Celebrating Our 10th Anniversary Special Edition Newsletter, Vol. 1, No. 2, September 2005

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1 Foreword In this special issue of Yebeteseb Mela, Pathfinder Ethiopia s quarterly newsletter, the articles and stories presented for your reading pleasure and information focus on women s issues. This is indeed relevant at this time when Pathfinder Ethiopia celebrates its tenth anniversary, for the bulk of its work over the last ten years, and that of Pathfinder International in its 23 country programs worldwide, center on the health of women, who are the pillars of family wellbeing and national development. Tilahun Giday, Country Representative, Pathfinder International/Ethiopia Celebrating Our 10th Anniversary Special Edition Newsletter, Vol. 1, No. 2, September 2005 Map of PI activity, 2005 The History of Pathfinder International in Ethiopia For nearly 50 years, Pathfinder International has been providing men, women and adolescents throughout the developing world with access to quality family planning information and services. Pathfinder s experience in Ethiopia echoes the success of its mission to support sustainable efforts to improve the quality of life of individuals and families throughout the developing world. Dr. Clarence Gamble, Founder Pathfinder has grown tremendously since it was founded in 1957 by Dr. Clarence Gamble. Its diverse and expansive portfolio now encompasses more than 500 employees in 23 countries. Pathfinder itself is not a service delivery organization; instead, its mission is carried out through the concerted and intensive efforts of local Implementing Partner Organizations (IPOs) that it supports in every country program. This is true in Ethiopia, where Pathfinder and its 45 partners have gained recognition for improving the health of families in underserved communities. Pathfinder s approach draws on its philosophy of working to enable local non-governmental organizations, communitybased organizations, faith-based organizations, and the private and public sectors to increase access to and utilization of quality Reproductive Health and Family Planning (RH/FP) services. This method has proven to be extremely effective, not only with regards to expanding access to services, but also in transferring the necessary know-how and skills that will sustain reproductive health services and program in each country for years to come. Pathfinder in Ethiopia Pathfinder began its work in Ethiopia during the reign of Emperor Haile Selassie. Prominent health officials and individuals were provided with the seed money, which led to the establishment of the Family Guidance Association of Ethiopia (FGAE) in FGAE has since become the local affiliate of International Planned Parenthood Federation. Pathfinder hoped to introduce family planning in Ethiopia as a way to combat high maternal and infant mortality rates. Despite the prevailing pro-natalist sentiments of government officials, religious leaders, and the community at large, the Emperor at the time had the foresight to permit the program, provided that it was not declared openly in order to avoid antagonizing traditionalist sentiment. These early efforts mark the beginning of Ethiopia s population program. FGAE s work in providing modern reproductive health and family planning services grew steadily over the next decade with the help of various donor agencies. Population programs, however, faced serious challenges during the socialist military regime that came into power in 1974, but despite the difficulties of the following seventeen years, FGAE persevered and is now one of the major providers of integrated reproductive health services in the country, as well as a leading advocate for policy initiatives. Thus Pathfinder s early efforts here bore fruit with the emergence of Ethiopia s first national independent RH organization. Pathfinder International Bole Kifle Ketema, Kebele 02 H. No. 2446, Addis Ababa, Ethiopia

2 Pathfinder International Ethiopia: Since 1995 First FGAE clinic at St. Paul Hospital (center building) Pathfinder s activity in Ethiopia was intensified with the emergence of democracy following the fall of the military regime in 1991, and the formulation of a progressive National Population Policy in the early years of this new government. Population activities in Ethiopia were reinvigorated in 1994 with financial support obtained from the United States Agency for International Development (USAID). Through its Africa Regional Office in Nairobi, Pathfinder immediately reestablished support to the local organization it helped found, FGAE. Under the title Bridging Family Planning Services in Ethiopia, an eighteen-month preparation for expanding Ethiopia s family planning activities was undertaken. This period resulted in the birth of another association: the Consortium of Family Planning Associations (COFAP), now known as Consortium of Reproductive Health Associations (CORHA). Building on the experiences of the previous years and in response to emerging local conditions, the next phase of the Ethiopian program took a more integrated approach to family planning and selected reproductive health services. The main objective was to offer a wider range of activities to complement its reproductive health and family planning (RH/FP) core, such as postabortion care (PAC) and women s empowerment. Through the mechanisms created for this partnership, STI/HIV/AIDS prevention interventions began, as well as maternal and child health (MCH) services and adolescent sexual and reproductive health activities. The marked success of early efforts led to the significant growth and development of Pathfinder-supported RH/FP activities in Ethiopia. In its current phase of development, Pathfinder is committed to improving Ethiopia s health indicators, while still focusing on the RH/FP needs of the community. Service delivery in the three USAID focus regions (Amhara, Oromia and SNNPR), along with limited services in Tigray, Benshangul Gumuz, and selected city administrations, is provided through both traditional and diverse alternative service delivery approaches, including community-based services, market-based services, depot holders, and peer educators. This diversification has been made possible through the involvement of a growing number of local implementing partners, now numbering more than 45, and an expanded community health network with over 7,000 CBRHAs and 1,400 clinics spread over 250 woredas, representing close to half the districts in the country. The mid-1990s were a busy time for Pathfinder in Ethiopia. In August 1995, ten years ago to date, Pathfinder established the Ethiopia country office in the nation s capital city, Addis Ababa. This reflected the organization s commitment to seriously addressing the country s growing need for FP services. Pathfinder embarked upon a multisectoral approach, working closely with government, non-governmental groups, and private sectors at the community, facility, and regional levels. During this time, significant advances were made to improve, strengthen and expand the availability of quality RH/FP services. Pathfinder worked to increase knowledge of and demand for services, while increasing the number and quality of family planning services, providers, and facilities, and securing the contraceptive supply. Community-based reproductive health agents (CBRHAs) were trained to counsel for and provide FP services at the grassroots level, while standards of practice and supervision methods for health professionals were revised and improved through development of training curricula and manuals. Recent grants from UNICEF and the Swedish International Development Agency (SIDA) complement and strengthen ongoing integrated RH/FP and HIV/AIDS efforts. Pathfinder Ethiopia will be expanding its woreda coverage in all four regions, increasing access to quality services and information on RH/FP and HIV/AIDS, and continuing with advocacy and community mobilizing efforts to promote women s rights and empowerment. By including diverse partner organizations on community and institutional levels, Pathfinder created a more supportive policy environment for FP service delivery, especially in the PI-E Staff presenting on Packard-funded women s most populous regions of Ethiopia, by involving religious and empowerment projects at the biannual grantee community leaders. The project also focused on improving meeting, 2005 the technical and management skills of the service providers to ensure their institutional strength and development. Pathfinder International 10th Anniversary Edition Newsletter Vol. 1, No.2,, September 2005

3 Winner of Best Practices Competition: ISAPSO Reaching out to vulnerable women with coffee and counseling Pathfinder International solicited accounts of best practices from our IPOs for this newsletter edition. The response was impressive, and our choice was difficult, given the wide range of program activities and many successes our partners have celebrated this CBRH agent and year. In order to help us narrow the ceremony attendees competition, we evaluated these accounts according to the following guidelines for identifying a Best Practice (from WHO s Implementing Best Practices Initiative): Methods and practices that have been proven effective as well as innovative they do not have to be universal in scope or application, and must offer valuable insight into successful approaches used in a given setting. Integrated Service for AIDS Prevention and Support Organization (ISAPSO) is an organization dedicated to creating awareness around reproductive health, HIV/AIDS, harmful traditional practices, and sanitation, as well as providing integrated RH/FP services and counseling through its CBRHAs. Pathfinder International Ethiopia has been supporting ISAPSO since 1999 with both USAID and SIDA funds, and currently works to support their activities in Addis Ababa, and Becho and Sedden Soro woredas in South West Shoa Zone of the Oromia Region. ISAPSO sent in a description of a certain project activity that well fits these criteria for Best Practices. One of ISAPSO s project areas is Addis Ababa s sub-city of Gulele, with a population of over 190,000 people with few economic prospects, characterized by a traditional, patriarchal society, low literacy, and high rates of fertility and maternal mortality. Most of the young women who live here travel each day to the steep, forested slopes of Entoto Hills on the city outskirts to gather large bundles of firewood, which they sell in the city for an average daily earning of 5-8 Birr (less than one US dollar.) They