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This research compendium provides an explanation of Ethiopia’s fundamental economic challenge of slowing economic growth after an exceptional growth acceleration — a challenge that has been compounded by COVID-19, conflict, and climate change impacts. Ethiopia has experienced exceptional growth since the early 2000s but began to see a slowdown in the capacity of the economy to grow, export, and produce jobs since roughly 2015. This intensified a set of macroeconomic challenges, including high, volatile, and escalating inflation. This compendium identifies a path forward for more sustainable and inclusive growth that builds on the government’s Homegrown Economic Reform strategy. It includes growth diagnostics and economic complexity research as well as applications to unpack interacting macroeconomic distortions and inform diversification strategies. Drawing on lessons from past success in Ethiopia and new constraints, this compendium offers insights into what the Government of Ethiopia and the international community must do to unlock resilient, post-conflict economic recovery across Ethiopia.

The research across the chapters of this compendium was developed during the Growth Lab’s research project in Ethiopia from 2019 to 2022, supported through a grant by the United States Agency of International Development (USAID). This research effort, which was at times conducted in close collaboration with government and non-government researchers in Ethiopia, pushed the boundaries of Growth Lab research. The project team worked to understand to intensive shocks faced by the country and enable local capability building in the context of limited government resources in a very low-income country. Given the value of this learning, this compendium not only discusses challenges and opportunities in Ethiopia in significant detail but also describes how various tools of diagnostic work and economic strategy-building were used in practice. As such, it aims to serve as a teaching resource for how economic tools can be applied to unique development contexts. The compendium reveals lessons for Ethiopian policymakers regarding the country’s development path as well as numerous lessons that the development community and development practitioners can learn from Ethiopia.

Executive Summary

Ethiopia suffers from a chronic shortage of foreign exchange (forex). [1] The resulting lack of access to imports prevents firms from accessing imported inputs required for production. This creates a vicious cycle as exporters are constrained by this same problem, which further reduces overall supply of foreign exchange in the Ethiopian economy. The inability to reliably access foreign exchange for imports affects firm decisions on sourcing, capacity, and output. While the cost of this constraint is known to be high on the Ethiopian economy and firms are known to use a range of measures to attempt to bypass this constraint, quantitative assessments of the problem and response actions by firms are limited. It is in this context that an importer survey was conducted with the goal of informing policy decisions. A total of 202 firms with an active importing license were interviewed in March-April 2022. These firms were randomly sampled from firms registered with an importer license.

All firms interviewed reported that they were operating below capacity, often well below capacity. Foreign exchange shortages were the main reason respondent firms cited for not operating at full capacity (63% of firms reporting this as their biggest constraint). Forex shortages far surpass the second and third reasons cited for not operating at full capacity — constraints due to the conflict (13%) and COVID-19 restrictions (11%). Firms operating below capacity cited forex shortages as the main constraint, regardless of whether they imported or not in the previous year. This was the most pressing constraint reported by firms of all sizes and sectors surveyed. It was the most pressing constraint faced by exporters and by foreign-owned firms as well as non-exporters and domestic firms. Amongst the total sample of firms with a renewed importer license, more than one-third of respondent firms (37%) had not imported in FY2020-21.

Overall, 74% of firms reported experiencing challenges in accessing forex. Access to forex was reported as most challenging for manufacturing firms and smaller firms but impacted all sectors and firm sizes. The losses attributed to forex scarcity at the firm level were largest for agricultural firms, for micro-firms, and for firms that did not import at all in the previous year. In general, the larger the firm sales, the higher the likelihood that they were able import. The survey found different types of imports for different sectors. Manufacturing firms imported a large share semi-finished goods as imports as compared to agricultural firms that primarily imported finished goods. The survey results find that foreign exchange shortages and an inability to import are most severe for the manufacturing and agriculture sectors, small and micro-sized firms, and all non-exporters. However, the constraint is also the top problem facing all firm types in the survey, including exporters and foreign-owned firms.

The primary means of accessing foreign exchange where it did occur was through specialized forex accounts or ‘diaspora’ accounts. The second most common means of accessing foreign exchange was through retention accounts available to exporters. The black market featured in many responses, but questions across the survey suggest that self-reported use of the black market by survey participants is underreported versus actual usage. The ability to source foreign exchange differed significantly by firm size. Exporting firms primarily used retention account earnings, as compared to non-exporters, which relied more on forex accounts. For faster access to forex, most firms reported that they approach banks, followed by turning to the black market. Friends and family abroad also served as a source of forex for one-quarter of firm respondents, and that foreign exchange was often used immediately. Foreign exchange access from banks is nevertheless a major pain point for firms. Most firms (55%) requested forex from a bank in the past year. On average, fulfilled forex requests took three months to be processed when they were fulfilled, but many firms reported that they have an unfulfilled request that has been in the system for more than a year. These firms are especially likely to report foreign exchange access as their top challenge.

The survey finds that individual firms do not tend to use both official and black-market foreign exchange sources but rather tend to access all their forex at the (lower) official rate or all at the (higher) black-market. Large firms import most of their products at the official rate. By contrast, most small and micro firms import through other means. Manufacturing firms are also more likely to import all their production through other means and outside of the banking system. Non-exporting firms tended to import through other means than the official rate and outside of the banking system at a higher prevalence than exporting firms. The survey gleaned new insights on the implicit exchange rate that firms face as they navigate official and black-market channels of foreign exchange access. The survey does not allow for a precise estimate of the transaction-weighted exchange rate facing the economy but finds firm-level estimates align with previous macro-level estimates. The implicit exchange rate was higher for non-exporting firms, which show a greater willingness to pay a higher exchange rate to access imports. This signals the importance of the retention account for exporters to guarantee an import price closer to the official exchange rate.

When asked about the maximum rate firms would pay to guarantee access to forex, some groups of firms were willing to pay higher amounts, including all non-exporters, firms that imported in the past year, and those that declared forex access a challenge. When compared to the implied rate they paid in the past year, many firms are willing to pay more than the implied rate to guarantee access to forex. Firm perspectives on policy changes to the exchange rate underscored challenges faced by policymakers. Current policy has been one of a crawling peg, with changes within the last several years to increase the rate of devaluation. The survey asked respondents about their support for faster devaluation, for a one-off movement to unify the official rate with the black-market rate, or about alternative exchange rate systems such as a floating exchange rate. Most respondents (71%) opposed maintaining the current regime, yet no option received majority support. Most firms appear to want both a stronger exchange rate and easier access to foreign exchange despite a tradeoff between these two priorities. The largest share of support for policy change was to adjust the exchange rate such that the official rate matches the black-market rate.

Ethiopia will need to increase the diversity of its export basket to guarantee a sustainable growth path. Ethiopia has shown stellar growth performance throughout the last two decades, but, in this period, export growth has been insufficient to finance the country’s balance of payments needs. As argued in our Growth Diagnostic report,1 Ethiopia’s growth decelerated as a result of the increasing external imbalances which have resulted in a foreign exchange constraint. This macroeconomic imbalance is now slowing the rate of economic growth, job creation and poverty alleviation across the country. Although export growth will not be rapid enough to address the foreign exchange constraint on its own in the short-term, the only way for the country to achieve macroeconomic balance as it grows in the longer term is to increase its exports per capita. With only limited opportunities to expand its exports on the intensive margin, the Government of Ethiopia (GoE) will have to strategically support the diversification of its economy to expand its exports base.

This report applies the theory of Economic Complexity in order to describe the base of productive knowhow and assess the opportunities and constraints to diversification in Ethiopia’s economy. The theory of Economic Complexity offers tools to capture and quantitatively estimate the diversity and sophistication of productive knowhow in an economy and to analyze the potential to develop comparative advantage in new industries. These tools provide valuable inputs for informing diversification strategies and the use of state resources by providing rigorous information on the risks and potential returns of government industrial policies in support of different sectors.

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The Ethiopian Journal of Social Sciences and Language Studies (EJSSLS)

The Ethiopian Journal of Social Sciences and Language Studies (EJSSLS) is an open access peer-reviewed journal (available online and in print version) published twice a year (June and December). The journal accepts research papers from the diverse fields of social sciences and language studies and allied disciplines. The contributions can be made in the form of original research, review articles, book reviews and letters to editor.

ISSN (Print): 2412-5180

ISSN (Electronics): 2408-9532

ISBN 978-99944-70-78-5

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Ethiopian Journal of Applied Science and Technology

EJAST publishes peer reviewed original research articles, short communications, reviews, feature articles, new releases, dissertation abstracts etc. on various disciplines of Agriculture, Veterinary Medicine, Natural Resources, Food Science & Technology, Post-harvest Management, Rural Development, Biological Sciences, and other related fields.

ISSN: (online) 2220-5802

PanAfrican Journal of Governance and Development (PJGD)

The PanAfrican Journal of Governance and Development (PJGD) is a peer-reviewed biannual, multi-, inter-, and trans-disciplinary journal that publishes editorials, articles, essays, book reviews, commentaries and notes on issues related to democracy, good governance, development and peace in Ethiopia and Africa. The biannual edition will be published in February and August of each year with the status of “Double Blind Peer Review Journal”.

ISSN: (Print) 2707-1308

ISSN: (Online) 2707-1316

Horn of African Journal of Business and Economics (HAJBE)

Horn of Africa Journal of Business and Economics (HAJBE) is an academic journal Published by College of Business and Economics, Jimma University, Jimma, Ethiopia. Aimed a t publishing high quality research papers in the field of Accounting, Economics, Finance, Management, leadership and Corporate Governance, Innovation and change Management, Supply Chain Management, International business, entrepreneurship and development, taxation and other topics related to business and economics contributing to international literatures.

