category": "Footnote", "text": "¹⁵ 2019 Ethiopian Mini Demographic and Health Survey (DHS) report"}, {"bbox": [86, 1451, 153, 1472], "category": "Footnote", "text": "¹⁶ *idem*."}, {"bbox": [86, 1474, 1142, 1523], "category": "Footnote", "text": "¹⁷ Improved performance of district health systems through implementing health center clinical and administrative standards in the Amhara region of Ethiopia, BMC Health Services research, 2019."}, {"bbox": [86, 1523, 846, 1546], "category": "Footnote", "text": "¹⁸ United Nations Children's Fund (UNICEF), Data bank. Consulted on 21 December 2021."}, {"bbox": [86, 1547, 1142, 1594], "category": "Footnote", "text": "¹⁹ While DHS 2016 and 2019 reports point to an increase, UNICEF data points to a continuous decrease in the neonatal mortality rate."}, {"bbox": [86, 1594, 590, 1619], "category": "Footnote", "text": "²⁰ World Bank, Data bank. Consulted on 21 December 2021."}, {"bbox": [1038, 1681, 1143, 1705], "category": "Page-footer", "text": "Page 7 of 21"}]