Sharing-Innovative-Experiences-Volume-19-2011.Pdf

VOLUME 19

SHARING Innovative Experiences

Experiences in Addressing Population and Reproductive Health Challenges

Global South-South Development Academy The series Sharing Innovative Experiences is part of the multidimensional strategy of the UNDP Special Unit for South-South Cooperation (SSC) to promote knowledge- sharing in the South. It presents Southern solutions to Southern challenges through the use of Southern expertise.

Each volume of case studies focuses on a specific topic that is identified by the Special Unit on the basis of its corporate priorities and their links to the Millennium Development Goals. The Special Unit works with partners to identify Southern initiatives that represent successful practices. A technical committee recommends initiatives that can be considered successful in their particular context. Following the methodology of the Global South-South Development Academy, representatives of the selected initiatives are invited to document their experiences in individual case studies and to present them at an international workshop for extensive sharing of information with other practitioners. The case studies are subsequently reworked to meet the criteria for publication.

ISSN: 1728-4171

Special Unit for South-South Cooperation United Nations Development Programme One United Nations Plaza New York, NY 10017 USA

The views expressed in this publication do not necessarily reflect those of the United Nations, the United Nations Development Programme or governments. The designations employed do not imply the expression of any opinion whatsoever concerning the legal status of any country, territory or area, or its frontiers or boundaries.

Design: Alamini Design, 145 West 28th Street, 12th Floor, New York, NY 10001, alaminidesign.com Cover photos: Main cover - © Didier Habimana SHARING Innovative Experiences

V OLUME 1 9

Experiences in Addressing Population and Reproductive Health Challenges

Global South-South Development Academy THE UNITED NATIONS DEV ELOPMENT PROG RA MME (UNDP) is the U N’s global dev elopment network, an organization advocating for change a nd connecting countries to knowledge, experience and resources to help people build a better life. It is on the groundin 166 countries, workingwith them on their own solutions to global and national development challenges. As they devel op local capacity, they draw on the people of UNDP and its wide range of partners.

THE SPECIAL UNIT FOR SOUTH -S OUT H COO PERAT ION , formerly known as the Special Unit for Technical Cooperation among Developing Countries (TCDC), was established by the United Nations General Assembly within UNDP in 1978. It carries out

Special Unit its United Nations mandate to mobilize international support for sustained South-South for South-South cooperation for development. It encoura Cooperation ges developing countries to become imp or- tant providers of multilateral cooperation, foste rs broad -based partnerships for supporting South-South initiatives, supports the efforts of t he South to pool the vast resources of Southern countries as a way of achieving common development goals, and facilitates South-South policy dialogues.

PARTNERS IN POP ULAT ION AN D DEVE LOP ME NT (PPD ) is an intergovernmental initiative created specifically to expand and improve South-to-South collaboration in the fields of reproductive health, population and development. PPD was launched at the 1994 International Conference on Population and Development. Its mission is to assist member cou ntries and oth er developing countries to a ddress successfully the sexual and reproductive health and rights and population and development challenges through South-South collaboration. PPD carries out its mission by ra ising a common voice and sharing sustainable, effective, efficient, a ccessible and acceptable solutions considering the diverse economic, social, political, religious and cultural characteristics of member countries.

THE UNITED NATIONS POP ULATIO N FUN D (UNFPA) is an international development agency that promotes the right of every woman,man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV, and every girl and woman is treated with dignity and respect. UNFPA works in partnership with governments, along with other United Nations agencies, communities, non-governmental organizations, foundations and the private sector, to raise awareness and mobilize the support and resources needed to achieve its mission. It works in some 150 countries, areas and territories and is a field-centred, efficient and strategic partner to the countries it serves. C o n t e n t s

Foreword 5

Acknowledgements 9

Introduction 11

1 Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 23

2 Focusing on Quality of Care in the Family Planning Programme – China 47

3 Training in Incorporating Population Factors into Development Planning – Ghana 73

4 Addressing Reproductive and Sexual Health Issues of Adolescents – India 97

5 Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 125

6 An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programme – Kenya 143

7 A System Approach to Training in Population, Environment and Development – South Africa 159

8 Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 191

9 Women’s Empowerment and Reproductive Health – Tunisia 211

10 Involving Parliamentarians as Advocates for Reproductive Health – Uganda 229 F o r e w o r d

The year 2011 will be remembered as the year when the world’s population reached 7 billion. According to the latest projections by the United Nations, the world population will continue to increase to 9.3 billion by the year 2050. To put these numbers in perspective, the world population did not reach one billion until 1804. It then took 123 years to reach 2 billion in 1927, 33 years to reach 3 billion in 1960, 14 years to reach 4 billion in 1974, 13 years to reach 5 billion in 1987 and 12 years to reach 6 billion by October 1999. Another billion will be added by October 2011. This growth in world population is phenom- enal. While on the one hand it reflects mankind’s enormous success in reducing mortality and improving quality of life for billions of people, on the other it raises the serious challenge of the social, political, environmental and developmental implications of adding additional billions of people so rapidly. One crucial feature of the current global demographic situation with significant implications for the future is the fact that more than 3 billion people are under the age of 25, with almost 1.8 billion people between the ages of 10 and 24, the parents of the next generation. How effectively the world helps these cohorts of young people in meeting their development and reproductive health needs will greatly influence the pace and nature of future demographic dynamics in the world. The International Conference on Population and Development (ICPD) held in Cairo in 1994 was a watershed in the history of the population, reproductive health and family planning movement. It heralded a move away from a past focus on demographic numbers to improving people’s quality of life. It redefined the structural antecedents of the population issue and has offered the world a rights-based, gender-sensitive and development-focused approach to its resolution. Central to the new

5 6 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES approach were, among other things, the rights of individuals and couples in deciding the number and spacing of their children; rights for universal access to reproductive health for all, including reproductive rights; the recognition given to inextricable linkages between gender inequality, women’s empowerment and reproductive health issues; and the clear implications of population dynamics for sustained economic growth and sustainable development. The ICPD Programme of Action includes a comprehensive set of recommendations to address population issues from these strategic perspectives. During the last decade and a half, most developing countries have formulated and implemented policy and programmatic measures based on the ICPD Programme of Action. They include efforts aimed at, inter alia, policy formulation, programme development, service delivery, advocacy, training and capacity development, and resource mobilization. The substantive focuses of such successful efforts have included family planning, reproductive health, gender empowerment, adolescent and youth reproductive health, and population and development integration. Although such successes have been important and are common knowledge within national contexts, they are not well known more widely mainly because many successful experiences have not been adequately documented. This publication is an attempt to address this gap. Recognizing the potential usefulness of such successful experiences to other countries in similar situations, PPD undertook, with the financial support of the United Nations Population Fund (UNFPA) and the Packard Foundation, an exercise to select and document case studies of innovative practices in population, reproductive health and development. This work was undertaken in partnership with the UNDP Special Unit for South-South Cooperation as part of its Global South-South Development Academy, which defines the methodology and standards for the publication of the series, Sharing Innovative Experiences. This publication confirms the PPD commitment to help to promote the goals of ICPD through South-South cooperation and to share, in particular, operational experiences in addressing issues in population dynamics and development, family planning and reproductive health among its member and other developing countries. The case studies cover successful experiences with innovative approaches adopted by PPD member countries in addressing important issues in expanding access to family planning, improving the quality of care in the delivery of family planning services, having national parliamentarians advocate for a reproductive health agenda, tackling the mother-to-child transmission of HIV/AIDS, empowering women and integrating population factors into development planning. It should be emphasized that these are experiences from the South, Southern solutions to Southern challenges arrived at through the use of Southern expertise. They were selected following a call for nominations by PPD member countries of practices in the population and reproductive health areas that the individual member countries considered to be innovative, Foreword 7

good or successful in their national contexts. From among the more than 80 submissions, 10 were chosen for documentation following an in-country process to ensure that there was consensus in the country on the relevance and usefulness of the practice for wider sharing and replication. An External Review Group comprising international experts, representatives of UNFPA and the Special Unit for South-South Cooperation, and PPD staff reviewed the drafts of the case studies. The authors subsequently presented the experiences for discussion at a workshop held in Bangkok, Thailand, in August 2010, which provided an opportunity for sharing as well as for capacity-building and mutual learning before the finalization of the drafts of the case studies. The practices included here are important in addressing more effectively the population challenge as the world moves towards the 9 billion mark by the middle of the century. To increase their impact, each case study has been edited into a non-technical version, making it accessible to a wider audience. As with other books in the series, the present volume will be distributed free of charge throughout the South. By providing such a collection of innovative practices and lessons learned, it is hoped that developing countries, with their limited human resources, will be able to select the most appropriate measures and adapt them to their own particular development needs. The present volume is also being made available online (ssc.undp.org) with the hope that the innovative practices that it contains will be able to reach an even wider audience.

Mr. Harry S. Jooseery Mr. Yiping Zhou Mr. Werner Haug Executive Director Director Director Partners in Population Special Unit for South-South Technical Division and Development Cooperation United Nations Population Fund Dhaka, Bangladesh United Nations Development Programme New York, New York, New York, New York, United States United States 8 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Acknowledgements

The present publication is part of a broader knowledge- sharing process promoted and coordinated by the UNDP Special Unit for South-South Cooperation, which issues the series, Sharing Innovative Experiences, in support of South- South learning. It results from a joint initiative of the Special Unit and Partners in Population and Development (PPD) in collaboration with the United Nations Population Fund (UNFPA) and the Packard Foundation. We wish to express our sincere appreciation to Dr. Thoraya Obaid, the former Executive Director of UNFPA, and to Dr. Babatunde Osotimehin, the current Executive Director, for their continued support of this initiative. We would also like to express our gratitude for the support and guidance provided to this exercise by the Honourable Ghulam Nabi Azad, Union Minister of Health and Family Welfare of India and the Chair of the Governing Board of PPD. This publication would not have become a reality without the support from Mr. Werner Haug, the Director of the UNFPA Technical Division, and Mr. Yiping Zhou, the Director of the Special Unit, and the coordination of Dr. Sethuramiah L. Rao, the Permanent Observer of PPD to the United Nations, and Mr. Francisco Simplicio, the Chief of the Division for Knowledge Management of the Special Unit. The 10 case studies in this volume were prepared by national government agencies, professional institutions, national experts and practitioners. Without their commitment to share experiences of developments in addressing issues of family planning, reproductive health, and the integration of population, environment and development interrelationships into policies and programmes for sustainable

9 10 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES development, this kind of international review would not be possible and we gratefully acknowledge their contributions to this volume. The preparation of these case studies also involved a long list of individuals at the country and global levels whose names are too numerous to be mentioned individually. We would, however, like to acknowledge the work done by the members of the External Review Group whose review of an earlier draft was invaluable in improving the quality of the presentations. They are Dr. Michael Hermann and Mr. Rabbi Royan, both of UNFPA; Dr. Denis Nkala of the Special Unit; and Mr. Harry Jooseery, Dr. Jotham Musigunzi, Dr. Sethuramiah Rao and Mr. Jyoti Singh, all of PPD. Our appreciation also goes to Ms. Lourdes Hermosura-Chang of the UNDP Special Unit for South-South Cooperation, who provided logistical, administrative and technical support to this publication, and to Dr. Barbara Brewka, an independent professional commissioned by the Special Unit to carry out editorial reviews and layout coordination during the publishing phase. The expertise and commitment of each member of these diverse groups helped to move the project forward efficiently and effectively. We express our thanks to all of them. Introduction

Background Partners in Population and Development (PPD) is committed to promoting an exchange of information and experience among the developing countries in general and among its member countries in particular. It recognizes that organizations, countries and communities throughout the world have been implementing programmes for many years in the field of population, reproductive health and development. The focus of these programmes has covered a broad array of concerns, including policy formulation, programme planning and implementation, service delivery, poverty alleviation, social mobilization, advocacy, support communication, capacity-building and institutional development. Such efforts have frequently been successful, and many innovative, promising, good or best practices have been part of these initiatives by countries or communities. Unfortunately, these successful interventions are often not documented or widely shared. In some cases, documented information may be available but not quickly or easily accessible to programme managers and others as they design and implement programmes. Furthermore, programme managers should be able to have confidence in the credibility of the information available. To address this critical need, PPD, in close collaboration with the United Nations Population Fund (UNFPA), has undertaken an exercise to help to identify and compile good practices to document the kinds of lessons learned by countries in successfully addressing policy, programmatic or operational issues in the fields of population, poverty and reproductive health in PPD member countries. PPD is convinced that sharing lessons learned from these country experiences with other countries would be beneficial not only to rap-

11 12 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES idly promoting the population and reproductive health agenda in general but also to achieving the Millennium Development Goals and the goals of the International Conference on Population and Development (ICPD) in developing countries. Experience has shown that many developing countries have indeed succeeded in, among other things, strengthening access to quality family planning services, reducing unmet needs for family planning, slowing the population growth rate, improving women’s status and integrating population factors into development planning. It would thus be very timely and useful to document some of these successful approaches for wider circulation and adaptation by other developing countries, given that many developing countries are still facing the population challenge.

Definition of “Innovative Practice” While there is no universally acceptable definition of a good or innovative or best practice, for the purpose of this publication, PPD has adopted the broad definition of a “good” or “innovative practice” used by UNFPA: “planning or operational practices that have proven successful in particular circumstances and which are used to demonstrate what works and what does not and to accumulate and apply knowledge about how and why they work in different situations and contexts.”1

The Documentation Process In documenting the innovative practices in population and reproductive health included in this volume, PPD adopted the following steps:

• In early 2009, PPD undertook an informal inquiry, using a simple questionnaire, to collect information among its member countries on practices in the population and reproductive health areas that the individual countries considered to be innovative, good or successful in their national contexts. Based on a preliminary analysis of a large number of submissions, totalling more than 80, PPD discussed the proposed topics with an internal review group and then decided that it should limit itself to focusing on a manageable number of countries. PPD advised the member countries to undertake an in-country validation exercise of the selected individual topic to ensure that the topic enjoys a broad consensus within the country on the relevance and usefulness of the practice for wider sharing and consideration for replication by other countries. • PPD prepared, with inputs from UNFPA, a set of detailed guidance notes for authors on documenting the practice by largely adapting the Guidelines of the Special Unit for South-South Cooperation.2 These were made available to the authors of the 10 case studies in November 2009.

1 UNFPA, Glossary of Evaluation Terms, New York, 2005. 2 UNDP, Special Unit for South-South Cooperation, Guidelines for Documenting Southern Development Solutions, New York, October 2008. Introduction 13

• A planning meeting of the authors was held in February 2010 in Dhaka, Bangladesh, to review the draft submissions and agree on a common format and approach to documenting the practices. • Authors were requested to revise their submissions by taking into account comments and suggestions made at the planning meeting and to have an in-country meeting to review the revised draft before submitting it to PPD. • PPD appointed an External Review Group of international experts, representatives of UNFPA and the Special Unit for South-South Cooperation, and PPD staff to review the revised drafts and to provide a final set of comments and suggestions for revisions by the authors. • A workshop for the authors with the External Review Group was held in August 2010 in Bangkok to provide comments and suggestions to the authors for the finalization of the country studies. • An external editor was appointed to undertake copyediting of the 10 submissions. • Finally, the edited final versions of the country studies were sent to the Special Unit for South-South Cooperation for review and layout.

Relevance of the Case Studies The International Conference on Population and Development (ICPD) held in 1994 in Cairo, Egypt, was a watershed in the area of population, gender and development. It mandated a new approach to the conceptualization as well as the resolution of the population and family planning issues. Among the many innovations stemming from the Conference, the following three are significant. First, the ICPD laid the foundation for looking at economic growth not only in terms of increases in per capita income but also in the broader context of sustained economic growth and sustainable development. Second, it reconceptualized and accorded a new basis to family planning in the broader context of reproductive health, within a human rights framework. Third, it brought to the forefront the issue of gender equality and women’s empowerment and the critical importance of addressing this issue not only in its own right but also as a complementary and necessary strategy to help to resolve the population and sustainable development issue. To help to implement the new vision, the ICPD made a large number of recommendations for implementation at policy, programme, operational and other levels. Since the adoption of the ICPD recommendations, many developing countries have reformulated their national polices and programmes in the population and family planning field to help to operationalize the new perspectives, and several of these countries have achieved success in implementing specific measures. This publication includes selected examples of such successes from countries in Africa, the Arab States and Asia. 14 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The 10 countries represented here are Bangladesh, China, Ghana, India, Indonesia, Kenya, South Africa, Thailand, Tunisia and Uganda. Taken together, the case studies substantively represent innovative practices in addressing the long-standing need to expand access to family planning services for the poor and needy as well as to meet concerns arising out the new perspectives on reproductive health and sustainable development mandated in the ICPD Programme of Action. Among the 10 case studies, four deal with improving access to family planning using different approaches; three focus on selected components of reproductive health, i.e., adolescent reproductive health, HIV/AIDS and advocacy for reproductive health; one deals with gender empowerment and reproductive health; and two are studies of training programmes: one on integrating population factors into development planning and the other on the broader issue of population and sustainable development. Several of the case studies are based on a longer time frame and are situated in a historical context (the examples from Bangladesh, China, Indonesia and Tunisia) whereas the six other studies cover more recent and shorter periods of time. Similarly, the case studies document the experiences of geographically widespread countries: four from sub-Saharan Africa, one from North Africa, two from South Asia, and three from East and Southeast Asia. Although the total number of case studies in the compilation is relatively small, the composition of the group is broad and represents considerable variability in programme context and cultural diversity. The group includes countries with relatively small populations such as Ghana and Tunisia as well as population giants such as China and India and many mid- sized countries in between. This diversity in geography, culture, programme context and approach contributes to the practical relevance of lessons learned that are identified in the case studies.

Overview of the Case Studies As already mentioned, the specific topic of the case studies pertains either to family planning, reproductive health, gender or population and development. More than one case study is generally included under each topic, and each case study deals with a complementary theme or a component element of the substantive topic. For example, under the topic of “family planning”, case studies concentrate on expanding or extending access to family planning services through different approaches such as the use of domiciliary services, improving the quality of care, strengthening community participation or promoting the greater use of a specific contraceptive method. Likewise, included under the rubric of “reproductive health” are case studies on addressing adolescent sexual and reproductive health, on addressing mother-to-child transmission of HIV within a community framework, and on parliamentarians’ advocacy for the reproductive health approach. Similarly, in the category of “population and development”, two case studies are included: one dealing with integrating population factors into decentralized development planning and the other with a system Introduction 15 approach to training in population and the broader concept of “sustainable development”. Finally, this volume includes a case study on women’s empowerment and its ram- ifications for family planning and reproductive health.

Family Planning The concept, practice and challenge of family planning have been a central element of population policy and programmes from the very beginning in the 1960s. While the context within which family planning services are provided has undergone fundamental changes over time, the relevance of these services has remained valid. However, there are some indications that the centrality of family planning in population programmes during the last decade or so has been diminished in terms of the proportionate allocation of resources to family planning and, in some cases, political support for it, especially in the context of decentralization and devolution of political power. Accordingly, there has been a call for renewed effort to put family planning back in a place high on the national and the global agenda. In this context, the four case studies included under this category take on an added significance. All four deal in one way or another with expanding or strengthening the access to family planning services in different national contexts. The Bangladesh innovation, for example, involves an approach to (a) generate greater demand for family planning services on the one hand, and (b) ensure easy access to services to help bring about changes in the reproductive health behaviour in a population characterized by poor infrastructure, a low literacy level, poor socio-economic conditions, pervasive gender inequality and an overall conservative attitude towards contraception on the other. The focus of the innovation was to successfully introduce the domiciliary (doorstep) service-delivery system rather than depending only on the static service centre approach. As is made clear in the case study, the country succeeded in expanding the practice of family planning, reducing the levels of fertility and decreasing the growth rate of the population. In addition, the approach has, according to the study, led to other benefits for women’s empowerment and social mobilization. The China case study is in many ways an illustration of the basic need to strengthen the quality of care in family planning services, as called for in the Programme of Action of the ICPD. The innovation here lies in the fact that, immediately following the Cairo Conference, China reoriented its family planning programme from a heavy emphasis on demographic targets towards a client orientation and a quality-focused approach to family planning. The case study demonstrates that, by reorienting the focus, upgrading services and improving facilities, the country succeeded not only in attaining low and stable fertility levels but also in generating among the people an improved awareness of reproductive rights and benefits, an improved relationship 16 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES between clients and service providers, and an improved image of the family planning programme. The example from Indonesia is a classic illustration of the importance of involving the community in the promotion and administration of family planning services to meet its needs. The innovation here was the introduction of the Village Family Planning Programme by the Government, with strong central political support. The idea was to use villages as bases for family planning and to decentralize the National Family Planning Programme to the village level and give responsibility for programme implementation to village officials and volunteers. Beginning with successful efforts in Bali, the Programme was expanded to Java and eventually to other islands. According to the study, the approach resulted in a growing and high level of contraceptive practice, a reduced fertility rate, a slowdown in the growth rate of the population, and an associated improvement in family well-being in the population. The study also argues that, with national decentralization, the political and financial support for family planning started to decline and the Programme began showing signs of weakness and instability. To address these new challenges, the country is now addressing the family planning issue through a modified approach, linking family planning with income-generating activities for more prosperous families. The Kenyan case study documents the Government’s successful approach in reintroducing the contraceptive method of the intrauterine device (IUD) into the National Family Planning Programme. The underuse of IUDs and other long-lasting and permanent methods in the National Programme had become a cause for concern to the Government and makers of health policy. According to the case study, overreliance on relatively more expensive methods had burdened the Kenya Family Planning Programme, which was already facing budget cuts as resources were increasingly direct- ed towards the HIV/AIDS programme, and had limited women’s access to a full range of contraceptive methods. By adopting an innovative approach consisting of (a) increasing the support for the IUD method among policymakers, service providers and clients, (b) increasing the quality of IUD services, (c) enhancing the demand for IUDs and (d) monitoring and evaluating the Programme performance, Kenya has succeeded in reintroducing the IUD method into the National Family Planning Programme and increasing the uptake of this method.

Reproductive Health The ICPD was a landmark moment in the history of the population movement since it argued for a different approach to both the conceptualization of the population issue and to its resolution. It introduced the concept of “reproductive health” and advocated for reproductive health care to include, inter alia, family planning, prenatal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, treat- Introduction 17 ment of reproductive tract infections and sexually transmitted diseases including HIV/AIDS, and human sexuality, reproductive health and responsible parenthood. In the context of this publication, three recommendations contained in the ICPD Programme of Action3 are significant: (a) that “[i]nnovative programmes must be developed to make information, counselling and services for reproductive health accessible to adolescents”;4 (b) that “Governments should also scale up, where appropriate, education and treatment projects aimed at preventing mother-to-child transmission of HIV”;5 and (c) that “[m]embers of national legislatures can have a major role to play in enacting appropriate domestic legislation for implementing the ICPD Programme of Action, allo- cating appropriate financial resources, ensuring accountability of expenditures and raising public awareness of population issues”.6 The three case studies of India, Indonesia and Thailand included here deal respectively with the three recommendations cited above. The Indian case study focuses on addressing the well-being and the reproductive health of youths and adolescents in the country by documenting the experience gained through a multisectoral and integrated approach in selected districts of the State of Haryana. Among the main objectives of the approach were helping to delay marriage and childbearing among adolescents, especially girls, and increasing access by married and unmarried adolescents to information and services regarding modern family planning and reproductive health. The Government of India adopted an innovative approach by undertaking a mapping exercise to identify issues and problems relating to adolescent reproductive sexual health and combining it with a broad strategy. The strategy comprised: (a) the provision of a comprehensive package of adolescent-friendly reproductive and sexual health services covering promotional, preventive, curative and referral elements; (b) the capacity-building of adolescents by health-care providers and peer-group educators from the community; (c) the creation of an enabling environment by establishing adolescent- friendly reproductive health centres, taking a letter box approach and adopting a frequently-asked-questions modality; (d) the promotion of communication with adolescents by establishing adolescent action groups, implementing a plan of action, organizing youth festivals and/or cultural shows, and arranging for debates or competitions on reproductive health issues; and (e) the carrying out of monitoring and evaluation activities by conducting a household survey and undertaking a quality assessment of adolescent health services using a set of normative standards. By using a classical experimental-and-control-area approach, the study demonstrates the effectiveness of the

3 Report of the International Conference on Population and Development, Cairo, 5-13 September 1994 (United Nations publication, Sales No. E.95.XIII.18). 4 Ibid., para. 7.8. 5 General Assembly resolution S-21/2, para. 69, Key actions for the further implementation of the Programme of Action of the International Conference on Population and Development, 1999. 6 Report of the International Conference…, para. 13.3. 18 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES innovative approach implemented in addressing the reproductive health issues of adolescents. Consistently, the levels of awareness and knowledge of reproductive health issues and of the availability of services in the experimental area are higher than in the control area. By involving peer-group educators in particular, the approach was able to overcome the familiar sensitivity of adolescents to discussing reproductive health issues and seeking advice and guidance on them. The Thailand case study deals with the country’s effort in addressing the prevention of the transmission of HIV from mothers to their children. While the national policy promulgated in 2000 was to provide a continuum of care including general care and psychological counselling, with linked services between hospitals and communities, it was not fully implemented owing to a manpower shortage and heavy workload. In 2005, the Government adopted an innovative approach to provide a continuum of care and support to HIV-infected mothers, their children and families through a project implemented by the Department of Health in collaboration and coordination with other related governmental, non-governmental and community-based organizations. By involving the Thai National AIDS Foundation, which brought into its network the peer leaders among the people living with AIDS, these leaders could work closely with the government service providers in clinics for maternal and child health/prevention of mother-to-child transmission of HIV. As the case study clearly demonstrates, it was a successful service model in that it helped HIV-infected women, their children and families to receive a continuum of care and remain within the HIV care programme. Furthermore, there was an increase in the number of diagnosed children born to HIV-infected mothers, permitting the provision of timely and appropriate care to those babies. Also, there was an increase in the number of husbands participating in the HIV care programme. The issue of involving parliamentarians as advocates for reproductive health is the subject of the case study from Uganda. In accordance with the ICPD recommendation cited earlier and in recognition of the role that parliamentarians can play in promoting the reproductive health agenda, Uganda adopted an innovative approach in using an evidence-based advocacy strategy to draw the attention of parliamentarians to socio- economic realities. The aim was to inform, motivate, persuade and prompt them to take actions that address population and reproductive health issues. By putting in place an implementation plan, developing tools and materials and producing a training-of-trainers manual, the project was able to build capacities of a large number of parliamentarians as advocates for reproductive health and family planning. After ten years of implementation, it has been clearly demonstrated that evidence-based advocacy through parliamentarians has had a great influence on the policy agenda in the country. According to the case study, parliamentarians’ messages have been taken on board and have served as the basis for decisions taken in various sectors and at different levels of the Government. Introduction 19

Population and Sustainable Development The ICPD achieved a major breakthrough in conceptualizing the linkages between population and economic growth. Instead of casting the relevance of population factors in the traditional context of economic growth, the Conference offered a paradigm shift to look at the linkages of population factors with sustained economic growth and sustainable development. By bringing in the concept of “sustainable development”, the ICPD has helped development practitioners to look at the significance of population dynamics in the interrelated context of, among other things, natural resources, environment, energy, patterns of consumption and production, technology and successive generations. While this comprehensive conceptualization has made the relevance of population dynamics even more compelling in development dialogue and policy, it has also necessitated more complex methods of analysis to understand better the linkages of population factors with sustained economic growth and sustainable development. The ICPD made a number of recommendations to address these issues more effectively. Among them, two are noteworthy for this publication: first, “[e]xplicitly integrating population into economic and development strategies will both accelerate the pace of sustainable development and poverty alleviation and contribute to the achievement of population objectives and improved quality of life of the population”;7 and second, “[r]esearch should be undertaken on the linkages among population, consumption and production, the environment, and natural resources, and human health as a guide to effective sustainable development policies”.8 The case studies of Ghana and South Africa describe successful efforts in these two countries to build national capacity of professional staff in order to help to move forward the agenda on population and sustainable development. The case study of Ghana deals with capacity-building to integrate population factors into development planning, with a view to helping to alleviate poverty. Given that the country has introduced the preparation of District Development Plans as part of the decentralization process in the country, the empowerment of District Assemblies to prepare and implement their own Plans to meet the needs and aspirations of their people is crucial. Recognizing that any effort to help to reduce poverty must take into account, among others, the four major variables of population factors, the development sector, development planning instruments and resources, the National Population Council of Ghana contracted the Department of Planning of the Kwame Nkrumah University of Science and Technology to develop a training course on integrating population factors into development planning.