Gadaa Journal

Gadaa Journal is an open access, peer reviewed, multidisciplinary bilingual journal (online and print version) published biannually by the Institute of Oromoo Studies (IOS) in Jimma University. It is a double blind, peer reviewed, open access, refereed Journal aspiring to have a brand value among the world’s multidisciplinary journals. The journal publishes original, multidisciplinary, scientific (theoretical and empirical) research in all fields of studies focusing on Oromoo and accepts articles that address aspects of the totality of Oromoo life in space and time.

e-ISSN: 2616-3985 p-ISSN: 2616-3977

Ethiopian Journal of Health Sciences

The first issue of the Ethiopian Journal of Health Sciences, published by the College of Health Science of Jimma University, appeared in July 1990 with the title 'Bulletin of Jimma Institute of Health Sciences'. The journal used to appear twice a year until July 2007. Thereafter, it used to be published trice a year until it became a quarterly publication in 2014. Since January 2016, it is appearing every other month. It is an open access journal available at http://ejhs.ju.edu.et .

ISSN: (Online) 2413-7170

ISSN: (print) 1029-1857

Jimma University Journal of law

Jimma University Journal of Law (JUJL), published by the Law School of Jimma University, first came out in 2007. The journal is published once in a year and features articles, notes, book reviews and case comments on Ethiopian or international laws. An article to be published in the journal must undergo a double-blind reviewing process. The reviewing process involves the editors of the journal and external reviewers. Authors who wish to submit a piece to the journal must first read the author’s guideline. Authors must know that their manuscripts are critically evaluated for their novelty, significance, importance and strong evidence for the conclusions that are drawn.

ISSN: (Print) 2074-4617

ISSN: (Online) 2411-9601

Ethiopian Journal of Education and Sciences

Ethiopian Journal of Education and Sciences (EJES) is a scholarly journal published by the College of Natural Sciences of Jimma University, Ethiopia.

Focus and Scope: The Journal focuses on publishing original research findings, short communication, and review articles, in the fields of sciences and education.

Open (online) submission at   http://journals.ju.edu.et/index.php/ejes Indexed in AJOL at www.ajol.info/index.php/ejesc

Peer Review Process: A manuscript is given to two relevant professionals for peer review and the author is communicated through the editor-in-chief or Managing Editor for the incorporation of the comment of the reviewers. The peer-review system of the journal is mainly bounded by the Jimma University Research, Publication and Consultancy guideline, modified to our particular suit.

Publication Frequency: Twice a year

ISSN: 1998-8907

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A Systems View Across Time and Space

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• Published: 21 February 2022

The role of micro, small and medium enterprises (MSMEs) to the sustainable development of sub-Saharan Africa and its challenges: a systematic review of evidence from Ethiopia

• Ebrahim Endris   ORCID: orcid.org/0000-0002-9048-2351 1 &
• Andualem Kassegn 1  

Journal of Innovation and Entrepreneurship volume  11 , Article number:  20 ( 2022 ) Cite this article

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Micro, small and medium-sized enterprises (MSMEs) have a potential impact on achieving many of the sustainable development goals much greater than their size. This review aimed to investigate existing literature on the contribution of MSMEs to the sustainable development of Ethiopia and its challenges. The review provides a comprehensive and systematic summary of evidence and provides future research directions. A systematic review methodology was adopted through reviewing the available literature comprehensively including research articles, policy documents, and reports over the period 2011–2021 from ScienceDirect, Google Scholar, ECONBIZ, IJSTOR, EBSCO, Web of Science, and Scopus databases. A search on these databases and grey literature returned 1270 articles; 87 papers were included in this review following screening of aticles using pre-determined criteria. The paper found that MSMEs significantly contributed to the sustainable development goals of Ethiopia through creating employment, alleviating poverty, and improving their living standards. However, the review has identified access to finance, access to electricity, and trade regulation are the major constraints for the development of the sector. The review outlines key policy implications to develop a comprehensive policy that alleviates the existing challenges of the sector and calls for further MSMEs impact evaluation research.

Introduction

Growth in the working age population is expected to be even more rapid, increasing by 265.8% in Africa and by 306.6% in sub-Saharan Africa, compared to 28.3% globally (Bhorat & Oosthuizen, 2020 ). Consequently, unemployment is a colossal problem in sub-Saharan Africa (Dey, 2012 ). Entrepreneurship can be a cure for Africa’s problems such as unemployment, inequality, low productivity, disconnect from global value chains, etc. (Devine & Kiggundu, 2016 ). The General Assembly adopted resolution 71/221 recognizes the important contribution entrepreneurship to sustainable development by creating jobs, driving economic growth and innovation, improving social conditions, and addressing social and environmental challenges (UN, 2018 ). Hence, investment in entrepreneurial ventures can contribute immensely to economic growth and job creation (Arko-Achemfuor, 2017 ) and thus jobs provide income, which improves living standards and consumption possibilities (IFC, 2013 ). Micro, small and medium-sized enterprises (MSMEs) are a major source of growth, innovation and jobs and their potential impact on achieving many of the sustainable development goals is much greater than their size (ITC, 2019 ). Therefore, there is a great interest of young people to start a business and many of them are willing to undertake risks and challenges of entrepreneurship (Papulová & Papula, 2015 ).

Sustainable development goals (SDGs) in Africa emphasize on labor-intensive sectors (SDG 8.2), increase small-scale enterprises’ access to affordable credit in support of decent job creation and entrepreneurship (SDG 8.3 and 9.3) (Brixiová et al., 2020 ). The informal sector (nonfarm) has been a growing source of employment for a large section of the African youth, but also for older workers trying to seize entrepreneurial opportunities. Its contribution to GDP and poverty reduction has been substantial, and it has become a major point of entry into the labor market (AFDB, 2019 ). Small and medium-sized enterprises (SMEs) make crucial contributions to job creation and income generation. The promotion of SMEs has been a key area of intervention in recent years in view of the major employment challenges (ILO, 2015 ). For that reason, the employment share of the self-employed in low-income countries is almost five times (54%) the share in high-income countries (11%), and the employment share of micro-enterprises (2–9 employees) also much higher (ILO, 2019b ). Small and medium enterprises have embraced technological innovations in creating new opportunities as well as expanding their businesses. In particular, high mobile phone penetration has brought opportunities to SMEs in rural and urban areas of Africa (Amankwah-Amoah et al., 2018 ).

Ethiopia most important development priorities were job creation for the increasing supply of labor force which contributed in reducing poverty (NPC, 2016 ; WBG, 2018 ). Hence, the implementation of the micro and small enterprises (MSEs) development strategies given undue role to achieve these objectives (NPC, 2016 ). The revised MSE strategy focus on enhancing the competitiveness of MSEs, ensuring continued rural development through sustainable growth of MSEs, and making the subsector a foundation for industrial development (FMSEDA, 2011 ). During Growth and Transformation Plan (GTP) I implementation period (2010/2011–2014/2015), construction sector was largest over other sector which accounts about 36.2%, followed by services with 20.8%, trade with 15.2%, manufacturing with 14.7% and urban agriculture accounts 13.1% employment through MSEs (EEA, 2015 ).

Establishment of MSEs strategy by itself cannot alleviate the problems facing MSEs and improve the development of the sectors (Hunegnaw, 2019 ). The ability of the firm to operate for longer time depends up on a proper tradeoff between management of investment in long-term and short-term funds (Dinku, 2013 ). The more rapid growth of small firms in Ethiopia is offset by a very high rate of firm failures (Page & Söderbom, 2015 ), this risk of business failure is high during the first 2–4 years of business operation (Woldehanna et al., 2018 ). Given the implication of MSMEs to the national development goals and it is a key development policy, there is little evidence that explore its role and prevailing challenges in a broader context. Hence, this review article aimed to provide an exploratory insight on the contribution of MSMEs in achieving sustainable development of Ethiopia and identify the prevailing challenges. The review contributes to the existing literature by providing evidence for these specific questions. (1) What is the role of MSMEs in attaining sustainable development goals of sub-Saharan Africa specifically Ethiopia? (2) What are the challenges hindering the development MSMEs in the country? This literature review identifies the specific research gaps uniquely relevant for future researches and policy direction for the development of the sector.

Review methodology

The review adopted a systematic literature review method, which offers an explicit, trustworthy, and reproducible method to minimize bias, thus providing more reliable findings for the evaluation and interpretation of previous research relevant to a particular field (Sniazhko & Muralidharan, 2019 ). The review based on extensive overview of relevant literature (research articles, policy documents, and reports) following a systematic review approach utilizing PRISMA guidelines (Liberati et al., 2009 ).

Literature search

The review retrieved from international databases using keywords identified. The literature search was conducted in ScienceDirect, ECONBIZ, IJSTOR, Google Scholar, EBSCO, Web of Science and Scopus databases that provides large collection of articles. The literature search was done using the following keywords: ((“micro enterprise” OR “small enterprise” OR “enterprise” OR “sustainable development”) AND “Ethiopia” OR “Africa”) in the citation information, keywords and abstracts. Moreover, we conducted a snowball search by examining the reference lists of included studies to include additional relevant studies that might have been missed for a variety of reasons. In addition, national university research repository used to search relevant thesis and dissertation to obtain a comprehensive set of evidence. The review used secondary data extracted from international organization databases such as World Bank, IFC, ILO, and NBE to support the review with empirical evidences. These databases are recognized as the key sources for retrieving relevant, up-to-date articles in socio-economic field, and are commonly used by other scholars to conduct systematic review (Sniazhko & Muralidharan, 2019 ). The preliminary searches within the databases using the abovementioned keywords identified 1270 records.

Study identification and the screening and selection process

The two fundamental components in a systematic literature review are (i) deciding on the inclusion and exclusion criteria of studies, and (ii) assessing the quality of the studies to be included (Čablová et al., 2017 ). The preliminary extensive list of identified articles was narrowed down to specifically relevant literature through inclusion and exclusion criteria. The articles retrieved from online database searches and different sources were collected in to Endnote Library. The articles identified in stage one was examined thoroughly to exclude the duplicated articles of the same titles that were available in multiple search databases. For the initial search, we set three inclusion criteria: (1) any literature that include at least one of key terms or words (2) literature written in English language, and (3) conducted over the last 10 years (2011–2021). In addition, filter criteria were applied to reduce the number of articles based on (1) articles published before 2011, (2) editorial comments, book reviews, and review articles, and (3) any literature out of the scope of this review were excluded. Then, repetitive articles, and articles not related to the subject using the inclusion criteria were excluded. By applying these inclusion and exclusion criterions, the search generated 210 records.

