Advancing Legislative and Policy Reforms on Sexual and Reproductive Health Ethiopia Research Brief September 2021 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health This brief was developed in partnership with the Ministry of Health of Ethiopia and the Global Financing Facility national multistakeholder platforms. It represents a review of Ethiopia’s current legislative framework and actions taken by the government and other entities to advance sexual and reproductive health. It does not reflect the opinions of the authors, including GFF secretariat staff and others who have contributed to the development of the brief. Also, it does not include policy recommendations based on the findings of the review. Rather, it is intended to provide a synthesized review of Ethiopia’s legal framework, including annexes with national legislation with brief legal analysis on specific restrictive provisions. The primary audience for this brief is the Global Financing Facility national multistakeholder platforms, Liaison Officers and Secretariat Focal Points, World Bank Task-Teams who are involved in operations. This brief may also be useful to a broader scope of partners working on the interlinkages between gender equality laws and improved health outcomes to empower women and girls. This work is a product of the Global Financing Facility Secretariat at The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, the governments they represent, or the Global Financing Facility’s Investors Group. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Cover page: Some of the beneficiaries who will be regular users of the daycare funded under Productive Safety Nets Program (PSNP) in Sire District, Arsi, Ethiopia. Photo: Binyam Teshome / World Bank © 2021 International Bank for Reconstruction and Development / The Global Financing Facility 1818 H Street NW. Washington DC 20433 Telephone: 202-473-1000 Website: www.globalfinancingfacility.org Any queries on rights and licenses, including subsidiary rights, should be addressed to: World Bank Publications The World Bank Group 1818 H Street NW, Washington, DC 20433, USA Fax: 202-522-2625 Email: pubrights@worldbank.org i ETHIOPIA ACKNOWLEDGMENTS This research brief was written and designed by Emelyne Calimoutou, Senior Policy and Legal Reforms Specialist, GFF. A special thanks goes to the Ministry of Health of Ethiopia and the Global Financing Facility national multistakeholder platforms for their extensive support. For additional information, contact ecalimoutou@worldbank.org and cnielsen@worldbank.org. Recommended citation for this research brief: Calimoutou, Emelyne. 2021. Advancing Legislative and Policy Reforms on Sexual and Reproductive Health in Ethiopia. Gender Equality, Laws, SRHR Series. Washington, DC: The Global Financing Facility and World Bank. This note is part of a broader series of research briefs studying the interlinkages between gender, laws, and sexual reproductive health. ii Advancing Legislative and Policy Reforms on Sexual and Reproductive Health CONTENTS KEY MESSAGES 1 INTRODUCTION 2 BACKGROUND AND CONTEXT 2 INTERNATIONAL AND REGIONAL LEGAL FRAMEWORKS 3 NATIONAL LEGAL FRAMEWORK 3 NATIONAL POLICY FRAMEWORK 7 NATIONAL INSTITUTIONAL FRAMEWORK 9 CONCLUSION 10 ANNEXES 12 iii ETHIOPIA KEY MESSAGES ▸ Sexual and reproductive health (SHR) are fundamental to the general health and well-being of adolescent girls and women and encompass multiple issues—including, but not limited to— access to sexual and reproductive health services as family planning, antenatal and postnatal care, prevention of sexual and gender-based violence, harmful practices, and the right to make decisions over one’s own body. ▸ Legislation and policy can play a role in creating barriers to SRH services, especially for adolescents.This series of briefs provides a comprehen­ sive review of key legal frameworks on SRH in Global Financing Facility (GFF) countries and highlights country-led actions to advance gender equality and SRH. ▸ The government of Ethiopia has made significant progress to improve access to SRH and tackle violence against women and girls. However, adolescent girls still experien­ ce certain legal restrictions in accessing family planning. These legal limitations drive health inequities. ▸ National and Technical Guideline for Family Planning Services (2020) and Safe abortion (2014) constitute an important initiative of the Ethiopian government for improving the quality of care in family planning services and safe abortion. Efforts to keep up to date, translate, facilitate access and raise awareness around these guidelines are fundamental to ensure its application by healthcare providers. 1 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health I. INTRODUCTION partners working on the interlinkages between gender equality, laws, and improved health The aim of this research brief: outcomes to empower women and girls. SRH has been identified as a priority within the reproduc­ tive, maternal, newborn, child and What is included in this brief: adoles­­cent health and nutrition (RMNCAH-N) This brief reviews laws and policies assessed continuum in all 36 current Global Financing against the following SRH: (1) access to Facility (GFF) coun­ tries. As a result, SRH has contraception; (2) access to safe abortion been prioriti­­ zed in every investment case to and maternal health services, including date. gynecology and obstetrical emergencies; (3) access to school for pregnant girls and This brief aims to provide a review of the comprehensive sexuality education; (4) interna­­­tio­nal, regional and national legal, prevention of child mar­ male riage and fe­ policy, and institutional frameworks on SRH genital mutilation;and (5) prevention of sexual in Ethiopia, with a focus on adoles­­ cent girls. and gender-based violence. This country It highlights current country-led ac­­­­ tions to brief was de­ loped in partnership with the ve­ advance legislative and policy re­ form­s on Ethiopia’s Minis­try of Health and the GFF natio­­ SRH (as defined by the Guttmacher & Lancet nal multistakeholder pla­ tforms. Commis­­­ sion) for adolescent girls and women of prio­­ rity popula­­tions across the country invest­­­­­ment cases. In addition, this brief II. BACKGROUND AND CONTEXT supports the operationalization of the GFF Road­ map for Advancing Gender Equa­ ty. li­ Ethiopia is the second most populous country in Africa, with health challenges resulting Who would read this brief: from limited number of health institutions, The primary audience for this brief is the GFF inefficient distribution of medical supplies national multistakeholder platforms, liaison and disparity between rural and urban areas, officers, GFF Secretariat focal points, and World due to severe under-funding of the health Bank task-teams involved in opera­ tions.This sector, make access to health-care services brief may also be useful to a bro­ader scope of very difficult (WHO, 2021). In this context and Table 1. Country-Led Actions to Advance Legislative Reforms and Policy Dialogue in Ethiopia Existing Restrictive Draft legal Policy Country- national provisions reform dialogue led legal initiated initiated actions framework Access to contraception 4 4 4 4 Access to safe abortion and maternal and health care 4 4 4 services Access to comprehensive sexuality education Access to school for pre­gnant girls Prevention of child marriage 4 Prevention of FGM 4 Prevention of sexual and 4 gender-based violence Source: Compiled by the author. 2 ETHIOPIA because of persisting social norms around grea­­ter impact (Starrs et al. 2018) as it will help childbearing, birth control, gender-based ckle the root cau­ ta­­ es of gender inequality s­ violence, women’s health in Ethiopia is at risk. and re­­ hape unequal power relations on s­­ Among the many sexual and reproductive SRH (Chandra-Mouli et al. 2018). Important health issues faced by adolescent girls and legal reforms benefit from being backed up women in Ethiopia due to gender inequality by enforce­ ment, including clear mandates, are sexual coercion, child marriage, female procedures, funding, and accountability genital mutilation, unintended pregnancies, mechanisms (Boydell et al. 2019). short interpregnancy,unsafe abortion, sexually transmitted infections (STIs). However, Ethiopia As shown in table 1, Ethiopia is currently had demonstrated significant progress in leading important actions to advance le­ sexual reproductive health outcomes over gisla­­­­ti­v­e and po­li­cy reforms and dialogue the past three decades. Ethiopia’s maternal to improve access to con­ cep­­ tra­ tion and mortality ratio has for instance been declining maternal health ser­vi­ces. with 1,030 in 2000 to 401 at deaths per 100,000 live births in 2017 (WHO, 2019). III. INTERNATIONAL AND REGIONAL Progress is not uniform across the region LEGAL FRAMEWORKS and population groups (Dessalegn et al. Ethiopia has ratified or acceded to the core 2020). Lack of education, unemployment, and international human rights treaties and is extreme poverty perpetuate the reproductive a party to the major regional human rights health problems faced by adolescent instruments that have relevance to protect girls and women. The current COVID-19 women and girls sexual and reproductive pandemic might exacer­­ bate even more these health (See Annexes for details about the vulnerabilities (Wen­ ham, Smith, and Morgan International and Regional Conventions). It is 2020). During the ear­ ly stages of the COVID-­ 19 worth noting that Ethiopia has not yet ratified outbreak, evidence emerge that es­ sential the Convention to Consent to Marriage, pro­ re­ ductive, maternal, newborn, child and Minimum Age for Marriage and Registration adolescent health (RMNCAH) servi­ ces were of Marriages (1962) and Ethiopia made also closing (Burki, Talha 2020), thus preventing several reservation upon ratification of the girls and women from acces­­ sing healthcare protocol to the African Charter on Human and and other so­ cial services for at least two full Peoples’ Rights on the Rights of Women in months from April to June 2020. Africa. Ethiopia has taken several steps to strengthen As shown in table 2, Ethiopia is par­ ty to key the legal protection of SRH for women and in­terna­tional and re­gional con­­ven­­tions that girls. This brief acknowledges progress pro­t­ect a­do­lescent girls and wo­­men’s rights constituting, the revised Federal Criminal to health and edu­ca­tion. By ra­­­tifying­ ­conven­­­­­­­­­­ Code (2005) and Regional Family Law (2000) t­­ions, member states commit to un­der­­taking supporting measures on different forms all appropria­­­­­­te le­gis­­la­tive, adminis­tra­tive, and of gender-based violence, including child other mea­­­­­­­­­su­­­­­­­res for the full realization of the marriage and female genital mutilation rights they con­­­tain. and liberalization of abortion. However, the implemen­ se laws remains a tation of the­­ challenge at the commu­ nity le­ vel, especially, IV. NATIONAL LEGAL FRAMEWORK tings (Oronje et al. in remote and rural set­­­­­­­ 2011). Ethiopia has pro­­gres­­­sively adopted legislative and po­li­cy fra­­me­­­works to pro­­­­­­tect a­dolescent Building a strong and resilient health system girls and women’s SRH to com­­ ply with its to pro­­­mo­te SRH and reduce gen­­­der inequality international and re­gional commit­­­­­­ments. would require repealing res­ trictive and However, some legisla­tions in­clude res­­­tric­­­­­ti­­­ve discrimi­­nato­­ry provisio­ns to impro­ve access to or discriminatory provisions pro­viding wo­­­­­­­­­men health care ser­ vices. By taking a gender lens and girls with a limited legal protection.