The Impact of the Global Gag Rule in Ethiopia

Publication date: 2005

THE IMPACT OF THE GLOBAL GAG RULE IN ETHIOPIA 2005 UPDATES BEYOND SEVERE FINANCIAL LOSSES, the gag rule has resulted in the loss of technical assistance and contraceptive donations to key NGOs in Ethiopia, worsening the country’s supply shortage. 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 mor- tality 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.1 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 United States Agency for International Development (USAID) has left gaps that cannot be filled, as these aspects make U.S. family planning assis- tance particularly unique and effective. A CLOSER LOOK Population: 74.2 million (by 2005)2 Percentage of women aged 15-49: 45.2%3 Contraceptive prevalence (natural and modern methods): 8.1%4 HIV prevalence in adults aged 15-49: 4.4%5 Average births per woman: 6.146 Percentage of population aged 24 or younger: 65.4%7 Life expectancy: 45.5 years8 Abortion policy: Initially, abortion was permitted to preserve physical health and to save a woman’s life. In 2004, the abortion law was slightly relaxed to allow for a greater number of exemptions, such as in the case of rape or incest.9 • Ethiopia’s pioneer family planning organizations have experienced significant budget cuts, which caused them to scale back services. • The country’s two major family planning organiza- tions have lost unique U.S. technical support and assistance, which hampers the effectiveness of their service delivery and reduces the efficiency with which family planning funds are spent. • Two urban health posts providing basic family plan- ning and health care were closed in 2001. • Vital community-based distribution (CBD) programs have been scaled back or abandoned altogether. In remote and underserved areas, CBD programs were often the only link to family planning services and HIV information and referrals. • A pre-existing contraceptive supply shortage has worsened as the country’s primary family planning organizations are no longer able to receive U.S.- donated supplies. KEY IMPACTS ON ETHIOPIA 2 1971 FGAE becomes affiliated to the International Planned Parenthood Federation. 1960 1970 1980 1964 The Family Guidance Association of Ethiopia is established. It is the first Ethiopian NGO to provide family planning services in the country. It also serves as the “government” provider of family planning services for several years, as the Ethiopian public sector has no such services of its own. A HISTORY OF FAMILY PLANNING SERVICES IN ETHIOPIA 3 2002: Ethiopia suffers a particularly harsh crisis in obtaining and distributing contraceptive supplies. 1990 2000 1996 MSIE begins receiving USAID funds amounting to US$50,000- $60,000 per year. 1990 Marie Stopes International Ethiopia is established. 1998 USAID funds (via Pathfinder) by this time account for 10 percent of FGAE’s annual budget (about US$250,000 per year). 2000 EngenderHealth begins working in Ethiopia with private funding to expand access to clinic-based contracep- tive services. 2001 The Mexico City Policy is reinstated. Marie Stopes International and the International Planned Parenthood Federation governing council refuse to abide by the gag rule conditions. EARLY 2002 Both FGAE and MSIE refuse to abide by the Global Gag Rule restric- tions and lose U.S. family planning assis- tance. FGAE loses the 10 percent of its budg- et funded by USAID, as well as a further 25 percent cut in support from International Planned Parenthood Federation – a loss of funding also brought about as a direct result of the gag rule. 2002-PRESENT Ethiopia suffers a particularly harsh crisis in obtaining and distrib- uting contraceptive supplies. 4 CONTRACEPTIVE CRISIS DEEPENED Ethiopia has long faced problems obtaining adequate contracep- tive supplies. These problems are complex, and arise from a com- bination of logistical difficulties, government apathy, general sup- ply shortages and an unprecedented growth in demand for con- traception. 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 contracep- tive shortages by preventing U.S. contraceptive supplies from reaching two promi- nent 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 contra- ceptive 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. The Global Gag Rule was reinstated by President George W. Bush on his first day in office in January 2001. Officially termed the Mexico City Policy, these restrictions mandate that no U.S. family planning assistance can be provided to foreign nongovernmental organizations (NGOs) that use funding from any other source to: perform abortions in cases other than a threat to the woman’s life, rape or incest; provide counseling and referral for abortion; or lobby to make abortion legal or more available in their country. Called the “gag” rule because it stifles free speech and public debate on abortion-related issues, the policy forces a cruel choice on foreign NGOs: accept U.S. assistance to provide essential health services – but with