Our search identified 1270 retrieved records, which were reduced to 960 after removing duplicates. Two of the researchers (E.E and A.K.) who used the above criteria to determine paper eligibility to be included in the study, reviewed titles and abstracts independently. From theses, 210 articles were identified eligible for full-text review after screening title and abstracts for final inclusion. There are 123 articles excluded because no empirical evidence relevant for this review. Any disagreements regarding the exclusion of an article were resolved through a discussion among the authors, through multiple round reading when necessary to achieve consensus. The details of procedures presented in the PRISMA flow diagram (Fig.  1 ), and 87 studies finally reviewed comprehensively in an attempt to identify the findings within the articles. The findings in the articles synthesized qualitatively to provide answers for review questions.

Study selection process (PISMA flow diagram)

Results and discussion

Implication of msmes towards sub-saharan africa sustainable development.

Entrepreneurial activity is crucial to the achievement of multiple SDGs, including SDG 1: “End poverty in all its forms everywhere”; SDG 8: “Promote inclusive and sustainable economic growth, employment and decent work for all”; SDG 10: “Reduce inequality within and among countries” (Bosma et al., 2020 ). The United Nations’ SDG 8 sets out a global consensus that business enterprises should aim for sustained, inclusive, and sustainable economic growth and also ensure decent work and living environments for all (Lin & Koh, 2019 ). Small and medium-sized enterprises play a key role in job creation, providing two-thirds of all formal jobs in developing countries and 80% in low-income countries. The sustained success of SMEs depends on local conditions, such as public services, good corporate law and access to finance (EDFI, 2016 ). In addition, MSEs provides a substantial collective contribution to the national economy (White, 2018 ), contribute more than 50% of most African GDP and an average of 60% of employment (Muiruri, 2017 ). It employs the vast majority of any local labor force and has an integral role in any sustainable growth trajectory and it is ‘the missing link’ for inclusive growth (ITC, 2018 ). Although African SMEs generate about 80% of new jobs, they also account for most lost jobs (ILO, 2019a ). Micro enterprises in Ethiopia account the greatest share of employment from developing countries (IFC, 2013 ).

Investing in SMEs can contribute to 60% of the targets established in the SDGs and about $1 trillion additional SME investment help developing countries reach the SDGs. Small and medium enterprise contribute to 83% of SDG 8 (Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all) targets, and 88% of SDG 9 (Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation) targets (ITC, 2019 ). Hence, financial stability in sub-Saharan Africa enhances entrepreneurial development which improve economic growth and accelerated achievement of SDGs (Babajide et al., 2020 ). There is a large concentration of enterprises in sub-Saharan Africa, 44 million MSMEs, of which 97% are micro-enterprises, of which the largest share (37 million MSMEs) accounted by Nigeria enterprise (IFC, 2017 ).

Even though, the contribution of MSEs to total employment and gross job flows were underestimated (Li & Rama, 2015 ), it contributed to economic growth through their operational activities, via job creation in Nigeria economy (Matthew et al., 2020 ) and micro-enterprises alone account for a staggering 97% of manufacturing sector employment in Ethiopia (Li & Rama, 2015 ). Entrepreneurship and new venture creation in South Africa emphasize on employment opportunities for MSMEs employees, and the social dimensions of poverty reduction approaches are broader than these economic imperatives (Rambe & Mosweunyane, 2017 ). Small-scale enterprises employment has absorbed over 49% of the increase in the labor force in five countries of sub-Saharan Africa (Botswana, Kenya, Malawi, Swaziland and Zimbabwe). Similarly, about 80% of employment growth in Tanzania accounted by informal enterprises (Diao et al., 2018 ).

Problems in the development of enterprise in sub-Saharan Africa

Entrepreneurial activity in low-income countries dominated by individuals who are forced into starting their own business due to a lack of employment and typically not highly productive (Doran et al., 2018 ). The main challenges constrained SMEs contribution to local economic development of developing countries are lack of finance, lack of business skills, poor market access, and lack of operating space (Gebreyesus & Adewale, 2015 ). The contribution of MSMEs to sustainable development is constrained by unfavorable business environments, inadequate access to finance and high levels of informality (ITC, 2019 ). The challenges such as lack of access to finance, weak entrepreneurial attitudes, government policies, regulations and practices for entrepreneurs, and training are main constraints to SME development in sub-Saharan Africa (Achtenhagen & Brundin, 2016 ; Herrington & Coduras, 2019 ; IFC, 2011 ). Due to this, the core focus of the owner of MSMEs are personal financial survival rather than on growing and developing the business, which affected the success of small businesses. In these circumstances, profit made in the business is often spent on personal expenses rather than being reinvested into the business (IFC, 2020b ).

Accessing finance for entrepreneurship development in Africa is still continuing and new challenges to MSMEs (Atiase et al., 2017 ; Beck & Cull, 2014 ). Access to credit currently fails to support entrepreneurship development in Africa (Atiase et al., 2017 ; Wang, 2016 ), and SMEs have limited access to finance even though banks have sufficient liquidity (Brixiová et al., 2020 ). Most financial institutions undermine smaller enterprises and instead focus on big businesses that can provide the required collateral for their loans (Atiase et al., 2017 ). Difficulty to obtain formal credit were due to small capital of MSEs below critical collateral value (lack tangible assets as collateral) (Jin & Zhang, 2019 ), high risk premiums, and higher transaction cost to banks, as SMEs loan size are generally small (Quartey et al., 2017 ). Sub-Saharan Africa have low financial inclusion index (Ofori-Abebrese et al., 2020 ). Hence, access to finance remains the largest obstacle for SMEs in the region and 75% of enterprises were financed by internal funds and other 10% used traditional banking loans (Leke & Signé, 2020 ). For example, 79% of informal businesses have never obtained loan, and only 21% utilized bank loan in South Africa. From this, only 19% of formal businesses used a bank loan to start their business (IFC, 2020b ). In Tanzania, only 30% of MSMEs had access to financial services (Ishengoma, 2018 ). A large number of enterprises in sub-Saharan Africa are occasional enterprises that function for a limited period of the year. For instance, lack of profitability and a lack of finance the most important reasons for enterprise exit in Uganda (Nagler & Naudé, 2016 ). Furthermore, lack of finance and harsh business environment tends to constrain the growth of MSMEs in Uganda (Lakuma et al., 2019 ), access to finance is still a hurdle to MSMEs establishment in Lesotho (Khoase & Govender, 2013 ), and access to both debt and equity markets also affected micro-enterprises in South Africa (Fatoki, 2017 ).

The limitation of finance has an inhibiting effect on the growth of African firms (Fowowe, 2017 ). For example, financially constrained firms have 6.6% lower marginal revenue product of capital relative to unconstrained firms. Moreover, constrained firms are also more inefficient and less productive relative to unconstrained firms in sub-Saharan Africa. Constrained firms are 15% less efficient due to borrowing constraints compared to unconstrained firms (Amos & Zanhouo, 2019 ). For instance, SME access to bank finance can further increase the contribution of SMEs to the Ghanaian economy and increase their chances of survival and success through exports (Abor et al., 2014 ).

The low performances in sub-Saharan Africa attributed exclusively to factors outside firms, such as poor infrastructure and unfavorable governance (Mano et al., 2012 ). The risks faced by entrepreneurs in Nigeria SMEs arose from the increasing complexity and sophistication of the industrial sector and increasing macroeconomic instability (Ejembi & Ogiji, 2017 ). The operational environment of SMEs strongly indicate that their productivity is constrained by lack of adequate infrastructure as well as inefficient institutions in Nigeria (Effiom & Edet, 2020 ). The lack of business infrastructure hampers MSMEs’ ability to scale and grow in South African, lack of equipment as the second largest challenge at startup (IFC, 2020b ), and limited awareness of government program (Fatoki, 2017 ). The results further indicate that the majority of MSMEs had no access to public infrastructure, i.e., only 16% and 28% of MSMEs had access to electricity from the national grid and water from the public or municipal sources, respectively (Ishengoma, 2018 ).

The impact of COVID-19 on sub-Saharan Africa MSMEs

COVID-19 lockdowns and social distancing measures influenced the MSMEs operation. Finding from study carried out in 132 countries revealed that two-thirds of micro and small firms reported that COVID-19 has affected their business operations and one-fifth of SMEs confirmed they face risks of closing down permanently within 3 months (ITC, 2020 ). The COVID-19 outbreak has posed great challenges for the survival and growth of SMEs (Guo et al., 2020 ). The upheaval caused by the spread of COVID-19 have a devastating effect on small businesses. Moreover, the economic fallout from this pandemic get worse for small businesses and their employees (Liguori & Pittz, 2020 ). The feature of MSMEs such as more labor-intensive activity hurt during COVID-19 lockdowns, limited reserves and lack of collateral for new credit lines are key factors which make SMES highly vulnerable to the impact of COVID-19 pandemic (COMESA, 2020 ).

The study on 367 agri-food MSMEs from 17 low and middle income countries revealed that 94.3% of firm’s operations had been impacted by the pandemic, primarily through decreased sales as well as lower access to inputs and financing amid limited financial reserves. Moreover, 84% firms reported changing their production volume as a result of the pandemic; of these, about 13% reported stopping production and about 82% reported decreasing production (Nordhagen et al., 2021 ). The pandemic has severely affected about 37 million microenterprise and 28,000 SMEs due their lack of adequate cash buffers and access to finance. About 25 million micro-enterprises operating in tourism, hospitality, entertainment, and trade had to close or face significantly reduced operating hours (IFC, 2020a ). Therefore, COVID-19 is a substantial threat to the attainment of SDGs 1, 2, 3 and 8 in Nigeria (Ogisi & Begho, 2021 ). The pandemic severely hurt financial health of MSMEs in sub-Saharan Africa via reduced profit, turnover decrease, and liquidity crunch. The percentage of MSMEs that suffered due to the pandemic is presented (Table 1 ) for some countries for which data were obtained.