­ to SRH, laws and policies are likely to have a 3 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health Table 2. International and Regional Legal Frameworks Conventions Ratification status Convention to Consent to Marriage, Minimum Age for Marriage and Registration Not ratified yet of Marriages (1962) International Covenant on Economic Social and Cultural Rights (1966) Ratified in 1993 International Covenant on Civil and Political Rights (1966) Ratified in 1993 International Convention on the Elimination of All Forms of Racial Discrimination Ratified in 1981 against Women (1979) Convention against Torture and Other Cruel, Inhuman or Degrading Treatment Ratified in 1994 or Punishment (1987) Convention on the Rights of the Child (1989) Ratified in 1991 Convention on the Rights of Persons with Disabilities (2008) Ratified in 2010 African Charter on Human and Peoples’ Rights (1981) Ratified in 1998 African Charter on the Rights and Welfare of the Child (1990) Ratified in 2002 The Protocol of the African Charter on Human and Peoples’ Rights on the Rights of Ratified in 2018 Women in Africa (2003) Source: Compiled by the author. *Accession has the same legal effect as ratification. Ethiopia comprises ten states, each with its 1. National Constitution own constitution. It worth noticing that in their content, most are similar, sometimes even The 1995 Federal Constitution of the Federal identical, to those of the federal constitution Democratic Republic of Ethiopia, which (Regassa et al. 2004). guarantees the rights of women and equality with men (art.25). It assures women of In addition, as shown in table 3, the Ethiopian equal rights with men in every sphere and Constitution promotes the right to equality emphasizes affirmative action to remedy the (art.25) and the rights of women, including past inequalities suffered by women. Having access to reproductive health services recognized the historical legacy of inequality (art.35). and discrimination of women, the Constitution stipulates the right to affirmative action for 2. National laws women in order to fight prevailing inequalities and level the field for equal participation of Several legislations have been recently women in political, social and economic life. adopted in Ethiopia to protect women and It also reiterates the rights of women to own girls’ sexual and reproductive health and and administer property as well as access to rights, the Revised Federal Criminal Code reproductive health services and incorporated (2005), the Revised Family Code (2000) and the protection of women from harmful Technical Guidelines for Safe Abortion (2014) traditional practices that has a consequence and Family Planning (2020). (See Annexes for of body and mental harm against women (art. details about national laws). 35). 4 ETHIOPIA Table 3. The Ethiopian Constitution (19) Article Provision 25 Right to Equality All persons are equal before the law and are entitled without any discrimination to the equal protection of the law. In this respect, the law shall guarantee to all persons equal and effective protection without discrimination on grounds of race, nation, nationality, or other social origin, colour, sex, language, religion, political or other opinion, property, birth or other status 35 Rights of Women 1. Women shall, in the enjoyment of rights and protections provided for by this Consti- tution, have equal rights with men. 2. Women have equal rights with men in marriage as prescribed by this Constitution. 3.The historical legacy of inequality and discrimina- tion suffered by women in Ethiopia taken into account, women, in order to remedy this legacy, are entitled to affirmative measures. The purpose of such measures shall be to provide special attention to women so as to enable them to compete and partici- pate on the basis of equality with men in political, social, and economic life as well as in public and private institutions. 4. The State shall enforce the right of women to eliminate the influences of harmful customs. Laws, customs, and practices that oppress or cause bodily or mental harm to women are prohibited. 5. a. Women have the right to ma- ternity leave with full pay. The duration of maternity leave shall be determined by law taking into account the nature of the work, the health of the mother, and the well-being of the child and family. b. Maternity leave may, in accordance with the provisions of law, include prenatal leave with full pay. 6. Women have the right to the full consultation in the formulation of national development policies, the designing and execution of proj- ects, and particularly in the case of projects affecting the interests of women. 7. Women have the right to acquire, administer, control, use and transfer property. In particular, they have equal rights with men with respect to the use, transfer, administration, and control of the land. They shall also enjoy equal treatment in the inheritance of property. 8. Women shall have a right to equality in employment, promotion, pay, and the trans- fer of pension entitlements. 9. To prevent harm arising from pregnancy and childbirth and in order to safeguard their health, women have the right of access to family plan- ning education, information, and capacity. Source: Compiled by the author. The Revised Federal Criminal Code (2005) services among this age-group. In 2006, criminalizes most forms of violence against the Ethiopian government made further women and girls including physical violence efforts to expand the provision of legal and within marriage or cohabitation (Article 564), safe abortion services by developing and Female Genital Mutilation (Articles 565-6), disseminating national guidelines for the trafficking women (Article 597), rape (Articles provision of abortion care. In Ethiopia, induced 620-28), prostitution/exploitation of another abortion was illegal, until 2004, and was only for financial gain (Article 634), and early permitted to save the pregnant woman from marriage (Article 648). In 2005, the abortion grave and permanent danger to life or health law was expanded to permit abortion in cases (Art. 534). Ethiopia changed its restrictive of rape, incest, and fetal impairment, to save abortion law to expand the grounds on which the life of the woman, if the woman has a a woman could legally obtain an abortion. physical or mental disability, or if she is under Safe abortion services are now freely available 18 years of age. Ethiopia is one of the few without justification for adolescents. Minors countries in Africa that explicitly acknowledges seeking abortions need neither parental the difficulties young pregnant women are consent nor any proof of age. The law also facing and the barriers to accessing abortion indicates that “the mere statement by 5 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health the woman is adequate to prove that her regions, some regional governments (for pregnancy is the result of rape or incest”. example, Afar and Somali) have not yet Prior to the revision of the law, the rape victim aligned their Regional Family Laws with the had to go through a long probation process revised Family Code. Harmonization of the in court and only if the court supported her family law at the regional level is among the case, would she be able to return to the clinic challenges identified to ensure the various to terminate the pregnancy. The clause in gender sensitive laws are being implemented. the present abortion law about the woman’s statement of rape or incest to qualify for Food, Medecine and Health Care abortion services allows for provision of timely Administration and Control Proclamation No. services. 661 (2009) defined the medecine legislation in Ethiopia. The objective is to safeguard The previous penal code of Ethiopia which was and protect the public health through adopted in 1960 has not specifically prohibited ensuring all medecines (produced locally FGM. However, there was a provision dealing and imported) that circulate in the market with the prohibition of torture and cutting of and used in the country are safe, effective the body parts of a human being. The 567 and consistently meet the acceptable of the Revised criminal code of Ethiopia quality standards. The sale and distribution specifically deal with bodily harm caused of contraceptives are governed by laws by harmful traditional practices by stating regulating pharmaceuticals in general. that “Whoever, apart from the circumstances Ethiopia does have a written national drug specified in this chapter, inflicts upon another policy upon which the Medicines Regulatory bodily injury or mental impairment through Proclamation 661/2009 is based. According a harmful traditional practice known for its to this proclamation, the Ethiopian The Food, inhumanity and ascertained to be harmful by Medicines and Healthcare Administration the medical profession, shall, according to the and Control Authority is mandated to execute circumstances of the case, be liable to one of the regulatory activities as per the council the penalties prescribed under the provisions“. of ministers regulation 189/2010. The legal The commission of such harm to a body of framework for pharmaceutical regulation of an individual is punishable from 3 months up Ethiopia was founded to fulfill all the medicines to 5 years depending on the circumstances regulatory functions potentially enabling to of the case. In cases where the harmful combat illegal, substandard and falsified traditional practice causes serious physical medicines and illegal establishments. he as well as other types of health injury, the Pharmacy and Laboratory Department under penal code makes it punishable with rigorous the then Ministry of Health was responsible imprisonment from 5 to 10 years. The Criminal for medicines regulation until June 1999 Code did not include a clear definition of all when a new regulation called the “Drug types of FGM practiced across Ethiopia and Administration and Control Proclamation criminalization of medicalized FGM or failure No. 176/1999” was promulgated on 29 June to specifically report FGM, whether it has taken 1999. DACA was re-structured as Food, place, is taking place or is planned. Medicine and Health Care Administration and Control Authority (EFMHACA) of Ethiopia by The Revised Family Code (2000) based on “Proclamation No. 661/2009” in 2010 bearing the principle of gender equality brought a additional responsibilities like regulation of major reform to the 1960 Family Law. While food, health care personnel and settings. the Family Law of 1969 had placed women The Penal Code sets the regulation of subordinate to men, and defined women’s information on contraception and penalizes roles as complementary, and supplementary, the advertisement of contraceptive methods: to men’s roles and aims. The new Family “Whosoever, (a) advertises or displays in Code established new standard for equality public, or sends to persons who did not solicit between women and men. This includes, for them or are not, by reason of their profession, instance that girls’ minimum age of marriage interested therein, contraceptive publications, was elevated from 15 to 18 years. Nevertheless, or contraceptive samples…is punishable with given the legal powers at the level of the fine or arrest not exceeding one month.” 