Population Action International : Ethiopia

Ethiopia

Overview

Historically dependent on U.S. population assistance, Ethiopia was hit hard by the gag rule restrictions. Ethiopia is one of the highest ranking countries in reproductive health risk worldwide with a maternal mortality rate of 1,800 per 100,000 deliveries; only 6 percent of births are attended by trained personnel, and 42 percent of pregnant Ethiopian women have anemia.

Two organizations that form the backbone of family planning service delivery in Ethiopia are the Family Guidance Association of Ethiopia (or FGAE, an affiliate of the International Planned Parenthood Federation, or IPPF) and Marie Stopes International Ethiopia (MSIE). Both refused to abide by the gag rule conditions in early 2002. As a result, FGAE lost 35 percent of its budget, while MSIE lost 10 percent. These funding losses forced both providers to scale back services and outreach efforts.

Although funding has been made up for somewhat by other donors (notably the Dutch government and private foundations), the loss of donated contraceptive supplies and technical support from the U.S. Agency for International Development (USAID) has left gaps that cannot be filled, as these aspects make U.S. family planning assistance particularly unique and effective.

Contraceptive Crisis Deepened

Ethiopian woman Ethiopia has long faced problems obtaining adequate contraceptive supplies. These problems are complex, and arise from a combination of logistical difficulties, government apathy, general supply shortages and an unprecedented growth in demand for contraception. Demographic Health Survey (DHS) statistics from 2000 reveal that while more than 80 percent of Ethiopian women know about contraception, only 8.1 percent use either modern or natural family planning methods. It is estimated that about 36 percent of married women have an unmet need for contraception. Against this backdrop, the gag rule has only worsened Ethiopia's contraceptive shortages by preventing U.S. contraceptive supplies from reaching two prominent family planning providers.

When the United States ended its supply of contraceptives to FGAE and MSIE (as a result of their refusal to abide by the gag rule conditions), the organizations turned to the government to bolster their supplies. Unfortunately, logistical difficulties faced by the Ministry of Health make it an unreliable source of contraceptive supplies. When supplies are available, the government gives preference to its own clinics, even though FGAE and MSIE are the population's preferred providers for long-term or permanent family planning methods. The contraceptive supply shortage has forced FGAE and MSIE to turn to social marketing agencies to purchase supplies, thus redirecting valuable financial resources from other essential family planning services.

Technical Assistance Lost

women reading The gag rule brought an end to U.S. technical support for FGAE and MSIE. U.S. family planning assistance has always been unique because it comes with high-quality technical assistance that includes training for NGO staff, as well as other support aimed at increasing the efficiency with which family planning funds are spent and improving the delivery of reproductive health services. Although other donors have stepped in to help FGAE and MSIE with funding, none of these new donors provide technical support. FGAE and MSIE staff can no longer receive U.S.-funded training, and for a while, both organizations were barred from attending NGO meetings that were funded by USAID. The loss of U.S. technical assistance has reduced the effectiveness of FGAE's and MSIE's service delivery; prevented them from keeping up to date on the latest developments in the field of reproductive health care; and weakened their advocacy efforts.

Community-Based Distribution Efforts Harmed

The gag rule forced both FGAE and MSIE to cut back on their unique community-based distribution (CBD) initiatives. These CBD programs ensure that community-based health staff can access isolated rural areas, providing basic family planning services, supplies and, increasingly, information about preventing HIV/AIDS, as well as referrals for counseling, testing and related services. As public health clinics are not geographically accessible to 45 percent of the Ethiopian population, community-based distribution programs are crucial in educating rural populations about HIV and in providing them with contraception. When CBD programs are scaled back, rural populations lose their only contact with the health care system.

HIV Prevention Hurt

HIV/AIDS is a looming crisis in Ethiopia, especially among youth and women. With a population of almost 74 million, the country's adult HIV-prevalence rate is 4.4 percent. The highest infection rates occur in those aged 15-24, and women in this age group have a prevalence rate three times greater than that of males.