Role of MSMEs development in Ethiopia

Micro and small enterprise development is the primary strategy of GTP II to expand employment and reducing poverty particularly focusing on women and youths (NPC, 2016 ). The government of Ethiopia proposed MSEs as means of creating employment to millions of youths and achieving sustainable development goals. Hence, there is policy support leads SMEs generating more employment compare to large firms (Ashenafi, 2014 ). Therefore, the contribution of MSEs to employment creation is much higher (99%) than that of medium and large enterprises (1%) (Abera et al., 2019 ). A sizable number of people are employed in small-scale tourism enterprises with a decent average monthly income that can improve their living standard in Hawassa City (Tamene & Wondirad, 2019 ). Similarly, MSEs program had led to positive outcomes on the income and livelihood of beneficiaries in Bahir Dar City (Melese, 2017 ). With respect to sector contribution, manufacturing and construction enterprise ranked first and second, respectively, in creating job opportunities for job seekers in Kolfe-Keranio Sub-City, Addis Ababa (Tafa, 2019 ). Manufacturing and urban agriculture sector provide huge contribution in reducing food insecurity of operators in Mecha district (Yimesgen, 2019 ).

The conceptual framework on the role MSMEs towards SDGs is presented in Fig.  2 . The framework showed that MSMEs has positive implication in meeting SDG 1, 2, 5, 8, 9, and 12 (Bosma et al., 2020 ; ITC, 2019 ; Lin & Koh, 2019 ).

Framework on MSMEs contribution to sustainable development. Source: own sketch based on literature review

Employment in micro-enterprises leveled as high in terms of its extent of importance to poverty reduction (Kidane et al., 2015 ). It have played a positive role in women’s livelihood by creating employment opportunity for those who are in need of job and with low level of income, empowered them socially and economically (Admasu, 2016 ; Menda, 2015 ). In addition, entrepreneurs have created job opportunities to others while also contributing to local economy and communities through income tax payment. It provides annual average of minimum 5–7 and maximum 17–23 employment opportunities in the last 5 years. The annual average income of the enterprises was at the minimum ranging between 30,000–50,000 Birr and maximum ranging between 141,001–200,000 Birr (Hiluf, 2018 ). The distribution of MSEs established and number of employment opportunities in the enterprise varying across years. Based on Fig.  3 , the number of enterprise and employment in MSEs was largest in 2014/2015.

Number of enterprise and employment created in Ethiopia. Source: authors calculation from NBE (2020)

Challenges of MSME in Ethiopia

Financing msmes in ethiopia.

Access to finance improve the survival rates, productivity and competence of MSEs. These enterprises in Debre-Markos town obtained from microfinance, Iqub , Idir , own capital and relatives than large banks (Tadesse, 2014 ). The main sources of initial capital for MSE’s are microfinance institution followed by bank and own capital (Alemu, 2018 ). Insufficient credit services for youth is a challenge in implementing rural youth economic development (Abdi, 2019 ). Financial institutions’ reluctance to give credit to young SMEs due to fear that firms may be defaulter (Nega & Hussein, 2016 ). The revolving funds of 10 billion birr for MSEs (FDRE, 2017 ) were not enough to ease financial challenges of the sector. The existence of inadequate loan size, borrowing cost and collateral requirement (Goshim & Tefera, 2018 ; Sissay, 2016 ; Tadesse, 2014 ), and high rate matching fund and liquidity problem for matching fund (Abeiy, 2017 ; Amentie et al., 2016 ; Sissay, 2016 ) constrained MSEs access to finance in Ethiopia. Moreover, loan duration affects MSEs access to finance from formal financial institutions (Petros, 2017 ; Tadesse, 2014 ). The business firms’ obstacle in Ethiopia (Fig.  4 ) showed that finance and electricity were the first and second major challenges in Ethiopia. As depicted in Fig.  5 , finance is a major barrier and high loan rejection rate for MSEs than medium enterprises.

Financial challenges across enterprise size. Source: Author calculation from World Bank enterprise survey (2015)

Financial challenges across enterprise size. Source: author calculation from IFC database (2019)

Micro and small enterprises (MSEs) needs business knowledge, skills and entrepreneurial orientation to profitably operate their business consistently in the existing business dynamics (Ghebremichael & Kassahun, 2014 ; Tarekegn et al., 2018 ). However, there are personal factor such as lack of business vision, risk averse of members, personal business exposure aggravate MSEs members dropout (Daba & Atnafu, 2016 ). The impact of aspiration to expand existing business and starting additional new business on growth of the MSEs is much higher for small enterprise compared to microenterprise (Amha, 2015 ).

Barriers against the development of MSMEs in Ethiopia

The existence of favorable working environment like government played a key role in the growth and development of MSEs (Hailu, 2016 ; Yimesgen, 2019 ). This support service program on average increased Dire Dawa MSEs monthly sales by 28%, employement by 42%, and capital asset formation by 60% (Eshetu et al., 2013 ). However, these supports are not sufficient for the development of micro and small enterprise (Hailu, 2016 ). In addtion, lack of training to start their own venture (Tewolde & Feleke, 2017 ), lack of awareness about the contribution and accessibility of consultancy service are the major problem of enterprises (Kidane et al., 2015 ). The ease of obtaining licenses to SMEs in Ethiopia was  better relative to sub-Saharan Africa region (Table 2 ).

Micro and small enterprises were formally registered when they start operation in Ethiopia. The challenge of informal competitor lower in Ethiopia than sub-Saharan Africa and its effect decrease as firms grow from small to large enterprises (Fig.  6 ). This is due to large firms have the capacity to compete at large scale than small enterprise. Informal firms are also more credit constrained compared to formal firms (Aga & Reilly, 2011 ).

Informality of small and medium enterprise. Source: author calculation from World Bank Enterprise database (2020)

Micro and small enterprise access to sufficient premises in proper location increases enterprises financial performance (Ababiya, 2018 ). Poor infrastructure (Abeiy, 2017 ; Kinati et al., 2015 ) would cause more than 25% worktime loss daily due to power interruption (Cherkos et al., 2018 ) and business location identified as significant factors that hinder the growth of enterprises (Batisa, 2019 ). Power outages affected firms’ productivity, and the overall total cost due to outage increased by approximately 15% of firm’s aggregate cost (Abdisa, 2018 ). The cost of power outages for MSMEs in Addis Ababa is substantial, and a reduction of one power outage corresponds to a tariff increase of 16% (Carlsson et al., 2018 ). The location of enterprise effect on business performance raises two different arguments. Empirical evidences showed that MSEs desire to established in the center of town for attracting large customers even though rent in the downtown is high (Yimesgen, 2019 ). The second argument showed that MSEs that operate out of town have better performance. This is because MSEs have easy access for input and potential for business expansion (Kebeu, 2014 ). Entrepreneurial opportunities were increasing in Ethiopia, as presented in Fig.  7 over the 5 years. The score of ease of doing business increased over the last 5 years. However, the score of getting credit is stagnant which indicates access to finance were the long existing challenge of MSMEs development in Ethiopia.

Performance of doing business in Ethiopia. Source: author calculation from World Bank Enterprise database (2020)

The presence of market linkage enables MSEs to supply their produce and acquire inputs in the commercial value chain, which create jobs and improve efficiency of enterprises. However, the existing vertical linkage between MSEs and large enterprises are very limited, and limited access to raw materials (Mechalu, 2017 ; Mohammed & Beshir, 2019 ) and high cost of raw materials are major challenges of MSEs (Seifu, 2017 ). The absence of market linkage identified the critical problems of enterprises (Daba & Amanu, 2019 ; Dabi, 2017 ). Furthermore, there are weak institutional and sectoral linkages (Abera et al., 2019 ). As a result, informal linkages have a significant role to access market (Hadis & Ali, 2018 ).

Micro, small and medium-sized enterprises (MSMEs) has been a key area of intervention to sustainable development specifically in growing youth population of sub-Saharan Africa. Given the implication of MSMEs in national development goals and it is a key development policy, there is little evidence particularly at broader context. Hence, this review article presents a systematic review of studies on the contribution of MSMEs in achieving sustainable development of Ethiopia and identifies the prevailing challenges. The paper has also demonstrated that MSMEs has myriad role in economy growth, poverty reduction, industrialization and livelihood as a whole. Micro enterprises in Ethiopia account the greatest share of employment from developing countries. Investing in small and medium-sized enterprises (SMEs) can contribute in some measure to 60% of the targets established in the SDGs. Manufacturing sector of Ethiopia micro-enterprises account for a staggering 97% of employment, 80% of employment growth in Tanzania accounted largely by informal enterprises. The review pointed that employment in micro-enterprises leveled as high in terms of its extent of importance to poverty reduction, empowered women socially, economically, and contributing to local economy and communities through income tax payment in Ethiopia.

The review revealed that lack of access to finance, poor infrastructure, and entrepreneurial attitudes are main challenges facing MSMEs in sub-Saharan Africa. Access to finance remains the largest obstacle for enterprises in the region. The problems became severe in time of crisis such as COVID-19 that lead two-thirds of micro and small firms in crisis and one-fifth of SMEs face risks of closing down permanently. The existence of inadequate loan size, borrowing cost and collateral requirement constrained MSEs in getting access to finance thereby the development of micro and small enterprise in Ethiopia. In addition, poor infrastructures are the main constraint that lead MSMEs to high worktime loss, reduce productivity, and increased cost of enterprise production.

Recommendations and future research directions

Based on the review of studies, key implications for policy and future research include:

It is essential to unlock entrepreneurship potential through integrated multi-sectoral and sustainable approach. Policy measures should prioritize inclusive financing schemes to vulnerable and marginalized entrepreneurs and enterprises that support business recovery during the crisis, and development of MSMEs.

In addition, strong intervention to infrastructure development particularly electricity supply, working premise that increase ease of doing business and sustainable development of the country.

Furthermore, this review calls for further research that focus on areas not given sufficient research attention such as the impact of MSMEs in achieving SDG 1 (No poverty), SDG 2 (Zero hunger), SDG 9 (Industrialization), SDG 12 (Responsible consumption and production). Future research needs to address ways to overcome the challenges hindering MSMEs’ development.

Availability of data and materials

Not applicable.