6 6 ETHIOPIA Present government National Population Policy aims at increasing access to reproductive health care and at repealing laws that inhibit the distribution of contraceptives. The Family Health Department of the Ministry of Health is currently revising a plan for the widest possible distribution of contraceptives. It also worth noticing that there is no explicit laws or policies preventing adolescents from obtaining family planning or maternal/ child health services. But there is no clear @ John Rae/The Global Financing Facility recognition of their rights. update on comprehensive service integration, National Guideline for Family Planning addresses underserved and special segments (FP)Services (2020), has been released of the population, and ensuring full, free, and by the Ministry of Health (MOH) to guide informed choice. stakeholders, as well as to expand and ensure the quality of family planning services. In this Technical and Procedural Guidelines for guidelines, the MOH designated new outlets Safe Abortion Services (2014) was produced for family planning services in addition to the by the Ministry of Health. These guidelines preexisting facility-based and outreach family referenced gender equality and choice and planning services. This FP guideline has been international treaties on human rights and developed to fulfill the following objectives: women’s rights as well as national policies guide FP programmers and implementers at on women and children. It is meant to ensure government, nongovernment, and bilateral that all women obtain standard, consistent, and multilateral organizations, and at private- and safe termination of pregnancy services sector as well as charity and civic institutions; as permitted by the law. The first edition of the serve as a guide to all cadres of health care national technical and procedural guideline providers directly or indirectly involved in the for safe abortion services was issued in provision of FP services, including for pre- 2006 and a revised version of the guideline service and in-service training.; set standards was released in 2014. The technical and for FP programs and services; standardize procedural guideline has been a valuable various components of FP services at all levels. resource in guiding service organization and National Guideline for Family Planning Services service provision. It has also been a guide for in Ethiopia expand and improve the quality of ascertaining quality of care. The aim of this the FP services to be offered and is used as guideline is to ensure that women in Ethiopia a general directive and management tool. considering safe termination of pregnancy The users of this guideline are: policy makers, have access to services of high standard and health managers FP program coordinators quality. and managers at all levels, all cadres of health care providers and instructors at health This document is meant to ensure that training institutions FP researchers, monitors, women obtain standard, consistent, safe and evaluators Donors, other stakeholders, termination of pregnancy services regardless and implementers of FP programs in the of the level of care of the health institution or government, nongovernment, and private the qualification of the service provider. The sectors. The national family planning guideline guideline is for health managers, program recommends integrating FP counseling during coordinators and health care providers – antenatal care, delivery and post-natal care gynecologists, general practitioners, health services. The guideline includes the role of officers, nurse midwives, nurses and health the private sector, emerging family planning extension workers. It clarifies who can perform initiatives, socio-ecological model for social an abortion, previously, it was a board of three and behavioral change where life skill based physicians who had to approve the service, education is emphasized at the individual now one mid-level provider is enough, and level. In addition, the guideline provides an he/she does not have to be a doctor. The 7 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health guideline has also eased requirements about stakeholders under the leadership of the who could provide safe abortion. In the past, Ministry of Health and Regional Health it was the doctor’s job to carry out abortions, Bureaus. The roadmap clearly stipulated the but the guideline stipulates that mid-level major steps of the development process, providers (nurses, mid-wives, clinical officers) planning approach and methodology and could provide both medical and surgical communication strategy. It also clearly abortion. This guideline is implemented in all indicated the roles and responsibilities health institutions recognized and registered of all actors giving due emphasis for the by MOH. The guideline includes an explanation involvement of all relevant stakeholders, of the provisions related to abortion and in the including the private sector to ensure appendix a consent form for comprehensive commitment by all for the implementation of abortion care draft. the strategic plan by having a shared vision. Ethiopia has no laws or policies related to The National Health Care Quality Strategy retention of pregnant girls or adolescent (2016-2020) is focused on improving quality mothers in schools or access to sexuality across the spectrum of the health care system education. from prevention to palliative care, with special emphasis on the following five priority public V. NATIONAL POLICY FRAMEWORK health areas: maternal Neonatal and child health, specifically reducing maternal and Several policies and plans have recently neonatal mortality; malnutrition, especially been adopted to protect adolescent girls and the prevention and management of severe women’s sexual and reproductive health and acute malnutrition; communicable diseases, rights, foundations for this started with the particularly malaria, HIV, and TB; non National Population Policy of 1993. Ethiopian communicable diseases prevention and government has made this a priority by laying management, particularly diabetes, cancer, out a clear vi­ sion, strategy and actionable cardiovascular diseases, mental health, plan to improve health outcomes for women and chronic respiratory diseases; clinical and girls. and surgical services, particularly regarding timeliness of care. The national policy of 1. Health women is now under revision and is done with the first draft. The National Costed Roadmap to End Child Marriage and FGM/C (2020-2024) is an The National Health Policy (1993) states evidence-based costed plan which outlines its main objective as to ensure provision the key strategies, packages of interventions, of comprehensive and integrated primary and expected results, targets and milestones health care in a decentralized and equitable towards the elimination of child marriage and fashion. The major emphasis is on health FGM/C in Ethiopia. The National Roadmap promotion and on prevention, focusing on applies across all contexts in Ethiopia, communicable diseases, nutritional disorders, including in humanitarian and emergency and environmental health problems, without situations which may exacerbate risks of neglecting essential curative activities. child marriage and FGM/C for girls, reduce The policy states that maternal health and access to protective services, and have cross- child health deserve due consideration. border dimensions. The National Roadmap The National Health Policy emphasizes has passed through a rigorous process of intersectoral collaboration, particularly with critical reflection and consolidation building regard to family health and population on lessons from interventions to-date, and planning. National Health Policy (1993) aims existing evidence. “to give a comprehensive and integrated primary health care in a decentralized and The Health Sector Transformation Plan equitable fashion.” It emphasizes health (2019/2020) is the next five-year national promotion and prevention for communicable health sector strategic plan, guided by a diseases and nutritional conditions and roadmap prepared jointly with all relevant environmental health problems. It highlights 8 ETHIOPIA the need for increased attention to maternal environment to meet young people’s and child health. The National Population reproductive health needs. Policy’s overall objective is to harmonize the rate of population growth with economic 4. Gender development and thereby improve the welfare of the people. The National Policy on Ethiopian Women (1993, currently being updated) incorporates The National Population Policy (1993) the elimination of harmful traditional harmonises the rate of population growth practices as one of its core objectives. The with economic development as a means of policy emphasizes the importance of fighting improving people’s welfare. The policy’s eight against Harmful Traditional Practices (HTPs) targets directly or indirectly relate to family which have negative consequences on the planning, including reducing the total fertility wellbeing of women and girls. Accordingly, rate to 4.0 and increasing the prevalence of of the three major policy objectives, one contraceptive use to 44%, both by 2015. of them focused on harmful traditional practices and it reads: ‘To