7 Ibid., para. 3.3. 8 Ibid., para. 3.31. 20 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The case study documents the substantive and programmatic aspects of the approach followed by Ghana in formulating and implementing the training programme for capacity-building of mid-level professionals involved in development planning. The course is conceived as an integrated package of fifteen modules, each of which is aimed at building capacity of participants to address the relevance of population factors for a selected component of the development sector. According to the study, a number of innovations have been incorporated into the running of the training programme and the course is considered as successful by all concerned: trainees, District Chief Executives, District Coordinating Directors and the National Population Council. The South African case study also looks at an exercise in capacity-building but one that is aimed at development policymakers and planners on the broader theme of interrelationships among the three primary fields of population, environment and development. Viewing the multiple interactions among the three fields as a nexus of interrelationships, the training course seeks to build capacity of participants to appreciate the systemic effect of interactions within the nexus and argues for the incorporation of this nexus when crafting development policies, plans and programmes. The training exercise was initially designed as a project with partnership among the Department of Social Development of the Government of South Africa, Leadership for Environment and Development (LEAD) and UNFPA for the development of an integrated approach to population, environment and development issues. According to the case study, the Population, Environment and Development Nexus Training Programme, after several years of implementation and adjustments, is assessed as an innovative practice that is portable, replicable and successful in addressing local development planning and implementation because of the focus and approach of the course: the application of a systemic understanding of the interactions among the key population, environment and development components in sustainable human development.

Gender Empowerment and Reproductive Health The 1994 International Conference on Population and Development as well as the Fourth World Conference on Women: Action for Equality, Development and Peace held in 1995 has provided a strong rationale for urgently addressing the issue of gender equality and women’s empowerment as well as the impetus needed to do so. While some progress on the issue has been noted in many countries, there has not been any consistent progress over a wide range of countries. It is hoped that, with the establishment of UN Women, the pace of progress will quicken around the world. In this general context, the case study of Tunisia on women’s rights and reproductive health is a welcome contribution. It is a compelling narrative of women’s empowerment in the national historical context of the country. When it is realized that foundations Introduction 21 for progress on women’s rights in the country had been laid long before the Cairo and Beijing Conferences, the Tunisian case study assumes even greater contemporary relevance. As the case study argues, the strategy adopted by Tunisia since its independence in 1956 has, over the years, reinforced the principle of equality between men and women as equal citizens in the society and in the eyes of the law of the land. This has, according to the case study, enabled the country to develop socio-economically, to experience demographic transition and to fully participate in the construction of a modern society. Among the favourable factors identified as facilitating forces for this transition have been the political will and vision of the founding fathers of the nation and the inclusion of the Code of Personal Status (CPS) in the country’s Constitution. The case study argues that as a result of that pioneering vision, Tunisia has become a leading country in the field of women’s rights among the Arab and Muslim countries. This documentation of the historical evolution of gender and reproductive health achievements in Tunisia is worthy of examination for implications for other contexts.

Conclusion This compilation of 10 case studies demonstrates, albeit selectively, that the ICPD Programme of Action is being implemented and progress is being achieved in adopting the new perspectives. Almost all of the case studies included in the publication contain elements of innovation either in programme design or implementation and all of them offer lessons learned that are useful for other countries and programme contexts. The authors of the case studies have all commented on the potential of the specific approaches for replication elsewhere. As we approach the twentieth anniversary of the adoption of the ICPD Programme of Action and the target date for achieving the Millennium Development Goals, it is well recognized that the universal access to reproductive health-care services for all and the promotion of sustainable development have remained an unfinished agenda. Furthermore, the latest projections by the United Nations indicate that the world population will reach 7 billion by October 2011 and will continue to increase to 9.3 billion by 2050. This gives an even greater sense of urgency to addressing the population and sustainable development challenge in the coming decades as many developing countries, especially the least developed countries, continue to face rapid population growth, high maternal mortality, ever-expanding cohorts of young people requiring attention to their development and reproductive health needs, and the challenge of incorporating population factors into development planning and policy. The national experiences captured in the case studies included in this volume offer useful insights into how some of the developing countries have addressed the population and reproductive health issues 22 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES during the last decade and a half. It is hoped that other developing countries will find the innovative practices reported here valuable in their own efforts at tackling the population and reproductive health issues in the future.

Sethuramiah L. Rao Permanent Observer of Partners in Population and Development (PPD) to the United Nations New York, New York, United States Domiciliary Services 1 in Reproductive Bangladesh Health and Family Planning

Mr. Mohammad Abdul Qayyum

Summary

Bangladesh, with an estimated population of 150 million and a corresponding population density of more than 920 people per sq km, is regarded as one of the most densely popu- lated countries in the world (National Institute of Population Research and Training, 2007). Development policies in Bangladesh recognized the pressing need to reduce the population growth rate in order to ease the mounting pressure on the country’s finite resources. This sense of urgency was amply expressed in the First Five Year Plan statement that “No civilised measure would be too drastic to keep the population of Bangladesh on the smaller side of 15 crores for the sheer ecological viability of the nation” (Government of Bangladesh, 1973).

Realizing the urgency of the need to contain the rapid population growth, the Government of Bangladesh introduced domiciliary services in 1976 as an innovative approach to provide maternal and child health and family planning services. Family Welfare Assistants were recruited for delivering the domiciliary services nationwide. One Family Welfare Assistant was to serve 500 to 600 eligible couples. All Family Welfare Assistants were women and local residents.

By introducing domiciliary services, the Government wanted to generate demand for family planning through counselling, cater to the people’s need for contraception, ensure easy access to services, and bring about changes in reproductive-health behaviour among

23 24 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

target groups. Poor infrastructure, the conservative attitude of people towards contraception, a high fertility rate but a low demand for contraceptives, a low literacy rate, the poor economic conditions of the people, and gender inequality were all the background reasons for starting this innovative approach.

With the introduction of the domiciliary service-delivery model, the Family Planning Programme of Bangladesh achieved remarkable results, with a rise in the contraceptive prevalence rate from 7.7 per cent in 1975 to 56 per cent in 2007. The population growth rate came down substantially, the level of knowledge of contraception increased to 100 per cent and maternal mortality was considerably reduced.

Doorstep service delivery provides benefits extending beyond those arising from the receipt of family planning services. Considering their socio-economic situation, hiring young women as providers of family planning services was a milestone in the history of women’s empowerment in Bangladesh. In time, Family Welfare Assistants became role models for the other women in the community. This service-delivery system for rural women was introduced in an effort to ensure universal coverage of services upon acknowl- edging the restricted mobility of village women. With the introduction of this service-delivery strategy, the overall demographic scenario of Bangladesh changed within two decades.

In 1998, the Government introduced a static, centre-based, service-delivery system to replace domiciliary services and Family Welfare Assistants were asked to provide services from fixed sites. As a result, the use of maternal and child health and family planning services decreased and the total fertility rate remained stagnant for a decade (1993-2004). Recognizing this adverse effect, the Government repositioned the domiciliary service- delivery system and the total fertility rate started to decline again.

This service-delivery system is replicable and can be a good option to provide specific priority services in areas with low resource settings, low education levels and poor accessibility to service facilities. Considering the results achieved, this system of service delivery is also cost effective.

Information on the Author Mr. Mohammad Abdul Qayyum , former Director General of Family Planning, Directorate General of Family Planning, Ministry of Health and Family Welfare. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 25

I NTRODUCTIONAND in regards to contraception and reproduc- B ACKGROUND tive health. Only clinic-based family planning activities were available, which was highly insufficient. Domiciliary servi - Bangladesh is located in the northeastern ces were introduced to generate demand part of South Asia and covers an area of for family planning, to cater to the press- 147,570 sq km. The country has a popu- ing need for contraception, to ensure easy lation of about 150 million. With a corre- access to services, and to bring about sponding population density of 920 per- changes in reproductive health behaviour sons per sq km, it is the most densely pop- among the target groups. Poor infrastruc- ulated country in the world, excluding ture, the conservative attitude of people city states such as Singapore. For the last about contraception, a low literacy rate, four decades, the Government has been the poor economic conditions of the peo- actively trying to reduce the population ple, low demand for contraceptives and growth by adopting various measures. gender inequality were the main reasons Family planning was introduced in for starting this innovative approach. Bangladesh (erstwhile East Pakistan) in Fully aware of the importance of fam- the early 1950s through the voluntary ily planning services, the Government efforts of social and medical workers. developed a population policy in 1976, During the 1960s, the Government took declaring population control as the num- over the programme, and, after inde- ber one issue, and introduced a broad- pendence, family planning received based, multisectoral family planning unanimous, high-level political support. programme. Recognizing the urgency of All subsequent Governments that have the need to contain the rapid population come into power have identified popula- growth, it introduced domiciliary servi - tion control as the priority for ces in the same year as an innovative Government action. approach to provide maternal and child In the period 1971-1975, women in health and family planning services. Bangladesh were having an average of 6.3 Family Welfare Assistants were recruited children, the contraceptive prevalence to deliver the domiciliary services. Over rate was 7.7 per cent and the population the years, 23,500 Family Welfare growth rate was almost 3 per cent. The Assistants were recruited. high total fertility rate with a correspon- Family Welfare Assistants play a very ding low contraceptive prevalence rate important role: they are the first contact was about to cause a population boom; person for maternal and child health and this in turn also adversely affected mater- family planning services in the communi- nal mortality, child mortality and the ty. They complement the facility-based nutrition status. During this period, there services provided by skilled human were very limited services for the people resources through their outreach services 26 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES and they link their services with the stat- rural women were introduced in an effort ic service for referral of clients as and to ensure universal coverage of services when required. In addition, they conduct upon considering the restricted mobility advocacy programmes and are part of a of village women (Rob, Talukder and network comprising local government Ghafur, 2006). Moreover, because representatives, local elites, non-govern- Bangladesh is a moderately conservative mental organizations (NGOs) and other Muslim country where women feel more government agencies. This network cre- comfortable receiving family planning ates broader social support for the Family services from women service providers, Planning Programme. the Government adopted the policy of employing only women to work as Family Welfare Assistants. D ESCRIPTIONOFTHE P RACTICE The Family Welfare Assistants providing door-to-door services to village women are paid by the Government The Family Welfare Assistants are female exchequer (financial department). Their grass-roots-level fieldworkers of the salaries are included in the revenue budg- Directorate General of Family Planning. et. Initially, they were recruited under the Their immediate supervisors are the development budget but were absorbed Family Planning Inspectors. Initially, one into the regular payroll once the impor- Family Welfare Assistant was recruited tance of their services was realized. for one ward of the Union parishad.1 In 1990, each ward was divided into two or more units and one Family Welfare F EATURESOFTHE Assistant was given the responsibility of D OMICILIARY A PPROACH one unit comprising 500 to 600 eligible couples. Nowadays, the number of eligi- The domiciliary approach has the follow- ble couples has increased to 900 to 1,200 ing characteristics: couples per unit. Family Welfare Assistants are locally appointed and oper- • confidentiality. Bangladesh is a ate from their own houses. country where contraception issues It is important to mention that need to be dealt with confidentially. women’s mobility, that is, women’s ability Women in particular do not like to to leave their homes and to visit health talk with others about the need for facilities, was restricted in the 1970s. and use of contraceptives. For this reason, confidentiality is a top- Doorstep family planning services for priority issue in delivery of family

1A parishad is the lowest local-government administrative unit, comprising around 30,000 to 35,000 people. One Union parishad was then divided into three wards. Later it was divided into nine wards. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 27

planning services; • special care for the marginalized • generation of demand. Given that people. A high level of poverty the total fertility rate was high at exists in Bangladesh, with almost the time when domiciliary servi - half of the people living below the ces were introduced and the con- poverty line. Poverty is a barrier traceptive prevalence rate was very that hinders the access to services. low (7.7 per cent), creating The domiciliary service-delivery demand for contraceptives was system has broken this barrier as it another major function of domicil- has been specially designed to iary services; reach the poor and the marginalized people; • interpersonal communication. A country such as Bangladesh with • female-focused service. Both the poor economic conditions, a low health and the economic status of literacy rate, a high level of gender women are low in Bangladesh. disparity and low accessibility to One of the primary focuses of the information network requires domiciliary services has been to interpersonal communication for improve women’s reproductive the discussion of family planning. health status through contraception The development of good inter- and counselling; personal relationships with the • informed choice. One of the basic clients is the key strategy for features of this service-delivery domiciliary services. It is also model is to disseminate information essential for disseminating infor- regarding different contraceptive mation, providing counselling and methods to help the clients to increasing the demand for family choose the option best suited for planning services; her, taking into account the age of • upholding the cultural and social the woman, the number of children values. In the rural areas, social that she has and her reproductive taboos and reservations about health condition; and women’s mobility, family planning • client screening. Since all contra- and reproductive health issues ceptive methods are not suitable were prevalent. To address this for all clients, screening is needed issue, the Family Planning to identify the most appropriate Programme has been designed in contraceptive method for an such a way that it will not create individual client. The primary any conflict with the existing screening for contraception is social norms and values of the done by Family Welfare Assistants. country; 28 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

R ECRUITMENTAND T RAININGOF Training FAMILY W ELFARE A SSISTANTS Two months of basic training were pro- Recruitment vided to the newly appointed Family Welfare Assistants. The training covered The Family Welfare Assistants had to family planning, maternal health, child meet the following requirements: health, primary health care, limited cura- • be female. The primary objective tive care, nutrition, gender issues, sexually of domiciliary service delivery is transmitted diseases and communication to reach the poor, vulnerable skills (especially one-to-one and one-to- women of rural Bangladesh, where many). New topics such as reproductive gender inequality exists at all lev- health and HIV/AIDS were added at a els. Women are the target benefi- later stage to the foundation training. ciaries, and to reach them, women Maternal mortality in particular is a service providers have been sensitive indicator of inequity. It reflects assigned to provide domiciliary services; the status of women and their access to health-care services that respond to their • reside in the same locality. needs. High maternal mortality in Maternal and child health and Bangladesh is due to the alarmingly low family planning service providers use of professional maternity care. The were recruited from the same percentage of deliveries attended by locality (unit). Being part of and medically trained persons is very low (18 responsible to the community per cent). For this reason, the ensures Family Welfare Assistant accessibility to the households as Government has undertaken an initiative well as the trust of the people; to provide midwifery training to the Family Welfare Assistants so that they • at a minimum, be a high school can give assistance at home births. Some Women with the mini- graduate. of the Family Welfare Assistants received mum of a high school certificate six-month, competency-based, skilled- were recruited for this special type birth-attendant training. Family Welfare of service; and Assistants trained in midwifery are now • cover a specified number of eligi- conducting safe deliveries at home, on ble couples. Initially, each Family average performing three deliveries per Welfare Assistant had to provide month. They also provide antenatal care services to 500 to 600 couples in and postnatal care services and are her working area. trained in administering misoprostol and oxytocin. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 29

Figure 1 Demand and supply model of domiciliary J OB R ESPONSIBILITIES services. OF FAMILY W ELFARE A SSISTANTS A clearly defined job description Demand Side was initially formulated for the

Co Family Welfare Assistants: they

ed u nse id were to provide family planning ices ov v r l li services at the household level, P ng Ser the main aim being the regulation of population growth. Later FWA D on, some adjustments were made s G em ene es ed to the original job description to a p nd en ra r a widen the scope of family plan- ted elo Aw Dev ning services. Supply Side The Family Welfare Assistant is the principal fieldworker of the Maternal and Child Health and Family Planning Programme. O BJECTIVESOFTHE D OMICILIARY S ERVICES During home visits, Family Welfare Assistants regularly collect information The main objectives of the domiciliary on eligible couples, acceptors of contra- services are to: ceptive methods, pregnant women, and birth and death statistics. They also pro- • provide reproductive health and vide services to young children, assist in family planning services as per clients’ needs; child vaccination and provide adolescent health-care services. They register all • increase the number of contracep- these data in the Family Welfare Assistant tive acceptors; register. For each month, the Family • reduce the total fertility rate; Welfare Assistants make a work plan, • increase the demand for long- which must be approved by the immedi- acting and permanent methods of ate supervisor, namely, the Family contraception; Planning Inspector. After approval, • improve women’s health status; Family Welfare Assistants, through door- to-door visits, distribute temporary meth- • ensure safe motherhood; ods of contraception and give advice on • improve the nutritional status of safe motherhood, nutrition and other the community; and related topics. At the end of the month, • improve children’s health status. they submit a performance report to their 30 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES supervisors. The responsibilities of the here that satellite clinics are located in the Family Welfare Assistants are described outreach area within the working unit of below. the Family Welfare Assistant, at a considerable distance from the static service Planning and Organizing centres (Union Health and Family In the Maternal and Child Health and Welfare Centre). Satellite clinics are usu- Family Planning Programme, Family ally set up in suitable houses in the com- Welfare Assistants must participate in the munity. A Family Welfare Visitor from the target-setting process and prepare a work nearby static service centre goes to a plan for achieving the set target. They satellite clinic to provide services such as attend monthly and fortnightly meetings, family planning, antenatal care, postnatal organize satellite clinics, refer clients and care and immunization. Family Welfare assist Family Welfare Visitors in provid- Assistants inform the communities about ing services to the pregnant mothers. the locations, dates and times of the satellite clinics. They motivate the mothers to Responsibilities Regarding Service attend health sessions, tell the Family Delivery Welfare Visitor to visit complicated cases Family Planning at home, and provide health education at satellite clinics. Through information, education and motivation activities, Family Welfare Assistants create demand among eligible clients for Pregnancy and Childbirth accepting contraception. They do this Pregnancy and childbirth constitute through home visitations. Family Welfare another important area where Family Assistants play a vital role in many aspects Welfare Assistants play an active role. of reproductive health such as the screen- Family Welfare Assistants maintain a cur- ing of new acceptors, the distribution of rent list of pregnant mothers in the area oral pills and condoms to the clients, and and submit an updated list to the Family the referral of clients for sterilization, intra- Welfare Visitor each month. They give uterine devices (IUDs), Norplants, injec- mothers and family members basic infor- tions and menstrual regulation. They also mation on safe delivery, exclusive breast follow up with clients and provide injecta- feeding, safe water and sanitation, nutri- bles from the second dose. To provide tion and immunization. They also identi- need-based services, Family Welfare fy high-risk pregnancies and refer them to Assistants design their work plan according satellite clinics or the health and family to client segmentation. welfare centres at the union level. In addition, they refer complicated cases to the Satellite Clinics Medical Officer (Maternal and Child Health and Family Planning) at the Another important task of Family Welfare Upazila Health Complex and normal Assistants is to help in selecting sites for pregnancies to Family Welfare Visitors, satellite clinics. It is important to mention Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 31 community-based skilled birth attendants nourished women and children. They and trained traditional birth attendants for provide information and education on safe delivery. Family Welfare Assistants health and convey nutrition messages to also provide postnatal care to the mother mothers by using flash cards or through and to the newborn. Community-based practical demonstrations. They distribute skilled birth attendants (midwifery- vitamin A capsules to children 12 to 59 trained Family Welfare Assistants) per- months old twice a year and to post-par- form deliveries and provide postnatal care tum mothers within 42 days of delivery. and essential newborn care. They also provide counselling on the early initiation (within one hour of birth) Immunization of breastfeeding and exclusive breastfeeding for six months. Family Welfare Assistants participate actively in the national immunization pro- Monitoring and Supervision gramme. They educate mothers and To ensure effective service delivery, a sys- women of childbearing age about the tematic, goal-oriented monitoring and importance of immunization for them- supervision mechanism is ensured from selves and for their children, inform the the national to the grass-roots level. At community about the time and place of the ses- Figure 2 A Family Welfare Assistant gives advice on the use of sions of the expanded contraceptives. programme of immunization, immunize the children in the outreach centres of the expanded programme of immunization, and follow up on and motivate the drop-outs to achieve full immunization. Each Family Welfare Assistant prepares a list of the children living in her working area. Figure 3 A Family Welfare Assistant and Nutrition a Family Planning Family Welfare Assistants Inspector attending also put a great deal of a courtyard meeting. effort into improving the nutritional status of mal- 32 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES the bottom level, Family Welfare within a two-month round, they visit 15 Assistants provide performance reports to to 20 couples each day. Family Welfare their supervisors, which are then com- Assistants always carry temporary meth- piled by the supervisor and sent to the ods of contraception (oral pill and con- next-higher authority. Finally, the reports dom) for distribution among eligible are analysed at the Directorate level and couples along with the register and flip feedback is given to the lower level. To charts. Besides home visits, they also ensure smooth operational activities, the organize courtyard meetings with the Directorate General of Family Planning clients, non-users, adolescents and preg- has an administrative setup from the nant women where they discuss issues national to the ward level. Various cate- such as contraception, safe motherhood gories of technical and non-technical and immunization and motivate the personnel with a standardized skill mix clients to receive the related services. work in the service centres as well as in the administrative offices. The Director PARTNERSHIPS General along with the directors super- The programme is being implemented by vises and monitors the activities. the Government and the NGOs.

Government Initiatives I MPLEMENTATION The public sector provides contraceptives to half of all the users, particularly in O VERVIEW the rural areas. Government fieldworkers After adopting the domiciliary service are the most important source of contra- policy, the Government started to recruit ceptives for the rural population, supply- and train Family Welfare Assistants ing one in five users (National Institute of nationwide. A Family Welfare Assistant Population Research and Training register was developed to record family (NIPORT), Mitra and Associates, and planning and demographic events of Macro International, 2009). Government every household. This is a comprehen- supplies contraceptives through multiple sive register in which all demographic channels. One fifth of the total contra- information on eligible couples and their ceptive supply is distributed through children is recorded. doorstep services. The remaining 30 per cent is distributed in hospitals (3.8 per The couple register is updated once a cent), Upazila Health Complexes (9.1 year. After completion of the registration, per cent), Mother and Child Welfare Family Welfare Assistants prepare their Centres (2.2 per cent), Health and “advance tour programme”. Once their Family Welfare Centres (9.1 per cent), advance tour programme is approved by satellite clinics (5.2 per cent) and com- their immediate supervisor (the Family munity clinics (0.2 per cent). It is impor- Planning Inspector), they start visiting tant to note that the urban population the households. To cover all the couples Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 33 does not fall under the direct purview of (National Institute of Population the Government Family Planning Research and Training (NIPORT), Mitra Programme. In urban areas, family plan- and Associates, and Macro International ning services are provided by fixed ser - Inc., 2009). Some of the NGOs provide vice centres, mostly by NGOs with the services through a depot-holder approach. local government authority coordinating The depot holders are women from the the programme. community who keep a stock of commodities (contraceptive pills, condoms, Non-governmental Initiatives oral rehydration saline, etc.) at home to NGOs also provide reproductive health distribute to women and children in time and family planning services along with of need. They also promote good health the Government programme. There are practices and refer clients to nearby clin- 160 NGOs currently working in ics. NGO fieldworkers coordinate their Bangladesh that provide maternal and activities with Family Welfare Assistants. child health and family planning services, primarily in disadvantaged urban areas Social Marketing Programme and in selected rural areas. NGO clinics The Social Marketing Programme was provide a full range of family planning started in 1974 through an agreement services along with maternal and repro- between Population Services International ductive health services and a functional and the Population Control Department referral system. In general, an NGO net- of Bangladesh. The country has an work has three levels of service delivery: active contraceptive Social Marketing a comprehensive reproductive health- Programme that distributes pills, con- care centre, a static clinic and a satellite doms, injectables and oral rehydration clinic. The most important facility in the solution through a network of retail out- NGO health network is the comprehen- lets (pharmacies, small shops). Forty-five sive reproductive health-care centre, per cent of pill acceptors use social mar- which serves as a referral centre for the keting brands compared with 52 per cent static and satellite clinics. With the sup- who use the Government-supplied port of the referral centre, family plan- brand, “Shukhi”. The Social Marketing ning, pregnancy care and immunization Company sells a wide variety of pills with have been brought to the community a nominal margin while the Government through satellite clinics. Doorstep servi - distributes only a single brand free of ces are also in place to publicize available charge. Condom brands sold by the services as well as to provide necessary Social Marketing Company have a high information (Talukder, Rob and Rahman, market share: almost three in five 2009). condom users buy Social Marketing Company brands. This marketing system NGOs provide services to 5.2 per cent of supplements the Family Welfare Assistant all the contraceptive users in Bangladesh network. 34 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

C HALLENGES International Inc., 2009). Reducing the unmet need for contraception A few challenges remain that must be requires the particular attention of addressed appropriately to achieve maxi- the fieldworker. To respond to mum results, including the following: these unmet needs, Family Welfare Assistants must update their regis- • timely recruitment and training. The recruitment procedure in the ters to identify the clients who are Government sector is sometimes not using any contraceptives and time-consuming in Bangladesh. In they need to ensure an uninterrupt- the near future, the country will ed supply of contraceptives; and have to face the challenge of • an uninterrupted supply of mobilizing new human resources contraceptives. Family Welfare since a large number of govern- Assistants distribute short-acting ment fieldworkers in the family contraceptives (pills, condoms and planning sector will be retiring injectables) to the clients. soon (Rob and Talukder, 2008). However, when they do not have There is apprehension that a enough supplies, they hesitate to shortage of well-trained, skilled perform their regular home visits. and competent service providers This has resulted in a reduction in and fieldworkers at the local level the frequency of visits. will slow down the performance of the Family Planning Programme In addition, the following challenges across the country (ibid.); should be considered: • reducing the unmet need for con- • Initially, each Family Welfare traception. Overall, 17 per cent of Assistant was in charge of 500 to the currently married women in 600 couples. She could easily Bangladesh have an unmet need make her round and was able to 2 for family planning services. visit each and every couple within Unmet needs increased from 11 the two-month schedule. per cent in 2004 to 17 per cent in Nowadays, however, the number 2007. The apparent increase in of couples to visit has almost dou- unmet needs reflects problems in bled for each Family Welfare the supply of family planning serv- Assistant. Consequently, it is diffi- ices and/or an increase in the cult for them to ensure home visits demand for family planning to all the couples in due time. (National Institute of Population Moreover, the overall workload of Research and Training (NIPORT), the Family Welfare Assistants has Mitra and Associates, and Macro increased significantly;

2 Fecund women who are currently married and who say either that they do not want any more children or that they want to wait two or more years before having another child but are not using any contraception are considered to have an unmet need for family planning. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 35

• Another important issue is the and Hossain, 2003). However, the gen- absence of scope for carrier devel- der benefits came from the programme’s opment. After a certain period impact on fertility regulation rather than (15-20 years) of working in the directly from the social interaction occur- same position, Family Welfare ring during home visits. Family Welfare Assistants become reluctant to do Assistants indirectly enhanced the status their job. Their work is demand- of women by fostering reproductive ing and tiring. House-to-house health autonomy. Nevertheless, domicil- visits are made on foot. iary service delivery had a direct influ- Commitment gradually declines ence on the following areas: and this is reflected in the reduced number of visits by Family Welfare • reducing social barriers. Assistants and in the services Reproductive health and family offered by them. planning services had been suffer- ing from a social taboo in Bangladesh, where people hesitat- RESULTSAND ACHIEVEMENTS ed to talk about the issues. By providing domiciliary services, an existing social barrier was broken. D IRECT I MPACT Women in particular were encour- From 1976 to 1997, the Government of aged to receive family planning Bangladesh recruited and trained married and maternal and child health women to provide family planning coun- services, which made them social- selling and services to couples in rural ly empowered. The Government households. At the peak of the pro- accepted the help of local elites gramme, a total of 23,500 Family Welfare and opinion leaders from different Assistants worked throughout the coun- levels to motivate women to work try. By the early 1990s, doorstep service in the family planning sector; delivery had helped to increase family • increasing the contraceptive planning awareness as well as the rate of prevalence rate. Domiciliary method uptake and continuity of method services had a strong influence on use among rural couples (Koenig, increasing the use of contracep- Hossain and Whittaker, 1989). tives. Various studies reported that Home visitation by Family Welfare the use of contraception was Assistants affected women’s fertility greatly influenced by the field- behaviour since it increased their aware- workers’ visits. For example, studies showed that clients who had ness of family planning and maternal and more than one contact with a child health services. The more visits the worker were more knowledgeable women received from Family Welfare and used family planning methods Assistants, the more likely they were to more often (Huq and Al-Sabir, experience an increase in status (Phillips 1992). The same study indicated 36 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

that clients who had not received • reducing the total fertility rate. information on family planning With the increase in the contra- from fieldworkers preferred having ceptive prevalence rate, the total male children and large families. fertility rate came down substan- Moreover, it was found that the tially, from 6.3 births per woman frequency of home visits also in 1975 to 2.7 in 2007 (see graph). reduced religious contentions Findings suggest that contracep- regarding family planning. The tion is the most important proxi- domiciliary services enabled the mate determinant, contributing to system to achieve the objectives of more than 50 per cent of the total the programme successfully and fertility reduction (Islam, effectively. Evidence suggests that Chakraborty and Rob, 2004); the introduction of domiciliary services into the Family Planning • reducing the maternal mortality Programme sharply increased its ratio. Family planning is the pillar performance. The contraceptive of safe motherhood. The Family prevalence rate increased from 7.5 Planning Programme adopted the per cent in 1975 to 56 per cent in maternal and child health-based 2007. The Bangladesh Family approach in 1976, and since then, Planning Programme earned a maternal and child health-based worldwide reputation and much of family planning has been the key the credit should go to the pro- feature of the Family Planning poor service-delivery system in Programme (Mabud and Akhter, rural areas (Rob, Talukder and 2000). Maternal and child health- Ghafur, 2006); based family planning services

Trends in the total fertility rate (TFR) and the contraceptive prevalence rate (CPR), 1975-2007.

