Ethiopia is currently experiencing several intersecting humanitarian crises including conflict, climatic shocks, COVID-19, desert locust infestation and more. These intersecting crises are affecting nearly 30 million people and resulting in food insecurity, displacement and protection risks.^1,2  As of February 2022, over 2.5 million people were estimated to have been displaced as a result of the ongoing conflict-driven humanitarian crisis in the Northern Ethiopian regions of Tigray, Amhara and Afar that began in November 2020. As of May 2022, 9.4 million were in need of humanitarian aid in the region.³ Private and public assets have been destroyed, already fragile livelihoods damaged, and communities left in dire need of support.

This brief outlines important contextual factors and social impacts of the Northern Ethiopian crisis and offers key considerations to improve the effectiveness of the humanitarian response. It is based on a rapid review of existing published and grey literature and conversations with relevant stakeholders, including people from affected regions and humanitarian responders. This brief is part of a series authored by participants from the SSHAP Fellowship and was written by Heran Abebe and Getachew Belaineh from Cohort 2. It was reviewed by Ezana Amdework (Addis Ababa University), Kelemework Tafere (Mekelle University), and Yomif Worku (independent humanitarian advisor), and was supported by Tabitha Hrynick from the SSHAP team at the Institute of Development Studies. The brief is the responsibility of the SSHAP.

Key considerations

Ethnic and political tensions and inclusion of ethnic minority groups

• Responders must be careful not to be perceived to support, or ‘side’ with, particular political or militant groups, especially groups associated with human rights abuses (including governmental entities). Ethnic and political tensions must be carefully navigated as they may complicate aid distribution and assistance, due to prevailing mistrust and past restrictions on or abuses of humanitarian aid.
• Non-violent civil society groups, including diaspora/international networks, may be important actors with which responders could more meaningfully engage. Such networks may be important channels through which gaps in humanitarian response might be addressed. While ethnic affiliation should not be conflated with political alignment or a ‘side’ in the conflict, responders should be aware of potential political sensitivities.
• Responders should increase their efforts to reach ethnic minority groups in affected regions and to ensure minorities are also supported in areas where they may be internally displaced. These groups have been overlooked by humanitarian response. In Tigray, for example, this includes the Irob and Kunama in areas bordering Eritrea. Many Agaw/Kamyr are also displaced in Amhara region, especially in Sekota.
• Responders should tap into local networks to identify locally relevant languages, customs and priorities and should engage translators to ensure inclusive assistance. Linguistic, religious and other cultural aspects of minority groups may be diverse, and one-size-fits-all approaches may fail.

Responding to the dynamics of displacement

• Response activities should be adapted to address the needs of IDPs and host communities in diverse settings. This includes informal and formal camps and communities where need has not been met by available resources, and communities of people on the move, including pastoralists.
• In IDP settings, responders should consider shelter locations for people with security and mobility challenges and the placement of service access points, such as latrines and food distribution. Infrastructure could be reinforced to ensure its continued functioning and safety in both dry and wet seasonal conditions. The rains bring new navigation challenges, especially for children, elderly people and those with disabilities. They also pose infectious disease threats. Dry seasons can lead to acute water shortages, requiring women and girls to travel further to fetch water.
• The concerns of returnees, such as loss of income, education, health, protection, access to food and continuing security risks must remain a response priority. Returnees may face destroyed livelihoods (e.g., loss of agricultural crops and inputs) and unrestored basic services.

Context-appropriate response to health and wellbeing

• Training and support for local leaders, influencers and institutions to support survivors of widespread sexual and gender-based violence (SGBV) is critical. SGBV is widespread and used as a weapon of war. Many survivors of SGBV feel stigmatised, which affects their willingness to seek support. Christian and Islamic religious leaders may be able to help change norms and attitudes about SGBV in the community, and support referral and service access for survivors. Local workers of ‘social courts’ – village-level institutions (usually male dominated) that adjudicate family matters across affected regions – could also be similarly trained. Mahiber, single-gender group associations common in Christian communities, may also be spaces through which collective healing and psychosocial support can be channeled.
• Vulnerable groups among IDPs, such as women, girls, elderly individuals and people with disabilities must be engaged in designing and determining locations of key services. Health services, including sanitation facilities, have had inadequate or uneven consideration of gender concerns like privacy and safety. Distance is also a key challenge for these vulnerable groups.
• The response should consider the gender of health service providers serving pregnant women. Past research has suggested the gender of health workers can influence care seeking for pregnant and lactating mothers in Afar communities.
• Responders should emphasise the importance and availability of adult health care. One opportunity to engage adults about their health may be during their engagement with child health services. Past research in the region has suggested that households of all socio-economic statuses seek care early for child health concerns. However, adults – particularly those with limited means – may put off seeking care for themselves. This may have been exacerbated in the conflict.
• Appropriate, sustainable mental health support is essential. Tapping into trusted religious and other local networks and institutions, such as mahiber and others (see below), may enhance access. Mental health issues, including psychological trauma from the conflict, are major concerns.
• Aim to engage with indigenous or religious healers and practices. Traditional practices (which may involve plants, holy water and prayer) remain popular and may be more accessible than biomedical care during crises.

