The POLICY Project

Justine Tantchou Ellen Wilson

Post-Cairo Reproductive Health Policies and Programs: A Study of Five Francophone African Countries

August 2000 Photo Credits All photos are printed with permission from the JHU/Center for Communication Programs. Post-CairoPost-Cairo ReproductiveReproductive HealthHealth PoliciesPolicies andand Programs:Programs: AA StudyStudy ofof FiveFive FrancophoneFrancophone AfricanAfrican CountriesCountries

IntroductionIntroduction situation regarding reproductive health. In addition, given that all respondents are Since the ICPD in 1994, reproductive prominent in the reproductive health field, health has been a focus of health programs their perspectives actually influence the worldwide. Many countries have worked development of policies and programs in to revise reproductive health policy in their respective countries. accordance with the ICPD Programme of In each country, two to three members Action. In 1997, POLICY conducted case of the Reproductive Health Research studies in eight countries—Bangladesh, Committee—the country’s local branch of Ghana, India, Jamaica, Jordan, Nepal, RESAR—conducted the study. Research Peru, and Senegal—to examine field teams included at least one medical experiences in developing and specialist and one social science specialist. implementing reproductive health policies. The team carried out the fieldwork for the In 1998, RESAR conducted similar case case studies between October and studies in five Francophone African countries—Benin, Burkina Faso, Cameroon, Côte d’Ivoire, and Mali.

RESAR’s purpose in conducting the studies was not to provide quantitative measurements of reproductive health indicators or an exhaustive inventory of reproductive health laws and policies but to improve understanding of reproductive health policy formulation and implementation. The study was qualitative, drawing on the perspectives of key informants—individuals who play an important role in formulating and implementing reproductive health policies and plans. The divergent perspectives show that the issues are often more Case Study Countries: Benin complex than they appear in a written Burkina Faso policy. Together, the different points of Cameroon view provide a clearer picture of the Côte d’Ivoire Mali 1 December 1998, by interviewing 25 to 29 implementation of services; national and key informants in each country in the international funding of reproductive fields of population and reproductive health activities; and remaining challenges health. Informants were selected from to reproductive health policy and program ministries, universities, NGOs, women’s implementation. Interviews focused on the groups, the private sector, donors, U.S. sections of the guide for which the technical assistance organizations, service respondent had knowledge and expertise. providers, and parliaments. The interview Interviews were recorded and transcribed guide covered the following topics: the for analysis. definition of reproductive health; reproductive health priorities and policy The content of the case studies, which formulation; structures responsible for is based primarily on expert opinions and policy development (including the level of various documents, reflects the situation at participation of various groups); support the time of the interviews. Since then, all for and opposition to reproductive health; the countries have continued to make the role of NGOs and the private sector; progress in implementation.

2 ReproductiveReproductive HealthHealth ContextContext inin thethe FiveFive CountriesCountries

The geographic, demographic, (ranging from 77 in Cameroon to 123 in economic, and social contexts vary among Mali), and the average maternal mortality the five countries. Total population size rate is 550 per 100,000 live births. Illegal, ranges from 6 million in Benin to more induced abortions and resulting than 15 million in Côte d’Ivoire (see Table complications contribute to an average of 1). In all five countries, the population is 25 percent of maternal deaths. The predominately young (nearly 50 percent proportion of women who take advantage under 15 years of age) and rural. Women of prenatal health care is low, particularly of childbearing age represent about 25 in Mali and Burkina Faso, and the percent of the population. Gross national proportion of women who give birth product (GNP) per capita is low, and without the assistance of a health care poverty affects the majority of the professional is high in all five countries, population. contributing to the high maternal mortality rate. The contraceptive prevalence rate for According to the Demographic and modern methods remains at or below Health Surveys (DHS) conducted between 7 percent, with significant disparities 1991 and 1998, the various reproductive between urban areas (12–20%) and rural health indicators shown in Table 1 remain areas (4–7%) even amid efforts undertaken poor despite efforts of the last 20 years. The by governments and NGOs. The rate of HIV table shows that the total fertility rate is infection among the adult population is high—about six children per woman highest in Côte d’Ivoire (10.1%) and lowest (between 5.2 in Cameroon and 6.9 in in Mali and Benin (1.7% and 2.0%, Burkina); the rate is even higher in rural respectively). The rate of female areas. High fertility leads to a rate of circumcision varies widely among the natural increase of 2.7 in Cameroon and countries (from 5% in Cameroon to 94% in Côte d’Ivoire, 2.9 in Burkina Faso, 3.0 in Mali). The practice of full breastfeeding for Benin, and 3.1 in Mali. Mortality remains a six months is high (over 90%) in all the concern in that the average infant mortality countries. rate is about 100 per 1,000 live births

3 TABLE 1. DEMOGRAPHIC AND REPRODUCTIVE HEALTH CHARACTERISTICS IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1990S

OUNTRY ITEM C

BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Population (mid-1998) 6,000,000 11,300,000 14,300,000 15,600,000 10,100,000 Land area (sq. miles) 2,710 105,637 179,691 122,780 471,116 Annual rate of growth 3.0 2.9 2.7 2.7 3.1 Percent of population under age 15 49 48 44 43 47 GNP per capita in US$ 350 230 610 660 240 Literacy rate Female 26 9 52 30 23 Male 49 29 75 50 39 Total fertility rate 6.3 6.9 5.2 5.7 6.7 Prevalence of contraceptive use (women in union) All methods 16 8 19 17 7 Modern methods 3 4 7 6 5 Maternal mortality (per 100,000 live births) 498 566 430 597 577 Infant mortality (per 1,000 live births) 94 94 77 89 123 Percent of women having at least one prenatal visit 80 59 79 85 47 Births attended by health professional (%) 64 42 58 45 40 Prevalence of HIV (adults 15–49) 2.0 7.2 4.9 10.1 1.7 Proportion of circumcised women 50 70 5 43 94 Contribution of abortion to maternal mortality (%) 15 n/a 23 n/a n/a

Sources: DHS. 1993–98. World Bank. 1998. World Development Indicators. Population Reference Bureau. 1998 and 1999. World Population Data Sheet. UNAIDS/WHO. 1998. Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Diseases.

4 TheThe PolicyPolicy Process:Process: DefinitionsDefinitions ofof ReproductiveReproductive Health,Health, Policies,Policies, andand PrioritiesPriorities

The focus on reproductive health in and supported by several donors, Francophone Africa developed much later including the World Health Organization than in other regions. For many years after (WHO) and the United Nations Population independence, most of the five countries Fund (UNFPA). The conference divided in this study operated under pronatalist reproductive health into four major policies. Family planning services were categories—children’s health, women’s not introduced into national health health, adolescent health, and men’s programs until the mid- to late 1980s. health—each containing various Their late introduction was due in part to a components. This general framework 1920 French law forbidding abortion and promotion of contraceptives. The law has ICPD Definition of Reproductive Health now been repealed in all of the countries except Benin and Mali, where it is no “Reproductive health is a state of complete longer enforced, though it remains in physical, mental and social well-being and not merely the absence of disease or infirmity, in all effect. Policies related to population issues matters relating to the reproductive system and to have evolved in all of the countries, albeit its functions and processes. Reproductive health at varying speeds. Initially, policies therefore implies that people have the capability to reproduce and the freedom to decide if, when and focused on maternal and child health how often to do so. Implicit in this last condition (MCH) programs, then MCH with family are the rights of men and women to be informed planning, and, finally, reproductive health. and to have access to safe, effective, affordable and acceptable methods of family planning of Among the five countries, Mali was the their choice, as well as other methods of their first to adopt an official population policy choice for regulation of fertility which are not (1990), followed by Burkina Faso (1991), against the law, and the right of access to appropriate health care services that will enable Cameroon (1992), Benin (1996), and Côte women to go safely through pregnancy and d’Ivoire (1997). childbirth and provide couples with the best chance of having a healthy infant. In line with the All the countries that participated in above definition of reproductive health, reproductive health care is defined as the this study have adopted the ICPD constellation of methods, techniques, and services definition of reproductive health (see box which contribute to reproductive health and well- at right). The concept of reproductive being through preventing and solving reproductive health problems. It also includes health was further refined at the First sexual health, the purpose of which is the Regional Forum on Reproductive Health enhancement of life and personal relations, and for Central and West Africa (the not merely counseling and care related to reproduction and sexually transmitted diseases.” Ouagadougou Forum) in September 1996. Paragraph 7.2 The forum was organized by the Family ICPD Programme of Action Health and AIDS Prevention (SFPS) Project 5 guided the development of national In each country, the Ministry of policies and programs in each of the five Planning is responsible for population countries. policy while the Ministry of Health is responsible for health policy, including In addition, the implementation strategy reproductive health. The ministries for for the Africa region developed by the youth (national education and youth) and WHO Office for Africa (validated by two for women are also involved in certain workshops in May and August 1998 in aspects of reproductive health. Table A1 in Bamako and Libreville) follows a slightly the appendix summarizes the evolution of different approach that includes the the various reproductive health policies. following six components (WHO, 1998): Benin. The focus of health programs in n safe motherhood; Benin has gradually expanded. In the n adolescent sexual and reproductive 1960s, the emphasis was on MCH; now, it health; encompasses general reproductive health. Family planning services first became n prevention of untimely and unwanted available when the Beninese Family pregnancies; Planning Association (ABPF) was founded n sexually transmitted disease (STD) and in 1972. The government began to include HIV/AIDS control; family planning in its programs after the 1978 Alma Ata Conference, but the n prevention, early screening, and concept of family planning was poorly management of cervical cancer; and accepted by the population. In 1987, the n reduction of female genital cutting, government folded family planning into a domestic violence, and sexual violence. broader focus of family well-being and added a nutrition component. All of the countries are working to Consequently, the Ministry of Health had revise policies, standards, and procedures to restructure, and the Directorate of to incorporate the new reproductive health Family Health (DSF) was created in May perspective. Côte d’Ivoire approved a 1994. Following the ICPD a few months comprehensive reproductive health policy later, Benin committed itself to a in October 1998; Mali and Benin have reproductive health focus. In 1996, drafted their policies but are still awaiting participants in the Ouagadougou Forum final approval. Burkina Faso and Cameroon further refined the concept of reproductive have not yet finished drafting their policies. health and concluded that each country Although no explicit priorities have been should define an essential services package set, country programs tend to emphasize for each of four areas: children’s health, MCH programs, birth spacing, and STD/ women’s health, adolescent health, and AIDS prevention while placing less men’s health. Benin defined its essential emphasis on infertility, cancers of the services packages in January 1997. reproductive tract, reproductive rights, and family planning for purposes of birth Benin drafted a population policy in limitation (which is still culturally 1995 and adopted it in 1996 after a change unacceptable to most of the population). in government. The National Commission The focus on reproductive health has also on Human Resources and Population, emphasized gender issues, the social which is composed of ministries directly context for health, and quality of care and concerned with population issues, is the has led to more programs addressing national agency responsible for services for youth and men and the coordinating population activities. The prevention of female genital cutting. 6 Population and Planning Unit, a body NGOs and government agencies involved under the Ministry of Planning, oversees in reproductive health reached a consensus the commission. on the definition of reproductive health and on the most pressing reproductive health In the health sector, a roundtable priorities. According to one university adopted the 1995–1999 Health Strategy in respondent, reproductive health is defined January 1995, identifying five areas of as a “triple well-being: physical, mental, intervention: decentralization of the health and social in all matters relating to the pyramid, reinforcement of managerial reproductive system and to its functions skills, improved financing, improved and processes, and not the absence of treatment of principal diseases, and disease.” Respondents emphasized four improved reproductive health. To help priority areas of reproductive health: MCH, institute the strategy, Benin adopted a family planning, STDs, and nutrition. In strategic framework in March 1997, Policy reality, existing programs and the and Strategy for Development of the availability of resources dictate which areas Health Sector, 1997–2001. Under the receive the greatest attention. framework, DSF is responsible for creating, monitoring, and evaluating reproductive Burkina Faso. Drafted in 1978, the first health programs in accordance with the program protecting MCH in Burkina Faso health strategy. A policy specific to emphasized nutrition. The second program, reproductive health, Policy and Standards drafted in 1988 and covering 1988–1992, in Family Health, was finally adopted in focused on primary health care and March 1999 (after fieldwork for this case included family planning activities for the study was completed). first time. A national population policy, which intended among other things to Benin uses the same definition of regulate fertility and reduce demographic reproductive health as the ICPD. Some key growth, was adopted on June 10, 1991. The informants felt that the concept is too third MCH program, covering 1994–1998, broad to be translated into a concrete had the same objectives as the population reality. A representative of the Ministry of policy and included family planning in the Health asked, “What are the activities we essential services package for health should include in reproductive health centers. On the legislative front, a law today? Reproductive health to me is a vast against female genital cutting was passed in area where we cannot have an impact 1997, but it has not been implemented. unless we target some specific areas.” A donor representative, however, said, Following the ICPD, Burkina Faso’s “There is no problem regarding the National Population Council (CONAPO) definition of reproductive health. It’s more updated the population policy to include a problem regarding implementation of the reproductive health as a national priority. content of the document.” To consider the concerns of all stakeholders, CONAPO used a Through a series of workshops, participatory process to revise the policy. In technical experts and representatives of July 2000, initial revisions had been completed but the policy was not yet in its final form. “Reproductive health to me is a vast area where we cannot have an impact unless Numerous ministries share we target some specific areas.” responsibility for implementing the national Representative of the Ministry of Health, Benin population policy, which includes reproductive health. CONAPO (within the 7 Ministry of the Economy and Finance) gender, and STD/AIDS control. Another plays the most significant role. The respondent said, “After Cairo, it is Directorate of Family Health (within the undeniable that new policies have been Ministry of Health) is in charge of created and old ones have been revised, in developing, planning, implementing, and order to include the overall concept of following up on programs to protect reproductive health in medical mothers, children, youth, men, and the interventions. Only the policy on abortion elderly. Other social ministries that are has not changed in that it is forbidden active at different levels in policy except with exceptional medical conditions formulation include the Ministry of Social and certain cases of proven abuse.” Action and the Family; the Ministry for the Promotion of Women (created in June In defining reproductive health, the 1997); the Ministry for Youth and Sports; Directorate of Family Health initiated a the Ministry of Basic Education and series of activities to develop a draft Literacy; the Ministry of Secondary and reproductive health strategy (Ministère de Higher Education and Scientific Research la Santé de Burkina Faso, 1998). The (through the Faculty of Health Sciences, strategy adopts the four categories defined which is responsible for reproductive by the Ouagadougou Forum—children’s health teaching reform); and the Ministry health, adolescent health, women’s health, of Communication and Culture, which and men’s health—and creates a fifth contributes to publicizing reproductive category: the health of the elderly. The health and providing information. strategy further describes elements CONAPO and the Directorate of Family common to all five categories, including Health in the Ministry of Health are family planning; STD/AIDS prevention; the responsible for coordinating policy and fight against all practices harmful to reproductive health actions. No specific reproductive health; reproductive health committee has been created to monitor information, education, and implementation of the ICPD Programme of communication (IEC); community Action, a factor contributing to a lack of participation; family life education; and coordination among agencies involved in responsible parenthood. Unfortunately, the reproductive health. strategy has not yet been completed because of coordination and funding Respondents agree that the concept of problems. As a result, this definition and its reproductive health in Burkina Faso has categories have not been sufficiently significantly changed since the ICPD. disseminated. According to one person, “Reproductive health policies before the ICPD were Respondents expressed concern about primarily focused on population and the absence of established priorities at the family planning programs with less national level as well as about the need for emphasis on STD/AIDS control, women’s rapid completion of the draft strategic plan. rights, sexual education, and maternal and In the absence of a final, approved child health.” The emphasis is no longer document on reproductive health, each on controlling population growth but partner or institution establishes its own rather on improving the quality of life. priorities based on the national situation, its New target groups are being taken into own concerns, and the approaches others account: youth, men, and the elderly. The have tried. For example, UNFPA seems to training of health professionals now focus its priorities on family planning, includes instruction in counseling, youth, gender, promotion of women’s contraceptive technology, quality of care, status, and STD/AIDS control. UNICEF 8 targets children’s health and improved respondents, the institutional framework for status of adolescent girls and women. population issues has been very unstable. CONAPO and the Association for Family The government agency responsible for Well-Being of Burkina Faso (ABBEF) population has changed from a directorate emphasize contraception, STD/AIDS in the Ministry of Planning (1982–1992) to control, women’s rights, promotion of a subdirectorate under the Directorate of income-generating activities, and service Planning and Development in the Ministry delivery through mobile clinics and of Economy and Finance (1992–1997) to a community-based distribution. directorate in the Ministry of Public Investments and Land Management (1997 Cameroon. In 1992, the government of to present). This structural instability has Cameroon manifested its concern about prevented the National Population population growth and adopted the Committee from meeting. National Population Policy, a significant departure from its pronatalist orientation of The health policies that guide current the 1960s and 1970s. The policy’s primary practices include the Standards of Maternal objective is to “…improve the level and and Child Health Care and Family quality of life of populations within the Planning, adopted in 1992; the limits of the resources available and in Implementation of Primary Health Care, accordance with human dignity and the 1993; and the Declaration of Health fundamental rights of man to health, Policy, 1996. The 1996 health policy is the nutrition, education, employment, and cornerstone supporting reorientation and housing.” Even though the policy reinforcement of the district health system. formulation process did not sufficiently It distinguishes three operational levels, involve representatives of civil society, each offering an essential services package implementation has been relatively that includes reproductive health care. No effective. Since the ICPD and the Fourth specific policy for reproductive health has World Conference on Women, been developed. Coordination of policymakers have been revising the reproductive health services was the population policy to meet the two responsibility of the Directorate of Family conferences’ objectives. According to and Mental Health until 1995, at which

