`

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH

Ethiopia Health Emergency Preparedness, Response and Resilience Project

Rapid Social Assessment

Final Report

JUNE 29, 2023ADDIS ABABA, ETHIOPIA

Table of Contents
Acronyms/Abbreviations.............................................................................................................................3
Executive Summary.....................................................................................................................................6
Background and Context.........................................................................................................................6
Development Objective...........................................................................................................................7
Project Components.................................................................................................................................7
Scope of the Rapid Social Assessment (RSA).........................................................................................9
Objectives of the Social Assessment.......................................................................................................9
Methodology...........................................................................................................................................9
Key RSA Findings.................................................................................................................................10
Proposed Mitigation Measures..............................................................................................................11
Synthesized Recommendations.............................................................................................................12
Conclusion.............................................................................................................................................13
1. Introduction.......................................................................................................................................15
1.1. Background and Context...........................................................................................................15
1.2. Scope of the Rapid Social Assessment......................................................................................16
1.3. Objectives of the Rapid Social Assessment...............................................................................17
1.4. Study Approach.........................................................................................................................18
1.4.1. Methodology......................................................................................................................18
1.4.2. Methods.............................................................................................................................19
1.5. Project Development Objectives and Components....................................................................19
1.5.1. Development Objective.....................................................................................................19
1.5.2. Project Components...........................................................................................................20
1.5.3. Institutional and Implementation Arrangements................................................................25
1.5.4. Project Intervention Areas.................................................................................................28
1.5.5. Project Beneficiaries..........................................................................................................28
2. Legal Frameworks: Basis for Social Assessment...............................................................................29
2.1. National Legal and Institutional Framework for Underserved and Vulnerable Groups..................29
2.2. The Nexus between Ethiopian Policies and Laws and the World Bank Environment and Social
Framework............................................................................................................................................33
3. Social Assessment Findings...............................................................................................................36
3.1. Characteristics of Vulnerability and Underserved Target Communities....................................36
3.1.1. Women..............................................................................................................................37

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 3.1.2. Women’s time poverty.......................................................................................................37
3.1.3. Female-Headed Households...............................................................................................38
3.1.4. Youth.................................................................................................................................39
3.1.5. Chronically ill and people living with HIV/AIDS..............................................................40
3.1.6. Elderly...............................................................................................................................40
3.1.7. Persons with disability.......................................................................................................41
3.1.8. Occupational Minorities.....................................................................................................42
3.1.9. Ethnic Minorities and Shifting Cultivators.........................................................................43
3.1.10. Pastoralists and Agro-pastoralists......................................................................................44
3.1.11. Urban Poor.........................................................................................................................46
3.1.12. General comments on the vulnerable groups.....................................................................47
3.2. Community Institutions.............................................................................................................49
3.3. Institutional Capacity.................................................................................................................51
3.4. Key Social Issues and Potential Challenges...............................................................................51
3.5. Proposed Mitigation Measures...................................................................................................57
3.6. Grievance Redress Mechanism..................................................................................................58
4. Lessons Learned from Previous Projects...........................................................................................59
5. Synthesized Recommendations.........................................................................................................61
6. Potential Risks and Recommendations: Summarized........................................................................63
7. Concluding Remarks.........................................................................................................................67
References.................................................................................................................................................68
Annexes.....................................................................................................................................................72
Terms of Reference...............................................................................................................................72
Guiding Questions:................................................................................................................................79
List of Consultation Participants............................................................................................................82

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Acronyms/Abbreviations
AF Additional Financing
AFE AFRITAC (Africa Regional Technical Assistance Center) East
AGP Agricultural Growth Program
CBO Community-based organization
CDC Centre for Disease Control
CEBS Community and Event Based Surveillance Services
CEDAW Convention on Elimination of All Forms of Discrimination Against Women
CERC Contingent Emergency Response Component
cVDPV circulating vaccine-derived polioviruses
DEVAW Declaration on the Elimination of Violence against Women
DPO Disabled Peoples Organization
DRS Developing Regional States
ECA Ethiopian Communications Authority
ECSA-HC East, Central, and Southern Africa – Health Community
EFDA Ethiopian Food and Drug Administration
ELEAP ETHIOPIA ELECTRIFICATION PROGRAM
EOC Emergency Operation Centre
EPHF Essential Public Health Functions
EPHI Ethiopian Public Health Institute
EPSA Ethiopian Pharmaceutical Supply Agency
ERM Emergency Response Manual
ERSNP Ethiopia Rural Safety Net Program
ESMF Environmental and Social Management Framework
ESIA Environmental and Social Impact Assessment
ESPES Enhancing Shared Prosperity through Equitable Services
ESS Environmental and Social Standards
ESSA Environmental and Social systems assessment
FDRE Federal Democratic Republic of Ethiopia
FEAPD Federation of Ethiopian Associations of Persons with Disabilities
GBV Gender Based Violence

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GDP Gross Domestic Product
GoE Government of Ethiopia
GMU Grant Management Unit
GRM Grievance Redress Mechanism
GQs Guiding Questions
GTP Growth and Transformation Plan
HEs Health Emergenccies
HEPRR Health Emergency Preparedness, Response and Resilience
HIV/AIDS Human Immuno-Virus/Acquired Immunodeficiency Syndrome
HoF House of Federation
HPR House of Peoples’ Representative
HSS Health Systems Strengthening
ICT Information Communication Technology
IGAD Intergovernmental Authority on Development
LLRP Lowland Livelihood Resilience Project
LMP Labour Management Procedure
M&E Monitoring and Evaluation
MDGs Millennium Development Goals
MoFED Ministry of Finance and Economic Development
MoH Ministry of Health
MoWCYA Ministry of Women, Children and Youth Affairs
MPA Multiphase Programmatic Approaches
NGO Non-governmental Organization
PAD Project Appraisal Document
PCD Partnership and Cooperation Directorate (of the Ethiopian MoH)
PCDP/ILLRP Pastoralist Development Program/Integrated Lowland Livelihood Resilience
Project
PDO Project Development Objective
PHEs Public Health Emergencies
PHEM Public health emergency management
PIM Project Implementation Manual

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PIU Project Implementation Unit
PoEs Port of entries
PPR Pandemic Preparedness and Response
PrDO Program Development Objective
PSNP Productive Safety Net Program
RAP Resettlement Action Plans
RLLP Resilient Livelihood and Landscape Program
RPF Resettlement Policy Framework
RPLRP Regional Pastoral Livelihood Resilience Program
RSA Rapid Social assessment
SDG Sustainable Development Goals
SEA/SH Sexual Exploitation and Abuse/Sexual Harassment
SE Sexual Harassment
SLMP Sustainable Land Management Program
SMP Social Management Plan
SNNPR Southern Nations, Nationalities and Peoples Region
STIs Sexually Transmitted Infections
TA Technical Assistance
ToR Terms of Reference
UN United Nations
WB World Bank

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Executive Summary
Background and Context

Ethiopia is Africa’s second-most populous country with a population of more than 115
million in 2021. The country has made important development gains over the past two decades
and has registered commendable achievements on Millennium Development Goals (MDGs)
mainly in reducing poverty head count, achieving universal primary education, narrowing gender
disparities in primary education, reducing child and neonatal mortality, and combating HIV, TB,
and malaria. The demand for equitable access and quality healthcare services is increasing
because of a rapidly growing population, epidemiological transition of diseases, rapid
urbanisation, and broader social and economic changes occurring in the country and the
geopolitical context in the eastern Africa region.

The COVID-19 pandemic, civil conflict and climate shocks including drought have severely
impacted the wellbeing of Ethiopia’s people. Ethiopia has had the second largest number of
COVID-19 cases and fatalities in Sub-Saharan Africa with almost half a million cases and 8,000
deaths since March 20201. Severe repeating droughts and flooding in 2021 further impacted the
livelihoods and food security of over 12 million people. 2 There are (Ibid.) over 2 million people
currently displaced due to drought, conflict, seasonal and flash floods. These shocks have had
dire economic consequences across the country and poverty rates are expected to increase. In
Fiscal Year (FY) 20, the pandemic contributed to a three percent decrease of Gross Domestic
Product (GDP) and foreign direct investment declined by 20 percent. The report of for FY22,
GDP is again expected to be significantly reduced due to the conflict and ongoing COVID-19
pandemic, while inflation has been steadily rising reaching over 33.6 percent in January 2023. 3 If
not addressed urgently, Ethiopia risks to erode the human capital gains achieved through decades
of investments.

Starting from the last quarter of 2022, Ethiopia is experiencing a prolonged drought after five
(5) consecutive failed rainy seasons since late 2020 affecting 24 million people: Somali (11
zones), Oromia (8 zones), Southwest (3 zones) and Southern Nations, Nationalities, and Peoples,
SNNP (7 zones). The number of severe acute malnutrition cases has increased in 2022 by 21 per
cent in drought affected woredas of Afar, Oromia, Somali and SNNPR, comparing with 2021.
Cholera and measles cases have been reported in January 2023 in drought affected regions in the
country and are expanding to other areas4. The overlap of COVID-19 outbreaks, and protracted
conflict have disrupted the delivery of essential maternal and child health services negatively
impacted the linear progress observed in key health outcomes in the past two decades. Prior to
the conflict, COVID-19 outbreak has reduced, averaging from 10% to 26%, utilization of out-
patient services, skilled birth attendant at health facilities, child immunization and vitamin A
supplementation and nutrition screening. The conflict has directly affected primary health care
infrastructures including 1,350 health posts, 750 health centers and 76 hospitals throughout the
country and whereby pre-conflict health and nutrition service delivery indicators to be dropped
1
Ministry of Health (MOH), “COVID-19 report,” April 26, 2022.
2
Reliefweb, 2021: https://reliefweb.int/disaster/dr-2015-000109-eth; and
https://reliefweb.int/sites/reliefweb.int/files/resources/ethiopia_drought_update_january_2022.pdf
3
Ethiopia: Monthly Economic Update – February 2023
4
Ethiopia Ministry of Health ^ Month Drought Response Plan

6
in the immediate aftermath of the conflict. The risk of outbreaks from vaccine preventable
diseases and other water borne sources is high implying the increased disease burden and
mortality therein and the need to invest on health system resilience in the country.

By way of responding to these challenges and augmenting its national development financing,
Ethiopia has partnered in multilateral and bilateral development projects with several
development financing institutions such as the World Bank (WB), Africa Development Bank
(AfDB) and others. As its continued development partnership, WB is financing this Health
Emergency Preparedness, Response, and Resilience (HEPRR) project, a regional capacity
building project in which Ethiopia is one of the implementing countries. The HEPRR project
will be implemented by the Ministry of Health (MoH), with the Ethiopian Public Health Institute
(EPHI) as the key technical entity for the implementation of the project activities. This rapid
social assessment (RSA) is prepared as part of the risk management instruments and focuses
primarily on the Health Sector.
This rapid RSA assessed the broad project risks and impacts on vulnerable (underserved peoples,
women, children, aged people, persons with disability, poor and other deprived segments) and
other communities and recommends risk mitigation measures that will be used at both the project
design and implementation phases to ensure all beneficiaries can receive the project benefits..

Development Objective
Project Development Objective: The Program Development Objective (PrDO) of the Health
Emergency Preparedness, Response and Resilience (HEPRR) Program is to strengthen health
system resilience and multisectoral preparedness and response to health emergencies in Ethiopia.

Building on ongoing World Bank and other development partners effort, and working cross
sector and cross border, HEPRR will strengthen two inter-connected pillars–
Preparedness/Response and Resilience—of health systems, enabling the rapid detection of and
response to health emergencies while ensuring the availability of essential pharmaceuticals and
health services continue to be delivered optimally even during emergencies. In addition, the
proposed project engages with regional integration institutions such as IGAD and HECSA to
support the cross border public health emergencies preparation and response through health
emergency information/data sharing, advancing the learning agenda and to strengthen capacity
building across countries. Furthermore, efforts will be made to leverage the academic and public
and private sector capacities in manufacturing diagnostic and preventive pharmaceuticals to
satisfy the requirements in Ethiopia and neighbouring countries and provide assistance to
enhance regulatory activities through strengthening collaboration with Africa Medical Agency
and expand market networking for sustainability.

Project Components

The proposed Project has four components.

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Component 1: Strengthening the Preparedness and Resilience of the Health System to manage
PHEs (US$80M).

This component would support institutional capacity building and resilience health systems
strengthening across the health system building pillars to cope with public health emergencies
while ensuring the continuity of essential health service delivery during public health
emergencies. Based on the lesson from the COVID-19 pandemic, Ebola outbreak in western and
eastern Africa and other health emergencies of communicable and non-communicable infectious
and non-infectious diseases in the country, effective emergency preparedness requires
connecting and working together across all building blocks of the health system including health
workforce, pharmaceutical supply and value chain, regulatory and governance capacity, and
quality data and evidence informed decision making, adequate and sustainable financing, and
integrated service delivery.

Component 2: Improving the detection of and response to public health emergencies (USD
$145M):

This component will support the national detection and response pillars which aim to strengthen
early warning system, revise the list of reportable diseases, strengthen risk screening at port of
entries (PoEs) including border areas, enhance digital information management of multi-hazards
(infectious disease outbreaks, biological, chemical, radiological and environmental), surveillance
data analysis and interpretation, community level information collection and verification, provide
feed-back to facilities and regions, finally, risk communication will be held alongside
information management.

Component 3: Program Management:

Sub-component 3.1: will support monitoring and evaluation and engagement of academia and
think tank groups. This component will provide financing for i) Coaching and technical support
for data analysis, interpretation and lesson sharing and support for decision-making; ii) Third
party implementation and monitoring to support implementation of the project activities in
conflict and security constrained areas and assure the validity of Results Framework indicator
data reported by governments; and (iv) Data-based cross-border learning initiatives, which will
share proven strategies to effectively collect and use data to enhance health emergency response.

Sub-component 3.2: will focus on all other aspects of program management. Implementing the
proposed project will require administrative and human resources that exceed the current
capacity of the implementing institutions, in addition to those mobilized through the other bank
projects including COVID19 emergency response project and Africa CDC Project. Specific
activities include: i) support for procurement, FM, environmental and social safeguards,
monitoring and evaluation, and reporting; ii) recruitment and Training of Grants Management
Unit and EPHI staff and technical consultants; iii) operating costs and iv) support for cross
border related administrative activities and collaboration with IGAD.

Component 4: Contingent Emergency Response Component (CERC): TBD

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Scope of the Rapid Social Assessment (RSA)

This RSA is a risk mitigation tool covering risks, challenges and recommendations that will
inform the implementation of ‘Health Emergency Preparedness, Response and Resilience’.5 As
clearly stated in the PAD, this is a capacity building project with a focus on Technical Assistance
(TA): “Building on ongoing World Bank and other development partners effort, and working
cross sector and cross border, HEPRR will strengthen two inter-connected pillars–
Preparedness/Response and Resilience—of health systems, enabling the rapid detection of and
response to health emergencies while ensuring the availability of essential pharmaceuticals and
health services continue to be delivered optimally even during emergencies”. The PAD adds
“The project will undertake interventions that are at policy and strategy level but still focusing on
creating the public health preparedness, response, and resilient health system capacity at the
district level”.

The project is implemented at national and sub-regional levels and this includes communities
that are underserved and vulnerable. RSA looks at (consistent with ESS7) how underserved
communities who are often disadvantaged in development projects can equitably access project
benefits in a culturally appropriate and inclusive manner. It, therefore, helps make the project
responsive to social development concerns, including seeking to enhance benefits for the poor
and vulnerable peoples and underserved groups, while minimizing or mitigating risk and adverse
impacts. It analyzes distributional impacts of intended project benefits on different stakeholder
groups, and identifies differences in assets and capabilities to access the Project benefits.

Objectives of the Social Assessment

The study aims to assess the social characteristics of local communities, including determining
the nature and characteristics of underserved groups in the HEPRR project intervention areas,
with special emphasis on their cultural characteristics, social institutions and organization and
establish that the project will not negatively impact the way of life of these people. RSA is a
systemic assessment of positive and adverse social impacts associated with the project and
proposes appropriate risk mitigation measures to ensure equitable project benefits.

Methodology

The HEPRR project is one among many development projects financed by Development
Partners, among which the WB is one. During these several years of financing development
projects6, many documents, e.g., PADs, ESMF, ESIA, RPF, RSA reports, etc. have been
5
The ‘Health Emergency Preparedness, Response and Resilience’ Concept Note.
6
For instance, recently the following projects were financed by the WB, and safeguards documents produced for
these were consulted: the Africa CDC Regional Investment Financing Project; Ethiopia COVID-19 Emergency
Response Project (parent project and AF); Sustainable Development Goal Program for Results; Ethiopia Program
for Results (Hybrid) for Strengthening Primary Health Care Services; Digital Ethiopia; and Response-Recovery-
Resilience for Conflict-Affected Communities in Ethiopia Project (3R-4CACE), 2022.

9
produced to inform project design, implementation and monitoring and evaluation processes of
projects in the country. These documents have amply documented information on various issues
about the beneficiary communities differentially located in the socio-economic structure of the
Ethiopian society, and serve as vital secondary sources of information for this RSA study.

The RSA for HEPRR project has used both primary and secondary sources of data. The data
from the existing works were used because most of the communities intended to be covered in
this project have already been studied in the past. Relevant published works were also consulted,
in addition to the review of the national laws, regulations, and relevant international conventions.
As much primary data as possible was generated to understand the views and document the
concerns of different social groups such as the vulnerable people in the underserved and
emerging regions. Consultations have been conducted with the Project design team members, the
federal, and regional public health officers and experts, as well as some potential beneficiaries on
the project as they related to the context of the RSA document. Health experts working for
NGOs among the underserved and vulnerable groups were the other major source of primary
data as they contributed to the RSA, some by responding in writing to the GQs and others
through telephonic interview.

Key RSA Findings

One key finding of the RSA is that there is a strong support for the project as it is believed to
address the systemic marginalization of the vulnerable people. The HEPRR project will build on
what has already been started and further enhances HE response capacity of the country, which
over the last few years was challenged by ‘drought, and IDP

Health infrastructures or facilities meant to serve permanently settled communities and the
modalities of their services rarely take into account the mobility-based (following the availability
of pasture and water) livelihood strategies of pastoralist communities. In light of this, pastoralist
communities are not benefitting from static health services often designed to serve settled
communities. Moreover, pastoralist communities are exposed to health problems such as cholera
and meningitis, which are aggravated during drought.
In the past couple of years, Ethiopia has been experiencing serious humanitarian challenges
largely attributable to conflict, drought and floods, each of these with its own devastating health
impacts. The first and most consequential impact of these are the displacement of millions of
people from their homes and belongings. Internal Displaced Persons affected by the internal
conflicts in the past years are facing several challenges, including food insecurity, shelter, water
shortage/unavailability for consumption and hygiene, personal security (risk of being attacked)
and risk of exposure to GBV and sexual exploitation and abuse/harassment. Women IDPs also
experience several maternal health problems, either as lactating mothers or pregnant women.
IDPS are among the most vulnerable in the context of Ethiopia today.

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Other most vulnerable and underserved groups in the Project context include women, the
poorest of the poor, persons with disability, the elderly, unemployed youth, low-income
households, people with low literacy status; IDPs; people living in border and remote areas;
minority groups; people with chronic illness like HIV/AIDS; widows; female-headed as well
child headed households; children, especially of pastoralist communities, because they are
always on a move.
Institutional capacity problems that limit/constrain program implementation is caused by
knowledge gap, low salary, understanding of project objectives, and low incentive mechanism.
GRM – Project implementing health institutions have existing government structure, namely
Ethics and Anti-corruption Office and Women, Child and Youth office which are working with
existing legal and justice structures to address GBV related complaints.

GBV and SEA/H: The project might not bring additional GBV and sexual exploitation risks.
But consultation participants emphasized these problems are already common, whether the
project is implemented or not and the project need to put in place effective and accessible GBV
GRM. There is a need for continuous community engagement on these and similar issues.
Consultation participants and all who contributed to this RSA emphasized that
traditional/indigenous organizations and leaders can play significant roles in health
messaging by clarifying misconceptions and serving as role models in health campaign.

Proposed Mitigation Measures

The following key mitigation measures were developed based on Consultations.
 Conduct participatory research on the pastoralists’ livelihoods, movement patterns,
etc. to make the project fit into the pastoralists’ contexts.
 To address barriers such as lack of access to health information, infrastructures that
are suitable to their special needs, awareness of the existence and affordability of the
services for the vulnerable and underserved communities: provide and disseminate
information through different means/platforms, put in place health
infrastructure/facilities that are accessible and services that are affordable.
 Support institutional capacity building; strengthen leadership commitment; training;
introduce employment benefit packages; clear and transparent institutional
arrangement.
 Introduce competitive salary and other benefit schemes (e.g., health insurance,
housing allowance, etc.).
 Conduct capacity assessment study to understand the facts on the ground in specific
project implementation area, specifically among the pastoral and underserved
communities.
 Modernize organizational structure and project prioritization process; and introduce
state of the art technologies.