Supporting conflict-affected children and youth

• The response must prioritise youth and child protection concerns, as those populations are most vulnerable to short- and long-term conflict-related harms. They face multiple risks, including loss of education, child marriage, physical violence, conscription into armed conflict, separation from family, mental health concerns and food insecurity. They, or their families, may also resort to negative coping strategies, such as exploitative work.

Supporting peace and sustainable resilience locally

• It is critical to support inclusive local-level peace building efforts, as political and interethnic tensions have flared. These efforts should include mapping and engagement of community leaders and less influential community members (youth, women and people with disabilities). Local cultural institutions, such as dagu – a ritual form of communication and performance among Afar people – may be one way of engaging different groups.
• Invest and support efforts to address acute needs and support recovery and sustainable resilience of local institutions, which have been badly impacted by the conflict. This should include support not just with technical capacities for services and infrastructure, but also for inclusive community engagement and strengthening for formal and informal community-based organisations. Equb and iddir are local institutions found in all conflict-affected regions which could facilitate support and humanitarian assistance, recovery and resilience at the local level.

Context of the conflict

Ethiopia has a population of 120 million, with over 81 ethnic groups. Its governance system is organised around ‘ethnic federalism’.⁴ This means each of its self-governing regions, which have significant legislative and executive powers, is associated with a particular ethnolinguistic group. This has created longstanding tensions between groups and regions,⁵ and between regions and federal authorities. Tensions between the federal government and the Tigray People’s Liberation Front (TPLF), the dominant political party of the Tigray region, also underlie the current conflict.⁶

The recent and ongoing violence was triggered by TPLF attacks on federal military bases in Tigray region in November 2020 and by the Federal Government of Ethiopia’s (GoE) military response.^7,8 This response has been mounted by the Ethiopian National Defense Forces (ENDF), in partnership with Eritrean troops and, at times, regional militias.^9,10 Some phases of the conflict have also seen popular support for armed government intervention among citizens and civil society, particularly in the south of the country.

The TPLF assault on the federal bases – claimed to be justified by the TPLF as necessary to thwart a perceived imminent federal intervention¹⁰ – was itself part of a broader movement of defiance by TPLF authorities. In September 2020, those authorities had conducted regional legislative elections despite federal orders to postpone them due to COVID-19.¹¹ For almost thirty years, until 2018, the TPLF dominated national Ethiopian politics, and it thus backed the ethnic federalist system under which it enjoyed disproportionate power within a ruling coalition of four regional parties.¹⁰ Despite relative prosperity during this time, the outsized power of the TPLF led their resentment by many elements in the country.

The conflict sharply escalated in late June 2021, following which the GoE declared a unilateral ceasefire. ENDF elements withdrew from Tigray, and the TPLF gained control of much of the region; the conflict expanded to neighboring districts in Afar (Zone 2 and Zone 4) and Amhara (North Wollo, South Wollo, North Gondar, South Gondar, Tegedie and Waghimera) regions. In response, the GoE declared a nationwide state of emergency on November 2, 2021 (lifted in late January 2022), under which licenses of NGOs and media outlets could be suspended if suspected of supporting ‘terrorist organisations’. As a result, humanitarian actors limited their entry to Tigray region during this time, which greatly exacerbated humanitarian need.^12,13  In the meantime, the ENDF regained control of Afar and Amhara regions following withdrawal of TPLF elements in December 2021.¹⁴

The conflict has now gone on for nearly two years, resulting in significant damage to lives, livelihoods, and public services and infrasructure.¹⁵ Grave human rights abuses have been committed against civilians by all warring parties.¹⁶ Despite pushes from the African Union, ceasefire negotiations have not gone ahead. Underlying mistrust hinders the process and weakens the likelihood that parties will uphold any resulting agreement. While the frequency and intensity of armed clashes has shifted and been unpredictable at times, the conflict is ongoing.  Violence and human rights abuses remain a threat in Tigray, Afar and Amara regions as armed actors fail to fully withdraw, and ethnic tensions persist.