7 6.3 70 5.8 58.1 6 5.5 53.8 55.8 60 5.1 49.2 5 4.3 44.6 50

4 30.8 3.3 3.3 3.0 40 39.9 2.7 3 25.3 3.4 30 19.1 2 20 7.7 1 10 0 0 1975 1983 1985 1989 1991 1993- 1996- 1999- 2004 2007 94 97 2000

TFR CPR Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 37

were extended to the community • reducing dropout rates. Retaining level and large numbers of female users of temporary methods is fieldworkers (Family Welfare another important aspect of the Assistants) were deployed to pro- family planning service. vide maternal and child health and Domiciliary services have proved family planning services at the to be an effective approach in this doorstep level. Domiciliary servi - context. Routine visits by the field- ces have encouraged pregnant workers help clients to obtain con- women to visit the static centres traceptive methods and resupplies for antenatal check-ups. As a in due time, especially in remote result, the rate of antenatal visits areas where there is no alternative has increased over the years, source of contraceptives. More - reaching 52 per cent in 2007. The over, in case of problems linked to increase in the contraceptive the use of contraceptives, timely prevalence rate, number of antena- and effective help can be provided tal check-ups, safe deliveries and to the clients. postnatal check-ups has contributed to the recent decline in I NDIRECT I MPACT the maternal mortality rate; A qualitative study concluded that • increasing the knowledge of con- doorstep delivery of services enhanced traception. It has been observed that counselling and advisory serv- women’s status (Simmons et al., 1988). ices by the Family Welfare For example, Family Welfare Assistants Assistants helped to increase cou- themselves benefited directly from ples’ knowledge of contraception. receiving cash wages and indirectly from Awareness of contraceptive meth- gaining mobility, prestige and authority ods is now high; roughly nine out from their work. In turn, the large-scale of ten women know what pills, deployment of female family planning condoms, injectables and female workers changed people’s perceptions of sterilization are (National Institute women’s roles: every hamlet in of Population Research and Bangladesh had a Family Welfare Training (NIPORT), Mitra and Assistant acting as a household visitor, Associates, and Macro adviser and confidante, clearly showing International Inc., 2009). Findings that women were employable, mobile, from a study suggest that this socially gregarious and autonomous, knowledge was acquired primarily without depending on male partners or from family planning fieldworkers the extended family. Young female clients (39 per cent) but also from the were particularly influenced by interac- mass media (26 per cent) and from tions with Family Welfare Assistants. The neighbours (23 per cent) (Huq programme was thus characterized as and Al-Sabir, 1992); and having a “beyond-supply” social effect. In 38 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES addition, by helping clients to achieve ning was launched (Ali et al., 1994). control over their fertility and therefore The development of interpersonal their lives (Huq and Murdock, 1997), contacts through home visits has proved doorstep delivery produced benefits to be undoubtedly effective. The key extending beyond those arising only players in this process of building inter- from the receipt of family planning serv- personal contacts were the large number ices. The work of the Family Welfare of full-time female fieldworkers recruited Assistants initiated a wider social impact: and deployed within the locality of their it has impacted women’s empowerment permanent residence. and gender equity and has brought about greater social change. Almost 83 per cent of rural eligible couples using family planning methods received contraceptives from Family A SSESSMENTAND Welfare Assistants. A continuous supply E VALUATION of contraceptives prevents unwanted pregnancies and ensures safe mother- The Bangladesh Family Planning hood. By improving the health status of Programme is a success story and a model the mother, child mortality and morbidi- programme for many countries. Its success ty have been reduced to a large extent. is due to a large extent to the deployment The source of contraceptives is an of a large contingent of government and important issue of the Family Planning NGO fieldworkers who made door-to- Programme, which has a direct linkage door visits to promote family planning and with the domiciliary services. In who distributed contraceptives. These vis- Bangladesh, both the public and private its along with mass media campaigns sectors are important sources of modern resulted in a remarkable increase in the contraceptive methods (50 per cent and contraceptive prevalence rate within a 44 per cent, respectively) (National very short time span. Studies have shown Institute of Population Research and that frequent home visits to all eligible Training (NIPORT), Mitra and couples, irrespective of their current status, Associates, and Macro International Inc., are associated with higher family planning 2009). The table shows that with the performance (Phillips et al., 1989). introduction of domiciliary services, the A study has shown that the success of total fertility rate declined dramatically the Family Planning Programme is due to from 6.3 births per woman in 1975 to 4.3 the contributions made by Programme in 1991. After that date, the rate interventions over the last two decades and remained stagnant for more than a more particularly in the mid-1970s, when decade (1993-2004). This was the time the first Five Year Plan of the Government when domiciliary services were with- of Bangladesh on health and family plan- drawn. When the domiciliary service Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 39

Total fertility rate, contraceptive prevalence rate, unmet need for family planning, prevalence of domiciliary services, dropout rate in contraceptive practice, and percentage of contraceptive supplies provided by the fieldworkers, 1975-2007.

Dropout Total Rate in Percentage Fertility Contra- Contra- of Contra- Rate ceptive Unmet Domiciliary ceptive ceptives Data (Births per Prevalence Need Visit Practice Provided by Source Woman) Rate (%) (%) (%) (%) Fieldworkers

BFS 1975 6.3 7.7 CPS 1983 - 19.1 CPS 1985 - 25.3 BFS 1989 4.9 31.4 41.0 CPS 1991 4.3 39.9 36.0 BDHS 1993-1994 3.4 44.6 19 38.0 47.8 41.8 BDHS 1996-1997 3.3 49.2 16 35.0 46.9 39.0 BDHS 1999-2000 3.3 53.8 15 21.0 48.6 27.9 BDHS 2004 3.0 58.1 11 18.0 49.4 23.0 BDHS 2007 2.7 55.8 17 15.7 57.0 20.0

BDHS = Bangladesh Demographic and Health Survey; BFS = Bangladesh Fertility Survey; CPS = Contraceptive Prevalence Survey.

system was reintroduced in 2003, however, ily planning services but they also strive the total fertility rate started to decline to generate demand for family planning again, as evidenced in 2004. services from the health facilities among the people. This is why, although the Contraceptive discontinuation, anoth- number of domiciliary visits gradually er source of concern for the Family declined from 1989 to 2007, the impact Planning Programme, has a negative cor- of demand generation in the early years relation with domiciliary visits: the facilitated the increase in the contracep- decreasing number of home visitations tive prevalence rate and fostered the cor- caused the dropout rate to increase (see responding decrease in the total fertility table). However, in reading the table, a rate in the following years. question arises: why, despite the decrease in home visits over the years, is the con- The political standpoint on how to traceptive prevalence rate increasing and deliver family planning services in the the corresponding total fertility rate communities is changing over time and decreasing? As explained earlier, Family new approaches are being examined. Welfare Assistants not only provide fam- Domiciliary services, although very 40 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES effective and needed at a time when com- • Women are especially efficient in munication networks and media coverage providing family planning and were not good, may be replaced by other reproductive health services at the types of services. doorstep. In the absence of domiciliary services, • Domiciliary services contribute to people can receive contraceptives from the improvement of women’s status and their empowerment at the other sources such as pharmacies, shops grass-roots level. and fixed service-delivery points. The problem is that in most cases, the hus- • Initially, the domestic financial bands are the ones buying the contracep- involvement was high but interna- tives for their wives; thus women no tional agencies such as the United longer have access to key aspects of Nations Population Fund, the maternal and child health and family Canadian International planning services: contraceptive coun- Development Agency, the Norwegian Agency for selling and follow-up services. Development Cooperation, the During the implementation of the Overseas Development first sector-wide programme (the Health Administration (now DFID) and Population Sector Programme (United Kingdom) and the 1998-2003), domiciliary services were Swedish International withdrawn, and for that reason, the per- Development Cooperation centage of home visitations dropped to Agency came forward and offered the minimum (see table). It was reported financial assistance. The initial that rural people wanted to receive fami- financial burden was thus reduced. ly planning services through home visita- • No major change has taken place in tions. The Government started to the domiciliary delivery pattern provide domiciliary services again with until now except for some changes the second sector-wide programme (the in the job description of the Family Health, Nutrition and Population Sector Welfare Assistant, which now Programme 2003-2011). includes more areas of service delivery. The increasing literacy rate, women’s empowerment, the existing L ESSONS L EARNED micro credit system, a different lifestyle and the development of mass media have brought about sig- • The introduction of domiciliary nificant changes in the way of life. services was a milestone for mater- However, there is still a strong nal and child health and family demand for more trained and capa- planning services in Bangladesh, ble Family Welfare Assistants to which contributed to the success respond to the needs of a growing of reproductive and family plan- population, especially of the huge ning services. number of newly-wed couples. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 41

• The reproductive behaviours of to service facilities. the people changed over the years • In situations where particular serv- thanks to the motivation and ices are needed urgently, domicil- counselling activities of Family iary services can be introduced to Welfare Assistants. achieve immediate results. • Couples trust Family Welfare • This service-delivery model is also Assistants. Not only do they trust suitable when the geographic loca- them with regard to family plan- tions are dispersed over a large ning and reproductive and child area and are hard to reach. health issues but also with respect to other family-related matters such • In case of natural disasters, when as children’s education and the all communication channels col- receipt of micro credit from NGOs. lapse, doorstep service delivery is a window through which primary It is therefore possible to say that health care, reproductive health, domiciliary service delivery is suitable for family planning and other emer- replication in similar settings in other gency services can be provided. countries. This service-delivery pattern is not needed in areas where economic devel- P OTENTIALFOR opment has taken place and demand for R EPLICATION E LSEWHERE maternal and child health and family planning services has already been created. This kind of service delivery can also Domiciliary services have been estab- be conducted on a voluntary basis, keep- lished and recognized as an effective ing a close watch on the achievements service-delivery model, especially for because professionalism is a must for rural communities. This model is suitable achieving any desired goal. mostly in low socio-economic settings where the demand for priority services has not yet been created. During the last O VERVIEWOFTHE three decades, this service-delivery pat- E VOLUTIONOF tern has changed the overall demograph- D OMICILIARY S ERVICES ic profile of Bangladesh.

Domiciliary services are suitable in Domiciliary services have gone through the following situations: various stages, as has the Bangladesh Family Planning Programme. The • Domiciliary services can be a good Government policy guidelines con- option for providing specific prior- tributed a great deal to these changes. ity services in settings with low Initially, when domiciliary services were economic resources, a poor level introduced, the primary goals were of education and low accessibility 42 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES twofold: generation of demand through Family Welfare Assistants are now pro- counselling and distribution of contra- viding all these services through the ceptives. With the introduction of domi- domiciliary model. ciliary services into the Family Planning The following is a chronology of the Programme, Bangladesh achieved imme- significant events in the evolution of the diate results: an increase in the contra- domiciliary services: ceptive prevalence rate from 7.7 per cent in 1975 to 18.6 per cent in 1980 and a • 1976: full time fieldworkers pro- decrease in the corresponding population viding domiciliary services growth rate from 3.0 to 2.32 per cent. were deployed; Currently, the contraceptive prevalence • 1980: registers of Family Welfare rate is 56 per cent and the growth rate is Assistants were introduced 1.39 per cent. In time, new activities at the unit level to record (e.g., safe motherhood, immunization, family planning and demo- adolescent health and early childhood graphic events of house- development) were introduced into the holds. In the same year, national Family Planning Programme and special training institutes

Experiences of a Family Welfare Assistant

Ms. Alima Begum became a Family Welfare Assistant in 1980 at the age of 28. Her working area was 1/ka unit of the Toakul union of the Gowainghat Upazila in Sylhet District, which is the remotest part of Bangladesh and one of the lowest-performing areas in the context of reproductive health and family planning activities. During the 1980s, poor infrastructure, coupled with religious barriers, made the family planning activities difficult to conduct.

When Ms. Begum started her journey as a Family Welfare Assistant, local people initially did not welcome her as a service provider. On the contrary, they pressured members of her family to make her resign from her job. Putting those adversities aside, Ms. Begum continued her work. When she joined the domiciliary services, the population of her working area totalled 3,445, among whom were 685 eligible couples. Out of the total number of eligible couples, only 15 were using family planning methods. Ms. Begum used to leave home in the morning and walk far to reach the clients’ houses. In the beginning, people did not listen to her advice but she did not give up and continued with her mission: she incited people to use contraceptive methods and to keep the size of their family small.

After six years of relentless effort and hard work, she was able to increase the number of contraceptive acceptors to 101 out of 715 eligible couples. All the people in her working area used to call her by her nick name, “Maya apa”. Maya was the brand name of the oral contraceptive pill supplied by the Family Planning Department. After serving 30 years with the Government, she retired in 2010. At the time of her retirement, she left 1,054 eligible couples in her unit; 631 of them were contraceptive users with a corresponding contraceptive acceptance rate of 59.43 per cent. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 43

(the National Institute of Disease Research, Bangladesh, and Mr. Population Research and Ubaidur Rob, Country Chief, Population Training and the Regional Council, Bangladesh, made valuable Training Centre) were contributions to this paper as internal established; evaluators. I also would like to express my • 1990: a broad-based, multisectoral gratitude to the external evaluators for approach was initiated to their outstanding contributions, which mobilize the community helped me to refine this study and pre- and engage civil society; pare this write-up. • 1998: domiciliary services were withdrawn; R EFERENCES • 2003: domiciliary services were reintroduced. Ali, N.M. et al. (1994). “Status of interpersonal communication by FWAs during their home visitation”. Dhaka: National A CKNOWLEDGEMENTS Institute of Population Research and Training. This case study was prepared to highlight Cleland, J. et al. (1994). The Determinates of domiciliary services as a best practice Reproductive Change in Bangladesh: Success in a approach in the context of providing Challenging Environment. Washington, D.C.: family planning and reproductive health World Bank. services in Bangladesh. While writing this paper, I was greatly supported by Mr. Government of Bangladesh, Ministry of Md. Mahbubul Alam, Family Planning Health and Family Welfare (2009). Officer, and Dr. Bishnupada Dhar, Bangladesh Population Policy. Dhaka: Programme Manager, Maternal and Ministry of Health and Family Welfare. Child Health Unit, Directorate General ______(2004). Bangladesh Health and of Family Planning, among other experi- Population Sector Programme 1998-2003: The enced officials. Without their contribu- Third Service Delivery Survey. Dhaka: tion and suggestions, this case study Community Information and would not have become a reality. Before Epidemiological Technologies and the submitting this paper to Partners in Ministry of Health and Family Welfare. Population and Development for external ______, (2004). HNP Strategic Investment evaluation, it was submitted to internal Plan. Dhaka: Ministry of Health and evaluators. Mr. Peter Kim Streatfield, Family Welfare. Head, Population Programme, and Head, Health and Demographic Surveillance ______(2003). Health, Nutrition and Unit, Public Health Sciences Division, Population Sector Programme 2003-2006: International Centre for Diarrhoeal Programme Implementation Plan. Dhaka: Ministry of Health and Family Welfare. 44 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

______(1998). Programme Implementation Population and Family Health Project, Plan, Part I: Health and Population Sector World Bank. Programme 1998-2003. Dhaka: Ministry of Mabud, M.A. and Akhter, R. (2000). Health and Family Welfare. Recent Shift in Bangladesh’s Population Government of Bangladesh, Ministry of Policy and Programme Strategies: Planning, Planning Commission (1973). Prospects and Risks. Paper 5. Dhaka: The First Five Year Plan 1973-78. Dhaka: Centre for Policy Dialogue. Planning Commission. Mitra, S.N. et al. (1997). Bangladesh Government of Bangladesh, Population Demographic and Health Survey 1996-1997. Control and Family Planning Division Dhaka, Bangladesh, and Calverton, (1976). Bangladesh National Population Policy: Maryland, United States: National An Outline. Dhaka: Population Control Institute of Population Research and and Family Planning Division. Training (NIPORT), Mitra and Associates, and Macro International Inc. Hoque, M.N. and Murdock, S.H. (1997). “Socioeconomic development, status of ______(1994). Bangladesh Demographic women, family planning, and fertility in and Health Survey, 1993-1994. Dhaka, Bangladesh: A district level analysis”. In Bangladesh, and Calverton, Maryland, Social Biology, 44(3-4):179-197. United States: National Institute of Population Research and Training Huq, M.N. and Al-Sabir, A. (1992). (NIPORT), Mitra and Associates, and Interaction between Clients and Grass-root Family Macro International Inc. Planning Workers: Implications for Programme Performance. Research Publication No. 44. National Institute of Population Research Dhaka: National Institute of Population and Training (NIPORT), Mitra and Research and Training. Associates, and Macro International (2009). Bangladesh Demographic and Health Huq, M.N. and Cleland, J. (1990). Survey 2007. Dhaka, Bangladesh, and Bangladesh Fertility Survey 1989. Dhaka: Calverton, Maryland, United States: National Institute of Population Research National Institute of Population Research and Training. and Training (NIPORT), Mitra and Islam, M.M., Chakraborty, N. and Rob, Associates, and Macro International, Inc. U. (2004). “Regional variations in fertili- National Institute of Population Research ty”. In U. Rob, M.N. Ameen and N. Piet- and Training (NIPORT), Mitra and Pelon (eds.), Fertility Transition in Bangladesh: Associates, and ORC Macro (2005). Evidence and Implication. Dhaka: United Bangladesh Demographic and Health Survey Nations Population Fund (UNFPA). 2004. Dhaka, Bangladesh, and Calverton, Koenig, M.A., Hossain, B.M. and Maryland, United States: National Whittaker, M. (1989). “The Influence of Institute of Population Research and Quality of Care upon Contraceptive Use Training, Mitra and Associates, and ORC in Rural Bangladesh”. Dhaka: Second Macro. Domiciliary Services in Reproductive Health and Family Planning – Bangladesh 45

______(2001). Bangladesh Demographic and Talukder, M.N., Rob, U. and Rahman, Health Survey 1999-2000. Dhaka, Bangladesh, M.M. (2009). “Improving the quality of and Calverton, Maryland, United States: family planning and reproductive tract National Institute of Population Research infection services for urban slum popula- and Training (NIPORT), Mitra and tions”. In Demand-based Reproductive Health Associates, and ORC Macro. Commodity Project Final Report. Dhaka: Population Council. Phillips, J.F. and Hossain, M.B. (2003). “The impact of household delivery of family planning services on women’s sta- Contact tus in Bangladesh”. In International Family Directorate General of Family Planning Planning Perspectives, vol. 29, pp. 138-145. Ministry of Health and Family Welfare Phillips et al. (1989). “A case study of Address: 6 Kawran Bazar, Dhaka-1215, contraceptive introduction: Domiciliary Bangladesh depot-medroxy progesterone acetate Tel.: +88 02 9119568 services in rural Bangladesh”. In S.J. Fax: +88 02 9124523 Segal, A.O. Tsui and S.M. Rogers (eds.), E-mail: [email protected] Demographic and Programmatic Consequences of Website: http://www.dgfp.gov.bd Contraceptive Innovations (Reproductive Biology). New York: Plenum Press. Rob, U. and Talukder, M.N. (2008). Strengthening Health and Family Planning Services in Low Performing and Hard-to-reach Areas of Bangladesh: Workshop Report. Dhaka: Population Council. Rob, U., Talukder, M.N. and Ghafur, T. (2006). “Health policies: Pledges and implementation”. In The State of Health in Bangladesh 2006: Challenges of Achieving Equity in Health, Bangladesh Health Watch – Abridged Report. Dhaka: James P. Grant School of Public Health, BRAC University. Simmons, R. et al. (1988). “Beyond supply: The importance of family planning workers in rural Bangladesh. In Studies in Family Planning, 19(1):29-38. 46 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Focusing on 2 Quality of Care in China the Family Planning Programme

Prof. Zhenming Xie

Summary

Since the 1990s, many national population and family planning programmes have been under re-examination and reorientation in light of the Programme of Action adopted at the International Conference on Population and Development in 1994. This is the case in China.

The present case study documents an experiment initiated by the State Family Planning Commission – now the National Population and Family Planning Commission – in 1995 to introduce the quality-of-care approach into China’s family planning programme in a few counties and districts. The introduction of this approach, which focuses on the standardized services and the client’s choices, was to serve as a means of reorienting the programme away from its previous demographically driven track as well as scaling it up nationwide thereafter.

Following the official call of the State Family Planning Commission to reorient the family planning programme in both its guiding ideology and implementation approaches, the experiment was intended to demonstrate, through the pilot projects, how the programme could be reoriented and what a client-centred and quality-focused programme might look like in the context of China. With the field evidence, the experiment also sought to convince the people in charge of the programme at all levels that the full-fledged promotion of the reorientation of the programme nationwide would be feasible.

47 48 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

To achieve sound implementation of the quality-of-care experiment, the latter was carried out in various settings but based on three major objectives: changing to a client-centred ideology, upgrading services through overall retraining, and improving the facilities to achieve the best care that could be provided. The strategy used in implementing the experiment consisted of four mutually supportive components: phase in before phasing out, pilot before scaling up, be flexible and encourage diversity, and learn via experience.

The experience of the pilot project has provided firm evidence that with an approach oriented towards quality of care, not only is the programme able to provide better services to the clients and to protect the clients’ health and rights but the approach is also able to lead to a more effective programme and even better demographic outcomes.

The quality-of-care approach was later adopted in several major international endeavours such as the United Nations Population Fund (UNFPA) Reproductive Health and Family Planning Project and the Japanese Organization for International Cooperation in Family Planning Integrated Project. It also was scaled up under the name of the “Quality-of-Care Advanced Unit” nationwide campaign.

While the State Family Planning Commission experiment was initiated with virtually no external assistance, the need to subject the experiment to international exposure as well as to request support from international collaboration was well acknowledged.

Information on the Author Prof. Zhenming Xie, Professor at the China Population and Development Research Centre and Secretary-General of the China Population Association.