9 time the directorate was demoted to the level of a subdirectorate. This demotion in “The concept of reproductive health has administrative standing, together with the remained in Yaoundé.” director’s departure, seriously affected the Peripheral-level service provider, Cameroon office’s ability to fulfill its coordinating role. Consequently, the different reproductive health components (STDs, AIDS, maternal Workshops to define reproductive health, child survival, and family planning) health have been postponed; consequently, have developed independently of one Cameroon has not yet reached a consensus another. on a definition. While awaiting the official consensus, various organizations have tried Policies in other sectors also address with mixed results to define reproductive various aspects of reproductive health. In health in the spirit of Cairo. One Ministry of 1997, the Ministry of the Female Condition Health respondent defined reproductive adopted an action plan, “Women and health as “a reorientation of family Development,” to implement the planning services that integrates the recommendations of the Fourth World management of STD programs, HIV Conference on Women. The Ministry of infection, and complications resulting from Youth and Sports is currently writing a illegal abortions, with prenatal care, youth sector policy in cooperation with the postnatal care, child health care, etc.” scout movement to emphasize educational Understanding of reproductive health is talks for youth and adolescents and to especially vague outside the capital. As address the need for separate reproductive one service provider at the peripheral level health services for youth. said, “The concept of reproductive health Cameroon adopted a pronatalist policy has remained in Yaoundé.” in 1968; since then, however, the policy Respondents identified the following environment has gradually become more priority reproductive health problems in favorable to family planning. A service Cameroon: rising maternal and child provider stated that “the topic of family mortality rates; low prevalence of planning was taboo when we began around contraceptive use; high prevalence of 1972. With the findings of studies sexually transmitted infections; high rate of conducted on maternal mortality and unwanted pregnancy among young girls perinatal mortality, the government and adolescents and related complications; authorized a family planning clinic in and illegal, induced abortion. In view of Yaoundé in 1975.” However, family these factors, one respondent stated, “The planning activities remained limited to priority of priorities remains safe major urban centers with private doctors motherhood.” Numerous respondents’ until 1984, when the president made a answers, however, made it clear that general statement on responsible priorities have not yet been set at the parenthood. From that time, services national level. Some respondents indicated gradually expanded, particularly through that priorities are based primarily on the projects supported by USAID, UNFPA, and the German Cooperation Agency (GTZ), and, in 1990, a new law that allows “Everything happens as if there were no pharmacists to dispense contraceptives. In plan If there’s money in a given area, early 1996 after the ICPD, family planning that’s all it takes for a leader to consider was integrated with MCH, and that area to be a priority.” contraceptives were included on the Respondent, Cameroon national list of essential drugs. 10 availability of donor funding. According to person delegation from Côte d’Ivoire one respondent, “Everything happens as if attended the ICPD. These actions there were no plan. If there’s money in a demonstrated an increased willingness of given area, that’s all it takes for a leader to government officials to focus on consider that area to be a priority.” reproductive health issues.

Côte d’Ivoire. From its independence In this propitious climate, a series of in 1960 until the early 1990s, Côte d’Ivoire meetings was organized, beginning in was a pronatalist country. The late November 1995, to develop a population President Houphouet Boigny believed that policy with support from UNFPA. A 1996 Côte d’Ivoire had enough land and workshop to consider the ICPD resources for 50 million inhabitants, or a recommendations, analyze existing tenfold increase over the population at that programs, and formulate the National time. According to a respondent from the Population Policy led to the policy’s National Population Bureau (BUNAP), the adoption in March 1997. conclusions from the 1974 conference entitled “Côte d’Ivoire: Outlook 2000” In April 1996, Côte d’Ivoire adopted its provided the basis for the country’s early first National Plan for Health Development, population policy. The policy was based 1996–2005, following a series of meetings on the idea that strong demographic with experts from the World Bank, officials growth can be beneficial due to economies from the Ministry of Health, service of scale despite resulting social costs. providers, representatives from NGOs and the private sector, and community leaders. During this pronatalist period, the only The plan defines the institutional family planning program in the country framework, structures, human and financial was run by the Association for Family resources, programs, and strategies for Well-Being of Côte d’Ivoire (AIBEF), which accomplishing objectives, including those was established in 1979 as a member in the area of reproductive health. The agency of the International Planned overall objective is “the improvement of Parenthood Federation (IPPF). From the the state of health and wellness of the time of its creation to 1990, AIBEF worked population through improved qualitative behind the scenes and faced much and quantitative balance between the opposition. Support for the organization supply of health services and the basic grew during the early 1990s, leading up to needs of the population.” the ICPD. During that time, the government signed a bilateral project with USAID to Several reproductive health programs entrust AIBEF with the delivery of family fall under the National Plan for Health planning services in Abidjan and four Development. The Program for Primary regional capitals. Health Care ensures the provision of the essential services package at the Many respondents stated that, for many community level. The Expanded years, it was difficult to gain policymakers’ Immunization Program—a vertical support for family planning policies program—aims to eradicate poliomyelitis, because of resistance to the concept of eliminate neonatal tetanus, and control limiting births. In the 1990s, however, other childhood diseases. The National family planning became more acceptable Program of Child Health runs several as proponents focused on the contribution programs, including diarrheal disease of family planning to MCH. In 1993, the control, acute respiratory infection control, government instituted a national family and breastfeeding; and its primary goal is planning program, and, in 1994, a 19- to control childhood diseases through 11 training and integrated management of ministerial departments cooperate with childhood diseases. The National Program bilateral and multilateral cooperation for AIDS, STDs, and Tuberculosis Control agencies, implementing agencies, and was created in 1987 in response to the HIV NGOs in the formulation of reproductive epidemic; its goal is to reinforce health activities. multisectoral action, encourage social mobilization, and promote and support In efforts to define reproductive health, community responses. The goals of the the Ministry of Health and UNFPA National Program for Reproductive Health organized a National Reproductive Health and Family Planning are in accordance Symposium in June 1996 with participation with the National Plan for Health from a broad range of governmental and Development and the National Population nongovernmental institutions. The objective Policy. of the symposium was to improve understanding of the concept of Further advances were made in the reproductive health and its components by policy environment in December 1998, adopting a consensual operational when Parliament—in response to the efforts definition specific to the Ivorian context. In of the Ministry of Family and the Promotion the end, the symposium adopted the ICPD of Women and the Ivoirian Women’s definition. The name of the national Rights Association—passed laws against program, National Program for female genital cutting and early, forced Reproductive Health and Family Planning, marriages. Three documents addressing explicitly reminds all stakeholders that reproductive health were drafted in reproductive health cannot be reduced to October 1998 and approved in 1999: family planning. Despite efforts to involve Reproductive Health Services Policy, all levels in the development of the Reproductive Health Service Standards, definition, service providers so poorly and National Program for Reproductive understand the concept of reproductive Health and Family Planning in Côte health that they confuse it with family d’Ivoire. planning. One respondent representing the government said, “There were some The institution responsible for difficulties understanding on our part, but developing and implementing population also on the part of the people we were policy is the Ministry of Planning, with speaking to and our target audience assistance from the following organizations: because the ‘medical’ aspect is seen but not the National Population Council the other [aspects].” (CONAPO), an advisory body charged with assisting the government in defining The definitional issue notwithstanding, population policy and monitoring the the major problem facing the national performance of activities; the regional reproductive health program is not population councils; and BUNAP, which is dissemination of the ICPD concept of responsible for coordinating the reproductive health but rather coordination development of population policies, among all the other programs responsible strategies, and programs. for one or more aspects of reproductive health. Respondents could not even agree The Executive Directorate of the on which institution was responsible for National Program for Reproductive Health coordination. Some cited the Ministry of and Family Planning is the structure Health, others the Executive Directorate of responsible for developing reproductive the National Program for Reproductive health policy within the Ministry of Health. Health and Family Planning, and still The Ministry of Planning and other social others, BUNAP. The reproductive health 12 program for youth is one critical area for government to affect levels and trends in which the ministries of Health and Youth demographic variables. Although these need to improve collaboration if they are to policies preceded the ICPD, they contain implement the program effectively. many of the principles of the ICPD. One respondent asserted that the elements of Neither the National Reproductive reproductive health were already being Health Symposium nor the approved implemented before the conference: “The National Program for Reproductive Health ICPD is not the beginning point, it is the and Family Planning assigned priority to concept that is new.” Another agreed by program areas in their various documents. saying saying, “What changed after the Based on donor support, however, the main ICPD was seeing all the elements linked.” priorities seem to be family planning (as an essential element of safe motherhood), the Since the ICPD, new policies have been control of STD/HIV/AIDS, and the developed and old policies revised to reflect reproductive health of young people. the new focus on reproductive health. The PSSP has been strengthened, and some new Mali. The first family planning program elements have been added. The new in Mali began in 1972 with the creation of Program of Priority Investments in the Malian Association for the Promotion Population, 1996–2000, which is the action and Protection of the Family (AMPPF). In its plan for implementation of the 1991 early years, AMPPF devoted itself primarily Population Policy, makes reproductive to IEC and advocacy activities rather than to health its first component. The Maternal and service delivery. Family planning services Child Health Policies and Standards were first became available after the Alma Ata replaced with Policies, Standards, and Conference in 1978, when the government adopted a Primary Health Care Strategy and integrated family planning services with MCH activities. Family planning activities were constrained, however, by the 1920 French law forbidding both abortion and the promotion of contraceptives. Over time, the situation changed; while this law is still in effect, it no longer poses an obstacle to family planning activities and services. For example, in January 1991, a ministerial letter authorized women of childbearing age to use family planning without the consent of parents or a spouse (MSPAS, 1991).