Abbreviations

Ethiopia Economic Association

Federal Micro and Small Enterprises Development Agency

Growth and Transformation Plan

Micro and small enterprises

Micro, small and medium enterprises

National Bank of Ethiopia

National Plan Commission of Ethiopia

Sustainable development goals

Small and medium enterprises

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Ebrahim Endris is lecturer and researcher in the Department of Agricultural Economics at Woldia University, Ethiopia. He received his M.Sc and B.Sc from Haramaya University. Andualem Kassegn is lecturer and researcher in the Department of Agricultural Economics at Woldia University, Ethiopia. He has M.Sc in Agricultural Economics from Wollo University and BA in Economics from Mekelle University.

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Endris, E., Kassegn, A. The role of micro, small and medium enterprises (MSMEs) to the sustainable development of sub-Saharan Africa and its challenges: a systematic review of evidence from Ethiopia. J Innov Entrep 11 , 20 (2022). https://doi.org/10.1186/s13731-022-00221-8

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Epidemiology and clinical characteristics of breast cancer in Ethiopia: a systematic review

Firaol guyassa dandena.

1 Departement of Research, Quality and patient safety, CURE International, Addis Ababa, Ethiopia

2 Department of Surgery, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Berhanetsehay Teklemariam Teklewold

Tadele dana darebo.

3 School of Public Health, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Yisihak Debodina Suga

Associated data.

All data generated or analysed during this study are included in supplementary file .

According to GLOBOCAN 2020 Breast cancer is the most common cancer among women and the prevalence is increasing worldwide and in Ethiopia. This review assessed studies conducted in Ethiopia on the clinical features and epidemiology of breast cancer.

Data base search conducted PubMed, Google Scholar African Journals Online (AJOL), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Hinari without time restrictions. The search keywords included; prevalence and pattern, clinical presentation, histological and molecular subtypes, and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline to identify, search, extract articles, and report this systematic review. The protocol was registered in PROSPERO, ID: CRD42023403320.

Twenty studies were included in the review with 33,369 participants and 3 were community-based and 17 were hospital-based. In all except two reviewed studies, breast cancer is the most common cancer among women of Ethiopia. The most frequent presenting symptom was a breast lump/mass and commonly affected side was right breast. Most patients presented at a late stage and they were premenopausal age group. The commonest histology type is ductal carcinoma, that the most prevalent receptor was estrogen receptor positive, and the most common molecular subtype was Luminal A in pathology samples. Surgery is main stay of treatment and the most common surgical technique practiced in Ethiopia is modified radical mastectomy.

Breast cancer incidence is rising, and it accounts for the major cancer burden in the country. There is a need for additional awareness-raising and health education because delayed presentation are critical problems throughout Ethiopia. For planning and monitoring cancer patterns, comprehensive demographic and clinical data from a population or facility-based registry are needed in the regions. The available treatment options are still limited in Ethiopia it needs infrastructural development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-024-12822-5.

Introduction

The World Health Organization (WHO) report shows that in 2020, 2.3 million women were diagnosed with breast cancer, making it the most common cancer with 685,000 deaths worldwide. It continues to cause more disability-adjusted life years (DALYs) in women worldwide than any other cancer. Deaths from breast cancer are high in African countries due to poor health infrastructure, poor vital records, delayed health-seeking behavior, and low community awareness [ 1 ].

Breast cancer incidence and mortality rates in the world have increased over the last three decades. Study done on Breast cancer incidence and mortality from 1990 to 2016. In 60 out of 102 countries, the incidence of breast cancer has more than doubled, while the death rate has doubled in 43 out of 102 countries [ 2 ]. By 2030, it is predicted that there will be 2.7 million new cases worldwide each year and 0.87 million deaths from breast cancer [ 3 ].

A country assessment showed that breast cancer is the most common cancer illness in Ethiopia, accounting for 16,133 (20.9%) of all cancer cases and 9,061 (17.5%) of all cancer-related deaths [ 4 ]. Approximately 80% of breast cancer cases in sub-Saharan Africa are detected at late stages (stage III or IV), compared to 15% in high-income countries [ 5 ].

Breast cancer arises from the epithelium lining the milk ducts, known as invasive ductal carcinoma. This is the most common subgroup (50–80%), followed by the group arising from the glandular tissue of the breast lobules [ 6 ]. Based on mRNA gene expression levels, breast cancer can be classified into molecular subgroups. The four main intrinsic subtypes of breast cancer (Luminal A, Luminal B, HER2-enriched, and basal-like). Regarding Hormone status of breast cancers ER-positive tumors account for almost 70% of all breast cancers in Western populations [ 7 , 8 ]. The TNM system for cancer staging refers to the classification of a tumor based on a list of factors, including the degree of disease affecting the main tumor (Tis to T4), regional lymph node status (N0 to N3), and distant metastases (M0 or M1) (0 to IV) [ 9 ].

When choosing a treatment plan, the type of breast cancer and its stage are often considered. Patients with breast cancer are often given several types of treatment. The current choices are radiation therapy, surgery, chemotherapy, hormonal therapy, biological therapy, and chemotherapy [ 10 ]. According to studies from underdeveloped countries, stage I and stage II have five-year survival rates of 90% and 65%, respectively, while stage III and stage IV have rates of only 33% and 6%, respectively [ 11 ].

Until April 2022, the Tikur Anbesa Specialized Hospital (TASH) was the only center in the country that offered radiotherapy. As of April 2022, Ethiopia has two additional functional radiation therapy centers: Jimma University Medical Center (JUMC) in the southwest of the country and Hiwot Fana Specialized Hospital at Haramaya University in the eastern part of the country.

Rationale of the study

Based on a preliminary search, we couldn’t find compressive evidence at the country level regarding breast cancer patients’ epidemiology and clinical profile. Therefore, a thorough examination of the existing evidence on breast cancer would aid in understanding breast cancer epidemiology and clinical profile in the country. This review provides evidence for the development of future strategies that are especially suited to the Ethiopian population.

Study objective

This study aimed to generate country wide evidence on epidemiology and clinical characteristics of breast cancer in Ethiopia.

The PROSPERO international prospective register of systematic review database checked for already-done or ongoing systematic reviews with the same objective before the data collection process started. The protocol of this review is registered in ID: CRD42023403320. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline to identify, search, extract articles, and report this systematic review [ 12 ].

Search strategy

The electronic databases and search engines PubMed, Google Scholar African Journals Online, Cumulative Index of Nursing and Allied Health Literature and Hinari were searched until June 20, 2023. The MeSH terms and key words were as follows: breast cancer, breast neoplasm, prevalence, epidemiology, Sign, Symptom Presentation, histology, molecular subtype, and management of breast cancer. The MeSH keywords were combined using Boolean operators (AND/OR), and Ethiopia’s name was appended at the end. To enhance the number of articles included and lower the number of missing articles, hand searching was done on the citations and references listed in the eligible articles ( Tables  1 and ​ and2 2 ).

Searching protocol of systematic review on the epidemiology and clinical characteristics of breast cancer in Ethiopia

Breast cancer OR Breast carcinoma OR Breast tumor OR Breast malignancy

AND

Epidemiology OR Prevalence OR Incidence OR pattern OR Trends

AND

Sign OR Symptom OR Presentation OR molecular subtype OR histology OR Diagnosis OR Stage OR Treatment

AND

Management OR Surgery OR Chemotherapy OR radiotherapy OR Hormonal therapy OR Immunotherapy

AND

Ethiopia

Inclusion and exclusion criteria of the systematic review on the epidemiology and clinical characteristics of breast cancer in Ethiopia

Eligibility Criteria for including studies in the review
i. Population, or participants and conditions of interest	Patients with Female breast cancer of any age, stage,
ii. Interventions/Exposure/item of interest	Epidemiology, Clinical presentation, histological and molecular subtypes, Management
iii. Comparisons or control groups	Not applicable
iv. Outcomes of interest	Epidemiology and clinical characteristic
v. Setting	Ethiopia
vi. Study designs	All type of study (exception included in exclusion criteria)
Criteria for excluding studies not covered in inclusion criteria
- Studies done Only Male breast cancer - Studies done Regarding knowledge, practice and attitude of breast self-examination and screening, identify risk factors, quality of life, survival and patient experience - Studies designs systematic reviews, randomized controlled trials, and experimental studies - Studies conducted outside Ethiopia - If only the abstract, review papers, reports, and commentaries - studies in other languages other than English

Eligibility criteria

Selection of study and extraction.

As shown in the PRISMA flowchart, all articles identified from the electronic database searches were imported into Zotero and Duplicates were removed. Further Exclusion of articles conducted using title and abstract screening. Articles with full text were assessed for eligibility and further full text exclusion done on those articles which do not have a clearly written result. FGD and BTT extracted data simultaneously and independently, and any disagreements were resolved after independent review by the TGD and YDS. Finally, we extracted relevant information from each literature using an Excel spreadsheet template to avoid missing important information when preparing the results of the review or for future cross-checking. The extracted data includes first author’s name, year of publication, study design, location, prevalence and pattern, Presenting Symptom, Stage at presentation, Histology findings, Molecular Features and Treatment.

Data analysis

The extracted data were further categorized into institution-based and community-based according to the setting in which the studies took place and further sorted according to the institution in which the studies were conducted. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist [ 13 ].

Study selection and characteristics

A total of 352 articles were found from electronic data base searching on the search engines and databases. All of these search results exported to Zotero computer software, where 140 duplicate records were removed and 149 were removed after being screened based on title and abstract. Further 43 articles were removed based on an objective of the review. Finally, 20 eligible articles, which enrolled 33,369 participants, were included in the systematic review (Fig.  1 ).

PRISMA flowchart for article Search and Selection Process

Most of the studies were conducted in Tikur Anbesa specialized hospital (TASH)(6/20), which was only hospital with radiotherapy treatment in the country until April 2022. Articles based on the study setting: 3 (15%) articles were community-based, and 17 (85%) articles were hospital-based. Based on study design, 9 (45%) articles were cross-sectional, 10 (50%) retrospective chart reviews, and one retrospective cohort.