Critical social context for humanitarian response

As humanitarian responders continue to make efforts to provide aid on the ground, there are aspects of key social context which they should be aware of to ensure effective and inclusive response.

Regions and ethnic groups

Although each conflict-affected region is associated with a dominant ethnic group, all are also inhabited by a range of diverse ethnic groups with different linguistic, religious and other cultural, political and geographical contexts. Responders should be aware of these and aim to adapt response accordingly.

Tigray is Ethiopia’s northernmost region. It is bordered by Eritrea to the north, Sudan to the west, Amhara region to the south and Afar region to the east and southeast. It is home to the Tigray ethnic group, after which it is named. The Tigray people (who also refer to themselves as Tigraway) are mainly subsistence farmers and followers of Ethiopian Orthodox Täwahǝdo Christianity, although about 8-10% are Muslim.¹⁷ Tigray people speak Tigringa – which is itself the third most spoken language in Ethiopia. Tigray region is also home to the minority Irob and Kunama groups.¹⁸ These latter groups lack political representation and formal administrative structures for self-government. Historically, the region has also hosted many Eritrean refugees. Despite the groups’ distinct ethnic identities, many families of mixed ethnicity live in Tigray and surrounding regions.

Ethnic minority groups in Tigray. The Irob – between 30,000 and 40,000 people – live in the semi-arid mountainous area bordering Eritrea and are predominantly Catholic. The Kunama are found mainly in the Gash-Barka area between the Gash and Setit rivers in the western and northwestern regions of Tigray. While some Kunama may continue to hold traditional religious beliefs, most have converted to Christianity or Islam. Only around 1,000 Kunama live in Tigray, making them one of the smallest ethnic groups in Ethiopia. The Irob speak Tigrigna and Saho, whereas Kunama speak Kunama and Ilit which is a family of Nilo-Saharan language.

Afar region and its people. The sparsely populated Afar regional state is in northeastern Ethiopia. It is bordered by Eritrea to the northeast, Tigray region to the northwest, Oromia region to the southwest, Somali region to the south and Djibouti to the east. The Afar (or Qafár) inhabit the Horn of Africa and speak the Cushitic Afar and Arabic languages.¹⁹ These people are also sometimes known as the Danakil, Adali or Odali people in other areas, but these names may be considered offensive by the Afar people and should be avoided by responders. They are a cross-border community of pastoralists who primarily live and herd livestock in the Afar region of Ethiopia and adjacent areas of Eritrea and Djibouti. This region has the harshest environment in the Horn of Africa, with extreme temperatures, a fragile environment and minimal access to water.²⁰ Serious drought conditions are now compounding conflict-related challenges.²¹ An estimated 1.3 million Afar live in Ethiopia, with smaller populations residing in adjacent countries.²² These Cushitic people are primarily Sunni Muslim. Afar society is governed by a clan system and a traditional ruler, the Sultan of Afar. Despite being marginalised by the state and having a fluid international identity, the Afar people have tended to back the ‘unitarian’ narrative of the federal government in the current conflict, rather than embracing a strong ethnically aligned stance.²³

Cross-border social ties. Ethnic groups, particularly in Tigray and Afar regions – including the Tigray, Irob, Kumana and Afar people – have longstanding ethnic ties across the Eritrean (and in the case of the Afar, also the Djibouti) border.²⁴ In fact, the vast majority of the Kunama people reside in Eritrea. This indicates the possibility of important cross-border solidarities, support and resources on which these groups may draw during the current crisis. Indeed, they have done so during past conflicts, including the Ethio-Eritrean war. Although international boundaries cut them off from one another, they nevertheless managed to sustain ties.²⁴ Conflict and other political dynamics have also propelled a large number of people from the region further abroad, leading to large, global diasporas, particularly of Tigray people. The Tigray Development Association, for example, a non-governmental organisation (NGO) with strong diasporic branches and ties, has been involved in peace-building and development activities in the Tigray region for decades.²⁵ Such groups and international networks may represent important channels through which resources may already be flowing, and with which formal responders might link up to coordinate and improve the overall effectiveness of response.

