• Abstract and Figures
• Public Full-text

FROM ADDING TO THE BURDEN TO SHARING THE LOAD:

GUIDELINES FOR MALE INVOLVEMENT IN REPRODUCTIVE HEALTH IN CAMBODIA

Margaret E. Greene Naomi Walston Anne Jorgensen Mean Reatanak Sambath Karen Hardee

January 2006 FROM ADDING TO THE BURDEN TO SHARING THE LOAD:

GUIDELINES FOR MALE INVOLVEMENT IN REPRODUCTIVE HEALTH IN CAMBODIA

January 2006

This publication was produced for review by the United States Agency for International Development. It was prepared by Margaret E. Greene, Naomi Walston, Anne Jorgensen, Mean Reatanak Sambath, and Karen Hardee. It was reviewed by Khieu Serey Vuthea, Meas Pheng, James Gribble, Anne Eckman, Candice Sainsbury, Morissa Malkin, Michelle Prosser, Mary Kincaid, Carol Shepherd, and Hun Ratana. The authors’ views expressed in this publication do not necessarily reflect the view of the United States Agency for International Development or the United States Government. CONTENTS

Acknowledgments...... iii

Executive Summary...... iii

Abbreviations...... iii

Introduction...... 3 What Is Male Involvement, and Where Did it Come From?...... 3 Why Is it Important to Think About Male Involvement at the Policy Level?...... 3 National policies set directions...... 3 Civil society increasingly informs policy...... 3 Transforming policy into action...... 3 Purpose of This Case Study...... 3 Background on Reproductive Health in Cambodia...... 3 Program and Policy Context for Male Involvement in Reproductive Health in Cambodia...... 3

Building Support for Male Involvement...... 3 RHPWG’s Advocacy Leads to High-level Consensus on Role of Male Involvement Guidelines...... 3 Developing Male Involvement Guidelines in Cambodia...... 3 Opportunities to Integrate the Guidelines into Concrete Actions...... 3 Integrating the Male Involvement Guidelines in the Strategic Plan for Reproductive Health in Cambodia (2006–2010)...... 3 A Snapshot of Activities and Accomplishments...... 3

Lessons Learned...... 3

Conclusion...... 3

Attachment 1: Approaches to Male Involvement in Reproductive Health (1999)...... 3 Attachment 2: Assessment of Opportunities to Involve Men in Cambodia’s Reproductive Health-Related Policies (October 2004)...... 3 Attachment 3: Male Involement is the Key to Reproductive Health (Fact Sheet, October 2004)...... 3 Attachment 4: Guidelines for Involving Men in Reproductive Health Activities in Cambodia (Abbreviated Version, November 2005)...... 3 Attachment 5: Strategic Plan for Reproductive Health in Cambodia (2006-2010): How Male Involvement Guidelines and Activities Can Contribute to the Effective Implementation of the Plan (November 2005)...... 3 Attachment 6: Guidelines for Involving Men in Reproductive Health in Cambodia (Draft, December 2005)...... 3

References...... 3

iii iv ACKNOWLEDGMENTS

The guidelines for involving men in reproductive health in Cambodia are the result of impressive hard work and collaboration of many individuals and organizations in Cambodia. Special thanks must go to the members of the Reproductive Health Promotion Working Group (RHPWG), past and present, for their continuous research and advocacy efforts. We are grateful to MEDiCAM, USAID’s Interagency Gender Working Group, and the United Nations Population Fund for supporting the RHPWG in its achievements. Thanks must also go to the National Reproductive Health Program, particularly the Director, Dr. Tung Rathavy, for her enthusiastic support for the guidelines, and to all who participated in the meetings and workshops where the guidelines were shaped. USAID’s ongoing support for this and other male involvement initiatives made this work possible.

Finally, special thanks also go to the late Dr. Ty Chettra of POLICY/Cambodia, who was a constant source of enthusiasm, knowledge, and guidance and a leading figure in moving male involvement forward. The team dedicates this paper in memory of Dr. Chettra.

v EXECUTIVE SUMMARY

There is growing global recognition of the important benefits of involving men in reproductive health (RH) programs. At the 1994 International Conference on Population and Development (ICPD) in Cairo, 179 countries signed a Program of Action that includes “male responsibilities and participation” as critical aspects for improving RH outcomes, achieving gender equality and equity, and empowering women (UNFPA, 1994).1 The ICPD fostered programs and studies that acknowledged the critical role that men play in reproductive health as sexual partners, fathers, decisionmakers, and actors in preventing sexually transmitted infections, including HIV/AIDS; controlling fertility; reducing gender-based violence; and improving health-seeking behaviors. As agents of social change, men can contribute to all of these desired outcomes.

While much attention has been devoted to designing program models to involve men, little focus has been paid to the policy environment and the practical policies and guidelines that could support these programs. Policies and guidelines should be formulated to ensure that male involvement efforts are more than a series of discrete program activities.

This case study focuses on Cambodia, where a group of advocates recognized that involving men was an important aspect of improving the country’s reproductive health status. Members of MEDiCAM, a large network of health nongovernmental organizations in Cambodia, formed the Reproductive Health Promotion Working Group (RHPWG), with technical assistance from the POLICY Project. Working as a bridge between implementers and policymakers, the RHPWG identified male involvement in reproductive health as its top advocacy priority. Through concerted advocacy efforts, the group succeeded in garnering policymaker support and worked with relevant ministries and other stakeholders to establish standard guidelines for male involvement programs. The draft guidelines were structured to align with the major components of the country’s forthcoming Strategic Plan for Reproductive Health in Cambodia (2006–2010), which now refers explicitly to male involvement in several places. Cambodia’s experience is a good model for other countries seeking to strengthen male involvement initiatives through advocacy, policy development, and implementation.

1 All discussion on the contents and commitments of the ICPD declaration pertain only to those countries where the declaration has been signed. The United States government supports many of the goals in the ICPD program of action contingent on several understandings, in particular that the ICPD documents do not create international legal rights, including any right to abortion, nor do they create any legally binding obligations on the states under international law.

vi ABBREVIATIONS

ANC antenatal care AIDS acquired immune deficiency syndrome AFRSH adolescent-friendly reproductive and sexual health ARSH adolescent reproductive and sexual health BCC behavior change communication CAPPD Cambodian Association of Parliamentarians on Population and Development CBD community-based distribution HIV human immunodeficiency virus ICPD International Conference on Population and Development IEC information, education, and communication IGWG Interagency Gender Working Group M&E monitoring and evaluation MCH maternal and child health MOE Ministry of Environment MOEYS Ministry of Education, Youth, and Sports MOH Ministry of Health MOI Ministry of Information MOP Ministry of Planning MOWA Ministry of Women’s Affairs (formerly the MOWVA) MOWVA Ministry of Women’s and Veterans’ Affairs MORD Ministry of Rural Development MSM men who have sex with men MTCT mother-to-child transmission NAA National AIDS Authority NGO nongovernmental organization NRHP National Reproductive Health Program PMTCT prevention of mother-to-child transmission RH reproductive health RHPWG Reproductive Health Promotion Working Group STI sexually transmitted infection UNFPA United Nations Population Fund USAID United States Agency for International Development VCCT voluntary confidential counseling and testing

vii INTRODUCTION

What Is Male Involvement, and Where Did it Come From?

Men’s involvement in sex and reproduction cannot be disputed. Yet, until recently, family planning programs have focused on women (Greene and Biddlecom, 2000; Jacobson, 2000). Since the 1994 International Conference on Population and Development (ICPD) in Cairo, international family planning programs have had a broad mandate to serve the needs of women and men of all ages and to address gender inequities (Boender et al., 2005). The ICPD Program of Action, signed by 179 countries, unequivocally links programs to improve reproductive health (RH) with efforts to address the gendered values and norms that harm both men’s and women’s health and impede development.2 Involving men has been a prominent part of the shift from family planning to the broader RH agenda, including HIV/AIDS.3 Men constitute an important asset in efforts to improve women’s health, and they make up a significant new clientele for programs. Efforts to involve them in ways that transform gender relations and promote gender equity contribute to a broader development agenda.

Since ICPD, there has been an evolving dialogue about different underlying program approaches and aims focused on involving men in reproductive health. Research conducted in 1999 laid out four paradigms for men’s involvement in reproductive health (Greene, 1999). The first was the “family planning” approach, which predominated prior to Cairo and in which women were the main targets of family planning. Since Cairo, three main approaches have predominated: the “men and family planning approach,” targeting men with family planning messages to increase their female partners’ use of contraception; the “male equality approach,” encouraging men to meet their own health concerns and addressing masculine norms that place men’s health at risk; and the “gender equity in reproductive health” approach, addressing men’s roles and gendered norms not only to improve male health but also to transform gender relations between men and women and to increase men’s support for women’s equity, rights, and health (see Attachment 1). Policies and programs that recognize that substantial male involvement is needed to promote gender equity and improve both men’s and women’s reproductive health are closest to this last approach.

Why Is it Important to Think About Male Involvement at the Policy Level?

While promising program models are emerging, as noted above, less explicit attention has been paid to the level of policy challenges or opportunities that could promote an enabling environment for addressing men’s roles in improving their own and their partners’ health.

National policies set directions Policy and political leadership bridges the gap between international frameworks and specific national programs; several national initiatives help illustrate this point. Uganda recognized early in the 1980s that promoting gender equity was crucial for stemming the tide of the AIDS

2 All discussion on the contents and commitments of the ICPD declaration pertain only to those countries where the declaration has been signed. The United States government supports many of the goals in the ICPD program of action contingent on several understandings, in particular that the ICPD documents do not create international legal rights, including any right to abortion, nor do they create any legally binding obligations on the states under international law. 3 The 2003 U.S. President’s Emergency Plan for AIDS Relief (EP) also notes the need to promote gender equity. Office of the United States Global AIDS Coordinator. The President’s Plan for AIDS Relief: U.S. Five-Year Global HIVAIDS Strategy. Washington, D.C., February 2004, p. 9.

1 epidemic in that country (Hogle, 2002). In recognition of the role of poverty and women’s vulnerability to HIV, President Museveni’s government promoted women’s political and economic participation, called on men to be more respectful to women, and fostered government and nongovernmental organization (NGO) programs that promoted gender equity. Jamaica, concerned with social exclusion of young men, has developed and promoted policies that focus attention on meeting the needs of young men, including through a multisectoral youth policy and strategic plan (POLICY Project, 2004). Guatemala’s 1996–2000 Presidential Action Plan for Social Development, created in collaboration with civil society organizations, led to the establishment of Guatemala’s Law of Social Development and Population of 2001 (Republic of Guatemala, 2001; Gribble, 2004). Its articles call for the promotion of gender equity and address responsible fatherhood and motherhood. The health sector is charged with implementing RH programs that serve both men and women. Costa Rica’s Responsible Fatherhood Legislation of 2001 has reduced the number of children unacknowledged by their fathers, which dropped from 29.3 percent in 1999 to 7.8 percent in 2003 (Ministerio de Educación Pública, República de Costa Rica, 2001; Centro Centroamericano de Población, n.d.). Botswana’s 1994 family planning policy guidelines and standards provide a good model of how to address men in the clinical aspects of the health system (Republic of Botswana, MOH, 1994). These examples illustrate the different ways in which policy changes have laid the groundwork for health and social programs that work with men.

Civil society increasingly informs policy In the past two decades, civil society has played an increasingly important role in influencing the way governments formulate and enforce policies and programs. Civil society advocacy is important for stimulating policy change and for bringing issues to national and regional attention. NGOs advocating for improvements in women’s health were instrumental in shaping the Cairo Program of Action and in subsequently calling for male involvement in programs and policies. In Cambodia, the input of civil society into the country’s healthcare system since the 1990s has been essential. After decades of conflict, the Ministry of Health (MOH) was chronically understaffed and under-resourced, and the public health system was weak. Civil society was looked upon to fill the gaps in services and build the capacity of the government’s health services. To this end, civil society continues to play an active role in guiding health sector reform, including identifying areas of greatest need, the most workable approaches for the delivery of healthcare, and the effects of health policy reform; and helping in the development of national guidelines (WHO, 2002). The link between the government and civil society is illustrated by the experience described in this case study.