forage in groups as often as possible, as the forest can be a dangerous place for a single woman, and upon bundling their firewood, trudge the four hours down the hills back to the city. The usual doorto-door approach of ISAPSO s 56 CBRHAs was failing in Gulele, as these women spend upwards of 12 hours a day in the forest or market and were rarely at home. To address this challenge, the CBRHAs and project supervisors met in early 2004 to brainstorm and devised a new strategy. Agents would go to the fringe of the forest during the working day and persuade the women to take a break for a coffee ceremony, during which they would initiate discussions and provide integrated RH/FP services, counseling, and referrals. The coffee ceremony is an Ethiopian ritual traditionally serving as a forum for conflict resolution, consultation and entertainment. This proved a remarkably successful way to capture the women s attention, participation and time. While serving coffee and popcorn, the CBRHAs lead discussions on health and gender issues, and counsel the women on family planning and reproductive health, HIV prevention, harmful traditional practices (HTPs) such as early marriage and female genital mutilation (FGM), sanitation, and other health issues. They provide the women with oral contraceptives and condoms, and conduct role plays addressing the dangers of FGM, early marriage, and other risky behavior. Through the CBRHAs, the women receive referrals for voluntary counseling and testing (VCT) and STI treatment, and for maternal and child health care at the Shiromeda Health Center, which Pathfinder has provided with equipment and support for MCH services. Since April 2005 alone, over 1,000 women have taken up modern methods of family planning through the interventions of CBRHAs. The coffee ceremony has proved a more conducive environment for honest discussion and disclosure on these sensitive issues than the home, as the women feel supported within CBRH agents acting out a role play on FGM their peer group, and are more forthcoming than they would be under the supervision of their husbands or the observation of their children. It has the added benefit of providing these women with a well-deserved rest during the day, while encouraging peer support, mobile education, and open discourse on previously taboo topics. This project highlights the adaptive and communityresponsive nature of Pathfinder s partners and projects as they evolve to best meet the RH/FP needs of underserved populations in Ethiopia, and serves as a Best Practice within the context of reaching out to vulnerable women in underserved populations. Committed to Changing Lives and Saving Lives in Ethiopia since 1995

4 Male involvement: Men must be part of the Solution Poverty, HIV/AIDS, violence, struggling to feed and clothe children: these daily challenges for women also affect men, who are vulnerable and suffer from these burdens as well. Men are part of the problem as much as they are part of the solution: true change in women s and family dynamics cannot come about without male involvement, support, and understanding. Men who have access to and knowledge of quality reproductive health and family planning services are better able to protect themselves, their wives, their partners, and their children. They are more able to meet the demands of being a good husband, a good father, and a good role model, by embracing a healthy, productive lifestyle. By discussing and practicing family planning and by sharing responsibility for household matters, a man and a woman can build a strong partnership that leads to economic and social stability and success. However, in order to do this, both men and women must have access to reproductive health services and education, in ways that are comfortable and appropriate for their respective situations and needs. Men and women are different, and to some extent have different needs. However, everyone, man and woman, wants to have good health, healthy, educated children, a stable partnership, and a productive livelihood. Pathfinder works to support these values by ensuring access to reproductive health services and information. This is done through working with local partners to identify both men and women in the community who can Raise your hands if you practice family planning. educate and counsel friends, family, and neighbors, while modeling positive behavior. Pathfinder involves men as key players in our efforts to improve the health of underserved and rural populations in Ethiopia, at all levels. At the community level, male and female community health agents mobilize the community and help them access essential services. These include family planning, maternal and child health services, postabortion care, immunization, and adolescent reproductive health services. Agents educate both sexes, youth, teachers, and mothers and fathers on the dangers of harmful traditional practices such as female genital mutilation, marriage by abduction, and early marriage. At the district level, woreda advisory committees consisting of community leaders and representatives, both male and female, help design and implement health policies, reforms, and community health programs. Religious leaders have joined our cause, many of whom are male, and speak to their colleagues and congregations about the role of family planning and good reproductive health practices for the family and for the nation as a whole. Pathfinder works with male legislators, prosecutors and judges to recognize and enforce the new penal code guaranteeing women s rights in cases of rape, early marriage, and FGM. Religious leaders and community elders at a community meeting in Alaba district, SNNPR Pathfinder International 10th Anniversary Edition Newsletter Vol. 1, No.2,, September 2005