The Sectoral Health and Population Policy (PSSP), adopted in December 1990, provides the political orientation and institutional framework for health and population issues. This policy is based on the conceptual framework of the Bamako Initiative: increased health coverage, accessibility of essential drugs, and community participation (see box, page 18). Adopted in 1991, the Population Policy outlines all the measures to be taken by the 13 Procedures for Reproductive Health and problematic. Coordinating structures Family Planning, which focuses on the function to some degree, but the respective health of the whole individual. roles of NGOs and state agencies are not Governmental and nongovernmental clearly defined. Administrative partners from all levels were involved in decentralization could exacerbate the developing new guidelines, which were problem further, but the issue is recognized widely disseminated (although a donor as a priority by all respondents and thus is respondent stated that the dissemination has likely to be addressed. been inadequate at the subnational level). Mali’s policy documents and standards The National Planning Directorate of use a slightly amended version of the ICPD the Ministry of the Economy, Planning, and definition of reproductive health as Integration is the structure responsible for appropriate to the Malian context. The developing and following up on the 1991 concept of reproductive health in Mali Population Policy. A population unit was includes a set of preventive, curative, and created within the directorate in 1983 to promotional measures intended to consider population issues. In 1993, an improve the care of vulnerable groups, advisory body, the National Council for the including “the mother/child pair, youth, Coordination of Population Programs and adolescents in order to reduce infant, (CONACOPP), was formed to replace the child and maternal mortality and population unit. CONACOPP’s primary morbidity and thus to promote the well- purpose is to provide advice and being of all individuals.” The respondents suggestions for all population projects and almost unanimously declared that all programs, implementation of population reproductive health aspects are addressed policy, and demographic and economic at one level or another except the issue of change in the country. Population councils abortion, which is forbidden by law in all were also planned at decentralized levels cases when it is not therapeutic, and (region, circle, arrondissement, and “women’s rights issues,” which “are not commune); according to respondents, taken into account anywhere,” according however, these decentralized units have to one respondent. not been able to fulfill their roles because Reproductive health priorities have not of lack of funds and lack of understanding yet been formally identified at the national of their value. level; however, they seem to focus on Leadership for health policy was family planning and eradication of harmful entrusted to the Ministry of Health. On the practices, such as excision. Some operational level, most aspects of respondents mentioned that trends, such reproductive health are the responsibility of as the worldwide movement against the National Directorate of Public Health, female circumcision, often help determine through the Division of Family and priorities, as do donor preferences. The Community Health. The Program for Health need for setting clear priorities is real. As and Social Development, 1998–2002, one respondent commented, “Mali is a proposes the creation of a reproductive country where everything seems to be a health directorate. Coordination among priority, but can one do everything at once actors in the area of reproductive health is and in the same way?”

14 Participation,Participation, Support,Support, andand OppositionOpposition

The ICPD recognized that participation Benin. According to Beninese of all reproductive health partners is government representatives, civil society essential for successful implementation of has participated fully in developing the Programme of Action. In the five reproductive health policies and programs. countries, most respondents confirmed One respondent from a government agency that NGOs and other civil society said, “The representatives of NGOs have representatives have been invited to attend always been involved in training workshops meetings at the national or subnational organized both inside and outside the levels to formulate reproductive health country to be able to gather useful policies and programs. Some NGOs, information for their sphere of activity.” however, think that the government is not According to a respondent from the sufficiently open and that opportunities for Ministry of Health, other stakeholders such effective participation are limited. as local leaders and donors were involved Moreover, government does not consider in consensus meetings; however, some NGOs to be true partners in the process of NGOs participated only as guests and did planning and implementing reproductive not feel they were involved since they health programs. A frequently cited could not contribute to creating the constraint to fuller NGO participation is national programs. For example, Policy and the relatively limited skills of most such Standards in Family Health was developed organizations. entirely by government representatives, with NGOs invited to the final presentation Support for reproductive health is of the policy document. One limitation on increasing, although some components full NGO participation is that most of the still encounter resistance. For example, organizations are relatively new and have many groups do not yet support the fight limited capabilities. The establishment of against female circumcision or the the Network of Beninese Health NGOs provision of family planning services to (ROBS) reflects the desire of the NGOs to adolescents. In general, government unite in an effort to increase their influence officials and politicians were reported to and effectiveness. be fairly receptive to reproductive health programs, but they are constrained by social conservatism at the grassroots level “The political will exists, but there is a and by religious group opposition. certain amount of social resistance that the policy is not prepared to attack.” NGO respondent, Benin 15 Opinions are divided between support orphans, educating girls, and improving the of and opposition to reproductive health status of women, youth, and the elderly. policy. Opponents use the 1920 French The National Assembly of Burkina Faso law still in effect in Benin to attack the participated in the ICPD and committed to program. A government executive promoting the status of women and girls. In indicated that the clergy in particular the 1998 action plan of the Ministry for the believe that “…the use of condoms is an Promotion of Women, general objectives open door to debauchery and encourages are structured around promoting women’s infidelity.” According to respondents, the access to resources, improving education public is not well informed about for girls, improving women’s health, and reproductive health principles because the protecting women’s rights. The president of new policy has not yet been widely the republic made six commitments, one of disseminated. An NGO respondent which deals with the economic and social indicated, “The political will exists, but promotion of women. The establishment of there is a certain amount of social training and production centers for young resistance that the policy is not prepared to girls in Sourou Province is one concrete attack.” Public support will probably grow step taken by the government to fulfill its with time, and the socioeconomic context commitments. is working in favor of reproductive health. “Life is becoming more and more difficult Popular support for reproductive and the deteriorating economic situation health remains low, however. Interviews encourages the population to be a bit more with community leaders suggest that a lack responsible in procreating,” stated a of awareness and understanding of respondent from the Ministry of Health. reproductive health is the primary constraint. Leaders did not oppose Burkina Faso. Many respondents from reproductive health activities when they NGOs and civil associations in Burkina understood them. Faso believe that their level of participation in formulating policies is insufficient. They Cameroon. Since the ICPD, a believe that government agencies consult proliferation of NGOs has been working in them only to a limited extent on matters of reproductive health, a phenomenon implementation and the search for explained by the relaxation of laws in 1990 financing. Donors and respondents from regarding the creation of associations; by cooperating agencies agree that the level of the increased availability of funding for NGO and civil participation is insufficient reproductive health activities; and by the and that government agencies sometimes encouragement of donors who appreciate reject NGO participation in policy the greater flexibility, administrative ease, formulation, even though the government and closeness to the community of NGOs could benefit from the NGOs’ skills. In as compared with the public sector. NGOs contrast, many respondents from help the government in the field, although government structures assert that NGOs are some respondents expressed concern about regularly invited to participate in the coordination problems. According to one process from the outset. Ministry of Health respondent, “The action of the NGOs is a waste of time if there is Government support for reproductive no coordination.” In response, the Ministry health is high at the national level. In the of Health, with the support of UNFPA, set Declaration of General Policy of the Prime up a unit to oversee coordination with the Minister (July 1996), the government NGOs, although some NGO respondents committed itself to promoting IEC actions expressed concern about conflicts of for AIDS prevention, assisting AIDS interest with the ministry. 16 reproductive health. Some respondents “Yes, the government is involved. But is suggested that the delay in formulating a the maximum being done? One has the policy reflects the lack of commitment on impression that there is more talk than the part of decision makers. One donor concrete action.” respondent commented, “Yes, the Donor, Cameroon government is involved But is the maximum being done? One has the Support for reproductive health is impression that there is more talk than mixed. The public frequently equates concrete action.” At the local level, reproductive health with family planning, administrators have supported which many community leaders still reproductive health programs, although consider an attempt “to prevent Africans local and regional elected officials have from reproducing,” as one respondent been much less involved, preferring not to explained. Some people still do not have a deal with sensitive issues and thus run the positive attitude toward condom use to risk of offending voters. prevent STDs and AIDS because they believe they are being tricked into not Côte d’Ivoire. Since the ICPD, the procreating. Reproductive health for number of NGOs in Côte d’Ivoire has adolescents is another sensitive area. As multiplied, and they have been actively one respondent from an NGO indicated, involved in formulating and implementing “According to many parents, talking about reproductive health policies, according to sexual relations with adolescents exposes both government and NGO respondents. youth to bad behavior; [the parents] do not The government has been particularly understand why you have to talk about supportive of NGO participation; it created sexuality with your children.” In addition, a unit within the Ministry of Health to health workers are often unwilling to coordinate NGO activities and has provide reproductive health services to channeled over 750 million CFA francs adolescents. Moreover, the Choas Arabs, (US$1.25 million) to NGOs active in the the only ethnic group in Cameroon to health sector, according to respondents. practice female genital cutting, resist all Most respondents felt that the efforts to end the practice. participation of civil society in all levels of The religious diversity of Cameroon the process (formulation, adoption, and makes it difficult to generalize about the implementation of policies and programs) position of religious leaders regarding is positive. They believe that NGOs have a reproductive health. The Protestant role to play in social mobilization, IEC, churches support all government health and community actions. However, some policies and provide reproductive health respondents acknowledged that some services through their health centers. The NGOs are primarily interested in enriching Catholic Church opposes those elements of themselves or lack needed skills. An NGO the policy related to artificial respondent said, “Theoretically, the contraception. Many Islamic leaders participation of NGOs is positive, but the oppose IEC programs that talk to youth problem is that the lack of professionalism about sexuality, and some oppose women’s use of contraception. “Theoretically, the participation of NGOs is positive, but the problem is that the lack In the absence of a clear reproductive of professionalism makes it difficult to health policy, nearly all respondents said gain trust.” that it is difficult to assess the level of NGO respondent, Côte d’Ivoire support among national leaders for 17 The Bamako Initiative The Bamako Initiative is a strategy to improve primary health care, including reproductive health. Given that the five case study countries are implementing the initiative, it helps to define the framework in which reproductive health services are delivered. The Bamako Initiative has important implications for community participation in decision making, financing, and quality of services. African Ministers of Health launched the Bamako Initiative in 1987 in Bamako, Mali, at a conference sponsored by WHO and UNICEF. The initiative’s objective is to ensure that high- quality primary health care is available to the entire population at an affordable price. Conference participants recognized that the quality of public health services was poor. Health centers frequently lacked basic drugs, infrastructure was deteriorating, qualified personnel were in short supply, and staff were not motivated. Consequently, use of services was low, and the population sought other (and frequently unreliable) alternatives. Furthermore, mismanagement and inefficiency squandered scarce resources. The Bamako Initiative focuses on a few key strategies to improve the quality of health services while improving the effective use of resources. o Communities contribute financially to their own health services, primarily through user fees, on the premise that even the poor will pay for high-quality services. Community funding is sufficient to cover all nonsalary recurrent costs. o Communities participate in decision making related to their health services through locally elected health committees. o Village health workers are trained to conduct outreach activities. o Emphasis is placed on provision of an essential services package, which includes cost- effective interventions and generic, essential drugs. o Health services are delivered through a decentralized, district-based health system. By the end of 1994, 33 countries—primarily in Africa—had adopted the Bamako Initiative along with countries in Asia and Latin America. All five case study countries are implementing the Bamako Initiative to varying degrees. Côte d’Ivoire began implementing the initiative in 1992 in nine districts and plans to extend it to all 29. Cameroon has also started to implement it in five out of 10 provinces. In Benin, the program was integrated into some health centers starting in 1988; by 1991, nearly all peripheral health centers were involved. In Burkina Faso, the Ministry of Health piloted the Bamako Initiative in six provinces in 1989 and extended it to nearly all health posts and centers in 1993. Mali has the most extensive program; the formal conceptual framework was developed in 1989 and continues through implementation of the Sectoral Health and Policy and covers the entire country. In general, the initiative has had a positive impact. Assessments show that use of services has increased significantly as a result of improved quality. Low-cost, quality drugs are more readily available, and resources generated by the initiative are sufficient to cover not only recurrent costs but also additional health activities. At the same time, a number of challenges have arisen, but programs are working to address them. Community health committees do not always adequately reflect the community; women in particular are generally underrepresented. Health committees lack transparency and accountability in their management of community funds. And while quality has significantly improved, particularly as related to the availability of drugs, more improvements need to be made.