Transforming policy into action National policies provide the broad vision and framework for government action and set forth the priorities and roles of contributing institutions. In documents like national development plans or ministerial speeches, references to men’s roles in reproductive health may be viewed as statements of intention. To succeed, national policies and statements of support must be translated into programs to achieve the goals set forth at the national level; this generally requires the development of operational policies that guide implementation: Operational policies, which include regulations, codes, and policies affecting health system operations, link national laws and policies to programs. Operational policies exist at different levels of the health structure, such as public sector regulations, health systems management, and at the service delivery level (Cross et al., 2001). Strategic plans are often used to provide more operational detail to national policies.

2 Purpose of This Case Study

The purpose of this paper is to document and share lessons learned from a civil society-led effort in Cambodia to formulate national guidelines for male involvement—that could not only be incorporated into the Strategic Plan for Reproductive Health in Cambodia (2006–2010) but also could be used to help implement other sector policies. The Reproductive Health Promotion Working Group (RHPWG), with assistance from the POLICY Project and the Interagency Gender Working Group (IGWG),4 began this effort in 2003.

Background on Reproductive Health in Cambodia

In Cambodia, 60 percent of the total population is below 25 years of age (UNFPA, 2005). Knowledge of contraceptive methods is high at 92 percent for all women aged between 15 and 49 years. Yet, the unmet need for family planning also remains high at 32.6 percent. Among those women who know about contraception, 79 percent know that condoms are a method of contraception; yet only 1 percent of women are currently using condoms as a method of family planning. Currently, Cambodia’s total fertility rate stands at 3.3—with the average number of births per woman higher than the average desired family size. The maternal mortality ratio is among the highest in the region at 437 per 100,000 live births.

Cambodia has one of the highest HIV prevalence rates in Asia at 1.9 percent in 2003 with transmission now occurring primarily through heterosexual sex in a generalized epidemic (NCHADS, 2004). Close to half (42%) of all new HIV cases are transmitted from husbands to wives (NCHADS, 2002). The practice of sex with multiple partners and the extremely low rates of condom use between married and regular partners, in addition to increasing high-risk sexual behavior among young people, have likely accelerated the disease’s progression into the general population (NCHADS, 2002). Currently, few programs effectively address condom use for people in long-term relationships, and minimal integration exists between HIV/AIDS and RH programs (UNFPA, 2005).

Cambodian men’s reproductive roles have been disregarded for various reasons, including assumptions about women’s responsibility for childbearing and about men’s perceptions of their own health. Family health is usually assumed to be a woman’s concern—at the household, service provision, and policy levels. Few family planning methods are available to or easily accessible for men, including male sterilization, which is only available in some referral hospitals. Because most RH services are provided through female-oriented maternal and child health programs, there has been little opportunity or incentive for men to become involved. Not surprisingly, men rarely attend RH facilities—either as clients or partners—and most service providers are not equipped or trained to accommodate male clients (Walston, 2005a). Moreover, the curricula for maternal and child health training do not currently cover male involvement. In Cambodia, the strategic plans of government departments and most nongovernmental agencies involved in reproductive health have not, up until now, included indicators on men, such as partner referrals and male clients of sexually transmitted infection (STI) services (Walston, 2005a).

4 Membership of the Interagency Gender Working Group (IGWG) represents NGOs, the United States Agency for International Development (USAID) cooperating agencies, and USAID’s Bureau for Global Health. IGWG’s goal is to foster sustainable development and improve reproductive health and HIV/AIDS outcomes. For more information, visit www.igwg.org.

3 The situation suggests that in Cambodia, as in many other countries, gender inequities inhibit reproductive health—particularly women’s—and that men’s central role in determining women’s reproductive and sexual health and well-being should be acknowledged by service providers and policymakers. In focus group discussions with men and women in Cambodia, one woman noted, “If we ask our husbands to use condoms, they say we don’t trust them. But if someone from the health center tells them, then they would believe that condoms were good” (Walston, 2005b).

Program and Policy Context for Male Involvement in Reproductive Health in Cambodia

A growing body of evidence in Cambodia and elsewhere has shown that involving men in RH programs can lead to favorable health and social outcomes (RHPWG and MEDiCAM, 2004). The Ministry of Women’s Affairs (MOWA) reports an increase in demand for contraception after involving men in RH projects in two rural areas of Cambodia. The Reproductive Health Association of Cambodia has reported that since including men in its education and counseling services, male clients seeking STI services has increased from 1 percent in 1996 to 13 percent in 2004. Outreach activities conducted by Marie Stopes Cambodia increased the uptake of its reproductive healthcare services by men from 1.1 percent in 2003 to 2.6 percent in 2004. The Reproductive and Child Health Alliance has also promoted voluntary surgical contraception for couples who meet the government criteria and wish to limit the size of their families—on the basis of informed choice. There has been a 28 percent rise in the number of men undergoing vasectomies as a result of this program (RHPWG and MEDiCAM, 2004). However, these and many other projects seeking to involve men are in their infancy. One argument for institutionalizing male involvement is that such projects would benefit from the circulation of approved guidelines of why and how to involve men.

In Cambodia, as in many other countries, men play a deciding role in women’s incentive to work, attend school, seek healthcare, and regulate their childbearing. Moreover, at the household level and even in workplaces and healthcare facilities, decisions over whether, when, and how to seek healthcare are usually made by men. Therefore, the creation of strategies, policies, and guidelines that show how men can best be involved is essential to improving the situation of not only women but also of entire families in terms of income, health, education, and standard of living.

Until recently, there has been little policy opposition to male involvement in Cambodia but neither has there been much engagement with the issue (Walston, 2005a). The national agenda recognizes the importance of gender issues, but that support is usually manifest in promoting the rights and situation of women. Now, however, there are signs that policymakers are recognizing male involvement as an important facet in addressing gender inequalities and promoting the health of both men and women.

For example, the MOH, with support from the United Nations Population Fund (UNFPA) and in consultation with all relevant government ministries, NGOs, and civil society organizations, is currently finalizing the new Strategic Plan for Reproductive Health in Cambodia (2006–2010). The mainstreaming of measures that address gender inequalities in reproductive health is recognized as a crucial principle of the strategic plan, which also acknowledges the importance of male involvement in, for example, birth spacing.

Other sector plans also call for gender equity. The 2002 Policy on Women, the Girl Child, STIs and HIV/AIDS was revised in 2003 by the Ministry of Women’s and Veterans’ Affairs (now the MOWA) in response to the National AIDS Authority’s National Strategic Plan for a

4 Comprehensive and Multi-Sectoral Response to HIV/AIDS (2001–2005). The revised policy recognizes the need to address the prevention of HIV in childbearing women in addition to focusing on the protection of infants born to HIV-positive women. It also gives male involvement in RH decisions a greater emphasis. The policy states that, “recognition of gender and gender inequality should not lead to a sole focus on women. Globally, we have learned that HIV/AIDS projects that have focused solely on women in recognition of their need for empowerment have failed or been unsustainable because they have failed to involve men” (MWVA, 2003, p. 5). The MOWA also has a program on mainstreaming gender into various issues, including reproductive health, and it has focal persons in all line ministries. These examples of successful male involvement programs and related policy reforms contribute to the positive environment in Cambodia for developing male involvement guidelines.

5 BUILDING SUPPORT FOR MALE INVOLVEMENT

RHPWG’s Advocacy Leads to High-level Consensus on Role of Male Involvement Guidelines

Family planning and RH programs are relatively new in Cambodia, and therefore, several components of the programs require strengthening. In mid-2003, POLICY/Cambodia led an effort to identify operational barriers to improved reproductive health. POLICY partnered with MEDiCAM, an NGO network with extensive links to NGOs, and other institutions working in the RH sector in Cambodia to establish the RHPWG. The RHPWG’s role is to identify and advocate for ways to improve reproductive health and reduce maternal and infant/child deaths through policy change. The group has 20 active members representing 11 NGOs working in reproductive health in Cambodia: the Reproductive Health Association of Cambodia, the Adventist Development Relief Agency, the Reproductive and Child Health Alliance, CARE Cambodia, the Women’s Development Association, Marie Stopes Cambodia, TASK (an organization providing health support to the poor), Women and Children Rights Development Kratie, the University Research Co., Population Services International, and the Cambodia People Living with HIV/AIDS Network. POLICY/Cambodia and the Cambodian Association of Parliamentarians on Population and Development are also members.

As its first task, POLICY conducted an advocacy training workshop for RHPWG in November 2003. During this workshop, RHPWG identified 29 RH issues as important, but selected male involvement as the group’s first advocacy issue—on the basis that men influence women’s choices about their health and have their own health needs, and yet, they are faced with limited information and services. The RHPWG recognized that most RH activities focus on and serve women as the principal target group but that male involvement is crucial to ensuring sustainable and effective RH policies and activities aimed at women. However, male involvement, as a key factor to improving reproductive health, was not being championed. At the workshop, the RHPWG drafted an initial advocacy goal of making adequate RH information and high-quality services for men accessible countrywide, but also drafted a more immediate objective of gaining commitment from the MOH and other ministries and institutions to develop male involvement guidelines and integrate them into existing RH policies. At this point, the group voiced its desire to promote guidelines applicable to other sectors but wished reproductive health to be the primary focus. In crafting the objective, the RHPWG specifically articulated its idea that integrating guidelines into policies would be more productive than creating “standalone” guidelines.

Immediately following the workshop, the RHPWG put together its action plan of activities— including training and technical assistance—and submitted a small grant application to POLICY. While the small grant was being reviewed, the RHPWG began to assemble documents detailing RH policy and efforts to involve men in reproductive health, including pilot projects in Cambodia; best practices from Cambodia and other countries; and information from ministries and other government organizations, NGOs, and donors. More than 100 documents were collected. The RHPWG also gathered information through face-to-face meetings with 48 representatives from 40 government departments and NGOs with related views and experiences to share. The information offered suggested that, in most cases, male clients were involved in RH programs on a purely ad hoc basis. In general, few men attended RH clinics, and although men were not turned away from clinics, they were neither encouraged nor provided with specific information. Given these circumstances, the informants welcomed the possibility of practical guidance on to how to actively and effectively involve men.

6 In March 2004, RHPWG members attended a POLICY/Cambodia workshop, “Policy, Data, and Presentation Training,” to enhance their understanding of policy, its formation, and its effects on reproductive health in Cambodia—specifically related to the lack of male involvement. The workshop helped equip RHPWG members with skills to collect and analyze data and present their findings on male involvement to policymakers. The analysis identified policy gaps and opportunities for male involvement in existing national RH policies and also produced many supportive arguments for RHPWG to apply to new advocacy tools and initiatives. An additional policy analysis by a consultant led to the creation of a matrix summarizing male involvement- related policy gaps and opportunities in the Cambodian context (see Attachment 2).

In May 2004, the RHPWG, with POLICY’s assistance, organized another workshop, “Developing Advocacy Tools.” Guests from government and nongovernmental agencies were invited to share their experiences and lessons learned on male involvement in Cambodia. During the workshop, RHPWG members drafted an advocacy fact sheet, and in 2004, the RHPWG held a consultative meeting to help improve the drafted fact sheet. Participants included experienced advocacy persons from relevant ministries, United Nations agencies, and local and international NGOs. By mid-2004, with the policy gaps and opportunities for addressing male involvement confirmed and advocacy tools drafted, it was time for the RHPWG to solidify plans to build support for its efforts. Also at that time, POLICY’s Gender Working Group had received core funds from USAID to help support technical leadership in the development of male involvement policies and guidelines. The male involvement work in Cambodia was identified as a unique opportunity to build on what had already been started and to provide technical assistance, with the goal of sharing the lessons learned in other countries. In part, this funding supported the POLICY team in designing and conducting a two-day training on male involvment, which was based on a draft IGWG curriculum. This workshop gave the RHPWG the opportunity to explore the issue in greater depth and to coalesce around clear principles and advocacy messages while moving forward.