B ACKGROUND The emergence of the pilot experiment in improving quality of care was by no The quality-of-care approach, well known means an isolated event; rather, it resulted as quality of care in family planning, focus- from the interplay of a number of factors es on the standardized services and the emerging in the early 1990s within and out- client’s choices. It was initiated in small side of China. areas and expanded to the whole country as The nationwide family planning pro- the means of reorienting the family plan- gramme was initiated in the early 1970s ning programme in China. when the population of the country was Focusing on Quality of Care in the Family Planning Programme – China 49 growing more than 2 per cent per annum issued an official call in 1995 for the “two and the fertility level was around six chil- reorientations”, with the intention of ini- dren per couple. The next two decades tiating the programme reform all over the witnessed a drop in the population growth country. As the first step in the reorienta- rate to less than 1 per cent. Thus China tion, several counties and one district can no longer be regarded as a country were selected in the mid-1990s for an with “rapid growth” of its population. In experimental project to explore the pro- addition, the fertility level has been below gramme, changing the focus from demo- the replacement rate since the early 1990s; graphic targets to quality of care. thus the country can no longer be regarded as having a “high-fertility” population. S TATE FAMILY P LANNING By the end of the twentieth century, COMMISSION G OALINTHE China’s population dynamics had experi- R EORIENTATION enced a historic transformation. At the beginning of the period of the Meanwhile, the “reform and opening Ninth Five-Year Plan (1996-2000) in late era” initiated from the late 1970s trig- 1995, the State Family Planning gered China’s booming economy and Commission issued an official call for social transformation towards a modern reorientation of the family planning pro- society. As the result of the market-driv- gramme from an emphasis on demo- en economy, people tended to be more graphic targets towards client-centred attuned to quality-of-life issues, including approaches and from a narrow focus on personal reproductive health care and contraceptive prevalence towards rele- reproductive rights as well as gender vant integration, with reproductive health equality. The family planning programme and women’s empowerment objectives. In faced an entirely new generation, which early 1998, it reiterated and elaborated its had grown up with the exposure to enor- goal in reorienting the programme, speci- mous amounts of information and an fying that with the successful demonstra- ever-changing life reality. Internationally, tion of the innovative experiment in a the International Conference on number of pilot counties and districts by Population and Development in Cairo in the year 2000, the client-centred and 1994 and the Fourth World Conference quality-focused approach to family plan- on Women in Beijing in 1995 exposed ning would be gradually expanded China to a whole set of new concepts throughout the country and the nation- such as “informed choice”, “reproductive wide reorientation of the programme rights and health”, “women’s empower- should be realized by the year 2010. ment” and “gender perspective”. O BJECTIVESOFTHE E XPERIMENT All these necessitated the reform of the family planning programme accord- While the State Family Planning ing to the changing situation. Therefore, Commission had explicitly called for the the State Family Planning Commission reorientation of the family planning pro- 50 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES gramme, the overall objective of the exper- centred approach was the priority goal of iment was to demonstrate, through the the experiment. pilot projects, how the programme could be reoriented and what a client-centred Upgrading Management and and quality-focused programme might Services look like in the context of China. The While the demographically driven experiment also sought to convince the approach was in place, the quality of people in charge of the programme at all services and the care of clients tended to levels throughout the country of the feasi- lose priority in the programme. After the bility of the reorientation process as inte- experiment unfolded, many managers gral preparation for the full-fledged and service providers found that they did promotion of the reorientation of the pro- not have the capacity to provide services gramme after 2000. The specific objectives according to the goals of the experiment. of the experiment crystallized over the For example, while the providers were course of the experiment and are threefold: trained to do insertions and removals of changing the ideology, upgrading manage- intrauterine devices (IUDs), they had not ment and services, and improving facilities been trained in the advantages and disad- and institutional support. vantages of the various IUDs nor were they knowledgeable about the potential Changing the Ideology side effects of a given IUD. The China’s programme had been on a demo- providers lacked awareness of and skills graphically driven track for so long that in pre-operation counselling and post- many of the programme managers and operation follow-up services and had no service providers had become used to it professional training in interpersonal and found it very difficult to conceptual- communication. Therefore, the Quality- ize, implement or manage the pro- of-Care Pilot Project considered the gramme in an alternative manner. Some upgrading of management and services as worried that negative demographic con- the main content of the experiment. sequences would result from a less strin- gent approach to the programme or that Improving Facilities and Institutional Support the experiment would meet resistance from the local managers and service When the quality of services rather than providers because it would imply a demographic targets is stressed, the greater workload and responsibility. working conditions of the programme Others also worried that they would with regard to infrastructure and facili- receive very little appreciation from the ties, resource allocation, contraceptive clients, who might not be aware of and supply and staff recruitment must be might even be skeptical about the need reshaped. Greater priority should be for reproductive health care. Therefore, given to the observance of aseptic condi- changing the ideology to accept a client- tions in the clinics and to service-procedure protocols, with more space allocated Focusing on Quality of Care in the Family Planning Programme – China 51 for examination and counselling and the new approach became well more attention paid to the privacy and established in the programmes and confidentiality of the client. Many of the was recognized and welcomed by local service clinics in the pilot areas had the local people, then it was time been expanded or renovated, and the to phase out the old approach; equipment necessary for quality of care • “Pilot first, expand later”. and reproductive health care had been Introducing a quality-of-care purchased and installed. With the sup- approach in the context of China port of the local government, additional was an experiment without prece- resources had been allocated and more dent. To proceed with the experi- qualified and capable staff were recruited ment in a step-by-step manner, a throughout the experiment. Thus, few pilot areas were first carefully improving facilities and institutional sup- selected as the quality-of-care pio- port were necessary as the safeguards for neers or models. The intention a successful experiment. was to initiate the experiment in smaller areas with relatively favourable socio-economic condi- S TRATEGIES tions and sound performance in To ensure a sound and healthy programme their family planning programmes transition in sensitive circumstances, an to ensure that the pilot would suc- innovative strategy had to be developed in ceed more easily. With the suc- the experiment among the pilot counties cessful demonstration of the and districts. The strategy had four mutu- experiment, the approach was ally supportive components: introduced to larger areas, following the successful models. The • “Phase in, phase out”. To ensure a goal of scaling up the strategy had smooth transition, the pilot pro - been kept in mind from the very jects adopted a strategy called beginning of the project; “phase in, phase out”. This means • “Be flexible and encourage diver- that throughout the experiment, sity”. The experiment in each pilot the priority was to introduce the area was initiated with what was new and innovative approaches locally deemed acceptable and into the programme first and then doable. Though the State Family make them workable within the Planning Commission set the local programme and acceptable overall goals for the experiment as to the local people, including the stated above, from the very begin- clients, providers, managers and ning of the experiment, no fixed local leaders. This process takes timetable or specific procedures time. Every effort was made to were dictated from the top. The avoid overzealous attempts to entire experiment emphasized abandon the existing approach great respect for local initiatives and systems prematurely. When and encouraged a great deal of 52 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

diversity. The experiment among or lectures but also through their the pilots started with a variety of own experiences. The experiment innovative efforts, such as the suggests that for the local pro- adoption of informed choice of gramme managers and service contraceptives and development of providers, rather than attempting to new information, education and understand the concepts theoreti- communication materials. Other cally, it is most useful to conceive innovations included the issuance the concepts in concrete terms. of the newly designed Reproductive Health Care Handbook, restructuring of service clinics by placing the I MPLEMENTATIONOFTHE contraceptive display desk in the P ILOT P ROJECT front of the clinic, invention of contraceptive display packages, During the period of initiating and imple- creation of “quiet-talk” rooms for menting the Quality-of-Care Pilot private counselling and installation Project (from 1995 to 1999), a number of of a 24-hour hotline telephone service. All of these local efforts activities were carried out. These are were acknowledged and encour- described in the following sections. aged so long as they contributed towards a client-centred, quality- P ILOT S ELECTION focused approach to their family The main mechanism adopted by the planning programmes; State Family Planning Commission to • “Learn via experience”. develop and establish the quality-of-care Throughout the course of the models was the selection of a few coun- experiment and even now, under- ties and districts as pilots for quality of standing of the concepts of care. At the beginning of 1995, the “quality of care”, “programme Commission selected five rural counties reorientation” and even “informed choice” have varied Figure 1 Quality-of-care pilots, 1995 and 1997. considerably among the leaders, managers and providers involved. Rather than debat- ing and attempting to clarify the concepts once and for all, the experiment followed the principle of “practice first”, i.e., letting people learn and begin to understand the concepts of “quality of care” and “reproductive health and rights” not only from books Focusing on Quality of Care in the Family Planning Programme – China 53 and one urban district as the first pilots More than 20 scholars or experts from uni- for the experiment (fig. 1). In 1997, five versities or institutes in China were involved more pilots were added. in the Quality-of-Care Pilot Project from the beginning. Some of them were L EADERSHIP D EVELOPMENT assigned as members of the advisory group; others participated as resource persons. In early 1995, the State Family Planning Commission set up the leadership group of the Quality-of-Care Pilot Project at C APACITY - BUILDING the national level with a vice minister of To implement the Pilot Project, several the Commission as the head and all activities for capacity-building were con- Directors General from departments of ducted as follows, with facilitation from the Commission as the members. The some international agencies and domestic operational office of the Quality-of-Care institutions: Pilot Project, under the Planning and Statistics Department of the State Family • Training-of-trainers (TOT) training Planning Commission, was in charge of workshops were organized by inter- planning, monitoring and evaluating at national and domestic experts to the national level. It was facilitated by the train national and provincial man- adviser group and the resource team from agers and service providers. Cascade some international or domestic universi- training sessions were conducted in each pilot county and district. ties or research institutions. The State Family Planning Commission required • Family-planning service stations at that, under its leadership, all pilot the county and township levels counties and districts set up their own were rebuilt or improved in most leadership groups, issue their own pilot counties and districts, follow- official documents and work plans, and ing the client-centred approach, to conduct initiation activities, such as make them a “user’s home”. social mobilization and advocacy. • Several study tours and training activities for directors of pilots PARTNERSHIP D EVELOPMENT were also organized by the Quality-of-Care Pilot Project International organizations and funding Operational Office in Thailand in agencies as well as international and October 1996 and in the United national expertise became involved in the States in July 1999. Quality-of-Care Pilot Project with finan- • Training of high-level officials was cial and technical support, especially in undertaken in the United States training, supervision, monitoring and for Directors General in the State assessment. These included the Population Family Planning Commission and Council, the International Council on provincial family planning com- Management of Population Programmes missions (1998-2002), organized (ICOMP) and the University of Michigan. by the State Family Planning 54 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Commission in cooperation with supervisory and monitoring visits were the Public Media Center in the made by international and domestic United States. experts, the Quality-of-Care Operational Office, the State Family Planning S UPPORTIVE COMMUNICATIONS Commission officials and international agencies, such as the Beijing offices of With respect to supportive communica- UNFPA and the Ford Foundation. tions, several activities were well organized as follows: R ESULTSAND • several seminars and symposiums A CHIEVEMENTSOFTHE in pilot areas, such as an international seminar on the evaluation of P ILOT P ROJECT the Quality-of-Care Pilot Project held in Yandu County in May After three years, a follow-up survey and 1997 and an international sympo- an assessment of the pilots were conduct- sium on the quality-of-care ed. Significant changes resulting from an approach in Beijing in November effort to achieve the two reorientations 1999; were observed at all pilot sites from dif- • a dialogue between China and ferent perspectives. For example, positive India on population and family feedback from local people showed that planning in April 1998; the clients welcomed the Quality-of- Care Pilot Project, as did the service • exchange activities among pilot- project counties and districts, providers and managers working at the organized by the Quality-of-Care grass-roots level. The long-term impact Operational Office of the State of the quality-of-care initiatives could Family Planning Commission for also be observed from national surveys exchanging experiences; some years later. models selected from pilot areas to be visited and followed; and ACHIEVEMENTS • sharing of experiences of several The changes in the contraceptive international cooperation projects method mix were the result of the pro- in China following the quality-of- motion of informed choice. Meanwhile, care approach since 1998; the more information on family planning and experiences from the international reproductive health was provided to peo- cooperation projects also enriched ple, with the information and education the contents of quality-of-care approaches improved. In addition, the approaches in China. clients received more high-quality clinic services, counselling and follow-up serv- During the experimental period ices, with services upgraded and facilities (1995-1999), many formal or informal improved. Finally, changes in administra- Focusing on Quality of Care in the Family Planning Programme – China 55 tive and management practices had been pilot counties, the contraception method brought about as well. mix of 14,339 couples with informed choice was as follows: IUD, 44.8 per Informed Choice and Changes in cent; sterilization, 12.2 per cent; con- the Contraceptive Method Mix dom, 31.2 per cent; hormonal methods, Informed choice is the key component 10.5 per cent; and others, 1.3 per cent. for client-centred service. For many years, IUDs had been highly recom- Improved Information and mended by providers of family planning Education Approaches services for spacing, and sterilization for A large amount of funding and human limiting the number of children born. capital was input on information, educa- After the introduction of informed tion and communication approaches. choice, more clients received counselling Major changes were made to readjust the before choosing the contraceptive focus of the content of information and method, more diverse contraceptive education in line with the needs of local methods were made available, and more people and to change the forms of infor- clients took the decision by themselves. mation and education. The percentage of survey respon- The family planning workers used to dents who reported that the current distribute family planning regulations contraceptive used was required or rec- and information, education and commu- ommended by family planning workers nication materials in general to families. rather than chosen by clients on their The materials were not taken seriously by own dropped from 38.7 per cent before local people since they were often not the quality-of-care experiment to 17.8 easy to read and were not of interest to per cent after quality-of-care implemen- the people. After the quality-of-care tation. More female users consulted with experiment, more specific information, service providers or had discussions with education and communication materials their husbands before they chose a were developed with pictures and words method to use. Furthermore, women’s to correspond to different needs of knowledge about the contraception that people at different life stages, such as they used was greatly improved, such as contraceptive informed choice, premari- the type of IUD, its function and its pos- tal education, breast feeding, infant nurs- sible side effects. ing and prevention of reproductive tract infections. The knowledge was also In addition, the contraception spread via mass media, such as broadcast- method mix changed to a more diversi- ing, television and wall newspaper. fied pattern, dominated not merely by Nong’an County, for example, developed the IUD and sterilization, implying a a portable information, education and more individualized selection of meth- communication package with contracep- ods. For example, in Deqing, one of the tive samples and a user’s handbook for 56 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

family planning workers to communicate Figure 3 Equipped operation room in a with clients face to face (fig. 2). township family-planning service station in Yandu County. Figure 2 Home visit by family planning workers with a portable information, education and communication package in Nong’an County.

Extended Scope of Service in Reproductive Health Care With the promotion of the quality-of- care experiment, the service provided at Improved Quality of Services, pilot sites greatly expanded to include a Especially Counselling and wide range of family planning services Follow-up Services and related reproductive health care, With the reconstruction or renovation of such as diagnosis and treatment of repro- service sites in counties, townships and ductive tract infections. Many of the villages of the pilots (fig. 3), a client- pilots launched the life-cycle service in friendly environment was created, reproductive health care for people in including some educational materials and different age and sex groups, for instance a video display in the waiting room and a sex education and contraception for ado- touch-screen information counselling lescents and health care for women in system in the reception area. menopause. The check-up for and treat- With the standardization of the ment and prevention of gynecological informed-choice procedures, the quality of diseases were considered as important services was emphasized, especially coun- components of the “universal access to selling and follow-up services (see table for primary reproductive health care” cam- more details), which had not received ade- paign at each pilot site. The 1998 follow- quate attention in the past. There were up survey found that about 90 per cent of more varieties of different contraceptive women had a gynecological check-up, a methods available with improved validity, much higher proportion than the nation- which gave people more choices for either al average (about 61-65 per cent). spacing or limitation. Focusing on Quality of Care in the Family Planning Programme – China 57

Counselling and follow-up services received before and after 1995, as reported by women at pilot sites.

Service Received (%) Service Provided before or Family Planning after the Operation Operation before 1995 after 1995

Introducing advantages and Female sterilization 61.1 93.7 disadvantages of contraceptives IUD insertion 66.6 89.9

Explaining the procedure of the Female sterilization 50.5 81.0 family planning operation IUD insertion 56.9 85.2 Abortion 50.5 70.5

Introducing possible risks and Female sterilization 79.8 93.7 their treatments IUD insertion 81.0 94.9 Abortion 67.9 86.0

Making a follow-up appointment Female sterilization 65.0 77.8 IUD insertion 71.2 91.8 Abortion 50.5 79.8

Source: Zhang, Gu and Xie (eds.), 1999.

Changed Administrative and record of information about child-bear- Management Practices ing and contraceptive use, which serves The reorientation of the way of thinking as information for both management (for was considered as the key point in each regular statistics) and service provision pilot site, meetings, training workshops (as a source of service need and follow-up and various discussions at different levels. visits). After years of efforts, the ideology All pilot sites explored the possibility changed and it brought changes in of new ways of evaluating, such as a administrative and management prac- change or modification of evaluation tices, such as the changing of “Birth indicators and a change in methods of Certificate” to “Reproductive Health evaluation, especially adding informa- Service Record Handbook” (this change tion on client satisfaction to the evalua- was followed nationwide later), which tion content. Although the period of the recorded the date and type of contracep- pilot experiment was not long enough to tive use and shift, pregnancy, maternal test the new indicators or to complete a check-up and child-birth as well as other list of recommended evaluation indica- service records. tors, the practice created a foundation A computerized information system for evaluation reform of the system in was set up at all the pilot sites to keep a the near future. 58 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

M AIN O UTCOMESOR D IRECT responsibilities in family planning. I MPACT O BSERVED According to annual statistics in a pilot The outcomes of the quality-of-care pro - county, the cases of unintended pregnan- ject were analysed from the perspective cy in the first nine months of 1998 repre- of the clients and the service system. sented a 57 per cent reduction from the Some are direct and immediate outcomes same period in 1995. while others have long-term impact. Impact on the Service System From the Clients’ Perspective The service facilities and personnel The feedback from local people about involved in service provision were great- the Pilot Project was very positive and ly improved to meet the requirements of supportive. People enjoyed the improved the quality-of-care approach in the pilots. services, especially with much more There were prominent changes in the age interpersonal communication while the structure and service knowledge of the services were being provided. More peo- local service providers. The technical ple felt respected and cared for in the capacities of the technical personnel in new approach. The providers listened to service stations were strengthened the clients and tried to provide better and through enhanced training and recruit- suitable contraceptives as well as to meet ing. For example, during the three years the reproductive health needs of the of the Pilot Project, the number of pro- clients. The managers were concerned fessional technicians increased from 7 to about the reaction of the people in terms 12 in the service stations at the county of quality of care and their satisfaction level in Deqing County while Yandu with the services. All these actions sent County recruited 60 university or poly- clear messages to clients that they were technic school graduates into the family no longer patients to be watched but planning service team. Intensive on-the- rather that they, as masters of family job training was carried out to emphasize planning, were respected and cared for. standardized service procedures, to learn new technology, to improve technical Counselling, informed choice, skills and to improve skills in interperson- knowledge-focused information, educa- al communication. tion and communication, and follow-up visits, all of these measures adopted in the All pilot sites input/allocated resources experiment made clients, particularly to improve the service environment at women, more knowledgeable about con- the county, township and village levels to traceptive use. In return for this, women ensure that each service station had stan- as beneficiaries of the project more dardized service rooms for different func- actively participated in informed choice. tions. Strict regulations and standards Thus fewer unnecessary contraceptive were developed and implemented for all failures and fewer abortions were the types of technical services, especially direct results of increasing the user’s emphasizing counselling during the Focusing on Quality of Care in the Family Planning Programme – China 59 whole process of any family planning questionnaires: one for clients and the operation and follow-up visits (as shown other for services providers and man- in the table). agers. Valuable quantitative data were collected for comparative analysis with the baseline survey of 1995. A SSESSMENTAND E VALUATIONOFTHE The rapid assessments in the six pilot areas were conducted in October- P ILOTS November of 1998 by an interdisciplinary team consisting of Chinese and Through carefully designed impact international specialists in sociology, assessments with mixed research management, demography, women’s methodologies, it was determined that studies, public health, etc. The method- changes at the pilot sites were significant, ologies adopted in the field included and the experiments were successful focus-group discussion, in-depth inter- regarding the goal of achieving the two views with clients, home visits and other reorientations in different aspects (man- qualitative methods. The qualitative data agement and decision-making) and the and information were also collected for principle of “quality of care”. The assess- in-depth analyses as a complement to the ment team suggested that the pilot expe- quantitative data obtained from follow-up riences were expandable and sustainable. surveys. A general report and six sub- reports (one for each pilot county and dis- M ETHODOLOGY trict) were drafted and published by the Immediately after the Quality-of-Care Quality-of-Care Operational Office in Pilot Project was initiated in six pilot 1999 (Zhang, Gu and Xie (eds.), 1999). counties and districts in 1995, a baseline survey of knowledge, attitudes and prac- M AJOR F INDINGSAND I MPACT tices was conducted regarding the six The follow-up survey and the rapid pilots to interview the sampled clients, assessment in 1998 indicated that most programme managers and service clients were satisfied with the family providers. The main purpose of the base- planning performance: 85.8 per cent of line survey was to assess the needs of respondents overall in the follow-up sur- local people. The survey was also vey in 1998 expressed their satisfaction designed to provide a base to measure the with family planning although with a effectiveness of the Quality-of-Care Pilot wide variation among the pilots, ranging Project. Three years later, follow-up sur- from 75.6 per cent to 95.6 per cent. veys and the rapid assessment survey Furthermore, 76.9 per cent of respon- were designed and carried out. dents in the survey indicated that they The follow-up surveys in the six pilot always or often participated in family areas in mid-1998 employed two kinds of planning activities in their community. 60 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Local people mentioned some indi- respondents in 1998 reported that either rect impacts of the Pilot Project, and they or their husbands made the decision some of the impacts were not expected at on the choice of the method of contra- the initial stage. These indirect impacts ception. This practice of free choice would have a long-term influence on the would affect more people in the longer family planning programme both locally term. The 2006 National Population and and nationally. Family Planning Survey found out that among 24,176 female respondents using Improved Awareness of contraceptive methods, 76 per cent Reproductive Rights and Benefits reported that the decision was made by The key message delivered by the quali- themselves or by the couple, and the per- ty-of-care approach and emphasized by centage was even higher among women the Pilot Project initiatives was to respect ages 20 to 29 (83 per cent). people’s reproductive rights. For example, the new information, education and com- Improved Relationship between munication approaches focused not only Clients and Service Providers on the knowledge of reproductive health Service providers also felt the effect of care but also on the reproductive rights the change on their work, which and benefits. Both programme managers became easier even though their work- and clients clearly understood that the load increased owing to more pre- and family planning had to be carried out in a post-operation services, and door-to- lawful manner, and people had the right door visits. They felt very good that to enjoy the benefits defined by the their services had met the clients’ needs, Government. In some of the pilot coun- and some of their clients became their ties and districts, a system was set up friends. In the family-planning service whereby the client would be compensat- stations, more efforts were made to ed if the programme failed to provide the improve the relationship with clients, service promised or in a timely manner. such as putting more colourful and decorated signs and greetings in the Female clients felt that their reproduc- stations, setting up more private coun- tive rights were more respected after the selling rooms, using polite and soft introduction of informed choice. A com- words, and providing patient explana- parison of the findings from the follow-up tions for a trusting relationship between survey in 1998 with the knowledge, the service providers and the clients. attitudes and practices baseline survey in The de-hospitalized and client-friendly 1995 showed that the number of women appearance and atmosphere attracted who reported that a contraceptive more clients to the service stations. In method used was suggested by family villages or communities, family planning planning workers or others fell signifi- workers or doctors became the most cantly. Nearly 50 per cent of female welcomed persons for counselling on Focusing on Quality of Care in the Family Planning Programme – China 61 health issues, daily life and even home Stable Low Fertility Rate businesses. After the new approach was introduced, A county doctor said that in the past couples’ needs for family planning and when she had visited villages, people had reproductive health were better met, kept a distance from her (because her job and therefore there were fewer unin- was mainly to delivery contraception). tended pregnancies. The low fertility After the services had expanded to rate became even more stabilized in all include gynecological check-ups and the pilot counties at a level much lower counselling, local people were looking than the replacement level (total fertili- forward to her visit and were anxious to ty rate = 2.1). Statistics showed that the know her schedule for the village because crude birth rates before (1994) and after she provided more services that local (1997) the quality-of-care approach in people needed. Some women called her each county and district were stable at a affectionately “elder sister” or “aunt” low level. The fact that there was stable instead of “doctor”. The improvement in low fertility in the regions eased the the relationship encouraged service concern about the negative impact of providers and family planning workers to quality-of-care approaches and provided build a more trusting relationship supporting evidence for the scaling up between service providers and clients and of the project later. to make great efforts to operate the programme more efficiently. E XPERIENCESAND Improved Image of the Family L ESSONS L EARNEDFROM Planning Programme P ILOTS The quality-of-care experiment in the long run changed the image of the family The successful experiment of the quality- planning programme from an approach of-care project not only sets the model driven purely by demographic targets to a for programme reform but also provides more comprehensive and human-centred the experiences and lessons for anyone one. Under the target-driven approach, who is interested in the model. the programme was seen as a tool to achieve the targets or a demographic out- G OVERNMENT COMMITMENTTO come rather than the goal of caring for Q UALITY - OF - CARE A PPROACHES people. The experiment reoriented the In China, the government commitment focus of the programme to people's well- at four levels – State, province, prefecture being and reproductive health care, thus and county – is the key to the success of greatly improving the image of the pro- the quality-of-care pilots. gramme among the clients in particular and in society in general. 62 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The State Family Planning of the quality-of-care approaches and Commission has been in charge of the comprised the framework of the quality- population and family planning pro- of-care working mechanism. gramme at the national level, initiatives The theoretical framework of the qual- of the Quality-of-Care Pilot Project, and ity-of-care working mechanism includes the promotion of scaling up nationwide. four groups of people involved in the Its roles were to: quality-of-care project: leaders/decision • develop national project strategies makers, service providers, managers and and implementation and scaling- clients. There is a logical connection up plans; among these four groups. The main activity of the leaders/decision makers is to focus • create a supportive policy environ- on the inputs, which guarantees the regular ment for quality-of-care innova- running of the service system and the man- tion; and agement system. The main activity of serv- • mobilize the financial and techni- ice providers and managers is to focus on cal resources from international implementing quality of care. The aim is to and domestic agencies. have clients participating in the family The host provinces and prefectures of planning/reproductive health activities to the pilot sites involved in the whole maintain the clients’ own rights and their process of the Quality-of-Care Pilot level of reproductive health. The relation- Project played the role of linkage and ships among these four groups of people bridge between the State Family are presented in figure 4. Planning Commission and pilot counties The three elements in the framework and districts. The county/district is the of the quality-of-care approach – target basic administrative unit of social struc- people (clients), service system and man- ture in China. Governments and family agement system – have an interactive planning commissions at the county/dis- relationship to carry out client-centred trict level made their own choice and interactions. From the experiences of the decision to participate in this Pilot pilots, none of the three elements can Project. They were encouraged to mobi- be absent. With the upgrading of the serv- lize local resources to implement the ice system, clients receive higher-quality innovation. family planning and reproductive health services. With the reform of the manage- F RAMEWORKOFTHE Q UALITY - OF - ment system, which was to remove the CARE W ORKING M ECHANISM quota of sterilization for service providers’ The three systems – the decision- evaluation, clients were free to choose the maker/leadership system, the service sys- methods that they preferred. The partici- tem and the management system – pation of target people/clients is the backed up the client-centred interactions dynamic for changing or reforming the Focusing on Quality of Care in the Family Planning Programme – China 63

Inputs Activities Outcomes

Impact

Service System: • Concept change • Capacity-building Client-centred Interactions: • Protocol of services Decision-maker/ • Informed choice • Facility improvement Leadership System: • Information, education Clients • Political commitment and communication activities Beneﬁted • Policy support • Quality services • Financial/personnel • Rights protection support Management System: • Interpersonal relationship built • Coordination • Decision-making • Administrative reform with needs assessment • Planning implemented with protocols • Evaluation reform • Information system

Figure 4 Working mechanism of the quality-of-care approach in China. service system and the management sys- ensured the subsequent project expan- tem based on the needs of people. sion to Western China where the socio- economic situation was underdeveloped. E XTERNAL S UPPORTFOR P ILOTS However, to keep innovation moving in the correct direction, technical support The success of quality-of-care approach- such as training workshops and domestic es in pilot counties did not rely on a large and international visits were important. amount of external financial input. They were supported by the central gov- Although the socio-economic develop- ernment and external donors. ment of China in the last decade made it possible to have financial resources in place, pilot counties were told from the R EPLICABILITYAND very beginning that they would not S CALABILITY receive any external financial support either from the central government or With the successful demonstration of international donors. They had to mobi- pilots in smaller areas, the State Family lize local resources to implement the Planning Commission immediately pro- changes and could not count on any posed a scaling-up strategy to push the external financial assistance. This was quality-of-care approach forward to the considered essential in order to ensure whole country. sustainability because quality of care was to become a regular programme orientation, which was intended to become P REREQUISITESFOR R EPLICATION institutionalized within local resource Before the experiences of the Quality-of- constraints. It proved to be strategic and Care Pilot Project are replicated by 64 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES potential users, some elements of the implementation are counteracted scaling-up procedure, such as the innova- by the benefits; tions, the environment and the resource • Easy to install and understand team, should be in place. rather than complex and complicated;