18 makes it difficult to gain trust.” In response, reports from those who partook of family the NGO network, Collective of NGOs planning services. Active in Côte d’Ivoire, held a workshop in February 1999 to develop a code of According to an AIBEF respondent, conduct for NGOs and to improve their policymakers in Côte d’Ivoire have practices. committed their support to reproductive health in general. The President of the The commercial sector has been less National Assembly, the President of the involved than NGOs. A commercial sector Republic, and the Minister of Health representative expressed frustration over demonstrated their support and took appeals for participation during policy concrete action by signing a bilateral formulation but not during implementation. agreement with USAID and accepting technical and financial support from The National Program for Primary UNFPA. These commitments reflect the Health Care/Bamako Initiative, which government’s new openness to started in 1992, has been encouraging reproductive health programs. community participation. According to the National Plan for Health Development, the However, some issues that affect program is the main means of traditional practices, such as female genital implementing the new health strategy, cutting, pose problems. Despite the 1998 Health for All in the Year 2000. law forbidding female genital cutting, Management committees were created by support for efforts to eradicate the practice decree to involve communities in is lukewarm because certain politicians fear managing their own health according to that they will alienate their electorate. One the principles of primary health care. So respondent, a parliamentarian, stated, “I far, the program has been fully would vote for the law against female implemented in just nine districts covered circumcision if I didn’t have to defend such by UNICEF, but the objective is to cover ideas in my territory. I’m sure I wouldn’t be the entire country. reelected!” In addition to female genital cutting, abortion is still highly controversial, At the national level, Côte d’Ivoire has although postabortion care is included as seen little organized opposition to an integral part of the national reproductive reproductive health. Awareness-raising health program. activities led by AIBEF were tolerated from the beginning in Abidjan. However, when it came to expanding family planning “I would vote for the law against female activities outside Abidjan, opponents to circumcision if I didn’t have to defend family planning invoked the 1920 French such ideas in my territory. I’m sure I law. Family planning is still at times wouldn’t be reelected!” Parliamentarian, Côte d’Ivoire equated with birth limiting, which provokes considerable resistance, while the concept of birth spacing is more acceptable. According to some respondents, the Mali. Though NGO involvement in principal resistance came from the medical health in Mali began before the ICPD, the establishment, which supported the conference helped reinforce NGO pronatalist policy of the time. One service participation in policy development and, provider indicated that, initially, the public especially, in implementation. Mali was distrusted family planning but did not one of the countries that included NGO oppose it; over time, the situation improved representatives in its official delegation to as a result of experience and positive the ICPD. NGOs have become privileged 19 partners and participate at all stages of fiercely opposed family planning, but now reproductive health policy and program some wholeheartedly defend it for married development. They are grouped under the couples. Reproductive health programs Bamako-based NGO network Groupe Pivot/ have encouraged the involvement of Health and Population, which facilitates religious groups and have even sponsored coordination and involvement at all levels the participation of both male and female (policy development, document approval, members of the groups in family planning program implementation, operations study trips to Islamic countries with strong research, and evaluation). In addition to family planning programs (Iran, Egypt, NGOs, the private business sector (offices Indonesia, and Niger (Forum on and clinics, associations of doctors and Reproductive Health and Islam in Africa)) private pharmacists, and so forth) is a to learn from their experiences. partner in reproductive health but is less involved in policy development. Policymakers are well informed about reproductive health issues and support the Community participation has been concept at least to the extent that they expanding since the implementation of the have organized many forums and Sectoral Health and Population Policy, workshops on reproductive health since which authorized communities to manage the ICPD. The highest national authorities their own health issues, including (namely the President of the Republic, the reproductive health. Federations of Minister of Health, the Minister of the community health associations participate Promotion of Women, Children, and the in the development and approval of policies Family) all support the ICPD Programme of and programs. Action, in addition to various reproductive health projects and programs. Thus, while The case study interviews revealed the general population hesitates, high- persistent opposition to some aspects of level authorities are committed to reproductive health, such as youth reproductive health. programs and efforts to eradicate female genital cutting; in addition, discussion of sexuality is still taboo. Respondents said that though many Islamic leaders fiercely oppose some aspects of reproductive health, some support it. All respondents mentioned that the National Union of Muslim Women of Mali is opposed to the eradication of female genital cutting. Nevertheless, opposition has not prevented the government from adopting action plans to address reproductive health. One respondent spoke for many when he said, “There is a sort of resistance to certain aspects. For example, old people say that they can no longer change their attitude toward the issue of female circumcision and that we have to increase awareness among young people.”

The attitudes of many religious groups have changed. Previously, several groups 20 PolicyPolicy ImplementationImplementation

Although not all ICPD goals have been One of the Cairo recommendations was met, all five countries have taken action in to integrate services to increase the the field to implement the ICPD and efficiency of reproductive health programs Ouagadougou Forum resolutions. At the and to better meet the needs of clients by operational level, several programs have offering reproductive health services in the been developed to reach specific groups, same place and at the same time. particularly youth and adolescents. Unfortunately, many obstacles have Moreover, reproductive health is prevented service integration from increasingly considered in the broader becoming a reality, particularly at the context of gender issues; some countries peripheral level. All of the countries, have even taken steps to improve the however, are making some progress, status of women through measures such as including training nursing personnel to be girls’ education programs. able to provide a broader range of services.

The government still provides most Benin. The Ministry of Health reproductive health services, but NGOs developed a reproductive health program, are predominant in areas such as youth coordinated by the DSF, that is based on programs, women’s rights, and the fight two 1996 National Population Policy against female genital cutting. While objectives (increased life expectancy and respondents acknowledged the important responsible parenthood), the 1996 DHS contributions of NGOs, they also noted the results, and the ICPD and Ouagadougou difficulties of coordinating interventions Forum recommendations. The program has between government and the growing four elements as follows: number of NGOs. n women’s health, including safe In the spirit of the Bamako Initiative motherhood and gynecological care; (see box, page 18), all of the countries n children’s health, including neonatology have made some attempt to increase services and well-child care; community participation in the management of government health n youth health, including family life services. In some countries, participation is education, reproductive health care, and effective in only a few districts. Mali has the promotion of an environment for gone the furthest in empowering youth favorable to a gender approach; and communities throughout the country to manage their own health services. n men’s health, with an emphasis on awareness of men’s reproductive health 21 responsibilities and management of disagreement by explaining that the sexual dysfunctions and genital cancers. concept of integration as conceived by the ICPD may not be universally understood. In addition, the program outlines activities that could contribute to the At the government level, the Ministry achievement of objectives under all four of Health and several other ministries are elements. Activities include family involved in reproductive health activities planning, STD/HIV/AIDS control, coordinated by DSF. For example, the nutritional promotion, and the control of Ministry of Youth collaborates with DSF on practices harmful to reproductive health two projects. An official from DSF (especially female genital cutting). cooperates with an official from the Complementary components include Ministry of Youth to undertake activities in sanitation; environmental protection; the field for youth health, such as setting literacy training; education, particularly for up youth centers. girls; and increased popular awareness of population issues. Burkina Faso. “In general, in terms of reproductive health policies and strategies Public entities such as the National in Burkina, we tend to remain at the AIDS Control Program, public health theoretical level. Because we do not start centers, and social promotion centers developing strategies and objectives with provide services. In addition, the ABPF our existing means, stumbling blocks arise and many other NGOs provide and there is no follow-through.” Despite reproductive health services or conduct the difficulties pointed out by the IEC campaigns, frequently in areas where respondent, efforts at implementation have public sector coverage is inadequate. been made and new or revised policies Public structures offer general integrated have been integrated into directives. Since services. For instance, in a public the ICPD, the government has emphasized maternity ward, basic MCH services (pre- the education of girls, with the goal of and postnatal care, delivery, vaccinations), reducing the rate of female illiteracy. It has family planning services, and IEC are also focused on gender, population available. NGOs more often work in education, family life education, and specific areas, such as family planning; the human rights. Moreover, it has revised ABPF, however, is an exception, offering a school texts to eliminate sexist stereotypes broad range of services extending to and created satellite schools and centers of family planning, prenatal care, and nonformal education with a system of reproductive health for youth, including mandatory quotas (50 percent reserved for counseling. In general, however, girls). Other initiatives include training and implementation of programs with a new production centers for young girls and reproductive health orientation is not far revision of the Penal Code in 1996 to advanced. A necessary first step is to increase service providers’ awareness of reproductive health and then deliver “In general, in terms of reproductive additional reproductive health training to health policies and strategies in Burkina such providers. Faso, we tend to remain at the theoretical level. Because we do not start developing Respondents disagreed over the strategies and objectives with our existing benefits of integrating services and the means, stumbling blocks arise and there is level of integration achieved thus far. no follow-through.” Some respondents accounted for the Respondent, Burkina Faso

22 include prison sentences for the practice of condom distribution and oral rehydration female genital cutting. therapy. Oral contraceptives and sometimes injectables are regularly sold in the market In addition to various government without prescription, thus testifying to actions, several donors have participated unmet demand. in the implementation of projects. For example, UNFPA has always supported The essential services package provided population and reproductive health at various levels of the health pyramid programs. WHO helped the government includes MCH and family planning develop the National Strategy for Safe services. Integrating services, however, is Motherhood, a youth program, an challenging, particularly because of the evaluation of reproductive health needs, wide range of skills required of health and the Integrated Management of personnel. As an executive at the Ministry Childhood Disease (IMSC) program. of Health said, “How are we going to CONAPO conducts research on integrate all these reproductive health ideas reproductive health, including family that call on skills in such widely different planning, youth health, and community- fields?” As a result, many structures still based services. UNICEF develops activities offer services on different days; however, to improve the status of women and some progress is being made toward adolescent girls and to promote integration. RESAR instituted an integrated emergency obstetrical care and the health approach to offer high-quality postabortion of children. GTZ is active in research and care and modern contraceptive methods; family planning and participates in the the effort is yielding positive results. The development of training curricula for ABBEF and DSF, with financial assistance family planning and community-based from UNFPA, developed youth counseling services. The World Bank is active through services that are still in the experimental the Population and AIDS Control Project, stage. Youth services are rare, but which is dedicated to decreasing fertility discussions are far advanced to integrate and the spread of AIDS. USAID works them into other structures, such as youth through the SFPS Project, which develops and cultural centers under the Ministry of models for high-quality services; the Youth and Sports, training centers for young agency also participates in the farmers under the Ministry of Agriculture, or development of national documents such other establishments under the Ministry of as the revision of norms and standards. Secondary and Higher Education.