Following the training, in October 2004, the RHPWG held a stakeholder meeting to raise awareness and support for male involvement in reproductive health. Seventy-five participants representing 45 different institutions (e.g., senior representatives of key government ministries, the donor community, and NGOs actively working in reproductive health) attended and heard presentations from the RHPWG and key stakeholders. The final fact sheet (Attachment 3) was distributed to all participants and also to other government and NGO partners. Through vigorous discussion, the participants agreed that there was a need for increased male involvement, more information regarding men’s RH knowledge and needs, informed strategies that demonstrated how to include men in RH programs, and the formulation and integration of clear guidelines on male involvement within RH policies. At the meeting, Professor Koum Kanal, the Director of the National Maternal and Child Health Center, endorsed the development of these guidelines. In Cambodia, as in many countries, the attendance of high-level officials at such meetings and their public endorsement is crucial for ensuring that issues are discussed and acted upon at the policy decisionmaking level.

“Putting together and conducting the stakeholders meeting was a great achievement for us, and I felt excited to see so many people talking about why male involvement is important to improve the health of Cambodian women and families. Important people from the government and donors came to this meeting, and they agreed with us and said we needed to move this process forward. That was a great reward for the work we had done.” ~Member of the RHPWG

7 Following the stakeholder meeting, in December 2004, a smaller roundtable discussion was held to review progress, garner support, and discuss how and when to develop male involvement guidelines. Attendees included policymakers from the MOH and MOWA; representatives from NGOs actively working in RH and gender issues; and POLICY/Cambodia staff. Prior to the roundtable, RHPWG members held one-on-one meetings with key ministerial officials to ensure their support for the male involvement concept. As a direct result of these advocacy activities, the RHPWG not only achieved a consensus from relevant line ministries as to the importance of the guidelines but was also nominated to draft them—in consultation with the MOH; MOWA; Ministry of Education, Youth, and Sports; parliamentarians; and other stakeholders. Consensus was also achieved on the importance of raising awareness among men; establishing more services for men; training health personnel on how to work with men; developing indicators to measure male involvement; and creating a more positive atmosphere for male responsibility, especially through school curricula.

The most important result of the stakeholder and roundtable meetings was that the MOH, represented by Dr. Tung Rathavy, then Deputy Director and now Director of the National Reproductive Health Program, officially voiced its support of the male involvement concept and stressed its commitment to include male involvement language in the upcoming Strategic Plan for Reproductive Health in Cambodia (2006–2010).

Developing Male Involvement Guidelines in Cambodia

By the end of 2004, the RHPWG had met its immediate objective, which was to convince relevant institutions of the importance of developing male involvement guidelines. It was now time to capitalize on that support and focus on drafting the guidelines; however, prior to doing so, the RHPWG and POLICY agreed on the need to conduct a more extensive assessment of Cambodia’s experiences in male involvement to date. In early 2005, POLICY helped to create a questionnaire and, with the RHPWG, conducted key informant interviews with various organizations working in reproductive health in Cambodia. Questions were asked to gauge local views, challenges, opportunities, and experiences in involving men in reproductive health. The findings and recommendations for moving forward with the guidelines confirmed that there were no real policy barriers to male involvement (Walston, 2005a). However, cultural and logistical barriers would need to be taken into consideration while moving forward. The cultural barriers include strong gender inequities and a sexual double standard, while logistical barriers include challenges for women-oriented services in finding the time, place, and staff to serve a broader clientele.

After completing the assessment’s summary report, “Challenges and Opportunities for Male Involvement in Reproductive Health in Cambodia,” the RHPWG and POLICY convened a two- day workshop in May 2005 to draft the guidelines. The workshop was launched by Cambodia’s Minister of Health, His Excellency Nuth Sokhom, who expressed his support for male involvement in his opening remarks and through his endorsement of working more closely with men as an important step toward improving reproductive health in Cambodia.

Using the assessment results and other available resources, the workshop’s 37 participants— representing ministries, civil society groups, donors, and NGOs—put forth suggestions for the content of the guidelines. Following the workshop, with POLICY’s assistance, these suggestions were organized into a draft document that was then circulated to the participants, donors, and all RHPWG members for comments.

8 Several principles regarding policies and programs to reach men were agreed upon and articulated in the guidelines (see the box below).

Principles for Male Involvement

. Policies and programs to involve men in reproductive health should be based on an approach that respects the dignity of both men and women and promotes equity between men and women.

. Involving men is not simply about serving an additional clientele but is about improving women’s health by educating and serving their male partners’ needs.

. Resources for programs and services for women and the quality of those programs and services should not be compromised by adding or scaling up programs and services for men.

. The needs of young men should be carefully considered, and met, to start this age group on the path to good, lifelong reproductive health.

. Gaps in research should not delay male involvement activities, as considerable evidence exists on the benefits of involving men (including young men) in reproductive health in Cambodia and elsewhere.

Opportunities to Integrate the Guidelines into Concrete Actions

The principles and components of the guidelines—although primarily drafted for incorporation into the national RH strategic plan—are applicable to other related policies. For instance, male involvement guidelines are relevant to several existing policies, such as the Birth Spacing Policy for Cambodia, which states that “couples and individuals have the right to decide freely and responsibly on the number and spacing of their children” (MOH, 1995, p. 1); the National Policy for the Prevention of Mother-to-Child Transmission of HIV 2001, which aims to protect women, their partners, and newborns from HIV infection (MOH, 2001); and the Policy on Voluntary and Confidential Counseling and Testing for HIV 2002, which states that all women and men have the right to determine the course of their reproductive health (MOH, 2002).

There are also opportunities to apply the male involvement guidelines and/or language during the formulation of other health sector guidelines and programs, such as the National Standard Guidelines for Adolescent-Friendly Reproductive and Sexual Health Services; the new guidelines for postabortion care; and the planned integration of RH education within the national general education curricula.

In recognition of these opportunities, UNFPA/Cambodia, in discussions with the RHPWG since early 2005 regarding support for its activities, has recommended that the male involvement concept and guidelines be discussed within the technical working groups responsible for developing each of the three program guidelines above. UNFPA funded the RHPWG through 2005 to attend the relevant working groups and promote the integration of male involvement language. By December, RHPWG representatives had attended meetings of the technical working groups for adolescent-friendly reproductive and sexual health (AFRSH) services and postabortion care. Indeed, thanks to the participation and advocacy efforts of RHPWG members, recent drafts of the national AFRSH services guidelines advocate for the promotion of male involvement through not only serving young men as clients but also through improving women’s health by educating male partners.

9 The Asia Region: Sharing Experiences Internationally

The RHPWG has already had two opportunities to share its experiences and learn from colleagues at international meetings. Shortly after the stakeholder meeting in October 2004, three members attended the “Men as Partners in Sexual and Reproductive Health” conference in Mumbai, India, from November 29 to December 1, 2004. Funded by UNFPA and the Reproductive and Child Health Alliance, RHPWG representatives presented on Cambodia’s experience in developing “male involvement policy” as it had evolved up to that point and returned with information and stories to share. In November 2005—with much more experience, information, and progress to share—a member of the working group presented a poster in Malaysia at the 3rd Asia Pacific Conference on Sexual and Reproductive Health. The poster summarized the report “Challenges and Opportunities for Male Involvement in Reproductive Health in Cambodia,” co-produced by the RHPWG with the POLICY Project in May 2005. The poster was well-received, with many international delegates requesting copies of the guidelines.

Integrating the Male Involvement Guidelines in the Strategic Plan for Reproductive Health in Cambodia (2006–2010)

Given the high-level support for male involvement garnered within the MOH, the forthcoming Strategic Plan for Reproductive Health in Cambodia (2006–2010) offered the most important opportunity for integrating and operationalizing the guidelines. The MOH and UNFPA were primarily responsible for initially drafting the strategic plan, but on November 10, 2005, all stakeholders were invited to a consultative meeting to discuss its completion. The meeting was an opportunity for all stakeholders to comment on the plan’s language, help flesh out some sections, and raise issues that they felt had been neglected. At the MOH’s request, representatives of POLICY/Cambodia and the RHPWG attended the meeting and circulated an abbreviated version of the draft guidelines (see Attachment 4). In addition, the team provided a summary document that explicitly outlined how the male involvement guidelines could contribute to the plan’s various components (see Attachment 5).

At the time of the meeting, the draft strategic plan had four guiding principles: (1) human rights and empowerment; (2) gender equity and male involvement; (3) multisectoral partnerships, linkages, and community involvement; and (4) evidence-based approach. The plan was also guided by the following four objectives:

 To improve the policy and resource environment for RH priorities (maternal and newborn health, adolescent reproductive health, STI/HIV/AIDS, birth spacing, and gender equity);  To improve delivery of high-quality reproductive healthcare for women, men, and adolescents;  To improve community understanding of reproductive health and demand for services; and  To improve the evidence base by conducting operational research to feed into future policy and strategy development.

The RPHWG and POLICY team were pleased to see that male involvement featured prominently in one of the plan’s guiding principles. This direct reference indicates the National Reproductive Health Program’s strong commitment to integrating male involvement within public sector RH programs. It also represents an interim advocacy achievement for the RHPWG, resulting from the one-on-one meetings and high-profile discussion held during the preceding 18 months.

10 During the November consultative meeting, it was agreed that the male involvement guidelines could potentially be inserted into the plan as an annex. This was a positive step forward as it meant that the guidelines would be circulated throughout Cambodia before the end of 2005 and would be directly linked to the reproductive healthcare services and activities as outlined by the MOH. However, as the decision would not be made until a December 2005 consultative meeting, it was up to the RHPWG and other stakeholders to continue their efforts to ensure that male involvement was upheld with clear, practical, and persuasive language. If male involvement were to remain a central and clear feature of the strategic plan, then the National Reproductive Health Program and its donors would be compelled to translate the male involvement rhetoric into action over the next five years.

“The process to include male involvement within national RH policy is going slowly, but it is moving forward. The spirit is there.” ~Dr. Tung Rathavy, Director, National Reproductive Health Program

At the December consultative meeting, the role of male involvement in the plan was strengthened in several new ways. In its text, implementers are now specifically referred to the draft guidelines (“a recently developed male involvement concept”) for ideas to address gender inequities—while noting that research has shown how involving men can improve the reproductive health of men and their families. The draft guidelines, with the RHPWG as the author, are listed as a reference to the strategic plan (see Attachment 6). It is also significant to note that male involvement is included in the proposed contents of the essential service package for reproductive health. Once UNFPA and the MOH complete their final review and approval of the guidelines, the current plan is to publish them as a stand-alone document. The guidelines can then be distributed to all relevant NGOs, civil society groups, and government institutions and be used to help formulate and implement policies, strategic plans, and programs. They may also be featured on UNFPA/Cambodia’s website for distribution internationally. Thus, the guidelines are an integral part of the strategic plan and will also “stand alone” as a resource for implementers.

These outcomes represent major advancements, not only for the RHPWG but also for male involvement in reproductive health in Cambodia. The influence of the research, advocacy, policy dialogue, and guidelines formulation process on the strategic plan signifies high-level recognition within the MOH of the importance of involving men and the necessity of distributing practical guidance about how to promote the concept. It also helps to assimilate male involvement as a central feature of RH services, education, and outreach work over the next five years and demands attention for male involvement activities from the technical, academic, and financial supporters of RH activities in Cambodia. This is what the RHPWG set out to do.