eliminate, step by 2. Sexual Reproductive, Maternal step, prejudices as well as customary and Newborn, Child and Adolescent other practices that are based on the idea Health and Family Planning of male supremacy.” For the realization of the policy objectives, it envisioned different The National Reproductive Health Strategy strategies such as ensuring the protection 2016-2020 seeks to garner multi-sectoral of the human rights of women, and ensuring action at community, health system and women’s right to easy access to basic health policy level to reduce unwanted pregnancies, care and the elimination of HTPs. Further, maternal and neonatal mortality and HIV the policy put in place an institutional infection; and to improve the reproductive mechanism with responsibilities allocated so health of young people. as to ensure the practical implementation of the policy at all levels and detailed accountability mechanisms to follow up on its 3. Adolescent implementation. The National Adolescents and Youth Health The National Action Plan for Gender Equality Strategy (2016-2020) seeks to provide (2010) aims at contributing towards the multi-sectoral support to every young Attainment of Equality between men and person living in Ethiopia with education women in social, political and economic and information that will lead to the development, and can specifically be used adoption of a healthy lifestyle physically, to monitor and evaluate government’s and psychologically, and socially.The strategy other stakeholders’ commitment to gender made a paradigm shift from SRH focus to a equality,promote gender budgeting, recognize comprehensive approach addressing the women’s contribution to development, build broader determinants of health for better SRH the capacity of civil servants who are mainly outcome. The formulation of this strategy is responsible for the implementation of the plan. informed by the findings of the comprehensive The goal of this 5-year National Action Plan and participatory situational analysis on for Gender Equality is to contribute towards adolescent and youth health in Ethiopia the attainment of equality between men and conducted in October and November of 2015. women, in social, political and economic development. The National Adolescent and Youth Reproductive Health Strategy (2007-2015) 5. Education seeks to empower young people through improved reproductive health by increasing National Girl’s Education Strategy (2010) access to quality reproductive health services, aims at increasing female benefit by giving increasing knowledge about reproductive special consideration to the effort of ensuring health issues, and creating an enabling provision of quality education and training, 9 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health their equal participation, competency and 1. Ministries effectiveness. Specific objectives of this strategy are among others to eliminate The Ministry of Health’s (MoH) mission is to gender imparity by promoting equal benefit reduce morbidity, mortality, and disability, and of girls in the programs established to provide to improve the health status of the Ethiopian quality education and training, ensure gender people through providing a comprehensive equity in the shortest possible time by giving package of preventive, promotive, due attention for competency development rehabilitative, and curative health services and effectiveness of female teachers and via a decentralized and democratized health learders. system in collaboration with all stakeholders. The Ministry’s overall goal for the cooperative 6. Gender-Based Violence agreement is to improve maternal health, reduce child mortality, and combat HIV/AIDS, The National Strategy and Action Plan on malaria, tuberculosis, and other diseases. Harmful Traditional Practices (HTP) against The Ministry of Health plays a pivotal role in Women and Children (2013) in Ethiopia creating and implementing policies. Currently, emerged from the existing national strategic the health sector hierachy is as follows: the framework, the Growth and Transformation Federal Ministry of Health (FMoH, Regional Plan (GTP), a five-year national plan aimed Health Bureaus ( RHBs), and Woreda or District to improve the country’s economic growth Health Offices. The MoH and the RHBs oversees from 2010-2015. This plan contained specific policies and provides technical support while targets for the reduction of child marriage, the Woreda Health offices are able to manage abduction and FGM as part of broader targets and ccordinate primary services. for gender and equity. The overall objective of the strategy is to institutionalize national, The Ministry of Women, Children and Youth regional and grassroots level mechanisms Affairs (MoWCYA) aims at monitoring, by creating an enabling environment for the facilitating and designing ways for prevention and elimination of all forms of HTPs, implementation of the National Women’s and to ensure multi-sectoral mechanisms Policy of 1993. Specific objectives include are available to support women and children fostering gender mainstreaming in all policies, through prevention, protection and provision/ programmes, projects and plans of the responsive services. Ministry, enhancing the participation of women employees in the organizational activities VI. NATIONAL INSTITUTIONAL and ensuring their rights in employment, FRAMEWORK training, decision making, conducting operational research and disseminate result Improving health outcomes for women pertaining to gender and health, ensuring and girls through legislative and policy re­ health statistics are disaggregated by sex forms in Ethiopia called for a multisectoral and monitor signs of gender gap, monitoring collaboration between ministries which have and evaluating the output and impact of a role to play in ensuring women’s quality policies and programmes in relation to ac­cess to sexual and reproductive health gender equity and equality; developing and services and tackling violence against women distribute gender mainstreaming guidelines, and girls. Ministries a ­ nd bodies listed below manuals and other technical tools; developing would be amongst the main counterparts for information education communication and a policy dialogue in SRH and gender equality public mobilization initiatives; expanding and for improved health outcomes in Ethiopia. The integrating networks. Ministry of Health and the Ministry of Youth, Sports, and Culture have served as platforms The Ministry of Education (MOE) oversees the to voice the reproductive health needs of teaching and learning process throughout the adolescent and government programs and country from elementary school education policies are beginning to prioritize adolescent to higher secondary school education. It reproductive health needs. regulates the general curriculum of public schools and also sets the precedent for 10 ETHIOPIA private schools. In addition, the ministry is VII. CONCLUSION the responsible for the Ethiopian National Exams. The department also has, in accord This brief is intended as a support for with Ethiopian law, the authority to regulate discussion and dialogue with governments all institutions of learning to a certain limited and country multi-stakeholder platforms. The extent. brief has outlined the key partners with whom to engage and the specific role they can The Ministry of Justice coordinates activities play. It has provided an overview of the legal involving international judicial assistance frameworks and policies in Ethiopia as well particularly with respect to criminal cases, by as analyzed the current ground for potential prioritizing and securing national interest, as national reforms in the intent of supporting a central authority, coordinating international the in-country dialogue to advance gender judicial legal assistance particularly of equality and SRH for improved health criminal matters related with foreign countries outcomes. and international organizations and thereby building the reliance of the ministry in the criminal justice administration system. But also, by concluding agreements in criminal, civil and commercial matters with selected foreign countries and international organizations making the country international judicial legal cooperation effective and efficient as possible, undertaking the country obligation created through bilateral and multilateral cooperation in a way that protects the interest of the country. Finally, to control crimes that need international cooperation, creating efficient relation with national justice organs and international actors and contributing its respective responsibility to ensure the protection of human rights and the country peace and security. The Ministry of Youth, Sport and Culture (MoYSC) enables youth to actively participate in national politics as well as the country’s democratic development. The Ministry has established specific policies to engage more youth in political processes. 2. National council Faith leaders and traditional leaders involved in awareness-raising campaigns can play a key role in contributing to shifting social norms, especially where they give up the practice of child marriage or FGM themselves and lead by example. They act as respected gate-keepers and should be engaged in education about the harmful effects of child marriage and FGM/C. 11 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health REFERENCES Boydell, Victoria, Marta Schaaf, Asha George, Derick W. Brinkerhoff, Sara Van Belle, and Rajat Khosla. 2019. “Building a Transformative Agenda for Accountability in SRHR: Lessons Learned from SRHR and Accountability Literatures.” Sexual and Reproductive Health Matters 27 (2): 64–75. https:// doi.org/10.1080/26410397.2019.1622357. Burki, Talha. 2020. “The Indirect Impact of COVID-19 on Women.” Lancet 20 (8): 904-5. https://doi. org/10.1016/S1473-3099(20)30568-5. Chandra-Mouli, Venkatraman, Marina Plesons, Sheena Hadi, Qadeer Baig, and Iliana Lang. 2018. “Building Support for Adolescent Sexuality and Reproductive Health Education and Responding to Resistance in Conservative Contexts: Cases From Pakistan.” Glob Health Sci Pract. 6 (1):128–36. https://doi.org/10.9745/GHSP-D-17-00285. Heymann, Jody, Jessica K. Levy, Bijetri Bose, Vanessa Ríos-Salas, Yehualashet Mekonen, Hema Swa- minathan, Negar Omidakhsh, Adva Gadoth, Kate Huh, Margaret E. Greene, and Gary L. Darm- stadt. 