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  Strengthen anti-corruption and complaints handling mechanisms to solve any conflict
of interest that might arise among the firms or companies and individuals involved in
the Project.
 Reinforce a robust, accessible and functioning GRM as an integral part of the project,
which also serves as GBV GRM.
 The vulnerable people should be consulted and take part in the project and their views
solicited.
 Enhance the status of women through access to digital technologies and information
that alleviate their burden and allow them greater time and freedom to engage in a
wide range of activities with reduced hardship and pressure.
 Develop and implement clear and transparent guidelines to mitigate the risks of
corruption, nepotism, and other unethical behaviour and practices.
 To address the challenges of urban poor and low-income households:
i. provide support to the urban poor and other low-income households in the
short-term (including subsidized health services by availing drugs and
medical supplies and equipment in accessible health facilities); and
ii. building community resilience by investing in health, communication
(including digital) and other essential infrastructures such as roads and
transportation in the long-term.

Synthesized Recommendations
The HEPRR project should learn from the challenges of past or current development projects
financed by the Bank and devise mechanisms in targeting project beneficiaries to ensure both
exclusion and inclusion errors are unlikely to occur due to the influence of traditional structures
(social and economic), corruption, clientelism and lack of awareness, livelihood strategies (e.g.,
pastoralism) especially at the grassroots levels. Adequate community consultation and
transparent and accountable institutional arrangements are the key antidotes of exclusion and
inclusion errors likely to take place due to the aforementioned reasons. Moreover, as repeatedly
discussed in the foregoing sections, participatory project identification, priority setting,
beneficiary targeting, design, planning, implementation, and M&E are the key successful project
implementation. Institutions closer to the vulnerable population and vulnerable community
groups should be consulted and take part in the project and their views solicited” from day one.

The need to build sustainable institutions at grassroots level can never be overemphasized, since
they are crucial for the delivery of services and the attainment of project objectives. Lessons
learned from various development programs/projects financed by the WB (e.g., AGP, PSNP,
SLMP, PCDP/RLLP, etc.) show that the quality of project implementation and outcomes
registered were good where local implementation structures were better organized and manned
with the requisite number and right combination of experts. The implementation structure,
especially at the grassroots levels, need to be well organized, resourced, nurtured, and sustained

12
through targeted capacity building work, and proper reward and incentive schemes put in place
for the staff.
The best way to address the adverse impacts or promote equitable access to Project benefits is,
according to an expert, health and resource distribution equity that should be anchored in a
strategic partnership with community organizations.

Programs such as HEPRR, which are implemented not only in diverse agro-ecological settings,
but also in areas where government implementation structures are not the strongest (e.g., under-
resourced remote and pastoralist areas) makes it critically important to put in place effective and
efficient monitoring and evaluation system.
Monitoring and Evaluation (M&E) should serve the intended purpose, and help the program
implementers to learn from their weaknesses and further boost their strengths, and for the higher-
level program structures to monitor performances and evaluate the impact of the program on the
program beneficiary and institutional capacity building at all levels of the program
implementation structures. M&E is not a routine activity reporting exercise meant to meet the
reporting requirement, which has been the major problem of some of these projects. Rather it is
an integral component of the program in which the information generated through the M&E
system is used to guide management decisions at both the local and higher levels of the program
implementation structure.
As a new initiative with its own unique characteristics, being regional and national at the same
time, the HEPRR project should learn from the past projects by not repeating their mistakes
(where M & E is seen as routine activity reporting exercise) and build on their strengths where
M&E becomes not only an integral part of the project implementation plans, but also an inbuilt
system of the Project implementing institutions.
Conclusion
The RSA findings showed a very strong support for the HEPRR project across the wide
spectrum of the potential project beneficiaries and experts with deep knowledge of the sector and
the livelihoods of the vulnerable and historically underserved groups. Though conducting actual
field visit was not possible due, largely, to time constraint and other challenges (security),
enough data needed for this RSA were generated from both secondary and primary sources (see
Methodology section).
Generally, there is a strong support for the project as it is believed to enhance the HE
preparedness, response and resilience of Ethiopian health sector building on what has already
been achieved in the last few years, including the capacity building accomplishments of the
federal and regional health institutions in the past few years including through the support
obtained from Ethiopia COVID-19 Emergency Response Project. Moreover, there is a huge
potential for the project to benefit people, especially the vulnerable population groups among the
underserved communities in the emerging regions. The commitment to realize the project

13
objectives is very high among all implementing agencies, especially the key implementing
federal institutions MoH and EPHI, and their partners in the regional states.
It is also worth noting the importance of taking into serious consideration during the remaining
phases of the Project the potential risks identified in this RSA and the proposed mitigation
measures which are the key to the successful implementation of the HEPRR project.

14
1. Introduction
1.1. Background and Context

Ethiopia is Africa’s second-most populous country with a population of more than 115
million in 2021. The country has made important development gains over the past two decades
and has registered commendable achievements on Millennium Development Goals (MDGs)
mainly in reducing poverty head count, achieving universal primary education, narrowing gender
disparities in primary education, reducing child and neonatal mortality, and combating HIV, TB,
and malaria. The demand for equitable access and quality healthcare services is increasing
because of a rapidly growing population, epidemiological transition of diseases, rapid
urbanisation, and broader social and economic changes occurring in the country and the
geopolitical context in the eastern Africa region.

The COVID-19 pandemic, civil conflict and climate shocks including drought have severely
impacted the wellbeing of Ethiopia’s people. Ethiopia has had the second largest number of
COVID-19 cases and fatalities in Sub-Saharan Africa with almost half a million cases and 8,000
deaths since March 20207. Severe repeating droughts and flooding in 2021 further impacted the
livelihoods and food security of over 12 million people. 8 There are over 2 million people
currently displaced due to drought, conflict, seasonal and flash floods (add reference). These
shocks have had dire economic consequences across the country and poverty rates are expected
to increase. In Fiscal Year (FY) 20, the pandemic contributed to a three percent decrease of
Gross Domestic Product (GDP) and foreign direct investment declined by 20 percent. According
to the official statistics for FY22, GDP is again expected to be significantly reduced due to the
conflict and ongoing COVID-19 pandemic, while inflation has been steadily rising reaching over
33.6 percent in January 2023.9 If not addressed urgently, Ethiopia risks to erode the human
capital gains achieved through decades of investments.

Starting from the last quarter of 2022, Ethiopia is experiencing a prolonged drought after five
(5) consecutive failed rainy seasons since late 2020 affecting 24 million people: Somali (11
zones), Oromia (8 zones), Southwest (3 zones) and Southern Nations, Nationalities, and Peoples,
SNNP (7 zones). The number of severe acute malnutrition cases has increased in 2022 by 21 per
cent in drought affected woredas of Afar, Oromia, Somali and SNNPR, comparing with 2021.
Cholera and measles cases have been reported in January 2023 in drought affected regions in the
country and are expanding to other areas 10. The overlap of COVID-19 outbreaks, and protracted
conflict have disrupted the delivery of essential maternal and child health services negatively
impacted the linear progress observed in key health outcomes in the past two decades. Prior to
the conflict, COVID-19 outbreak has reduced, averaging from 10% to 26%, utilization of out-
patient services, skilled birth attendant at health facilities, child immunization and vitamin A
supplementation and nutrition screening. The conflict has directly affected primary health care
infrastructures including 1,350 health posts, 750 health centers and 76 hospitals throughout the

7
Ministry of Health (MOH), “COVID-19 report,” April 26, 2022.
8
Reliefweb, 2021: https://reliefweb.int/disaster/dr-2015-000109-eth; and
https://reliefweb.int/sites/reliefweb.int/files/resources/ethiopia_drought_update_january_2022.pdf
9
Ethiopia: Monthly Economic Update – February 2023
10
Ethiopia Ministry of Health ^ Month Drought Response Plan

15
country and whereby pre-conflict health and nutrition service delivery indicators to be dropped
to zero in the immediate aftermath of the conflict. The risk of outbreaks from vaccine
preventable diseases and other water borne sources is high implying the increased disease burden
and mortality therein and the need to invest in health system resilience in the country.

By way of responding to these challenges and augmenting its national development financing,
Ethiopia has partnered in multilateral and bilateral development projects with several
development financing institutions such as the World Bank (WB), Africa Development Bank
(AfDB) and others. As its continued development partnership, WB is financing this Health
Emergency Preparedness, Response, and Resilience (HEPRR) project, a regional capacity
building project in which Ethiopia is one of the implementing countries. The HEPRR project
will be implemented by the Ministry of Health (MoH), with the Ethiopian Public Health Institute
(EPHI) as the key technical entity for the implementation of the project activities. This rapid
social assessment (RSA) is prepared as part of the safeguard instruments.
This rapid RSA is, therefore, initiated to assess broad project risks and impacts on vulnerable
(underserved peoples, women, children, aged people, persons with disability, poor and other
deprived segments) and other communities and recommend risk mitigation measures that will be
used at both the project design and implementation phases.

1.2. Scope of the Rapid Social Assessment

This Rapid SA is a risk mitigation tool covering risks, challenges and recommendations that will
impact the implementation of ‘Health Emergency Preparedness, Response and Resilience’.11 As
clearly stated the PAD, this is a capacity building project with a focus of Technical Assistance
(TA): “Building on ongoing World Bank and other development partners effort, and working
cross sector and cross border, HEPRR will strengthen two inter-connected pillars–
Preparedness/Response and Resilience—of health systems, enabling the rapid detection of and
response to health emergencies while ensuring the availability of essential pharmaceuticals and
health services continue to be delivered optimally even during emergencies”. The PAD adds
“The project will undertake interventions that are at policy and strategy level but still focusing on
creating the public health preparedness, response, and resilient health system capacity at the
district level”.

The project is implemented at national and sub-regional levels and this includes communities
that are underserved and vulnerable. RSA looks at (consistent with ESS7 and the World Bank
Directive on Addressing Risks and Impacts on Disadvantaged or Vulnerable Individuals or Groups 12)
how underserved communities who are often disadvantaged in development projects can
equitably access project benefits in a culturally appropriate and inclusive manner. It, therefore,

11
The ‘Health Emergency Preparedness, Response and Resilience’ Concept Note.
12
https://documents1.worldbank.org/curated/en/573841530208492785/Environment-and-Social-Framework-ESF-
Good-Practice-Note-on-Disability-English.pdf

16
helps make the project responsive to social development concerns, including seeking to enhance
benefits for the poor and vulnerable peoples and underserved groups, while minimizing or
mitigating risk and adverse impacts. It analyzes distributional impacts of intended project
benefits on different stakeholder groups, and identifies differences in assets and capabilities to
access the Project benefits.

The RSA consists of the analysis of context and social issues with a participatory process of
stakeholder consultations and involvement, to provide operational guidance on, project
implementation, and a monitoring and evaluation (M&E) framework. It also complements other
risk management relevant in this project, with the aim to prevent and mitigate undue harm to
people and their environment in the development process. These standards provide guidelines for
the World Bank and borrower in the identification, preparation, and implementation of programs
and projects; and more importantly, these standards provided a platform for the participation of
stakeholders in this project design, and have been an important instrument for building
ownership among local populations.

Different project sub-components will have varying levels of impacts on different community
groups. Some will have marginal direct impact on the grassroot level communities (e.g.,
Component 3: Program Management), while others (e.g., Component 1: Strengthening the
Preparedness and Resilience of Regional and National Health Systems to manage HEs) have
more direct impacts, both positive and negative. This means, this rapid RSA needs to explore the
potential risks and impacts of the project, with more emphasis on some components (e.g., sub-
comp.1.3, 1.4, 1.5 and 2.1)13 and their impacts on the vulnerable segment of the population. This,
by no means, should imply other project components and their impacts on the larger society will
be less emphasized. To reiterate what was stated in the ToR, the RSA is “intended to help the
Project to understand key social issues and risks, and to determine social impacts on different
stakeholders. It needs to include needs and priorities of key stakeholders, outline their views on
proposed implementation mechanisms of the project, and build capacity and involvement”. It
will also outline “requirements for the design of an appropriate institutional arrangement to
implement, monitor, and evaluate the project on the achievement of social outcomes”.

1.3. Objectives of the Rapid Social Assessment

The study aims to assess the social characteristics of local communities, including determining
the nature and characteristics of underserved groups in the HEPRR project intervention areas,
with special emphasis on their cultural characteristics, social institutions and organization and
establish that the project will not negatively impact the way of life of these people. RSA is a

13
Subcomponent 1.3: supports the readiness of healthcare systems and essential services continuity; subcomponent
1.4: supports information systems for HEs and the digitalization of the health sector; subcomponent 1.5: supports
climate resilient health systems; and subcomponent 2.1: supports collaborative surveillance and laboratory
diagnostics.

17
systemic assessment of positive and adverse social impacts associated with project and propose
appropriate risk mitigation measures.
This rapid RSA is intended to help the Project to understand key social issues and risks, and to
determine social impacts on different stakeholders, specifically looking at historically
underserved communities and other vulnerable groups. It also assesses the needs and priorities of
key stakeholders, outlines their views on the design and proposed implementation mechanisms
of the project, and build capacity and involvement. It will also provide requirements for the
design of an appropriate institutional arrangement to implement, monitor, and evaluate the
project on the achievement of social outcomes.
The RSA is the basis for the preparation of the Social Management Plan (SMP) in which all the
mitigation measures are provided as actions and if those actions require budget, an indicative
budget and the timeline for the implementation will be included in the SMP.

1.4. Study Approach

1.4.1. Methodology

The development of the social assessment involved a participatory process led by the MoH. The
HEPRR project is one among the hundreds of development projects financed by Development
Partners in Ethiopia, among which WB is one. During these several years of financing
development projects14, many documents, e.g., PADs, ESMF, ESIA, RPF, SA reports, etc. have
been produced to inform project design, implementation and monitoring and evaluation
processes. These documents have amply documented information on various issues about the
beneficiary communities differentially located in the socio-economic structure of the Ethiopian
society, and serve as important secondary sources of information for this RSA study.

The RSA for HEPRR project has used both primary and secondary sources of data. The data
from the existing works were used because most of the communities intended to be covered in
this project have already been studied in the past. Relevant published works were also consulted,
in addition to the review of the national laws, regulations, and relevant international conventions.
As much primary data as possible was generated to understand the views and document the
concerns of different social groups such as the vulnerable people in the underserved and
emerging regions. Consultations have been conducted with the Project design team members, the
federal, and regional public health officers and experts. Health experts working for NGOs among
the underserved and vulnerable groups were the other major source of primary data as they

14
For instance, recently the following projects were financed by the WB, and safeguards documents produced for
these were consulted: the Africa CDC Regional Investment Financing Project; Ethiopia COVID-19 Emergency
Response Project (parent project and AF); Sustainable Development Goal Program for Results; Ethiopia Program
for Results (Hybrid) for Strengthening Primary Health Care Services; Digital Ethiopia; and Response-Recovery-
Resilience for Conflict-Affected Communities in Ethiopia Project (3R-4CACE), 2022.

18
contributed to the RSA, some by responding in writing to the GQs and others through telephonic
interview.
As the project has a national coverage with primarily TA related activities and no specific project
sites are identified, this RSA relied on gathering of primary data from underserved communities
accessible within the constraints of communication, logistics and other accessibility issues.
Information was also gathered from key implementing Federal institutions, i.e., MoH and EPHI,
a few regional Health Bureaus for the collection of primary data. Moreover, a handful of written
comments on key social issues were also received from both the federal and regional health
institutions, and experts working among the local communities in the underserved areas.

1.4.2. Methods
As mentioned in the forgoing sections, both primary and secondary data sources were used for
this RSA. The secondary data sources included, reports of the previous and current Bank
financed projects15. Moreover, primary data sources were also used for which open-ended
Guiding Questions (GQs) were prepared for different categories of respondents, i.e., officials and
experts from key implementing Federal institutions, officials and experts of the regional health
Bureaus and experts from beneficiary institutions. Consultations with potential beneficiaries and
public health experts, themselves from the emerging regional states and working among the
underserved communities, and health experts working with local communities for NGOs, were
consulted and their views included (see Key RSA findings section below).

1.5. Project Development Objectives and Components

1.5.1. Development Objective
Project Development Objective: The Program Development Objective (PrDO) of the Health
Emergency Preparedness, Response and Resilience (HEPRR) Program is to strengthen health
system resilience and multisectoral preparedness and response to health emergencies in Ethiopia.

Building on ongoing World Bank and other development partners effort, and working cross
sector and cross border, HEPRR will strengthen two inter-connected pillars–
Preparedness/Response and Resilience—of health systems, enabling the rapid detection of and
response to health emergencies while ensuring the availability of essential pharmaceuticals and
health services continue to be delivered optimally even during emergencies. In addition, the
proposed project engages with regional integration institutions such as IGAD and HECSA to
support the cross border public health emergencies preparation and response through health
emergency information/data sharing, advancing the learning agenda and to strengthen capacity
building across countries. Furthermore, efforts will be made to leverage the academic and public
and private sector capacities in manufacturing diagnostic and preventive pharmaceuticals to
15
For instance, RLLP, 2020; SEAN-Enhanced SA and Consultation, 2020; ERSNP, Enhanced SA and Consultation,
2017; AGP-II, 2015; PSNP-IV, 2014; SLMP-II, 2013; Enhancing Shared Prosperity through Equitable Services
(ESPES) Additional Financing (AF) Incremental Environment and Social Systems Assessment (ESSA), 2017;
ESSA for ELEAP, 2018), Ethiopia Digital Foundation, COVID-19 Emergency Response Project (2021), and
Response-Recovery-Resilience for Conflict-Affected Communities in Ethiopia Project (3R-4CACE), 2022).

19
satisfy the requirements in Ethiopia and neighbouring countries and provide assistance to
enhance regulatory activities through strengthening collaboration with Africa Medical Agency
and expand market networking for sustainability.

1.5.2. Project Components

The proposed Project will have four components.

Component 1: Strengthening the Preparedness and Resilience of the Health System to manage
PHEs (US$80M).

This component would support institutional capacity building and resilience health systems
strengthening across the health system building pillars to cope with public health emergencies
while ensuring the continuity of essential health service delivery during public health
emergencies. Based on the lesson from the COVID-19 pandemic, Ebola outbreak in western and
eastern Africa and other health emergencies of communicable and non-communicable infectious
and non-infectious in the country, effective emergency preparedness requires connecting and
working together across all building blocks of the health system including health workforce,
pharmaceutical supply and value chain, regulatory and governance capacity, and quality data and
evidence informed decision making, adequate and sustainable financing, and integrated service
delivery.

Subcomponent 1.1: Strengthen cross- sectoral and cross-border public health emergency
preparedness and response and develop necessary legal frameworks and directives
emphasizing essential public health functions. The support under this subcomponent goes
beyond the conventional health sector and encompass both human and animal aspects of public
health emergency while still focusing on integration of such efforts within the wider health
systems building pillars and reflecting the roles and contribution of other sectors. Human and
animal health are administered separately by different intuitions in Ethiopia with limited
functional coordination and surveillance and event information sharing when it comes to public
health emergency preparedness. Endemic and epidemic infectious diseases, emergence of newly
discovered pathogens, drug resistance, and outbreaks of emerging and re-emerging zoonotic
diseases are causing substantial personal and economic loss in the human, livestock, and
environment sub-sectors of the country. In Ethiopia, the human and animal sectors have their
own surveillance systems at all levels that help to anticipate prevention, preparation for, early
detection and response for health emergencies in their respective sectors.

Specifically, this subcomponent supports: i) establishment of national public health security

council to serve as a mechanism for collaboration among the relevant ministries and create
accountability and political commitment; ii) Enhance the linkage between the surveillance
system, information communication, and diagnostic laboratory system within the public health
sector and between the public and animal health sector; iii) under the umbrella of IGAD,
establish/strengthen framework of agreement between neighboring countries to enhance cross
boarder collaboration and coordination mechanism with neighboring countries including human
and animal health; iv) revise and codify the existing one-health and multi-sectorial public health
emergency response legal frameworks and guidelines; v) expand the capacity of national
Emergency Operating Center (EOC) in Ethiopia to be fit for non-traditional health sector related

20
emergencies in terms of its preparedness level as well as ability to respond, both at national and
sub-national level; and vi) as an important element of the PHEM preparedness, establish a public
health emergency response contingency and equity fund with matching from government, private
sector, and other partners will be established.