Many NGOs and associations in Constraints to effective implementation Burkina Faso play a decisive role in of reproductive health programs are varied. developing and implementing At the clinic level, personnel are highly reproductive health programs. In an mobile and poorly motivated, efforts to attempt to coordinate activities, they are monitor the implementation of reproductive grouped under the Permanent Secretariat health programs are limited, and service of NGOs and the NGO Monitoring Office. providers lack information about reproductive health. Financial resources, The public sector typically provides infrastructure, and supplies are inadequate. MCH and family planning services. Except At the community level, cultural practices for the pharmaceutical sector, which is such as female genital cutting, religious primarily limited to large towns, the for- beliefs prohibiting the use of condoms, and profit and not-for-profit private sector is the general low social status of women only slightly developed. Social marketing is a recent strategy that is so far focused on 23 hinder improvements in reproductive clinics as well as hospitals affiliated with health. In addition, the extreme poverty of religious groups. many beneficiaries makes the cost of Health structures are organized to services prohibitive to them. supply a maximum number of services Cameroon. Cameroon’s adoption of needed by the population. The Standards health policies has not been followed up of Maternal and Child Health Care and by an action plan or adequate sectoral Family Planning stipulates that services strategies. For example, norms for MCH must be integrated. In fact, they are and family planning services have not necessarily integrated in health centers been expanded to cover other areas of where the nurse, who generally has a wide reproductive health such as STD/AIDS, range of skills, often works alone. postabortion care, genital infections, or Moreover, given that provision of the diseases, including cancer. Nonetheless, essential services package requires the lack of an action plan has not generalists, the government is undertaking prevented the implementation of programs the ongoing training of personnel. in the field. For example, contraceptives Currently, almost 22 percent of service are now available throughout the country, delivery points include integrated family and the number of private structures planning, and almost 40 percent address offering family planning services has diarrhea, acute respiratory infections, increased. The fight against STD/AIDS has immunization, and newborn monitoring, gained in intensity, as have immunization according to a Ministry of Health programs for poliomyelitis. Particularly at representative. the central level, additional progress has Inadequate infrastructure and been made in the battle against resources and insufficient and unequal gynecological cancers. IEC materials are distribution of personnel make it difficult being used to increase men’s awareness of to deliver the full range of services. Other reproductive health issues and men’s role constraints include sociocultural barriers, in reproductive health, and personnel are such as community and religious attitudes undergoing training to provide a broader toward reproductive health for range of reproductive health services. adolescents, and legal barriers, such as the Public clinics provide most absence of a legal framework requiring reproductive health services. Community- service providers to offer services to based services are still not highly adolescents. developed. Social marketing provides Côte d’Ivoire. On an operational level, condoms and pills and, since early March both the Triennial Population Plan and 1999, oral rehydration therapy. In Triennial Action Plan for the Development addition, several NGOs offer reproductive of Women are under development in Côte health services, such as the IPPF affiliate d’Ivoire. Plans already completed and Cameroon National Association for Family partially implemented include the Welfare, which delivers integrated services Expanded Immunization Program Action for contraception and provides activities in Plan, the Strategy for Management of the youth centers of four towns, Childhood Diseases, and the National counseling, prenatal care, and STD AIDS, STDs, and Tuberculosis Control management. The private sector, both for- Action Plan. The National Program for profit and not-for-profit, is highly Reproductive Health and Family Planning developed and operates many private is implementing activities. The Project for

24 the Development of Integrated Health marketing program, implemented by Services is also being operationalized Population Services International, is through the application of the essential another source of services, offering services package at peripheral levels and condoms, oral contraceptives, and oral the simultaneous reinforcement of priority rehydration solution. national programs for family planning (entrusted to AIBEF) and STD/HIV/AIDS Côte d’Ivoire and donors such as (managed by the National Program for UNFPA have initiated projects, including a AIDS, STDs, and Tuberculosis Control). youth project under the Ministry of Youth, a project for family life education with the Ministry of Education, and a project for reproductive health in the military. Service providers have been trained in postabortion care and reproductive tract infection treatment while syndromic diagnosis of STDs is being integrated into the essential services package. In addition, the government is developing a program for the prevention of female genital cutting, although activities are not yet underway.

In 1996, Côte d’Ivoire operated 1,364 Several constraints inhibit the effective public health establishments. In addition, implementation of reproductive health. the private sector claimed 53 hospitals and Health services are concentrated in the private offices, 82 businesses with a south of Côte d’Ivoire, particularly in the medical service, and 212 private nursing capital Abidjan, and coverage in the north stations. Only 3 to 4 percent of public is deficient. Health personnel have been sector facilities had already integrated inadequately trained, and those who have family planning into their services, undergone training are frequently not although the National Program for given the supplies necessary to carry out Reproductive Health and Family Planning their functions. Sociocultural factors also envisions the progressive introduction of pose challenges to improving reproductive reproductive health services into all public health. For example, 70 percent of women health units. Currently, AIBEF provides in Côte d’Ivoire are illiterate (World Bank, most family planning and STD/AIDS 1998) and therefore have little access to services through its own clinics and at information about family planning and family planning service delivery points in other reproductive health services; some public clinics. The Ministry of consequently, they are susceptible to Health and the World Bank selected AIBEF misinformation and rumors and hold many to implement family planning service false beliefs regarding the dangers of delivery in rural zones under the Project family planning. Some programs, such as for Development of Integrated Health those for youth, are controversial and meet Services. AIBEF manages nine clinics and with resistance. Finally, decisive action to supports family planning activities in 15 implement policies is frequently lacking. Ministry of Health hospitals and 87 According to one respondent, “There are Ministry of Health distribution points. It too many hesitations in implementation.” also provides community-based Mali. As mentioned, Mali’s 1990 distribution in several locations. The social Sectoral Health and Population Policy 25 provides the overarching policy extension of health coverage, availability orientation for the health sector, including of medications, community participation, reproductive health. A 10-year plan for and water provision. A central component health and social development (Plan of the project has been the construction of Décennal de Développement Sanitaire et community health centers, which are built Social, 1998–2007) and a five-year and equipped with combined state and program (Programme de Développement community resources, managed by Sanitaire et Social, 1998–2002) were community committees, and maintained created to help operationalize the Sectoral through cost recovery. In five years, 374 Health and Population Policy, including its community health centers were built or components regarding reproductive renovated under the project, with 300 health. Plans and programs for some more envisioned for the next five years. specific areas of reproductive health have Both the public and private sectors also been developed or revised since the (NGOs, community associations, private ICPD, including plans for AIDS control, and religious clinics) carry out activities. STD control, and the elimination of Liberalization of regulations governing the excision, and programs related to perinatal practice of private medicine before the care, NGOs, and integrated care for ICPD has facilitated the growth of the childhood diseases. private sector. NGOs have been Under the Sectoral Health and particularly active in developing projects Population Policy, Mali has emphasized related to adolescent reproductive health the decentralization of health service and the elimination of excision. delivery. Starting from the community The government of Mali had already level, each level in the health pyramid has begun integrating services before the a well-defined role as follows: ICPD. It established a spatial integration n village groups and urban neighborhoods system with a precise description of the provide an essential services package positions and duties of service providers. and community management of health Policies, standards, and procedures have centers; been revised and integration improved, n the circle level is responsible for making but the optimal level of integration has not primary referrals, supervising the first yet been achieved because, as one level, and planning and management; respondent says, “structures are inadequate to integrate all the new n the regional level provides secondary aspects.” Another respondent spoke of the referral care and technical assistance to “inadequacy of personnel and training.” the circles; and One respondent said that family planning, n the national level is responsible for postnatal visits, STD screening, newborn orientation and strategic planning, monitoring, and immunization are some defining norms and procedures, and integrated services that are offered by the evaluation.

Community participation is a key strategy to improving access to health “[The NGOs] are truly independent; there services. The Health, Population, and are some that do not want to refer to the Rural Hydraulics Project was developed to state structures, and that often creates carry out the Sectoral Health and conflicts in roles and responsibilities.” Population Policy, focusing specifically on Regional-level respondent, Mali

26 One constraint to implementing reproductive health programs is poor coordination of interventions. Several respondents mentioned that NGOs have helped the state provide services, but coordination between the state and the numerous NGOs has been difficult. As one respondent at the regional level said, “[The NGOs] are truly independent; there are some that do not want to refer to the state structures, and that often creates conflicts in roles and responsibilities.” Some regions have tried to address coordination problems by organizing regional forums. Another constraint is related to personnel. same staff at the same places. At the Though considerable efforts have been peripheral level, community health centers made to improve geographic access to have the technical capabilities to provide health services, the number of personnel is the essential services package, including insufficient, with just one doctor per curative, preventive, and promotional 17,000 inhabitants and one midwife per activities. Staff have received some 23,000 inhabitants. Additional constraints training in reproductive health, primarily concern inadequacy of infrastructure and family planning. funding and sociocultural factors.

27 Financial Resources for Reproductive Health

The five countries examined in this Although respondents acknowledge case study, especially Benin, Burkina Faso, the critical importance of donor support, and Mali, are poor countries with weak some expressed concern about economies; consequently, they depend overdependence on donors and the heavily on donor funding to implement continuity of programs when donors their projects. With the exception of Côte withdraw. Respondents also emphasized d’Ivoire, the countries do not have a that improving effective use of funds is as specific line item for reproductive health; important as generating more money. therefore, it is difficult to determine the Efforts to improve program sustainability amount of money the governments are being made by implementing and allocate to reproductive health. For health reinforcing the cost-recovery system programs in general, government budget specified in the framework of the Bamako allocations are low, but two of the five Initiative (see box, page 18). countries have made praiseworthy efforts to increase their contribution. Mali Benin. Government financing for allocated 10.8 percent of its national reproductive health in Benin remains low. budget to health in 1996, surpassing the Most respondents agreed that donors 10 percent recommended by WHO. Côte finance almost all reproductive health d’Ivoire dedicated only 8 percent of its activities. According to a respondent from budget to health but dramatically a training research center, however, “The increased its contribution to reproductive most important innovation of the decade health between 1995 and 1997. With a of the 1990s is community financing, and contribution of less than 5 percent of its in 1994, it was estimated that 85 percent budget allocated to health programs, of health clinics were self-financed Cameroon seems to be the least through community management, with the committed. government participating only in the payment of salaries.” The primary donors and technical agencies involved in reproductive health The primary donors and technical sectoral programs and projects are agencies involved in reproductive health UNFPA, USAID, WHO, the World Bank, in Benin are UNFPA, USAID, and UNICEF. GTZ, UNICEF, United Nations These organizations are followed by the Development Program (UNDP), and IPPF. WHO, GTZ, UNDP, World Bank, and IPPF is an international NGO that IPPF. UNFPA, for example, gave Benin contributes to the financing of national US$10 million in financing, of which $5 family planning associations. million was for reproductive health in the 28 five-year program ending in 1998. Overall, Wiederaufbrau (KFW), the share of internal donor contributions for reproductive resources would have been fairly weak.” health have increased since the ICPD. The primary donors that provide Some respondents, however, criticized the support to Burkina Faso for population absence of a coordinating structure for policy are the World Bank and KFW, donors, noting that the lack of such which, respectively, provided 61 and 20 structure hinders the efficient allocation of percent of total spending for population resources. activities in 1997 (Ministère de la Santé, Responses from the Benin case study 1998). Other donors included the United show that underuse of available funds Nations (UNFPA, UNDP, UNICEF, stemming from administrative sluggishness UNAIDS), USAID (through the SFPS is a major concern. For example, Phase II Project), the Netherlands, Denmark, the of the Ministry of Health’s IEC and Health Rockefeller Foundation, and Family Project was not carried out because Planning Action International. NGOs officials were not able to develop a active in Burkina Faso include Save the description of the program’s goals and Children, Plan International, World scope in a timely fashion. One respondent Solidarity, IPPF, and the Population pointed out another difficulty: “Funds Council. provided by donors for reproductive health are not always used for activities. There “Projects funded by the donors that have are examples of several Ministry of Health come to term have been either projects that were not carried out inadequately assumed by the successfully because of poor management government, or not at all.” or allocation of funds and resources to National institution representative, Burkina Faso activities different from what was defined in the terms of reference.”