Prevalence and pattern

Five studies assessed the prevalence and pattern of breast cancer in the country. All hospital-based studies showed the prevalence of breast cancer compared to other cancers. Breast cancer accounts for 15.2–26% of all cancers [ 14 , 15 ] and from female cancer 29.3–37% [ 11 , 16 ].

A community-based study done using the Addis Ababa City Cancer Registry (AACCR) showed the incidence of breast cancer (2012–2013) to be 31.5% of all female cancers [ 17 ] and a study done during 2012–2015 from AACCR and six regions showed breast cancer constituted 33% of all cancers in women and 23% of all cancers [ 18 ].

According to a study done at Hawassa University Comprehensive Specialized Hospital (HUCSH) from 2013 to 2019, the number of women diagnosed with breast cancer in hospitals has increased from 69 (12.3%) In 2013, 106 (19%) in 2019 [ 19 ].

A study from Gondar University Comprehensive Specialized Hospital (GUCSH), showed breast cancer accounts for 76 (14.1%) of all cancers [ 15 ] and finding from TASH showed breast cancer accounts for 26% of female cancers [ 14 ].

A study conducted at St. Paul’s Hospital Millennium Medical College (SPHMMC), of all malignancies, breast cancer accounted for 587 (29.3%) in 2019, making it the second most common disease after cervical CA [ 16 ].

Presenting symptom

Fourteen studies reported Age at diagnosis. The median age ranges 38-55.8 years [ 19 , 20 ] and mean age ranges 42.1–47.5 years [ 16 , 21 ].

Premenopausal patients represent the majority of female breast cancer patients at the time of diagnosis, with the median age being between 40 and 46 years (14,15,17,19,23,2829). Breast lumps or masses were the most common presenting symptoms in all studies, followed by breast pain and ulceration [ 20 , 22 – 25 ]. A study conducted at the GUCSH, where 65 (79%) patients presented with breast mass and breast ulceration in 15 patients (18%) [ 26 ].

Similar findings from two university hospitals (Gondar and Felege Hiwot University Comprehensive Specialized Hospital) (GUCSH and FHCSH) revealed that breast lump or mass was the most common presentable symptom in 328 (88.4%), followed by painful wound in 161 (43.4%) [ 22 ].

A study at Dessie Referral Hospital (DRH) showed 117 (57.4%) patients presented with breast lumps, followed by breast pain in 70 (34.3%) [ 25 ]. A multicenter study in Addis Ababa showed that breast lumps were found in 344 (78.0%) patients, followed by pain in 53 (10.2%) patients [ 24 ].

Regarding lymph node involvement, the findings from GUCSH and FHCSH showed that (320, 86.3%) and DRH 30, (14.7%), had a lymph node involvement at presentation [ 22 , 25 ]. According to studies done at the GUCSH and TASH, breast CA commonly affects the right breast 48 (59%), and, 160 (38.4%) respectively ( 26 , 19 and 27 )and unlike others finding from HUCSH showed left breast in is commonly affected 302 (54%), and the upper outer quadrant was the most commonly involved according to the findings from TASH 154 (78.2%) ,40 (9.6%) [ 27 , 28 ].

Stage at presentation

Nine studies included stage at presentation. Eight studies showed most of the patients presented in late stages (stage III and stage IV), and the prevalence of advanced stages ranges from 57 to 71.2% in ( 22 , 19 , 29 , and 25 ). This was shown in a study conducted in GUCSH and FHCSH, in which 53 (14.3%) patients were diagnosed at stage IV and 211 (56.9%) patients were diagnosed at stage III [ 22 ]. According to HUCSH findings, 24 (12.2%) were diagnosed with stage IV disease, 113 (57.4%) with stage III disease, and 160 (30.4%) with early-stage disease [ 19 ].

Findings from DRH showed 82 (40.2%) and 53 (25.5%) were diagnosed with stage IV and stage III, and early stage presentation was 69 (33.8%) [ 27 ]. TASH stages at diagnosis: 74 (57%) were diagnosed at stages III and IV. Stage III: 63 (48.5%); Stage IV: 11 (8.5%) [ 29 ].

Unlike the previous papers, a finding from the TASH showed that the majority of patients 56(59%) of patients presented with early and late stages accounted for 40(41%) [ 30 ].

Histology findings

Nine studies included histologic findings and in all reviewed studies, ductal carcinoma is the most prevalent histology type. The prevalence of ductal carcinoma in studies done in SPHMMC, (GUCSH and FHCSH), GUCSH, and HUCSH studies was 479 (81.6%), 347 (93.5%), 61 (74%), and 156 (79.2), respectively [ 16 , 22 , 26 , 28 ]. Out of nine studies 5 studies were from TASH. Ductal carcinoma is the most common histology type in TASH, followed by lobular carcinoma, with a prevalence ranging from 55.3 to 83.7% [ 20 , 27 , 29 – 31 ].

Regarding the level of differentiation, studies conducted in TASH and HUCSH, showed that moderate differentiation carcinoma is the commonest type (177 (31.7%) and 91 (46.2%), followed by poor differentiation (155 (27.7%) and 72 (36.5%), respectively [ 28 , 31 ]. Unlike the previous study findings, those from northern Ethiopia (GUCSH and FHCSH) and GUCSH showed that poor differentiation was the most common among types 140 (45.6%) and 30 (37%), followed by moderate differentiation in patients 79 (40.7%) and 14 (17%), respectively [ 22 , 26 ].

Molecular features

Two studies from TASH looked at the prevalence of hormone receptors and molecular subtypes. Both papers showed that the most prevalent receptor was estrogen receptor positive, and the most common molecular subtype was Luminal A in pathology samples. In a study from TASH in 2018, the prevalence of estrogen receptor positivity was 74 (65%), progesterone receptor positivity was 49 (43%), and HER2 positivity was 26 (23%). Regarding molecular subtype, the prevalence of Luminal A (ER + and/or PR+, HER2-) was 45 (40%), Luminal B (ER + and/or PR+, HER2+) was 30 (26%), HER2-enriched (ER-, PR-, HER2+) was 11 (10%), and Triple Negative/Basal like (ER-, PR-, HER2-) was 26 (23%) [ 30 ]. In a similar study from the same institution (2017), 137 biopsies were found to be ER+ (65.5%), PR+ (58%), and HER2 positive (28%) in a study, and the prevalence of molecular subtypes was shown to be Luminal A (54%), Luminal B (22%), HER2-enriched (6%), and Triple 29 Negative/Basal-like (18%) [ 29 ].

Studies included in this review Reported modalities of treatment, including surgery, chemotherapy, radiotherapy, and hormonal therapy. Surgery remain the mainstay of management in many settings in Ethiopia, and the most prevalent surgical technique was modified radical mastectomy (MRM) [ 19 , 22 , 25 ].

Finding from GUCSH showed, surgery was done for all 82 patients of which 51 (62%) of patients underwent MRM, and 79 (96%) received chemotherapy. The commonest chemotherapy regimen is Adriamycin and Cyclophosphamide (AC). Hormonal treatment given to 60 (73%) and Tamoxifen 18 (22%) was the commonest type [ 26 ].

Surgery was performed in 357 (96.2%) patients by two university hospitals (GUCSH and FHCSH); chemotherapy was performed in 163 (43.9%); and hormone therapy was performed in 50 (13.5%) [ 22 ].

According to a study conducted at HUCSH, chemotherapy provided for all 559 (100%) patients and Doxorubicin, cyclophosphamide, and paclitaxel were the chemotherapy regiment was commonest. Hormonal therapy provided 168(30%) and Tamoxifen regiment was commonest hormonal therapy patients, and surgery (modified radical mastectomy) was done for 196 (35.1%) [ 19 ].

Chemotherapy was given for 275 (90.7) patients in TASH in 2019, with the most prevalent regimen being 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) in 66.9% of cases. Surgery was done for 257 (85%) , combination therapy (surgery, chemotherapy, and palliative care) delivered to 189 (55.8%) and Radiotherapy was provided for 107 (35%) [ 21 ].

A similar study from TASH on 2013 Surgery was done for 902 (87%), and the majority had a modified radical mastectomy of 880 (95%). The majority of patients 893 (83%) also received chemotherapy, mainly anthracycline-containing chemotherapy (FAC)782 (73%). Hormonal therapy provided for 864 (81%) [ 31 ].

According to a study conducted at ACSH, 121 (65.1%) patients had surgery and 33 (17.7%) had chemotherapy, while the rest had both surgery and chemotherapy [ 30 ]. In TASH(2017), 192 (74%) patients received surgical intervention, the commonest being mastectomy 126, (65.6%); radiotherapy was provided for 53 (20.5%); and chemotherapy was provided for 231 (89.2%) patients [ 29 ].

Breast cancer is the most common type of cancer in Ethiopia in most reviewed studies, where the prevalence ranges from 15.2 to 26% from all cancers [ 14 , 15 ] and from female cancer 29.3–37% [ 11 , 16 ]. The pattern of breast cancer is increasing in Ethiopia. A study from HUCSH showed the breast cancer rate in hospitals has increased from 69 (12.3%) in 2013 to 106 (19%) in 2019 [ 19 ] and Results from TASH showed changes in breast cancer between 1997 and 2012, with a prevalence in 2012 has increased by more than seven times compared 1997 [ 32 ].

finding from different studies support this review’s finding which shows incidence increased by 1.44% per year from 1990 to 2017 and as for regional changes in incidence, all regions of breast cancer had increased incidence except North America, and the Middle East and North Africa had the largest increase in overall incidence [ 33 ]. In a similar study conducted between 2000 and 2012, incidence rates of breast cancer increased in South Korea, China, and the United Kingdom while decreasing in the United States [ 34 ]. The breast cancer incidence in Africa continues to increase and is projected to double by 2050.

This review showed commonest age group was from 40 to 46 years ( 7 , 22 , 23 , 21 , 16 , 28 , and 20 ) which similar finding other African studies [ 35 – 37 ].