Acceptable Innovations • Compatible with the potential users’ established values, norms The experiences of the quality-of-care and facilities; fit well into the pilots have been systematically summa- practices of the national pro- rized and well documented as innova- gramme; and tions, including the national guidebook, a series of publications on the pilot • Testable without committing the experiences, and an advocacy package potential user to complete adop- containing the main aspects of the quali- tion when results have not yet been seen. ty-of-care approach. Some training curriculums and teaching materials have Favourable Environment also been developed. These documents, some with English translations, are avail- In China, governments at all levels able and can easily be adapted by different involve the population and the family user organizations. planning programme in the national or local socio-economic development plan. The innovations of the quality-of-care This means that the main leaders of gov- project are also in line with the “COR- ernment must take responsibility for deal- RECT” attributes that enhance the poten- ing with population and family planning tial for scaling up as proposed by the issues. Since 2000, several national laws World Health Organization (WHO) and and regulations have been issued. For ExpandNet (Simmons, Fajans and Ghiron example, the Law on Population and (eds.), 2007): Family Planning and the Regulation on Family Planning Technical Service and • redible in that the innovations C Management issued in 2001 emphasize are based on sound evidence the client’s rights such as contraceptive and/or advocated by respected informed choice and quality of service. In persons or institutions; 2002, the National Population and Family • Observable to ensure that poten- Planning Commission proposed quality- tial users can see the results in of-care approaches as the innovations of practice; population and family planning reforma- • Relevant for addressing persistent tion and required the governments at all or sharply felt problems; levels to adopt the quality-of-care • Relative advantage over existing approaches. Then several official docu- practices so that potential users ments and policies were issued for scaling are convinced that the costs of up, which created a favourable policy Focusing on Quality of Care in the Family Planning Programme – China 65 environment for expanding quality-of- replicate the innovations of the quality-of- care innovations to the whole country. care pilots. With the experiences of quality-of-care pilots spontaneously duplicated, Support of a Resource Team the number of counties and districts adopt- The Quality-of-Care Pilot Project had a ing quality-of-care approaches in China resource team that included both interna- increased to 200 in 1998, 300 in 1999 and tional and domestic experts with differ- more than 800 by 2000. ent academic backgrounds and practical In the second period, the State Family experience in the field of family planning Planning Commission officially announced and reproductive health. The resource the expansion of the innovation of the team was involved in the process of pro - quality-of-care pilots to the whole country. ject design, supervision, monitoring and In order to spread the quality-of-care evaluation. Having a good relationship approach as well as to scale it up systemat- with national and local government offi- ically, it adopted a top-down strategy cials, it facilitated the pilots and the scal- and model demonstration to initiate a ing-up process with high-level advocacy national campaign on the Quality-of-Care and supervision. The names and designa- Advanced Unit in 2002 (the name has the tions of the experts can be found in the same meaning as Quality-of-Care Pioneer “Contacts” section of this case study. or Model given to quality-of-care pilot counties/districts selected in the mid- R EPLICATIONAND S CALING U P 1990s). The State Family Planning The process of replicating the quality-of- Commission set the unified criteria care experiences in other areas in China and indicators for the Quality-of-Care could be divided into two periods: spon- Advanced Unit and requested provincial taneous duplication (1998-2000), and family planning commissions to select the scaling up vertically and horizontally provincial models first and recommend (2000-2010). them to the national Commission. Since 2003, the National Population and Family In the first period, with the positive Planning Commission (formerly the State results from the quality-of-care pilots Family Planning Commission, which was found in the follow-up evaluation and renamed in 2003) has organized several assessment, some provincial family plan- evaluation teams each year, comprising ning commissions were encouraged to fol- experts and officials, to evaluate the candi- low State Family Planning Commission dates for national Quality-of-Care pilots and to implement their own experi- Advanced Unit proposed by provincial ments. Meanwhile, some international commissions. Up to 2009, about 2,021 cooperation projects, such as the UNFPA counties and districts had been evaluated Reproductive Health and Family Planning and awarded recognition as the national Project and the Japanese Organization for (918) or provincial (1,103) Quality-of- International Cooperation in Family Care Advanced Units, accounting for 70 Planning Integrated Project, decided to 66 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES per cent of the counties and districts in into full play in scaling up. The China. This campaign will not end until National Population and Family the quality-of-care innovations have spread Planning Commission requested to the entire country. provincial family planning commissions to select the provincial E XPERIENCESAND L ESSONS models first and recommend them L EARNEDFROM S CALING U P to the national Commission. With decentralization in China, the The experiences and lessons learned from local governments have more scaling up could be adapted and applied power to take decisions based on by other regions or countries, especially their socio-economic affairs those still not achieving a great deal in including population and family the area of family planning and reproduc- planning. Therefore, some tive health care. Several issues that arose provinces overstated their privi- from the scaling-up process are listed leges and refused to follow the below for further discussion: national standard for recommending advanced units, which may • Advantage vs. disadvantage of a produce an adverse effect on scal- top-down strategy ing up. The national campaign of the • Unified standard vs. flexible Quality-of-Care Advanced Unit adaptation was initiated by the National To control the quality of the scal- Population and Family Planning ing up, a unified evaluation mod- Commission with a top-down ule with 33 indicators and a strategy. Being awarded the desig- methodology was developed by nation of national Quality-of-Care the National Population and Advanced Unit means a great hon- Family Planning Commission and our for county leaders and their followed by all provinces. With superiors and some local officials rapid changes in the socio-eco- will spare no effort to win such an nomic situation in recent years, honour. However, the disadvan- the concepts and content of quali- tage of this top-down strategy is ty-of-care approaches have been that it might excessively push extended and improved. For exam- local governments at provincial, ple, integrating gender perspec- prefecture and county levels to tives and considering ageing chase the award instead of follow- issues, family planning and repro- ing the innovation. ductive health services should be • Centralization vs. decentralization provided not only to women of In a country with a vast territory reproductive age but also to the such as China, the role of local family members including the governments such as those at the husband, the elderly and youths as provincial level must be brought well as to migrants. Quality of Focusing on Quality of Care in the Family Planning Programme – China 67

care is an open-ended approach. with poor economic conditions. The standard of quality of care Considering that people in poor must be modified according to regions are in urgent need of bet- social changes. Meanwhile, owing ter-quality family planning and to the regional differences, adapta- reproductive health services, more tion to the standards of quality of supportive policies and inputs care should always be encouraged. need to be put forward by govern- • Ownership vs. sharing of ments at all levels. resources • Some counties have been evaluat- The National Population and ed and named as a “Quality-of- Family Planning Commission had Care Advanced Unit”, but with the initiated and has the ownership of changing situation, there is in fact the quality-of-care project. This a gap between their work and the does not mean that the project is quality-of-care approaches. This is an isolated, static project. In the shown in two areas: lack of capaci- past few decades, China conduct- ty to meet the increasing needs of ed some international cooperation clients, and lack of gender sensi- projects and many domestic pro- tivity and inadequate male partici- jects. Although these projects had pation. their own executive agencies, the Commission adopted the integra- P OLICY O BJECTIVES tion approach and established a coordination mechanism for shar- The State Council of China has empha- ing resources and experiences with sized family planning as a programme for one another. the people’s well-being. It was pointed out in the 2010 Report on the Work of the Government that China “will do a good job F UTURE P LAN in population and family planning work. We will continue to maintain a low birthrate. We will provide good family planning services for the C HALLENGES floating population. We will provide regular Although the overall goal of reorienta- gynecological examinations and subsidize hospi- tion of the family planning programme tal childbirths for rural women. We will strength- has been realized in most regions in en intervention in birth defects; carry out a pilot China, the scaling up of the quality-of- program of free pre-pregnancy checkups; and pro- care approaches is still ongoing. vide quality health services for infants, pre-school • Currently, about 30 per cent of children, and prenatal and nursing women…We counties in China have yet to will intensify strategic research on coping with an reach the standards of quality of aging population and move more quickly to create care. Most of these counties are a sound system of old-age services so that people located in the western regions can live a happy life in their old age.” 68 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The National Population and Family • establishing the whole-population Planning Commission has realized that fur- information system and increasing ther promotion of the quality-of-care accessibility of clients to quality approaches should be integrated with service with information technolo- comprehensive reform of the family plan- gy; and ning programme, socio-economic devel- • speeding up the reform of the opment, the anti-poverty strategy and the Target Responsibility Management Millennium Development Goals (MDGs). System in the family planning programme in China, establishing an ACTION P LAN assessment and evaluation system for population and family planning In 2009, the National Population and in the new era, and promoting the Family Planning Commission announced “Quality-of-Care Advanced Unit” that the “Quality-of-Care Advanced national campaign. Unit” national campaign would be “upgraded and sped up”. It requested that The overall goal of promoting the the public service and management in quality-of-care approaches consists of fam- family planning and reproductive health ily planning programme reform, pays be equalized in urban and in rural China greater attention to people’s needs and and that the quality-of-care standards requirements, respects their rights to access should reach everywhere in the country. necessary information and high-quality A nationwide public service system, services, and helps people to enjoy happi- which meets the needs of family planning er and more decent lives. and reproductive health, should be established by 2015. A CKNOWLEDGEMENTS Specific goals of the action plan include: I would like to thank the countless peo- • further strengthening the con- ple, agencies and institutions both in struction of a quality service sys- China and in other countries that have tem, strengthening professional been heavily involved in the implementa- development, improving the com- tion and have contributed tremendously petencies and capability of to the success of the experiment over the technical services, and providing last 15 years. family-based family planning and reproductive health services; R EFERENCES • promoting the healthy-baby project, fully carrying out first-level Gu, B., Simmons, R. and Szatkowski, D. intervention in birth defects, and (2002). “Offering a choice of contracep- developing the pilot project for free tives in Deqing County, China: pre-pregnancy health check-ups; Focusing on Quality of Care in the Family Planning Programme – China 69

Changing practice in the family planning District on Quality of Care in Family Planning program since 1995”. In Responding to (1995-1998) (in Chinese). Beijing: China Cairo: Case Studies of Changing Practice in Population Press. Reproductive Health and Family Planning, N. Haberland and D. Measham (eds.). New Contacts York: Population Council. Gu, B., Zhang, E. and Xie, Z. (1999). Practice Documentation Team “Toward a quality of care approach: Head of Team: Reorientation of the family planning pro- Zhenming Xie gram in China”. In Innovation, vols. 7-8, Chapter 4, J. Satia, P. Matthews and A.T. Professor, China Population and Lim (eds.). Kuala Lumpur, Malaysia: Development Research Centre, International Council on Management of and Secretary-General, China Population Programmes. Population Association Address: #12 Da-Hui-Si Road, Haidian Kaufman, J., Zhang, E. and Xie, Z. District, Beijing, 100081, China (2006). “Quality of care in China: From E-mail: [email protected] pilot project to national program”. In Website: www.fpqoc.org.cn Studies in Family Planning, (37)1:17-28. Members: Simmons, R., Fajans, P. and Ghiron, L. (eds.) (2007). Scaling Up Health Service Baochang Gu Delivery: From Pilot Innovations to Policies Professor, Renmin University of China and Programmes. Geneva: World Health E-mail: [email protected] Organization. Zhenzhen Zheng (Ms.) Xie, Z. and Tang, M. (2008). “From popu- Professor, Chinese Academy of Social Sciences lation control to reproductive health: E-mail: [email protected] Evolution of China’s family planning program”. In K. Zhang (ed.), Reorienting Mengjun Tang (Ms.) Concepts and Methodology: The 30 Years SRH Associate Professor, Director of the [Sexual and Reproductive Health] in China, Project Management Division, 1978-2008 (in Chinese). Beijing: Social China Population and Development Sciences Academic Press, pp. 1-34. Research Centre E-mail: [email protected] Xie, Z., Wang, T. and Feng, Q. (2007). Guide Book on Quality of Care in Family Ying Liang (Ms.) Planning (in Chinese). Beijing: China Associate Professor, International Population Press. Research Division, China Population and Development Zhang, E., Gu, B. and Xie, Z. (eds.) (1999). Research Centre Assessment Reports on the SFPC’s [State Family E-mail: [email protected] Planning Commission’s] First Pilot Counties/ 70 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Hongtao Hu under the Quality-of-Care Approach” Director General, Department of E-mail: [email protected] International Cooperation, National Xinhua Guo (Ms.) Population and Family Planning Former Director, Xuanwu District Family Commission, Coordinator of practice Planning Commission of Beijing documentation Municipality, Team Member of the E-mail: [email protected] subproject “Management and Evaluation Reform under the Quality-of-Care Resource Persons of the Quality- Approach” of-Care Pilot Project E-mail: [email protected] International Consultants: Kaining Zhang Ruth Simmons Professor, Director of the Health and Professor, University of Michigan, Development Institute of Kunming International Consultant for the Medical College, Yunnan, Team Leader Quality-of-Care Project in China (1997- of Quality-of-Care West Expansion 2008) E-mail: [email protected] E-mail: [email protected] Shuzhuo Li Jay Satia Professor, Director of the Institute of Former Executive Director, International Population and Economics, Xi’an Committee of Management on Jiaotong University, Team Leader of Population (ICOMP), International Quality-of-Care and Gender Consultant for the Quality-of-Care E-mail: [email protected] Project in China (1997-2008) Junqing Wu (Ms.) E-mail: [email protected] Professor, Shanghai Institute of Planned Resource Teams: Parenthood Research, Team Leader of Informed Choice Tieming Wang E-mail: [email protected] Former Deputy Director, Tianjin Municipality Family Planning Hongyan Liu (Ms.) Commission, Team Leader of the sub- Professor, Deputy Director of the China project “Management and Evaluation Population and Development Research Reform under the Quality-of-Care Centre, Team Leader of AIDS Approach” Prevention within Family Planning E-mail: [email protected] Service System E-mail: [email protected] Qingcai Feng Former Deputy Director, Qingdao Xiaoming Sun Prefecture Family Planning Commission, Professor and Deputy President, Team Member of the subproject Population Manager College, Nanjing, “Management and Evaluation Reform Team Leader of the Japanese Focusing on Quality of Care in the Family Planning Programme – China 71

Organization for International Cooperation in Family Planning Integrated Project E-mail: [email protected] Yuanming Shi Division Chief, International Operation Department, National Population and Family Planning Commission, Coordinator of the Quality-of-Care Operational Office E-mail: [email protected] 72 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Training in 3 Incorporating Ghana Population Factors into Development Planning Dr. Yaw Nsiah-Peprah

Summary

Since 1990, the Government of Ghana has put in place several mechanisms to reduce poverty and improve the standard of living of Ghanaians. These include the New Local Government System on Decentralization consolidated by the Local Government Act (Act 462) of 1993, the National Development Planning Commission Act (Act 479) of 1994 and the National Planning Systems Act (Act 480) of 1994. The goal of this legislation was to promote local development and encourage grass-roots participation in development.

In 1996, when the National Development Planning Commission introduced the preparation of district development plans as part of the decentralization process, the aim was to promote a comprehensive and responsive approach to solving the problem of poverty by allowing District Assemblies to prepare their own plans to meet the needs and aspirations of their people. By 2000, it was clear that most of the district development plans prepared had not been implemented. This failure was held to be due to the theoretical nature of the plans, which did not reflect what departments could implement and what central government, the private sector and non-governmental organizations (NGOs) were able and prepared to fund. This lack of linkage between the plans and the ability to carry them out was related to the limited capacities of District Assemblies, which are responsible at the grass- roots level for designing comprehensive plans aimed at poverty reduction. Thus in the preparation of the Ghana Poverty Reduction Strategy 1 and 2 policy documents, human resource development and good governance were seen as key to poverty reduction.

73 74 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

Based on the objectives of the decentralization system in Ghana, the Government and the United Nations Population Fund (UNFPA) developed a fourth Country Programme under which UNFPA assisted the Government in implementing its population programme. The population programme identified the interrelationship between population, sustained economic growth and sustainable development as a critical issue that required urgent attention. Thus the National Population Council took steps to build the capacity of District Assembly staff in the area of integrating population variables into the preparation of district development plans to tackle the problem of poverty. The Department of Planning of Kwame Nkrumah University of Science and Technology was contracted to design and implement population training modules to build the capacities of District Planning Officers and District Budget Officers who were mandated to prepare district development plans for their districts. Fifteen modules were developed and were used to train these Officers of District Assemblies all over the country. The modules have been used to train over 250 Officers to integrate population variables into the preparation of district development plans so that the plans meet the needs and aspirations of people and communities, helping to reduce poverty and improving their living conditions.

Since 1999, poverty in Ghana has dropped from 39.5 per cent to about 28 per cent, using the international poverty line of US$1.25 a day (Government of Ghana, National Development Planning Commission, 2009). This success has been attributed partly to the improved capacities of District Planning Officers and District Budget Officers as a result of their training in development plans. The simple nature and comprehensiveness of the training programmes that link population variables to poverty reduction mean that the programmes can be replicated in the whole of Africa and beyond. Most importantly, the training programmes have been reviewed by beneficiaries and stakeholders, who have identified them as relevant for preparing district development plans with the aim of reducing poverty in Ghana.

Information on the Author Dr. Yaw Nsiah-Peprah, Former Head, Department of Planning, and Former Vice Dean, Faculty of Planning and Land Economy, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Training in Incorporating Population Factors into Development Planning – Ghana 75

I NTRODUCTION be responsive to the needs and aspiration of citizens, use resources efficiently and pro- For countries such as Ghana that practise mote the sustainable development of com- decentralization and thus depend on munities. Based on the needs and capacities local governments for their development, of the local population, development plan- well-trained local government officials ners can identify the potential, scale, loca- are critical to any efforts aimed at decen- tion, speed and patterns of development. tralization. Decentralization involves These population factors serve as indicators highly charged, political decisions about to measure welfare improvement; by identi- new roles and responsibilities, the way in fying changes in these population variables, which organizational structures and the success or failure of a development terms and conditions of service are intervention can be assessed. It is crucial revised, and how staff are allocated that development planners understand between the central and peripheral levels. population factors and integrate these pop- Developing staff capacity to meet these ulation variables when producing effective challenges is of paramount importance. and sustainable development plans. Good development planning must also Figure 1 shows the relationships between population factors and develop-

Figure 1 RESOURCES FOR DEVELOPMENT PLANNING A schematic HUMAN RESOURCES • Number of Personnel presentation of • Quality/Skills of the Personnel • Motivation and Incentives population factors ECONOMIC for poverty • Financial Resources • Financial Management Systems reduction through ENVIRONMENT • Availability of Logistics decentralized DEVELOPMENT PLANNING INSTRUMENTS • Quality of Logistics • Working Atmosphere planning. • Management Practices and Systems LEGISLATIVE/REGULATORY INSTRUMENTS IN GHAN • Inter-organizational Linkages • Local Government Act of 1993 (Act 462) POPULATION FACTORS • National Development (Planning) System Act of 1994 (Act 480) • Size of Population • National Development Commission Act of • Structure of the Population POVERTY REDUCTION THROUGH 1994 (Act 479) and DECENTRALIZED PLANNING • Distribution of Population in Space • District Assemblies Common Fund Act of • Population Growth 1993 TECHNICAL INSTRUMENTS

DEVELOPMENT SECTORS • National Development Policy Documents (Ghana Vision 2020, 1996-2000; GPRS I, 2002-2005; GPRS II, 2006-2009; and ECONOMIC National Development Policy Framework, • Employment 2010-2013) • Occupational Distribution • Guidelines for the Preparation of • Food Security Medium-term District and Sector Plans • Income and Expenditure • District Medium-term Development Plans • Resource Mobilization and Utilizations SOCIAL • Education • Health • Water and Sanitation • Housing • Transport and Energy ENVIRONMENT Note: GPRS = Ghana Pverty • Land Management • Built Environment Reduction Strategy • Natural Environment Source: Author’s construct, October 2010. 76 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES ment sectors. It underscores the rationale development planning requires a com- for the development of the integration of prehensive and integrative approach to population factors into the Ghanaian development planning at the local level. model. It illustrates that effective decen- The National Population Council tralized development planning to support identified the issue of integrating popula- poverty reduction can happen if the plan- tion issues into development planning as ning is supported by instruments that a key objective in the implementation of provide a legal basis for planning func- its population programme. tions and by well-trained people and if there is enough money to support the In its revised National Population planning process. Policy (1994), the Government identified the interrelationship between population, The ability of a country to reduce sustained economic growth and sustain- poverty is dependent on four major variable development as an important issue ables: population factors, the development requiring urgent attention. This was in sector, development planning instruments line with the tenets and objectives of the and resources. Population factors include Programme of Action adopted at the the size of the population, its structure, its International Conference on Population distribution and its growth. Development and Development held in Cairo (Egypt) planning instruments, including national in September 1994. This Conference development policy documents and sought to encourage Governments to regional and district development plans as fully integrate population concerns into well as the legislative instruments that the formulation, implementation, moni- establish the institutions, their roles and toring and evaluation of policies and pro- their functions, are highly critical. Finally, grammes relating to the cultural, eco- in order for the institutions to perform nomic and social development of their their roles effectively, efficiently and sus- countries. tainably, resources and facilitating factors are needed. These include personnel train- Based on this objective and the ing, adequate financial resources and a implementation of the National reliable working environment including Population Policy (Revised Edition, management systems as well as an effec- 1994), the National Population Council tive administration system. took steps to build the capacity of District Assembly staff in the area of integrating population issues into develop- T HE I NNOVATIVE ment planning. By this means, it was D EVELOPMENT P LANNING hoped that District Assembly plans P RACTICE would be more comprehensive and responsive and would drive poverty- reduction interventions at the local level. B ACKGROUND Integrating population variables into The Government of Ghana and the Training in Incorporating Population Factors into Development Planning – Ghana 77

United Nations Population Fund The modules were influenced by the (UNFPA) developed the Fourth Country multi-dimensional nature of poverty Programme (2001-2005), which had two where emphasis on the causal factors of components: population and develop- poverty includes not only economic indi- ment, and reproductive health. Under cators but also social, environmental, cul- this Programme, UNFPA would assist the tural and institutional factors. Although Government in implementing its popula- UNFPA (2010) identifies poverty as a tion programme. complex and multifaceted phenomenon that can only be approximated, not ade- The integration of population vari- quately captured, by the level of house- ables into development planning has also hold income or consumption, the agency been a key objective of the International further asserts that poverty can be under- Commission on Population and stood either as the lack of economic Development and the Revised National opportunities, associated with economic Population Policy of 1994. To achieve underdevelopment (at the macro level), this objective, the National Population or the lack of human capital, which is Council, in collaboration with the closely associated with health and educa- Department of Planning of Kwame tion (at the micro level). This highlights Nkrumah University of Science and the many interdependencies between Technology, produced a training manual these two spheres since human capabili- titled “Integrating Population Variables ties are determined not only by internal into Development Planning” in 2002. factors (health and education) but also by The manual, a compilation of the lecture external factors (political environment, notes prepared by the facilitators for the infrastructure, human rights), as illustrat- Integrated Training Programme that ed in figure 2. This brings to the fore the began in 2002, consists of 15 training need for a comprehensive approach to modules covering population and devel- building the capacity of human resources opment, health needs, education needs to effectively integrate all the causal fac- assessment, water and sanitation, housing tors into development planning and needs, land, food security, employment, interventions. rural transportation, man-made environment, natural environment, energy The manual was used to train District needs, and fiscal resource mobilization Planning Officers and District Budget and management. These modules are Officers in Ghana to build their capaci- seen as critical areas that must be consid- ties to efficiently prepare development ered to reduce poverty at the local level. plans that integrate population variables A computer-based template for the into the district planning process, there- Integrated Training Programme was also by addressing poverty while also driving produced. sustainable national and local socio-economic development. 78 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Figure 2 Population-poverty linkages.

Education Rights (including (non-discrimination, sexual) gender equality and women’s empowerment)

Health Culture (including reproductive (timing, spacing and health and HIV/AIDS) Human capabilities and number of children, household dynamics gender equality, sexual practices, etc.)

Micro Poverty Macro

Growth and size of Economic development Population and population and structual change resource balances (high-fertility (demand on and supply and low-fertility of public services and challenges) natural resources, food balances, food security, environmental pressures, Age structure Spatial distribution climate change, of population of population etc.) (ageing societies, youth (including rural-urban bulges, dependency, migration, urbanization ratios, demographic and international dividends, income migration) transfers, etc.)

Source: The chart is a stylized representation of population and poverty linkages. It is reproduced here from UNFPA (2010). Impacts of Population Dynamics, Reproductive Health and Gender on Poverty, a UNFPA Concept Paper prepared for the United Nations Summit on the Millennium Development Goals, New York, September 2010, p. 8, unpublished.