5 Restoring Life and Hope: Fistula repair In Ethiopia, progress in achieving meaningful change in the lives of women has been hampered by widespread poverty disproportionately affecting women, and religious/cultural practices and beliefs that subordinate women in society. Ethiopian women have a 1 in 14 chance of dying due to complications during childbirth, and suffer from one of Africa s highest maternal mortality rates. Despite many attempts to change people s attitudes and enforce the new legal age of marriage of 18, harmful traditional practices such as FGM and early marriage are still prevalent in Ethiopia. Many of these young women, should they survive, suffer permanent damage from childbirth as a result. A woman in Ethiopia is dead as soon as she is born. A workshop participant, Tigray. As part of its Women s Empowerment Project in Ethiopia, funded by the David and Lucile Packard Foundation and further supported by USAID and SIDA, Pathfinder and partners support women who suffer from fistula, a condition that occurs following a long obstructed labor and delivery. Fistulae usually afflict girls, who are given in marriage as young as six years old, and who become pregnant in their early teens, well before their bodies have developed to handle the demands of childbearing. Many of them die from obstetric complications due to youth and malnutrition. During the prolonged struggle to give birth through a too-narrow pelvic canal, the tissues separating the vaginal, urinal, and/or anal canals tear, leaving the woman without control over the flow of her bodily waste. Survivors are usually rejected and ostracised by their communities and families, and divorced by their husbands, due to the stigma of the condition. Lack of awareness and poor access to clinical care prevent many women from seeking medical help (some endure up to 10 years without treatment, unaware that there is any treatment available for their condition.) At the community level Once identified, fistula cases are referred for special care by one of Pathfinder s network of CBRHAs. They are referred to one of 3 hospitals in Ethiopia that are able to perform a simple surgery and counsel and restore the woman to good health. CBRHAs also publicize the availability of treatment, in encourage women to discuss their condition and receive referrals for treatment. The agents take preventive measures by ensuring that all girls considered for marriage in their vicinities are of legal age and approved by the appropriate kebele committees. This activity has proven very effective, with over 9,000 scheduled marriages cancelled in Amhara region this year alone, through the intervention of CBRHAs, women s associations, and kebele Early Marriage committees. Smiling women recovering from fistula repair, awaiting discharge at Bahirdar Hospital Justice, to discourage early marriage. Prosecutors, judges, and woreda authorities attend workshops about the dangerous medical and psychological consequences of early marriage and other harmful practices. They are encouraged to enforce the penal code forbidding early marriage and FGM, and to advocate for women s and girls basic and reproductive health rights. Advocacy sessions for legislators, regional assemblies, and religious leaders are held sensitize these influential figures on the dangers of HTPs, especially early marriage and FGC. Traditional and religious leaders exercise enormous influence over popular opinion. Through training and workshops, many leaders have gained new awareness of the harmful and crippling impacts of traditional practices like early childbearing an awareness they become committed to passing on to their communities in an effort to eradicate these practices. Keeping young girls in school is a key preventive measure against early marriage that promotes increased independence, economic opportunity, and self-confidence. Pathfindersponsored scholarships and girl s clubs keep girls in school and promote leadership and life skills, including reproductive health and family planning education. In the future, Pathfinder expects to be able to provide victims of fistula with rehabilitation services, including counselling, training, and seed money to develop income-generating skills and achieve financial independence. Our nationwide work in promoting family planning is another essential preventative measure, ensuring that a woman s health and development is given time to prepare for childbirth and to recover afterwards. Pathfinder s intended expansions of other integrated services, especially postabortion care, ante- and postnatal care, and safe delivery, is also anticipated to play a decisive role in the overall improvement of women s health practices, lives and status. At the national level To prevent fistula and its subsequent suffering, Pathfinder works with many organizations, including the Ministry of Committed to Changing Lives and Saving Lives in Ethiopia since 1995