Amhara region. Amhara regional state is located in northwestern and north central Ethiopia.²⁶ It is bordered by Tigray to the north and Afar to the east, Benishangul-Gumuz to the west and southwest, Sudan to the west and northwest and Oromia to the south. It is predominantly inhabited by people from the Semitic-speaking Amhara ethnic group, who make up 91.47% of the population. They are agriculturalists and place great value on land ownership. Most other residents hail from other Cushitic language communities, including the Agaw/Awi and Oromo, Qemant and Agaw/Kamyr, and other groups such as the Beta Israel and Argobba. The region is one of the most democratised in that each ethnic group manages their own administrative structures, reflected for instance, in the Awi, Waghimra and Oromo special zones. Such a setup is unusual in other regions inhabited by multiple ethnic groups. Amharic is widely spoken across the region and Agewegna, Himtagna and Afan Oromo are spoken in Awi, Waghimra and Oromia special zones respectively.²⁷ Ethiopian Orthodox is the predominant religion in the region, followed by Islam. In the escalation of the conflict, the Waghimra, North Wollo, South Wollo, South Gondar, North Shewa and Northeast Gondar zones have been the most heavily affected in the region.

Social impacts of the crisis

Economic, social, and cultural rights – including the rights to health, adequate food, water and sanitation, as well as access to basic services such as electricity, banking and communications infrastructure – have been seriously affected, both directly by the conflict and indirectly by a lack of mitigating measures.²⁸ Tigray, in particular, lies in ruins. The region’s social, cultural, economic, and infrastructural assets have been damaged.⁵

Exacerbating inter-ethnic tensions, ethnic targeting and minority marginalisation

The conflict has exacerbated tension between ethnic groups, particularly between the Amhara and the Tigray people. Roads into Tigray through Amhara have been blocked since 2018 by locals due to their resentment of the TPLF for its long dominance of the national government and for its perceived annexation of land historically administered by ethnic Amhara.²⁹  Consequently, trade and livelihoods for people living in Tigray had already been adversely affected for more than a year and a half before the onset of the conflict, as the only consistently open route into the region was through Afar.⁵ Tensions flared further in the conflict when TPLF forces seized humanitarian aid entry corridors into Tigray from Afar and Amhara regions.³⁰ State media has claimed that humanitarian aid en route to Tigray through these channels has not always been delivered to its intended recipients, and that the TPLF has used it to extort youth into joining the TPLF army, in exchange for food for their families.³¹

Amnesty International and Human Rights Watch have claimed in reports that Tigrayan civilians have been targeted for ethnic cleansing in the disputed Western Tigray Zone – one of the areas annexed into Tigray – by Amharic militia, led by Amhara regional government actors and with the complicity of national forces.³² In other reports, Amnesty International has claimed ethnic Amharic people have also been targeted by the TPLF. This targeting has included a massacre of civilians living in western Tigray in November 2020³³ and summary killings, rape and looting elsewhere in Amhara region.³⁴

Although not necessarily specifically targeted, other ethnic minority groups, such as the Irob and Kunama of Tigray region described above, have also been caught in the crossfire of the conflict from the start. Their minority status, both within Tigray region and nationally, has meant they have been effectively invisible, including to humanitarian actors delivering aid. It is believed they could be facing extreme food insecurity due to the difficulty of reaching them with aid because of security risks.³⁵ As the conflict expanded into Afar and Amhara regions, girls and women, especially those of the Agaw/Kamyr, Qemant (a small ethnic group in Gondar, Amhara Region), and Oromo ethnic groups have also been affected.

Displacement and returnees

As of February 2022, an estimated 4.51 million people were thought to be internally displaced across Ethiopia, with conflict being responsible for about 81% of IDPs.³⁶ Additionally, nearly 50,000 refugees fled to Sudan in what the UN called the worst exodus of refugees from Ethiopia in more than two decades.³⁷ However, data gaps, security risks, lack of fuel and cash, and the breakdown of communications infrastructure have made it difficult to know exactly how many may have been displaced by the northern conflict³⁸ or what specific challenges IDPs may be facing. Table 1 shows data from the Emergency Site Assessment round 9 (Jan-Feb 2022) across affected regions.  However, these figures are likely underestimates, especially in Afar and Tigray. Numbers and locations of IDPs are likely to have shifted and fluxed throughout the crisis.

Certain areas have been of particular concern during the conflict. For instance, influxes of IDPs from hard-to-reach areas along the Tigray border have exacerbated an already dire humanitarian situation in Amhara’s Wag Hemra zone.³⁹ Here, there are reportedly tens of thousands of IDPs, many concentrated in Sekota town. The majority are from the Agaw/Kamyr ethnic group who, as mentioned, have received relatively less humanitarian attention than Tigrayan IDPs. The area is particularly affected by limited fuel availability and volatile security risks, which continue to seriously hamper humanitarian response.^40,41