Regarding stage at presentation, most of the patients presented with late stages (stages 3 and 4), with a prevalence range of 57–71.2% [ 19 , 22 , 25 , 29 ]. which is supported by papers from Africa showed with 89.6% and 72.8% of breast patients in Kenya and Nigeria respectively presenting with advanced stage disease [ 38 – 40 ]. Studies in South Africa reported an advanced stage breast cancer incidence of 50 and 55% [ 40 ]. This review showed that early-stage (stages I and II) accounts for 15–35% [ 6 , 8 , 15 , 27 ]. Similar findings were found in other developing countries, where only 20–50% of patients in the majority of low- and middle-income countries were diagnosed in these earlier stages [ 39 ].

Breast lump or mass is the most common presenting symptom in all studies from various parts of the country, ranging from 57.4 to 88.4% [ 22 , 24 – 26 ].

Regarding histological findings of breast cancer in Ethiopia, the commonest histology is ductal carcinoma, followed by lobar carcinoma in all reviewed research and prevalence ranges (55.3–93.5%) [ 16 , 20 , 22 , 26 – 29 , 31 , 41 ].

The prevalence of hormone receptors and molecular subtypes is high; estrogen receptor positivity is the most common receptor and is found in more than 65% of breast cancer patients. In terms of molecular subtype, Luminal A (ER + and/or PR+, HER2-) is the most common finding in breast cancer biopsies, accounting for more than 40% of cases, while Triple Negative/Basal-like cases account for more than 15% of cases [ 20 , 29 ]. Similar finding from studies from south Africa showed Estrogen Receptor is the commonest hormone receptors [ 39 , 40 ].

This review showed surgery is the mainstay treatment for breast cancer in Ethiopia, and radiotherapy is only provided in the capital city on TASH. A similar study from Africa showed a mastectomy rate greater than 85% and a huge difference from Europe’s breast cancer mastectomy of 30% [ 41 ].

Limitations of the study

Only English language articles were included.

Conclusion and recommendation

This review summarized the epidemiology, clinical and histological characteristics, and treatment modalities of breast cancer in Ethiopia. Breast cancer incidence is rising, and it accounts for the major cancer burden in the country. There is a need for additional awareness-raising and health education because delayed presentation is a critical problem throughout Ethiopia. For planning and monitoring cancer patterns, comprehensive demographic and clinical data from a population- or facility-based registry are needed. Currently, only one exists in the capital, the Addis Ababa City Cancer Registry (AACCR). There is a need to establish and strengthen histologic and pathology labs, as most hospitals are doing surgeries without histologic, molecular, or receptor identification since it helps with targeted therapy, according to what current best practice suggests. The available treatment options are still limited in Ethiopia; it needs Expanding radiation facilities is a major step toward improving outcomes for breast cancer patients.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Acknowledgements

Not applicable.

Abbreviations

AACCR	Addis Ababa City Cancer Registry
ACSH	Ayder Comprehensive Specialized Hospital
BC	Breast Cancer
CA	Cancer
DRH	Dessie Referral Hospital
EPHI	Ethiopian Public Health Institute
ER	Estrogen Receptor
FHCSH	Felege Hiwot Comprehensive specialized hospitals
GUCSH	Gondar University Comprehensive Specialized Hospital
HER2	Human Epidermal Receptor
HUCSH	Hawassa University Comprehensive Specialized Hospital
IRB	Institutional Review Board
JUMC	Jimma University Medical Center
LMIC	Low- and Middle-Income Country
MeSH	Medical Subjects Headings
MRM	Modified Radical Mastectomy
PR	Progesterone Receptor
PRISMA	Preferred Reporting Items for Systematic Reviews and Meta-Analyses
SPHMMC	St. Paul’s Hospital Millennium Medical Collage
TASH	Tikur Anbesa specialized hospital
WHO	World Health Organization

Author contributions

FGD and BTT developed the protocol, reviewed the reference list, extracted data, and conducted the analyses. TDD and YDS assessed the quality of the data, ensured the absence of errors and arbitrated in case of disagreement. FGD developed the draft manuscript and TDD critically reviewed it. All authors have read and agreed to the published version of the manuscript.

No fund received for this work.

Data availability

Declarations.

The authors declare no competing interests.

Publisher’s note

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

The World Bank in Ethiopia

The World Bank is following a people-centric approach that focuses on delivery of basic services, food security, and addressing the needs of vulnerable populations, while retaining a long-term development focus.

With about 126.5 million people (2023), Ethiopia is the second most populous nation in Africa after Nigeria, and one of the fastest-growing economies in the region, with an estimated 7.2% growth in FY2022/23. However, it also remains one of the poorest, with a per capita gross national income of $1,020. Ethiopia aims to reach lower-middle-income status by 2025.

Ethiopia’s strong growth rate builds on a longer-term record of growth over the past 15 years where the country’s economy grew at an average of nearly 10% per year, one of the highest rates in the world. Among other factors, growth was led by capital accumulation, in particular through public infrastructure investments. Ethiopia’s real gross domestic product (GDP) growth slowed down from FY2019/20 to FY2021/22 due to multiple shocks including COVID-19, with growth in industry and services easing to single digits. However, agriculture, where over 70% of the population is employed, was not significantly affected by the COVID-19 pandemic, and its contribution to growth slightly improved compared to previous years.

The consistently high economic growth over the last decade resulted in positive trends in poverty reduction in both urban and rural areas. The share of the population living below the national poverty line decreased from 30% in 2011 to 24% in 2016 and human development indicators improved as well. However, gains are modest when compared to other countries that saw fast growth, and inequality has increased in recent years. Furthermore, conflicts in various parts of Ethiopia risk undermining the economic and social development progress the country has achieved.

The government has launched a 10-Year Development Plan, based on its 2019 Home-Grown Economic Reform Agenda, which runs from 2020/21 to 2029/30. The plan aims to sustain the high growth achieved under the Growth and Transformation Plans of the previous decade while facilitating the shift towards a more private-sector-driven economy. It also aims to foster efficiency and introduce competition in key growth-enabling sectors (energy, logistics, and telecom), improve the business climate, and address macroeconomic imbalances.

Development Challenges

Ethiopia seeks to chart a  development path that is sustainable and inclusive in order to accelerate poverty reduction and boost shared prosperity. Significant progress in job creation, as well as improved governance, will be needed to ensure that growth is equitable across society. Achieving these objectives will require addressing key challenges including the following:

• Addressing macroeconomic distortions that constrain private sector development, structural transformation, and generation of jobs.
• Reducing the incidence of conflict that has been having a substantial impact on lives, livelihoods, and infrastructure. The cessation of hostilities in the North in November 2022 is an important step in this direction.
• Overcoming the effects of the COVID-19 pandemic. Like the rest of the world, Ethiopia has been experiencing the unprecedented social and economic impact of the pandemic. While exports and foreign direct investment rebounded in 2020/21 and jobs have been recovering, some lasting scars are likely to remain. Urban employment levels have not recovered fully, some households and firms continue to report income losses, and poverty is estimated to have increased.
• Addressing food insecurity, which is growing due to adverse weather events, locust invasion, conflict, and global conditions leading to high inflation of food prices. Frequent severe weather events alongside long-term impacts of climate change undermine agriculture and pastoral livelihoods as well as food security.  The 2022 drought is the worst in forty years, severely affecting millions in the southern and eastern parts of the country. Overall, more than 20 million persons faced severe food insecurity in 2023.
• Improving human capital. Ethiopia’s Human Capital Index is at a low 0.38 (2020) which means that a child born in Ethiopia today will be 38% as productive when s/he grows up as s/he could be if s/he enjoyed complete education and full health. This is lower than the average for the Sub-Saharan Africa region but slightly higher than the average for low-income countries. Learning poverty stands at 90% and 37% of children under 5 years of age are stunted.
• Generating good jobs. The country’s growing workforce (with roughly 2 million persons reaching working age per year) puts pressure on the absorption capacity of the labor market, necessitates improving current jobs, while creating sufficient new jobs.

In February 2024, the Ethiopia Country Climate and Development Reports (CCDR)  was released, sharing findings regarding the increasing impact of climate change that are threatening Ethiopia’s development prospects. The report notes that annual average losses to gross domestic product (GDP) are expected to range between 1-1.5% of GDP and to rise to 5% by the 2040s, potentially pushing millions more Ethiopians into poverty ( press release ).

The new analysis also points to opportunities for growth and increasing prosperity from climate-informed development policies. These are especially visible in agriculture where, with the support of reforms, Ethiopia can potentially shift from being a net importer of agricultural commodities to generating sizable surpluses of as much as 20% (relative to domestic demand), with climate change, especially under potentially warmer and wetter conditions, increasing these surpluses to 25%.

Last Updated: Apr 09, 2024

The World Bank Group’s (WBG) strategic focus is to assist Ethiopia in forging a more inclusive and sustainable growth path, supporting the objectives of the Home-Grown Economic Reform Agenda and the current 10-Year Development Plan. The WBG supports a more spatially inclusive approach to development, one that leverages national programs to provide quality services to all areas of the country. The WBG is helping to promote structural and economic transformation through increased productivity in rural and urban areas by focusing on basic education, access to markets, and job opportunities for youth. It is also helping to build resilience and inclusiveness (including gender equality) by improving safety nets, investing in productive landscapes, and focusing on the Early Years Agenda.

The WBG also supports institutional accountability and assists in combating corruption by focusing on improving governance and promoting social accountability. The private sector is expected to be a key contributor to Ethiopia’s future development, and prominent roles are being played by the International Finance Corporation (IFC) and Multilateral Investment Guarantee Agency (MIGA) towards supporting private domestic firms and foreign investors.

As of April 2, 2024 the World Bank’s portfolio in Ethiopia consists of 46 lending operations with $16.4 billion in commitments, complemented by $1.13 billion in trust fund financing. The portfolio includes financing for conflict-afflicted communities and internally displaced persons (IDPs), national programs on social safety nets, agriculture, sustainable land management, basic service delivery (including health, education, and water and sanitation), as well as support in the energy, transportation, trade logistics, digital development, and financial sectors.