6 Earning health, Wealth, and Independence: Income Generation for Women Pathfinder International helps partners such as the Addis Ababa Women s Association (AAWA) implement small-scale business programs that integrate reproductive health and business management, improving women s self-reliance, health, and opportunities, paving the way for a brighter future. Wozero Tenaye Mekonnen (above making injera), mother of 2 daughters and owner of a successful smallscale business, was not always the smiling, lively and confident woman she is today. Three years ago she was an employee of a glass factory near her house. Her job involved carrying heavy loads of glass, earning her no more than 4 birr per day. She would return home late in the evening to pick up her daughters from the neighbours, and even though very tired from the day s work, start preparing dinner for her husband, who would be shortly returning home from work. Such used to be a typical day in Tenaye s life until 2003, when Tenaye was forced to seek a better alternative to her meagre wages after her husband was injured in an accident at work. Tenaye attempted to take loans out from t eff merchants to commercially prepare and sell injera, but was struggling to sustain her business and the family s future grew bleak. In 2004, Tenaye was selected by AAWA as a vulnerable woman to benefit from their small-scale business training and support program. In February, after attending training on business management which also included an RH/FP awareness and skills workshop, she received a seed loan of 2000 birr and began her injera business again, but this time, with the necessary skills, follow-up support, and preparation. Now, she bakes up to 150 pieces of injera per day with the help of her daughter and her niece. I had to get extra help once the business picked up and I was required to Today, Tenaye also hosts 15 regular customers for breakfast and lunch every day, offering up freshly-baked bread, tea, and coffee. bake more. My niece used to work as a maid in people s houses, but now she stays with us and I pay her 50 birr every month. Her daugher is in high school and wants to study biology. With the infusion of new income, a purchase of 30 chickens set up Tenaye s husband, Ato Minyichil, in the poultry business. Supported by his wife s help and advice, he is learning how to run a solid business. Evenings find them jointly reviewing the day s income and expenses from both businesses. Though neither is formally schooled, Tenaye says they both do the sums in their heads. She remarks that they have had no misunderstandings so far because they trust each other and they always consult one another before deciding on anything. Actually, Minyichil adds, I would like to tell all husbands that they need to openly communicate with their spouses and involve them in making all decisions. Since the start of her business, Tenaye says that her life has improved dramatically. Besides the full chicken coup next to the house, the extra kitchen built for baking injera, and the amenities that she has added to her home such as a telephone line and water pipe, she has also found free time to visit her neighbours. With Pathfinder International 10th Anniversary Edition Newsletter Vol. 1, No.2,, September 2005

7 E arning health, Wealth, and Independence: them she shares the life skills she has learnt through her training about the value of family planning and good reproductive health practices. By word and example, she demonstrates just how important limiting family size is to attaining a better living standard, both for women and their families. Tenaye wants to teach her daughters all that she has learned from the trainings, so that they too can live better lives. She hopes to set an example of how far a woman can go if she takes care of herself and is determined. I may be uneducated but I think I have a lot to contribute. With their education and encouragement from us, both of my children can do very well. Income Generation for Women and the crucial role that they can play. She says men need to understand that women can make better use of their time by getting educated rather than staying at home. Some men still don t allow their women to leave their houses, let alone attend meetings that may empower them. When I first started attending these training sessions people used to go to my husband and ask him how he could allow me to leave the house locked up and the children with the neighbours. But I have a husband who also wanted to learn from the lessons that I received. Most women aren t that lucky. When I was a full-time employee, I was always short of money and time, but ever since I started working for myself I have enough of both. Tenaye embodies the unmistakable message that smallscale business training and support allow women to gain independence, success and confidence. None of this is possible without a sincere commitment to limiting family size and pregnancies, as frequent childbearing not only threatens the woman s health and wellbeing but also severely depletes the family s resources and available time to run their businesses. Empowered women are able to contribute well to their own lives and their families by