While it is more important than ever to involve trusted reproductive health service providers, such as FGAE and MSIE, in the fight against HIV/AIDS, it seems the gag rule has been informally – and incorrectly – extended to U.S. HIV/AIDS assistance in Ethiopia. The misled belief that NGOs that refuse to abide by the gag rule conditions are ineligible for HIV/AIDS funds is currently widespread in the country.

For example, one well-known U.S.-based NGO wanted to include FGAE sites as part of an HIV/AIDS project, but declined to do so operating on the belief that FGAE's gag rule status rendered it ineligible for participation. This is an example of the gag rule's "chilling" effect. The confusion and fear surrounding the language of the gag rule restrictions allow it to be over-extended and misapplied, causing even more harm than necessary and preventing the creation of valuable partnerships between reproductive health NGOs, thereby weakening their ability to fight collectively against HIV/AIDS.

In May 2003, the United States introduced the President's Emergency Plan for AIDS Relief, or PEPFAR – a new five-year, $15 billion initiative to fight the HIV/AIDS pandemic. Ethiopia is a designated PEPFAR country and therefore will receive a significant increase in U.S. HIV/AIDS funding. These new funds come with certain restrictions, but are exempt from the Global Gag Rule. It remains to be seen, however, whether PEPFAR efforts will be negatively impacted by the gag rule or a similar chilling effect. In the meantime, additional guidelines need to be passed to clarify that the gag rule and PEPFAR funds are not related in any way, and that organizations that refuse to abide by the gag rule conditions are still eligible for PEPFAR funds.

NGOs Impeded in Advocacy for Policy Change

The Ethiopian Parliament voted in July 2004 to revise the Penal Code provisions on abortion after an extensive process of nationwide debate. As a result of the gag rule, USAID-funded NGOs were not able to participate in the debate leading to this legal change. Fortunately, other non-USAID-funded NGOs, such as the Ethiopian Society of Obstetricians and Gynecologists (ESOG) and the Ethiopian Women Lawyers Association (EWLA), were able to facilitate an informed public debate that increased support for adoption of the new law. While new provisions will allow abortion for additional circumstances, including threats to a woman's health, the gag rule still restricts NGOs that receive U.S. family planning assistance from providing counseling or referrals to these newly available services; it also prevents NGOs from supporting, even with non-U.S. funds, the Ethiopian government's efforts to provide women with access to life-saving, safe abortion care under the new law.

Conclusion

The Global Gag Rule has worsened an already fragile contraceptive supply and distribution system in Ethiopia. At a time when demand for modern methods of contraception is skyrocketing within the country, the loss of U.S. contraceptive supplies to Ethiopia's two major providers of family planning services has critically worsened the contraceptive shortage. Climbing HIV infection rates among young women, aged 15-24 in particular, emphasize that HIV/AIDS is a sexual and reproductive health issue that requires the involvement of the country's leading family planning and reproductive health organizations. Yet the gag rule has caused a withdrawal of funding, an end to the supply of contraceptives, and the removal of technical assistance from the major family planning organizations, thus impairing the ability of NGOs to provide comprehensive reproductive health care and HIV-prevention services to Ethiopian women, men and youth.

Case Study Sources

Save the Children, Report on: State of the World's Mothers, 2004.

USAID, Country Profile HIV/AIDS – Ethiopia, Dec. 2003.

A Closer Look Sources

United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: http://esa.un.org/unpp/ (accessed Oct. 28, 2004).

United Nations Population Division, Dept. of Economic & Social Affairs, World Contraceptive Use 2003 Wall Chart, ST/ESA/SER.A/227, 2004.

UNAIDS 2004 Report on the Global AIDS Epidemic 2004. Available at: http://www.unaids.org/bangkok2004/report_pdf.html (accessed Oct. 28, 2004).

United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: http://esa.un.org/unpp/ (accessed Oct. 28, 2004).

Center for Reproductive Rights, The World’s Abortion Laws, June 2004. Available at: http://www.reproductiverights.org/pub_fac_abortion_laws.html (accessed Oct. 28, 2004).