Subcomponent 1.2: Support health workforce skill development and resilient engagement
during public health emergency. Ethiopia’s health workforce is characterized by a shortage and
substantial imbalance of health professionals across rural and urban areas. Staff shortages will be
amplified by population growth, a changing disease burden, urbanization, and public health
emergencies due to outbreaks and conflict. Early detection, response, and recovery in times of
public health emergencies requires the availability of a multidisciplinary health workforce with
the right knowledge, number and skill mix, clear risk compensation and incentive package. The
public health emergency management (PHEM). Preparedness and Resilience PHEMs is heavily
reliant on availability and capacity of a multidisciplinary health workforce with a strong surge
capacity to mobilize experts from various institutions in times of PHEs. It is, therefore, important
to strengthen PHEM leadership and the PHEs health workforce by rostering/preparing surge
capacity, training public health cadres, and capacity building in PHEM staffs and stakeholders,
as well as the development of emergency management, to strengthen, respond to, and lead public
health emergencies. This subcomponent supports, specifically, i) strengthen the pre-service
education and capacity to mainstream public health emergency detection and response in to the
existing health science training curriculums for both undergraduate and graduate studies through
curriculum revisions to reflect the emerging, re-emerging, and endemic causes of public health
emergencies ii) training of additional field epidemiologists, genomics, data scientists, and health
informatics, and laboratory professionals in a way that links different sectors that will involve in
the preparedness and response of the emergencies both at national and sub-national level; v)
Establish Ethiopia Multisectoral Emergency Response Team at national, regional, district level
and cross border areas with a clear training curriculum, SOPs, reporting and accountability
framework and equipped with necessary tools, medical equipment’s and incentive package. This
is on-call response team organized based on existing civil servants working in government
institutions.

Subcomponent 1.3: Support health systems readiness for continuity of essential health service
delivery during public health emergencies. Another critical challenge in times of public health
emergencies is to ensure continuity of essential health programmes and services delivery. During
the COVID-19 pandemic, for example, delivery of essential primary health care services has
been significantly affected in Ethiopia, as in other settings. An average of 10 – 23 percent
reduction is observed in utilization of essential health services including child immunization,
skilled birth attendance, out-patient services, antenatal care and treatment of chronic diseases
such as TB, Diabetes Mellitus and HIV/AIDS. This is mainly derived by a shift in leadership
focus, resources, clear plans/strategies on how to manage the continuity of essential health
service delivery while managing public health emergencies. Beyond COVID19 pandemic, the
health system is also tested to cope with the fast-evolving and unprecedented manmade crisis
such as conflict and insecurity which led to a major disruption of essential health services to a
point of zero.

Hence, this component strengthens the ability of all actors and functions related to health to
collectively mitigate, prepare, respond and recover from disruptive events with public health

21
implications, while maintaining the provision of essential functions and services. Specifically, i)
establishing regulatory, governance and management mechanisms to health facilities and health
bureaus at different level to mobilize rapidly in times of crisis: not only to respond to threats, but
also to sustain essential service provision during shock events; ii) review the budgeting, public
financial management and supply chain systems to reflect contingency resource commitments,
fiscal flexibilities and autonomy to quickly respond to public health emergencies at all levels; iii)
revise the essential health service package and medicines and equipment list to include supplies
needed to deal with public health emergencies and review the system of forecasting,
procurement, and distribution of medical supplies and equipment’s to be accommodative of
emergency operations, iv) Establish risk communication and community engagement strategies
and mechanism for assessing and maintaining public trust in health services and public health
measures to ensure routine health service utilization during public health emergencies; and v)
Develop capacities for quickly reorganizing and utilizing alternative service-delivery platforms
to prevent service disruption during emergencies (e.g. digital and virtual services) and
institutionalize simulation exercises that test health systems resilience regularly and at all levels.

Subcomponent 1.4: Support digitalization of health sector processes and PHE information
systems. The COVID19 pandemic, conflict and associated displacement and refugee crisis,
drought induced measles and cholera outbreaks, and other crisis’s has s showed that well-
functioning digital services and data interoperability are crucial components during a public
health crisis as essential as rapid response and management strategies including contact tracing,
case surveillance, diagnostic testing, case treatment and vaccination efforts. There are various
digitization efforts at point of care and institution levels that presented opportunities for
unprecedented impact on the foundation of Ethiopia’s public health system. The ministry of
health has established electronic health information management system that tracks health
service delivery, public health emergency information and community-based activities that
generate information from community level and aggregate at health facility and different health
care administration level to track service delivery and decision making. However, there is poor
interoperability among the different health information systems, limited and variable geographic
coverage (example, eCHIS 18% and DHIS-2 65%) no clear mechanism for data sharing
(interface mechanism) with agricultural, veterinary, and environmental disease surveillance
systems. There is a lack of a real-time surveillance system for health emergency preparedness
and response due to inadequate data collection, analysis, and mechanisms for data-sharing.

This subcomponent specifically supports, i) establish integrated and interoperable health

information systems to monitor health risks, public health events and their impacts on health
systems and services: (iii) Establish/strengthen structures and resources for
dissemination/communicating of information related to public health emergency and strengthen
the platforms to engage with populations/communities; (iv) Invest in cutting-edge, cost-effective
technologies for risk registering and profiling at all levels of healthcare provision for the
populations served; (v) Engage private health service providers (institutional and individual) in
the integration and alignment of health information systems to build health systems resilience,
responding to and recovering from disruptive events; (vi) Develop functional Information
systems to improve the integration of critical public health, health care services, environment,
port health, and veterinary surveillance data; and (viii) Establish real-time monitoring systems to
assess the disruptions to essential health services, incorporating specific thresholds to trigger
support and ameliorative action from the onset of emergencies and throughout an evolving

22
response;

Component 2: Improving the detection of and response to public health emergencies (USD
$145M):

This component will support the national detection and response pillars which aims to strengthen
early warning system, revise the list of reportable diseases, strengthen risk screening at port of
entries (PoEs) including border areas, enhance digital information management of multi-hazards
(infectious disease outbreaks, biological, chemical, radiological and environmental), surveillance
data analysis and interpretation, community level information collection and verification, provide
feed-back to facilities and regions, finally, risk communication will be held alongside
information management.

Subcomponent 2.1: Support the Collaborative Surveillance and Laboratory diagnostics

(US$5M): This sub-component focuses on the integration of surveillance information, laboratory
investigation and feedback mechanisms and decision making at the cross-border areas
considering the geopolitical situation of Ethiopia in part of the east Africa region which are
characterized by frequent conflict and fragile health systems, high number of refugees and
internally displaced peoples (IDPs), unregulated movement of peoples and cattle across border
and commercial movements. The most recent available joint external evaluation (JEE) and state
party annual reporting tool (SPAR) assessments have documented that the minimum IHR-2005
capacities at points of entry was documented to be low, and it was clearly stipulated that
enhancing the detection and response capacities at cross border areas is critical. Poor integration
among animal and human sectors in data sharing, joint analysis and interpretation of findings and
joint action are missing or ad-hoc based. Hence, tis component also entails the need to strengthen
the one health approach in cross-border area through a focus on multi-sectorial approach and
enhanced engagement of regional institutions such as IGAD and HECSA.

Specifically, the support will include: i) strengthening the capacity of selected points of entries
for screening, isolation, and quarantine as well as expanding the capacities of those existing
centers to integrate one-health approach; ii) strengthen the linkages between field level bio-safety
level (BSL-2) laboratories constructed by the Africa CDC project to the cross border detection
and response activities and enhance the information exchanges practice using state of the art
digital health technologies; iii) develop the legal frameworks, institutional structures with clear
accountability for multisectoral and cross border engagement with neighboring countries through
the support and leadership of IGAD; and iv) Engage with academic institutions and think-tank
groups to develop a research priority list and conduct evidence generation on prioritized zoonotic
diseases and other health threats at the animal-human-environment interface.

Subcomponent 2.2: Support the Emergency Management and Coordination. Investments from
the world bank COVID19 emergency response project and Africa CDC investment financing
project have focused on. As demonstrated through different outbreak and other public health
emergency responses including COVID-19, Ethiopia has not reached its optimum capacity in
terms of rapid and effective emergency management and disease outbreak controls. To improve
the capacity of the country to effectively respond integrated with regional public health agencies
such as AU-CDC and others, to any public health hazard, improving human resource
capacity/subject matter experts, coordination centers and platforms, conduct operational

23
research/outbreak investigations and equipping the response team with necessary logistics are
critically important. Specifically, this component involves i) Strengthening readiness and
response coordination mechanism at national and sub-national level including strengthening the
public health emergency operation centers (PHEOC) towards effective coordination of public
health emergencies (PHEs) preparedness and response activities to COVID-19 pandemic, IDP
health Intervention, Cholera and cVDPV outbreak response and Monkey pox and EVD
preparedness activities; ii) capacitate and strengthen the rapid response team through identifying,
training, and rostering subject matter experts at national and sub-national levels.

Subcomponent 2.3: Support accelerated access to and deployment of R&D, legal, and
regulatory countermeasures in a PHE, leveraging public and private sector resources. The
major causes of disarray in health outcome between low income and developed countries is the
inequitable access to essential diagnostic and treatment pharmaceutical supplies. Despite hosting
17% of the global population and untapped natural resources, Africa produce only 1% of the
continental vaccine needs; many countries including Ethiopia fully rely on import for essential
vaccines. In 2020, Ethiopia’s pharmaceutical market averaged nearly US$ 1 billion and is
estimated to reach more than US$ 3.6 billion by 2030. The market for pharmaceuticals and
medical devices in Ethiopia is met through import (purchase and donation) and local production.
With local production contributing less than 10% of the total market for pharmaceutical products
and medical devices, the Ethiopian Pharmaceutical Supply Service Agency (EPSSA), private
importers, donors, and international organizations are involved in the import and distribution of
pharmaceutical products and medical devices.

For Ethiopia, with growing population, increasing disease burden and unmet needs for
pharmaceutical supplies such as medicines, diagnostic supplies, and vaccines, investing in
local production is very strategic and an issue of national security as demonstrated by the
COVID19 pandemic. It is worth noticing that vaccine manufacturing is technology and capital
intensive with stringent regulatory requirements. The ongoing government commitment in
infrastructure development and policy reform; the growing local and regional market to be
facilitated by regional institutions such as IGAD; the implementation of attractive incentive
schemes for local manufacturers can be enabling factors to invest in vaccine manufacturing in
the country. Pharmaceutical manufacturing (pharmaceuticals, vaccine, medical supplies, and
diagnostics) is identified as a major focus area of the ten-year manufacturing industry
development plan (2021-2030), highlighting significant opportunities to strengthen the sector to
promote import substitution and satisfy domestic demand, improve access to essential medicines,
and supply the export market by producing competitive products. Despite the market dominance
of pharmaceutical manufacturers based in high and middle-income countries, there are many
reasons why Ethiopia wants to establish its own pharmaceutical supply, such as the need for
supply security, control over production scheduling and sustainability, control of costs, better
control over the quality of vaccines, socio-economic development, rapid response to local
epidemics including emerging infectious diseases, and dealing efficiently with endemic and
pandemic disease.

This component supports the local pharmaceutical manufacturing initiative of the government
and other sector actors along the value chain of pharmaceutical manufacturing. Specifically, i)
support to strengthen the national enabling environment including medicine regulatory system;
ii) develop human resources through relevant education and training; iii) encourage cluster

24
development and production of active pharmaceutical ingredients; iv) create a research and
development platform; and procure medical equipment’s, supplies and other inputs to furnish
and make functional the already existing industrial park dedicated to local pharmaceutical
production. This initiative needs to be complemented by the overall government investment
strategies that focuses on attracting more foreign direct investment in the pharmaceutical sector
and create incentives designed to move companies along the value chain in sustainable
pharmaceutical production that satisfies the local diagnostic and treatment needs.

Component 3: Program Management:

Sub-component 3.1: will support monitoring and evaluation and engagement of academia and
think tank groups. This component will provide financing for i) Coaching and technical support
for data analysis, interpretation and lesson sharing and support for decision-making; ii) Third
party implementation and monitoring to support implementation of the project activities in
conflict and security constrained areas and assure the validity of Results Framework indicator
data reported by governments; and (iv) Data-based cross-border learning initiatives, which will
share proven strategies to effectively collect and use data to enhance health emergency response.

Sub-component 3.2: will focus on all other aspects of program management. Implementing the
proposed project will require administrative and human resources that exceed the current
capacity of the implementing institutions, in addition to those mobilized through the other bank
projects including COVID19 emergency response project and Africa CDC Project. Specific
activities include: i) support for procurement, FM, environmental and social safeguards,
monitoring and evaluation, and reporting; ii) recruitment and Training of Grants Management
Unit and EPHI staff and technical consultants; iii) operating costs and iv) support for cross
border related administrative activities and collaboration with IGAD.

Component 4: Contingent Emergency Response Component (CERC): TBD

1.5.3. Institutional and Implementation Arrangements

The Ministry of Health (MoH) of the Government of Ethiopia will be the implementing
agency for the project and oversee the overall implementation of the project. The state
minister for Programs will be responsible for the execution of project activities and oversee the
overall implementation of the project. The Grant management unit of the Ethiopia MoH’s
Partnership and Cooperation Directorate (PCD) will be responsible for the day-to-day
management of activities supported under the project as well as the preparation of a consolidated
annual workplan and a consolidated activity and financial report for the above-mentioned project
components. The PCD already manages and coordinates several World Bank funded projects in
the health sector, including the Africa Centre for Disease Control (CDC) and Prevention regional
investment financing project (P167916); Ethiopia COVID19 Emergency Response Project
(P173750); Sustainable Development Goal Program for Results (P123531); and Ethiopia
Program for Results (Hybrid) for Strengthening Primary Health Care Services (P175167).

25
The Ethiopian Public Health Institute (EPHI)16 will serve as the key technical entity for the
implementation of the project activities. It will both support the PCD and directly implement
certain technical activities. The EPHI will report directly to the state minister, and it will share
the project’s technical and financial updates with the grant management unit. If necessary, the
EPHI will also reinforce the GMU with additional staff, including accountants and procurement
officers, to manage project activities under its purview. The Ethiopia MoH will also deploy the
staff needed for proper implementation of the environmental and social management plan as
specified in the project’s Environmental and Social Impact Assessment (ESIA). In addition to
MOH and the Ethiopia Public Health Institute (EPHI), the Ethiopia Pharmaceutical Supply
Agency (EPSA), Ethiopian Food and Drug Administration (EFDA), Regional Health Bureaus,
technical directorates at the MoH and other key agencies will be involved in project activities
based on their functional capacities and institutional mandates.

The implementation of the ongoing World Bank Funded projects has provided several
insights in key implementation capacity gaps that this new operation needs to address to ensure
enhanced implementation capacity and achieve intended results through efficiency in the use of
project resources. The three key aspects that are important lessons learned incorporated into the
design of this operations are: i) Cross border collaborations, multi-sectorial coordination, and
limited project implementation capacity in emerging regions are key factors affecting project
implementation and achievement of the intended result of the project. Establishment of cross-
border coordination task force, strengthening multi-sectorial platforms and capacity building on
quality data collection and utilization for decision making are key project components; ii) Access
and implementation of project activities in areas of affected by conflict and insecurity, especially
in the border areas. The team has explored all options and is incorporating the possibility of
using the contracting of a third party for the implementation of project activities in the areas
affected by the conflict and insecurity. Based progressive assessment of the situation, activities
being implemented by third party will be transferred to ministry of health on a phased based
approach; and iii) capacity gaps in project management and technical gaps in preparedness,
response and building resilient health systems. It is critical to build the capacity of grant
management unit in sequencing of project activities that are in alignment with the results
framework and government’s budget cycles and other guidelines and rules that affect planning,
disbursements, and procurement processes.

Strengthening the capacity of the GMU has already been agreed within the framework of
the ongoing bank projects, and further expansion of the unit will be supported under this
project. A hands-on approach to supervision of key fiduciary aspects will support Ethiopia
Ministry of Health and the GMU in exploring all the options to help tackle the key barriers for
accelerated implementation of procurement processes and budgeting. For this effect a technical
assistance fund will be established as part of component 3 (project management) and finance key
capacity gaps and technical assistance needs based on annual work plans. The GMU may also
recruit specialized technical staff as needed, and some activities may be outsourced to third
parties through contract agreements acceptable to the World Bank.

16
EPHI is under the Ethiopian Ministry of Health and is responsible for implementation of several WBG supported
projects (e.g., the COVID-19 and Africa CDC projects in Ethiopia), while the MoH is the primary recipient of WBG
funding.

26
The resources of this project are designed to leverage resources provided by government
and other development partners. The project is also designed to ensure the desired outcomes
can be accomplished with ownership of the regional and subregional entities that are also
engaged in supporting key public health interventions. Using the existing country’s policy
dialogue platforms, the World Bank will work closely with development partners and other
regional institutions (TBD) to engage in relevant activities and have an ongoing discussion that
can foster complementarities and exchange of information.

Table 1: Project Components and Implementing Agencies

Component Sub-component Implementing

Agency

Component 1: Subcomponent 1.1: Strengthen cross- MoH/EPHI/

Strengthening the sectoral and cross-border public health RHB/MoA
Preparedness and emergency preparedness and response and
Resilience of the Health develop necessary legal frameworks and
System to manage PHEs directives emphasizing essential public
health functions.

Subcomponent 1.2: Support health MoH/EPHI/RHB

workforce skill development and resilient
engagement during public health
emergency.

Subcomponent 1.3: Support health systems MoH/EPHI/RHB

readiness for continuity of essential health
service delivery during public health
emergencies

Subcomponent 1.4: Support digitalization of MoH/EPHI/RHB

health sector processes and PHE
information systems

Component 2: Subcomponent 2.1: Support the MoH/ AHRI/

Improving the detection Collaborative Surveillance and Laboratory EPHI/RHB
of and response to public diagnostics
health emergencies
Subcomponent 2.2: Support the Emergency MoH/EPHI/RHB
Management and Coordination

Subcomponent 2.3: Support accelerated MoH/EPHI/RHB

access to and deployment of R&D, legal,
and regulatory countermeasures in a PHE,
leveraging public and private sector
resources

27
Component 3: Program Sub-component 3.1: support monitoring and MoH
Management evaluation and engagement of academia and
think tank groups

Sub-component 3.2: will focus on all other MoH

aspects of program management

Component 4: MoH
Contingent Emergency
Response Component
(CERC)

28
1.5.4. Project Intervention Areas

This is a national project covering all the eleven regional governments and two city
administrations, but the bulk of the project interventions will likely be carried out in “high-
potential” climate crisis prone low land areas and border areas due to the cross-border
nature of the project. The project will undertake interventions that are at policy and strategy
level but still focusing on creating the public health preparedness, response, and resilient health
system capacity at the district level. Due to the multisectoral nature of the project, the project
will engage with regional governments within Ethiopia to ensure their buy-in, support
coordination with sectors other than health and able to reflect their unique context in the design
of the project interventions.

Already in its design that this is a regional integration project, Intergovernmental agency
for Development (IGAD) and Africa Center of Disease Control (Africa CDC) will be
involved in the project implementation. In addition to working on broader public health
emergency preparedness, response and resilient health system building at national and sub-
national level, the project will work with regional integration institutions such as
Intergovernmental agency for Development (IGAD) and Africa Center of Disease Control
(Africa CDC). The selection of IGAD as regional institution is based on the comparative
advantage and leveraging power of IGAD in engaging political leaders in the east Africa to work
together in cross border public health emergency, cross country information and data sharing
among member countries that border with Ethiopia.

1.5.5. Project Beneficiaries

The project will benefit communities in Ethiopia, especially poor households, communities
bordering other countries, refugees, and other populations that are at high risk of epidemic
disease. Key beneficiaries include populations in Ethiopia (115 million), as well as communities
in countries directly bordering Ethiopia: Sudan (46.6 million), South Sudan (11.5 million),
Djibouti (1.01 million), and Eritrea (3.7 million). Projects indirect beneficiaries extends to other
IGAD member countries through knowledge and information/data sharing on public health
emergency management. In addition, due to the “one health” focus of the project, the project
beneficiaries extend to Animal health and increase productivity in the rural sector by reducing
animal deaths, increasing animal fertility, and boosting the marginal output of animal products.
The project will improve the overall social and economic benefits of improved health indicators
and lower mortality rates, finally, through working with regional integration institutions such as
IGAD and Africa CDC, the project will strengthen domestic, regional, and continental
institutions and build the capacity of their staff, reinforcing the framework for an integrated
Africa.

2. Legal Frameworks: Basis for Social Assessment

This section discusses the national legislations and World Bank environmental and social
safeguard policies relevant to historically underserved communities.

29
2.1. National Legal and Institutional Framework for Underserved and Vulnerable Groups

Various national legislations have been used during the implementation of projects. These
emanate from the 1995 Constitution of the Federal Democratic Republic of Ethiopia (FDRE) and
various policies, strategies, proclamations and regulations. This will be discussed in the
following sections.

The 1995 Constitution of the federal Republic of Ethiopia recognizes the presence of different
socio-cultural groups, including historically disadvantaged and underserved communities,
pastoralists, agro-pastoralists, and minorities, as well as their rights to socioeconomic equity and
justice.

Article 39 of the Ethiopian Constitution recognizes the rights of groups identified as “Nations,
Nationalities and Peoples”. They are defined as “a group of people who have or share a large
measure of common culture or similar customs, mutual intelligibility of language, belief in a
common or related identity, a common psychological make-up, and who inhabit an identifiable,
predominantly contiguous territory.” This represents some 75 out of the 80 groups 17 who are
members of the House of Federation (HoF), which is the second chamber of the Ethiopian
legislature (Van der Beken, 2007). The HoF is the representative organ of the diverse Ethiopian
ethnic groups in the federation because Article 61(1-3) of the federal constitution stipulates that
all nations, nationalities and peoples, including those with less than 100,000 population and who
cannot elect their representatives to the lower house, the legislative House of Peoples’
Representative (HPR), are entitled to at least one representative, elected either by the regional
parliaments or within the framework of direct elections organised by these parliaments.