While the situation remains unstable, the number of IDPs in Afar and Amhara decreased significantly following the mass return of 1.5 million, mostly in east Amhara, facilitated in part by regional authorities.^36,42 Authorities in Afar also reported both spontaneous and organised returns of IDPs, despite ongoing concerns about insecurity and lack of basic services.⁴³ However, there have also been reports about forced internment in camps of ethnic Tigrayans in Afar.⁴⁴ Response efforts must emphasise the right of voluntary movement and return, as well as aim to address the needs of returnees, who may have lost access to livelihoods and basic services. Reports suggest returns may also be driven by lack of resources such as food and shelter in IDP camps.⁴⁵

Sexual and gender-based violence as a weapon of war

Ethiopia had high rates  of sexual and gender-based violence (SGBV), especially Intimate Partner Violence (IPV), Female Genital Mutilation (FGM), even before the current conflict.⁴⁶ However, as is common amidst situations of conflict and displacement,⁴⁷ the vulnerability of women, girls, people with disabilities, and even men and boys to the worst forms of SGBV has been exacerbated. This has included physical violence and assault, rape (including gang rape), insertion of foreign objects into genitals and even reports of intentional transmission of HIV committed by TPLF, ENDF and Eritrean forces.²⁸ Reports from key informants spoken to for this brief, as well as the authors’ own observations in response activities indicate offences have occurred in all conflict-affected regions and districts, with women and girls of all ages being targeted both at home and while fleeing war. Women whose husbands or relatives are (or are suspected of) fighting for a particular side have also been specifically targeted by opposition fighters. There is a strong stigma associated with sexual assault. Most survivors are unwilling to disclose, making it difficult to estimate the number of survivors. One key informant noted that survivors from the Amhara ethnic group have been labeled as “Ye junta tirafe”, or “leftovers of the junta.”

Indeed, Amnesty International reported that rape and sexual violence has been used as weapon of war in Tigray, and that this is inflicting long lasting physical and psychological damage on survivors.⁴⁸ A substantial number of women and girls have also become pregnant after rape and have been forced to carry unwanted pregnancies to term due to an absence of functioning health infrastructure. There have also been reports that in some cases, family members including children have been forced to witness acts of rape. Reports also suggest survivors and their families have been subjected to ethnic slurs and death threats, while perpetrators have claimed they are “cleansing” women of enemy blood. Perpetrators have also taken some survivors hostage, subjecting them to sexual slavery for days or weeks and inflicting brutal torture.⁴⁸

Responding to SGBV. Integration of SGBV response into the overall emergency response has been a key focus of responders.  They have conducted SGBV prevention and risk mitigation awareness-raising activities and distributed dignity kits and SGBV prevention booklets to women and girls. In Tigray, this work has been carried out by health extension workers (HEWs) deployed in partnership with the Organization for Social Service, Health and Development (OSSHD) in Tigray.⁴⁹ In Amhara, community facilitators and SGBV focal persons trained in psychological first aid and SGBV in emergencies have been deployed.⁴⁹ SGBV caseworkers have also been deployed in partnership with the Amhara Women’s Association (AWA) in Debark and Dabat woredas of North Gondar zone, Amhara.⁴⁹

Ongoing challenges and needs for SGBV services. The destruction of health facilities and a critical shortage of supplies and healthcare providers continues to affect the availability and accessibility of quality SGBV services to vulnerable populations. Additionally, key informants have stressed there is an urgent need for more mental health and psychosocial support. This includes interventions for emotional resilience and collective healing for survivors not only of SGBV, but of other wartime traumas, such as other forms of violence, displacement, family breakdown and loss of livelihoods.

Context-appropriate institutions for support and healing. The lack of material resources/infrastructure and a context of stigmatisation of SGBV survivors points to the need to draw on and support existing community-based institutions and traditions. Mahibers are small single-gender groups established based on religious (usually Christian) or cultural affiliation, which traditionally come together on a monthly basis. Such associations have potential to address emotional healing. Mahibers have also been identified as safe spaces for women to exchange personal information and solicit support and opinions from their peers. Where conditions allow, such community-led groups could serve as one channel through which psychosocial support for survivors could be channeled, with resource support from humanitarian responders. However, independent services, which protect the privacy of survivors, are also critical.

It is also not clear whether or to what extent religious leaders (e.g., clergy of Ethiopian Orthodox Täwahǝdo Christianity, who are widely respected in Tigray) have been engaged to support SGBV survivors. Ethnographic research has suggested this could be an important missing component in SGBV response, as survivors may be subject to perceived, or indeed very real, stigmatisation on cultural-religious grounds.⁵⁰ This may prevent them from speaking out or seeking help. With training, religious leaders could play a significant role in reducing stigma, linking survivors to appropriate services, directly facilitating healing and support and, importantly, shifting local norms around SGBV. Workers in ‘social courts’, accessible village-level institutions which adjudicate family matters and other civil issues in Tigray and other regions, could also play a similar role, including in IDP sites. They also likely require training and sensitisation, as most are male and may not understand how best to support survivors.⁵⁰ Many men have also suffered psychological trauma from witnessing the rape of their wives or daughters and may require appropriate services and support.

