African countries are too often lumped together as one big composite of grave statistics and chronic epidemics. Because of this, it’s especially important that the global development and reproductive health communities recognize and amplify those success stories that can be told. Especially when these stories are designed and driven by local efforts.
Less than 20 years ago, contraceptive use in Ethiopia among married women of reproductive age was a measly 3 percent, and maternal mortality rates were among the highest in the world. Today, contraceptive use is at 29 percent, double that of just five years ago and higher now than the level of contraceptive use in Sub-Saharan Africa as a whole. It’s an exponential increase in record time. Maternal deaths have also dropped, and now occur at less than half the rate they were just a few decades ago.
“Government ownership is critical [for improving reproductive health],” says Dan Pellegrom, President of Pathfinder International, which has worked in the country since 1964.“ And Ethiopia’s government took ownership.” That ownership took the form of renewed commitment to women and girls, and creative collaborations with aid agencies to make long-acting contraceptive methods in particular more available. (Injectable contraceptives are by far the most popular method countrywide). A waiver of the 2007 import tax on contraceptives also increased the flow of supplies throughout the country.
It may or may not be a coincidence, but Ethiopia is one of the world’s largest recipients of humanitarian aid, which supports a range of sectors from health and agriculture to democracy building. This latter point deserves a caveat, since Human Rights Watch has been vocal in its accusation that the Ethiopian Government has co-opted donor funding as a tool to maintain the power of the ruling Ethiopian People’s Revolutionary Democratic Front (EPRDF). Investigations are still ongoing.
In 2003, the government rolled out a novel initiative, called the Health Extension Programme, in an effort to deliver basic health care to some of the farthest and most remote reaches of the country. This was crucial, since as 2009 data indicate, 84 percent of Ethiopians still live in rural areas. Through this program, more than 30,000 health extension workers are trained and posted at 15,000 rural village health offices around the country. Their ranks are drawn exclusively from women who come from the communities they serve (except for pastoralist areas, where men may be selected). These women, often without any formal education, are trained to deliver a range of care, including contraceptive counseling and provision.
It’s a simple but revolutionary concept, and it’s one that’s gaining a lot of traction. It’s essentially taking the power and knowledge to be healthy and giving it to women, and in turn giving those women the opportunity to improve the health of their communities. Call them health extension workers, midwives, or frontline workers, but they are uniquely positioned to reach women most in need because they are those women. Most already have the trust and the networks to deliver quality care, and can often provide care that is discrete, non-judgmental, and immediate in a way that doctors and nurses may not be able to.
This is crucial when it comes to contraceptive use, which is still considered taboo, especially for unmarried women and adolescents. Ethiopia’s Health Extension Programme is an impressive and workable model for affecting dual wins: empowering women at the community level as providers and educators, and reaching a dramatically larger scope of the population with essential health services.
Ethiopia is uniquely positioned to push the envelope on reproductive health and women’s rights, since its national policies are relatively progressive among African nations. Abortion is permitted to preserve the life and health of the woman, and under additional more nebulous circumstances such as age, and ability to care for a child. The constitution includes provisions that state: “Women shall have equal rights as men” and “Laws, customs, and practices that oppress or cause bodily or mental harm to women are prohibited.”
Yet as is often the case, laws on the books and visions proscribed in policies can be quite different than reality for many women. Overall progress on the use of contraception masks important variations around the country. In Addis Ababa, for instance, 63 percent of women use it, compared to less than 10 percent in the more remote Affar and Somali regions. Unsafe abortion is still a grave issue countrywide, and Ethiopia is still sprinting to meet Millennium Development Goal 5 by 2015, to improve maternal health and achieve universal access to reproductive health services.
Last year, the Guttmacher Institute laid it out clearly, insisting that Ethiopia “would save lives and money by improving contraceptive services.” The most compelling case for this will be the positive ripple effect that increased access to contraception has. Women are healthier, their children and their families are, they can work, they can contribute to their communities, and the list goes on. The preliminary report of Ethiopia’s 2011 DHS survey suggests just this. In a short amount of time, relative contraceptive use has skyrocketed, and infant, child, and maternal health have all improved. “These changes are already having an impact on women’s lives today. Our hope is that this will provide a continuing, positive trend for the women we serve, their families, and their communities,” says Tilahun Giday, Pathfinder International’s Ethiopia Country Representative.
Progress is undeniable. Yet in the face of overall unmet contraceptive need, and the magnitude of Ethiopia’s population (the second-most populous country in the continent), 29 percent of married women using modern contraception still falls short of acceptable. There is still a long way to go, and what rapid change must be sustained over the next ten years. Still, it’s important to celebrate these successes – in part because there are too few reproductive health success stories across Africa, and in part because this story might offer concrete clues and inspiration to other African countries seeking to do the same. Access to and use of contraception is an essential part of a healthier society, and Ethiopia right now is on the road to better health.