The Constitution recognizes the rights of these Nations, Nationalities and Peoples to: self-
determination, including the right to secession; speak, write and develop their own languages;
express, develop and promote their cultures; preserve their history; and, self-government, which
includes the right to establish institutions of government in the territory that they inhabit and
equitable representation in state and Federal governments.

The Constitution also recognizes the rights of pastoral groups inhabiting the lowland areas of the
country. The constitution under article 40(4) stipulates ‘Ethiopian pastoralists have a right to
free land for grazing and cultivation as well as a right not to be displaced from their own lands’.
Article 41(8) affirms that “Ethiopian pastoralists have the right to receive fair prices for their
products, that would lead to improvement in their conditions of life and to enable them to obtain
an equitable share of the national wealth commensurate with their contribution. This objective
shall guide the State in the formulation of economic, social and development policies.’
Pastoralist regions/areas recognized by the government are: Afar; Somali; Borena Zone and

17
The national minorities constituted 8.8% of the total population of Ethiopia, which was 73,918,505 according to
the 2007 Population and Housing Census.

30
Fentale Woreda (Oromia); South Omo Zone, Bench-Maji Zone, and parts of Decha Wereda in
Keffa Zone (SNNPR); and Nuer Zone (Gambella).

The pastoralists comprise approximately 12-15 million people that belong to 29 groups of
Nations, Nationalities and Peoples.18 Whilst government policies have strengthened and resource
allocations increased over the last decade, 19 pastoralist areas are still amongst the least served in
terms of basic services. Education indicators for pastoralist areas are among the lowest in the
country: lowest literacy rates, highest dropout rates and greatest distance from schools (Jennings
et al., 2011). Some pastoral households view formal education as a threat to the contributions
that children make to the household and the pastoralist way of life and girls’ access to education
is also constrained by the perceptions of parents that schooling compromises girls’ reputation,
makes them less compliant which, in turn, reduces their worth as marriage partners (Brocklesby
et al. 2011).

Article 54(1) of the FDRE Constitution also recognizes another group called “national
minorities”, i.e., Nationalities and Peoples whose total population is “less than 100,000 members
and most [of them] live in the ‘Developing Regional States’”.

Owing to their limited access to socioeconomic development and underserved status over
decades, the GoE has designated four regions, i.e., Afar, Somali, Benishangul-Gumuz, and
Gambella as Developing Regional States (DRS). In this respect, Article 89(2) of the 1995
Constitution stipulates: ‘The Government has the obligation to ensure that all Ethiopians get
equal opportunity to improve their economic situations and to promote equitable distribution of
wealth among them’. Article 89(4) in particular states: ‘Nations, Nationalities and Peoples least
advantaged in economic and social development shall receive special assistance’.

In connection with the institutional framework designed to ensure equity between regions, the
government has set up the Ministry of Federal Affairs (MoFA) 20. The responsibilities of this
Ministry include promoting equitable development, with emphasis on delivering special support
to the developing regions. The main purpose of the special support is to address the inequalities
that have existed between the regions over the decades, thereby hastening equitable growth and
development. Federal Special Support Board, which consists of relevant sector ministries
including the MoA, was reorganized in March 2011. The MoFA acts as Vice Chair and
secretariat of the Board. A Technical Committee (TC) composed of sector ministries constituting
the Board was also set up under the MoFA to monitor and report the implementation of special
support plans. As its main aim, the Board coordinates the affirmative support provided to the
18
Pastoralist Forum Ethiopia, http://www.pfe-ethiopia.org/about.html
19
PASDEP (2005 -2010), the previous five-year poverty reduction plan to GTP promoted more targeted assistance to
marginalized areas – the emerging regions and pastoralist/agro-pastoralist areas (MoFED 2010).
20
Now a defunct Ministry, but most of its mandates such as Federal and Pastoralist Development Affairs, inter-
regional affairs and issues related to peace were put under the Ministry of Peace. A new department tasked with
Low-land irrigation was established under the Ministry of Agriculture.

31
developing regions by the different organs of the federal government, and ensures the
effectiveness of the implementation process.

In addition, Equitable Development Directorate General has been set up within the MoFA, with
Directorates put in place to operate under it for the respective developing regions. Among many
other activities, the Directorate General coordinates and directs case teams to collect, organize
and analyze data in relation to the gaps in capacity building, social and economic development,
good governance, gender and environmental development in the regions in need of special
support.

With the announcement of the National Policy of Women in 1993 and the promulgation of the
new Constitution in 1995, the Ethiopian Government declared its commitment to the equitable
socio-economic development of women. The National Policy on Ethiopian Women aims to
institutionalize the political, economic, and social rights of women by creating appropriate
structures in government offices and institutions so that public policies and interventions become
gender-responsive in order to ensure equitable development for all Ethiopians.

Labour Proclamation (Proc. No. 377/2003) provided women with a special attention. This
proclamation is aware of the fact that women are marginalized historically, and hence genuine
equality will not be maintained only by the principle of non-discrimination on the basis of sex
rather women should also be given with a special treatment, affirmative action.
After long discussions, the Government recently announced revision of its 15-year-old Labour
Law. The revised Labour Proclamation (Proc. No. 1156/2019) is one of the key pieces of
legislation that the Government has adopted in order to move forward in alignment with the
Country’s fast economic growth and evolving employment relations, and to comply with
multiple International Labour Organization’s (“ILO”) Treaties and Commentaries. 21 The new
Proclamation No. 1156/2019 which repeals the previous proclamation No. 377/2003 and Labour
(Amendment) Proclamation No. 466/2005. One of the major additions in the revised Labour
proclamation relates to Sexual violence and Harassment in the work place. The new
Proclamation defines sexual harassment as “means to persuade or convince another through
utterances, signs or any other manner, to submit for sexual favor without his/her consent”
(Art.2(11)). Sexual violence is defined as “means sexual harassment accompanied by force or an
attempt thereof” (Art.2(12)). Moreover, the hitherto thirty days pre-natal and sixty days post-
natal leave has been changed to thirty consecutive days pre-natal and ninety consecutive days
post-natal leave (88(3)). Additionally, the revised Proclamation has introduced paternity leave of
three working days with full pay (Art.81(3)), which was not recognized under the previous
proclamation.

In 2005, the Women ‘s Affairs Ministry was established to coordinate women’s activities and
translate the policy objectives. In 2006, the Ministry of Women’s Affairs issued the National
Plan of Action for Gender Equality (NAPGE) for the period 2006 – 2010. Its goal is “to
contribute to the attainment of equality between men and women in social, political and
economic development”.
21
https://mehrteableul.com/images/Legal_Update_Employment.pdf

32
Recently, the GoE has put in place a strong policy foundation for the social protection sector,
with the approval of the National Social Protection Policy (NSPP) 2014 and National Social
Protection Strategy 2016. This policy envisions “to see all Ethiopians enjoy social and economic
wellbeing, security and social justice “and recognizes the contribution of social protection to the
development goals of the country. It further indicates that the Government will commit human
and financial resources to reducing poverty and provide social protection to its poorest and most
vulnerable citizens. The NSPP has a broad objective of providing an overall Social Protection
system and creating an enabling environment in which Ethiopian citizens have equitable access
to Social Protection services that will enhance inclusive growth and development. Overall, the
policy commits the government to move beyond the partial, and fragmented, provision of Social
Protection to establish a comprehensive Social Protection system (MoLSA 2014).

The policy has five integrated focus areas, which includes: (1) Promote Productive safety nets;
(2) Promote employment opportunities and improve livelihood: (3) Promote social Insurance:
(4) Enhancing equitable access to and use of basic services; and (5) Providing legal protection
and support services for those vulnerable to violence and abuse. Across these areas, both the
Policy and the Strategy seek to bring together a variety of existing programs into a national
social protection system for supporting vulnerable Ethiopians. The fourth area of focus that
aimed to enhance access to health, education and other social services introduced specific
strategies among others: ‘health fee waivers and health insurance subsidies, services for the
elderly and labour-constrained, establishing a social work system and school feeding’ (MoLSA
2014; 2016). The policy serves as a framework for collaboration and coordination system of
social protection in order to provide different services by different organization at all level.

Moreover, Ethiopia’s ‘Growth and Transformation Plan’ (GTP I 2010/11-2014/15 & GTP II
2015/16-2019/20) is a national five-year plan initiated and developed by the Ethiopian Federal
Government to improve the country's economy by achieving a projected gross domestic product
(GDP) growth of 11-15 percent per year from 2015/2016 to 2019/2020. Among others, GTP II
envisages strengthening the empowerment of women so as to ensure their active participation in
the political, social and economic processes that are taking place in the country. All public
development programs will be designed in such a way that they engage women and ensure their
equity in the outcomes of such programs. During GTP II, the political empowerment of women
will be realized by establishing mechanisms for women’s equal participation and equitable
representation at all levels of the political process and public life in society. A critical element in
this endeavour is promoting women organizations that articulate and advance women’s concerns,
needs and priority agendas, and that influence public policies and actions” (p.3)22.

22
Enhancing Shared Prosperity through Equitable Services (ESPES) Additional Financing (AF) Incremental
Environment and Social Systems Assessment (ESSA).
http://documents1.worldbank.org/curated/en/280901496649106913/pdf/115609-EA-P161373-Box402912B-
PUBLIC-Disclosed-6-2-2017.pdf

33
Following the end of GPT II, the Ten Years Development Plan: A Path to Prosperity (2021–
2030)23 was launched. The ten-year development plan lays a long-term vision of making Ethiopia
an “African Beacon of Prosperity” by creating the necessary and sufficient conditions. It states
“prosperity should be defined in terms of the overall human and institutional capability we create
over the long-term whose development outcomes can be expressed as follows” (p.19).
1. Improvement in income levels and wealth accumulations so that every citizen would be
able to satisfy their basic needs and aspirations.
2. Basic economic and social services such as food, clean water, shelter, health, education,
and other basic services should be accessible to every citizen regardless of their economic
status.
3. Creating an enabling and just environment where citizens would be able to utilize their
potentials and resources so that they lead quality life.
4. Improvement in social dignity, equality, and freedom where citizens can freely
participate in every social, economic, and political affairs of their country regardless of
their social background.

One of the six key development objectives of the Plan is no. 6 says “Building strong and
inclusive institutions that would ensure peaceful society, access to justice and upholding the rule
of law and human rights.” (p.20) Among the eight key strategic pillars identified to realize the
development objectives, number 8 is pertinent here: “Gender and Social Inclusion” (p.21)/
The key priority areas are: (p.21)
1. Multi-sectoral and Diversified Sources of Growth and Job Opportunities,
2. Sustainable and Inclusive Financial Sector Development,
3. Harnessing the Demographic Dividend,
4. Quality and Efficient Infrastructure Development,
5. Sustainable Urban Development, and
6. Peace, Justice, and Inclusive Institutions

The whole Chapter 8 of the Ten Years Development Plan is dedicated to Gender and Social
Inclusion pillar, while health was treated under chapter 7, i.e., Demography and Human
Resource Development.

2.2. The Nexus between Ethiopian Policies and Laws and the World Bank Environment and
Social Framework
The Federal Democratic Republic of Ethiopia has formulated several development policies,
strategies, proclamations, regulation, programs and projects to improve the livelihood and to
promote sustainable development of Ethiopian people in general and the pastoral as well as agro-
pastoral communities in particular. The government has also made certain shift in the thinking of
pastoral development from its predecessors by bringing pastoralists themselves to participate in
the policy making processes that affect their livelihoods.
Detail review of Ethiopia’s relevant policies, strategies and proclamations on Social and
Environmental issues along with the pertinent social and environmental safeguard framework of
23
file:///C:/Users/soria/Downloads/ten_year_plan_popular_version.pdf

34
the World Bank is covered under the ESMF/ESIA. Here suffice it to say, pastoralists and agro-
pastoralists as well as disadvantaged communities are adequately considered in the Ethiopian
constitution and this concurs with the World Bank’s Environmental and Social Standards (ESS)
(ESS 1, 5, 7 and 8)24. This will help ‘Health Emergency Preparedness, Response and Resilience’
(HEPRR)’ project to give due attention to the vulnerable and underserved communities during
implementation that in turn enables it to meet the intents of World Bank’s ESF in socially and
culturally appropriate ways. The WB’s ESS7 recognizes that Indigenous Peoples/Sub-Saharan
African Historically Underserved Traditional Local Communities have identities and
aspirations that are distinct from mainstream groups in national societies and often are
disadvantaged by traditional models of development. In many instances, they are among the
most economically marginalized and vulnerable segments of the population. This is clearly
shown in its 6 points objectives.
1. To ensure that the development process fosters full respect for the human rights, dignity,
aspirations, identity, culture, and natural resource-based livelihoods of Indigenous
Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities.
2. To avoid adverse impacts of projects on Indigenous Peoples/Sub-Saharan African
Historically Underserved Traditional Local Communities, or when avoidance is not
possible, to minimize, mitigate, and/or compensate for such impacts.
3. To promote sustainable development benefits and opportunities for Indigenous
Peoples/ Sub-Saharan African Historically Underserved Traditional Local Communities
in a manner that is accessible, culturally appropriate, and inclusive.
4. To improve project design and promote local support by establishing and maintaining an
ongoing relationship based on meaningful consultation with the Indigenous
Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities
affected by a project throughout the project’s life cycle.
5. To obtain the Free, Prior, and Informed Consent (FPIC) of affected Indigenous
Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities
in the three circumstances described in this ESS.
6. To recognize, respect, and preserve the culture, knowledge, and practices of Indigenous
Peoples/ Sub-Saharan African Historically Underserved Traditional Local Communities,
and to provide them with an opportunity to adapt to changing conditions in a manner and
in a time frame acceptable to them.

A key purpose of ESS 7 is to ensure that Indigenous Peoples/Sub-Saharan African Historically

Underserved Traditional Local Communities present in or with collective attachment to the
project area are fully consulted about, and have opportunities to actively participate in,
project design and the determination of project implementation arrangements. The scope and
scale of consultation, as well as subsequent project planning and documentation processes, will
24
ESS1 – Assessment and Management of Environmental and Social Risks and Impacts; ESS5 – Land Acquisitions,
Restrictions on Land Use and Involuntary Resettlement; ESS7 - Sub-Saharan African Historically Underserved
Traditional Local Communities; and ESS8 – Cultural Heritage.

35
be proportionate to the scope and scale of potential project risks and impacts as they may affect
Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local
Communities. As amply demonstrated in the analyses of Ethiopian legal and policy frameworks
crafted to address the problems of the underserved and vulnerable groups of the Ethiopian
population, they all duly recognize the peculiar characteristics of the underserved and vulnerable
groups of the nations in the pastoral and agropastoral areas and this meets the expectations of
ESS 7 despite the fact that they are, as the first paragraph of ESS 7 clearly stipulates, “referred to
in different countries by different terms”.

36
3. Social Assessment Findings

3.1. Characteristics of Vulnerability and Underserved Target Communities

The Ethiopian Constitution recognizes the presence of different socio-cultural groups, including
historically disadvantaged and underserved communities.
According to the National Social Protection Policy (NSPP), 2014 of Ethiopia, in the Ethiopian
context, vulnerability is associated with low agricultural growth, natural calamities, economic
shocks, health and nutrition risks, and population explosion. It is also connected with
environmental degradation and dependence on rain-fed agriculture, which are the contributory
factors of chronic food insecurity, one of the major challenges in Ethiopia today 25, as well as
with unemployment and underemployment. Broadly defined, the term vulnerability applies to all
social groups that find themselves disadvantaged because of the deprivation of access to
socioeconomic benefits, or the adverse consequences suffered as a result of mainstream
development interventions and exacerbated by lack of access to information.
Vulnerability describes the factors which expose people to the negative impacts of their living
circumstances, and render them less resilient to cope with these impacts. Economic poverty is
obviously a vulnerability factor; other factors include sudden shocks such as economic collapse
or natural disasters (price hikes, sudden conflict, desert locus invasion as observed in the horn of
Africa in 2020, and prolonged drought as observed in the lowland areas of Oromia, Somali, and
SNNR in 2021 and 2022). Further vulnerability factors are:
 Lack of adequate understanding and awareness resulting from insufficient or
inappropriate communication of information and ideas (which ‘Digital Ethiopia’ project,
currently operational and also funded by the WB, aims to address); [One of the key
activities of component 2 of the HEPRR project is exactly this, i.e., enhance digital
information management of multi-hazards (infectious disease outbreaks, biological,
chemical, radiological and environmental.]
 Embedded social and cultural attitudes and practices which discriminate against or give
precedence to certain people on certain grounds (gender, age, ethnicity, religion, and
occupation) also sustained by lack of information about the national and international
standards on human rights and respect for human dignity;
 Attitudes towards people manifesting certain behaviour, or reactions to people with
certain conditions (persons with disability, people living with HIV/AIDS and other
chronic health problems such as people with leprosy).
Vulnerability can also be seen in terms of biophysical environment such as people who live in
semi-arid lowland areas, where poverty, gender-based inequalities, forms of agricultural
25
“Overall, an estimated 12.9 million people are expected to be facing high levels of acute food insecurity (IPC
Phase 3 or above) in the presence of currently planned and funded humanitarian response interventions from January
to June 2021.” Ethiopia: IPC Acute Food Insecurity Analysis October 2020 – September 2021, Issued December
2020 - Ethiopia | ReliefWeb

37
livelihood, customary practices, and spatial disparities in resource potential are the key factors
affecting people’s abilities to access services that would enhance their means of livelihoods.
Irrespective of their vulnerability, no community members in the project implementation areas
will be intended to be excluded from the ‘Health Emergency Preparedness, Response and
Resilience’ (HEPRR)’ Project.
The socioeconomic and cultural profile of the population groups described as vulnerable and
underserved and considered as potential beneficiaries of the HEPRR Project are presented
below.

3.1.1. Women
The HEPRR Project Concept Note (parag. 20) acknowledges the risk of exclusion from project
benefits of vulnerable groups including women. Gender-based social exclusion, discrimination
and differential treatment constitute key risks and addressing those should be an important entry
point to the design and implementation of development programs such as HEPRR. Women
become vulnerable because of lack of education, gender bias, traditional and cultural norms, and
their reproductive and productive roles and more importantly lack of access to up to date and
reliable information.
More specifically, socially constructed determinants mainly societal attitudes towards women,
women’s socioeconomic status, their levels of education, and the awareness of their rights define
women’s roles and position in society. In relation to this, specific issues for deeper examination
are: societal attitudes placing the burden of domestic responsibilities on women, their low
economic status evidenced by their limited property rights (land and livestock), little or no access
to education and unaffordability of ICT services with its ramifications of rights conscious
deficiency at all levels, and their vulnerable status emanating from the difficulty to balance their
triple roles competing for their equal attention in male-headed households and single-handedly
running the households in female-headed households.

3.1.2. Women’s time poverty

Document review of the SA studies of various development projects (e.g., RLLP, 2020; SEAN-
Enhanced SA and Consultation, 2020; ERSNP, Enhanced SA and Consultation, 2017; AGP-II,
2015; PSNP-IV, 2014; SLMP-II, 2013; Digital Ethiopia SA 2021) show women play a
significant role in farm activities, domestic chores, and off-farm tasks in addition to their
reproductive roles and maternal responsibilities towards their children. There were also cases in
which women found it difficult to balance their triple roles competing for their equal attention:
bearing and rearing children, maintenance of household members and domestic work,
community managing role and productive role such as harvesting, weeding, threshing the
harvest, etc. The difficulty of balancing these equally important responsibilities resulted in the
risk of losing project benefits in varying degrees (e.g., SLMP-2).

38
Besides, women are responsible for much of the buying and selling at the local markets to earn
additional sources of income for the household. Despite the embeddedness of gender-based
division of labor in many communities, women often perform the jobs assigned to men. For
instance, among the Gumz and Majanger women normally perform all the tasks considered to be
in the domain of men such as forest clearing, hoeing farm plots, planting, weeding, and threshing
(AGP-II SA report, 2015:31). Women’s multiple roles in productive, reproductive and
community-related activities which all compete for their effort and attention result in what is
often called time poverty. With their time and attention divided among these commitments, they
find it difficult to balance their responsibilities including participation in development programs
which would, at the end of the day, benefit them and their families (AGP-II SA report, 2015:31-
2).
Women’s vulnerability is further aggravated by out-migration of male adults and youths among
some of the communities (e.g., Enmor ena Ener Woreda of SNNPR). This deprives households
of male labor for agricultural engagements, forcing women to carry the entire burden of farm and
domestic work. Being labor intensive and the exclusive domain of women, the chore of enset
(enset edulis, also called “false banana”) processing is another taxing duty that adds pressure to
women and causing them time poverty in Enmor ena Ener Woreda, as in other enset growing
areas of the country. Enset is a staple in Ethiopia, where around 20 million people rely on it for
food.
Women’s drudgery is exacerbated by economic hardships, exposing them to even higher
vulnerability. Hence, the worse off women are, the greater their burden of work, with the
consequence of increased time poverty. Moreover, as stated in the HEPRR project Concept Note
(Parag. 1, last sentence), Health Emergencies (HEs) “affect vulnerable populations unevenly,
with forcibly displaced communities and their hosts, women, and children often bearing the
brunt of the adverse impacts”. Therefore, HEPRR project will further enhance the status of
women and other vulnerable populations through improved health with more investment in HE
preparedness.

