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.