2019. “Improving Health with Programmatic, Legal, and Policy Approaches to Reduce Gen- der Inequality and Change Restrictive Gender Norms.” Lancet 393 (10190): 2522–34. https://doi. org/10.1016/S0140-6736(19)30656-7. Oronje, Rose, Joanna Crichton, Sally Theobald, Nana Oye Lithur, and Latifat Ibisomi 2011. “Opera- tionalising Sexual and Reproductive Health and Rights in Sub-Saharan Africa: Constraints, Di- lemmas and Strategies.” BMC Int Health Hum Rights 11 (Supp 3): S8. https://doi.org/10.1186/1472- 698X-11-S3-S8. Starrs, A. M., A. C. Ezeh, G. Barker, A. Basu, J. T. Bertrand, R. Blum, A. M. Coll-Seck, A. Grover, L. Laski, M. Roa, Z. A. Sathar, L. Say, G. I. Serour, S. Singh, K. Stenberg, M. Temmerman, A. Biddlecom, A. Popin- chalk, C. Summers, and L. S. Ashford. 2018. “Accelerate Progress—Sexual and Reproductive Health and Rights for All: Report of the Guttmacher-Lancet Commission.” Lancet 391 (10140): 2642–92. https://doi.org/10.1016/S0140-6736(18)30293-9. Wenham, Clare, Julia Smith, and Rosemary Morgan. 2020. “COVID-19: The Gendered Impacts of the Outbreak.” Lancet 395 (10227):846–48. https://doi.org/10.1016/S0140-6736(20)30526-2. 12 ETHIOPIA ANNEXES ANNEX 1: INTERNATIONAL AND REGIONAL CONVENTIONS International Covenant on Economic, Social and Cultural Rights commits its parties to work toward granting economic, social, and cultural rights, including the right to health, specifically “the highest attainable standard of physical and mental health”. International Covenant on civil and Political Rights commits its parties to respect the civil and political rights of individuals, including the right to physical integrity, in the form of the right to life and freedom from torture and slavery. International Convention on the Elimination of All Forms of Racial Discrimination against Women defines what constitutes discrimination against women and sets up an agenda for national action to end such discrimination including guarantees women equal rights in deciding “freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.” It also specifies that women’s right to education includes “access to specific educational information to help to ensure the health and well-being of families, including information and advice on family planning”. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment aims to prevent torture and other acts of cruel, inhuman, or degrading treatment or punishment around the world and the right. Convention on the Rights of the Child set out the civil, political, economic, social, health and cultural rights of children. Children’s rights includes their right to association with both parents, human identity as well as the basic needs for physical protection, food, universal state-paid education, health care, and criminal laws appropriate for the age and development of the child, equal protection of the child’s civil rights, and freedom from discrimination on the basis of the child’s race, gender, sexual orientation, gender identity, national origin, religion, disability, color, ethnicity, or other characteristics. Convention on the Rights of Persons with Disabilities promote, protect, and ensure the full enjoyment of human rights by persons with disabilities with provisions for the enjoyment of the highest attainable health without discrimination on the basis of disability, including providing on the same quality of care in the area of sexual and reproductive health as it does for other persons. Convention to Consent to Marriage, Minimum Age for Marriage and Registration of Marriages reaffirms the consensual nature of marriages, to require the establishment of a minimum age of marriage by law, and to ensure the registration of marriages. The Protocol of the African Charter on Human and Peoples’ Rights recognizes civil, political, economic, social and cultural rights of individual human beings, such as the right to respect for one’s inherent dignity as a human being, including freedom from slavery, the slave trade, torture, cruel, inhuman or degrading punishment and treatment and the right to enjoy the best attainable state of physical and mental health. African Charter on the Rights and Welfare of the Child defines the rights and responsibilities of a child and mandates protection of the girl child from harmful cultural practices such as child marriage. Protocol to the African Charter on Human and Peoples Rights on the Rights of Women in Africa guarantees extensive rights to African women and girls and includes progressive provisions 13 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health on harmful traditional practices, e.g. child marriage and female genital mutilation (FGM); reproductive health and rights and ending violence against women. ANNEX 2: NATIONAL LEGISLATIONS The Revised Family Code, 2000 Article 7. Age. (1) Neither a man nor a woman who has not attained the full age of eighteen years shall conclude marriage. (2) Notwithstanding the provisions of Sub-Article (1) of thi Article, the Minister of Justice may, on the application of the future spouses, or the parents or guardian of one of them for serious cause, grant dispensation of not more than two years. The Revised Criminal Code of Ethiopia, 2005 Abortion Article 545. - Principle. (1) The intentional termination of a pregnancy, at whatever stage or however effected, is punishable according to the following provisions, except as otherwise provided under Article 551. (2) The nature and extent of the punishment given for intentional abortion shall be determined according to whether it is procured by the pregnant woman herself or by another, and in the latter case according to whether or not the pregnant woman gave her consent. Article 546. - Abortion Procured by the Pregnant Woman. (1) A pregnant woman who intentionally procures her own abortion is punishable with simple imprisonment. (2) Any other person who procured for her the means of, or aids her in the abortion, shall be punishable as a principal criminal or an accomplice, with simple imprisonment. Article 547. - Abortion Procured by Another. (1) Whoever contrary to the law performs an abortion on another, or assists in the commission of the crime, is punishable with simple imprisonment. (2) Rigorous imprisonment shall be from three years to ten years, where the intervention was effected against the will of the pregnant woman, or where she was incapable of giving her consent, or where such consent was extorted by threat, coercion or deceit, or where she was incapable of realizing the significance of her actions. (3) A pregnant woman who consents to an act of abortion except as is otherwise permitted by law, is punishable with simple imprisonment. Article 548. - Aggravated Cases. Where abortion is performed apart from the circumstances provided by law the punishment shall be aggravated as follows: (1) in cases where the criminal has acted for gain, or made a profession of abortion (Art. 92), he is punishable with fine in addition to the penalties prescribed in Article 547 above; (2) in cases where the crime is committed by a person who has no proper medical profession, the punishment shall be simple imprisonment for not less than one year, and fine; (3) in cases where the crime is committed by a professional, in particular, by a doctor, pharmacist, midwife, or nurse practising his profession, the Court shall, in addition to simple imprisonment and fine, order prohibition of practice, either for a limited period, or, where the crime is repeatedly committed, for life (Art. 123). 14 ETHIOPIA Article 549. - Attempt to Procure an Abortion on a Non-Pregnant Woman. The general provisions relating to crimes impossible of completion (Art. 29) shall apply in the case of attempt to procure an abortion on a woman wrongly supposed to be pregnant. Article 550. - Extenuating Circumstances. Subject to the provision of Article 551 below, the Court shall mitigate the punishment under Article 180, where the pregnancy has been terminated on account of an extreme poverty. Article 551.-Cases where Terminating Pregnancy is Allowed by Law. (1) Termination of pregnancy by a recognized medical institution within the period permitted by the profession is not punishable where: a) the pregnancy is the result of rape or incest; or b) the continuance of the pregnancy endangers the life of the mother or the child or the health of the mother or where the birth of the child is a risk to the life or health of the mother; or c) where the child has an incurable and serious deformity; or d) where the pregnant woman, owing to a physical or mental deficiency she suffers from or her minority, is physically as well as mentally unfit to bring up the child. (2) In the case of grave and imminent danger which can be averted only by an immediate intervention, an act of terminating pregnancy in accordance with the provision of Article 75 of this Code is not punishable. Article 552.- Procedure of Terminating Pregnancy and the penalty of Violating the Procedure. (1) The Ministry of Health shall shortly issue a directive whereby pregnancy may be terminated under the conditions specified in Article 551 above, in a manner which does not affect the interest of pregnant women. (2) In the case of terminating pregnancy in accordance with sub article (1) (a) of Article 551 the mere statement by the woman is adequate to prove that her pregnancy is the result of rape or incest. (3) Any person who violated the directive mentioned in sub-article (1) above, is punishable with fine not exceeding one thousand Birr, or simple imprisonment not exceeding three months. Article 848.- Publicity relating to Abortion. Whoever, apart from the cases permitted by law, advertises or offers for sale means or product designed to cause abortion, or publicly offers his services to perform abortion, is punishable with fine or arrest. Female Genital Mutilation Article 565.- Female Circumcision. Whoever circumcises a woman of any age, is punishable with simple imprisonment for not less than three months, or fine not less than five hundred Birr. Article 566.- Infibulation of the Female Genitalia. (1) Whoever infibulates the genitalia of a woman, is punishable with rigorous imprisonment from three years to five years. (2) Where injury to body or health has resulted due to the act prescribed in sub-article (1) above, subject to the provision of the Criminal Code which provides for a more severe penalty, the punishment shall be rigorous imprisonment from five years to ten years. 15 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health Article 567.- Bodily Injuries Caused Through Other Harmful Traditional Practices. Whoever, apart from the circumstances specified in this Chapter, inflicts upon another bodily injury or mental impairment through a harmful traditional practice known for its inhumanity and ascertained to be harmful by the medical profession, shall, according to the circumstances of the case, be liable to one of the penalties prescribed under the provisions of Article 561 or Article 562 of this Code. Article 568.