A crisis of trust

Inter-ethnic tension and violence has created conditions in which trust between many communities in northern Ethiopia has been destroyed. Trust is also fragile at the political level. One view is that the GoE has been reluctant to include the TPLF (which it has officially labeled a terrorist organisation) in “national dialogue” efforts towards reconciliation, and that this may affect its perceived legitimacy among both armed and non-armed opposition parties, people and religious leaders and reduces the likelihood of sustainable and inclusive peace.⁵¹

In conditions of polarisation and fragile political trust, humanitarian responders must be careful not to align or appear to be aligned with political factions, especially those associated with brutal crimes against civilians. When and where possible, engaging directly with trusted non-violent local networks, institutions and civil society (some of which may be ethnically affiliated) may be productive channels to deliver key services and support. It may be particularly critical to harness the role of religious leaders and networks which often cut across ethnic and political lines. Indeed, religion may play a stronger role in many families and communities in Ethiopia than do formal laws or institutions. Religious leaders can act as brokers in peace-building efforts at household, community and regional levels.⁵² As mentioned, religious leaders could also play a role in counseling survivors of SGBV, strengthening community support for survivors and condemning stigmatising behaviour and the commission of offenses.

Other local institutions and traditional associations common across many ethnic groups may also facilitate support and humanitarian assistance for affected people at the local level. These include:

1. Iddir – traditional voluntary associations in which members make monthly monetary contributions to be used during emergencies. Iddirs exist in many communities affected by the conflict, but some may have more financial resources than others to support response and recovery efforts.
2. Equb – associations established by small groups of people to provide substantial rotating funding for members in order to improve their lives and living conditions.⁵³ Equbs may similarly be channels through which responders can engage at the community level to provide assistance and support.

It is important to note that the crisis might have affected the existence of these institutions themselves. Responders can map functioning iddirs, equbs and other trusted and locally rooted institutions and networks, as well as support their reformation in order to build on their activities to support people in need.

Health and health system impacts and health seeking behaviour

The conflict has resulted in looting and destruction of health, education, water, telecommunications, electricity, and banking infrastructure in Afar, Amhara and Tigray regions.²⁸ Communications blackouts and complete interruption of electricity has also limited responders’ ability to accurately understand what is happening and to mitigate impacts.⁵⁴

Health and health system impacts. Ethiopia has made significant investments in its health system over the last decade, especially through establishment of health posts and health centres and trained personnel.^55,56 This infrastructure, especially in war-torn Tigray, has been severely damaged by the conflict. This has occurred through deliberate destruction, looting and even militant occupation of health facilities, and by critical supply shortages related to the war such as a blockade of land routes into the region.^49,57 In Tigray, for example, only 27.5% of hospitals, 17.5% of health centres and none of 712 health posts were fully functional six months into the war.⁵⁴ A lack of fuel in affected areas has also impeded the operation of Mobile Health Units.⁴⁹ Along with significant attrition and displacement of health workers, this has led to reductions in availability of critical services such as maternal and child health services and contributed to exacerbation of malnutrition and infectious and non-infectious illnesses.^54,58–60 Health workers in diasporic networks – such as a large roster maintained by the organisation HPN4Tigray –  are eager to provide services directly. But they have been prevented from entering the country for fear of being arrested by the government as activists or terrorists.

Commentators have noted how a once premier hospital in Mekelle has been forced to send patients home to die of preventable conditions due to lack of supplies and manpower.⁶¹ The brutality and hardship experienced by many in affected areas has also sparked concerns about widespread serious mental health impacts. There are nearly 30,000 people estimated to be in need of acute mental health support for psychological trauma and other conditions in Afar and Amhara regions.⁶² Immediate damage to health system infrastructure and people’s health will also have long-term consequences requiring substantial investment and attention going forward.