P ROBLEMS A DDRESSEDBY T HIS Northern region lived in poverty. This P RACTICE contrasted with the Central and Eastern The incidence of poverty in Ghana was regions, where 50 per cent of the popula- 50 per cent in 1990, decreasing to 39.5 per tion was classified as poor in 1999 cent in 1998-1999 (World Development (Government of Ghana, National Indicators 2006). Notwithstanding this Development Planning Commission, achievement, the incidence was still high. 2003). Five out of ten regions had more than 40 In 1996, the National Development per cent of their population living in Planning Commission introduced the poverty in 1999. The worst-affected area preparation of district medium-term comprised the three northern savannah development plans by District regions (the Upper East, Upper West and Assemblies and included specific objec- Northern regions). Ninety per cent of tives. One critical objective was for people in the Upper East, 80 per cent in development planning at the district and the Upper West and 70 per cent in the local levels to be responsive to the needs Training in Incorporating Population Factors into Development Planning – Ghana 79 and aspirations of the people. The devel- efforts to reduce the poverty rate, which opment planning process was to be fell from around 40 per cent in 2001 to participatory and comprehensive to help 28.5 per cent in 2008 (an indication of to improve the standard of living of all improved development planning prac- Ghanaians and achieve the Government tices in the country), they had limited goal of Ghana’s becoming a middle- capacity to design responsive and com- income country (US$1,000 per capita) prehensive interventions to completely by 2015. mitigate this phenomenon. Thus in the preparation of the Ghana Poverty The National Development Planning Reduction Strategy 1 and 2 policy docu- Commission designed guidelines to aid in ments, human resource development and the preparation of district medium-term good governance were seen as priority development plans for 1996-2000. After areas for poverty reduction. The rationale this period, certain challenges were iden- was that technical staff at the district tified through the process of develop- level who could implement interventions ment planning at the district level. One that responded to the needs and aspira- critical issue was the low level of under- tion of people at the grass-roots level standing of development issues by the were fundamental for poverty reduction. District Planning Officers who are Consequently, training modules were responsible for preparing development designed to build the capacity of these plans. For instance, between 1996 and district technical staff. The goal was to 2000, most of the prepared district plans provide them with training so that, by were not implemented. This failure was integrating population variables into said to be due to the theoretical nature of their development planning process, they the plans, which did not reflect what could prepare development plans that departments could implement or what would help to reduce poverty and pro- central governments, the private sector mote human welfare in their districts. and NGOs were able and prepared to fund. Laryea-Adjei (2000) found that, generally, the guidelines emphasized D ESCRIPTIONOFTHE comprehensive planning at the expense I NTEGRATION T RAINING of strategic planning. The district plans P ROGRAMMEFOR that were prepared were not responsive to the needs of the people. This was I NNOVATIVE D EVELOPMENT believed to be because those who pre- P LANNING pared the plans did not understand the importance of population variables, O VERALL O BJECTIVE which are critical in the development It is said that effective decentralization is planning process. achieved only when development plan- Although local governments made ning at the local level is responsive to the 80 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES needs of the people and ensures effective contracted the Department of Planning use of resources. This was the fundamental of Kwame Nkrumah University of goal of the Training Programme. Science and Technology to design and implement a training programme for In terms of the objective, the Training District Planning Officers and District Programme was developed mainly to Budget Officers who were mandated to achieve the revised National Population prepare development plans for the dis- Policy objective of integrating population tricts. The facilitators were mainly from variables into development planning. The academia, the Department of Planning of intent was to equip participants with the the University, and technical staff from necessary capacity and skills to be able to the National Population Council. There carry out this integration, focusing on the was also an information technology spe- preparation of district development plans cialist attached to the Training so as to help to reduce the poverty of the Programme. These facilitators were peo- people in the districts and improve their ple with diverse professional backgrounds living standards. in health, education, housing, demography, statistics, environment, finance, O RGANIZINGTHE D EVELOPMENT development planning, transport and OFTHE T RAINING P ROGRAMME infrastructure, energy, and water and san- The achievement of the objective of the itation among others. They had in-depth Training Programme depended on the knowledge of how the local government local technical staff who were the plan- worked as a result of the consultancy ning and budget officers at the district work and training programmes that they level; they needed to have the requisite had undertaken for development partners knowledge and skills to carry out the for the District Assemblies. integration of the population variables into their district development plans. The COMPONENTS Metropolitan, Municipal and District Fifteen modules were designed for the Assemblies constitute the highest politi- Training Programme. With the exception cal, legislative and executive body at the of the first two – “Decentralized Planning local level, charged with the responsibili- as a System” and “Population and ty for planning for the development of Development” – which are considered to the districts. Consequently, the National contain basic information, the remaining Population Council took steps to build 13 modules have practical application the capacity of the local technical staff using field data to demonstrate the inte- through training to enable them to be gration of population variables into devel- able to integrate population variables into opment planning through the use of a development planning. simple Excel computer programme. The National Population Council Training in Incorporating Population Factors into Development Planning – Ghana 81

O BJECTIVESOFTHE I NDIVIDUAL ered in development planning; M ODULES 3. “Health Needs Assessment” The Training Programme, as indicated To provide a comprehensive under- earlier, seeks to build the capacity of the standing of planning for health. district technical staff who are mandated More specifically, the module aims to prepare district development plans so to enable participants to appreciate that they are equipped with the necessary the importance of health needs in skills to enable them to integrate popula- development planning and to tion variables into the preparation of understand the concept of “health” these plans. The plans will in turn be used in the context of planning and to help to provide the local people with development; the necessary basic infrastructure includ- 4. “Education Needs Assessment” ing housing, potable water, health facili- To develop participants’ awareness ties and educational facilities in order to that a population’s educational further improve their living conditions. needs vary according to its culture The objectives of the 15 modules are and level of development, for described below: instance, the educational needs of a predominantly young and growing 1. “Decentralized Planning as a population in developing countries System”: compared with those of an ageing To introduce participants to the population, and capacity to concept of a system; the under- respond to this fact. Since there are standing of development as a sys- scarce resources in most develop- tem is discussed under this particu- ing countries, planning must pro- lar module. Also provides an vide a sound basis for meeting the overview of the relationships educational needs of the people. among development and the sys- Based on this idea, trainers using tems inherent in it as well as the this module worked with partici- basis for the integration of popula- pants to use population data to tion variables into development assess educational needs, identify planning. This module was the type(s) of educational needs to designed for the course; be assessed and help participants to select the most appropriate means 2. “Population and Development” of determining educational needs. To equip participants with the requisite techniques of finding, 5. “Water and Sanitation” analysing and organizing population To build the capacity of partici- data to ascertain district develop- pants to understand the Ghanaian ment needs. Comprises two parts: water supply systems and ways to population and development plan- plan for the management and sus- ning issues, and issues to be consid- tainability of these systems. 82 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Emphasizes water supply systems lation distribution; and assess land in the country, major demand suitability for the required resource determinants of water consump- needs of a given population. tion, methods of forecasting 8. “Planning for Food Security” demand for water, and the main To increase participants’ awareness methods of demand projection of sustainable development and available to planners. resource management and to build 6. “Housing Needs” their capacity to assess the sustain- To raise participants’ awareness of ability of resources and the mecha- the importance of housing (eco- nisms for integrating the outcomes nomic and social), the concept of of the assessments into develop- housing need (existing and future), ment planning in the context of the housing demand and supply (fac- focus on food security. Land capa- tors affecting the demand for and bility analysis, analysis of land car- the supply of housing), methods of rying capacity and analysis of land assessing housing need, housing suitability were the critical concepts demand analysis (assessment of discussed under this module. current housing need and projec- 9. “Planning for Employment” tion of housing need and house- To focus on three main topics for hold income), estimation of discussion: the elements of employ- housing needs (determination of ment, data needs for employment different packages, assessment of projections, and meeting the affordable level and identification employment demand. This module of target group(s) for housing pro- is underpinned by the understand- grammes), estimation of housing ing that employment is the means investment, and analysis of delivery to survival. In addition, discussions systems. about the unemployment and 7. “Planning for Land” underemployment that have bedev- To guide participants to relate pop- iled developing countries since ulation growth and the distribution their independence and the failure of land resources, including use and of development interventions to conservation, since land is a funda- address these problems were used mental resource for human survival by trainers to build participants’ and is even more crucial in a coun- capacity to handle employment try where the majority of the peo- problems in their districts. ple are farmers. Specifically, the 10. “Rural Transportation” objectives are to: assess the land To increase participants’ under- carrying capacity of any given pop- standing of the link between devel- ulation size; identify and analyse opment and transportation together the land-use capability of any given with the issue of the country’s space and the implication for popu- Training in Incorporating Population Factors into Development Planning – Ghana 83

transportation problems and the tion and for transport; thus energy various options that existed to availability is an essential determi- tackle them. More specifically, the nant of economic development. objective of this particular module 14. “Planning for Fiscal Resource was to increase participants’ knowl- Mobilization” edge of the challenges of rural To enable participants to analyse transportation and how to effec- the relationships between revenue tively plan to increase accessibility. mobilization and population and to 11. “Planning for the Built develop the capacity to deal with Environment” the challenges that characterize To look at the natural environment revenue mobilization: fiscal policy that provides a livelihood for all formulation, revenue collection, people, especially for rural monitoring of operations and per- dwellers, focusing on implications formance assessment. The objec- of use, abuse or misuse of resources tives were achieved by increasing for the environment. awareness and understanding of the 12. “Planning for the Natural following: local revenue instru- Environment” ments, revenues and revenue mobi- To introduce participants to the lization including critical issues, issues of sustainable development analysis of revenue performance, and environmental management and methods for improving local through training in four main areas: revenue mobilization. (a) the principles of ecosystem 15. “Planning for Fiscal Resource functions and their implications for Utilization and Management” humans; (b) principles of ecosystem To build the capacity of participants sustainability and implications for a to plan how to manage their budg- human population; (c) ecosystem ets by teaching them the skills and balance and the implications for the giving them knowledge regarding human population; and (d) estima- the expenditure estimation outline, tion of the impact of population how to use the existing expenditure growth on the natural environment. base, increases in expenditure and 13. “Energy Needs Assessment” expenditure measures. To provide training regarding the A schematic presentation of the train- uses of energy, including sources of ing modules for human resource capacity- energy, and energy needs assess- building is shown in figure 3. It should be ment tools and techniques since noted that all these modules mutually satisfying energy needs is an important component of any devel- interact in that they all aim at building the opment strategy. Energy is vital for capacity of District Planning Officers and industrial and agricultural produc- District Budget Officers to integrate population variables into development plan- 84 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Figure 3 A schematic presentation of the training modules for human resource capacity-building.

Source: Author’s construct, October 2010. ning, with the aim of reducing poverty and tion of the Training Programme. The improving the welfare of the local people. Department of Planning of the Kwame Nkrumah University of Science and Technology (KNUST) was contracted I MPLEMENTATIONOFTHE by the National Population Council with I NTEGRATION T RAINING support from UNFPA to develop the P ROGRAMME modules. However the actual development of the modules involved the The Integration Training Programme was National Population Council; the a National Population Council activity KNUST Department of Planning, under the third Government of Centre for Land Studies and Centre for Ghana/UNFPA Country Programme. Settlement Studies; and the Centre for The structures for the management of the Scientific and Industrial Research. In all, Country Programme as well as existing 25 experts contributed to the design of structures and systems at the National the modules. Population Council, the Metropolitan/ The Training Unit of the Programmes, Municipal Assemblies and District Research and Training Division of the Assemblies were used in the implementa- National Population Council Secretariat Training in Incorporating Population Factors into Development Planning – Ghana 85 was responsible for the coordination of the Integration Training Programme con- the Integration Training Programme. The centrated on principles underpinning the Council used its regional officers to con- training modules. They were divided into tact the district officers including the two phases: an introductory phase and a District Chief Executives and Regional main phase. The introductory phase took and District Coordinating Directors to the participants through the systems view release and sponsor their District of development (modules 1 and 2) while Planning Officers and District Budget the main phase focused on the remaining Officers, who are mandated by Local 13 modules. Government Act 462 of 1993 to prepare, The second week was devoted to implement and monitor district develop- practical training of the participants in ment plans. The Council also arranged the use of computer-based packages for the venues and other logistics in the the 13 modules. This section was handled regions. by a computer facilitator and the resource The Government/UNFPA Programme persons who delivered the lectures in the also had structures for managing the first week. A number of cross-cutting Country Programme that were also used issues were identified, such as the rela- to manage the Integration Training tionship between housing, environment Programme. The quarterly programme and health and how these affect the wel- review meetings of implementing part- fare of people and thus reduce their ners also provided an opportunity for the poverty. partners to report on their activities, In addition to the training given to share ideas, clarify issues and identify the District Planning Officers and areas of collaboration among partners. District Budget Officers, the Ministry of The main collaborating agencies, howev- Local Government and Rural er, were the National Population Development and the National Council, Kwame Nkrumah University of Population Council, in collaboration Science and Technology, District with the Department of Planning, also Assemblies and UNFPA. organized one-day orientation and train- The entire Training Programme was ing workshops for District Chief held in 10 working days through lectures, Executives and District Coordinating seminars, discussions, exercises and com- Directors since, as the two critical mem- puter applications. It was divided into bers of District Assemblies, they play a two main components of five days each. crucial role in drawing up and indeed in implementing district development In the first week, participants were plans. The objective of these orientation taken through lectures, group discus- workshops was to help the District Chief sions, participant-led seminars and practi- Executives and the District Coordinating cal exercises. Fifteen modules were Directors appreciate the importance of taught during this week, during which 86 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES these training programmes in the devel- Officers to be competent in the prepara- opment planning process. tion of their plans. They therefore allocated financial resources through E XPERIENCESAND I SSUES investing in computers, printers and A RISING O UTOFTHE other necessary equipment to support I MPLEMENTATION these Officers in preparing their develop- Before the training programmes, District ment plans rather than giving the Chief Executives and District assignments to consultants. Coordinating Directors were not enthu- Similarly, the training of District siastic about financing and encouraging Planning Officers and District Budget District Planning Officers and District Officers provided them with the neces- Budget Officers in the preparation of dis- sary skills and confidence to prepare district development plans since they did trict development plans that met the not find the Officers to be competent needs and aspirations of the people in enough. As a result, they employed con- their districts in terms of reducing their sultants in the preparation of their district poverty and promoting sustainable devel- development plans. opment in their respective districts. The District Planning Officers and the District Budget Officers also were not R ESULTSAND confident and lacked the necessary skills A CHIEVEMENTS for the preparation of their district development plans. As a result, the plans that they prepared were not responsive to the The modules have been used to train the needs and aspirations of the people in core staff of District Assemblies since their districts. Therefore, the people did 2002. Most importantly, the conception, not give their necessary support to the preparation and publication of the mod- implementation of the plans. ules constitute a great achievement. These modules were realized after many After the orientation given to the consultations between the National District Chief Executives and District Population Council and key partner Coordinating Directors, however, they agencies. To date, around 15 training were motivated to provide the necessary programmes have been conducted and support to their District Planning over 250 staff have been trained using Officers and District Budget Officers for these modules. From a review undertaken the preparation of their district develop- by the National Population Council and ment plans. In addition, as a result of the its stakeholders, it was observed that as a training given to these Officers, the result of the training programmes, the District Chief Executives and the District performance of participants in the prepa- Coordinating Directors found the ration of their district development plans Training in Incorporating Population Factors into Development Planning – Ghana 87 has improved greatly according to their A SSESSMENTAND District Chief Executives and District E VALUATIONOFTHE Coordinating Directors. These Officers C ONTENT, I MPACTAND are now capable of preparing their plans USTAINABILITYOFTHE instead of the District Assemblies engag- S ing the services of private consultants to T RAINING P ROGRAMME perform these tasks for them at a very high financial cost. A SSESSMENTBY PARTICIPANTS Prioritizing training for about 40 One important aspect of the Integration District Planning Officers and District Training Programme is an assessment of Budget Officers in all the districts of the its relevance. This is done by the imple- three northern regions (Upper East, menters of the Programme, who ask Upper West and Northern) was also an participants to complete structured ques- achievement. As noted earlier, these tionnaires with questions relating to: regions are among the poorest in the country. It was thus appropriate that • achievement of Programme the human resource capacity-building objectives; programme started from there. • training methods; Subsequently, around 210 Officers from • level of instruction and relevance the other districts in the country have of Programme content to also been trained. This has helped to participants’ work; build the human resource capacity of • computer application and relevance; these core Officers in the preparation of their plans. • length of the Programme; and • overall evaluation. The training has also contributed to reducing poverty levels in Ghana by The overall evaluation of the building the capacity of District Planning Integration Training Programme by par- Officers and District Budget Officers in ticipants showed that 82.3 per cent grad- preparing and implementing programmes ed the Programme as “excellent”, 11.8 per and projects that respond to the needs cent rated it as “very good” and 5.9 per and aspirations of the local people. Since cent of the participants deemed it to be 1999, poverty in Ghana has dropped from “good”. None of the participants graded 39.5 per cent to about 28 per cent of the the course as “fair” or “poor”. population using the international poverty line of US$1.25 a day (Government of The evaluation has served as a basis for Ghana, National Development Planning planning subsequent courses. Generally, Commission, 2009). when asked, about 69 per cent of the participants observed that the course objectives had been completely met, 23 per 88 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES cent asserted that the course objectives District Assemblies be properly had almost been met and only 8 per cent resourced by the Government by increas- judged that the participants’ objectives ing the District Assembly Common Fund had been met fairly well. from 5 per cent to 7 per cent of gross domestic product. District Assemblies are The method of delivery of the being requested to increase the capacity Integration Training Programme was of their resource mobilzation staff to col- identified as being easy to understand, lect the internally generated funds effi- participatory and flexible. It encouraged ciently. As far as utilization is concerned, team-building and individual dynamism, it is recommended that the capacity of critical attributes that development plan- budget officers in the district, i.e., the ners at the local level must possess. In District Coordinating Directors and the terms of the length of the Programme, District Chief Executives, should be the majority (52.9 per cent) of the parti - improved through rigorous training. cipants responded that their preferred length of time for the Programme was Participants who attended the three weeks, 23.5 per cent mentioned Integration Training Programme found it four weeks and 11.8 per cent indicated to be very useful. The response to the six weeks. After the evaluation, it was training was very positive and partici- decided that the duration of the course pants returned to their districts with should be increased to three weeks, with copies of both the modules and templates the first two weeks devoted to lectures on a CD-ROM. As far as the participants and the third week devoted to computer and authors are concerned, the modules application. simplified the planning process and made it easy for its users to undertake needs Module 12, which looked at the nat- assessment and planning in order to iden- ural environment, was deemed to be tify the specific needs of the people and difficult by participants. This can be plan to address them. attributed to the fact that it involves a great deal of complex mathematical cal- culation. Most importantly, participants A SSESSMENTBY I NSTITUTIONS AND I NDIVIDUALS observed that Module 14, “Planning for Fiscal Resource Mobilization”, and The National Population Council organ- Module 15, “Planning for Fiscal Resource ized a review of the training programmes Utilization and Management”, were very to assess whether or not they truly important and that the issues covered by increased the capacity of the participants those modules were extremely relevant. who attended the training. At this review The reason for this assessment is that the meeting, 44 individuals from 18 institu- capacity of District Assemblies to pro- tions participated. Participants were very mote development is constrained by happy about the way in which the mod- inadequate financial resources. It has ules were being integrated into develop- therefore been recommended that ment planning. Officers who participated Training in Incorporating Population Factors into Development Planning – Ghana 89 in the training programmes were said to Training Programme were satisfied with be very skillful in the preparation of their the general conduct of the Programme district development plans. They recom- and the output of Officers who had been mended that the course be extended by trained. Many districts with trained offi- one week so that participants would be cials have stopped employing consultants well schooled in the theoretical aspects of in the preparation of district develop- the modules. They also corroborated the ment plans since their own officials can observation that Module 12 (“Planning prepare them effectively. for the Natural Environment”) was difficult because it was very mathematical. L ESSONS L EARNEDIN Participants also indicated that the T ERMSOF P OSITIVEAND training seemed to be working. They N EGATIVE I MPACT cited the example of trained District Planning Officers who were using the modules to effectively plan and mobilize Between 1996 and 2000, when the first resources in their districts. They also stat- medium-term development plans of ed that supervisors (the District Chief District Assemblies were prepared and Executives and District Coordinating implemented, the plans were found to be Directors) of these District Planning rigid and non-responsive to the needs of Officers also were satisfied with the out- the people. Thus there was a need to puts of the Officers. intervene to make development plans more effective. The Integration Training Participants further stated that the Programme subsequently provided the knowledge acquired by the Officers in technical staff who prepared these plans the Integration Training Programme was with the necessary skills to assess the translated into the preparation by these needs of their various communities in Officers of better district development terms of housing, health, education, plans, which were very responsive to the water and sanitation, economic develop- needs of their people. They acknowl- ment, transportation and the environ- edged that more than 70 per cent of the ment to make development planning well-prepared district development plans more responsive to their needs. The tech- came from districts where personnel had nical staff also learned how to mobilize been trained. They therefore recom- fiscal resources and how to advise on the mended that this Programme be contin- use of such resources in their districts, ued to increase the effectiveness of with the aim of reducing poverty among decentralized development planning in their people. From 2002 when the Ghana Ghana and help to reduce further the Poverty Reduction Strategy 1 was being poverty of the people. implemented, components of the training Overall, the institutions and individu- modules were integrated into the guide- als that helped to evaluate the Integration lines prepared by the National 90 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Development Planning Commission for districts, they carried with them the Districts Assemblies in the preparation of knowledge gained and are therefore still their medium-term development plans. very useful to the country. Another major positive impact is that district political heads (District Chief R EPLICABILITYOFTHE Executives and District Coordinating I NTEGRATION T RAINING Directors) have supported the implemen- P ROGRAMME tation of the training programmes by encouraging their staff and providing them with financial support to attend the Since the first implementation of the training. This was made possible by sen- Integration Training Programme in 2002, sitizing the District Chief Executives and which targeted only the three regions in District Coordinating Directors about the north of Ghana (Upper East, Upper the benefits of the Integration Training West and Northern), the modules have Programme and its relevance for develop- been used to train staff of District ment. Again, the involvement of major Assemblies across the country. This was stakeholders, including ministries and informed by the understanding of the agencies, and the National Development Government that to promote effective Planning Commission at the national development and poverty reduction at level has made the inclusion of these the local level, population factors had to modules in national policy programmes be integrated into the formulation, imple- possible. mentation, monitoring and evaluation of policies and programmes relating to cul- Even though around 250 District tural, economic and social development Planning Officers and District Budget including resource allocation at all levels Officers have been trained in the use of in the country. the modules to integrate population variables into development planning, certain The modules have been used to train challenges have been identified. These staff of District Assemblies to appreciate include the fact that, in 2005, when the the critical issues that determine the National Population Council assessed the needs and aspirations of people and com- effectiveness of the training programmes, munities. Although the training was start- it found that some of the trained Officers ed in districts in the three northern and had either been transferred from their poorest regions, extending the training to districts or had resigned and had taken cover other districts did not pose any jobs with NGOs because of their challenge. Participants understood the improved capacity. It was therefore nec- relevance and appreciated the need to essary to train more Officers to be able to have their development plans reflect the replace those who left. It should be noted needs and aspirations of the people for that even though these Officers left the whom they plan. Training in Incorporating Population Factors into Development Planning – Ghana 91

It is the authors’ view that the I MPACT Integration Training Programme can be replicated in the whole of Africa and Following the introduction of the beyond. In terms of substance, the Integration Training Programme, all Programme has been designed to look at activities at the local level have revolved all the components and various factors around the issues and approaches recom- captured in the modules that affect the mended by the training. This has encour- lives of the people by examining the aged the Government to fully integrate detailed relationship between these fac- population concerns into the formula- tors and the lives of the people. tion, implementation, monitoring and Political backing, which is quite strong evaluation of policies and programmes for the Programme in Ghana, is needed to relating to cultural, economic and social ensure the success of the Integration development including resource alloca- Training Programme in other African tion in all the regions of the country. This countries. There is also a need for an assertion is based on the fact that every- umbrella coordination institution like the day activities of all human beings, com- National Population Council in Ghana to munities and countries are influenced by liaise between the national and subnation- population change, the use of natural al levels (e.g., District Assemblies). This resources, the state of the environment, facilitates easy interaction between the and the pace and quality of social and two parties and ensures the provision of economic development. necessary resources by the national leader- The innovative practice was integrat- ship to the district leaders. ed into the Growth and Poverty The national and the local govern- Reduction Strategy (GPRS II) (2006- ment must work together to provide 2009) and has also been incorporated into resources for the Integration Training the current Medium-term National Programme. Resources such as computers, Development Policy Framework (2010- printers and photocopiers as well as funds 2013). Guidelines prepared by the for data collection are prerequisites for the National Development Planning adoption of these modules in the prepara- Commission for the preparation of sector tion of district development plans. and district development plans identified population as a cross-cutting issue based If all these conditions are met, then on the knowledge gained from the prac- the Integration Training Programme can tice. The National Population Council, be replicated in other countries in Africa which facilitated the practice, succeeded and elsewhere to help to reduce poverty in the inclusion of the population vari- and improve the living conditions of the ables in the two above-mentioned docu- people of these countries. ments. The preparation of these two national policy documents was facilitated 92 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES by the National Development Planning When promoting effective decentraliza- Commission, which established cross-section, there is a need for effective plan- toral planning groups on various themes. ning, implementation, budgeting and monitoring at the local level. In Ghana, Under GPRS II (2006-2009), there the decentralization process is relatively were three major themes: priorities for pri- young and the effective functioning of vate-sector competitiveness, human the system requires that officials respond resource development, and good gover- to the objectives of this decentralization nance and civic responsibility. The process, which are poverty reduction and Medium-term National Development improved living conditions. Several stud- Policy Framework (2010-2013), on the ies have illustrated the need to build other hand, has five themes: Ghana’s com- capacity at the local level, especially petitiveness in industry and service, accel- when it comes to human resources. The erated agricultural modernization, reasoning behind this is that if District expanded development of production Assemblies drive development at the infrastructure, human resources for nation- local level, then it is critical that the con- al development, and transparent and ditions necessary to promote the effec- accountable governance. The cross-sec- tive, efficient and sustainable use of toral planning groups discussed the various resources that responds to the needs of key issues that the participating ministries Ghanaians (i.e., reducing poverty) be and agencies wanted to be included in the enhanced. After the implementation of national documents. The National the first phase of Ghana Vision 2020 and Population Council served on all the cross- the introduction of the medium-term sectoral groups; however, it focused on the development plans approach to develop- human development group. Apart from ment planning, it became obvious that the cross-sectoral groups, the National attention must be paid to the needs of Development Planning Commission also people at the local level. The only way to established a core team that drafted the train the necessary personnel to be able documents. The National Population to facilitate this was to provide them with Council participated intensively in the the skills needed to be able to integrate activities of the core team and noted that population variables into the develop- serious consideration needed to be given ment planning process. to population variables in the national policy programmes. The training modules have facilitated the easy integration of population variables into development planning. The C ONCLUSION Integration Training Programme is a best practice in the sense that it provides an J USTIFICATIONOFTHE innovative basis for more holistic and I NTEGRATION T RAINING effective planning for the future. The P ROGRAMMEASA B EST P RACTICE modules are also user-friendly, and dis- Training in Incorporating Population Factors into Development Planning – Ghana 93 trict development plans have been the preparation of the Training Manual, reviewed and made more focused using the use of the Manual for the training them. programme, the review of the Manual and the financing of the entire exercise. I The continued training of district would like to express my sincere appreci- officers by the National Population ation to all of them since without them, Council and the Department of Planning this case study could not have been writ- of Kwame Nkrumah University of ten and the training programme could Science and Technology in the use of the not have been held. modules in the preparation of development plans continues to show the First, I am very grateful to the importance of this approach to the devel- National Population Council for initiat- opment planning process in Ghana. ing the idea of preparing the modules and the training programmes to integrate population variables into development F UTURE P LANS planning. I also wish to thank the Department of Planning of Kwame It is envisaged that new modules will be Nkrumah University of Science and added to the existing ones. These could Technology, which put these ideas into include topics such as “youth in develop- practice, and especially the lecturers in ment”, “women in development” and “risk the Department who prepared the mod- and vulnerability”. ules and were the facilitators for the training programmes. My thanks also go to The Integration Training Programme Dr. Seth Ohemeng Dapaah, a statistician modules have been in use for some time and a computer expert from the Centre and the National Population Council and for Scientific and Industrial Research the Department of Planning in collabora- (CSIR) Kumasi, who helped to develop a tion with UNFPA are in the process of template on computer-aided techniques reviewing them to rectify gaps and to in support of all of the 13 main modules update them to include new and emerg- to help the trainees to update the data on ing issues. The Council also plans to their districts for the preparation of their advocate that they be incorporated into district development plans, and to Mr. I. the curricula of some training institutions K. Kitrisku, who edited the training man- in Ghana to enable many more district ual before its publication. personnel to be equipped with the skills to use them. I am grateful to the many government ministries, departments and agencies that participated in the review of the A CKNOWLEDGEMENTS modules and the programmes that were organized using the modules. My very Many institutions and individuals have special thanks go to the United Nations contributed in one way or the other to 94 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Population Fund for the provision of Implementation of the Growth and Poverty financial resources for the exercise. Reduction Strategy (GPRS II) 2006-2009. Accra: National Development Planning I would also like to express my grati- Commission. tude to the individuals who contributed at the review meeting on the modules, espe- ______(2003). Ghana Poverty Reduction cially Mrs. Ester Apewokin, Former Strategy 2003-2005: An Agenda for Growth Executive Director, National Population and Prosperity. Vol. 1, Analysis and Policy Council; Mr. Steve Gray, Deputy Statement. Accra: National Development Director, National Population Council; Planning Commission. Ms. Marian Kpakpah, Director, Technical Laryea-Adjei, G. (2000). “Building capac- Services, National Population Council; ity for urban management in Ghana: Nana Prof. J. S. Nabila, President, Some critical considerations”. In Habitat National House of Chiefs; and many International, 24(4):391-401. other top officials too numerous to men- Li, W. (2005). A Survey of Institutional tion individually here. Capacity of Local EPBs [Environmental I also wish to express my sincere Protection Bureaux] in China. Paper pre- appreciation to Partners in Population pared for the Urban China Research and Development for selecting the Network Annual Conference: Chinese manual on “Integration of Population Cities in Transition, Shanghai, 2 May Variables into Development Planning” as 2005. a best practice and inviting me to its two Lindley, C. (1975). “Changing policy technical meetings in 2010 in Dhaka and management responsibilities of local leg- Bangkok as well as to all the authors/ islative bodies”. In Public Administration experts who attended both technical Review, 35 (Special Issue, December meetings for their constructive comments 1975), pp. 794-797. that have helped in many ways to shape this case study into its present form. Lusthaus et al. (2002). Organizational Assessment: A Framework for Improving Finally, I wish to thank Mr. Stephen Performance. Ottawa: International Kofi Diko, my teaching and research Development Research Centre/Inter- assistant, for his immense contribution in American Development Bank. . Schermerhorn, J. R., Jr. (2002). Management. R EFERENCES New York: John Wiley and Sons, Inc. Government of Ghana, National United Nations Population Fund Development Planning Commission (UNFPA) (2010). Impacts of Population (2009). 2008 Annual Progress Report: The Dynamics, Reproductive Health and Training in Incorporating Population Factors into Development Planning – Ghana 95

Gender on Poverty. Concept Paper prepared for the United Nations Summit on the Millennium Development Goals, New York, September 2010. Unpublished, p.8. World Bank (2009). Systems of Cities: Harnessing Urbanization for Growth and Poverty Alleviation. The World Bank Urban and Local Government Strategy, . Accessed on 28 November 2009. ______(2006). World Development Indicators 2006.