- Transmission of Disease Through Harmful Traditional Practices. Where the victim has contracted a communicable disease as a result of one of the harmful traditional practices specified in the above provisions, the penalties prescribed in this Code concerning the spread of communicable diseases shall apply concurrently. Article 569.- Participation in Harmful Traditional Practices. A parent or any other person who participates in the commission of one of the crimes specified in this Chapter, is punishable with simple imprisonment not exceeding three months, or fine not exceeding five hundred Birr. Article 570.- Incitement Against the Enforcement of Provisions Prohibiting Harmful Traditional Practices. Any person who publicly or otherwise incites or provokes another to disregard the provisions of this Code prohibiting harmful traditional practices, or organizes a movement to promote such end, or takes part in such a movement, or subscribes to its schemes, is punishable with simple imprisonment for not less than three months, or fine not less than five hundred Birr, or both. Child Marriage Article 648.- Early Marriage. Whoever concludes marriage with a minor apart from circumstances permitted by relevant Family Code is punishable with: a) rigorous imprisonment not exceeding three years, where the age of the victim is thirteen years or above; or b) rigorous imprisonment not exceeding seven years, where the age of the victim is below thirteen years. Food, Medicine and Health Care Administration and Control Proclamation No. 661/2009 4. Power and Duties of the Executive Organ The executive organ shall have the powers and duties to: 1/ prepare and submit to appropriate organ health regulatory standards for safety and quality of food, safety, efficacy, quality and proper use of medicines, competence and practice of health professionals, hygiene and environmental health, competence of health and controllable health related institutions; and upon approval ensure the implementation and observance of the same; 2/ issue, renew, suspend and revoke certificate of competence for specialized health institutions, food and medicine processing plants, quality control laboratories, bioequivalence centers, importers, exporters, storages and distributors and trans-regional health service institutions; 3/ initiate policies and legislation to strengthen the quality of food and medicines and the competence of health professionals and health institutions; and submit the same for government approval; 16 ETHIOPIA 4/ serve as medicine, food, health professionals and health and controllable health related institutions information center; 5/ identify ingredients that caused death or ill health due to medicine residue or adulteration of medicine and food and take appropriate measures by conducting investigation of sample ingredients; 6/ organize quality control laboratories as needed to carry out its duty; 7/ issue import and export permits for food, medicine, raw materials and packaging materials and undertake dead bodies control and give entry or exit permit; 8/ prepare pharmacopoeia for the country, structure the medicines included in the pharmacopoeia into different categories, revise the pharmacopoeia whenever necessary; 9/ evaluate and register medicines on the basis of registration requirements, and renew, suspend and revoke such registrations; 10/ undertake and coordinate post marketing surveillance in order to ensure the safety and quality of food and safety, efficacy and quality of medicines that are put into use and take appropriate measures; 11/ authorize conducting clinical trial, monitor the process as to its conduct in accordance with good medical procedure, evaluate the results and authorize the use of the result in such a way that it benefits the public; suspend or stop the clinical trial where necessary; 12/ monitor and control manufacture, import, export, distribution, prescribing, dispensing, use, recording and reporting of narcotic drugs, psychotropic substance and precursor chemicals, prevent their abuse and report the same to the International Narcotic Control Board; 13/ regulate the content, manufacture, import, export, distribution, sales, use, packaging and labeling, advertisement and promotion, and disposal of tobacco products; 14/ undertake inspection on planes entering the country to ensure the protection of health and control of communicable diseases and undertake fumigation and give certificate for planes departing the country; 15/ undertake control of communicable diseases at entry and exit port on international travelers and, where necessary, prohibit them from entry or exit or subject them to be quarantined; ensure that necessary preventive and control measures are taken in the case of outbreak of trans-regional communicable diseases; 16/ issue, renew, suspend and revoke license to insufficiently available health professionals, complementary and alternative medicine practitioners and health professionals coming privately or in group from abroad to deliver health service; 17/ ensure proper disposal of expired medicine and foods and their raw materials; 18/ ensure that handling and disposal of transregional solid and liquid wastes from different institutions are not harmful to public health; 19/ control illegal food, medicine and health services and take appropriate measures; 17 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health 20/ ensure that the quality of trans-regional water supply for the public is up to the standard; 21/ ensure the availability of necessary hygienic requirements in controllable health related institutions under the federal government; 22/ provide the necessary support to state regulatory bodies on food, medicine and healthcare with a view to harmonizing federal and regional regulatory system. National Guideline for Family Planning Services in Ethiopia, 2020 4. Guiding Principles This guideline considers the following guiding principles in designing FP programs and expanding access to quality family planning services: • Availability: Health care facilities, trained providers and contraceptive methods are available to ensure that individuals can exercise full choice from a range of contraceptive methods, including follow-up and removal services for implants and IUDs. • Accessibility: Health care facilities, trained providers and contraceptive methods are accessible—without physical, economic, socio-cultural or informational barriers. • Acceptability: Health care facilities, trained providers and contraceptive methods are respectful of medical ethics and individual preferences, are sensitive to gender and life cycle requirements and respect confidentiality. • Quality: Individuals have access to full range of quality contraceptive methods which are scientifically and medically appropriate, have access to clear and medically accurate information, and should get the service from technically competent provider at a well-equipped health facility that ensures client-provider interactions. • Empowerment: Individuals are empowered as principal actors and agents to make decisions about their reproductive lives, and can execute these decisions through access to contraceptive information, services and supplies. National Guideline for Family Planning Services in Ethiopia, 2019 MOH Page25 • Equity and non-discrimination: Individuals have the ability to access comprehensive contraceptive services free from discrimination, coercion and violence. FP services should not vary by non-medically indicated characteristics, such as age, geography, language, ethnicity, disability, HIV status, income, and marital or other status. • Informed choice: Individuals have the ability to access accurate, clear and readily understood information about a variety of contraceptive methods and their use. • Voice and participation: Individual beneficiaries have the ability to participate meaningfully in the design, provision, implementation, and evaluation of contraceptive services, programs and policies. 5. Family Planning Services 5.1. Definition of FP Family planning is defined as the ability of individuals or couples to anticipate and attain their desired number of children, and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. 5.2. Service eligibility Any person, male or female, who is sexually active and married is eligible for FP services, including information, education, and counseling. 5.3. Range of services and activities to be offered in FP The following services and activities offered at different levels of the national health care delivery system, in accordance with Tables 1 and 2: National Guideline for Family Planning Services in 18 ETHIOPIA Ethiopia, 2019 MOH Page26 • FP Counseling • Provision of contraceptive methods • Prevention, screening, and management for STIs, including HIV • Prevention and management of infertility • Counseling and linkage to other SRH services including for sexual dysfunction • Prevention, screening, and treatment for reproductive organ cancers focusing on breast and cervical cancer • Follow-up and referral • Supporting supervision and clinical mentorship • Record Keeping and reporting 5.3.1. FP counseling Counselling should be an interactive process between the service provider and client using the REDI counseling framework. The health care professional should provide adequate information to help the service user has informed and voluntary decision-making capacity to take the service. There should be no incentive or coercion to adopt FP practices or to use any particular method of contraception. Service providers should have basic counseling techniques to provide a balanced and updated counseling service. Family planning providers may encounter clients with additional needs, in which case the service providers need to be capacitated to link the client to other SRH and health services. Similarly, service providers working in different units across a health facility should be able to counsel clients for family planning service to avoid any missed opportunities. 5.3.2. Provision of contraceptive methods The contraceptive mix in Ethiopia consists of the following commodities and methods: • Fertility awareness–based methods, such as the standard day‘s method (SDM), rhythm (calendar) method, two-day method/or cervical mucus method, and sympto-thermal method • Lactational amenorrhea method (LAM) • Male and female condom • Emergency contraceptives • Progestin-only pill • Combined oral contraceptive pills • Injectable contraceptives • Implants • Intrauterine contraceptive device (IUCDs) • Bilateral tubal ligation (BTL) • Vasectomy • Others as approved by the Ethiopian Food and Drug Authority (EFDA) Specific medical eligibility criteria for each contraceptive method needs to follow the world health organization (WHO) fifth edition Medical Eligibility Criteria for contraceptive use (MEC 2015). The safety of each contraceptive method is determined by several considerations; primarily whether the contraceptive method creates risk to the clients, worsens an existing medical condition, or whether the medical circumstance makes the contraceptive method less effective. The safety of the method needs to be weighed along with the benefits of preventing unintended pregnancy. While respecting clients‘ rights and supporting full, free and informed choice, ensuring method- mix is central to quality FP services. 