Ethiopia is a landlocked country located in the Horn of Africa and is surrounded by Djibouti, Eritrea, Kenya, Somalia, and Sudan. The total land mass is 1.1 million square kilometers and includes high plateaus, mountain ranges, and low lands, with tropical rainy, dry, and warm climates.

Ethiopia has a diverse population of 80 ethnic groups, most of which are Christian (51% Orthodox Christians and 10% Protestants) and Muslim (33 %). The population is 79 million (according to the 2007 census), with an annual growth rate of 2.5% (FMOH/cMYP, 2009), and an average household size of 4.8 (EDHS, 2000). Approximately 84% of the total population is rural. The 2003 UNDP Human Development Index ranks Ethiopia at 170 of 177 listed countries, with an estimated per capita income of US$100. Despite policies resulting in economic improvements and a growing GDP in recent years, urban and rural poverty remain, with 47% of the total population living below the poverty line. Ethiopia is an agrarian country and agriculture accounts for 54% of the GDP, with coffee as the main export.

Officially known as the Federal Democratic Republic of Ethiopia, the country is administratively divided into nine regional states and two city administrations, which are further divided into 103 zones, 800 woredas (districts), and 15,000 kebeles (smallest administrative unit) (cMYP, 2009). With the decentralization of power to the regional governments, public service delivery, including health care, has come primarily under the jurisdiction of the regions. The approach has been to promote decentralization and meaningful participation of the population in the local development programs. The administration of public health care is through Regional Health Bureaus, Zonal Health Departments, and the woreda health offices (JaRco, Ethiopia Country Profile 2011).

Since the 1970s, Ethiopia has endorsed a primary health care strategy, which is currently being implemented through a 20-year Health Sector Development Program (HSDP). In order to improve access and equity to essential health services, the government introduced in 2002/2003 the Health Extension Program (HEP), which is viewed as an innovative community-based health care delivery system. The HSDP also provides an institutional framework for achieving Ethiopia’s Millennium Development Goals (HSDP III Report, FMoH, 2005). Recognizing the huge gap between need and available health care services, the government has focused on providing quality promotive, preventive, and selected curative health care services in an accessible and equitable manner to reach all segments of the population, with special attention to mothers and children. The policy places particular emphasis on establishing an effective and responsive health delivery system for people who live in rural areas. A recent Lancet article discusses the Minister of Health’s commitment to community-based health care (Donnelly, 2011).

A core component of the HEP are the health extension workers, who implement the 16 components of the health extension package at the kebele level. The health extension package is divided into four main areas: Hygiene and environmental sanitation, disease prevention and control, family health services, and health education and communication as part of outreach. Immunization is one of the preventive interventions in the health extension package. The ARISE Ethiopia country study included the HEP in its review of drivers of routine immunization, discussed later in this report.