11 A Snapshot of Activities and Accomplishments

Date Activity Milestone/Achievement September 2003 Reproductive Health Promotion RHPWG specifies its RH Working Group formed advocacy mission November 2003 Initial workshop on advocacy RHPWG identifies advocacy objective to develop male involvement guidelines February 2004 RHPWG advocacy small grant awarded March 2004 Workshop on policy analysis and Policy gaps and opportunities presentation skills identified May 2004 Workshop to draft advocacy tools POLICY identifies additional and plan stakeholder meeting technical assistance needs June 2004 POLICY core and IGWG funds allocated September 2004 Workshop on male involvement RHPWG adopts male involvement principles and finalizes advocacy materials October 2004 Stakeholder meeting with NGOs, MCH Director supports ministries, donors formulation of male involvement guidelines December 2004 Roundtable with senior ministry MOH, MOWVA, MOE agree on officials need for guidelines; RHPWG tasked with drafting February 2005 POLICY and RHPWG complete paper summarizing recommendations from key informants May 2005 Workshop to draft guidelines Minister of Health endorses male with multisectoral partners involvement June 2005 Male involvement language included in National Standard Guidelines for Adolescent- Friendly Reproductive and Sexual Health Services November 2005 RHPWG formally introduces Male involvement included in one draft guidelines at MOH of four guiding principles consultative meeting on the Strategic Plan for Reproductive Health in Cambodia (2006– 2010) December 2005 Final MOH consultative meeting Male involvement incorporated in the on the strategic plan Strategic Plan for Reproductive Health in Cambodia (2006– 2010): implementers specifically referred to draft guidelines; draft guidelines cited as reference, with RHPWG listed as author; male involvement included in proposed essential service package

12 LESSONS LEARNED

Although there was little political opposition to involving men in reproductive health in Cambodia, prior to RHPWG’s advocacy efforts, there was little high-level support for working with men. The RHPWG’s initiative has helped to reinforce that involving men in reproductive health would help Cambodia achieve major development goals, such as a decrease in maternal mortality, an increase in the contraceptive prevalence rate, and a reduction in the overall prevalence of HIV. Moreover, by mobilizing evidence from other settings and making its relevance to the Cambodian context clear, the group has also shown that these goals can most likely be met if men are involved—not only as clients of reproductive healthcare services but also as partners, service providers, policymakers, teachers, and project managers. Many lessons have been learned along the way.

“By [getting involved] with RHPWG, I learned more on what male involvement really means, how to encourage them, and how to negotiate [with] policymakers to understand the situation and to support the group. I am very honest and proud to be a chair of the working group… and committed to see the achievement of the project.” ~Dr. Ping Chutema, Chair of the RHPWG until late 2004

 Civil society can be effective in placing issues on the RH policy agenda in Cambodia. The RHPWG’s members championed male involvement so that it would be included in major government strategic plans. The group also recognized at an early stage that placing male involvement on the political agenda would be most quickly and effectively achieved with strong and consistent support from and ownership among governmental institutions. Thus, ensuring high-level government representation at the RHPWG’s October 2004 stakeholder meeting, December 2004 roundtable discussion, and May 2005 guidelines-drafting workshop was a critical and important achievement for the working group.

 International technical assistance can help ensure that the local effort is evidence-based and grounded in the latest international thinking—but the learning goes both ways. Without technical assistance, the RHPWG, like many other local NGOs, would have lacked the technical, financial, and practical resources to advocate for an issue and ensure that that issue reaches the policy arena. POLICY provided the RHPWG with training (in advocacy, policy analysis, and communication), a small grant, and ongoing technical support from POLICY/Cambodia and POLICY/Washington. The technical assistance was particularly useful in creating tools and presentations and in preparing for workshops and public meetings. The focus on capacity building had visible effects in motivating RHPWG members to complete the guidelines and to advocate for and incorporate the lessons learned about gender and male involvement within their own NGO work and that of other agencies. However, this was not a one-way learning process. This collaboration has, in turn, allowed the POLICY Project the opportunity to gain and share with others significant practical experience related to how to support the drafting of male involvement policy.

 Building a shared definition and consensus on the principles of male involvement is galvanizing. Just before the stakeholder meeting in October 2004, POLICY conducted a workshop on male involvement based on a draft IGWG curriculum. This was a critical time for the RHPWG to come to a clear and deeper understanding of what male involvement means and to agree on principles that would guide their work. With the help of some practice sessions on advocacy, they were able to build consensus on the desired advocacy messages,

13 allowing them to speak with one voice. The cohesion was evident and effective at the stakeholder meeting.

 Carefully targeted resources and donor coordination were important catalysts. With modest funding and ongoing guidance from POLICY, the RHPWG was able to conduct a review of RH polices and how they relate to men, participate in training workshops on policy analysis and presentation techniques, create and publish advocacy materials to increase support of men’s involvement in RH, hold one-on-one meetings and a roundtable with key policymakers to discuss and formulate an action plan for men’s involvement in reproductive health, and, finally, draft a set of male involvement guidelines. POLICY was able to leverage both field support and core funds to stretch its technical assistance for two years. However, because integrating issues into policy can be a long-term effort and often requires multiple sources of support, donor coordination is essential. The handoff of the RHPWG support from POLICY to UNFPA in the latter half of 2005 kept the group closely focused on its objectives; they will look to others for collaborative opportunities in the future.

 A multisectoral approach was effective during the policy development phase—and presents challenges ahead. The integration of guidelines—particularly those designed to be multisectoral—is challenging in a political environment characterized by sharply stovepiped institutions. In Cambodia, even different departments within the health sector deliver their services independently, using different staff, communication materials, training curricula, and funding. Institutionalizing cooperation between different ministries is even more challenging. Often a lack of understanding of how other sectors can work together on similar issues is a barrier to multisectoral work. The RHPWG—although itself largely representative of health NGOs—brought in people outside the health and gender sectors during the process of advocating for and drafting the guidelines, including representatives from education, military, and legislative fields. However, tailoring the guidelines for use outside of reproductive health will likely be an ongoing challenge, as there may be issues regarding ownership, dissemination, and monitoring. In a political environment such as Cambodia’s, the adoption and use of guidelines across sectors is an ambitious goal for a civil society group that itself is focused on one sector.

14 CONCLUSION

A policy foundation for program work can help ensure the scaling up of initiatives. Prior to this work in Cambodia, activities to involve men were small in scope and primarily conducted by NGOs. Weaving male involvement into the Strategic Plan for Reproductive Health in Cambodia (2006–2010) makes it more likely that male involvement will become a central feature of public and NGO-led RH activities. This factor is important because male involvement plays a significant part in most, if not all, aspects of reproductive health. Involving men can strongly influence the uptake of family planning and maternal health services, reduce husband-to-wife transmission of STIs and encourage the uptake of STI counseling and treatment, and also lower the incidence of mother-to-child transmission of HIV through effective birth-spacing programs and uptake of voluntary confidential counseling and testing. Male involvement has also been shown to have beneficial effects on the health-seeking behavior of young and adult men themselves, which positively affects men as individuals and the health of their partners.

Over the last two years, civil society in Cambodia has made immense strides—through research, building support, and advocacy—in bringing male involvement to the forefront of work on reproductive health. The RHPWG was able to see that several government policies and strategies mention men, and that they, and others, offer strong opportunities for integrating male involvement. It was understood that linking the male involvement guidelines to the strategic RH plan was the first and best option for institutionalizing male involvement in Cambodia.

The guidelines can help direct the effective implementation of appropriate programs and provide program planners and implementers with an essential tool to help address gender inequalities in RH services. The first of the guidelines’ six guiding principles underscores this commitment: “Policies and programs to involve men in reproductive health should be based on an approach that respects the dignity of both men and women and promotes equity between men and women” (see Attachment 6, p. 46). The male involvement concept is itself a central theme within the strategic plan, and establishing this policy basis has been a crucial step in recognizing the importance of male involvement in Cambodia. The passionate advocates of RHPWG have shared their enthusiasm and commitment to involving men with a wide range of policy and program stakeholders, and these stakeholders now understand that men should be involved in reproductive health services—for their own sake and that of their partners and children.

Cambodia is one of only a few countries in the world that has gained such high-level support for male involvement in reproductive health. The challenge the country now faces is to set priorities for implementing its male involvement guidelines and to assemble the human and financial resources necessary for this important work.

15 ATTACHMENT 1: APPROACHES TO MALE INVOLVEMENT IN REPRODUCTIVE HEALTH (1999)

16 Approaches to Male Involvement in Reproductive Health

Approach Assumptions Purpose/Strategy Programmatic Obstacles Implications/Examples

TRADITIONAL Men are absent & Increase contraceptive Contraceptive delivery to women Focus on women precludes FAMILY problematic prevalence only. work with men PLANNING Inclusion of men not Reduce fertility Provide family planning methods to Provider bias against male necessary from an women in the context of maternal contraceptive methods efficiency and child health standpoint

1994 -- CAIRO International Conference on Population and Development ------

MEN AND FAMILY Men stand in the Increase contraceptive Contraceptive delivery to women Perceived low cost- PLANNING way of women’s prevalence and men. effectiveness of men’s contraceptive use Men as clients & recruiters of programs Reduce fertility women Men can be Difficult to integrate men involved Address men only as a practical into programs that had consideration in pursuing other emphasized women program goals Male reluctance to seek out Enlist men in the recruitment of services female contraceptors. Provider bias against male methods

MALE EQUALITY Men have been Address men’s Extend same range of reproductive Difficult to integrate men neglected reproductive health health services to male clients as to into programs that had Men as Reproductive needs, much as women emphasized women Health Clients Men’s needs must women’s have been be met addressed Concern with male sexuality Male reluctance to seek out services

17 Male health workers Provider bias against male Expand services currently serving methods women to provide services for men as well GENDER EQUITY Global gender Promote gender equity Men as partners, active in promoting Reluctance to spread time inequity influences gender equity and money on an additional The ICPD Ideal fertility desires and Promote women’s and constituency reproductive health men’s reproductive Careful assessments need to be done health through re: how we might want to involve Fear that women will lose Addressing inequity substantial male men in different programs and power in reproductive health requires the full involvement settings decisionmaking participation and cooperation of men, Broader range of activities—multiple While female fertility is the who hold more entrees to work with men as partners, concern of family planning power and constrain fathers, and community members programs, male sexuality is women’s choices getting new attention Male health workers

Encourage men to take their children to well-child clinics, and support them in developing parenting skills

18 ATTACHMENT 2: ASSESSMENT OF OPPORTUNITIES TO INVOLVE MEN IN CAMBODIA’S REPRODUCTIVE HEALTH-RELATED POLICIES (OCTOBER 2004)

19 Policy Reference to men and RH Recommendations/activities Gaps/Opportunities for potentially including men guidelines Birth Spacing Policy, General principles: Cambodia will take all  Individuals and couples should have  Mention’s men specifically only with appropriate measures to ensure, on a basis of unrestricted access to birth spacing regard to everyone’s access to reproductive 1995 equality of men and women, universal access to services. health services. health-care services, including those related to  Women and men should have  Training of staff. reproductive health care, which includes birth access to a range of reproductive health  Reproductive health education. spacing and sexual health. Couples and services including treatment and individuals have the right to decide freely and prevention of reproductive tract responsibly on the number and spacing of their infections (including HIV/AIDS), ante- children and to have the education and means to natal and delivery care as well as birth do so. spacing services as part of the MCH services.  Skills and training of birth spacing providers important.  Age-appropriate education, especially for adolescents, on RH including birth spacing techniques, should be available both at home and in the community, as part of the educational curriculum.  Specifically mentions providing the services through MCH, but hopes eventually to have them available at all government health outlets. Safe Motherhood “The main focus of the policy will be on  “Increase the awareness of families,  Community mobilization, public improving maternity care services including men, and women about the importance education about caring for women’s health National Policy and child spacing and nutrition at all levels of the of safe motherhood, the recognition of during pregnancy, labor and delivery. Strategies, 1997 health care delivery system starting from the danger signs and the importance of  Community mobilization to organize family and the community. It will also aim at community participation in organizing transport for emergency services in labor Ministry of Health, behavioural and societal changes at community emergency transport, blood donors, and and delivery. and service delivery levels in order to improve to saving funds for health care  IEC with community leaders, men, National Maternal and community participation.” emergency use or specifically for families, teachers, religious bodies, Child Health Centre transportation for patient referral children. purposes.”  National campaign on safe  “Strengthen information, education, motherhood. and communication (IEC) for public  Antenatal counseling may be awareness of Safe Motherhood and important time to involve men. increased coverage of maternity care.”