Burkina Faso. In Burkina Faso, the Donor assistance has been invaluable government allocated 19 percent of its in getting reproductive health programs funds to the social sectors in 1997 established, but respondents expressed (Ministère de l’Economie et des Finances, concern that the country has grown too 1998), close to the 20 percent dependent on outside sources and that the recommended by the 1995 World Summit sustainability of programs cannot be for Social Development in Copenhagen. ensured over the long term. As one The UNFPA progress report on the flow of representative of a national institution said, resources allocated for population “Projects funded by the donors that have activities estimated that about 5 percent of come to term have been either financing for population activities comes inadequately assumed by the government, from the government; 80 percent from or not at all.” USAID’s departure in 1995 funds allocated by donors for projects in is an edifying example. USAID had partnership; 10 percent from NGOs; and 5 ensured the national provision of percent from various other associations contraceptive supplies, but after the (UNFPA, 1998). According to the report’s agency’s departure, the national structures conclusion, “In general, we note a were ill prepared to take over that function weakness in internal resources (state and such that stockouts have been frequent. NGO) for financing population activities. If As part of an effort to increase the it hadn’t been for the government credit sustainability of health programs, including from the World Bank and Kreditanstalt fur reproductive health, the Bamako Initiative 29 was launched in 1993. The goal was to specific to reproductive health. As one acquire standardized kits of generic drugs, Ministry of Health representative said, to train health personnel and members of “We have no particular interest in management committees, and to supply reproductive health. It is one activity each health center with a drug kit and among many others in the ministry.” In management tools. Many lenders, fact, donor funding for reproductive health including the World Bank, supported the would seem to replace ministerial funds, creation of a purchasing cooperative for which get used for programs that are less generic drugs. In the beginning, the results attractive to donors. of the cost-recovery strategy were excellent. Community involvement In Cameroon, the primary reproductive increased and considerable income was health donors cited by key informants are generated. Difficulties arose, however, UNFPA, USAID, and the World Bank. when program managers accelerated the Other donors include UNICEF, UNDP, process in 1994. Popular participation WHO, GTZ, the European Union, and the ebbed, other donors felt crowded out by African Development Foundation. Several the World Bank and lost interest, and a respondents criticized the donors for their lack of control over the management of lack of coordination. funds led to significant misappropriations. To ensure the sustainability of services, To deal with these problems, the Ministry the government is increasingly taking steps of Health created 11 regional health to mobilize internal resources, particularly offices in 1996 to replace the 30 former the spread of cost recovery through drug provincial offices that were recognized as purchases and the payment of services in incapable of managing the situation. health centers. Some hospitals have even Cameroon. In Cameroon, the Ministry obtained a special waiver permitting them of Health’s total budget for fiscal year to use 50 percent of receipts collected 1995–1996 was less than 5 percent of the locally. Community participation began in national budget (Ministère de la Santé, the late 1970s and has been reinforced 1998), the lowest allocation of the five since 1989 by the Bamako Initiative. case study countries. The government Nonetheless, the initiative has been therefore relies heavily on foreign financial successfully implemented in only five out assistance. International aid received in of 10 of Cameroon’s provinces, primarily 1996 accounted for 66 percent of total in the English-speaking region, where public health spending, according to a policy has called for community Ministry of Health respondent. participation in health management since Government funds are used primarily for the colonial era. Because of the long infrastructure redevelopment, payment of tradition of community involvement, the salaries, and health unit operating government had no trouble convincing the expenses. The development of population in the English-speaking reproductive health programs is funded provinces to accept the principle of principally by donors. The Ministry of participation. In contrast, the initiative has Health’s budget contains no line item not yet taken hold in the French-speaking provinces because people have become accustomed to receiving free care. “We have no particular interest in The Northwest Province is one area reproductive health. It is one activity among many others in the ministry.” where community participation has Ministry of Health representative, Cameroon succeeded. In 1995, the Provincial Health Delegation developed the Northwest 30 Health Fund, to which village recovery. The unavailability of essential communities in each health district make drugs and limited success in collecting monthly or annual contributions to finance fees have, however, undermined the cost- health services in the province. One recovery system. service provider said that funds from the Through certain donors or specific central level are unreliable, but, “…thanks programs, it is possible to assess the scope to this [community] fund, our activities of interventions according to level of don’t stop often.” Locally elected health financing. In the project for developing committees are responsible for managing integrated health services, the World Bank materials, equipment, and funds from cost provided $13.5 million for the recovery. reproductive health and STD/AIDS Côte d’Ivoire. Currently, the Ministry component. UNFPA contributed $12.5 of Health receives over 8 percent of Côte million under its government assistance d’Ivoire’s general operating budget. It is program (1997–2001), including $6.5 difficult, however, to determine the million for reproductive health activities. proportion of government contributions The regional SFPS Project, funded by specifically allocated for reproductive USAID, has provided $40 million between health programs because contributions 1995 and 2000 for activities supporting primarily cover infrastructure and salaries. development and skill acquisition. Other Nonetheless, the budget for the National donors in reproductive health include the Program for Reproductive Health and African Development Bank, the European Family Planning has increased Union, UNESCO, WHO, UNICEF, and dramatically in the past few years, from 3 donor organizations from France, Japan, million CFA francs in 1995 to 300 million Germany, Belgium, and Canada. in 1996 to 650 million in 1997 (according to a respondent from the National Program for Reproductive Health and Family Planning). AIBEF activities receive state support through an annual subsidy of 200 million CFA francs. In 1998, other NGOs active in the health sector received 554 million CFA francs from the Ministry of Health to cover fixed operating expenses.

Both the government and NGOs are making efforts to promote the sustainability of programs through cost recovery. At AIBEF, clients pay for the first Given the substantial levels of visit (200 CFA francs). Follow-up services government and donor contributions to are free, but products require payment. In reproductive health, several respondents other structures, such as the National concurred that the primary problem is not Institute of Public Health, payment is a lack of financial resources but rather the made according to the type of service ineffective use of those resources. As one except in the case of prevention activities recent report affirms, “The weak (nutrition, immunization, child follow-up, performance of the public health system is etc.), which are free. Implementation of not related to an inadequate budget… It the Bamako Initiative in nine districts results from the choice of the allocation of represents another effort to increase cost resources that has given precedence up to 31 now to the tertiary level and curative care but other areas of reproductive health do to the detriment of the primary and not receive as much attention. secondary levels of the health pyramid…” To continue projects after foreign (Tapinos et al., 1998). Similarly, one financing ends, Mali has, like all the other respondent reported that resource countries in the subregion, implemented allocation does not always correspond to the Bamako Initiative. It conducted the first priorities, as was the case with one project experiments with cost recovery in the late on adolescent sexual and reproductive 1980s but did not develop the conceptual health, which, according to one framework for the initiative until August respondent, began “…without an 1989. At that time, goals, objectives, and evaluation of the needs of the youth strategies were recorded in the “Plan for because people were in a hurry to have the Stimulation of Primary Health Care/ the financial resources.” Bamako Initiative: Conceptual Mali. Mali has no separate line item for Framework.” reproductive health, but respondents agree that reproductive health accounts for a The first implementation stage of the significant part of the overall health Bamako Initiative was the development budget. Government contributions to and implementation of a master plan for health increased in recent years from 9.6 supplying essential drugs, thereby making percent of the total budget in 1997 to 10.0 it possible to ensure the availability of percent in 1998 and 10.8 percent in 1999 essential drugs even in peripheral (MSPAS, 1997–1999). Moreover, the structures. The next stage was the government finances some NGOs, such as development and negotiation of health the AMPPF and the Health, Population, maps by the health services at the circle and Rural Hydraulics Project; however, level. Finally, as mentioned, community most funds for NGOs come from donors. health centers were established with community participation and cost Primary donors include UNFPA, recovery, and referral and cost-sharing USAID, UNICEF, WHO, and international systems were established within each NGOs and associations (Plan circle. International, Population Council). Most One respondent stressed the respondents felt that lender resources have importance of not only increasing funds increased since the ICPD; in fact, they but also using existing funds efficiently: have decreased. The proportion of health “The health niche is lucrative and sector funds received from donors dropped everyone knows it. Financial resources from 57.9 percent in 1997 to 46.7 percent have been wasted with respect to the in 1998 and 35.3 percent in 1999 (MSPAS, results obtained.” To avoid duplication 1997–1999); however, given that donor and waste, the new Health and Social contributions are still extremely important Development Program is designed to in absolute terms, reproductive health provide services through a coherent financing remains heavily dependent on “program approach” rather than a foreign aid. Funding for family planning piecemeal, vertical “project approach.” and AIDS programs is generally sufficient,

32 SummarySummary andand ConclusionConclusion

Not surprisingly, the five case studies country. Despite the similarities, however, reveal many similarities. After all, the five each country has its own unique history, countries share a similar colonial heritage, culture, and political context, all of which exhibit many of the same general social lead to differences in the specific and cultural patterns, and confront some of challenges faced by the five countries and the same general economic and the approaches to addressing them. developmental challenges. The countries also interact regularly. They participate in Table 2 shows the progress made by the same regional conferences that help to each country in formulating and shape their policies; they use their implementing reproductive health policies neighbors’ policies and programs as and programs. While the context in all five models; and they consult the same countries has limited the delivery of high- technical experts and donor quality reproductive health services to representatives who travel throughout the much of the population, all five countries region and apply similar ideas in each have made significant progress in developing reproductive health policies.