3.1.3. Female-Headed Households

It is a common to see female-headed households struggling to sustain their families in both rural
and urban settings of Ethiopia. However, data on the number of female-headed households are
not easy to come by. Female-headed households are challenged not only because of absence of
adult male to shoulder the responsibility assigned to him, but also by access to only small
farmland (often 0.25 hectare in in some parts of the country such as Tigray and Amhara) with
large household size.
A significant proportion of the female household heads are widows in childbearing age with
small family size. Due to the shortage of manpower in the household, these widows mostly
depend on external labor, which they find through land rent or share-cropping. Having to share
the produce with others in both cases, they are left with reduced benefit, not being able to get the

39
full amount of what their land can offer them. Female-headed households with small farmland
and shortage of draft power (e.g., Kafta Humera Woreda) are more vulnerable groups, e.g., they
lease out the land because of lack of money to hire draft oxen or machinery, which means
forfeiting the income they would otherwise be able to earn. When dispute arises between the
female leaser and male leaser in the traditional dispute settlement mechanisms, disputes are
mostly handled in favor of the better offs, i.e., male leaser. Because of lack of resources, time
and money, the leaser female household heads do not pursue the disputes through the formal
legal channels, which are often time consuming and expensive.
The fact that gender inequality is embedded in the societal fabric in Ethiopia, i.e., women
experience higher rate of unemployment, far less participating in seasonal (37%) and temporary
(13%) employment, poorer women and girls especially facing multiple disadvantages, 58 percent
of women being illiterate, and less than 12 percent of women access internet, the risk of women
and girls being left out from the project beneficiary is very high.
To provide equitable benefits and opportunities, the project will ensure active participation of
women in the project implementation units (PIU) and various committees including the Project
Steering and Technical Committees. The project will also engage women groups to ensure that
men and women have access to information on project related business opportunities. Gender-
disaggregated data will be collected as part of the routine tracking and monitoring system of the
project.

3.1.4. Youth
Ethiopia is a country of youthful population and the issue of youth has received greater attention
in Ethiopia over the last one and half decades. Ethiopia’s National Youth Policy (2004) marks a
major step in recognizing and promoting the rights of young people in the country. The policy
“aims to bring about the active participation of youth in the building of a democratic system and
good governance as well as in the economic, social and cultural activities and to enable them to
fairly benefit from the results”. It envisions “a young generation with democratic outlook and
ideals, equipped with knowledge and professional skills.” Ethiopia's youth have the potential to
play a significant role in the country’s socio-economic and political development and its
participation is increasingly recognized by the public authorities, following the government’s
strategy to involve youth in decision-making processes.26
Currently the youth are facing various challenges to be involved in economic activities. Some of
these challenges include acquiring productive farmland in rural areas (Schmidt and Bekele,
2016), work place in the towns, start-up capital, skills and smart ICT. Unemployment and
underemployment, compounded with other challenges, are the main drivers of youth
vulnerability. Unemployed youth in who have, for various reasons, dropped out of school at
primary, secondary or preparatory levels. Others are young men and women who have returned
to live in their natal villages, not being able to find work in the towns/cities after completing
26
http://www.oecd.org/dev/inclusivesocietiesanddevelopment/youth-issues-in-ethiopia.htm.

40
technical and vocational training or college education. The underemployed are by and large rural
youths who have not had access to school and continue to live with their parents assisting them
with farm work or it includes those who have married and survive on small portions of farm
plots transferred to them by their parents. Both groups are underemployed because the small
farm plots on which they work can hardly fully engage them and support themselves. These
problems are pronounced among the pastoral and agro-pastoral communities due to natural and
man-made challenges such as recurrent drought, flood, inter-and intra-group conflict, cattle raids,
low schooling and lack of access to affordable ICT services, and high risk of community wide
impoverishment.
As reflected in the findings of this RSA, “The educated and urban residents are more likely to
benefit from any project due to access and affordability advantage they have over others”.
Likewise, the HEPRR project might involve this selectivity bias in favour of the educated, the
resourced/financed, the urbanites, people with strong connection to the politically and
economically privileged, etc., the risk that the unemployed/underemployed youth (women and
men), the rural youth, and youth from the low-income households, particularly girls might be left
out in beneficiary targeting process is high. Moreover, corruption/nepotism and elite capture
risks are also high, including political corruption where affiliation to the ruling party might make
one a stronger candidate for selection (e.g., PSNP-IV SA report). The SA for Digital Ethiopia
concurred with previous studies and similar concerns were raised in this RSA. As a way forward,
it is recommended to involve the youth from all the differentially positioned groups in the
committees that might be established as part of project implementation organs.

3.1.5. Chronically ill and people living with HIV/AIDS

Chronic illness and HIV/AIDS cause labour shortages in resource-poor households, preventing
them from diversifying income activities. These people endure extended periods of pain and
suffering and face high costs for treatment and medication, which may erode savings and make
them dependent on family and friends. The chronic illness leads to the loss of their ability to earn
a livelihood and support themselves. Although development programs such as the HEPRR
project are meant to address the major health, information and mobility challenges of the
chronically ill persons of the project target communities, their chance of being excluded from the
actual beneficiary groups is high due to the financial, information and may be literacy constraints
they have. That is why, beneficiary selection needs to be carefully planned and executed in a
participatory way, namely involving direct project beneficiaries and the existing
traditional/indigenous institutions renowned for their integrity in their respective communities.

3.1.6. Elderly
According to the UN definition, older people are those people whose age is 60 years and above.
This also corresponds with Ethiopia's official retirement age. 27 Although gradually being
27
Vulnerability of Older People in Ethiopia The Case of Oromia, Amhara and SNNP Regional States | Humanitarian
Library

41
eroded/diminishing due to urbanisation and “modernisation” “older people in Ethiopia used to be
treated with respect and love, and they received support from their families, relatives and the
community” (ibid.). Their accumulated knowledge and experience are recognized.
However, when families or communities themselves face problems, it is difficult for older
persons to get the support and assistance they need. Some elderly persons who lack a social
support network and cannot find work may turn to begging. It is also recognized that the
Ethiopians’ long-standing culture of intergenerational solidarity and mutual support may be
declining due to urbanization, “modernization”, and economic stress on the younger generation,
in turn caused by unemployment and underemployment, resulting in increasing vulnerability,
particularly among older persons. The interaction of several factors exacerbates the vulnerability
of the elderly people.
Poverty has become more acute among older people and it is much more difficult for
them to come out of it. Ill health, unsuitable residential areas, diminishing family and
community support, limited social security services, lack of education and training
opportunities, limited employment and income generating opportunities, and lack of
balanced diet and shelter are some of the factors contributing to the poverty of older
people. (ibid.)
Access to affordable health services and improved HE responses will definitely benefit the
elderly people, which in turn will benefit the community (e.g., healthier and productive senior
citizens). The big question, however, is what is the likelihood of their inclusion in the project
given all the aforementioned challenges that exacerbate their vulnerability? Therefore, there is a
need for an honest community consultation to assess the scale of this challenge and in
consultation with the respective local community devise a workable and inclusive project
implementation plan.

3.1.7. Persons with disability

Disability of one sort or the other is one of the major challenges in Ethiopia. According to
UNICEF: “Using survey data from 2015/16, nearly 7.8 million people in Ethiopia are estimated
to live with some form of disability, or 9.3 percent of the country’s total population. Of these, up
to 2.2 million people (2.4 percent) have very profound difficulties. The estimated number of
people with severe disabilities in Addis Ababa is around 47,000, and 324,000 in other urban
areas of the country.”28
The underlying causes of physical disability are often misunderstood in rural Ethiopia, often
thought of as ‘a curse from God.’ As a result, disabled people’s access to education is a
challenge and rejection by family and society is common. Health care challenges also mean that
mobility aids are not widely available; those who are unable to walk unassisted have no choice
but to crawl.

28
3.Situation and access to services of persons with disabilities in Addis Ababa Briefing Note.pdf (unicef.org)

42
The recent SA conducted for the ‘Digital Ethiopia’ project (2021) benefitted from the thoughtful
and enlightening responses of the Federation of Ethiopian Associations of Persons with
Disabilities (FEAPD). According to FEAPD:
A lack of accessible communication and information affects the life of many disabled
people. Individuals with communication difficulties, such as hearing impairment or
speech impairment, are at a significant social disadvantage, in both developing and
developed countries. This disadvantage is particularly experienced in sectors where
effective communication is critical – such as those of health care, education, local
government, and justice.
FEAPD, based on a survey conducted in different countries on access to and the use of digital
media, argues “disabled people are half as likely as non-disabled people to have a computer at
home, and even less likely to have Internet access at home. The concept of the digital divide
refers not only to physical access to computers, connectivity, and infrastructure but also to the
geographical, economic, cultural and social factors – such as illiteracy – that create barriers to
social inclusion.” The positive impact of affordable access to digital technologies and ICT for the
persons with disabilities is too obvious to tell, as FEAPD argues:
Once they are able to access the web, they value the health information and other
services provided on it. Online communities can be particularly empowering for those
with hearing or visual impairments or autistic spectrum conditions because they
overcome barriers experienced in face-to-face contact. People with disabilities who are
isolated value the Internet in enabling them to interact with others and potentially to
conceal their difference.
According to FEAPD the risk of exclusion is there, at least based on past experiences and
proposes the mechanism to address the problem: “Persons with disabilities should have the same
choice in everyday telecommunications as other people – in access, quality, and price.
Subcomponent 1.4 of HEPRR project that supports ‘information systems for HEs and the
digitalization of the health sector’ will build on the project activities currently being supported
by the ‘Digital Ethiopia’ project in availing accessible and affordable health information for
persons with disabilities, who, as FEAPD noted, “have significantly lower rates of ICT use than
non-disabled people. In some cases, they may be unable to access even basic products and
services such as telephones, television and the Internet. Hence the project will help them in
availing accessible and affordable information.”

3.1.8. Occupational Minorities

Occupational minorities constitute potters, smiths, weavers, tanners and carpenters, who have
been historically despised and marginalized because of their occupation. In the PSNP woredas of
Amhara and SNNPR regional states, occupational minorities used to be excluded for generations
from mainstream social and economic activities including access to land. Although there are
improvements in attitudes and practices that facilitated the integration of the occupational
minorities into the mainstream society, there are still challenges.

43
The Manja, who live in the Konta and Decha woredas SNNPR, are a largely despised and
vulnerable occupational minority. They are associated with a number of stereotypes related to
their eating habits and personal hygiene. It is said that they eat the meat of religiously prohibited
animals and that they do not keep themselves and their clothes clean. Such views and attitudes
have led to the treatment of the Manja as social outcasts, resulting in their exclusion from all
forms of interaction in the community including engaging in agricultural activities. A recent PhD
study at Addis Ababa University (Samuel, 2015:168) showed unimaginable level of
discrimination towards the Manja/Mana, even among the recently converted Evangelical
Christians. They are segregated in the church premises, sit in a separate corner of the church hall
and “were not allowed to be buried at the same cemetery with the converted Malla” [the
politically powerful upper ‘caste’] being members of the same Evangelical Church. The reason
given, Samuel explains, is “based on the credence that the cemetery of Malla would be polluted
if the Manja were buried there” (ibid.).

Sub-components 1.3, 1.4 and 1.5 of the HEPRR project will contribute to the social and cultural
integration of occupational minorities, and enhance their standing in the socio-cultural and
economic life of the so-called “mainstream” society. Occupational minorities are diverse and live
distributed in different parts of the country, hence one-model-fits-all approach might not work to
ensure they all benefit from this project. Detail implementation plans should be informed by
locally specific information, but providing and disseminating information through different
means, including traditional mechanisms available in those respective communities, putting in
place health infrastructure/facilities that are accessible and affordable, including drugs, medical
supplies and equipment in the health facilities, are key.

3.1.9. Ethnic Minorities and Shifting Cultivators

The other vulnerable groups include ‘ethnic minorities’ and ‘shifting cultivators. The former is
either indigenous to the area where they currently live (e.g., Tsemai, Nyangatom, Dassanech,
Benna in SNNPR) or recent immigrants (i.e., the Irob, Saho and Kunama in Tahtay Adiabo and
Kafta Humera woredas of Tigray, and the Gumz and Shinasha in Guangua Woreda of Awi Zone
of Amhara region). The latter are the people who occupy the western borderlands of Ethiopia,
stretching from western Tigray and running through the frontier districts of the regions of
Benishangul-Gumz and Gambella is spoken an interrelated set of languages belonging to the
Nilo-Saharan. The Ethiopian Nilo-Saharan language speakers consist, among others, of the
Kunama, Gumz, Berta, Anuak, Majanger and Mao-Komo. Most of the shifting cultivators
occupy the hot lowlands from the slopes of the western edges of the Ethiopian plateau and
penetrating deep into the inhospitable gorges and valleys of the Dinder, the Abay River, and the
Anger-Diddessa rivers and many of their tributaries.
They practice a system of shifting hoe cultivation and in times of food shortages, they also resort
to the more ancient practices of hunting and gathering, as well as fishing and honey collection 29.
29
Wolde-Selassie Abbute (1997) “The Dynamics of Socio-Economic Differentiation and Change in the Beles-
Valley /Pawe/ Resettlement Area, North Western Ethiopia”. Department of Social Anthropology, Addis Ababa

44
Historically, shifting cultivators have been the most underserved communities in Ethiopia, much
like nomadic pastoralists. Mainly as a result of certain ‘myths’ about the way of life of shifting
cultivators, previous governments in Ethiopia used to favor the mainstream iron-tipped ox–
drawn plow settled agriculture over shifting cultivation. Largely due to this, there was a tendency
in those times for the expansion of the mainstream agriculture, leading to the undermining of
slash and burn cultivation.

Dating back to past centuries, the shifting cultivators have been the objects of discrimination and
stereotyping in the society. As they have always done, the horticulturalists produce their
subsistence crops using simple agricultural tools such as hoes and digging sticks. By contrast,
their neighbors have had a long tradition of using draft animals. In the course of time, this led to
social attitudes and perceptions that resulted in viewing sedentary plough culture as superior,
which become the basis of discrimination against slash-and-burn cultivators. The situation of
shifting cultivators/horticulturalists was further compounded by lack of due policy attention by
successive previous Ethiopian governments.
These communities are exposed to all sorts of risks (i.e., conflict, drought, flood, communicable
diseases, etc.) due to the fragile natural environment which they inhabit and their minority status
among the majority ethnic groups, and projects such as the HEPRR need to take their
vulnerability into account and ensure they benefit from the project as the most vulnerable
historically underserved traditional communities30.

3.1.10. Pastoralists and Agro-pastoralists

Although they only form 6% of the country’s rural population, pastoralists inhabit a great part of
the east and far south of the country. This is because only they can make a living out of the
otherwise unpromising semi-arid environments where the rainfall will not support any crops.
Although pastoralists consume far more milk than the cropping population, even than their agro-
pastoral neighbors, only the better off minority of herders manages to live primarily on milk and
meat. For the rest, the household economy centers on getting the cash to buy the grain that makes
up the better part of their diet. In the main, it is the sale of animals and their products, destined
chiefly for distant urban consumption that brings in the money. But poorer pastoralists with
fewer animals to sell must usually supplement this by selling firewood or gums or bush products,
or by paid work for others. Seasonal change means great fluctuations in milk availability and in
animal condition and therefore sale prices. The annual hunger season is keenly felt by most
pastoralists, and they are particularly at risk if the rains that bring this period to an end fail.
Experts with long experience working among the pastoralist communities underscore the
peculiar vulnerability risks related to mobility and low literacy status of some sections of the
society such as girls, boys, women and the elderly people among the pastoralists. The major
challenges identified among the pastoralist communities include: lack of IT infrastructure, power
University, MA Thesis.
30
For specific recommendations, see Table 2.

45
interruption, unreliable networks (both telephone and internet), low literacy level, low economic
status, lack of digital skills and mobile livelihood strategies. They recommend tailored
participatory research on the pastoralists’ livelihoods, movement patterns, etc. to contextualize
the design and implementation plan and ensure HEPRR project is inclusive enough of the youth,
women and girls, the elderly, people with low economic status, and persons with disability
among the pastoralist and other underserved communities.
According to a study conducted by Ethiopian Health and Nutrition Research Institute, Food
Science and Nutrition Research Directorate in collaboration with FMoH and WB, the major
challenges in the endeavor to provide adequate healthcare service to Ethiopian pastoralists are
summarized as follows:31
i. The food insecurity and consequently the widespread acute and chronic malnutrition is
directly or indirectly associated with chronic poverty, poor infrastructure, ecological
constraints, limited arable land, absence of irrigation, disease, poor water and sanitation,
inadequate nutritional and health knowledge and ethnic conflicts.
ii. The reasons behind the low performance of healthcare service are associated mainly with
pastoralist lifestyles that include dispersed settlement pattern, seasonal mobility,
pervasive prevalence of harmful traditional practices, which, among other things,
perpetuate underutilization of services even when and where the health services are
available.
iii. Health facilities in pastoralist communities are limited in number, are under-staffed and
service delivery is poorly organized. Most facilities operate at a level far below their
potential capacity. Those which give service did not meet the need of pastoralists as they
only provide preventive care rather than curative care.
iv. Recruiting, training and retaining female HEWs is most difficult. In some areas, female
who completed their secondary school are scarce. In few places the recruitment was
conducted not based on merit and performance but just to benefit clan members and
family. As a result, it became difficult for woreda health offices to take disciplinary
measures when those HEWs underperform due to fear of conflict. In all the studied areas
staff turn-over are among the major problems.
v. Absence of commitment of frontline staff (HEWs & WoHO), very low salary, absence of
means of transportation together with dispersed settlement of pastoral community and
absence of incentives despite the livelihood hardships (Hardship (temperature, Water,
Housing, food items, ...)
vi. Prevalence of endemic diseases, such as malaria, trachoma, and zoonotic diseases (e.g.,
bovine TB) and infectious diseases associated with poverty (poor housing, poor
environmental and personal hygiene, lack of potable water, etc.) are common.

As indicated above, health facilities in developing regional states, where majority of the
underserved communities live, are limited in number and most often under-staffed. One NGO
expert with work experience in Benishangul-Gumuz observed “many Gumuz women still give
birth alone in a forest”. The reasons are, as one recently published work indicated, “provision of
free maternal initiative alone is not sufficient to increase utilization of delivery services to the

31
https://ephi.gov.et/images/nutrition/adaptation%20pastoralto.pdf

46
desired level”.32 Among others, the key barriers to utilization of delivery services in low-income
settings are distance and awareness. Therefore, “Strengthening efforts to bring delivery
services closer to home and enhancing birth preparedness and complication readiness (BPCR)
are necessary to increase institutional delivery service utilization”. The study clearly shows that
health facilities are still not closer enough for people to seek those services and awareness about
BPCR arrangement are so low that they do not opt to give birth in health facilities. It is,
therefore, important, as one Jigjiga based public health expert advised: (a) improve access to
health care; and (b) create awareness of health and health related practices. 33
Broader contextual challenges such as climate change induced drought and flooding (causing
outbreaks such as malaria, diarrheal diseases, Acute Respiratory Infections (ARIs), meningitis
and cholera), conflict and overall fragility, which Ethiopia is facing at the time, further
compound this reality and heighten the threat of infectious diseases, access to essential health
services, and food insecurity of the already vulnerable and historically underserved communities.
The pastoralist regions, where people are highly dependent on animal husbandry and farming,
are particularly vulnerable to worsening floods and drought compromising food security and
human nutrition for instance, eastern and southern parts of the country.
For the pastoralist communities, livestock are the key livelihood strategies and human health and
welfare are inseparable from the health and wellbeing of their herds. In good years, there is
abundant rain, which means abundant water and pasture resources, which in turn means enough
food and cash in the hands of the pastoralist communities. In the years when rain fails,
lack/absence of water and pasture means, such as what was unfortunately the case in the Horn of
Africa, including large areas of eastern and southern parts of Ethiopia this year, deprivation and
catastrophic humanitarian crisis, with millions of livestock perished. According to OCHA “Over
9.5 million livestock—which pastoralist families rely upon for sustenance and livelihoods—have
already died across the region, including 4 million in Ethiopia, 2.5 million in Kenya and over 3
million in Somalia, and many more are at risk”.34 That is why, as one expert working among the
local communities with an NGO commented “They strongly need veterinary clinic, medicine,
and vaccination more than their own health needs”. It is, therefore, critically important to take
into account this intertwinement and rethink the project components and activities, i.e., by way
of integrating veterinary services with human health. This perfectly fits into One Health
approach that ‘recognizes the health of people is closely connected to the health of animals and
our shared environment’.