20  Empower families with basic  Postpartum counseling about birth knowledge for care and when they spacing should seek help in labor  Registration of birth – opportunity to  Encourage registration of births and involve men deaths that occur at home  Referral hospitals – any role for men  Mobilization of transport for who go with their wives? obstetric emergencies  Training of staff to encourage men’s  Blood donation through community involvement mobilization  Include a measure of men’s  Health information system participation in health information system  Educate teachers to address broad  RH education curriculum range of RH issues with primary 5&6 and secondary school students, develop  Current work in this area is focused curriculum, drama in schools on communities

Towards a Population Cover of the policy says “Women are the key Guidelines on voluntary sterilization exist, and Development actors.” but are somewhat restrictive. Strategy for Cambodia, 2002

Ministry of Planning Women, Girl Child and Principles: “As the HIV/AIDS epidemic grows,  Calls for respect of human rights, Specific strategies do not explicitly mention there is a need to improve services and promote need to address HIV/AIDS in the context men. HIV/AIDS, 2002 the protection and empowerment of women and of the family and community, freedom girls. The Ministry also recognizes that this is a from stigmatization and discrimination, Ministry hopes to cooperate with others in Ministry of Women’s gender-based pandemic and that the spread of confidentiality, equality and equity, realizing its objectives—committed to multi- HIV/AIDS among women and girls can be accessibility and quality of services, sectoral work to address these challenges. and Veterans’ Affairs slowed only if concrete change are brought cultural appropriateness, multi- about in the sexual behavior of men. Gender and sectoralism and greater involvement of HIV mainstreaming efforts at the national, people living with AIDS. provincial and local levels are hampered by  Objectives include: negative attitudes towards discussing sex, o Need to promote public sexuality and reproductive rights. Accordingly, awareness and encourage men and MWVA places prevention, care, support and women to take personal protection of women and the girl child plus the responsibility in protecting need to change the behavior of men on the themselves from STI and HIV agenda for policy-makers and service-providers transmission. through this Policy on Women, The Girl Child o Need to ensure that STI/HIV and STI/HIV/AIDS.”

21 education programs are targeted at earliest age to children, who should be provided with the skills to negotiate for safe sex and the means to prevent infection. o “To support and promote a sharing of responsibility between men and women in prevention programs, home care, community- based care and support services. Policy for HIV/AIDS Update: “The Health Policy for HIV/AIDS and  Awareness and education through  Men are not mentioned frequently, but and STI Prevention and STI Prevention and Care is based upon three mass media, skill building, IEC play a key role in all of these steps. concepts: messages  PMTCT – men are not mentioned, but Care in the Health  That a series of high risk situations for  Outreach via effective messages on women cannot prevent transmission to their Sector in Cambodia, HIV transmission exist in the country: these HIV/AIDS, STIs and life management children without cooperation and care of 1998 situations arise from the behaviour of large skills to high-risk populations husband – opportunity to involve men in numbers of both married and single men, who  MOH has responsibility to protecting their children if not their wives. continue to buy large amounts of commercial implement 100% condom use at places  AIDS care – opportunity to get men Update to policy, 2001 sex. where sex services are provided more involved in providing care.  That the HIV prevalence rates among men  Ensure knowledge about condom throughout the country are already sufficiently use for HIV/AIDS and STI prevention Ministry of Health, high that the spread, via their wives and girls among young people and general National AIDS friends, into the general population, and population Authority eventually into children, is already taking  Improve quality and use of STI place. services  That sufficient numbers of HIV infections  PMTCT – “Women are able to already exist in the country that a significant avoid HIV infection through improved burden of increased morbidity and mortality is counseling, and strengthened ANC and inevitable. health care services.”  AIDS care  Expansion of counseling and testing Abortion Law, 1997 No mention of men. Focuses on women’s right Abortion may be provided only in specific Trip to clinic for procedure may provide and freedom to have an abortion if they wish, health settings approved by the Ministry of chance to counsel men as well as women and under circumstances that are safe, clean and Health. about risks of abortion and importance of Ministry of Health where the provider is properly trained. birth spacing services.

22 ATTACHMENT 3: MALE INVOLEMENT IS THE KEY TO REPRODUCTIVE HEALTH (FACT SHEET, OCTOBER 2004)

23 24 25 26 27 ATTACHMENT 4: GUIDELINES FOR INVOLVING MEN IN REPRODUCTIVE HEALTH ACTIVITIES IN CAMBODIA (ABBREVIATED VERSION, NOVEMBER 2005)

28 Guidelines for Involving Men in Reproductive Health Activities in Cambodia

Reproductive Health Promotion Working Group

Overview of Male Involvement in Reproductive Health (RH) in Cambodia

There is a growing recognition, on a global scale, that there are important benefits, both to men and women, in involving men in RH policy and services. “Male responsibilities and participation” are acknowledged as critical aspects for improving RH outcomes, including preventing STIs, reducing maternal mortality, achieving gender equality, and empowering women (Program of Action, ICPD, Cairo 1994).

Gender inequities inhibit both women’s and men’s RH. Yet, reproductive health is usually assumed to be a woman’s concern - at the household, service provision and policy levels - while men’s own reproductive needs and their role in women’s RH are often disregarded. For instance, few methods of contraceptives for men exist, most RH services are provided through MCH programs, services and strategic plans lack indicators on men and most service providers are not equipped or trained to accommodate male clients. Yet there is growing acknowledgement of the central role that men play in determining women’s health and well-being. Involving men in RH would help Cambodia achieve some major development goals, such as a decrease in maternal mortality and an increase in contraceptive prevalence. In Cambodia, 42% of all new HIV cases are transmitted from husbands to wives (NAA 2003), indicating that the involvement of men could also help to reduce the overall prevalence of HIV/AIDS. The important role that reproductive health services can play in countering the gender inequities that undermine health, especially through programming that enhances male involvement, needs to be clarified and expanded. This will only be possible if men are involved, not just as clients of RH services, but also as partners, service providers, policy makers, and educators.

There is little opposition to involving men in reproductive health in Cambodia, and several government policies and strategies offer strong opportunities for increasing male involvement. The Strategic Plan for Reproductive Health in Cambodia 2006-2010 is the most important of these opportunities. While the guidelines reflect an emphasis on the health sector, they are relevant to work in other sectors as well.

These guidelines are the result of a workshop in May 2005 that brought together 25 non- governmental organizations and government agencies under the leadership of the Reproductive Health Promotion Working Group. These guidelines do not include an analysis of the costs of implementation, which will need to be considered carefully.

Principles for Involving Men in RH

The following principles should apply when implementing programs and activities that involve men.

 Polices and programs to involve men in RH should be based on an approach that respects the dignity of both men and women and promotes equity between men and women.

 Involving men is not simply about serving an additional clientele, but about improving women’s health by educating their male partners and serving their needs.

29  Resources for programs and services for women and the quality of those programs and services should not be compromised by adding or scaling up programs and services for men.

 The needs of young men should be carefully considered and reflected in RH policy and program development, to start this group on the path to good lifelong reproductive health.

 Existing research on the benefits of involving men in RH in Cambodia and elsewhere should be used to guide male involvement activities.

1. Expansion of Services for Men

Services for men and couples need to be expanded and the quality of those services improved in order to increase the number of men who use them.

1a. Reaching Men

 RH services should be provided to men of all ages and all social groups. . Reaching these groups will require new approaches, using peer educators and other outreach methods. Outreach workers must be properly trained, and good educational materials provided for distribution.  Referral systems should be established that refer men to health facilities.  All organizations working in RH should recruit more male providers and more male volunteers for outreach activities, CBD and educational activities.

1b. Types of Facilities and Settings for Reaching Men

 Health facilities should have “male-friendly” services available. Extended opening hours, IEC materials that are appealing to men, and waiting areas that are more welcoming to men are all factors to consider when deciding how to facilitate the access to services by men.  MCH and RH facilities could be called “Family Health Centers,” a more inclusive term that will make the facilities more welcoming to everyone.  RH services could also be established in settings where men currently receive health services (e.g., where men go for STI treatment). Other places where men could receive services or information about services might include pharmacies, newspapers, snooker halls, and other sites where men congregate.

 Special care should be taken to establish adolescent/youth-friendly RH services.

1c. Range and Scale of Services and Information for Men

 Existing services should be made more comprehensive. Additional services specifically for men should be added and expanded in the areas of:

o Family planning – information and services

30 o Prostate and other male RH concerns – screening, diagnosis and treatment o VCCT—for men and couples o STI—screening, diagnosis and treatment o Referral system for these services

2. Strengthening Service Provider Capacity to Serve Men

Substantial new skills and training are required for meeting the RH needs of men and supporting and promoting attitudes in men that are supportive of their partners’ reproductive health. Providers themselves need to develop gender equitable attitudes and behaviors in order to promote these among men. Training needs assessments and refresher training should be conducted on a regular basis.

2a. Who Gets Trained to Work with Men and RH?

Training should cover service providers in public and private health facilities, as well as those who work outside the formal medical system such as village health workers, traditional birth attendants, etc. Training should also be available to all others who potentially, or actually, provide RH services and information to men, such as teachers, military personnel, pharmacists, traditional healers, etc. Training should be developed in partnership with a broad range of ministries and NGOs.

Managers will also need basic and refresher training to ensure that male involvement is incorporated into health systems.

2b. Who Provides the Training on Men and RH?

Training should be provided by a broad range of organizations, including NGOs, civil society groups, and the MOH. Specialists with expertise on MCH, RH, BCC, M&E, and gender should also be involved.

2c. What Types of Training Should be Offered on Men and RH?

 Primary school curricula should introduce health and matters of mutual respect.  Secondary school curricula should include male involvement and RH themes, the need to respect one’s sexual partners, and information about human rights. Training in these areas should be provided to schoolteachers.  Staff of the MoH should be trained, as appropriate, in the medical and counseling aspects of reaching men.  MoWA, MoEYS, other ministries, the armed forces, and others should be invited to training on male involvement in RH in order to mobilize their audiences to work on related issues.  Training should be offered through a wide range of approaches and venues, including on-the-job training opportunities.

2d. Content of Training for Reaching Men

The content of training on male involvement should include:

31  A rights-based approach to RH, such as: gender issues, (including how gender norms and roles affect the RH of women and men), client confidentiality.  Male involvement in central RH issues, such as: family planning, STIs and HIV/AIDS, ANC, PMTCT, VCCT, responsible parenthood, domestic violence.  Specific communication issues, such as; the special needs of male and female youth, the importance of a non-judgmental approach.  New systems to accommodate male involvement, such as: recruiting and referring male clients, and monitoring new services and an expanded clientele.

3. Strengthening Managerial Capacity to Support and Promote Male Involvement in RH

In order to involve men in RH, managerial capacity should be strengthened from top to bottom of the public health system, and within NGOs, the private health sector and outside the health sector (e.g., MOWA, MOEYS, MOI, MORD and others).

 IEC, training curricula, and data collection and supervisory tools must be revised to reflect the commitment to gender equitable male involvement, and to help managers educate providers on working with men and couples.  Information systems should be strengthened to assist managers in their (new) programmatic planning. Managers at all levels should be given monitoring and supervisory tools with indicators for male involvement.  Logistics systems should be strengthened and expanded to include and ensure a regular supply of the RH materials and commodities that male clients need.

4. Effective IEC to Promote Male Involvement in RH

IEC is essential for promoting new understandings of how to maintain the good reproductive health of women and men. The dimensions of IEC to consider include the purpose of the IEC, the messages developed, and the specific groups targeted. Materials need to be entertaining, educational, emotionally appealing and culturally appropriate, and should be adapted for different population groups.

 IEC for male involvement should be directed at motivation, education, advocacy, and the promotion of respectful and supportive sexual relationships.