Contacts

Drafting Contact Dr. Yaw Nsiah-Peprah Former Head, Department of Planning, and Former Vice Dean, Faculty of Planning and Land Economy Kwame Nkrumah University of Science and Technology Kumasi, Ghana Tel.: +233 248 583996, +233 208 121251 E-mail: [email protected] [email protected] Website: http://www.knust.edu.gh

Project/Practice Contact Mrs. Esther Apewokin Former Executive Director National Population Council Accra, Ghana Tel.: +233 21 665713/665944 Fax: +233 21 662249 E-mail: [email protected] Website: http://www.npc.gov.gh 96 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Addressing 4 Reproductive and India Sexual Health Issues of Adolescents Prof. Deoki Nandan Dr. Poonam Khattar Prof. Neera Dhar Dr. Vijay Kumar

Summary

Investment in adolescent reproductive and sexual health yields dividends in many important ways. The Ministry of Health and Family Welfare, under the Reproductive and Child Health-II project, has included the adolescent reproductive and sexual health strategy to take care of the emerging needs and demands of adolescents. The present case study highlights the successful interventions carried out by the Society for Women and Children’s Health, a national NGO, in partnership with the State government in Yamuna Nagar District of Haryana, India.

Prominent deficiencies existed such as a lack of provisions for privacy and confidentiality in the health centres and hospitals, no special clinic or fixed hours for adolescents, and inadequate information about the adolescents in the available records. The modules developed by the Government of India were used for the training of staff, and the health personnel in the district were trained through three-to-five-day training courses. Peer-group educators were selected according to the criteria developed and were trained in how to address queries by using the “‘frequently-asked-questions” approach.

Youth melas (youth fairs/festivals) were organized during a period of one year and were attended by adolescents and youths as well as some elders and opinion makers. The youth

97 98 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

festivals offered an opportunity to specifically address sexual and reproductive health needs. The organization of these festivals was part of the implementation strategy to help to create awareness of adolescents’ issues.

It was observed that over a period of nine months, a total of 2,851 adolescents (927 males and 1,924 females) visited the general outpatient departments and 283 cases were recorded as referral cases.

Evaluation consisted of household surveys and quality assessments of health facilities based on standards set by the Government. A household coverage survey on 1,200 adolescents in 60 village clusters (30 control and 30 intervention clusters) was carried out, which demonstrated impressive improvements in the intervention villages. Remarkable improvements were demonstrated in the knowledge and use of adolescent-friendly health services and the utilization of public health services and better coverage in the iron deficiency anaemia prevention package, the purchase of sanitary napkins for menstrual hygiene, better access to contraception, knowledge of sexually transmitted infections (STIs) and the use of condoms.

Quality assessment was carried out in 12 health facilities (10 sub-centres and 2 primary health centres) each in the control villages and intervention villages where the adolescent- friendly health centres were established. The scores for different standards varied between 44 and 94 per cent in adolescent-friendly health and counselling service facilities in comparison to 1 to 59 per cent in the control facilities.

Information on the Authors Prof. Deoki Nandan, Director, National Institute of Health and Family Welfare. Dr. Poonam Khattar, Associate Professor, National Institute of Health and Family Welfare. Prof. Neera Dhar, Professor, Department of Education and Training, National Institute of Health and Family Welfare. Dr. Vijay Kumar, Executive Director, Society for Women and Children’s Health (SWACH). Addressing Reproductive and Sexual Health Issues of Adolescents – India 99

B ACKGROUND O RIGINOFTHE P ROJECT The adolescent reproductive and sexual TARGET P OPULATION health strategy was implemented as per Haryana is one of the wealthiest States of the National Policy Guidelines by the North India. According to the 1991 Government of India in the nine selected Census of India, three quarters of districts in Haryana, including Yamuna Haryana live in rural areas. Thirty-seven Nagar. per cent of the population is below 15 Problems Identified Relating to years of age (according to the 2005-06 Adolescent Reproductive and National Family Health Survey). Eighty- Sexual Health nine per cent of children ages 6 to 14 Findings of a Mapping Exercise attend school. The disparity in school attendance by sex grows with increasing A mapping exercise to assess the services age. For example, between 6 and 10 years provided for adolescents revealed that of age, 93 per cent of boys attend school more than 90 per cent of all the health compared with 90 per cent of girls, and facilities were far below the standards as between 15 and 17 years of age, 68 per recommended in the Implementation cent of boys attend school compared Guide of the Government. Some of the with 50 per cent of the girls. Forty-seven prominent deficiencies noted in the proper cent of females have some degree of vision of adolescent-friendly health serv- anaemia, 31 per cent are mildly anaemic ices were as follows: and 15 per cent are moderately anaemic, the prevalence being higher for rural • the providers were not trained in women. A considerable proportion of the adolescent-friendly health females in Haryana still marry before services package; reaching the legal minimum age of 18 • supplies such as iron and folic acid years. Twenty-three per cent of women tablets and contraceptives were 15 to 19 years old are already married available (although supplies were and the proportion for married females is erratic) but were not provided to higher in rural areas. More than two out adolescents; of five women in Haryana did not receive • there were no provisions to main- an antenatal check-up for births in the tain privacy or confidentiality in three years preceding the 2005-06 the health centres and hospitals; National Family Health Survey. Sixty- • no special clinic or fixed hours for three per cent of women from rural areas adolescents were observed; are aware of all modern methods of fami- • the available records contained ly planning (contraception, birth control inadequate information on adoles- and spacing) compared to 79 per cent of cents (the records only identified their urban counterparts. disease symptoms) and this information was neither analysed nor 100 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

reported. Sometimes even the age of pimples (boys and girls) and the adolescents was not recorded; physical illnesses; • there was very low use by the ado- • 88 per cent of adolescent girls lescents of public health services were using home-made pads relating to reproductive and sexual during menstruation; health issues; • information on sexual activity, • the girls who were not going to especially premarital sex, was diffi- school demonstrated a high preva- cult to obtain but those who stated lence of anaemia and low coverage that they had had sexual activity of tetanus toxoid; and did not adopt safe sexual practices; • there was a lack of knowledge among • a survey of adolescents who service providers of the key issues were and who were not attending relating to physical, psycho-social, school showed a very high and reproductive and sexual health. prevalence rate of anaemia; and • the coverage with tetanus toxoid Findings of Formative Research was 96 per cent in girls attending school and only 44 per cent in Formative research revealed the following: girls not attending school. • the attendance rate of adolescents The mapping exercise and the findings in government health facilities was only 5 to 10 per cent; of formative research provided the benchmark information on the gaps and helped • when sick, 64 per cent of girls and to identify specific areas needing interven- 52 per cent of boys reported to tion and improvement. In order to address village doctors (mostly unquali- these deficiencies, the decision was taken to fied) for treatment; adopt a multi-pronged strategy in line with • about 70 per cent of the boys and the guidelines of the adolescent reproduc- 45 per cent of the girls were not tive and sexual health strategy by the aware of the physical changes in Government of India, as outlined below. their body; A State Programme Implementation • the main sources of information Programme (PIP)1 was prepared that about sexual health were media (television) and friends; included the important components relating to planning the adolescent and • the main stressors for adolescents sexual reproductive health strategy for were financial problems, fights the State of Haryana. The case study pre- among parents, tension about sented was implemented in the selected studies and relationships; community health centres/primary health • prominent health concerns included centres/sub-centres in Yamuna Nagar pain during menstruation (girls),

1 PIP is the standard title used by the States for developing future implementation programmes relating to health. Addressing Reproductive and Sexual Health Issues of Adolescents – India 101

District in Haryana in 2008-2009. The • improve the reproductive health operational area was selected in consulta- and well-being of youths and ado- tion with the Chief Medical Officer and lescents in the selected districts District Nodal Officer, Haryana. through a multisectoral and integrated approach; Intervention Area • strengthen the ability of youths and adolescents to delay marriage District: Yamuna Nagar and make informed decisions Population: 100,000 (estimated) about reproductive health matters, Villages: 88 especially among girls; and Primary health centres: Kot, Kharwan, • increase the access of married and Kalanaur and Burhia unmarried adolescents to modern Community health centres: Khizrabad family-planning and reproductive- and Naharpur health information and services. Sub-centres: 17 S TRATEGY F ORMULATION O BJECTIVESOFTHE I NTERVENTION A comprehensive package (box 1) of ado- The objectives of the intervention were to: lescent-friendly reproductive and sexual

Box 1 The innovative adolescent reproductive and sexual health strategy at a glance.

Organizing effective Service providers in place; services Available supply of equipment and basic amenities; Notice board outside the centre in prominent position; Display of services offered.

Conducive Designated staff available; environment Registration of adolescents; Privacy and confidentiality; Special clinic day/time, as decided by community.

Service delivery Promotive – focused care during the antenatal period, counselling and package provision for emergency contraceptive pills; Preventive – services for tetanus immunization, prophylaxis against nutritional anaemia and nutrition counselling; Curative – treatment for common reproductive-tract infections/sexually transmitted infections, counselling for menstrual disorders and sexual concerns of male and female adolescents; Referral – Voluntary Counselling and Testing Centre, any other issue; Outreach – periodic health check-ups, community camps and health education activities. 102 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Box 1 The innovative adolescent reproductive and sexual health strategy at a glance (continued).

Capacity-building Health-care providers.

Communication with Peer-group educators; adolescents through Addressing adolescents attending and not attending school; convergence Letter-box approach; Frequently-asked-questions (FAQs) approach.

Environment-building Establishing adolescent action groups; Community involvement; Youth festival/cultural show/competitions/debates on key issues.

Monitoring and Household Survey; evaluation Quality assessment of adolescent-friendly health services as per the seven standards recommended by the Government of India.

health services was planned as per the I NNOVATIONS : D ESCRIPTION recommendations by the Ministry of OF A CTIVITIES Health and Family Welfare. Adolescent-friendly health clinics were PARTNERSHIPWITH N ON - GOVERN - selected and established at the sub-centre/ MENTAL O RGANIZATIONS primary health centre/community health The implementation of the strategy was centre level and at the district level based undertaken by adopting the partnership on the criteria contained in the standards approach in which six mother non- recommended by the Government. The governmental organizations (NGOs) innovative strategy consisted of the follow- were selected to work with the ing activities carried out simultaneously. Government. The role of the NGOs was primarily community mobilization and O RGANIZING E FFECTIVE S ERVICES training of health providers and other The following were ensured: stakeholders including the peer-group educators in the districts selected. The • adequate service providers in Society for Women and Children’s place; Health implemented the innovative ado- • a Notice Board outside the centre lescent reproductive and sexual health in a prominent position; strategy in Yamuna Nagar, Haryana. • posters displaying the services offered and visible to the clients; Addressing Reproductive and Sexual Health Issues of Adolescents – India 103

• adequate waiting space and cents were referred to a primary health reasonable cleanliness; centre/community health centre for treat- • availability of the specified sup- ment of common reproductive-tract plies, equipment and basic ameni- infections/sexually transmitted infections ties such as clean water and a clean and for voluntary counselling and testing toilet facility; and for HIV/AIDS. • reasonable privacy and confiden- Two types of outreach services were tiality. added: periodic health check-ups under the school health programme and com- CONDUCIVE E NVIRONMENT munity camps, and information about the health services provided by the peer A conducive environment was creat- educators. ed through the following: During the period under review, 13 • designated staff were present, and such clinics were established at various punctuality and regularity were levels. The peer-group educators and ensured; health workers at the village level • registration was required for all ensured that the demand for health serv- adolescents; ices by the adolescents was created. • privacy and confidentiality were Clients availing themselves of services ensured; were also contacted to assess their satisfaction level. Over a period of 10 months • a special clinic day and time were (June 2008-March 2009), a total of 1,676 established as decided by the com- cases attended the adolescent-friendly munity; and health and counselling services (544 • reading material was displayed on male and 1,132 female) and 1,175 cases relevant issues. (383 male and 792 female) in the General Outpatient Department (total S ERVICE D ELIVERY PACKAGE number of cases = 2,851). During this period, 283 referred cases were As part of promotive care, focused addressed. The attendance of females antenatal care was provided to all adoles- outnumbered that of males more than cent pregnant mothers. Counselling twofold. One major reason for this was information, advice on and the supply of the reluctance of the male adolescents to contraceptives, sexual and reproductive be seen by a female provider. Another health issues and the common concerns reason for the higher number of consul- of the adolescents (both boys and tations by females related to menstrual girls) were addressed. Service for problems. The types of problems toxoid, iron and folic acid tablets and addressed are summarized in table 1. counselling for nutritional anaemia were provided. Wherever required, the adoles- 104 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Table 1 Types of problems addressed in health facilities (General Outpatient Department and Adolescent- friendly Health and Counselling Services).

Serial No. Problem Male No. (%) Female No. (%)

1. Menstrual problem - 404 ( 21.0)

2. White discharge 8 ( 0.9) 173 ( 9.0)

3. Itching in and around genital area 66 ( 7.1) 76 ( 3.9)

4. Lower abdominal pain 15 ( 1.6) 138 ( 7.2)

5. Facial blemishes 85 ( 9.2) 174 ( 9.0)

6. Burning micturition 71 ( 7.7) 100 ( 5.2)

7. Weakness 133 (14.3) 185 ( 9.6)

8. Diarrhoea 51 ( 5.5) 66 ( 3.4)

9. Boils on the skin 68 ( 7.3) 104 ( 5.4)

10. Acute respiratory illness (ARI) 110 ( 11.9) 136 ( 7.1)

11. Fever 149 ( 16.1) 163 ( 8.5)

12. Abdominal pain 80 ( 8.6) 103 ( 5.3)

13. Mouth ulcer 91 ( 9.8) 102 ( 5.3) Total 927 1,924

C APACITY - BUILDINGOFTHE health-care providers with respect to the A DOLESCENT - FRIENDLY H EALTH - adolescent-friendly health and coun- CARE P ROVIDERS selling services so that they would Health-care providers form the backbone become a pull factor in attracting the of the health system and many of them adolescents and encourage them to avail could be tapped and designated to themselves of the health-care services. become providers of adolescent-friendly The training also focused on how to health services in the community. They improve the quality of services rendered. include the doctors, auxiliary nurse mid- The following criteria were set for wives, anganwadi workers, peer-group the selection of adolescent health-care educators and teachers. Capacity-build- providers: ing of these health-care providers was undertaken by providing training. The • has been trained in adolescent- purpose of the training was to orient the friendly health services (has participated in the full training package); Addressing Reproductive and Sexual Health Issues of Adolescents – India 105

• keeps and uses the training material The training was carried out using the given to him/her; training package developed by the • is functional in sharing information, Ministry of Health and Family Welfare. A maintains records and provides data; five-day State-level training programme on adolescent reproductive and sexual • participates in meetings and health was undertaken by the Society for provides feedback; Women and Children’s Health in collab- • promotes adolescent-friendly oration with the State government. This health services; refers adolescents was followed by training of trainers com- to adolescent-friendly health serv- prising medical officers/dental surgeons/ ice facilities regularly and follows counsellors in collaboration with the dis- them up; and trict trainers for a period of three days in • participates in promotional activi- 2008. These trainers in turn trained the ties for adolescents, i.e., anaemia lady health visitors/auxiliary nurse mid- prevention and control, tetanus wives/anganwadi workers in the district prevention, menstrual hygiene, through five days of training. The details family planning and prevention of of the training sessions organized in sexually transmitted infections and Yamuna Nagar are given in table 2. HIV/AIDS.

Table 2 Capacity development in adolescent reproductive and sexual health (total number of training courses: 3).

Serial No. Category of Trainer No. of Trainees Days

1. Medical Officer 15

2. School Medical Officer/Medical Officer 63

3. Dental Surgeon 63

4. Counsellor 23

5. Lady Health Visitor/ Auxiliary Nurse Midwife 40 5

6. Anganwadi Worker 20 5

Total 75

COMMUNICATIONWITHTHE Keeping this in mind, the peer-group edu- A DOLESCENTS : P EER - GROUP cators were selected to serve the school E DUCATORS children/out-of-school adolescents in the Adolescents/young people prefer to dis- community to deal with issues of a sensi- cuss sensitive issues with their peers. tive nature, to participate in selected 106 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES public health efforts (distribution of iron and ready to work on a voluntary basis. and folic acid tablets, tetanus toxoid, con- A total of 200 peer-group educators traceptives, clean pads) and to increase use (100 males and 100 females) were selected of adolescent-friendly health service cen- from 88 villages and training was provided tres. The criteria used for the selection of once a month by the Society for Women peer-group educators were as follows: is a and Children’s Health. Details of topics good communicator, is acceptable to ado- covered in the various rounds/phases of lescents, is interested in work, is able to training and participants are summarized understand the problems of adolescents, in table 3. has a good personality, and is confident

Table 3 Topics covered and participants in the training of peer-group educators.

Number of Participants Rounds/Phases Topic Covered PGE (M) PGE (F) Total PGEs ASHA AWW ANM

1. Selection Round 100 100 200 --- 2. Body Image 88 92 180 --- 3. Nutrition and Anaemia 86 86 172 41 -- 4. Health Problems 90 97 187 39 -2 5. Menstrual Problem 88 95 183 50 43 6. Friendship, Love and Marriage 87 88 175 54 20 1 7. Psychological Issues 92 86 178 53 10 3 8. RTI, STI and HIV/AIDS 83 90 173 47 23 - 9. STI, Sexual Health, HIV/AIDS 69 74 143 48 16 2 10. Accidents 54 65 119 32 71 11. Adolescent Pregnancy and Abortion 53 59 112 36 92 12. RTI/STI/ Safe Sex 40 64 104 26 11 3 13. Education, Employment and Work Plan 21 22 43 13 06 2

Note: PGE = peer group educator; ASHA = accredited social health activist; AWW = anganwadi worker; ANM = auxiliary nurse midwife; RTI = reproductive tract infection; STI = sexually transmitted infection.

Addressing the Adolescents of the youths and peers to enhance the Attending and Not Attending School demand for services for the out-of-school A sizeable proportion of adolescent girls adolescents. and boys (about 35 per cent) were not attending school; therefore, school-based Letter-box Approach interventions were not expected to cover them. Keeping this in mind, peer-group To encourage conversation on the issues educators were trained to raise awareness and concerns of the adolescents and Addressing Reproductive and Sexual Health Issues of Adolescents – India 107 maintain confidentiality, letter boxes vention, the peer-group educators should were set up in selected schools and in immediately refer such adolescents to the selected villages. The adolescents were Medical Officer or the auxiliary nurse briefed that they could put the question, midwife. issue or any problem relating to health in During the monthly interactions, the the box without identifying themselves peer-group educators were trained in but that they should mention the class. A how to fill out the Record Form. The fol- similar strategy was used for out-of- low-up of their work was done by review- school adolescents by the peer-group ing the Record Form filled out by the educators. The letter boxes were opened peer-group educators and their ability to once in a week and the answers were pro- solve the adolescents’ problems. An vided by project staff and subsequently assessment of the work done was under- by teachers and thereafter by the taken regularly by a community coordi- peer-group educators. It was observed nator/counsellor in collaboration with that initially the questions asked were not health workers. related to reproductive or sexual health concerns but as a result of friendly discus- The peer-group educators were not sion with the peer-group educators, more remunerated for their work although they questions and concerns relating to sexual received 100 rupees as motivation to and reproductive health were gradually attend meetings and to cover the expens- expressed to the project staff. es that they incurred on travel to the place of training as well as expenses. All Frequently-asked-questions Approach the key health-care providers and peer- group educators were given an identity More than 10,000 questions were card that helped the adolescents to iden- received. Based on these, a total of 105 tify them as adolescent-friendly health- most-frequently-asked questions and care providers. their responses were consolidated in the form of a simple book in English and in In the beginning, most adolescents Hindi as a resource and material for train- approached the peer-group educators for ing of selected peer-group educators. The their general health problems. These were training was participatory and the focus addressed by referral and by taking the ill was on hands-on practice and on improv- adolescents to local village doctors or ing communication and counselling auxiliary nurse midwives. After about six skills. It focused mainly on being able to months, the trend had changed and the provide accurate and adequate knowl- concerns reported were more psycho- edge to the adolescents. It was stressed social or reproductive and sexual in that wherever it was felt that the knowl- nature. This showed that the peer-group edge provided was inadequate or the educators were able to increase the aware- adolescent did not appear convinced ness of and demand for services. Besides and/or there was a need for medical inter- the provision of accurate information, the 108 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES increase in demand for services was also The idea was to bring convergence to the attributable to the following: availability health and development of adolescents. of trained and motivated providers who An agreement was made to meet once in were adolescent-friendly; provision of a month on a voluntary basis and partici- services and supplies to adolescents; and pate in the activities that improve adoles- the organization of a dedicated clinic on a cent health and development. fixed day and time of the week. The increased referral of about 271 adolescents Planning by providers, volunteers and peer-group A handout written in simple Hindi relat- educators was an impressive contribution ing to the above-mentioned subjects was towards creating a demand in a population distributed. The plan identified a SMART for availing the health facilities for repro- objective to be achieved and included ductive and sexual health issues. It is details of what, why, by whom, when and important to emphasize here that the ado- where. A detailed plan for implementa- lescents were reluctant to use these servic- tion during the next one month was es before the intervention. chalked out, which listed the roles and responsibilities of each member. A copy E NVIRONMENT - BUILDING of the written plan was left with the peer- THROUGH COMMUNITY group educator or a member chosen by I NVOLVEMENTOF A DOLESCENT the group members for ease of reference ACTION G ROUPS and follow-up meetings. The programme Involvement of community is essential to of meetings also included the agenda to the sustainability of any intervention. review the previous month, with identifi- The decision was taken to identify inter- cation of achievements and gaps. ested persons from the community (vil- From the beginning of the project, lages) and obtain their agreement to eight meetings were held for each action become adolescent-friendly providers. group and were attended by more than Therefore, community-based voluntary 77 per cent of the group members. In groups were established in 12 villages. order to provide recognition to the They were called “adolescent action action groups, efforts were made to take groups”. The adolescent action group was up the adolescent sexual and reproduc- formed as a voluntary group of 9 to 13 tive health issues with the village health members comprising care providers and and sanitation committee. The experi- care recipients in the villages. The care ence showed that these health and sanita- providers included the auxiliary nurse tion committees had not been constituted midwives, anganwadi workers, accredited or were not functional. Therefore, the social health activists and school teach- adolescent action group served as the ers. The care recipients included Mahila starting point for the functioning of such Panch (women’s group), peer-group edu- a committee. cators (male and female) and teachers. Addressing Reproductive and Sexual Health Issues of Adolescents – India 109

The subjects covered in the meetings adolescents and youths in the communi- of adolescent action groups included: ty. The intent was to increase the aware- prevention and control of anaemia; men- ness of and enhance the demand for strual problems and menstrual hygiene; services. The attendance at the youth adolescent pregnancy and unsafe abor- festivals was as follows: 550 persons at tion; and prevention of reproductive tract Kot, 573 at Kharwan, 601 at Khizrabad, infections, sexually transmitted infections 327 at Primary Health Centre Bhurian, and HIV/AIDS among the adolescents 356 at Naharpur and 486 at Kalanaur. and young people. The activities were comprised of The adolescent action group suc- debate competitions, poster competitions ceeded in bringing about convergence in and slogan competitions on topics relat- the services, an improved understanding ing to adolescent and other issues of con- among the providers of services and a cern such as: the right age for marriage, supportive community attitude towards sexually transmitted infections, HIV/ the goals and objectives of the adolescent AIDS, substance abuse, alcohol and health and development programme. It tobacco addiction, female foeticide and helped to remove any doubts and misgiv- education of the girl child, short height, ings concerning the sensitive nature of the dowry, climate change and nutrition. the issues to be addressed in the commu- Cultural shows were also organized dur- nity and it was enthusiastic in providing ing the youth festivals that dealt with cooperation in supporting different prominent issues relating to adolescent aspects of the implementation of various health by organizing role plays, street adolescent reproductive and sexual plays and folk dances. health activities in the village. The adolescent action group took the initiative to Important Outcomes of Peer-group establish intersectoral convergence wher- Educators ever it did not exist and strengthen exist- During the monthly interactions with ing linkages wherever they were already peer-group educators and other village- in place. based health workers, the adolescents seen in Yamuna Nagar District were Organization of Youth Melas (Youth reviewed by the staff of the Society for Fairs/Festivals) Women and Children’s Health. Male Youth melas (youth fairs/festivals) were peer-group educators reported having organized as per the State programme addressed 13,193 problems and concerns Implementation Plan as a partnership of the male adolescents. The female peer- between district health authorities and group educators reported having the Society for Women and Children’s addressed 20,653 problems and concerns Health. During the one-year implemen- of female adolescents. Accredited social tation period, six such fairs were organ- health activists reported having handled ized, with the objective of mobilizing the 3,317 concerns, i.e., 9.8 per cent of the 110 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

total cases. The types and numbers of A SSESSMENTAND E VALUATION problems and concerns addressed by Monitoring Mechanism peer-group educators and health workers are summarized in table 4. Monitoring was undertaken by using the reporting formats provided by the State

Table 4 Types and numbers of problems and concerns addressed by peer-group educators.