32
Predictors of facility-based delivery utilization in central Ethiopia: A case-control study.
https://doi.org/10.1371%2Fjournal.pone.0261360

33
For specific recommendations such as mobile human and veterinary clinics, see Table 2.
34
Horn of Africa Drought: Regional Humanitarian Overview & Call to Action (Revised 28 November 2022).
https://reliefweb.int/report/ethiopia/horn-africa-drought-regional-humanitarian-overview-call-action-revised-28-
november-2022#:~:text=The%20severity%20and%20duration%20of,at%20risk%20in%20Ethiopia%20alone.

47
3.1.11. Urban Poor
According to the 2016 report of Ministry of Urban Development and Housing (MoUDH), though
there is low level of urbanization, there is high rate of urban growth in the big and small cities of
Ethiopia.35 Urbanization is considered as an essential element to make Ethiopia a middle-income
status by 2025. However, following rapid urbanization, poverty has significantly risen in urban
centers, i.e., 11% of Ethiopia’s poor lived in cities in 2000, but this rose to 14 percent in 2011.
Poverty rates in the two largest cities of Addis Ababa and Dire Dawa are much higher than this
trend would predict (World Bank, 2015).

The rate of urbanization increased at a 4.63 percent rate due to the high rate of rural to urban
migration and the number of urban centers has also been increasing (Hagos, 2019). The root
causes of food insecurity in urban Ethiopia are disorganized rural-urban migration, inadequate
employment opportunities, poor market exchange system, poor service delivery, poor working
environment, absence of organized social protection for deprived people, among others.
Consequently, a large number of urban people are vulnerable to food price inflation, food
insecurity, unemployed and underemployed, which significantly affects their health seeking
behaviour. As discussed earlier, the recent uptake in the IDP number in Ethiopia in general and
in the towns and cities in particular, believed to be relatively safer, exacerbated the problems of
urban poverty and the overall vulnerability of urban poor and millions of low-income households
who are already struggling to make means meet ends due to inflation. As discussed under the
foregoing sub-sections, the impact of broader contextual challenges such as climate change
induced drought and flooding (causing outbreaks such as malaria, diarrheal diseases, ARIs,
meningitis and cholera), conflict (resulting in damages to health infrastructures) and over all
fragility (i.e., inflation causing unavailability/shortage of drugs and medical supplies, and rising
cost of health services), worsen the livelihood challenges of urban poor.

During the implementation of HEPRR and beyond, the livelihood challenges that the urban poor
face need to be taken into serious consideration as a distinct vulnerable group. As argued above,
their inherent problems such as food insecurity, inadequate housing/homelessness, joblessness,
severe overcrowding and underdeveloped infrastructure such as ill-equipped health facilities are
aggravated by continued displacement and growing IDP population. Therefore, there is a need
for wide-ranging national social protection programmes, specifically in the context of this project
support to the urban poor and other low-income households in the form of subsidized health
services and by availing drugs and medical supplies in accessible health facilities, building
community resilience by investing in health, communication (including digital) and essential
infrastructures such as roads and transportation.

35
https://knoema.com/atlas/Ethiopia/Poverty-rate-at-national-poverty-line

48
3.1.12. General comments on the vulnerable groups

As discussed in the forgoing sections, vulnerable groups are so diverse in terms of their
livelihoods (e.g., from hunter-gatherers who live in the remotest corners of the country,
pastoralists who live in the arid/semiarid areas to the urban poor who live in big cities),
geographical location, access to basic services such as health and education, literacy level (from
the unable to read and write to unemployed University/College graduates), from the chronically
ill and those living with HIV/AIDS to the elderly and persons with disabilities, and to women,
girls and female household heads trapped in complex socio-economic and cultural problems. As
also discussed from the outset, this project is a capacity building one whose exact
implementation site is yet to be identified. It is, therefore, recommended that site specific
consultations are conducted and appropriate risk mitigation measures identified and implemented
when specific project location are identified. Notwithstanding the above, potential risks and
proposed mitigation measures are summarized in Table 3 below.
Table 2: Summary of Potential Risks and Proposed Mitigation Measures

Vulnerable Potential Risks Proposed Mitigation Measures

Groups
Women, girls Risk being left out from the  Ensure they have access to information on project
and female- project beneficiary– due to related business opportunities.
headed embedded gender  Gender-disaggregated data should be collected as part
households inequality, poverty, higher of the routine tracking and monitoring system of the
illiteracy project.
 Ensure their active participation in the project
implementation units (PIU) and various committees.
Youth Unemployment & Involve the youth from all the differentially positioned
underemployment, groups in the committees that might be established as
compounded with other part of project implementation organs
challenges36
Chronically ill Exclusion from the actual Beneficiary selection needs to be carefully planned and
& people beneficiary groups is high executed in a participatory way, namely involving
living with due to the financial, direct project beneficiaries and the existing
HIV/AIDS information, and may be traditional/indigenous institutions renowned for their
literacy constraints integrity in their respective communities.
Elderly people Poverty, lack of access to Conduct honest community consultations to assess the
affordable health services scale of this challenge and in consultation with the
respective local community devise a workable and
inclusive project implementation plan
Persons with ‘Digital divide’ – “disabled Build on the project activities currently being
disabilities people are half as likely as supported by the ‘Digital Ethiopia’ project in availing
non-disabled people to have accessible and affordable health information for
a computer at home, and persons with disabilities “have significantly lower rates
even less likely to have of ICT use than non-disabled people.
Internet access at home”
See Subcomponent 1.4 of HEPRR project that supports

36
Acquiring productive farmland in rural areas, work place in the towns, start-up capital, skills and smart ICT.

49
 ‘information systems for HEs and the digitalization of
the health sector’
Occupational Risk of exclusion because
Minorities of socio-culturally  Detail implementation plans should be informed by
embedded segregation and locally specific information, but providing and
historical margination disseminating information through different means,
Ethnic Exposed to all sorts of risks including traditional mechanisms available in those
Minorities and (i.e., conflict, drought, respective communities.
Shifting flood, communicable  Put in place health infrastructure/facilities that are
Cultivators diseases, etc.) due to the accessible and affordable, including drugs, medical
fragile natural environment supplies and equipment in the health facilities.
which they inhabit and their
minority status
Pastoralists Risk of exclusion due to Take into account the intertwined nature of the
and Agro- mobility, poverty, low challenges they face and rethink the project
pastoralists literacy, poor infrastructure components and activities, i.e., by way of integrating
veterinary services with human health. This perfectly
fits into One Health approach that ‘recognizes the
health of people is closely connected to the health of
animals and our shared environment’.
Urban poor Risk of exclusion due to Support to the urban poor and other low-income
poverty, low literacy, and households in the form of subsidized health services
poor infrastructure (e.g., ill- and by availing drugs and medical supplies in
equipped health facilities) accessible health facilities, building community
aggravated by continued resilience by investing in health, communication
displacement and growing (including digital) and essential infrastructures such as
IDP population roads and transportation.

3.2. Community Institutions

Community institutions are mechanisms of social order that govern the behaviour of a set of
individuals within a given community, which promote cultural, social, political and economic
aspects of local communities. Local/informal community institutions rely on local communities’
cultures that have distinctive structures or forms. They play important roles in shaping the
capacities of communities to respond to changes in natural and socio-economic systems of their
respective communities. Thus, it is imperative to see how local community institutions facilitate
or enable interaction between the local communities and external actors. Formal community
institutions depend on written laws by government or other bodies. The two forms of local
institutions were existent in the selected pastoral and agro-pastoral communities and are briefly
discussed below.
Several SA studies documented among the pastoral and agro-pastoral communities of Ethiopia,
both the formal and informal authority structure function side by side, in fact, in practice, with
more power to enforce rules vested in the informal structure (e.g., LLRP, 201937; PSNP-IV,

37
FDRE, Ministry of Peace, Final Social Assessment Report for Lowland Livelihood Resilience Project (LLRP)
(P164336), March 15, 2019, Addis Ababa, Ethiopia.

50
2014). For instance, the SA report for the LLRP (2019: vii) stated: “Participants in all of the
Woredas selected for the assessment indicated that in the Pastoral and Agro-pastoral (PAP)
communities, concurrent with formal government structure, the community uses the traditional
administration system. Besides government structure, there are several formal organizations such
as community-based organization (CBO) in all regions.”
Informal community institutions rely on local communities’ cultures that have distinctive
structures or forms. They play important role in shaping the capacities of communities to
respond to changes in natural and social systems. Thus, it is imperative to see how local
community institutions facilitate or enable interaction between the local communities and
external actors. Pastoral and agro-pastoral communities have their own local institutions that are
very strong and enable them ease their daily activities. The Balabat system is an informal
institution found in many communities in South Omo, for example, in Hamar, Kara, Bashada and
Benna ethnic groups where all members of the group are loyal to their respective Bittas/balabat
and believe they perform all traditional rituals and religious practices for their members. There
are also social positions in these communities such as Donza, Zarsi, and Ayo for communal
political decisions or solution of problems of public concern.
Likewise, the Oromo people have the Gadaa system, which is based on an age-set system that
cross-cuts kinship organization. The Jaarsumma (elders council) institution particularly plays
significant role in mediating various problems encountering the community including solving
intra- and inter-clan conflicts as well as conflicts with other ethnic groups (e.g., with the Somali,
Konso). Similarly, among the Afar co-operation is based on the local community structure of
clan, sub-clan, family, etc. and the higher units are clan (Mela) and the level below it is the local
community (Kaidoh), and the next lower level is the extended family (Dahla), followed by the
household (Burra). For that reason, the Sultanates are clan leaders, Firma or Balabat are
community leaders, and household heads that reflect their daily socio-cultural aspects.
The Somali also have their own traditional institution called Ugas System for making decision
and it is inevitably recognized by all members of the ethnic group. Every clan has their own
representatives that take messages from the Ugas and pass down to their respective community
members. Gudi/elders committee, composed of clan representatives, is another structure that
plays the role of solving problems that encounter the community. In the event where the Gudi
could not solve the problems, the cases are brought to the formal government structures. The
Anyawa uses Juatut traditional conflict redress mechanism while the Nuer practices Ruach.
In short, in one way or the other, the significances/contributions of various traditional
institutions, particularly the local informal institutions were emphasized as important factors to
be adequately involved in the project design (esp. sub-project design and implementation) in
their respective communities. According to Oromia Health Bureau experts, Gadaa systems and
the Jaarsumma institution can greatly contribute to make the project successful by creating a
sense of ownership. The organized nature of these traditional institutions (including Iddir and

51
Equb38) provide easy access to members in such a way that it makes it easier for awareness
creation, beneficiary targeting, conflict resolution and other activities. One public health expert
stressed the need to bring on board indigenous institutions such as Iddir and Equb saying: “they
have great impact on the integrity of the community for effective project implementation”.
Participants in this RSA concur that indigenous/traditional institutions can help in creating a
conducive environment for project implementation through their symbolic power in
collaboration with local government structures.

3.3. Institutional Capacity

Strong institutions significantly encourage trust, promote property rights and avoid or at least
reduce the exclusion risks of different sections of the population. Particularly grassroots level
institutions play important roles in upholding the interest of the local people, safeguarding their
physical cultural resources, facilitating development initiatives, as well as mitigating unexpected
adverse effects. Currently, lower-level government structures are increasingly involved in
community development efforts in Ethiopia. These structures include the different government
and non-government organizations at woreda and kebele levels. The woreda level administration
structure is more or less similar in all regional states (MCB, 2007). Almost all sector ministries
and bureaus at federal and regional levels are represented at woreda level (AGP-I SA report, p.
44).
Notwithstanding their relevance and grassroot level presence, they have very serious capacity
limitation which compromises effective implementation of development projects and the quality
of services provided to the communities they serve. As one EPHI staff based in Amhara region
said “Low capacity and poor facility performance adversely affect sustainability of the
project.”
The challenges are more pronounced in underserved/emerging regions and they include: (1) high
illiteracy rate; (2) poor infrastructure, including ICT; (3) low salary and poor incentives; (4) lack
of skilled human resources; and (5) low project management skill. Inadequate capacity will
further widen the inequality gap among the differentially positioned project beneficiaries, such as
urban and rural, women and men, poor and rich, illiterate and the educated, youth and elderly,
persons with disability and others, etc. It means, low capacity and poor facilities will have
adverse impact on the successful realization of any development project, exacerbating the further
marginalization of the vulnerable groups and historically underserved communities.

3.4. Key Social Issues and Potential Challenges

Time constraint, in addition to overall security situation in many parts of the country, did not

38
Iqub is an association established by a small group of people in order to provide substantial rotating funding for
members in order to improve their lives and living conditions, while Iddir is an association established among
neighbours or workers to raise funds that will be used during emergencies, such as death within these groups and
their families.

52
allow dedicated consultations beyond public authorities and health experts, both at the federal
and some regional health bureau levels. As this is a regional capacity building project with
regional (AFE) and national level institutional focus, it will build on the consultations and
implementation experiences gained from the projects currently operational or recently phased
out. Moreover, as discussed under the Methodology section of this report, recent community
consultation results of other projects were used to inform both the design and implementation
plan of this project. Additional consultations were conducted via virtual interview based on key
Questions. The following summarizes the findings.

Consultation:

In all discussion sessions, stakeholders expressed strong interest to support the project
implementation through their full cooperation.

For instance, Consultation participants from Oromia Health Bureau emphasized the importance
of institutional capacity building projects such as this one based on their experiences of the
implementation of Ethiopia COVID-19 Emergency Response Project, which helped them:

 Increased well-equipped fully functional laboratory from 2 to 15 in Oromia and, to

the extent possible, evenly distributed in the vast and ecologically diverse region. One
of these is located in Moyale, Borana zone, with the aim of serving the entire pastoral
areas of the region currently experiencing immense HEs resulting from drought
induced famine.
 Established 2 Emergency Operation Centres (EOC) located in Jimma and Bale.
 Established 10 well organized and resourced fully-functional One-Stop-Centre
service provision facilities for GBV victims.
 Started Community and Event Based Surveillance Services (CEBS) which are still
working very well in collaboration with community leaders such as Abba Gada,
religious leaders and Haadha Sinqe.
 Free call centers established and people trained.
 Strengthened their data management and sharing system.
 Conducted several multi-disciplinary research, some of them already published, as
part of technology and new knowledge transfer component of the project.

Therefore, they are very much eager to be part of the upcoming HEPRR project as this will
build on what has already been started and further enhances HE response capacity of the Region,
which over the last few years was challenged by, what one Public Health expert at Oromia
Health Bureau called, ‘Triple Burden’, namely drought, cholera outbreak and IDP (caused by
drought-induced famine and conflict). The data obtained from Oromia Health Bureau show that

53
over the last three years: 870 health posts; 174 health centers; 11 hospitals; and 12 woreda health
offices were damaged. Moreover, 78 ambulances, 9 vehicles, and 81 motorbikes were burned,
looted and damaged.

The damage on health infrastructure is much worse in Tigray, Afar and Amhara regions that
were directly affected by the recent conflict in northern Ethiopia and vulnerability to health-
related risks has significantly increased. More than 22 million people were estimated to need
humanitarian assistance in Ethiopia in 2022. Many faced the tragic consequences of conflict,
particularly communities in the regions of Afar, Amhara, Tigray and Southern Nations
(SNNPR). At the same time, natural disasters pushed people’s coping mechanisms to their limits.
Communities across the vastness of the Somali region experienced what is reported as the worst
drought in 40 years, and when floods struck the Gambella region, more than 180,000 people
were displaced from their homes, and health facilities suffered extensive damage. 39
Unfortunately, data showing the extent of the damage couldn’t be obtained, at least at the time of
working on this document.40 In Afar, where malnutrition rates remain high, conflict, drought and
floods have affected a total of 1,164,906 people as of 1 March 2023 according to data from the
regional Disaster Risk Management and Food Security Commission (DRMFSC).41
In Benishangul-Gumuz region sporadic conflict has left thousands to flee for safety. According
to the Regional Disaster Risk Management Commission (DRMC), 440,000 people were
displaced across 16 woredas in Metekel, Kamashi and Assosa zones. In addition to the
displacement, the conflict in the region has affected basic services provision. It was found out
that 97 Health Posts and 6 Health Centers were partially damaged, 42 primary schools and five
secondary schools were partially damaged, and 103 primary and 6 secondary schools were fully
damaged in the 7 conflict affected woredas of the Metekel zone. According to an expert working
for Ethiopian Red Cross Society (ERCS) 42, the security situation worsened an already bad
situation, i.e., health facilities stressed by shortage/unavailability of drug and medical supplies,
high staff turn-over and poor health infrastructure. Now with hundreds of thousands displaced,
either sheltered in IDP camps or struggling on their own in a relatively safe environment of
Assosa Zone, the available health facilities are overcrowded and drugs and medical supplies the
greatest challenge for service providers. According to this expert, there were times when patients
were asked to bring their own gloves when they go to a hospital, health centre or a clinic seeking
health services. In situations like this it is the vulnerable groups such as the low-income families,
urban poor, female-headed households, people with chronic health problems such as HIV/AIDS,
diabetes, etc. who suffer most. These only make maternal health seeking behaviours worse,
forcing expectant Gumuz women to resort to customary child delivery practice, give birth ‘alone
and in the forest’.

39
https://www.msf.org/treating-people-all-across-ethiopia
40
But, one can imagine the gravity of the problem from this recent update of OCHA (20 March 2023): (i) 104
woredas in Amhara, hosting more than 600,000 IDPs, have been classified as hotspots; (ii) Children with global
acute malnutrition exceeding the 15 per cent threshold identified in five woredas in Afar.
41
https://reports.unocha.org/en/country/ethiopia/
42
Telephone Interview, March 27,2023.

54
Consultation participants and all who gave responded in writing to the guiding questions were
unanimous on one key concern they have about projects financed by multilateral institutions for
country level implementation through the federal government. Most projects financed by
multilateral institutions such as the WB are identified, designed and approved for financing
based on a general information about Ethiopia, despite the fact that there are huge differences
within a given region let alone in Ethiopia at large. The gap in cultivating community sense of
ownership of projects was underscored by other health experts at the federal level. One expert
said “the project should be considered and designed to keep community beliefs, social structure
and create mutual understanding with the group of people like women, local leaders like
religious leaders, and the community should own the project in all its implementation stages”. A
written comment by a public health officer from Amhara region confirms the same: “Majority of
the development projects were donor driven and community engagement was very low so that
when the project phases out no other activity is left for sustainability”. Another expert working
with an NGO added “several projects are designed with little or no involvement of the target
population at grass root level and without any regard for population diversity in practical
sense”.

 Therefore, there is a need for more coordinated and participatory project

identification, prioritization, planning and implementation, including and up to M&E.
As one expert noted, “there is a need for practical community engagement not a
theoretical one mentioned in reports”. This will create a strong sense of ownership of
the project. An expert working on public health related projects in Amhara reiterated
the need to improve community sense of ‘ownership or participation for those
institutions being in the surrounding areas of the project’ and this could be realized
through continuous engagement and consultation with the local level stakeholders,
identify and address the concerns people have about the project and its
implementation.

Focusing on health sector, which they know better, experts and consultation participants with
work experience among the pastoralist communities said that most of the health infrastructures
or facilities are meant to serve permanently settled communities and the modalities of services of
these projects rarely take into account the livelihood strategies of pastoralist communities, such
as regular mobility following the availability of pasture and water. In such circumstances,
pastoralist communities who are moving from place to place depending on the seasonal
availability of water and pasture will be left out. A public health expert based in Jigjiga, capital
of Somali Regional State, added the vulnerability of pastoralist communities not only from the
mobility necessitated by availability of pasture and water, but also from their “susceptibility to
shocks [such as drought], which are occurring more frequently now and has weakened the
already fragile health system in these regions”. Since communities are fleeing as a result of
these shocks, “health services are unable to meet the needs of such communities”.

55
What is becoming more evident is that mobility is both an adaptation strategy in the arid and
semi-arid regions, and also a source of vulnerability in light of static nature of service providing
institutions such as health and education. The latter gets worse in the context of shocks, natural
(drought and flooding) or man-made such as conflict. Moreover, pastoralist communities are
exposed to health problems such as cholera and meningitis, which are aggravated during
drought.

 They recommended: (a) the need for mobile health services, which are equipped with
health emergency facilities and technology, and projects such as HEPRR need to
include mobile health services tailored to meet unique health needs of the pastoralist
communities; and (b) System strengthening based on the context, because contexts
vary even within one region.