 Promoting male involvement requires the use of varied approaches, including: o Mass media: electronic, radio, TV, newspapers o Small media: leaflets, posters—used for target audiences such as schools and communities o Interpersonal communication: public events, role-plays, community theatre, other outreach activities

o School curricula:  teachers, student peer educators o Influential role models; celebrities, community and religious leaders

32  Messages need to go beyond spreading information about RH and men’s roles. IEC needs to address men’s and women’s rights, and gender inequity. If traditional values are to be contradicted, then it must be done sensitively and appropriately.

 M&E methods should be employed throughout to assess all IEC approaches to male involvement.

5. Developing Political & Institutional Support for Male Involvement in RH

Key dimensions of developing political and institutional support for male involvement include which institutions should be involved, their roles, and the advocacy strategies to be used by government and NGOs to stimulate interest and support for male involvement. Involving men in RH requires broad institutional support.

 CAPPD/PPAP should encourage the National Assembly and Senate to promote male participation in RH. They should also share experiences and information on men’s involvement in RH nationally and internationally. CAPPD should integrate male involvement in RH into its plan of action and help to disseminate and support implementation of the guidelines.

 As an inter-ministerial committee, the National Committee for Population and Development should monitor and evaluate the implementation of the male involvement guidelines across ministries.

 Relevant ministries (MOH, MOI, MOWA, MOEYS, etc), NGOs and other health partners, should disseminate and encourage the implementation of the male involvement guidelines at all levels. Relevant government departments (at central, provincial and OD levels) should implement the guidelines into their plans of action.

 Local authorities, religious leaders should help disseminate and implement the guidelines and increase community participation.

6. Research and Monitoring and Evaluation on Male Involvement in RH

Research, monitoring and evaluation have important roles to play in structuring and evaluating male involvement programs and in advocating to program and policymakers on the need to expand them. Channels of communication should be enabled to disseminate research and M&E results for reference and use by all relevant stakeholders at the local, district, provincial and central levels. Men themselves should be involved in all aspects of research, from data collection, to analysis, to deciding how to use it.

 Emphasis should be given to collecting data of broad relevance that could be used by the range of institutions involved in promoting male involvement. Research should be conducted at a level that is feasible given a specific topic, group, service, or program structure.

33  Indicators of male involvement in RH should appear in the national statistics that are collected and disseminated by the National Institute of Public Health, and others, from year to year.

 Indicators need to be carefully chosen to help monitor the activities of a program and to help determine if objectives and goals are being met.

 Each new male involvement initiative should ideally conduct a KAP survey on the client base, and follow-up surveys to review the effectiveness of its activities.

 Research should be used to determine the effects of involving men on both their own and their partners’ health and on gender equality. Research topics and methods should take into account the sensitive nature of the sexual and reproductive health issues of specific target groups, such as adolescents and MSM.

ATTACHMENT 5: STRATEGIC PLAN FOR REPRODUCTIVE HEALTH IN CAMBODIA (2006-2010): HOW MALE INVOLVEMENT GUIDELINES AND ACTIVITIES CAN CONTRIBUTE TO THE EFFECTIVE IMPLEMENTATION OF THE PLAN (NOVEMBER 2005)

34

STRATEGIC PLAN FOR REPRODUCTIVE HEALTH IN CAMBODIA 2006-2010

HOW MALE INVOLVEMENT GUIDELINES AND ACTIVITIES CAN CONTRIBUTE TO THE EFFECTIVE IMPLEMENTATION OF THE PLAN

INTRODUCTION

This year, with support from the POLICY Project and UNFPA, the Reproductive Health Promotion Working Group (RHPWG) worked with key stakeholders to advocate for and develop guidelines for the integration of male involvement into reproductive health practices, services, education initiatives and training. These guidelines are a culmination of activities undertaken by the RHPWG since 2003. The launch of the Strategic Plan for Reproductive Health in Cambodia 2006–2010 is seen as a critical opportunity to promote male involvement as a central facet of RH activities and also to show how male involvement can contribute to many aspects of RH services, policies and programs in Cambodia. This brief document identifies the areas, discussed in the 2nd draft of the Strategic Plan, in which male involvement can play an active role and in so doing, contribute to the overall effective implementation of the Plan.

INTRODUCTION AND CONTEXT

1. Human Rights and Empowerment (p. 1)

The strategic plan recognizes that the empowerment of people, so that they can make free and informed decisions about their reproductive lives, is a crucial principle of the plan. Male involvement increases the understanding of men so they can help and respect women as they make informed choices about their reproductive health, and also helps men to make decisions regarding their own reproductive health.

2. Gender Equity and Male Involvement (p. 1)

The strategic plan recognizes that mainstreaming gender equity is essential if the plan is to be implemented effectively. The recently-developed male involvement guidelines should provide program planners and implementers with an essential tool to help address gender inequalities in RH services.

REPRODUCTIVE HEALTH SITUATION

3. National Reproductive Health Program (p. 5)

The goal of the NRHP is to implement activities that work towards the ICPD Program of Action and the United Nations Millennium Development Goals. Male involvement can play a central role in reducing maternal mortality, infant mortality, unwanted pregnancy, HIV transmission and gender-based violence in Cambodia. Research has shown that enabling men to make informed and joint decisions about family planning, with their partners, can help to increase contraceptive prevalence, decrease the overall number of births per family while increasing the intervals between each child, and also to increase communication and negotiation between partners.

4. Adolescent Reproductive and Sexual Health (p. 8–9)

35 Male involvement is an essential component of ARSH and male involvement guidelines can contribute to the numerous protocols under construction (developed under the MOH, MOEYS and MOWA) that together, will represent an integrated national policy for ARSH.

Effective ARSH activities currently face constraints through issues such as privacy, methods of reaching out-of-school and working youth, cultural norms that prevent discussion of sexual issues, and existing perceptions among providers and adolescents. All of these issues also affect the perception and access to SRH services as experienced by men. Therefore, the work already undertaken in male involvement with respect to these, and other, issues, can help to address the constraints experienced by ARSH program planners and implementers.

5. RTIs and HIV/AIDS (p. 10–11)

Men are currently reluctant to access some services for STI and RTI due to issues such as embarrassment, privacy and the tendency for such services to be offered in a women-orientated environment. Education for men and couples, promotion of services for men and training of RH services providers, as outlined in the guidelines, should help to overcome this reluctance and help to avoid the financial and health costs of men accessing the unregulated private sector.

The strategic plan acknowledges that HIV has become a key RH issue. Male involvement activities can play a significant role in addressing, among others, the key issues of HIV transmission between married couples and MTCT through, for example, the promotion of dual protection, education about transmission, and counseling and services for high-risk couples.

6. Gender and Male Involvement (p. 13–14)

Research and analysis into the impact of male involvement in RH has been continuing for a number of years in Cambodia. Pilot projects already indicate the beneficial effects of involving men and information and lessons learned from all over the world have indicated what does and does not work. The guidelines for male involvement represent a critical output of this research and can help direct the effective implementation of the strategic plan through the implementation of appropriate programs and the acknowledgement of a rights-based approach to RH services.

HEALTH POLICY ENVIRONMENT (p. 15–17)

Male involvement can help to inform, complete and implement several new policies and protocols developed under the new strategic plan; the ARSH Policy and the Policy on Gender and RH being just two examples. Male Involvement guidelines can also help to implement a number of existing policies that are central to the effective implementation of the strategic plan. For example: the National Policy on Birth Spacing (1995) which states that “couples and individuals have the right to decide freely and responsibly on the number and spacing of their children”; the National Policy for the Prevention of Mother-to-Child Transmission of HIV (2001), which aims to “protect women, their partners and newborns from HIV infection”; and the Policy on Voluntary and Confidential Counseling and Testing for HIV (2002), which states that all women and men have the right to determine the course of their reproductive health. Male involvement guidelines give educators, program implementers and service providers the tools with which they can inform and assist men to exercise these rights.

7. Strategic Objectives (p. 18)

36 The strategic plan has four strategic objectives. Male involvement activities and guidelines can assist the plan in reaching all of these objectives. The male involvement guidelines can help to improve the policy and resource environment by contributing to ARSH and HIV/AIDS policies, as well as contributing to the implementation of the plan in their own right. Male involvement activities can help to improve the delivery of quality RH services for men, women and adolescents. They can contribute to community understanding of RH, help to increase demand for services through education and service-improvement activities and lastly, the existing and on- going research into male involvement, in Cambodia and globally, can contribute to future policy and strategy development.

IMPLEMENTATION

8. Strengthening Technical and Managerial Capacity of Health Personnel (p. 19)

Male involvement guidelines can be used to assist in the training of public and private healthcare providers, in developing and revising training curricula, and in enhancing managerial capacity.

9. Social, Economic, and Epidemiological Research (p. 22)

The strategic plan has identified key areas that require additional research. Research already undertaken on male involvement can help to inform many of these areas, such as “reproductive health needs assessment and social impact of reproductive health,” “research on gender-based violence,” “research on birth spacing utilization,” “prevalence of postnatal depression,” and “studies on infertility in Cambodia.”

CONCLUSION

Male involvement is just one of many issues that will affect the successful implementation of the new RH strategic plan. However, it can be said that male involvement plays a key part in most, if not all, aspects of RH services. It has a role in providing for the RH needs of Cambodia’s adolescent population; it strongly influences the uptake of family planning and maternal health services; it plays a key part in addressing HIV transmission as an RH issue in terms of reducing husband to wife transmissions, encouraging the uptake of STI counseling and treatment, and lowering the incidence of MTCT through effective birth spacing programs and uptake of VCCT. Male involvement has also been shown to have beneficial effect on the health seeking behavior of men themselves, which positively affects men as individuals but also their wives and families. Despite this evidence, male involvement is still largely unrecognized as a critical facet of RH activities across the world. Over the last three years, Cambodia has made immense strides in bringing male involvement to the forefront of RH approaches, and its comprehensive inclusion in the RH Strategic Plan 2006–2010 and accompanying protocols will give it the recognition and the support it deserves to truly make an impact on the RH concerns of Cambodia’s population.

37 ATTACHMENT 6: GUIDELINES FOR INVOLVING MEN IN REPRODUCTIVE HEALTH IN CAMBODIA (DRAFT, DECEMBER 2005)

38 Guidelines for Involving Men in Reproductive Health in Cambodia

Prepared by the Reproductive Health Promotion Working Group

39 Table of Contents

Preface...... 3 Acknowledgments...... 3 Abbreviations...... 3 Introduction...... 3 Overview of Male Involvement...... 3 Origins and Purpose of the Guidelines...... 3 Process of Guidelines Development...... 3 The Guidelines...... 3 Key Principles for Involving Men in Reproductive Health...... 3 1. Expansion of Services for Men...... 3 1.1 Numbers of people and different groups of men reached...... 3 1.2 Types of facilities and settings for reaching men...... 3 1.3 Range and scale of services for men...... 3 2. Strengthening Service Provider Capacity to Serve Men...... 3 2.1 Who gets trained to work with men and reproductive health...... 3 2.2 Who provides the training on men and reproductive health...... 3 2.3 The types of training offered on men and reproductive health...... 3 2.4. Content of training for reaching men...... 3 3. Strengthening Managerial Capacity to Support and Promote Male Involvement in Reproductive Health...... 3 4. Effective IEC to Promote Male Involvement in Reproductive Health...... 3 5. Developing Political and Institutional Support for Male Involvement in Reproductive Health...... 3 6. Research on Male Involvement in Reproductive Health...... 3

40 Preface (to be completed with MOH endorsement)

Male involvement plays an important role in most, if not all, aspects of reproductive health (RH) services. Not only does it strongly influence the uptake of family planning and maternal health services and have a role in providing for the RH needs of Cambodia’s adolescent population, but it also plays a key part in addressing HIV transmission by helping to reduce husband-to-wife transmission, encourage the uptake of counseling and treatment for sexually transmitted infections, and lower the incidence of mother-to-child transmission through effective birth-spacing programs and the uptake of voluntary confidential counseling and testing. Male involvement has also been shown to have beneficial effects on the health-seeking behavior of men themselves, which positively affects men as individuals and also their wives and families.