TABLE 2. PROGRESS TOWARD IMPLEMENTING POST-CAIRO REPRODUCTIVE HEALTH (RH) POLICIES AND PROGRAMS, 1998

COUNTRY ADOPTION OF PARTICIPATION SUPPORT SETTING PRIORI- RH PROGRAM MOBILIZATION ICPD DEFINI- AMONG STAKE- AMONG STAKE- TIES AMONG RH IMPLEMENTATION OF RESOURCES TION HOLDERS HOLDERS ELEMENTS FOR RH

Rating scale ++ adopted ++ high ++ broad ++ fully set ++ full ++ strong ICPD + partial + partial + partially + partial/in + partial + toward = low = low set progress = little/no ICPD = not set = little/no change = the same change

Benin ++ + + + + =

Burkina Faso ++ ++ + = = +

Cameroon + ++ + = + +

Côte d’Ivoire ++ ++ + = + ++

Mali ++ ++ + = + ++

Note: The assessment reflects the judgment of the local study teams. 33 Except for Cameroon, all the countries held overall health. However, some workshops following the ICPD to spread components of reproductive health, the concept of reproductive health and to including reproductive health services for arrive at a consensus on the meaning of the youth and programs for the elimination of term in each country’s context. While Côte female genital cutting, have been d’Ivoire is the only country to have controversial and have elicited opposition. developed and disseminated a program In addition, many respondents commented specific to reproductive health, all of the that, although the political leadership may countries have incorporated the concept be supportive, the population is generally into new plans for health and population. socially conservative and lags behind. And some countries revised the national Religious leaders, particularly Islamic and population policy to include reproductive Catholic leaders, have also opposed some health. Many respondents commented, aspects of reproductive health. however, that the new policies require Little progress has been made in further dissemination and that the concept setting reproductive health priorities. As of reproductive health is still not widely countries have developed reproductive understood, particularly outside the health programs, they have tried to address capital city. the full range of issues outlined in the The case studies revealed that ICPD Programme of Action without governments have warmed to civil society systematically assessing which areas participation in developing and should receive high priority. When implementing reproductive health national programs embrace all programs and that the number of reproductive health components without reproductive health NGOs in the countries identifying priorities, each organization is has multiplied in recent years. However, left to set its own priorities according to its the effectiveness of such participation is own perceptions. Setting national priorities uncertain. Several respondents cited the is critical to the effective channeling of the institutional weakness of many NGOs. For region’s limited resources to support their part, several NGO representatives said programs in areas of greatest need. that although they are often invited to Though the five countries were already attend workshops, the invitation is usually a implementing some reproductive health formality, and they are not included as programs before the ICPD, the new active partners, which limits their ability to reproductive health concept focused on effectively participate. issues that had not previously received Only in the past 10 years has political much attention. These issues have been support for family planning programs largely incorporated into policies and begun to take root in the five case study programs but are just beginning to be countries. Support increased as leaders, implemented in the field. Some of the first, began to perceive family planning as a newer projects address areas such as critical element of MCH rather than as a female genital cutting and reproductive means to control population growth and, health services for youth and men. In second, came to understand the potential addition, personnel are being trained to negative consequences of rapid population increase their understanding of the new growth. Leaders have also had an easier reproductive health orientation and to time accepting the new focus on the improve their skills in order to provide a broader, more integrated concept of broader range of integrated reproductive reproductive health and its emphasis on health services. 34 Despite these efforts, actual All five countries have limited implementation of programs lags far financial resources and rely heavily on behind policy formulation. Numerous donor assistance. Despite these challenges confront those trying to make constraints, they are trying to mobilize high-quality reproductive health care internal resources for reproductive health. available and accessible to the population. Mali and Côte d’Ivoire in particular devote Some frequently cited obstacles include a a substantial portion of their budgets to lack of personnel and the unequal health in general and reproductive health distribution of existing personnel and in particular. All of the countries, but infrastructure (generally concentrated near especially Mali, are making efforts to the capital city). At the same time, social mobilize community resources through issues, such as the generally low status of cost recovery. In addition to the quantity women and women’s low income and of resources, however, more effort needs education levels, are serious barriers to to be devoted to ensuring the effective and reaching women with reproductive health efficient use of resources. information and services. Poor In conclusion, all of the countries have coordination is another problem that has made tremendous progress toward hindered program implementation. The developing reproductive health policies integrated reproductive health approach and programs, and, at the same time, they requires the involvement of a large have become more receptive to the number of actors to implement the various participation of civil society in the policy parts of the program. A few of these actors formulation process. While the five include representatives from the ministries countries have initiated activities to of Education, Health, and Planning, donor improve the delivery of reproductive agencies, and NGOs. All of the countries health services, they still need to do much reported that coordination among these in the area of implementation. Poverty and actors has been problematic. However, underdevelopment in the region are major many respondents pointed out that only a constraints, making it more important that few years had passed since the ICPD, and countries focus on priority interventions it was therefore not surprising that and improving the efficient use of existing implementation was still incomplete. resources. The case studies also Initially, countries focused on the highlighted the need to continue efforts to development of plans and policies to create broad-based support for guide interventions—a process that is now reproductive health programs, improve nearly complete. Currently, they are coordination among stakeholders, and turning their attention to interventions in strengthen the growing number of NGOs order that the comprehensive reproductive that can effectively participate in policy health services described in the plans and processes. policies are actually available in the field.

35 Appendix

Summary Tables of Reproductive Health Policies and Programs SummarySummary TablesTables ofof ReproductiveReproductive HealthHealth PoliciesPolicies andand ProgramsPrograms

TABLE A1. EXISTENCE OF POLICIES COVERING REPRODUCTIVE HEALTH IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1999

COMPONENTS COUNTRY OF REPRODUC- TIVE HEALTH BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Family planning 1996: National 1991: National 1992: Standards 1999: Reproductive 1991: Population Population Policy Population Policy for Maternal and Health Services Policy Child Health/Fam- Policy 1996: National Ma- 1992: Policy and ily Planning 1990: Sectoral ternal and Child Standards for Ma- 1999: Reproductive Health and Popula- Health, Family ternal and Child 1992: National Health Service tion Policy (revised Planning, and Nu- Health/Family Population Policy Standards post-ICPD) trition Program Planning 1996: Declaration 1999: National 1996: Policies, Stan- 1999: Policy and 1996: Reproduc- of Health Policy Program for Repro- dards and Proce- Norms in Family tive Health Strate- ductive Health and dures in Reproduc- Health gic Plan Family Planning in tive Health/ Family Côte d’Ivoire Planning 1997: National Strategy of Safe In progress: Na- Motherhood tional Reproductive Health Program 2000: Revision of National Popula- tion Policy (draft)

Prenatal care 1996: National 1992: Policy and 1992: Standards 1999: Reproductive 1990: Sectoral Population Policy Standards for Ma- for Maternal and Health Services Health and Popula- ternal and Child Child Health/Fam- Policy tion Policy (revised 1997: Policy and Health/Family ily Planning post-ICPD) Strategy for Devel- Planning 1999: Reproductive opment of the 1992: National Health Service 1996: Policies, Stan- Health Sector, 1994: National Population Policy Standards dards and Proce- 1997–2001 Program for Mater- dures in Reproduc- nal and Child 1993: Primary 1999: National tive Health/ Family 1999: Policy and Health/Family Health Care Pro- Program for Repro- Planning Standards in Family Planning gram ductive Health and Health Family Planning in 1997: National 1996: Declaration Côte d’Ivoire Strategy of Safe of Health Policy Motherhood

38 TABLE A1. EXISTENCE OF POLICIES COVERING REPRODUCTIVE HEALTH IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1999 (CONT.)

COMPONENTS COUNTRY OF REPRODUC- TIVE HEALTH BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

STDs 1997: Policy and 1990: National 1989: National 1987: National 1987: National Strategy for Devel- AIDS and STD AIDS Control Pro- Committee for AIDS Control Pro- opment of the Control Program gram AIDS Control gram Health Sector, (CNLS) 1997–2001 1992: Standards 1990: Sectoral for Maternal and 1993: National Health and Popula- 1996: National Child Health/Fam- AIDS and STD tion Policy (revised Population Policy ily Planning Control Program post-ICPD)

1999: Policy and 1993: Primary 1995: National 1994: Guidelines Standards in Family Health Care Pro- AIDS, STD, and for Syndromic Man- Health gram Tuberculosis Con- agement of STDs trol Program 1996: Health Policy

HIV/AIDS 1997: Policy and 1990 National 1989: National 1987: CNLS 1987: National Strategy for Devel- AIDS and STD AIDS Control Pro- AIDS Control Pro- opment of the Control Program gram 1993: National gram Health Sector, AIDS and STD 1997–2001 1990-93 Medium 1992: Standards Control Program 1990: Sectoral Term Plan I for Maternal and Health and Popula- 1996: National Child Health/Fam- 1995: National tion Policy (revised Population Policy 1993-95 Medium ily Planning AIDS, STD, and post-ICPD) Term Plan II Tuberculosis Con- 1999: Policy and 1993: Primary trol Program Standards in Family Health Care Pro- Health gram

1996: Health Policy

1999: AIDS re- search program

Infertility 1996: National Ma- 1992: Policy and 1992: Standards 1999: Reproductive 1996: Policies, Stan- ternal and Child Standards for Ma- for Maternal and Health Services dards and Proce- Health, Family ternal and Child Child Health/Fam- Policy dures in Reproduc- Planning, and Nu- Health/Family ily Planning tive Health/Family trition Program Planning 1999: Reproductive Planning Health Service 1999: Norms and 1994: National Standards Standards in Re- Program for Mater- productive Health nal and Child 1999: National Policy Health/Family Program for Repro- Planning ductive Health and Family Planning in Côte d’Ivoire

Safe mother- 1999: Norms and 1992: Policy and 1992: Standards 1999: Reproductive 1993: Program for hood Standards, National Standards for Ma- for Maternal and Health Services perinatal period de- Family Planning, ternal and Child Child Health/ Policy veloped and subse- Maternal and Child Health/Family Family Planning quently imple- Health Program Planning 1999: Reproductive mented 1996: Health Policy Health Service 1997: National Standards Strategy of Safe Motherhood 1999: National Program for Repro- ductive Health and Family Planning in Côte d’Ivoire 39 TABLE A1. EXISTENCE OF POLICIES COVERING REPRODUCTIVE HEALTH IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1999 (CONT.)

COMPONENTS COUNTRY OF REPRODUC- TIVE HEALTH BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Postabortion 1999: Norms and 1998: Develop- No policy 1999: Reproduc- 1996: Policies, Stan- care Standards, National ment of two ex- tive Health Ser- dards and Proce- Family Planning, perimental projects vices Policy dures in Reproduc- Maternal and Child tive Health/ Family Health Program 1999: Reproductive Planning Health Service Standards

1999: National Program for Repro- ductive Health and Family Planning in Côte d’Ivoire

Genital tract 1999: Norms and 1994: Policy and 1992: Standards 1999: Reproductive Included in 1990 infections Standards, National Standards for Ma- for Maternal and Health Services Sectoral Health and Family Planning, ternal and Child Child Health/Fam- Policy Population Policy. Maternal and Child Health/Family ily Planning No specific docu- Health Program Planning 1999: Reproductive ment. 1992: National Health Service 1996: Reproduc- Population Policy Standards tive Health Strate- gic Plan 1993: Primary 1999: National Health Care Pro- Program for Repro- 1997: National gram ductive Health and Strategy of Safe Family Planning in Motherhood 1996: Health Côte d’Ivoire Policy

Reproductive 1999: Policy and 1996: Reproduc- No policy No policy but exist- Nothing specific be- health services Standards in Family tive Health Strate- ence of project IVC/ yond the documents for adolescents Health gic Plan 98/PO3.1998 cited above which include reproductive 1996: National health for adoles- Youth Health Pro- cents; other consid- gram (being devel- erations in progress. oped)

Maternal and 1999: Policy and 1994: National 1992: Standards Policy and program Being drafted. child nutrition Standards in Family Maternal and for Maternal and in the approval Health Child Health/Fam- Child Health/ process ily Planning Pro- Family Planning gram

1997: National Nutrition Action Plan

Genital cancers 1999: Policy and 1992 Policy and 1992: Standards 1999 Reproductive 1996: Policies, Stan- Standards in Family Standards for Ma- for Maternal and Health Services dards and Proce- Health ternal and Child Child Health/ Policy dures for Reproduc- Health/Family Family Planning tive Health/ Family Planning 1999: Reproductive Planning 1994: Primary Health Service 1994: National Health Care Pro- Standards Maternal and gram Child Health/Fam- 1999: National ily Planning Pro- Program for Repro- gram ductive Health and Family Planning in 40 Côte d’Ivoire TABLE A1. EXISTENCE OF POLICIES COVERING REPRODUCTIVE HEALTH IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1999 (CONT.)