Considerations for health service provision. There is little evidence about how people have sought health care amidst the conflict and the devastation of the health system, even as the health needs of affected populations have spiraled. The conflict is likely, however, to have driven some people on dangerous journeys to access health services, such as across occupied areas of western Tigray to Sudan.  Evidence from before the conflict offers some insight for responders seeking to make sure those services that are able to function can be most effective. A study conducted in Tigray and Amhara showed an almost universal preference for biomedical care for many common illnesses, and early health-seeking across socio-economic groups for child illnesses.⁵⁵ Adult health-seeking, however, has been shown to be more conditioned by socio-economic status, with those from poorer households being more likely to delay care seeking.⁵⁵ In the context of the conflict and severe depletion of economic resources, this is likely to be even more pronounced, making mobile health units and the provision of no-cost care critical. Furthermore, despite widespread acceptance of biomedical care, indigenous and religious healing practices involving plants,⁶³ prayer or holy water may also remain popular, and possibly, more accessible. Religious institutions and healers can also influence perceptions of disease and people’s care-seeking practices. Responders should be aware of this and aim to work with non-biomedical healers where relevant, in addition to providing access to critical biomedical care. There may also be differences in care seeking by religion. Orthodox Christian households have been observed to seek biomedical care and to seek it sooner than Muslim households.^55,64 Other considerations, including gender, may be important. The gender of health workers, for instance, has been shown to influence health-seeking behaviour in communities in Afar region. Pregnant women may refuse to go to facilities to avoid physical contact with male health workers during labour and delivery.⁶⁵

Impacts on youth

Overall, evidence is limited on the impact of the conflict on youth, and more information is critically needed to ensure young people are appropriately supported.

Education. Nearly 8,700 schools nationwide have been reported as fully or partially damaged, affecting 2.9 million children, or 17% of the country’s school-aged population. About 70% of damaged schools are in Tigray, Afar and Amhara.⁴³ This represents not only loss of learning, but also loss of access to food through school feeding programmes at a time of extreme food insecurity in the region. Teachers, too, are likely facing extreme personal challenges which may affect their ability to keep schools open. Negative coping strategies for households struggling to deal with food insecurity and loss of income may also mean that children are forced to work in exploitive conditions and forego education, even if education services are available.⁶⁶

Child marriage. Ethiopia has one of the highest rates of child marriage globally, and northern Ethiopia is no exception. Drought conditions have led to a doubling of child marriage in some parts of the country in the space of one year,⁶⁷ as families struggle to cope with severe food insecurity. Similar worries about food insecurity in northern Ethiopia, as well as loss of schooling, are additional risk factors for child marriage. Humanitarian response must be vigilant, working with key local actors and networks such as teachers and women’s associations and bureaus to identify and support girls and households at risk.⁶⁸

Mental health concerns. The conflict, including experiences of violence, can have a significant impact on children and youth and can have long-term consequences for their wellbeing and life chances. One study of 122 adolescents in Tigray found a three-fold increase in experiences of anxiety, and an increase in depression from 16% to 25% between the period just prior to and that shortly after the conflict began.⁶⁹

Direct victims of conflict. Youth also tend to be direct victims of conflict, for example conscripts or prisoners of war. Some may fall victim to smugglers as they flee conflict, or be accused of being enemy combatants or infiltrators, and then subject to detention.

Increasing food insecurity

Malnutrition and food insecurity are reaching unprecedented levels in the face of devastating overlapping crises of conflict and drought across Ethiopia. Although humanitarian convoys carrying food and other supplies are now more able to access conflict-affected areas by overland routes (while airdrops of critical supplies continue),⁷⁰ 13 million people in northern Ethiopia now require food assistance⁴³ and between seven and eight million are facing severe acute food insecurity.³

Impacts on agriculture. One key factor contributing to food insecurity has been interruption of farming activities. In Tigray, researchers showed how ploughing, planting and other farming activities, on which 75% of the region’s population rely – many for survival – were affected by the conflict in 2021. These effects included lack of availability and access to farming inputs, military interference with planting, destruction or looting of agricultural tools and killing of plough animals. Many male farmers also fled or hid for fear of being killed by soldiers, leaving elders, women and children to work the land.⁷¹ Ongoing insecurity and displacement will likely continue to affect agriculture in the region. Even where growing is possible, some farmers have reported a shift towards focusing on cereals instead of more diverse food crops. Although less labour intensive, cereals are also less nutritious than vegetables.⁷¹ Where and when people are able to return to their homes, assistance for resuming agricultural activities will be critical. However, it will take some time for food production, which may also be affected by drought conditions, to recover. It is critical that food and nutrition assistance continue to be made available for returnees.

Other factors contributing to food insecurity. The interruption of subsistence agriculture, along with the loss of other livelihoods and income-generating opportunities, high food prices, limited access to markets⁷² and displacement have all contributed to food insecurity in the region. Women and girls who have to travel long distances to reach IDP centers are the most food insecure. This may increase their vulnerability to other risks, including sexual exploitation and abuse by those who control access to food and other resources.