In the past couple of years, Ethiopia has been experiencing serious humanitarian challenges
largely attributable to conflict, drought and floods, each of these with its own devastating health
impacts. The first and most consequential impact of these are the displacement of millions of
people from their homes and belongings. There are different figures for the number of IDPs in
Ethiopia, one because the figures change frequently (IDPs moving in and out of the
camps/centres for various reasons, probably pursued by their attackers even in the camp), or, as
UNCHR rightly argues, they “often move to areas where it is difficult” to trace them or “deliver
humanitarian assistance”. As a “result, these people are among the most vulnerable in the
world”.43 Nevertheless, some figures were obtained on this: “The DTM National Displacement
report 1444 indicates that, as of September 2022, an estimated total number of 2.73 million IDPs
were identified across 11 regions of the country because of conflict and natural disaster…”. 45

Apart from the northern conflict, the western part of Oromia and some parts of the Benishangul
Gumuz and the Somali regions have been vulnerable to violent attacks by armed groups that
contributed to loss of lives, damaged properties, and livelihoods, disrupted essential social
services, and forced people into displacement within and out of the region of origin. Similarly,
some parts of the Southern Nations Nationalities and Peoples’ region (SNNPR), such as Konso,
also witnessed violent communal conflicts, which led to displacement and damages to
livelihoods and public infrastructures.46

Therefore, in light of the various challenges the country is facing at the moment and its direct
impact on the people and their livelihoods, IDPs are among the most vulnerable, and constitute
43
https://www.unhcr.org/internally-displaced-people.html
44
IOM, National Displacement Report 14, (August - September 2022) : Note-due to operational constraints, figures
from Tigray region were not included in the total. file:///C:/Users/soria/Downloads/UNHCR%20Response%20to
%20Internal%20Diplacement%20in%20Ethiopia%20Report%20%234.pdf
45
Ethiopia: Response to Internal Displacement, January - December 2022.
https://reliefweb.int/report/ethiopia/ethiopia-response-internal-displacement-january-december-2022
46
file:///C:/Users/soria/Downloads/UNHCR%20Response%20to%20Internal%20Diplacement%20in%20Ethiopia
%20Report%20%234.pdf

56
huge number (whatever the available data say about the figure) and they are available in almost
all regions of the country. IDPs are facing several challenges including food insecurity, shelter,
water shortage/unavailability for consumption and hygiene, personal security (risk of being
attacked by their earlier attackers) and risk of exposure to GBV and sexual exploitation and
abuse/harassment. Women IDPs also experience several maternal health problems, either as
lactating mothers or pregnant women. As IOM says, “When the number of displaced people in
Ethiopia increased over the past few years due to several factors, the number of women needing
support also increased. Despite their limited involvement in conflict and other man-made
disasters, women and children are disproportionately the major victims.” 47 These, for sure,
constitutes some of the key HE issues this project aims to address.

Other most vulnerable and underserved groups in the Project context include women, the poor,
persons with disabilities, the elderly, unemployed youth, low-income households, people with
low literacy status; minority groups; people with chronic illness like HIV/AIDS; widows; IDPs;
people living in cross border and remote area; female-headed as well child headed households;
children, especially of pastoralist communities, because they are always on a move. A public
health expert from Amhara region explains why they are the most vulnerable “Because they lack
the resources that might be needed to cope with the impact if adversely affected by the
project”.

The major barriers for vulnerable people and underserved communities to equitably benefit from
the project are lack of access to health information, infrastructures that are suitable to their
special needs, awareness of the existence and affordability of the services.
 Hence, recommended providing and disseminating information through different
means/platforms, put in place health infrastructures/facilities that are accessible and
affordable.

As the main capacity problems that limit/constrain program implementation, experts identified
knowledge gap, low salary, understanding of project objectives, and low incentive mechanism.
These concerns are almost common issues raised during community/stakeholders’ consultations
of most of the WB financed projects (e.g., Digital Ethiopia, UPSNP).

Grievance Redress Mechanism (GRM): Federal health institutions have existing government
structure, namely Ethics and Anti-corruption Office and Women, Child and Youth office which
are working with existing legal and justice structures to address GBV related complaints.

GBV and SEA/H: The responses on potential of GBV/SEA/H tend to concur that the project
might not bring additional GBV and sexual exploitation risks. But they emphasized these
problems are already common, whether the project is implemented or not and the project need to

47
https://ethiopia.iom.int/stories/ethiopias-gondar-iom-providing-maternal-health-care-displaced-women

57
put in place effective and accessible GBV GRM. They also strongly recommend continuous
community engagement on these and similar issues.

Traditional/indigenous organizations and leaders: Consultation with Oromia Health Bureau

experts revealed that traditional/indigenous organizations and leaders can play significant roles
in health messaging by clarifying misconceptions and serving as role models in health campaign.
They pointed out the roles played by the Abba Gadaa and religious leaders during the COVID-
19 pandemic by being vaccinated and showing those on the media and telling their followers that
it is safe to get vaccinated, against the misconception surrounding COVID-19 vaccine (e.g.,
COVID-19 vaccines can lead to sterility and the inability to conceive, serious side effects like
severe allergy). In fact, the role of Abba Gadaa, who are influential and recognized source of
relevant information, goes way back to the era of HIV/AIDS where they served as important
agents facilitating HIV awareness creation activities at community level. 48
As was discussed under the ‘Local Institutions’ section of this report, in Ethiopia there is a
wealth of indigenous institutions serving their respective communities in many respects, i.e.,
resource management49, grievance handling and conflict resolution mechanisms, communal
political decisions or solution of problems of public concern. In fact, in some areas like the
Somali, Afar, Oromia, and SNNPR regional states, traditional management systems are well
established and acknowledged and often used by the government structure. For example, the,
odiyash deganka in Somali, jarsuma in Oromia, mebloo in Afar, and denb in SNNPR were used
though not always, by the government to solve interethnic conflict. Among the Somali and
Borana pastoralists and agro-pastoralists, the Ugas and the Gadaa, respectively, are key for the
maintain social order and mobilizing community resources for common good. The Balabat
system is an informal institution found in all PAP communities in South Omo, for example, in
Hamar, Kara, Bashada and Benna ethnic groups where all members of the group are loyal to
their respective Bittas/balabat and believe they perform all traditional rituals and religious
practices for their members. There are also social positions in these communities such as Donza,
Zarsi, and Ayo for communal political decisions or solution of problems of public concern.
 Therefore, there is a need for these indigenous institutions and their leaders to be
consulted during the design of the project [they are opinion makers among their
respective communities]; help in project beneficiary targeting [esp. for the most
vulnerable groups]; influence project participants to change the skill and use
opportunities to be provided by the project; create conducive environment for project
implementation through their symbolic power in collaboration with the local
governments.

48
Mirgisa Kaba, ‘Tapping local resources for HIV prevention among the Borana pastoral community. Ethiop. J.
Health Dev. 2013, Vol.27(1), p.33-39.
49
Eela – water wells are efficiently managed among the Borana under the leadership of Abba Gadaa.

58
3.5. Proposed Mitigation Measures
The following key mitigation measures were developed based on Consultations.
 Adopt the principle of participatory project design, beneficiary targeting, planning,
implementation, and M&E as core principle of the Project.
 Conduct participatory research on the pastoralists’ livelihoods, movement patterns,
etc. to make the project fit into the pastoralists’ contexts.
 To address barriers such as lack of access to health information, infrastructures that
are suitable to their special needs, awareness of the existence and affordability of the
services for the vulnerable and underserved communities: provide and disseminate
information through different means/platforms, put in place health
infrastructure/facilities that are accessible and services that are affordable.
 Support institutional capacity building; strengthen leadership commitment; training;
introduce employment benefit packages; clear and transparent institutional
arrangement.
 Introduce competitive salary and other benefit packages (e.g., health insurance,
housing allowance).50
 Conduct capacity assessment study to understand the facts on the ground in specific
project implementation area, specifically among the pastoral and underserved
communities.
 Modernize organizational structure and project prioritization process; and introduce
state of the art technologies.
 Strengthen anti-corruption and complaints handling mechanisms to solve any conflict
of interest that might arise among the firms or companies and individuals involved in
the Project.
 Establish a robust, accessible and functioning GRM as an integral part of the project,
which also serves as GBV GRM.
 The vulnerable people should be consulted and take part in the project and their views
solicited.
 Enhance the status of women through access to digital technologies and information
that alleviate their burden and allow them greater time and freedom to engage in a
wide range of activities with reduced hardship and pressure.
 Develop and implement clear and transparent guidelines to mitigate the risks of
corruption, nepotism, and other unethical behaviour and practices.
 To address the challenges of urban poor and low-income households:
i. provide support to the urban poor and other low-income households
(including subsidized health services by availing drugs and medical
supplies and equipment in accessible health facilities); and

50
Among the key challenges of project implementation in the underserved areas are low salary and poor incentives
resulting in high-staff turn-over.

59
 ii. building community resilience by investing in health, housing, water,
employment, communication (including digital) and other essential
infrastructures such as roads and transportation in the long-term.

3.6. Grievance Redress Mechanism

Effective grievance handling mechanisms constitute an important aspect of human relationship.
For these arrangements to serve their purpose, they need to be developed and operated in such a
way that they meet the needs of the target populations, being cost effective, accessible and
working on the basis of a well-defined time schedule. Of course, such grievance handling
arrangements do not replace the formal justice system, and so complainants who feel their
grievance have not been fairly handled may seek justice in the court of law.
As was discussed under the ‘Local Institutions’ section of this report, there is a wealth of
indigenous grievance handling and conflict resolution mechanisms practiced by different
communities of Ethiopia. In fact, in some areas like Somali, Afar, and Oromia regional states,
traditional grievance management systems are well established and acknowledged and often used
by the government structure. For example, the denb in SNNPR, odiyash deganka in Somali,
jaarssumma in Oromia, and mebloo in Afar, were used though not always, by the government to
solve interethnic conflict. Among the Somali and Borana pastoralists and agro-pastoralists, the
type of penalty imposed on the offender is set in written form which varies in accordance with
the type of offense and the extent of damage inflicted. Among the pastoralists and agro-
pastoralists in SNNPR, the conflict resolution system is more traditional and well established.
Though the balabats are the main agents in conflict resolution, they are less educated, highly
traditional, and important in the day-to-day life of their ethnic group.
These well-established institutions can be mobilized both in project design, implementation and
to support the formal GRM to be institutionalized as per the safeguards’ requirements of the GoE
and the WB, which will be discussed at length in the ESMF of the Project. In the institutions
under the jurisdiction of MoH, notwithstanding their organization and capacity, there are
grievance rules and procedures in the institutions, at the MoH, EPHI, and Regional Health
Bureaus. Apart from official claims, none of the participants of this RSA said there was a strong
functioning GRM in their respective institutions.
In view of this, it is worth noting here that the Project has to “ensure that the GRM is suitable to
address more sensitive type of grievances such as Gender Based Violence (GBV) and Sexual
Exploitation and Abuse related issues”. The GRM committees that will be established at the
various levels should address such complaints, including logging, tracking, and resolving
grievances promptly during and after the implementation of the Project. The GRM need to have
specific procedures for GBV including confidential reporting with safe and ethical documenting
of GBV cases; and have project workers and local community undergo training on SEA and SH.
The project needs to identify GBV service providers to effectively respond in case of incidents of
SEA/SH and build this into the existing GRM.

60
4. Lessons Learned from Previous Projects
The SA for SLMP II (SLMP-II SA, 2013:25) revealed that the the implementation of the ‘Rural
Land Administration and Certification’ sub-component of the project, designed to ensure the
tenure security of smallholder farmers, and thereby motivate them to adopt sustainable land
management, unintentionally tended to exclude the section of the population who do not possess
land (due to age, economic status, gender, etc.) where individual land possession by households
was the norm, or pastoralist communities, hunting and gathering, and shifting cultivating groups
where individual/family landholding system did not exist. Such unintended exclusionary
practices need to be carefully studied and appropriate mitigation measures put in place.
Commenting on the exclusion risk in the Digital Ethiopia project, Ethiopian Communication
Authority (ECA) experts cautioned, people living in low-infrastructure, low-income and
underserved parts of the country, the less educted, the unemployed, and people with information
gap might experience exclusion, which could be aggravated by language barrier and non-
localized technologies.
As discussed under the ‘Key Social Assessment Findings’ section, despite good intentions, there
are risks of some sections of the society being excluded (literacy and low-income affecting
accessibility and affordability of certain services such as ICT, mobility compromising accessing
services of permanent nature such as health and education). Therefore, depending on the nature
of the project, certain categories of the communities such as the elderly, low-income households,
unemployed youth (men and women), persons with disabilities, pastoralists, and people with
low/no digital literacy face exclusion risks.
On the other hand, the PSNP IV Social Assessment (2014) documented problems of both
targeting exclusion and inclusion errors both during community consultation and the discussion
with the experts. These errors were attributed to nepotism, corruption and clientelism 51, which
both the kebele leadership and some powerful (social, economic, or political) community
members practiced to benefit themselves (PSNP IV, 2014:36). For instance, the Meket Woreda
FSTF members and PSNP staff at the woreda argue that targeting is susceptible to abuse in a
situation where resources are scarce and wealth ranking, which the PSNP uses for beneficiary
targeting, is not based on community level baseline information on households’ wealth or food
security status.52 The Woreda FSTF members were unanimous that a few kebele chairmen used
their power to favour their associates and some economically powerful members of the
community organized their supporters to be included in the beneficiaries’ list or used their
51
Although there are different angles from which clientelism is understood, in this context PSNP-IV SA it was taken
to describe the relationship between individuals with unequal economic and social status (“the economically
powerful” and “the poor”) that entails the reciprocal exchange of favours, goods and services based on a personal
link that is generally perceived in terms of “moral” obligation. Although this information was based on field data
gathered from two kebeles, experts observed that these problems are by no means limited to these kebeles alone
52
It was stated in the targeting PIM that “Community targeting is a method of selecting safety net program
beneficiaries by the community based on their own knowledge about the food security situation of their locality area
and of each other on individual basis.” The major points that need to be taken into account include, among others,
asset ownership, access to asset, remittance, family size and food aid recipient for three consecutive years. (Food
Security Coordination Bureau, Safety Net Targeting Guideline, p. 14-15.)

61
established status to influence the targeted poor households from their villages to register their
children as family members, since refusal to do so costs the latter a lot, e.g., helping hands when
they are in need of cash, pack animals, seed to plant, etc. (ibid.:42)
Other observations from some of the projects, such as the Urban Productive Safety Net include
risks such as “(ii) social exclusion and elite capture for targeting (Assessments conducted in the
country indicate that young people and women are at a significant disadvantaged position in the
urban labour market. These groups of people will face further exclusion in this project unless a
careful targeting system is put in place.), (iii) insufficient community engagement”. (p.6) 53
The SA finding for the Digital Ethiopia project (2021) also indicates the risk of corruption and
nepotism in the imeplementation of the project. Responding to whether targeting project
beneficiaries could be influenced by informal networks (e.g., nepotism, corruption, elite
capture, etc.], an official from one of the Federal implementing institutions warned “recruiting
Digital businesses can be exposed to nepotism”, which could result in unfit individuals taking
advantage of the project implementation, in turn discouraging ‘individuals with high potential’ to
work in the project. Many respondents also indicated the risk of “community members who have
relatives in the government structure” unfairly benefiting from the project.
The commitment of the local administration in supporting women’s, youth, persons with
disability and other vulnerable groups participation in development is judged as very low. The
capacity and facilities at the grassroots government structures to support the implementation of
the Project is believed to be low, but still varies from region to region/place to place. This is
pronounced in the developing regional states, largely attributable to overall structural problems,
historically marginalized as communities. Therefore, it needs site specific focused assessment to
get a clearer picture of the facts on the ground.
The institutional capacity limitations that might affect program implementation in
underserved/emerging and other regions include: (i) high level illiteracy rate; (ii) poor
infrastructure, including ICT; (iii) low salary and poor incentives resulting in high-staff turn-
over. Inadequate capacity will further widen the inequality gap among the differentially
positioned project beneficiaries, such as urban and rural, women and men, poor and rich,
illiterate and the educated, youth and elderly, persons with disability and others, etc. As a public
health expert from Benishangul-Gumuz observed “low capacity and poor facilities highly
contribute to marginalize and exacerbate challenges of the vulnerable groups. It affected the
quality and access of health care services”.

Lack/Absence of community participation in the project from the beginning has an adverse
impact on the sustainability of development projects. One EPHI expert asserted: “Majority of the
development projects were donor driven and community engagement was very low so that when
the project becomes phase out no any other activity is left for sustainability”. It is recommended
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that participatory project design, beneficiary targeting, planning, implementation, and M&E need
to be the core principle of the Project.

5. Synthesized Recommendations

The HEPRR project should learn from the challenges of past or current development projects
financed by the Bank and devise mechanisms in targeting project beneficiaries to ensure both
exclusion and inclusion errors are unlikely to occur due to the influence of traditional structures
(social and economic), corruption, clientelism and lack of awareness, livelihood strategies (e.g.,
pastoralism) especially at the grassroots levels. Adequate community consultation and
transparent and accountable institutional arrangements are the key antidotes of exclusion and
inclusion errors likely to take place due to the aforementioned reasons. Moreover, as repeatedly
discussed in the foregoing sections, participatory project identification, priority setting,
beneficiary targeting, design, planning, implementation, and M&E are the key successful project
implementation. Institutions closer to the vulnerable population and vulnerable community
groups should be consulted and take part in the project and their views solicited” from day one.

The need to build sustainable institutions at grassroots level can never be overemphasized, since
they are crucial for the delivery of services and the attainment of project objectives. Lessons
learned from various development programs/projects financed by the WB (e.g., AGP, PSNP,
SLMP, PCDP/RLLP, etc.) show that the quality of project implementation and outcomes
registered were good where local implementation structures were better organized and manned
with the requisite number and right combination of experts. The implementation structure,
especially at the grassroots levels, need to be well organized, resourced, nurtured, and sustained
through targeted capacity building work, and proper reward and incentive schemes put in place
for the staff.
The best way to address the adverse impacts or promote equitable access to Project benefits is,
according to an expert, health and resource distribution equity that should be anchored in a
strategic partnership with community organizations.

Programs such as HEPRR, which are implemented not only in diverse agro-ecological settings,
but also in areas where government implementation structures are not the strongest (e.g., under-
resourced remote and pastoralist areas) makes it critically important to put in place effective and
efficient monitoring and evaluation system.
Monitoring and Evaluation (M&E) should serve the intended purpose, and help the program
implementers to learn from their weaknesses and further boost their strengths, and for the higher-
level program structures to monitor performances and evaluate the impact of the program on the
program beneficiary and institutional capacity building at all levels of the program
implementation structures. M&E is not a routine activity reporting exercise meant to meet the
reporting requirement, which has been the major problem of some of these projects. Rather it is

63
an integral component of the program in which the information generated through the M&E
system is used to guide management decisions at both the local and higher levels of the program
implementation structure.
As a new initiative with its own unique characteristics, being regional and national at the same
time, the HEPRR project should learn from the past projects by not repeating their mistakes
(where M & E is seen as routine activity reporting exercise) and build on their strengths where
M&E becomes not only an integral part of the project implementation plans, but also an inbuilt
system of the Project implementing institutions.

64
6. Potential Risks and Recommendations: Summarized
Based on the RSA findings, Table 2 presents the key social issues, potential risks, and recommendations with a responsible body and
timeframe as a Social Management Plan for the HEPRR project.
Table 3: HEPRR Project Input for Social Management Plan

Issues Potential risks and challenges Mitigation measures Responsibility Time Frame
Project identification Project identification and Coordinated and participatory project GoE Always
and financing financing decisions do not take identification, prioritization, planning
decision particular needs of different and implementation, including and up
communities into account to M&E. This will create a strong
sense of ownership of the project.
Health  Mobility based livelihood Put in place mobile health services PIU Throughout the
Infrastructures strategies of pastoralist equipped with HE facilities and project cycle
positioning: communities is a constraint technology and that are tailored to
for equally benefitting from meet the unique health needs of the
static health facilities and pastoralist communities.
services
 Pastoralist communities exposed
to health problems such as
cholera and meningitis, which
are aggravated during drought
and flooding
Vulnerable and Risk of exclusion  Provide and disseminate information PIU Throughout the
historically through different means/platforms. project cycle
underserved  Put in place health
communities; infrastructure/facilities that are
Occupational accessible and affordable. In the long
minorities and run the GoE

65
shifting cultivators;  Ensure availability of affordable drugs
IDPs; people and medical supplies and equipment
residing in border in the health facilities.
and remote areas
Urban poor Inherent vulnerability  Provide support in the form of PIU
challenges such as food augmenting their income in the
insecurity, inadequate short-term (including subsidized
housing/homeless, joblessness, health services by availing drugs
severe overcrowding, and medical supplies and equipment
underdeveloped infrastructure in accessible health facilities);
(e.g., ill-equipped health  Building community resilience by GoE
facilities) are aggravated by investing in health, housing, water,
continued displacement and employment, communication
growing IDP population. (including digital) and other
essential infrastructures such as
roads and transportation in the long-
term.
Gender Gender inequality: Enhance the status of women through PIU Throughout the
access to digital technologies and project cycle
Risk of women and girls being information that would alleviate
excluded their burden and allow them greater
time and freedom to engage in a
wide range of activities with
reduced hardship and pressure. GoE Always
Enhance the status of women through
access to information and
employment.
GBV/SEA/H Risks are high: (i) insecurity and Extra precaution needs to be taken to PIU Throughout the

66
 violence; (ii), project activities, mitigate any risk of GBV/SEA/H project cycle
including interactions between Establish an effective GBV grievance
project workers and local redress mechanism (GRM) with
communities, as well as sexual multiple channels to initiate a
harassment among project complaint.
workers. Provide community members the toll-
free hotline information to report
any incidents or concerns;
Train project workers and local
communities on SEA and SH (e.g.,
specific procedures and confidential
reporting)
 Employ GBV service providers to
effectively respond in case of
incidents of GBV/SEA/H and build
this into the existing GRM.
Women’s weak bargaining Enhance the status of women through PIU
power and the power difference access to information
may put them in a vulnerable Oversight and accountability
position The GoE
Institutional capacity Weak institutional capacity  Training PIU Throughout the
Poor leadership commitment  Introduce employment benefit project cycle
 Low salary and lack of benefit packages
schemes resulting in high staff  Clear and transparent institutional
turn-over. arrangement
 Introduce competitive salary and other
benefit schemes (e.g., health
insurance, housing allowance, etc.)