prioritizing the need to provide well for their children over the need to have more of them. Tenaye and Minyichil in their new chicken coop Minyichil admits that had it not been for her acquired skills and determination, the family would not be enjoying the life they are now. Women do have the capacity to help and contribute [to family wellbeing] as long as they are encouraged to do so, he says, and I would advise all husbands to encourage their wives as much as possible. Tenaye believes that in order for organizations like AAWA to better reach women and help them change their lives, they also ought to work on educating men The couple outside their home in Gulele sub-city, Addis Ababa This story contributed with the help of Mussie Yasin, Project Coordinator, Addis Ababa Women s Association, Addis Ababa. Committed to Changing Lives and Saving Lives in Ethiopia since 1995

8 L ooking Ahead: Pathfinder s Future in Ethiopia For more than 10 years, Pathfinder International s Ethiopia office has been fruitfully investing resources and effort in building partnerships with 45 indigenous NGOs and other organizations and 126 private forprofit clinics, thereby successfully establishing an influential and lasting presence at the community level. Each year, Pathfinder s achievements have surpassed expectations in expanding access to quality reproductive health and family planning services for underserved communities, through both traditional and alternative service-delivery approaches, from public health clinics to the marketplace. Pathfinder leads the way in addressing Ethiopia s most pressing health challenges. It is uniquely situated to respond effectively to community concerns and needs through its extensive Community-Based Reproductive Health Agents and mobilized Woreda Advisory Committees, active in almost half the country. Within its current funding agenda, which will last until September 2007, Pathfinder has added a number of interrelated projects to its portfolio to create an enabling environment for RH/FP services at all levels of existing health structures with both government and non-government partners. Grants from SIDA have enabled expansion of HIV/ AIDS services such as orphan and vulnerable children and nutritional support, community home-based care and VCT. Packard funds help implement gender activities which include income generating activities and advocacy against HTPs throughout Ethiopia. Comprehensive projects, tailored through community input and participation, implement high-impact maternal and child survival activities, as well as promoting proper infant feeding and nutrition, environmental sanitation, and immunizations. Furthering reduction of maternal mortality, Pathfinder supports PAC programs, an essential step in reducing a leading cause of maternal deaths from unsafe or spontaneous abortion. Facilities are provided with technical assistance, training and equipment to improve their capacity in PAC. Successful results during the reporting period reveal widespread demand for these services, which Pathfinder will continue to address. Addressing gender inequality and harmful traditional practices is another major step in developing a healthy nation of women, men and youth who have control over their livelihoods and health. Pathfinder incorporates genderspecific messages and counseling in all of its trainings, and advocates for increased women s equality and independence on a national level, while supporting interventions in eradicating early marriage, FGM, gender-based violence, and promoting income-generating activities for women at the community level. In light of our renewed commitment to improving gender equality, Pathfinder s own personnel and recruitment policies were revised according to a new gender policy, Pathfinder International Ethiopia Staff, September 2005 and women now occupy 30 percent of PI-E s professional positions. Information, education and behavior change communication (IE/BCC) are major forces in changing community attitudes and improving health practices. Pathfinder collaborates with Johns Hopkins University s Communication Center Program to assess and improve existing IE/BCC approaches, as well as overall communication capacity of implementing partners and stakeholders. Pathfinder will continue building the capacity of its partners through training, sharing experiences, developing guidelines, and establishing an innovative community feedback system, which has already been successfully piloted in 16 districts. Pathfinder Ethiopia intends to continue taking the lead in building well-founded collaborations between the newly established Health Extension Program of the government of Ethiopia and its community-based RH/FP services, HIV/AIDS activities, and work with vulnerable groups. This partnership will ensure reliable and quality integrated health services at the community level. As Pathfinder continues to make a difference in health services for underserved communities in Ethiopia, it wishes to express gratitude to its donors, USAID, Packard Foundation, SIDA and UNICEF, and collaborators for their generous and ongoing support and guidance. The David and Lucile Packard Foundation Sida Swedish International Development Agency Pathfinder International 10th Anniversary Edition Newsletter Vol. 1, No.2,, September 2005