Negative coping. Food insecurity has pushed many to engage in negative coping strategies to survive. These may include depleting savings and resources, cutting spending on health and education, and increasing reliance on familial and social networks. As mentioned, some have been forced to join fighting forces in exchange for food, while others may be driven to resort to transactional and/or commercial sex work. Research on adolescent IDPs from elsewhere in Ethiopia has also suggested that youth may be forced to forego schooling in order to take on low paying jobs to help feed themselves and their families.⁶⁶ Rather than forms of resilience, such strategies must be recognised as unsustainable, and humanitarian response should aim to limit people’s need to resort to them.

Access to WASH services

Significant WASH needs. Access to sufficient and safe water is a basic right enshrined in Ethiopia’s constitution.⁴ Yet significant humanitarian WASH needs have been projected for 2022, with an estimated 16.2 million people identified as in need of assistance.⁷³ Provision of adequate WASH services at IDP sites across northern Ethiopia is critically important to prevent disease outbreaks and malnutrition.⁷⁴ Although partners of the WASH Rapid Response Mechanism have reached 1.4 million IDPs and host community members with water and sanitation services since June 2020,⁷⁵ WASH service remains insufficient in most IDP centers.⁷⁶

Limited gender sensitivity.  The response focus on rapid construction of water points and provision of water tanks has resulted in a lack of uniformity in addressing gender concerns in WASH infrastructure. Due to gender roles, women and girls must travel long distances to fetch water and must carefully ration it for cooking and cleaning purposes, especially during dry seasons. This puts them at risk of SGBV and limits their ability to engage in educational or other activities. Their needs around sanitation, such as the availability of menstrual hygiene kits, and privacy and safety during toilet use have been under-emphasised, particularly at the peak of the war.^77–79

Seasonality concerns. Both rainy and dry seasons pose challenges and risks for water and sanitation in IDP camps. During rains, grounds may become muddy, making it more difficult for people to navigate, especially children, the elderly and people with disabilities. WASH infrastructure and water quality may also be damaged or compromised. Disease risks for cholera, diarrhea and other illnesses may also be heightened in such conditions.⁸⁰

Supporting peace and resilience

While it is critical that emergency humanitarian needs of conflict-affected communities be met, it is also important that relevant responders contribute to peace-building efforts and to sustainable recovery and development. This should include sustained and increased investment in community-led conflict management and peacebuilding.⁸¹ A new civil society organisation (CSO) law in 2019 allowed both foreign and local CSOs to engage in governance and peace-building activities, and to leverage funds from abroad for these and other activities. However, risk remains that CSOs’ licenses could be revoked by the government if the latter perceives them to be engaging with organisations labelled as ‘terrorist’.

Peacebuilding efforts should be inclusive and intentional, engaging the voices of vulnerable groups and leveraging existing peace-building practices at the local level. This requires assessment of vulnerable social groups and opinion leaders in the community, and power mapping efforts to find ways to ensure all can participate and be heard. For example, in Afar region, clan leaders are influential when it comes to making community-level decisions, while women, young people and people with disabilities are often excluded. Cultural institutions and indigenous communication practices may also provide opportunities for engaging with specific groups. For example, a cultural tradition known as dagu – an oral, ritual form of communication and performance by members of the ethnic group – may be harnessed to support resilience.⁸² Other examples from Eastern Tigray region include Aa’dar (a form of oral poetry), Goila (song and dance) and proverbs.⁸³

It is also vital to finance and support local capacity to bolster post-conflict recovery of services, infrastructure and institutions in a sustainable way. This can enhance community resilience to what will likely be long-term effects of the conflict and overlapping crises. At woreda level, capacity enhancement activities can focus on the existing local civil servant workforce to support improvement not just of standard working procedures (including, for instance, capacity for rapid deployment of resources), but also for engaging with people and communities in inclusive ways. At kebele level, efforts should focus on strengthening both formal and informal community structures such as community-based organisations that can support local solutions.⁸⁴

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Acknowledgements

This brief has been written by Heran Abebe and Getachew Belaineh, with support from Tabitha Hrynick at the Institute of Development Studies. We also wish to acknowledge expert review from Ezana Amdework (Addis Ababa University), Kelemework Tafere (Mekelle University), and Yomif Worku (independent humanitarian advisor). Additional reviews were provided by Hayley MacGregor (Institute of Development Studies) and Leslie Jones (Anthrologica).

Contact

If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Olivia Tulloch ([email protected]).

The Social Science in Humanitarian Action is a partnership between the Institute of Development Studies, Anthrologica and the London School of Hygiene and Tropical Medicine. This work was supported by the UK Foreign, Commonwealth and Development Office and Wellcome Grant Number 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of IDS, Anthrologica or LSHTM.