Despite this evidence, the practice of involving men as service providers and clients of RH services is still largely unrecognized as a crucial facet of RH activities worldwide.

Over the last two years, Cambodia has made immense strides in bringing male involvement to the forefront of RH policy. Comprehensive research and analysis of the effects of male involvement in reproductive health, including an examination of the lessons learned worldwide, have resulted in these guidelines. The guidelines will help to ensure that male involvement can make an impact at policy, program planning, and service provision levels by helping to direct the implementation of appropriate programs through a rights-based approach to RH services.

The Reproductive Health Promotion Working Group and all its collaborators and supporters must be congratulated on their achievements in bringing male involvement to the policy table and providing the tools to effectively translate policy into action.

41 Acknowledgments

These guidelines to involve men in reproductive health in Cambodia are a result of more than two years of impressive hard work and collaboration between numerous individuals and organizations in Cambodia. Special thanks must go to the members of the Reproductive Health Promotion Working Group (RHPWG), past and present, for their continuous research and advocacy efforts; MEDiCAM, the USAID-funded POLICY Project, the Interagency Gender Working Group (IGWG), and UNFPA for supporting the RHPWG in its achievements; the National Reproductive Health Programme for its enthusiastic support for the guidelines; and all of those who attended and contributed to the key meetings and workshops that helped to shape the guidelines.

42 Abbreviations

AIDS acquired immune deficiency syndrome BCC behavior change communication CAPPD Cambodian Association of Parliamentarians on Population and Development HIV human immunodeficiency virus IEC information, education, and communication IGWG Interagency Gender Working Group MOEYS Ministry of Education, Youth and Sport MOH Ministry of Health MOI Ministry of Information MOP Ministry of Planning MOWA Ministry of Women’s Affairs NGO nongovernmental organization RH reproductive health RHPWG Reproductive Health Promotion Working Group STI sexually transmitted infection

43 Introduction

Since 2003, the Reproductive Health Promotion Working Group (RHPWG) has been working to develop guidelines for the integration of male involvement into reproductive health (RH) practices, services, education initiatives, and training. The guidelines are now ready to inform the policies and programs aimed at improving the reproductive health of Cambodia’s population.

Overview of Male Involvement

There is growing global recognition of the important benefits, both to men and women, in involving men in RH policy and services. At the Cairo 1994 International Conference on Population and Development, 179 countries signed a program of action that includes “male responsibilities and participation” as critical aspects for improving RH outcomes, achieving gender equality, and empowering women. The conference catalyzed programs and studies that confirm the viability of involving men as sexual partners, fathers, decisionmakers, and actors in preventing sexually transmitted infections (STIs) including HIV/AIDS.

Involving men in reproductive health would help Cambodia to achieve some major development goals, such as a decrease in the maternal mortality rate, a decrease in the infant mortality rate, and an increase in the contraceptive prevalence rate. Involving men could also help to reduce the overall prevalence of HIV/AIDS, unwanted pregnancy, and gender-based violence. Research has shown that enabling men to make informed and joint decisions about family planning, with their partners, can help to increase contraceptive prevalence, decrease the overall number of births per family while increasing the intervals between each child, and also increase communication and negotiation between partners. This will only be possible if men are involved, not just as clients of RH services, but also as partners, service providers, policymakers, teachers, and project managers.

Men have a central role in determining women’s reproductive health and well-being, as well as their own. Indeed, the National AIDS Authority in Cambodia estimated in 2003 that 42 percent of all new HIV cases are transmitted from husbands to wives; yet, men’s sexual and reproductive roles have been disregarded for various reasons including assumptions about women’s responsibility for family health—at the household, service provision, and policy levels. Few methods of contraceptives for men exist; most RH services are provided through female-oriented maternal and child health programs. Services and strategic plans lack indicators on men, and most service providers are not equipped or trained to accommodate male clients. The important role that RH services and providers can play in countering the gender inequalities that undermine health needs to be clarified and expanded.

Although there is little opposition to involving men in reproductive health in Cambodia, there is little specific institutional support for working with men. However, several government policies and strategies mention men, and others offer strong opportunities for

44 male involvement. It is the hope that these guidelines can contribute to the policies, strategies, and programs, inside and outside the health sector, that have opportunities for involving men.

Origins and Purpose of the Guidelines

In 2003, the Reproductive Health Promotion Working Group (RHPWG) began researching and advocating for male involvement in reproductive health with a view to producing guidelines that would help implement relevant policies, strategies, and programs.

The guidelines were first drafted in May 2005 at the two-day “Workshop to Draft Guidelines on Male Involvement in Reproductive Health.” The workshop was opened by the Minister of Health who, in his opening remarks, warmly endorsed working more closely with men. Thirty-seven participants—representing ministries, civil society groups, donors, and NGOs—worked together to draft the guidelines under the RHPWG’s guidance.

One of the first and most appropriate opportunities for the application of the guidelines was the Strategic Plan for Reproductive Health in Cambodia (2006–2010). However, while the guidelines reflect an emphasis on the health sector, they are also relevant to work in other sectors.

Process of Guidelines Development

Following the workshop in May, the RHPWG began to assemble information and documents referring to male involvement in reproductive health, including best practices from other countries and the details of pilot projects in Cambodia. In total, more than 100 documents were collected. The RHPWG also gathered information from its secondary (supportive) and primary audiences through face-to-face meetings.

Key informant interviews were conducted with various organizations working in reproductive health in Cambodia. Questions relating to male involvement were asked to gauge local views, challenges, opportunities, and experiences in involving men in reproductive health. These interviews helped confirm that there were no real policy barriers to male involvement, which opens the door to opportunity. However, before moving forward, it is important to consider cultural and logistical barriers. The cultural barriers include strong gender inequities and a sexual double standard, while logistical barriers include the challenges for women-oriented services in finding the time, place, and staff to serve a broader clientele.

Following the male involvement workshop in May 2005, the participants’ suggestions for the guidelines were organized into a draft document and then circulated to the participants, donors, and all members of the working group for comments. Estimating resource requirements to implement the male involvement guidelines was beyond the scope of this activity but will be a crucial activity in the strategic planning process.

45 The Guidelines

Key Principles for Involving Men in Reproductive Health

The following principles should apply when implementing programs and activities that involve men.

. Policies and programs to involve men in reproductive health should be based on an approach that respects the dignity of both men and women and promotes equity between men and women.

. Involving men is not simply about serving an additional clientele but is about improving women’s health by educating their male partners and serving their needs.

. Resources for programs and services for women and the quality of those programs and services should not be compromised by adding or scaling up programs and services for men.

. The needs of young men should be carefully considered and reflected in RH policy and program development to start this group on the path to good, lifelong reproductive health.

. Existing research on the benefits of involving men in reproductive health in Cambodia and elsewhere should be used to guide male involvement activities.

1. Expansion of Services for Men

Although several programs involving men in reproductive health have evolved in Cambodia, they are not working on a large scale; services need to be expanded (particularly in rural areas) in terms of people and groups reached, types of facilities and settings, the range and scale of services, and the quality of services. Improving the scale and quality of services is likely to increase the number of men who use those services.

Men are often reluctant to access some services for STI and reproductive tract infections due to embarrassment, privacy, and the tendency for such services to be offered in a women-orientated environment. Education for men and couples, promotion of services for men, and training of RH services providers should help to overcome this reluctance and avoid the financial and health costs of men accessing the unregulated private sector.

HIV has become a key RH issue. Male involvement activities can play a significant role in addressing, among other issues, mother-to-child transmission and HIV transmission between married couples through, for example, the promotion of dual protection, education about transmission, and counseling and family planning services for high-risk couples.

46 1.1 Numbers of people and different groups of men reached

. RH services should be provided to people of all ages and to neglected groups. . There is a need to reach out to specific groups like youth (in- and out-of- school), moto and cyclo drivers, members of the armed forces, and other special groups. Reaching these groups will require new approaches, using peer educators and other outreach methods. Their health teachers must be properly trained and good educational materials provided for distribution.

. RH services should consider recruiting more male providers and male volunteers for their outreach activities. Community-based distribution and educational activities that target men should be increased to cover all provinces.

1.2 Types of facilities and settings for reaching men

. Health facilities should have “male-friendly” services available, including extended hours; information, education, and communication (IEC) materials that are appealing to men; and waiting areas that are more welcoming to men.

. Maternal and child health and RH centers could be called “Family Health Centers,” a more inclusive term that will make the facilities more welcoming to everyone.

. RH services could also be established in settings where men currently receive health services (e.g., where men go for STI treatment). Other places where men could receive services and/or information about services might include pharmacies, newspapers, snooker halls, and other sites where men congregate.

. Special attention should be paid to those places frequented by target groups (youth, uniformed services, men who have sex with men, and so forth).

. Special care should be taken to establish adolescent/youth-friendly RH services for young men.

. The Ministry of Health (MOH), other ministries, NGOs, and outreach workers should disseminate information to men about where they can access services for their own reproductive health.

. A referral system should be implemented to connect men to outreach workers and health facilities.

47 1.3 Range and scale of services for men

. Existing services should be more comprehensive. Additional services specifically for men should be added and expanded in the areas of

o Family planning—information and services o Prostate and other male RH concerns—screening, diagnosis, and treatment o Voluntary confidential counseling and testing—for men and couples o STI—screening, diagnosis, and treatment o Referral system for these services (see 1.2 above)

2. Strengthening Service Provider Capacity to Serve Men

Substantial new skills are required to meet the RH needs of men while at the same time supporting and promoting attitudes in men that are supportive of their partners’ reproductive health. Providers themselves need to develop gender equitable attitudes and behaviors in order to promote those among men. Providers will need training to involve men in reproductive health—both as clients and as supportive partners. Training, including refresher training, should be ongoing and training needs assessments should be conducted on a regular basis.

Strengthening service provider capacity includes planning for who gets trained, who provides the training, the types of training offered, content, and the frequency of the training. The recommendations cover service providers in both public and private health facilities, as well as those who work outside the medical system.

2.1 Who gets trained to work with men and reproductive health

Inside the formal health sector, those who should receive training include nurses, doctors, midwives, community-based distributors, pharmacists, laboratory technicians, village health workers, traditional birth attendants, and private health practitioners. Outside the health sector, those who provide services and information to men—such as teachers, outreach workers, military and police officers, peer educators from NGOs, medicine- sellers, shop owners, and traditional healers—should be trained. Training should be developed in partnership with a broad range of ministries, NGOs, and civil society organizations.

Managers will also need basic and refresher training to ensure that male involvement is incorporated into health systems (and the systems of other ministries).

2.2 Who provides the training on men and reproductive health

Training should be provided by a broad range of organizations and groups, including NGOs, central and provincial health departments within the MOH, provincial and

48 municipal AIDS offices, and civil society groups. Specialists with expertise on maternal and child health, reproductive health, behavior change communication (BCC), monitoring and evaluation, and gender should also be involved.

2.3 The types of training offered on men and reproductive health

. Primary school curricula should introduce health and matters of mutual respect.

. Secondary school curricula should include male involvement and reproductive health themes, including the universality of human rights and the need to respect one’s sexual partners. Training in these areas should be provided to schoolteachers and student peer educators.

. MOH staff should be trained, as appropriate, in the medical and counseling aspects of reaching men.

. Employees of the Ministry of Women’s Affairs (MOWA), the Ministry of Education, Youth and Sport (MOEYS), the armed forces, and other ministries and government organizations should be invited to training on male involvement in reproductive health in order to expand male involvement initiatives in these ministries and organizations.

. Training should be offered through a wide range of approaches and venues, including conferences, workshops, and on-the-job training opportunities.