67
GRM None of the institutions studied Establish a robust, accessible and PIU Throughout the
have strong, accessible and functioning GRM as an integral part of project cycle
functioning GRM. the project, which also serves as GBV
GRM.
M&E M & E is seen as routine activity  Establish an effective and PIU Throughout the
reporting exercise participatory M&E system project cycle
 Make it only an integral part of the
project implementation plans, but
also an inbuilt system of the Project
implementing institutions.
Corruption and other  Corruption Strengthen anti-corruption and PIU Throughout the
unethical behaviour  Nepotism complaints handling mechanisms project cycle
 Elite capture risks Develop and implement clear and PIU Throughout the
transparent guidelines to mitigate the project cycle
risks of corruption, nepotism, and
other unethical behaviour and
practices.

68
7. Concluding Remarks
The RSA findings showed a very strong support for the HEPRR project across the wide
spectrum of the potential project beneficiaries and experts with deep knowledge of the sector and
the livelihoods of the vulnerable and historically underserved groups. Though conducting actual
field visit was not possible due, largely, to time constraint and other challenges (security),
enough data needed for this RSA were generated from both secondary and primary sources (see
Methodology section).
Generally, there is a strong support for the project as it is believed to enhance the HE
preparedness, response and resilience of Ethiopian health sector building on what has already
been achieved in the last few years, including the capacity building accomplishments of the
federal and regional health institutions in the past few years including through the support
obtained from Ethiopia COVID-19 Emergency Response Project. Moreover, there is a huge
potential for the project to benefit people, especially the vulnerable population groups among the
underserved communities in the emerging regions. The commitment to realize the project
objectives is very high among all implementing agencies, especially the key implementing
federal institutions MoH and EPHI, and their partners in the regional states.
It is also worth noting the importance of taking into serious consideration during the remaining
phases of the Project the potential risks identified in this RSA and the proposed mitigation
measures which are the key to the successful implementation of the HEPRR project.

69
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Annexes
Terms of Reference
Terms of references for an Social Consultant for preparation of Social Assessment (SA)
and Resettlement Framework for Ethiopia Component of AFE Health Emergency
Preparedness, Response and Resilience MPA (P180127)

I. Project Background
Program Components: The proposed MPA will have four components, namely: (i) Strengthening
the preparedness and resilience of regional and national health systems to manage PHEs; (ii)
Improving the detection and response to public health emergincies ( PHEs) at the regional and
national levels; (iii) Program management; and (iv) Contingent Emergency Response
Components (CERC). While regional institutional capacity building is proposed to be supported
through component 3, a strong regional focus on issues such as equity and inclusion, effective
governance/integration/coordination, information sharing, seamless knowledge creation, capacity
building and exchange, cross-border surveillance, and robust technology transfer among all
relevant public and private entities in the participating countries is cross-cutting across all
components.
Component 1: Strengthening the Preparedness and Resilience of Regional & National Health
Systems to manage PHEs
The widespread health and socioeconomic impact of the COVID-19 pandemic on all aspects of
society is by now well-documented, but the impact of other PHEs is less well recognized. The
disruption of essential health services has threatened the gains made in achieving the Sustainable
Development Goal (SDG) 3 (Ensure healthy lives and promote well-being for all at all ages) and
is clear evidence of the need to ensure the resilience of health systems worldwide in the face of
health emergencies, going beyond simply preparedness and response. What has perhaps been
less studied and documented–albeit just as important–are the impact of other acute and chronic
health emergencies, such as climate change induced floods and drought, as well as non-
communicable diseases, which are now the biggest contributors to the global burden of disease.
This component will support the strengthening of essential institutions and activities that directly
contribute to the resilience of the health systems to cope with PHEs and be complimentary to
other HSS activities being conducted by other World Bank and partner investments.
Operationalizing health systems resilience involves an array of system elements that must
connect and work together, with contributions from all stakeholders within and outside the
traditional health sector, as well as synergies between various efforts within and between all
administrative and health-service-delivery levels.
Component 2: Improving the detection of and response to PHEs
The ability to detect and respond effectively to health emergencies at national, regional, and
global levels depends on the operational readiness and capacities across the following critical
74
subsystems that will be supported under this component: Collaborative surveillance and
laboratory diagnostics; Emergency management and coordination; Community engagement,
empowerment, and protection; and Access to and deployment of countermeasures in a PHE
context.
Component 3: Program Management
Sub-component 3.1 will support monitoring and evaluation. Accurate and timely data enable
assessments of whether a project is on track to achieve its intended outcomes. This component
will provide financing for the following activities: (i) Support for countries to ensure data
collection related to program activities which is complete, accurate, and timely. This can include
the development of monitoring frameworks, preparation of data collection tools, equipping data
collectors with necessary skills and technology, data quality assurance, analysis and reporting of
results, and integration of findings into managerial and strategic decision-making; (ii) Coaching
and technical support for data collection, analysis, and use for decision-making. This support
could be provided by national or international consulting firms, universities, or technical bodies;
(iii) Third party monitoring to assure the validity of Results Framework indicator data reported
by governments; and (iv) Data-based cross-border learning initiatives, which will share proven
strategies to effectively collect and use data to enhance health emergency response.
Sub-component 3.2 will focus on all other aspects of program management, including equipment
and materials, compliance with fiduciary, procurement, and safeguards (environmental and
social) requirements. At the national level, these activities will be undertaken by the Program
Implementation Units (PIUs).
Component 4: Contingent Emergency Response Component (CERC)
There is a possibility that, during the implementation of this MPA program, the participating
countries may experience an outbreak of public health importance, or other health emergencies
with the potential to cause major adverse economic and/or social impacts. In such an event, this
component will finance the eligible expenditures. Activation of this component allows funds to
be disbursed rapidly to reduce damage to infrastructure, ensure business continuity, and recover
more rapidly from a disaster. Following a major health emergency, the affected participating
country may request that the World Bank channel resources from other AFRE MPA HEPRR
components into the CERC. As a condition for disbursement, an CERC Manual along with an
Emergency Response Manual (ERM) and updated instruments (where applicable), will be
developed for each country, stipulating the fiduciary, safeguards, monitoring, and reporting
requirements related to invoking the CERC, as well as other coordination and implementation
arrangements.

Experiences of the World Bank and those of Government of Ethiopia indicate that proper
assessment/documentation and management of social risks and impacts add to the sustainability

75
of development works. Likewise, project risks and impacts on vulnerable (indigenous peoples,
women, children, aged people, poor and other deprived segments) and other communities need to
be properly documented and managed.

The MoH seeks to hire a lead consultant to review the social context within which the project
will be implemented and conduct an analysis of social impacts on key stakeholders.

1. Objective

Rapid Social Assessment (RSA) is the process used by the Borrowers to assess the likely impacts
of projects on key stakeholders. The rapid Social Assessment is intended to help the Project
identify key social issues and risks, and to determine social impacts on different stakeholders.
The RSA will focus on the health sector impacts with a focus on mitigating possible negative
impacts and identifying opportunities for inclusion of vulnerable and marginalized groups. It
needs to include needs and priorities of key stakeholders, outline their views on the design and
proposed implementation mechanisms of the project, and build capacity and involvement. It will
also provide requirements for the design of an appropriate institutional arrangement to
implement, monitor, and evaluate the project on the achievement of social outcomes.

The RSA is the basis for the preparation of the Social Management Plan (SMP) in which all the
mitigation measures are provided as actions and if those actions require budget, an indicative
budget and the timeline for the implementation will be included in the SMP.

The Resettlement Framework clarifies the resettlement principles, organizational arrangements

and design criteria to be applied to sub projects or project components to be prepared during
project implementation. The RF will estimate displacement impacts, determine eligibility
criteria, valuation methods for affected assets, procedures for compensation payments,
description of grievance mechanism, cost estimates oof resettlement and arrangements for
funding, consultation mechanisms and arrangements for monitoring.

The objective of this assignment is to provide assistance to the MoH (Ministry of Health) (MoH
and other project beneficiaries in undertaking a targeted social assessment for the proposed
project and identify potential list of indicators for monitoring and evaluation of project
effectiveness as far as social impacts are concerned. Furthermore, assistance will be provided to
develop a Resettlement Framework to mitigate risks of land acquisition, restriction on land use
and involuntary resettlement as a result of implementation of project activities. The RPF will be
an annex to the ESMF.

2. Methodological approach and process

3.1. Indicative Methodology

76
Development of the Social Assessment (SA) is a participatory process led by the MoH. The
consultant is required to consult, next to the project design team members, also with federal,
regional, and local public authorities as well as randomly selected beneficiaries on the project as
they related to the context of the RSA document.

An inception report to be developed by the Consultant(s), and approved by the Client, will
outline structure methodology, timeframe, and resources for conducting the assessment and
development of the RF. The data for social assessment, is expected to be collected both from
primary and secondary sources. The data collection process will be supported by the Client
following the development of a user-friendly data collection template by the Consultant. The
Consultant required coming up with data collection tool(s) that also allow producing analytical
reports mainly on qualitative description. Other data collection tools as may deem necessary can
be employed by the Consultant,

The primary data will be collected through conducting various consultations, interviews, Focus
Group Discussion (FGD), field level observations, and others. As secondary data, relevant
documents to be shared from implementing partners are considered, as well as any additional
document, the consultant may be aware of.

3.2. Scope of the assessment

The assessments is country wide and will cover historically underserved communities in the
regional states of Benishangul, Gambella, Southern Nations Nationalities and Peoples, South
Western Ethiopia, Somali and pastoral and agro-pastoral communities in Oromia regional state.
To delineate the data collection process, the Consultant will randomly select at least 2 woredas in
each region, totaling 12 Woredas, being representative for the project implementation area. The
inception report will furthermore outline any suggestion on data collection if necessary to
achieve a balanced and comprehensive picture.

3.3 Tentative Outline of the Social Assessment document

The Report shall encompass the following structure:

 Introduction / SA team / data collection and research methods
 Background information / Project Description
 Description of the socio-cultural, institutional, historical and political context
 Legislative and regulatory considerations & institutional framework
 Key social issues including social diversity and gender; institutions, rules and behavior;
stakeholders; participation; and social risks
 Stakeholder consultations and stakeholder management plan

77
  Strategy to achieve social development outcomes/Recommendations for project design and
implementation arrangements
 Monitoring Plan
 Outputs, schedule, and reporting

Tentative Outline for Resettlement Framework:

 Overview of impact of project on land acquisition and involuntary resettlement
 Overview of legislation and regulatory framework,
 institutional arrangement for RPF
 Eligibility criteria, valuation methods and compensation process
 Grievance Mechanisms for project affected persons
 Stakeholder Consultation and disclosure
 Budget, workplan and monitoring
,

3. Scope of Services, Tasks, and Expected Deliverables

The Consultant will be a team member of the Project Implementation Unit (PIU) supporting the
implementation of the and will report to the PIU Director / PIU Coordinator. The scope of these
ToR is to ensure a systemic assessment of positive and adverse social impacts associated with
project and that the appropriate mitigation measures will be in place. Moreover, RF will be
developed based on projects risks on land acquisition. . The drafts must be disclosed as soon as
possible and before project appraisal and the Borrower will seek the views of stakeholders,
including on the identification of stakeholders and the proposals for future engagement.

Specific tasks to be carried out by the individual consultant include but are not limited to the
following components:
 Understand the ToR and better foundation of the project nature and issues;
 Review relevant information at federal and regional levels,
 Conduct an in-depth desk review of available reports from participating Government
institutions and WB on earlier projects,
 Develop data collection tools, if need be and get the approval of the design team through
MoH;
 Identify the most significant social and cultural features that differentiate social groups in
the study area, and ensure proper capturing and consolidation of stakeholders’ views and
opinions;
 Examine social groups’ characteristics, intra- group & inter-group relationships, and the
relationships of those groups with public and private (e.g. Market) institutions (including
the norms, values and behavior that have been institutionalized through those
relationships).
78
  Describe the institutional environment; consider both the presence and function of public,
private and social institutions relevant to the operation,
 Identify the type of social impacts including gender-based violence and sexual exploitation
that could be occurred due to the implementation of the new project in the area,
 Identify the stakeholder groups/people who may be affected negatively or positively due to
the implementation of the sub projects in the area,
 Identify social inclusion and exclusion related risks and impacts
 Examine how people are organized into different social groups, and its implication for sub
project implementation,
 Recommend mitigation measures for any adverse social impacts that could be occurred in
the study area,
 Organize national project design team and other partner consultation workshops;
 Regional consultations, meetings conducted with key regional stakeholders;
 Deliver the above-described reports;
 Present the social assessment and potential recommendations; and
 Review and compile the final reports with all the deliverables and specific objectives met

For Resettlement Framework:

 Review project activities and the extent of potential impacts on land
 Define the type of adverse social impacts related to land including cultivable land,
grazing land and water resources, structures, livelihoods and loss of crops and trees.
 Provide socio economic context of project affected areas
 Review the relevant land policies, laws and regulations both national and state levels
 Identify and consult with project affected communities and other key stakeholders at
different levels
 Review institutional arrangements, assess implementation capacities
 Propose monitoring and evaluation plan for RF
 Provide grievance mechanism
 Propose budget for implementation of RF

Documents to be consulted include:

 Social assessments of other projects; including RPFs other projects
 World Bank Development Assistance Framework and Environmental and Social
Framework
 The GoE environmental and social policy and legal documents;
 Any sectoral documents at federal and regional levels

4. Duration of the Assignment

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The Project Preparation stage of this assignment is expected to be completed in about 45 days

Prepare an inception report which includes information on stakeholders and groups that need to
be consulted and involved as well as the methodology to be implemented for the assignment.

5. Qualification and Experience

The individual consultant should be able to offer all, or at least most, of the following
qualifications and experience:

 An advanced degree (Master’s degree or above) in sociology, Social anthropology, social

policy, development economics, international development, or relevant field.
 Minimum of 10 years progressive experience in development related work.
 Strong analytical skills, a demonstrated ability to conduct interviews with a range of
stakeholders, and experience in pulling together analysis and data into reports.
 Experience in reviewing and compiling multiple data sets and strong understanding of
quantitative and qualitative analysis with Social Assessment.
 Work experience as a social specialist in/ with World Bank funded activities and
knowledge of the World Bank safeguard policies and requirements will be a strong asset.
 Prior experience of working with complex national level social assessment or strategic
plans involving multiple stakeholders.
 Ability to identify implementation issues and operational challenges and provide
recommendations to remedy these issues to accelerate program delivery.
 Adequate understanding of human rights-based approach to development, gender
equality, environmental sustainability, results-based management.
 Experience of carrying out similar assignment is an asset.
 Excellent proficiency in English is required.
 Strong writing abilities is required.

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Guiding Questions:
Federal Democratic Republic of Ethiopia

Ministry of Health (MoH)

AFE HEALTH EMERGENCY PREPAREDNESS, RESPONSE AND RESILIENCE

(HEPRR) MPA AND PROPOSED 3 PROJECTS UNDER PHASE 1

Social Assessment (SA)

Dear Participant,
Thank you for your generosity in taking a few minutes of your precious time to answer the
questions outlined below. Your honest and critical reflection is invaluable not only for the timely
completion of this study, but will also have an immense positive impact on the design and
implementation of the ‘HEPRR’ project by bringing out key social issues, potential risks and
recommending practical mitigation measures.

Project Goal and Objective of the SA

The overall aim of the proposed HEPRR’ project is to ensure a sustained, comprehensive, and
transformational impact on both health emergency preparedness/response and resilience,
building on the many achievements of previous WBG supported projects. This Social
Assessment is intended to help the Project implementers understand key social issues and risks,
and to determine social impacts on different stakeholders. The objective of this assignment is
thus to provide assistance to the MoH and other project beneficiaries in undertaking a targeted
Social Assessment for the proposed project and identify potential list of indicators for monitoring
and evaluation of project effectiveness.
Guiding Questions for Experts from Implementing/Beneficiary Institutions:
1. What are the most significant social and cultural features that differentiate social groups in
the Project area? [Ensure proper capturing and consolidation of stakeholders’ views and
opinions.]
2. Who are the most vulnerable and underserved groups in the Project context/area? [Probe for
the poor; the poorest of the poor; women and children; the elderly; persons with disability;
female-headed households; people living with HIV/AIDS (PLHIV); outcast and underserved
occupational groups.]
3. What are the major needs and barriers for institutions (universities, government offices,
businesses, etc.) located in underserved/emerging regions to equally access and benefit from
this project?

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 a. What are the specific recommendations to address the needs and barriers of such
communities and institutions/offices based there?
4. What are the major needs and barriers for vulnerable people (persons with disability, the
elderly, women, girls, youth etc.) to equally access and benefit from the project?
a. What are the specific recommendations to address the needs and barriers?

5. Are there persons/community groups who will be adversely affected by or particularly

benefiting from project activities?
 If yes, who are:
 adversely affected?
 particularly benefiting?
 In what ways are they:
 adversely affected?
 positively affected?
6. In your opinion, what are the best ways to address the adverse impacts or promote equitable
access to Project benefits?
7. What traditional or indigenous social organizations exist in the Project area?
a. How do you envisage their impacts on the Project?
8. In what ways do you think the Project might promote:
 social capital [self-help groups, mutual assistance mechanisms, dispute settlement
institutions, and indigenous natural resources use and conservation knowledge and
practice];
 social inclusion; and
 existing power structures [i.e., the risk of further concentration of power due to
beneficiary selectivity factors that tend to tilt towards certain sections of the
population, e.g., the educated, the haves, able-bodied, the credit worthy better-offs,
youths, male, etc. over the others.]
9. Do you think the project will be inclusive and equitably supportive of vulnerable and
underserved populations?
 If yes, how so?
 If no, why so?
10. Is there a risk of exclusion of certain sections of the community?
 If yes, what are the possible/likely basis of exclusion? [i.e., gender, economic status,
education, employment, age, etc.]
 If yes, what are the mechanisms to mitigate these risks?
11. Are there any known conflicts of interests arising among different groups in relation to the
Project that may affect its implementation?
a. If yes, what possible mechanisms can be used to address the problem?
12. In what ways are women likely to be involved in the Project?
13. In what particular ways are women benefiting from this Project?
14. Or, are women at a disadvantaged position as a result of the project?

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 a. If yes, how?
15. How do you evaluate the commitment of the various structures of government in supporting
women’s participation in development?
16. What are the possible social impacts including gender-based violence (GBV), sexual
exploitation and abuse/sexual harassment (SEA/SH) that could occur due to the
implementation of the Project?
a. What possible mechanisms can be used to address the impacts?
17. Do you recall any past development project in which targeting project beneficiaries was
based on informal networks? [e.g., nepotism, corruption, elite capture, etc.]
 How did it impact the implementation of the project?
 What lessons can we learn from that project?
18. Do you envisage any potential constraint that might have differential impacts on
beneficiaries? (economic status, urban vs. rural, literacy level, gender, age, livelihood
strategies, etc.)
19. Who are the stakeholder groups/people that might be affected negatively due to the
implementation of the Project/sub-projects?
a. What do you recommend to mitigate the impacts?
20. What level of capacity and facilities exist in grassroots government structures to support the
implementation of the Project?
21. In what ways can low capacity and poor facilities contribute to marginalize and exacerbate
challenges of the vulnerable groups?
22. What are the main capacity problems that limit/constrain program implementation?
a. For instance, lack of knowledge and skill, low salary and other benefit schemes
resulting in high staff turn-over, etc.?
23. What grievance procedures exist for individuals/groups to express their complaints?
a. Are these procedures/mechanisms effective?
b. If yes, in what way?
c. What are the strengths and constraints of the grievance procedures?
d. What Grievance redress mechanism can be applied for the project to address
environment & social issues including GBV/ SEA/SH?
24. What were the lessons learned from the implementation of the previous development projects
financed by the World Bank that could be used here?
a. Probe for adequate community consultation, capacity building, leadership
commitment, inclusiveness, regular monitoring, etc.

THANK YOU!

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Name: ___________________________________ Responsibility
______________________________

Email address: ______________________________

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List of Consultation Participants

See Attached PDF files

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