5.3.3. Prevention, screening and management of STIs and HIV/AIDS All clients should get information on STIs, including HIV. These diseases should be described clearly, using local terms, where they exist. Clients should be informed about the symptoms of STIs, the methods of prevention, how they are treated, and in the event of suspected diseases, offer STI/ HIV screening or refer to where clients can obtain examination and treatment. If a client is found 19 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health to have an STI, it should be managed according to the national guideline for the management of STIs, using the syndromic approach. Health care providers should strongly recommend dual protection to all clients suspected of STIs and HIV/AIDS. 5.3.4. Prevention and management of infertility The role of FP in the prevention of infertility is through the promotion of responsible sexual behavior, use of condoms (dual protection), STI counseling, screening and treatment when indicated. Health professionals should make clear that contraceptives do not cause infertility. Despite the presence of variations related to age and health status of the woman, most modern contraceptive methods do not cause a significant delay in the return to fertility. However, if a client presents with infertility, appropriate counseling and information on where to get services should be provided. 5.3.5. Counseling and linkage to other SRH services including sexual dysfunction Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. Health facilities mainly focus on providing access to reproductive health service. The focus towards creating access to sexual health including counseling for sexual dysfunctions, gender-based violence, and the prevention of sexually transmitted infections is usually overlooked. This guideline recommends that health facilities integrate sexual health into family planning services. Health care providers also need to identify and manage sexual problems and/or ensure referral where needed. 5.3.6. Prevention and screening for reproductive organ cancers FP offers a unique opportunity to screen for cervical cancer and teach the client to do self- examination for breast cancer. Where facilities exist, women should be encouraged to have an annual Pap smear or visual inspection of the cervix using acetoacetic acid (VIA) or Lugols Iodine Solution (VILI). Health workers should educate women and their families about reproductive organ cancers (ROCs) and the benefits of screening. Women found to have ROC should receive their treatment either in the same facility or be referred as urgently as possible. 5.3.7. Follow-up and Referral Ensuring follow up, referral and continuity of care is an important component of family planning services. 5.3.8. Clinical mentorship and supportive supervision Clinical mentorship is a system of practical training and consultation that fosters ongoing professional development to yield sustainable and high-quality clinical care outcomes. Clinical mentors need to be experienced, practicing clinicians in their own site, with strong teaching skills. Mentorship should be seen as part of the continuum of education required to create competent health care providers. It ensures that guidelines are being followed and clients‘ needs are being met. It should be encouraged, and the mentor should be seen as a team member who motivates staff and guarantees the rights of providers and clients. Supportive supervision is a facilitative approach that promotes mentorship and joint problem solving between supervisors and supervisees. Supportive supervision should be conducted periodically from a supervisor to supervisees to ensure the generation of quality data for evidence-based decisions and improved service quality across all levels. 5.3.9. Record Keeping and reporting All FP providers should maintain proper records on each client and on the distribution of contraceptives. Each service should be age and sex disaggregated and show service utilization by adolescent and youth communities. All service delivery outlets including public health facilities, non-governmental organizations (NGOs), higher institution and school clinics, workplace clinics, 20 ETHIOPIA and the private sector should document and report FP service provision to the nearest Ministry of Health structure. Pharmacies and drug venders on the other hand should record and report dispensed commodities. 6. Integration of FP and other Health services Service integration is an approach in which health care providers use opportunities to engage the client in addressing broader health and social needs beyond those promoting the initial health care encounter. In the case of family planning, it might be either using an internal referral mechanism (especially for long acting contraceptives) or direct provision of FP services depending on the context. Integration of FP with other RH and non-SRH service delivery units is cost-efficient and enables maximum utilization of health care services in one visit. 6.1. HIV Testing and Counseling (HTC) HTC services can be good entry points for FP services, and vice versa. Both HIV and unintended pregnancy are, in most cases, the consequences of unprotected sex. Integrating HTC and FP service delivery is cost-effective and enables maximum utilization of health care in one visit. Health care workers who provide services for people living with HIV should have basic knowledge and counseling skills to provide FP services. Facilities should also create the enabling environment to strengthen the integration of FP services. Women at high risk of acquiring HIV infection can generally use all methods of contraceptives. With minimum input, both types of providers can deliver services to clients seeking HTC and FP services in one stop. 6.2. Comprehensive abortion care A woman seeks safe abortion or post abortion care largely because of unintended pregnancy. Abortion and post abortion care may be the first encounter of a woman within the health system, so providers should utilize this opportunity to counsel and provide FP services to the woman or couple. The Technical and Procedural Guidelines for Safe Abortion Services in Ethiopia recommends that a woman should be provided with the choice of contraception immediately after abortion (MOH, 2014). Global evidence indicates that post abortion women accept family planning methods at a higher rate when the method is offered at the same time and location as abortion or post abortion care treatment prior to discharge from the facility. Therefore this guidance recommends that post abortion family planning counseling and services be provided to women seeking abortion or post abortion care services prior to being discharged from the treating facility. 6.3. Antenatal care, delivery care, and postpartum care Evidences suggest that there is high-unmet need for post-partum family planning in Ethiopia (Reference). Despite a high proportion of women being exposed to health providers when utilizing maternal health services, only a small proportion receive FP information during these interactions. Accordingly, this guideline advises integrating postpartum family planning (PPFP) into maternal, newborn, and child health services to increase the likelihood that every new mother will leave the clinic having made an informed choice about family planning. National Guideline for Family Planning Services in Ethiopia, 2019 MOH Page31 During antenatal care visits, providers should discuss the benefits of spacing between births, counsel on family size, post-partum family planning and exclusive breastfeeding along with having a skilled birth attendant. Similarly, during delivery and post-partum period, providers should support breast-feeding; introduce lactational amenorrhea method (LAM) and other immediate post-partum contraceptive options; injectable, implants, post-partum IUCD and others as per the MEC criteria 2015. 6.4. Child health, immunization, and other RH services Child health and immunization services create a good opportunity for the provision of FP information and counseling. Furthermore, programs that address harmful traditional practice (HTPs,) gender-based violence (GBV), prevention and management of infertility, screening for 21 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health Reproductive organ Cancer (ROC), life skill education and other RH services create opportunities for FP services. Hence, these services should be utilized to address issues related to FP. 6.5. Integration with other health services (inpatient and outpatients) It is true that the large majority of health facility users visit a facility for an outpatient clinical service. In 2017 in Ethiopia, more than 36 million clients visited outpatient departments out of which, more than 18 million were women visits. With a minimum input to health care providers in an outpatient department, integration of family planning services will provide an opportunity to expand access to quality FP service provision. Integration of services at OPD might be either using an internal referral mechanism (especially for long-acting contraceptives) or direct provision of FP services at OPD level (especially for short acting FP services) depending on the context. 6.6. School Health program Recognizing the more than 28 million adolescent and youth population that attend school, the ministry of health has started implementing a school health program in collaboration with the ministry of education. This school health program (SHP) aims to guide service providers and administrators at different levels of school to provide quality, standardized promotive, preventive, and curative health services to school students at the pre-primary, secondary and tertiary levels of National Guideline for Family Planning Services in Ethiopia, 2019 MOH Page32 education in a healthy environment. Sexual and reproductive health interventions including family planning services are components of the basic service packages. The health sector and partners working in the SRH area need to support capacity building, service provision and referral service to ensure access to quality SRH services including family planning10. 