2.4. Content of training for reaching men

The content of training on male involvement should include:

. Gender issues, including how gender norms and roles affect the reproductive health of women and men . Violence . Pregnancy prevention (family planning and reproductive health) . STIs, HIV/AIDS . Voluntary and confidential counseling and testing . Prevention of mother-to-child transmission . Antenatal care . Human rights . Client confidentiality . Responsible parenthood . Communication . The importance of a respectful and nonjudgmental approach . The special needs of male and female youth . New systems of recruiting and referring male clients . Monitoring new services and an expanded clientele

49 3. Strengthening Managerial Capacity to Support and Promote Male Involvement in Reproductive Health

To involve men in reproductive health, managerial capacity should be strengthened from top to bottom in the public health system and within NGOs, the private health sector, and outside the health sector (e.g., MOWA, MOEYS, the Ministry of Information (MOI), the Ministry of Rural Development, and others).

. IEC materials, training curricula, data collection tools, and supervisory tools must be revised to reflect the commitment to gender equitable male involvement and to help managers educate providers on male involvement and working with couples.

. Information systems should be strengthened to assist managers in their (new) program planning. Managers at all levels should be given supervisory tools with indicators to monitor male involvement activities.

. Logistics systems should be strengthened and the list of basic RH supplies expanded to include and ensure a regular supply of the RH materials, equipment, and commodities that male clients need.

4. Effective IEC to Promote Male Involvement in Reproductive Health

IEC is essential for promoting new understandings of how to maintain the good reproductive health of women and men of all ages. The dimensions of IEC to consider include the media selected, the purpose of the IEC materials, the messages developed, and the specific groups targeted for communication. Strong, acceptable materials need to be entertaining, educational, emotionally appealing, culturally appropriate, and tailored for different population groups. Special emphasis should be put on using the media to reach youth. Principles that should guide the development of IEC materials include:

. IEC efforts for male involvement should aim to motivate, educate, advocate, and promote respectful and supportive sexual relationships.

. Promoting male involvement requires the use of varied media channels, including: o Mass media: electronic, newspapers, radio, television o Small media: leaflets, posters—used for target audiences such as schools and communities o Interpersonal communication: public events, role-plays, community theatre, and other outreach activities

o School curricula: a

50 o natomy, physiology, sexuality—need to work first with teachers, then student peer educators o Influential role models: celebrities, community and religious leaders of all kinds

. Messages need to go beyond simply spreading information about reproductive health and men’s roles. IEC messages must be carefully phrased, especially references to men’s and women’s rights. Messages must address gender inequity, or effectiveness will be reduced. If traditional values are to be contradicted, then it must be done sensitively and appropriately.

. Appropriate monitoring and evaluation methods should be employed throughout to assess all IEC and BCC approaches to male involvement.

5. Developing Political and Institutional Support for Male Involvement in Reproductive Health

Male involvement guidelines can help to inform, complete, and implement several new policies and programs under development. The National Standard Guidelines for Adolescent-Friendly Reproductive and Sexual Health Services and MOWA’s Gender Mainstreaming and Advocacy Project are just two examples. Male involvement guidelines can also help to implement some existing policies, such as the National Policy on Birth Spacing (1995) that states that “couples and individuals have the right to decide freely and responsibly on the number and spacing of their children”; the National Policy for the Prevention of Mother-to-Child Transmission of HIV (2001) that aims to “protect women, their partners and newborns from HIV infection”; and the Policy on Voluntary and Confidential Counseling and Testing for HIV (2002) that states that all women and men have the right to determine the course of their reproductive health.

Key dimensions of creating political and institutional support for male involvement include identifying which institutions should be involved, their roles and how their roles should best be managed, and the advocacy strategies to be used by government and NGOs to stimulate interest and support for male involvement. Involving men in reproductive health requires broad institutional support and should reflect these basic considerations:

. To gain institutional and programmatic support for male involvement, the guidelines must be disseminated widely at all levels and to all relevant ministries, government organizations, NGOs, civil society organizations, and senior government representatives through conferences, workshops, and person-to- person advocacy.

. The Cambodian Association of Parliamentarians on Population and Development (CAPPD) and the Person-to-Person Advocacy with Parliamentarians organization should play important roles in encouraging the National Assembly and the Senate

51 to support the promotion, implementation, and monitoring of male involvement in reproductive health and identifying gaps for improvement. They should also share experiences and information on men’s involvement in reproductive health nationally and internationally. CAPPD should integrate male involvement into its RH plan of action and include ways to support the dissemination and implementation of the guidelines.

. As an inter-ministerial committee, the National Committee for Population and Development (Office of the Council of Ministers) should monitor and evaluate the implementation of the male involvement guidelines across ministries.

. Relevant ministries (MOH, MOI, MOWA, MOEYS, and so forth), NGOs, and other health partners should disseminate and encourage the implementation of the male involvement guidelines at all levels. Relevant government departments (at central, provincial, and operational district levels) should implement the guidelines in their plans of action.

. Local authorities and religious leaders should help disseminate the guidelines and be involved in activities that facilitate their implementation at the community level.

6. Research on Male Involvement in Reproductive Health

In Cambodia, there are RH issues and RH-related issues that require further research. Existing research on male involvement can help to inform many of these areas, including gender-based violence, use of birth-spacing, prevalence of postnatal depression, and infertility in Cambodia.

Research has an important role to play—for example, in helping to structure and evaluate male involvement programs and in serving as a basis for advocacy with policymakers on the need to expand the programs. While gaps in research should not slow the implementation of male involvement policies and programs, specific, large gaps should be addressed as a matter of urgency.

Research on male involvement should consider the following:

. Emphasis should be given to collecting data of broad relevance for use by the various institutions involved in promoting male involvement. Research should be conducted at a feasible level given a specific topic, group, service, or program structure.

. Indicators need to be carefully chosen to help monitor the activities of a program and to help determine if objectives and goals are being met. (See the following box for sample indicators.)

52 . Each new male involvement initiative should ideally conduct a knowledge, attitude, and practice survey on the client base and follow-up surveys to review the effectiveness of its activities.

. Research should be conducted to determine the effects of involving men (young and adult) in reproductive health—on both their own and their partners’ health and on gender equality. Research topics and methods should take into account the sensitive nature of the sexual and reproductive health issues of specific target groups, such as men who have sex with men and adolescents.

. Channels of communication should be enabled to disseminate research results for reference and use by all relevant stakeholders at the local, district, provincial, and central levels. Men themselves should be involved in all aspects of research, from data collection to analysis to deciding how to use it.

. Indicators of male involvement in reproductive health should appear in the national statistics that are collected and disseminated by the National Institute of Public Health and others from year to year.

53 Example of Male Involvement Indicators

Example of expanded indicators for monitoring programs that seek to involve men in reproductive health

Objective Type of activity Indicator (s) (the ones in italics Where/how to collect the necessary data are process indicators; the others are outcome indicators) To increase men’s 1. As part of A. relevant training materials A. Project records support for training for developed or adapted to women’s sexual providers on CPI include a male component; and reproductive (client-provider # of providers trained health interaction), include B. Changes in providers’ B. Before and after training assessments: (Programming components on knowledge and attitudes questionnaires or interviews categories: couple reproductive about the roles men can and individual rights, the play in support of women’s counseling for men importance of RH and women, as including men, and appropriate; IEC couple C. Changes in provider C. Client exit interviews (pre/post) and outreach, communication attitudes/practices in terms especially to youth; of including men in reproductive health counseling sessions education in schools and for D. Changes in clinic hours to D. Clinic records out-of-school make it easier for couples to youth) come in together

E. Change in # of E. Clinic records men attending counseling sessions, either with partner or alone

Source: Yinger, Nancy with Anne Peterson, Michal Avni, Jill Gay, Rebecca Firestone, Karen Hardee, Elaine Murphy, Britt Herstad, and Charlotte Johnson-Welch. 2002. “Illustrative Indicators for Programming in Men & Reproductive Health.” Prepared under the auspices of the Interagency Gender Working Group, Subcommittee on Men and Reproductive Health. Available at http://www.prb.org/pdf/FramewkIdentGendrIndic.pdf

54 REFERENCES

Boender, C., D. Santana, D. Santillán, K. Hardee, M.E. Greene, and S. Schuler. 2005. “‘The So What Report’: Does Integrating a Gender Perspective Make a Difference to Reproductive Health Outcomes?” Interagency Gender Working Group Task Force Report. Presentations at 2002 APHA and 2004 USAID Global Health Mini University.

Centro Centroamericano de Población. n.d. http://ccp.ucr.ac.cr/observa/CRindicadores/naci.htm, accessed September 18, 2004.

Cross, H., N. Jewell, and K. Hardee. 2001. “Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs.” POLICY Occasional Paper No. 7. Washington, D.C.: Futures Group, POLICY Project.

Greene, Margaret. 1999. “The Benefits of Involving Men in Reproductive Health.” Paper presented at the meetings of the Association for Women in Development, the American Public Health Association, and USAID. Also published in WHO. 2001. Programming for Male Involvement in Reproductive Health. WHO/FCH/RHR/02.3.

Greene, Margaret E., and Ann E. Biddlecom. 2000. “Absent and Problematic Men: Demographic Accounts of Male Reproductive Roles.” Population and Development Review 26(1): 81–115.

Gribble, Jay. 2004. “Guatemala Case Study: The Law and Policy of Social Development and Population.” Washington, D.C.: Futures Group.

Hogle, Janice A. 2002. “What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response.” Project Lessons Learned Case Study. Washington, D.C.: Synergy Project.

Jacobson, Jodi. 2000. “Transforming Family Planning Programmes: Towards a Framework for Advancing the Reproductive Rights Agenda.” Reproductive Health Matters 8(15).

Ministerio de Educación Pública, República de Costa Rica. 2001. http://www.mep.go.cr/LeyPaternidadResponsable.html, accessed September 15, 2004.

Ministry of Health (MOH). 1995. Birth Spacing Policy for Cambodia. Phnom Penh: MOH.

Ministry of Health (MOH). 2001. National Policy for the Prevention of Mother-to-Child Transmission of HIV. Phnom Penh: MOH.

Ministry of Health (MOH). 2002. Policy on Voluntary and Confidential Counseling and Testing for HIV. Phnom Penh: MOH.

Ministry of Women’s and Veterans’ Affairs, Government of Cambodia (MWVA). 2003. Policy on Women, the Girl Child, and STI/HIV/AIDS. Phnom Penh: MWVA.

National Center for HIV/AIDS, Dermatology, and STIs (NCHADS). 2002. HIV Sentinel Surveillance 2002. Powerpoint presentation (unpublished).

55 National Center for HIV/AIDS, Dermatology, and STIs (NCHADS). 2004. HIV Sentinel Surveillance 2003: Results, Trends, and Estimates. Phnom Penh: MOH.

POLICY Project. 2004. “Jamaica: Strengthening Multisectoral Coordination for Youth.” Youth Reproductive Health Policy Brief No. 1. Washington, D.C.: Futures Group, POLICY Project.

Republic of Botswana, Ministry of Health. 1994. “Botswana Family Planning General Policy Guidelines and Services Standards.” Gaborone: Maternal and Child Health/Family Planning, Department of Primary Health Care, MOH.

Republic of Guatemala. 2001. Decreto Número 42-2001. Guatemala City: Congress of the Republic of Guatemala. http://paginas.corpotelsa.com/ceg/doctos/2001/leydesoc.html, accessed September 14, 2004

RHPWG and MEDiCAM. 2004. “Male Involvement is Key to Reproductive Health.” Fact sheet. Phnom Penh: MEDiCAM.

United Nations Population Fund (UNFPA). 1994. Program of Action, International Conference on Population and Development. New York: UNFPA.

United Nations Population Fund (UNFPA). 2005. Population, Gender and Reproductive Health. Cambodia at a Glance. Phnom Penh: UNFPA.

Walston, N. 2005a. “Challenges and Opportunities for Male Involvement in Reproductive Health in Cambodia.” Phnom Penh: POLICY Project.

Walston, N. 2005b. Cambodia: Family Planning Programs and HIV/AIDS Services, Results of Focus Group Discussions.” Phnom Penh: POLICY Project.

World Health Organization (WHO). 2002. WHO and Civil Society: Linking for Better Health. WHO: Geneva.

56

Load more

  63

Copy Link