restrictions that may jeopardize the health of many patients – or reject the policy and lose vital U.S. funds, contraceptive supplies and technical assistance. Our continuing research shows the gag rule is eroding family planning and reproductive health services in develop- ing countries. There is no evidence that it has reduced the incidence of abortion globally. On the contrary, it impedes the very services that help women avoid unwanted pregnancy from the start. ABOUT THE GLOBAL GAG RULE “We are experiencing a national crisis in contraceptives here. The Global Gag Rule has come at the wrong time.” – the Country Director of an Ethiopian NGO 5 TECHNICAL ASSISTANCE LOST 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 deliv- ery 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 pop- ulation, 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. 6 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.10 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 inel- igible for participation. This is an example of the gag rule’s “chill- ing” 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 cre- ation 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 des- ignated 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 neg- atively 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. FGAE used to have “condom corners” in its clinics: boxes full of free condoms for anyone who needed them. Condoms were taken and these boxes were refilled on a regular basis. Due to funding and supply cuts following the Global Gag Rule reinstatement, this is no longer possible. Now, those who wish to be supplied with condoms need to sign up for them in advance to ensure that some are set aside upon arrival. Condoms also are no longer free; at the time of this writing, the cost is 50 cents (Ethiopian) for six condoms. The executive director of a family planning organization there says people are discouraged by these new requirements. STORIES FROM THE FIELD 7 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 lead- ing 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 addi- tional circumstances, including threats to a woman’s health, the gag rule still restricts NGOs that receive U.S. family planning assis- tance 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 con- traceptive supply and distribution system in Ethiopia. At a time when demand for modern methods of contracep- tion 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 con- traceptive 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 comprehen- sive reproductive health care and HIV-prevention services to Ethiopian women, men and youth. “The bad thing about the Global Gag Rule is not only the money – it’s the isolating factor that hurts more. The money can be replaced, but the reproductive health community needs to work in unity, and this is hampered by the Global Gag Rule. These working relationships cannot be easily replaced.” – the Executive Director of an Ethiopian family planning organization 8 SOURCES 1Save the Children, Report on: State of the World’s Mothers, 2004. 2United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: (accessed Oct. 28, 2004). 3Id. 4United Nations Population Division, Dept. of Economic & Social Affairs, World Contraceptive Use 2003 Wall Chart, ST/ESA/SER.A/227, 2004. 5UNAIDS 2004 Report on the Global AIDS Epidemic 2004. Available at: (accessed Oct. 28, 2004). 6United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: (accessed Oct. 28, 2004). 7United Nations Population Division, World Population Prospects, the 2002 Revision. Available at: (accessed Oct. 28, 2004). 8Id. 9Center for Reproductive Rights, The World’s Abortion Laws, June 2004. Available at: (accessed Oct. 28, 2004). 10USAID, Country Profile HIV/AIDS – Ethiopia, December 2003. Photo credits: © Wendy Turnbull/PAI (inside front cover and pgs. 2, 5, 8) © Jim Daniels (pg. 6) THE GLOBAL GAG RULE IMPACT PROJECT is a collaborative research effort led by Population Action International in partnership with Ipas, Planned Parenthood Federation of America, and the International Planned Parenthood Federation and with assistance in gathering the evidence of impact in the field from EngenderHealth and Pathfinder International. Recognizing the historic leadership role of the United States in supporting voluntary family planning and related health care internationally, the project's objective is to document the effects of the Global Gag Rule on the availability of life-saving family planning services, as well as efforts to address other major threats to public health, including HIV/AIDS and maternal deaths due to unsafe abortion. The project received its funding solely from private sources. The Global Gag Rule Impact Project gratefully acknowledges the research and writing of Wendy Turnbull and Dina Bogecho of Population Action International. • U.S. RESTRICTIONS ON INTERNATIONAL FAMILY PLANNING Printed on recycled paper with soy-based ink. February 2005. ISBN: 1-889735-26-4

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