7. Family planning service delivery modalities Currently, estimations show that close to 100% of the Ethiopian population has potential health service coverage. All public health institutions in Ethiopia—rural and urban, hospitals, health centers, health posts; school clinics, workplace-based clinics, youth center clinics, private clinics and clinics owned by non-governmental organization shall provide FP services. FP services shall be delivered through the following service delivery modalities: • Facility-based services (private and public) • Social marketing through pharmacies, drug stores and rural drug venders • Outreach based community services • Mobile health team approaches • School health services • Workplace services • Social franchising 7.1. Family planning services by level of Health facility The provision of FP services is dependent upon the integration of services throughout the health care system, starting from the community level to specialized referral hospitals. In addition to outpatient clients, FP counseling and services should be made available to postpartum women, post abortion women, and individuals with special needs. All health workers providing FP services should have competency in clinical and counseling skills. Table 1 is a summary of the types of recommended services to be rendered and the types of providers who should be staffing the different levels of care. The skill level and task analysis by provider are summarized in Table 2. Technical and Procedural Guidelines for Safe Abortion Services , 2014 Aim of the guideline The revised guideline is working document on the techniques and procedures that must be observed in providing safe termination of pregnancy as permitted by the penal code of FDRE (May ,2005). The aim of this guideline is to ensure that women in Ethiopia considering safe termination of pregnancy have access to services of high standard and quality. The guideline 22 ETHIOPIA is meant to ensure that women obtain standard, consistent, safe termination of pregnancy services regardless of the level of care of the health institution or the qualification of the service provider. The guideline is for health managers, program coordinators and health care providers – Gynecologists, General Practitioners, health officers , IESO and nurse midwives, nurses and health extension workers. This guideline will be implemented in all health institutions recognized and registered by FMOH. Types of Abortion Services Abortion is the termination of pregnancy before fetal viability, which is conventionally taken to be less than 28 weeks from LNMP. If the LNMP is not known a birth weight of less than 1000gm is considered as an abortion. The abortion may occur either spontaneously or induced. Induced abortion can be safe or unsafe. There are two types of care related to termination of pregnancy. These are safe abortion care and postabortion care. all abortion care should be women centered. Women-centered abortion care is a comprehensive approach to providing abortion services that takes into account the various factors that influence a woman’s individual mental and physical health needs as well as her ability to access services and her personal circumstances and her ability to access services. Women-centered abortion care includes a range of medical and related health services that support women exercising their sexual and reproductive rights. Women-centered abortion services have three key elements. • Choice that includes the right to determine if and when to become pregnant, to continue or terminate a pregnancy, the right and opportunity to select between options, and having complete and accurate information. • Access, includes having termination of pregnancy service by trained competent providers with up-to-date clinical technologies, easy-to-reach services that are affordable and non- discriminatory. • Quality service, address respectful, confidential services tailored to the woman’s needs using accepted standards with appropriate referral procedures. • Safe Abortion care is a comprehensive termination of pregnancy that is offered to clients as permitted by the law • Postabortion care is a comprehensive service to treat women that present to a health care facility after abortion has occurred spontaneously or after attempted termination. Post abortion care has five essential elements. These are: • Community-service provider partnership involving the local community and actors like Health Development Army., in addition to the formal health personnel to address recognition of symptoms and signs of pregnancy complications, resource mobilization, social and economical issues at the community level. • Counseling where women are provided with accurate and complete information on RH issues including FP, VCT, gender-based violence and other concerns and queries. • Emergency treatment of incomplete abortions and its complications • Family Planning services based on free and informed choice as well as method- mix. • Linkage of the above services with other RH services including STD diagnosis and treatment, information on breast feeding, child nutrition and immunization, screening of reproductive tract cancers, etc. Several methods of termination of pregnancy are available now. Which method is best for individual client depends on the duration of pregnancy, the general health status 12 Revised Technical and procedural guidelines for safe abortion services in Ethiopia National Norms & Guidelines for Safe Abortion Services in Ethiopia second edition of the client, availability of method, distance from referral center, knowledge and skill of the provider, and level of care. 23 Advancing Legislative and Policy Reforms on Sexual and Reproductive Health Legal Provisions for safe abortion services Health workers involved in the care of women should be well aware of the provision of this guideline which is the official interpretation of the law on safe abortion services a outlined below. Knowledge of the law is essential so that providers not only know what is expected of them but can also inform and educate women and community at large. Article 551 of the penal code of the Federal Democratic Republic of Ethiopia allows termination of pregnancy under the following condition 1. Termination of pregnancy by a recognized medical institution within the period permitted by the profession is not punishable where: a. The pregnancy is a result of rape or incest ; or b. The continuation of the pregnancy endangers the life of the mother or the child or the health of the mother or where the birth of the child a risk to the life or health of the mother; or c. The fetus has an incurable and serious deformity ; or d. The pregnant woman , owing to a physical or mental deficiency she suffers from or her minority , is physically as well as mentally unfit to bring up the child . 2. In case of grave and imminent danger which can be averted by an immediate intervention , an act of terminating pregnancy in accordance with the provision of Article 75 of this code is not punishable Timing and place for terminating pregnancy 1. Termination of pregnancy as permitted by the law can be conducted in a public or private facility that fulfills the pre-set criteria. 2. A woman who is eligible for pregnancy termination should obtain the service within three working days. This time is used for counseling and diagnostic measures necessary for the procedure. 3. All public health facilities at the level of a health center and above and Private facilities starting primary clinics can perform termination of pregnancy as permitted by law article 551 for pregnancies less than 12 weeks of gestation from the last normal menstrual period. 4. Termination of pregnancy between 13-24 weeks should be performed in a primary , General or tertiary Hospital, MCH specialized center and MCH specialized hospitals as permitted by article 551. 5. Termination of pregnancy between 24-28 weeks should be done in a tertiary level of care as permitted by article 551. 6. Women who are eligible for pregnancy termination should have the necessary information to seek abortion care as early in pregnancy as possible. Implementation guide for article 551 1. Implementation guide for Article 551 sub article 1-A, Where the pregnancy is a result of rape or incest • Termination of pregnancy shall be carried out based upon the disclosure of the woman whether rape or incest has occurred. This fact will be noted in the medical record of the woman. • Women who request termination of pregnancy after rape and incest are not required to submit evidence of rape and incest and/or identify the offender in order to obtain an abortion services. 2. Implementation guide for Article 551 sub article 1B When the continuation of the pregnancy endangers the life of the mother or the child or the health of the mother or where the birth of the child is a risk to the life or health of the mother. • The provider should, in all good faith, follow the knowledge of standard medical indications that necessitate termination of pregnancy to save the life or health of the mother. • The woman should not necessarily be in a state of ill health at the time of requesting safe abortion services It is therefore the responsibility of the health provider in charge to assess the woman’s conditions and determine in good faith that the continuation of the pregnancy or the birth of the fetus poses a threat to her health or life. 14 Revised Technical and procedural 24 ETHIOPIA guidelines for safe abortion services in Ethiopia National Norms & Guidelines for Safe Abortion Services in Ethiopia second edition 3. Implementation guide for Article 551 sub article 1C When the fetus has an incurable and serious deformity • If the physician after conducting the necessary tests diagnoses a physical or genetic abnormality that is incurable, termination of pregnancy can be conducted. 4. Implementation guide for Article 551 sub article 1D When the pregnant woman, owing to a physical or mental deficiency she suffers from or her minority, is physically as well as mentally unfit to bring up the child: • The provider will use the stated age on the medical record for age determination to determine whether the person is under 18 or not. No additional proof is required. • A disabled person is one who has a condition called disability that interferes with his or her ability to perform one or more activities of everyday living. Disability can be broadly categorized as mental or physical. • The provider should assess if the woman is suffering from any form of mental or physical disability. 5. Implementation guide for Article 551-subarticle 2 In the case of grave and imminent danger, which can be averted only by an immediate intervention, an act of terminating pregnancy in accordance with the provisions of Article 75 of this Code is not punishable. 25 www.globalfinancingfacility.org @thegff