The  International Development Association  (IDA), the World Bank’s fund for the poorest, also provides analytics and advisory services to support evidence-based decision-making and stronger implementation on a wide range of development issues. IDA is Ethiopia’s largest provider of official development assistance. It has committed more than $29 billion to nearly 166 projects in Ethiopia since 2000, most notably the:  Enhancing Shared Prosperity through Equitable Services Program, COVID-19 Emergency Response Project, Rural and Urban Productive Safety Net Programs, Flood Management Project, Locust Emergency Response Project, Agriculture Growth and Food System Resilience Projects, Response–Recovery–Resilience for Conflict-Affected Communities Project, Digital Foundations Project, as well as several important energy, water, and transportation sector projects.

IDA’s support for the education sector—including through the  General Education Quality Improvement Program for Equity  and the  Enhancing Shared Prosperity Through Equitable Services Program —has helped Ethiopia expand access to quality pre-primary and primary education over the last ten years. There has been significant expansion of the general education system, increasing from 7.1 million students in 2000 to 26 million in 2020. As a result, net enrollment rates in primary education and secondary education have increased to about 95% and 25% respectively. In addition, IDA supports the technical and vocational education and training, and higher education sub-sectors through its regional projects — e.g.,  East Africa Skills for Transformation and Regional Integration Project  — to increase access and improve quality of Technical and Vocational Education and Training (TVET) programs in selected Regional Flagship TVET Institutes and to support regional integration in East Africa; and  Eastern and Southern Africa Higher Education Centers of Excellence Project —to strengthen selected institutions to deliver quality postgraduate education and build collaborative research capacity in the regional priority areas.

Water and Sanitation

IDA’s support to the water and sanitation sector has helped the country make significant progress in improving services in the past decade. More than 60 million people in Ethiopia now live within 1 kilometer of an improved drinking water source and open defecation rates fell by 63%, which was the largest decrease observed in the world. About 101 million people gained access to any type of latrines, specifically, at least basic (11.1 million), shared (9.8 million) and unimproved (80.2 million). With the rapid increase in population, however, around 60 million people remain without access to drinking water and over 112 million have no access to at least basic sanitation and over 22 million people are still practicing open defecation. Current projects addressing these challenges include the:

One Wash National Program (OWNP)-Phase II  ($300 million),  Second Urban Water Supply and Sanitation Project  ($445 million), and  Ethiopia Horn of Africa Groundwater for Resilience Project  ($210).

These projects are also providing COVID-19, drought, and post-conflict emergency response support.

The OWNP Consolidated WASH Account Project plays a catalytic role in sector financing, attracting $257.3 million of finance from seven other donors and international financial institutions into a pooled fund that is managed under the Bank’s oversight. OWNP-CWA creates a unique platform for coordinating WASH sectors and harmonizing development partners in the sector.  It is focused on enhancing climate resilience and access to water supply service, quality, and sustainability, as well as providing equitable access to improved urban and institutional sanitation services – targeting 4.1 million people with improved water supply and 4.75 million with improved sanitation.

The transport program in the country aims to improve access and mobility (rural and urban), enhance safety, and increase climate resilience while strengthening the capabilities of the sector institutions to deliver and manage transport infrastructure and services. The active portfolio amounts to $1.6 billion and includes:  urban mobility and road safety, supported by the Transport Sector Improvement Project (TRANSIP),  rural access and regional connectivity, supported by the  Road Sector Support Project (RSSP) , the  Expressway Development Support Project (EDSP) , and Horn of Africa Initiative: Regional Economic Corridor Project (HoA-RECORD); policy dialogue and other institutional support in the areas of rural connectivity for food security, road safety, climate resilience, Public Private Partnerships (PPP), urban mobility, logistics efficiency, and railway reforms. As of 2021, over 166,000 km of roads have been built and upgraded under the government-led  Road Sector Development Program (RSDP)  initiated in 1997. IDA has invested more than $2 billion to support the government’s efforts over the past two decades of the RSDP period. IDA has worked with other development partners including the African Development Bank, European Union, and bilateral partners in building country capacity in areas like road asset management (including piloting of performance-based contracts), road safety, urban transport planning and management, enhancing climate resilience, boosting road agency safeguards management, and expanding the Expressway Development Program.

The IDA funded  Ethiopia COVID-19 Emergency Response Project  assisted the country in filling critical financing gaps in implementing the government’s Emergency Preparedness and Response Plan (EPRP) providing over $690 million in financing for Ethiopia’s COVID-19 emergency preparedness and response that supported:

• Ethiopia to establish COVID-19 testing, screening points, and enhance risk communication and community engagement.
• the training for health workers on COVID19 vaccine deployment and conduct awareness raising campaigns.
• the development of the national COVID-19 Vaccine deployment strategy.
• and financed the purchase of 45 million doses of COVID-19 vaccines and supported Ethiopia’s vaccine deployment strategy; so far 53.5 million doses of COVID-19 Vaccines have been administered.

Several development partners are active in Ethiopia and most international partners are keen to strengthen the process of harmonization of development support efforts, in the spirit of the Paris Declaration (2005) and Accra Agenda for Action (2008).

Ethiopia is a pilot country for the Organization for Economic Co-operation and Development (OECD) Assistance Committee harmonization agenda, and for the European Union’s initiative on donor division of labor. Partners are currently considering how to build on this progress in light of the Accra Agenda.

The WBG, with the United Nations Development Programme and a bilateral donor, is one of the rotating co-chairs of the Development Partners Group (DPG), the main forum for donor coordination in Ethiopia. Through the DPG, efforts are made to advance implementation of commitments in the Paris and Accra Declarations, including joint economic and sector work (much of the WBG’s major analytical work has already been prepared with its partners) and joint missions. Much of the collective effort is focused on furthering harmonization through major multi-donor programs and policy areas of importance.

The WBG has taken the lead in developing a set of multi-donor programs to reduce transaction costs, aligning support with the country’s decentralized model, and enhancing the predictability of aid. These instruments allow for large-scale leveraging of IDA support. Such approaches are used in several IDA-supported programs including:  Enhancing Shared Prosperity through Equitable Services ; the Productive Safety Nets Program; the Water Supply, Sanitation, and Hygiene Universal Access Program; the Sustainable Land Management Project II; and the Agricultural Growth Program II.

The launch of the  Expressway Development Support Project  (EDSP) marked a historic moment in the WBG’s partnership with Ethiopia, as it is the first project co-financed with China EXIM Bank and South Korea EXIM Bank. The project brings together traditional and non-traditional development partners to work on a single project, with standardized design, safeguards, and joint implementation support.

More recently, the WBG is coordinating with the United Nations Office for Project Services (UNOPS), which has been contracted by the Government of Ethiopia to implement the  Response-Recovery-Resilience for Conflict-Affected Communities in Ethiopia Project  in areas of high risk of conflict. The project supports efforts to address the immediate needs of communities, rehabilitate infrastructure destroyed by conflict, and increase community resilience to the impacts of conflict in a sustainable manner.

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Thesis Writing in Ethiopia: Student Guidebook

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Anecdotal evidence suggests that, even when academic staff are aware of the existence of a plagiarism policy, many still don't use it. They either prefer to deal with it in their own way, or ignore the issue. In order to encourage increased and improved use of the existing policy, we were interested in understanding staff concerns about plagiarism generally. As part of a Postgraduate Certificate (PG Cert) in Teaching and Learning in Higher Education, a 3 hour workshop is devoted to Academic Integrity. At the start of the workshop, participants are asked to complete a survey on their experience and concerns regarding plagiarism, and their awareness of local policies and procedures. Staff are then asked to articulate their single biggest concern around academic integrity, and this collection of concerns and the ensuing discussion is used to direct aspects of the workshop. With different groups, the emerging group concerns will have different flavours; some teaching-focused, some student-focussed and some policy-focussed. The data from the surveys over the last 3 years gives an insight into staff awareness of policies and procedures at our institution as well as highlighting the general ethos and attitudes regarding student plagiarism. This paper will compare the collected data against early results from the IPPHEAE project staff survey. Knowledge about the levels of awareness of plagiarism policy amongst staff has implications for staff development. This paper will give an overview of various approaches to awareness raising and staff development that have been used in our institution, with an indication of the levels of success and factors contributing to this.

Dr. Stella-Maris Orim

Abstract: In the last ten years, there has been much research into academic integrity with a focus on plagiarism in developed countries. There is still a dearth of such research in developing countries like Nigeria. This paper presents the results from a larger exploratory study on student plagiarism in Nigerian Higher Education Institution of Learning (Nigerian universities), which is associated with the Impact of Plagiarism Policies in Higher Education Across Europe (IPPHEAE) project. It seeks to contribute to the body of knowledge by focusing on the experiences of previous institutional interventions on student plagiarism issues and their impact on student experience when they study elsewhere. Nigerian students studying abroad had to adapt to diverse teaching, learning and assessment styles under a different institutional system. This resulted in the students struggling when they had to apply skills they had not acquired during their previous study. This study adopted a mixed method approach; 25 Nigerian Postgraduate Students studying in a United Kingdom University were interviewed for the qualitative data and 171 IPPHEAE student questionnaires were completed for the quantitative data. Results from the data suggest that the previous institutional system experienced by the students was quite different from what they met in their present institutions of study in England. As a result, the students struggled to cope with their studies when they had to apply skills they had not acquired.

Bounthanh Lee

A book like this cannot be written in isolation. While most of the text found in this manual is original, dozens of similar books and experts were consulted, and many colleagues and friends provided information, feedback, and suggestions. My greatest thanks goes to Nancy Vyhmeister, author of the first AIIAS writing manual, for her willingness to share original content and ideas from her work. Chapter 1 is taken largely from her prior work. She was also instrumental as a consultant for the Turabian chapter and in overall editing of this book. Thanks also to Juanita Bissell, for contributing the basis for the Turabian chapter from her earlier AIIAS Turabian manual. This has been revised, updated, and shortened, but her work is still the basis for Chapter 6. Thanks to Elsie Dela Cruz, Prema Gaikwad, and Esther Papaioannou for their substantial contributions to the APA explanations in Chapter 7. Thanks also to Bonnie Proctor, the editor at Andrews University, for her willingness to share ideas, resources, and materials. By now it is difficult to tell where her ideas end and mine begin, but some of her work is included especially in the introduction, and in the chapters on academic writing conventions, mechanics, APA and Turabian. Her support has been much appreciated.

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