COMPONENTS COUNTRY OF REPRODUC- TIVE HEALTH BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Female circumci- 1999: Policy and 1990: Creation of No policy No assessment National Committee sion Standards in Family National Commit- (n/a) against Practices Health tee against Exci- Harmful to the sion Health of Women and Children cre- 1997: Law penaliz- ated by Decree No. ing practice of fe- 382/PM-RM of the male genital cut- 12/31/1996 Na- ting tional Action Plan for the Abandon- 1998: Action Plan ment of Excision, of the Ministry for drafted in 1997, fi- the Promotion of nalized and pre- Women sented to the Coun- cil of Ministers in 1998

Violence against None 1998: Action Plan 1997: National Ac- National Policy for National Action women of the Ministry for tion Plan for the In- the Development of Plan for the Promo- the Promotion of tegration of Women tion of Women Women Women in Devel- 1996–2000 (not opment National Action limited to violence Plan for Women against women, ad- currently in the dresses many other adoption process topics as well)

41 TABLE A2. POLICY ENVIRONMENT FOR IMPLEMENTING REPRODUCTIVE HEALTH PROGRAMS IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1998

COMPONENTS OF POLICY COUNTRY ENVIRONMENT BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Level of participation in the de- velopment of reproductive health policies and programs by:

o Ministries (other than Health) High High High High High o NGOs involved in reproduc tive health Medium Medium High Medium High o Women’s lobbies Low Medium Medium Medium Low o Religious leaders Very low Low Medium Low Medium o Community leaders Medium Medium Medium High High o University Medium High High Almost Medium nonexistent

Degree of support for reproduc- tive health by political leaders: o President High High High High High o Prime Minister High High Medium No assessment Medium o Members of Parliament Mixed High Varies Medium High o Ministers High Varies Varies No assessment No assessment

Degree of support for reproduc- tive health and influence of reli- gious leaders: o Support Low Low Mixed Medium Medium o Influence High Low Low Medium Medium

Existence of a plan for imple- mentation of reproductive health policies and programs o National level Yes Yes Not yet Being developed Yes o Subnational level Yes Yes Yes Being imple- Yes mented

Structure of reproductive health Integrated: Partially Gradually inte- Implementation Integrated programs maternal and integrated grating services in progress particularly for o Vertical or integrated? child health/ in health centers, (prenatal/ family planning/ family planning/ including the reproductive postnatal care, STDs National AIDS health/family immunization Control Program planning) /EPI/nutrition/ MCH/family 42 planning TABLE A2. POLICY ENVIRONMENT FOR IMPLEMENTING REPRODUCTIVE HEALTH PROGRAMS IN FIVE FRANCOPHONE AFRICAN COUNTRIES, 1998 (CONT.)

COMPONENTS OF POLICY COUNTRY ENVIRONMENT BENIN BURKINA FASO CAMEROON CÔTE D’IVOIRE MALI

Knowledge of reproductive health components of reproduc- tive health policy and programs by service providers: o in the public sector Low Medium Medium Medium Low o in the private sector Low Medium Medium Low Very low o in NGOs Medium Low Low Medium (high Very low for AIBEF, low for the rest)

Training on various reproductive health components for service providers belonging to: o the public sector Mixed Medium Medium Medium Medium o the private sector Low Low Medium Low Medium o NGOs Low High Low High for most Medium AIBEF providers

Increase in resources allocated to reproductive health following the resolutions of the ICPD in 1994: o of the public sector Yes Yes Yes Yes Yes o of the private sector Yes No assessment Yes No Yes o of NGOs Yes Yes Yes Yes Yes o of donors Yes Yes Yes Yes Yes

Adequacy of resources for imple- Inadequate Substantial for No assessment No assessment Adequate for mentation of reproductive health family planning family planning/ programs and AIDS con- AIDS; trol insufficient for other elements

Percent of national resources for Very low 20% of national 5% for health 8% for health, 11% for health, implementation of reproductive budget allocated significant in- no separate health programs (% of national to social sectors crease for repro- budget for budget) including health ductive health in reproductive 1997 health

43 References

Ministère de l’Economie et des Finances Tapinos G., P. Hugon, and P. Vimard. and United Nations Development 1998. Etude relative aux défis Program. 1998. Initiative 20/20 au démographiques majeurs et au Burkina Faso. Ouagadougou: Ministère développement durable en Côte-d’Ivoire. de l’Economie et des Finances. Abidjan/Paris: BNEDT–FNSP/IEP. Ministère de la Santé. 1998. Plan UNAIDS/WHO. 1998. Epidemiological stratégique de santé de la reproduction Fact Sheet on HIV/AIDS and Sexually du Burkina Faso, 1998–2008. 1st draft. Transmitted Diseases. www.unaids.org/ Ouagadougou: Ministère de la Santé. hivaidsinfor/statistics/june98/factsheets/ pdfs/reunion.pdf. Ministère de la Santé. 1998. Programme National de Développement Sanitaire, United Nations Population Fund. 1998. 1998–2008. Yaounde: Ministère de la Rapport sur le flux des ressources Santé. nationales affectées aux activités de population au Burkina Faso en 1997. Ministère de la Santé Publique et Action Draft. Ouagadougou: UNFPA. Sociale (MSPAS). 1991. Lettre Ministérielle Circulaire no. 004/MS.PAS/ World Bank. 1998. World Development CAB, 25 janvier 1991. Bamako: MSPAS. Indicators. Washington, DC: World Bank. Ministère de la Santé Publique et Action Sociale (MSPAS). 1998. Programme de World Health Organization, Africa Développement des Services socio- Regional Bureau. 1998. Santé de la sanitaires. Bamako: MSPAS. reproduction: Stratégie de la région africaine 1998-2007. World Health Ministère de la Santé Publique et Action Organization. Sociale, Direction Administrative et Financière (MSPAS). 1997–1999. Budget documents. Bamako: MSPAS. Population Reference Bureau. 1998 and 1999. World Population Data Sheet. Washington, DC: Population Reference Bureau.

44 ContentsContents

iv Preface v Acknowledgments vi Executive Summary vii Abbreviations

1 Introduction

3 Reproductive Health Context in the Five Countries

5 The Policy Process: Definitions of Reproductive Health, Policies, and Priorities

15 Participation, Support, and Opposition

21 Policy Implementation

28 Financial Resources for Reproductive Health

33 Summary and Conclusion

37 Appendix

44 References

iii PrefacePreface

The mission of the Network for Reproductive Health Research in Africa (RESAR) is to improve reproductive health through research and training. The organization receives grants for operations under project performance contracts with governmental and nongovernmental organizations as well as with bilateral and multilateral donors involved in reproductive health. RESAR is currently made up of 10 national units in Francophone Africa called CRESARs.

The goal of the POLICY Project is to create supportive policy environments for family planning and reproductive health programs, including HIV/AIDS, through the promotion of a participatory policy process and population policies that respond to client needs. The project has four components—policy dialogue and formulation, participation, planning and finance, and research—and is concerned with crosscutting issues such as reproductive health, HIV/AIDS, gender, and intersectoral linkages.

POLICY Occasional Papers are intended to promote policy dialogue on family planning and reproductive health issues and to present timely analysis of issues that will inform policy decision making. The papers are disseminated to a variety of policy audiences worldwide, including public and private sector decision makers, technical advisors, researchers, and representatives of donor organizations.

An up-to-date listing of POLICY publications is available on the project’s website. Copies of POLICY publications are available at no charge. For more information about the project and its publications, please contact:

Director, POLICY Project The Futures Group International 1050 17th Street, NW, Suite 1000 Washington, DC 20036 Telephone: (202) 775–9680 Fax: (202) 775–9694 E-mail: [email protected] Internet: www.policyproject.com www.tfgi.com iv AcknowledgmentsAcknowledgments

This paper reflects findings from five case studies conducted by RESAR with financial and technical support from the POLICY Project. RESAR’s Justine Tantchou coordinated the research, which was carried out by country teams. Country case studies were conducted and written by RESAR members and reviewed by Tantchou and POLICY’s Ellen Wilson. Titles and authors of the case studies are given below: n Formulation de politiques post-Caire: Le cas de la République du Bénin by Béatrice Aguessy and Elisabeth Fourn. n Formulation de politiques et mise en œuvre des programmes post-Caire: Etudes de cas sur la santé de la reproduction au Burkina Faso by Stanislas Paul Nebié and Idrissa Ouedraogo. n Formulation de politiques et mise en œuvre des programmes post-Caire: Etudes de cas sur la santé de la reproduction au Cameroun by Paschal Awah and Justine Tantchou. n Formulation de politiques et des programmes post-Caire: Le cas de la Côte d’Ivoire by Zoumana Kamagate and Aminata Noëlle Sangaré. n Formulation de politiques et mise en œuvre des programmes post-Caire: Etudes de cas sur la santé de la reproduction au Mali by Hafsatou Diallo, Tamo Tamboura, and Mahamadou Traore. The full text of the individual country reports, in French, can be obtained by contacting RESAR at the following address: Dr. Justine Tantchou Vice President in Charge of Training and Research RESAR PO Box 8176 Yaounde, Cameroon E-mail: [email protected] We heartily thank everyone who contributed to this evaluation of reproductive health policy development and program implementation in Francophone Africa. We give special thanks to the respondents in the five countries who found the time for multiple interviews in spite of their busy schedules and who so graciously provided the interviewers with numerous documents.

We also give thanks to the POLICY Project for its moral, financial, and technical support. In particular, we wish to thank Jen Marenberg for her tireless assistance with the editing of this paper and Karen Hardee and Kokila Agarwal for reviewing earlier versions. Finally, we would like to thank Elizabeth Schoenecker and Barbara Crane for their helpful comments. The opinions expressed in this report, however, do not necessarily reflect those of USAID. v ExecutiveExecutive SummarySummary

The 1994 Cairo International Conference on Population and Development (ICPD) increased worldwide focus on reproductive health. Many countries have been working to revise their reproductive health policies in accordance with the ICPD Programme of Action. In 1998, the Network for Reproductive Health Research in Africa (RESAR), with support from the POLICY Project, conducted case studies in five Francophone African countries—Benin, Burkina Faso, Cameroon, Côte d’Ivoire, and Mali—to examine field experiences in formulating and implementing reproductive health policies. Findings were based on in-depth interviews with key informants active in the reproductive health field in their respective countries.

Because the five countries are located in the same region, they exhibit many similarities, yet each differs slightly in the challenges it faces and the approaches it takes to confront them. In general, the five countries have made considerable progress in integrating the concept of reproductive health into policies and programs, although more needs to be done to disseminate new policies and implement effective programs. While some aspects of reproductive health generate opposition, particularly programs for youth and programs against female genital cutting, overall support for reproductive health has increased in recent years. Governments are allowing nongovernmental organizations (NGOs) to participate in policy formulation, and most countries are devoting more internal resources to reproductive health. Though these changes are encouraging, continued resistance on the part of the public sector to full partnership with NGOs, as well as the varying capabilities of many NGOs, has hindered NGO participation. Moreover, countries are still highly dependent on support from international donors for their funding. Less progress has been made in program implementation than in policy formulation. Some concrete changes are apparent, but the task of converting the concept of reproductive health into a reality in the field is sure to be a long, slow process.

Poverty and underdevelopment in the region are major constraints to reproductive health programs; consequently, countries must focus their efforts on priority interventions and use their existing resources more efficiently. The case studies also highlight the need to continue efforts to create broad-based support for reproductive health programs, improve coordination among stakeholders, strengthen NGOs so that they can effectively participate in the policy process, and enhance the financial sustainability of programs. vi AbbreviationsAbbreviations

ABBEF Association for Family Well-Being of Burkina Faso ABPF Beninese Family Planning Association AIBEF Association for Family Wellness of Côte d’Ivoire AIDS Acquired immune deficiency syndrome AMPPF Malian Association for the Promotion and Protection of the Family BUNAP National Population Bureau (Côte d’Ivoire) CNLS National Committee for AIDS Control CONACOPP National Committee for the Coordination of Population Programs (Mali) CONAPO National Population Council (Burkina Faso, Côte d’Ivoire) DHS Demographic and Health Survey DSF Directorate of Family Health (Benin) GNP Gross national product GTZ German Technical Cooperation Agency HIV Human immunodeficiency virus ICPD International Conference on Population and Development IEC Information, education, and communication IMSC Integrated Management of Childhood Disease IPPF International Planned Parenthood Federation KFW Kreditanstalt fur Wiederaufbrau MCH Maternal and child health NACP National AIDS Control Program NGO Nongovernmental organization PSSP Health and Population Policy (Mali) RESAR Network for Reproductive Health Research in Africa ROBS Network of Beninese Health NGOs SFPS Family Health and AIDS Prevention Project STD Sexually transmitted disease UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Program UNESCO United Nations Educational, Scientific, and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization vii