Serial No. Type Male No. (%) Female No. (%)

1. Body image 6,308 (47.8) 9,535 (46.2)

2. Food and eating habits 249 (1.9) 333 (1.6)

3. Health-related concern 4,645 (35.2) 6,002 (29.1)

4. Substance abuse and its consequences 157 (1.2) 26 (0.1)

5. Problem relating to menstruation --2,915 (14.1)

6. Sexually transmitted infection, HIV/ AIDS and sexual health 604 (4.6) 492 (2.4)

7. Friendship, love and marriage 56 (0.4) 67 (0.3)

8. Psychological and emotional problems 973 (7.4) 1,148 (5.6)

9. Economic problem 201 (1.5) 135 (0.6)

Total 13,193 (100.0) 20,653 (100.0)

government on a regular basis. Each vol- Evaluative Results of the Household unteer, worker and doctor was contacted Survey at least once a month. This provided an The evaluation of the impact of adoles- opportunity to review the progress of the cent reproductive and sexual health inno- work, identify problems and decide about vations was undertaken with the help of a the possible solutions. household survey conducted in Yamuna Evaluation Mechanisms Nagar 10 months after the implementation of the project. The tool for this sur- Two types of evaluation were conducted vey included a questionnaire, which was to identify the impact of the interven- developed by the Society for Women tions: the household survey and the qual- and Children’s Health, with technical ity assessment of the adolescent-friendly and financial support from the World health services. Addressing Reproductive and Sexual Health Issues of Adolescents – India 111

Health Organization Headquarters. The cents in the intervention area (83 household survey was carried out in two per cent) understood the explana- areas of the Yamuna Nagar District, tions about the health problems Haryana. One area represented the compared to 42 per cent in the implementation site of the adolescent control area. reproductive and sexual health interven- • Only 39 per cent of adolescents in tions and the other a control area where the control area reported the avail- the interventions had not been imple- ability of medicines while this mented. In both areas, 30 village clusters figure was 80 per cent in the inter- each with a total of 600 adolescents were vention area. Furthermore, a large covered. After thorough training of the proportion of adolescents visited surveyors, the survey was carried out in private providers (qualified and November 2008 in a two-week period unqualified) in the control area. during which 1,193 adolescents were Coverage for the prevention and interviewed. control of anaemia The findings of the household survey on various indicators are as follows: • Awareness of anaemia and understanding about it were substantially Coverage of adolescent-friendly higher (82.6 per cent) in the inter- health services vention area than in the control area (49.4 per cent). In the inter- • The awareness of adolescent- vention area, almost all the adoles- friendly health services in the cents were aware of the role of intervention area (68 per cent) was iron and folic acid tablets and a more than eight times that in the good diet in the prevention and control area (8 per cent). control of anaemia. • The use of government health facilities was 55 per cent in the According to adolescents, the avail- intervention area compared to 36 ability of iron and folic acid tablets is per cent in the control villages. greater in the intervention area (94 Among the government health per cent) than in the control area (73 facilities visited, the sub-centre per cent). About 89 per cent of the topped the list, followed by the adolescents received the deworming community health centre and the tablet free of cost in the intervention district hospital. area while only 52 per cent received • The supply of contraceptive serv- the same in the control area. ices to unmarried adolescents was Coverage in the use of sanitary pads denied to a majority both in the control as well as in the interven- • Sanitary pads were used by 56.3 tion area. per cent in the intervention group • A higher proportion of adoles- in comparison to only 29.6 per 112 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

cent in the control villages. Local mentation of the adolescent-friendly peer-group educators and volun- health services strategy in the District. It teers were popular providers in the also provided a benchmark for the con- intervention villages. trol area. The survey showed a very low • In both areas, the reasons for not proportion of married adolescents and an using the sanitary napkins were: extremely low proportion of pregnant adolescents. The fact that awareness of – too embarrassed to obtain the pads; adolescent-friendly health services was – lack of knowledge about their high in the intervention area was attrib- availability; uted mainly to the influence of peer – too expensive; and groups and locally available health serv- – did not perceive any problems ices from health-care providers. with current practice of using home-made pads. Evaluative Results from Quality Assessment Coverage of sexually transmitted infections, HIV/AIDS and contracep- Quality assessment was done based on tives the seven standards of adolescent-friendly health services set out in the Adolescent • Although more than 85 per cent Reproductive and Sexual Health of adolescents in both areas were Implementation Guide of the Ministry of aware of HIV/AIDS, the knowl- Health and Family Welfare about 15 edge of sexually transmitted infec- months after establishing adolescent- tions was substantially higher in friendly health services. These are sum- the intervention villages (73 per marized below. A comprehensive tool was cent) compared to the control developed for assessment of the standards villages (27 per cent). The main of adolescent-friendly health services source of information was the covering all seven standards recommend- peer-group educator in the inter- ed in the Implementation Guide by the vention area. The knowledge of Government of India. The tool provided the role of the condom in prevent- information on the general performance ing HIV/AIDS was 20 percentage of the provision of health services at the points higher in the intervention sub-centre and primary health-centre lev- area compared to the control area. els as well as information on the quality of The knowledge about contracep- adolescent-friendly health services. tive availability was higher in the intervention villages (90 per cent) The objectives of the quality assess- compared to the control villages ment of adolescent-friendly health services (64 per cent). were to:

The findings of the household survey • assess the current status of the showed the positive effect of the imple- quality of care delivered under Addressing Reproductive and Sexual Health Issues of Adolescents – India 113

adolescent-friendly health services 3. Adolescents find the environment at selected health facilities in at health facilities conducive to Haryana; seeking treatment. • determine the availability of key 4. Service providers are sensitive to types of health system support adolescent needs and are motivated required for implementation of the to work with them. adolescent-friendly health services; 5. An enabling environment for • identify the principal barriers to adolescents to seek services exists effective implementation of ado- in the community. lescent-friendly health services; 6. Adolescents are well informed and about the health services. • compare the quality of health-care 7. Management systems are in place services provided to adolescents in to improve/sustain the quality of the identified adolescent-friendly health services. health service facilities and non- adolescent-friendly health service The key findings of the quality assess- facilities. ment of the performance of facilities where adolescent reproductive and sexual Seven standards set by the health services were implemented for Government of India were used for the about one year showed substantial quality assessment of adolescent-friendly achievement in all the standards set for health services: the quality of care of services for adoles- 1. Health facilities provide the spe- cents as compared to facilities where the cific package of health services programme had not been introduced. that adolescents need. Noticeable differences were observed in the implementation of all seven standards 2. Health facilities deliver effective (graph 1). The majority of the adolescent- services to adolescents.

Graph 1 100 94 Implementation of 90 86 standards in adolescent- 80 78 friendly and non- 70 65 63 adolescent-friendly 60 59 45 health service facilities. 50 44 Adolescent-friendly 40 39 Health Services 33 30 22 Non-adolescent-friendly 20 Health Services 12 13 10 1 0 1 2 3 6 d d 4 d 7 ard ard ndar ndar tandard tand tandar ta tandard 5 tand ta S S S S S S S 114 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Graph 2 80 Performance of health facilities designated as 68 70 67 adolescent-friendly and non-adolescent- 60 friendly.

Adolescent-friendly 40 Health Services

Non-adolescent-friendly 30 27 Health Services 25

0 Primary Health Centre Sub-centre friendly health service facilities scored health strategy in the District of Haryana above 50 per cent and as high as 94 per has been attributed to implementation of cent, whereas all non-adolescent-friendly all seven standards set for the quality of health service facilities scored below the care of services for the adolescents. The average and as low as 1 per cent. differences in the attainment of standards by adolescent-friendly and non-adoles- As stated earlier, the success of the cent-friendly health services are summa- adolescent reproductive and sexual rized in box 2.

Box 2 Differences in the attainment of standards by adolescent-friendly and non-adolescent-friendly health facilities.

Key Indicator Survey Result

Standard 1: Health facilities provide the specific package of health services that adolescents need.

Dedicated adolescent-friendly Nine out of ten centres were organizing adolescent-friendly health service clinics health services for a period of at least 2 hours per week.

Referral services Referral services and procedures were in place in 60% of the health facilities in the intervention area and were found to be functional. Addressing Reproductive and Sexual Health Issues of Adolescents – India 115

Box 2 Differences in the attainment of standards by adolescent-friendly and non-adolescent-friendly health facilities (continued).

Key Indicator Survey Result

Outreach services Health services and health-education activities were being organized as outreach services in 69% of the intervention-area facilities while some health-related activities were reported in 27% of the control-area facilities.

Equitable services Services to the adolescents were reported to be equitable (i.e., they were provided irrespective of age, sex or social status) in 77% of the health facilities in the intervention areas as compared to 44% in the control areas.

Standard 2: Health facilities deliver effective services to adolescents.

Staff adequacy and training More than 60% of the staff in the intervention villages consid- relating to adolescent-friendly ered themselves competent and skilled to manage the problems health services of adolescents while this proportion was only 25% in the control villages. The reason for this lower percentage is that only some of the staff members in the control villages had received some training that related to adolescent health.

Drugs and supplies Drugs and supplies were available to the adolescents in a higher proportion (81%) in the intervention areas compared to only 54% in the facilities where the programme was not implemented. Some staff members in the intervention areas agreed to give iron and folic acid tablets to adolescents and condoms by making condoms accessible without embarrassing the staff or the adolescents.

Waiting time and medical According to the perception of the 120 adolescents interviewed, consultation the waiting time and the time spent during consultation were satisfactory and acceptable to more than 90% in both the control and intervention groups.

Standard 3: Adolescents find the environment at health facilities conducive to seeking treatment.

Basic amenities and conven- Basic amenities as assessed by the adolescents were considered iences of adolescent clients satisfactory by 85% of the adolescents interviewed in the intervention area while the comparable proportion was 32% in the control area. 116 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Box 2 Differences in the attainment of standards by adolescent-friendly and non-adolescent-friendly health facilities (continued).

Key Indicator Survey Result

Provision of privacy and Adolescents were satisfied about the privacy and confidentiality confidentiality during consultation with health-care providers (8 to 9 out of 10 adolescents) in the intervention area as compared to three out of 10 in the control area.

Standard 4: Service providers are sensitive to adolescent needs and are motivated to work with them.

Provision of supportive and The interpersonal skills of providers were used to demonstrate non-judgmental care for ado- supportive and non-judgmental care in 88% of the instances lescent clients in the intervention area compared to only 38% in the control area.

Standard 5: An enabling environment exists in the community for adolescents to seek services.

Information, education and Communication materials relating to adolescent reproductive communication materials and and sexual health were available and distributed to 80% of information dissemination stakeholders in the intervention villages and none in the control areas. Linkages with 70% of stakeholders in the community were established in the intervention villages and with only 40% in the control villages. Mass media and folk media were playing a minimal role in the control as well as the intervention villages.

Standard 6: Adolescents are well informed about the health services.

Awareness and communica- There was no evidence of awareness-generating activities in the tion activities in communities control area. In the intervention area, awareness was being on adolescent reproductive created through anganwadi workers, accredited social health and sexual health/adolescent- activists, peer-group educators and other outreach mechanisms. friendly health services

Standard 7: Management systems are in place to improve/sustain the quality of health services.

System of reporting and moni- Records for adolescents were maintained in all facilities but toring adolescent-friendly were not kept confidential. Efforts were made to keep separate health services information records in 40% of the facilities. Even though the data were collected, they became a part of information only in 30% of the facilities in the intervention villages. Supportive supervision was claimed to have been undertaken by 40% of the managers in the intervention area and only 10% in the control area. Addressing Reproductive and Sexual Health Issues of Adolescents – India 117

Recommendations by the project imple- addressed (service package); and menting authority regarding quality • involvement of the service assessment, were as follows: providers of the health facilities. • The tool for quality assessment Pull-and-push Approach needed to be reviewed and revised (a) for quality assessment for plan- The Intervention adopted a dual strategy ning adolescent health services at of “pull and push”. The “pull” strategy the State/national level, and (b) attracted the adolescents to avail them- because a greatly simplified ver- selves of the health services, which were sion was required for quality made more adolescent-friendly. The assessment and quality improve- “push” strategy focused on enhancing the ment at the local level. If possible, service delivery package and organizing the simplified tool should be the effective services by the Government integrated with the Reproductive of India. and Child Health-II project. In addition, the tool needed to be Quality Services translated into local languages. The intervention focused on improving • The quality assessment tool should the quality of services rendered. Success add on an observation element was demonstrated by the implementation and focused group discussion to of the seven standards set forth in the improve it further. Implementation Guide mentioned earlier.

• Additional tools for assessment of Assuring Accessibility clinical skills needed to be developed. The case study clearly demonstrated that assuring access to the adolescent-friendly health clinics on the dedicated days S UCCESSESAND L ESSONS resulted in an increase of a substantial EARNED L number of cases seen and referrals made to the primary health centres. S UCCESSES Adolescent-friendly Health Services The success of the interventions is attributable to the adoption of a three-fold Another reason for the success of the strategy: intervention was the adoption of the adolescent-friendly approach and the atti- • addressing the intended benefici- tude of the health workers in the general aries of the adolescent-friendly Outpatient Departments. The health reproductive and sexual health personnel addressed the issues with services (target group); appropriate counselling and maintained • addressing the health confidentiality and privacy. problems/issues that need to be 118 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Providing Information about the period of about one year demonstrated Health Services to Adolescents that the caregivers (auxiliary nurse mid- Youth festivals provide an opportunity wives, accredited social health activists, for adolescents and young people to anganwadi workers, teachers, etc.) and the advocate for adolescent health and community (peer-group educators, Mahila address social issues such as early mar- Panch (women’s group), other activists in riage, sex selection, dowry, household the village) can bring about a convergence violence and the dangers of HIV/AIDS. in the services for adolescents. Advocacy measures used during the programme such as the logo, the setting up Monitoring and Evaluation of notice boards to identify adolescent- The monitoring of adolescent reproduc- friendly health clinics, the display of tive and sexual health services focused on posters that articulate the services avail- problem identification, solving problems able for the adolescents, and the provision through appropriate activities, and track- of identity cards to adolescent-friendly ing the progress made on the take off and providers were found to be extremely use of adolescent reproductive and sexual useful. health services. For this purpose, the monthly adolescent reproductive and Delivering Effective Services to sexual health-service register was created, Adolescents which reflected the progress in training Capacity-building of the health person- and communication activities. nel is an important aspect of delivering effective services. A systematic approach Health Management Information to building the capacity of all health per- System sonnel and peer-group educators was In the Indian context, although the infor- adopted by conducting training. The mation about the adolescents is recorded training sessions were assessed for quali- in the registers and the information on ty, which was rated as high. adolescents visiting the public health facilities is available, the information is Regular Supply of Essential Items incomplete and never analysed. It is not The timely supply of items such as con- included in the reporting format of the doms is an important measure of the Reproductive and Child Health project. quality of services. If the supplies meant There is a need to insist that the health- for adolescents are not provided regular- care providers collect data accurately and ly in the health facility, this dampens the incorporate them into the information enthusiasm of newly inducted peer-group system. This should become a part of the educators. monthly reporting format.

Intersectoral Convergence This case study provides an example of policy planning and adopting and Forming “adolescent action groups” and implementing an adolescent-friendly engaging them for voluntary work for a Addressing Reproductive and Sexual Health Issues of Adolescents – India 119 approach in line with the National Rural • Awareness and advocacy can bring Health Mission and the Reproductive behavioural change among adoles- and Child Health-II project. It demon- cents provided that there is a regu- strates that this is only the first step and lar supply of essential commodities, that the application of the best practice e.g., iron and folic acid tablets, san- through continuous innovation is neces- itary napkins and condoms. sary for the success of the programme. • With respect to addressing the concerns of male peer-group edu- L ESSONS L EARNED cators, one of the lessons learned is that, although the services to The following lessons can be drawn from the adolescents have been provid- the implementation of the innovative ed equitably, the adolescent males practice described in this case study: were at a disadvantage since all the service providers were females • Training of all levels of health-care below the primary health-centre providers is essential to make the level. Male adolescents were reluc- health service adolescent-friendly. tant to consult the female health- However, one-time training is not care providers, especially when sufficient. Regular, follow-up, the reason for the visit related to interactive training and supportive sexual or reproductive health supervision are equally necessary concerns as well as psycho-social to sustain it. problems. Even though male • Age- and sex-disaggregated data, peer-group educators assisted in particularly on adolescents, are still addressing the problems of male not maintained. The existing health adolescents, there was still a big information management system difference in the number of ado- has not yet internalized the data. lescents who contacted them in • The peer-group-educator model comparison to females. This con- works well in addressing adoles- cern needs to be addressed by the cents’ concerns provided that the programme since male involve- educators receive quality training ment is crucial to the success of followed by regular contact and the reproductive and sexual health support to keep their motivation of male adolescents. level high. • The performance of school-going peer-group educators shows a F UTURE P LANS : decline during examination days. E XTENSIONS • The adolescent action group can be a good advocacy mechanism at STRENGTHENINGTHE CLINICAL SKILLS the grass-roots level to improve adolescent health. In addition to the adoption of an adoles- 120 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

cent-friendly health services approach, it U SEOF S ANITARY PADSAND would be necessary to strengthen the N APKINS clinical skills of the providers trained in Even though efforts have been initiated adolescent-friendly health services. The to promote and popularize the use of credibility of health-care providers would clean pads during menstruation, these increase only when they were able to need to be scaled up and sustained. The effectively and convincingly treat and main challenge to be addressed is not so counsel the adolescents in addition to much demand creation or unaffordable using an adolescent-friendly approach. cost; rather, it is related to lack of access.

A DDING C LIMATE C HANGETOTHE T RAINING C URRICULUM R EPLICABILITY Climate change and its adverse impact on health constitute a problem that concerns P REREQUISITESFOR R EPLICATION all adolescents. The youths and adoles- • Supportive policy. A support poli- cents can play a meaningful and decisive cy to ensure supplies to adoles- role in addressing this problem. cents that relate to basic rights of all adolescents irrespective of age, E FFORTSTO I MPROVETHE sex, caste or creed is the basis for N UTRITIONAL S TATUSOF improving the quality of services A DOLESCENTS rendered to adolescents. Efforts to improve the nutritional status • Strategic information. Strategic of adolescents and tackle the widespread information would be required for problem of anaemia can contribute to replicability in order to quantify nation-building in addition to addressing the felt needs based on age and the health and reproductive problems of disaggregated by sex. Further, the adolescents and youths. A supportive and assessment of coverage and assess- specific policy in the form of once-a- ment for quality improvement week iron and folic acid supplementation based on the seven standards artic- as a package for anaemia control and ulated in the Implementation mid-day meal programmes as an entry Guide would have to be set forth point for achieving optimum potential based on felt needs and baseline for physical growth should contribute to data. the scaling up of the programme to • Resources. Additional resources include a large number of beneficiaries. would be required to add value to This would contribute significantly to the existing sexual and reproduc- higher educational attainments and pro- tive health services within the ductivity in employment. framework of the National Rural Health Mission. It would be crucial to recognize the vast unmet Addressing Reproductive and Sexual Health Issues of Adolescents – India 121

needs of adolescents. In this con- would have to be created and sus- text, resource commitment is to be tained. The NGOs could take a considered as a critical investment. forward-looking role in mentoring, • Capacity development of male initiating and sustaining intersec- health-care providers. Limited toral linkages. provisions for the male adoles- • Role of NGOs. This case study cents to be able to obtain guid- highlights the value addition from ance and treatment for their the partner NGO with substantial personal, sexual and reproductive and sustained efforts along with problems and concerns from males the government staff at all levels. have been one of the major weak- The evidence-based innovations nesses. There are no male health have helped to sharpen the imple- workers or volunteers below the mentation of the Programme level of primary health centres. Implementation Plan, with the Therefore, in the majority of the government and the NGO cases, the closest accessible place partner contributing to demand- for the males is a public health generation and quality improve- centre. This situation deprives the ment. Such mentorship should be male adolescents of access to taken forward to bring optimal information and services close to returns on the investments made. the place of their residence. Without male involvement, the E XPERIENCESOF R EPLICATIONIN success of the adolescent repro- OTHER A REASAND CONTEXTS ductive and sexual health programme cannot be achieved to its In the programme context, adolescent fullest. Capacity development reproductive and sexual health is a new with a focus on community-based addition to the Reproductive and Child providers to meet the enormous Health-II project. In terms of implemen- needs of this large population by tation, the experiences are only begin- training more male peer-group ning to emerge. The Society for Women educators would ensure increased and Children’s Health, in partnership success of the programmes. with the State of Haryana and district • Sustainable partnerships and authorities, has implemented most of the partnership with a mentoring recommendations of the Ministry of agency. Partnership with key sec- Health and Family Welfare as articulated in tors such as education and the the national strategy and Implementation media and entities such as village Guide of the Government of India, with health and sanitation committees, the addition of some innovations in pro- the Department of Women and gramme implementation. Child Development, the Department of Youth and Sports, The experience can be replicated in and Panchayati Raj institutions other areas and contexts with greater 122 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES optimism since the intervention package, • undertake an annual review of tools for capacity development, knowl- progress at the State level and a edge of what works, and tools for moni- quarterly review at the district toring and evaluation have been level based on the standards for developed, tried and tested. However, it quality assurance; would be wise to plan for a limited imple- • incorporate quality assessment and mentation initially rather than widespread quality improvement into the pro- rapid expansion. Carefully monitoring gramme as an ongoing process and and reviewing the experience of imple- integrate them with the reproduc- mentation in selected areas of districts tive and child health programme; representing different geographical areas • increase coverage progressively would also be crucial. Until the over a period of the next five years programme is widely implemented, part- to ensure full coverage by the end nership with a mentoring agency such as of that period and undertake mid- the Society for Women and Children’s course corrections on a yearly Health would be of critical importance. basis as guided by the experience.

S UGGESTED S TEPSFOR P OTENTIALFOR PARTNERSHIPS R EPLICATION Selected partnerships should be explored Suggested steps for replication are as with the departments that already have follows: high stakes in adolescent health. These include Education, Women and Child • conduct a mapping exercise to undertake a situational analysis Development, Youth and Sports, and and needs assessment of the ado- Media as well as Panchayati Raj institu- lescents and the community; tions/elected leaders. • plan and implement an adolescent The following collaborating depart- reproductive and sexual health ments/institutions have also undertaken strategy (adolescent-friendly many related activities such as: health and counselling services) in selected areas for at least one year • conducting the annual school before expanding it to other areas. health examination: Education; Expansion should build on the • kishori shakti yojna: Women and experience and lessons learned; Child Development; • involve a mentoring agency for • mid-day meal programme: guidance, capacity development, Education; close monitoring and evaluation to • cultural and other activities: Youth facilitate effective implementation, and Sports; expansion and future planning; • media exposure: Media; and Addressing Reproductive and Sexual Health Issues of Adolescents – India 123

• village health and sanitation com- for ANMs/LHVs to Provide Adolescent- mittees: Panchayati Raj institutions. Friendly Reproductive and Sexual Health Services: Handouts. May. These activities serve as building blocks for the sustainability of partner- ______(2006) Orientation Programme ships and further development of inter- for Medical Officers to Provide sectoral coordination and networking. Adolescent-Friendly Reproductive and The Health Department should con- Sexual Health Services: Facilitator’s Guide. May. tribute to the capacity development of key persons in the above-mentioned ______(2006) Orientation Programme departments by providing accurate infor- for Medical Officers to Provide mation and essential health-related sup- Adolescent-Friendly Reproductive and plies and participate in the periodic Sexual Health Services: Handouts. May. review of progress. Practice Documentation Team

R EFERENCES Project Team Advisers 2005-06 National Family Health Survey (NFHS-3), India. Available at: . Director Society for Women and Children’s Government of India, Ministry of Health Health (SWACH) and Family Welfare (2009). Reproductive Panchkula, Haryana, India and Sexual Health of Young People in India: Tel.: +91 09815909587 Secondary Analysis of Data from National E-mail: [email protected] Family Health Surveys of India – 1, 2, 3 (1992-2006) for Age Group 15-24 Years. July. Dr. Neena Raina Regional Office for South-East Asia ______(2006). Implementation Guide on World Health House, IP Estate, RCH II Adolescent Reproductive and Sexual Mahatma Gandhi Marg Health Strategy for State and District New Delhi 110 002, India Programme Managers. May. Tel.: +91 11 23061955 Government of India, Ministry of Health Fax: +91 11 23062450 and Family Welfare, Information, E-mail: [email protected] Education and Communication Division Dr. Rajesh Mehta (2006). Orientation Programme for Medical Officer - Child & Adolescent ANMs/LHVs to Provide Adolescent-Friendly Health Reproductive and Sexual Health Services: WHO Regional Office for South-East Asia Facilitator’s Guide. May. I P Estate, New Delhi 110002, India ______(2006). Orientation Programme Tel.: + 91 11 23370804, Ext. 26651 124 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Fax: + 91 11 23370197, 23379395 26166441, +91 11 26107773 Mobile: + 91 9717494823 Fax: +91 11 26101623 E-mail: [email protected] E-mail: [email protected] Dr. Dinesh Agarwal Dr. Vijay Kumar National Programme Officer Executive Director UNFPA Society for Women and Children’s 55 Lodi Estate Health (SWACH) New Delhi 110003, India Panchkula, Haryana, India Tel.: +91 11 46532333 Tel: +91 09810088321 Fax: +91 11 24628078 E-mail: [email protected] E-mail: [email protected]

Authors Prof. Deoki Nandan Director National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi 110067, India Tel.: +91 11 26100057, +91 11 26185696, +91 9971104666 Fax: +91 11 26101623 E-mail: [email protected], [email protected] Dr. Poonam Khattar Associate Professor National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi 110067, India Tel.: +91 11 26165959, +91 11 26166441, +91 11 26107773, Ext. 332 Fax: +91 11 26101623 E-mail: [email protected] Prof. Neera Dhar National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi 110067, India Tel.: +91 11 26165959, +91 11 Importance of 5 Community Indonesia Participation in the Implementation of the Family Planning Programme Mr. X. Sukamdi

Summary

The Family Planning Programme in Indonesia has evolved in two phases. First, during the New Order era (a term coined by former President Suharto to distinguish his regime from that of his predecessor when he came to power in 1966) and with strong support from the Government, the number of participants in the Programme increased significantly. The declining fertility rate has slowed population growth, which is turn has had a positive impact on the poverty alleviation programmes. Involvement of community leaders, non- governmental organizations (NGOs) and civil society organizations was key to the success of the Programme. Indonesia is the biggest Muslim country in the world. Working closely with Muslim organizations and key leaders to get their support, the Family Planning Programme was able to forestall any objections on the part of religious leaders or opposition parties.

The second phase unfolded following the Southeast Asian economic crisis, governmental change and decentralization at the end of the 1990s and early 2000s. In difficult economic circumstances and in a decentralized context, the Government was forced to scale back its commitment to family planning, which made it more difficult for people to obtain family

125 126 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

planning services. Today the Government has introduced the Income-generating Activities for Prosperous Families (Usaha Peningkatan Pendapatan Keluarga Sejahtera, UPPKS) Programme to increase participation in family planning across the board.

Information on the Author Mr. X. Sukamdi, Senior Researcher, Center for Population and Policy Studies, Gadjah Mada University, Indonesia.

B ACKGROUND the collapse of the Old Order regime in which a family planning programme was Population policy in developing countries implemented when there was lower popula- has been influenced mostly by the conception growth. The Old Order (in Bahasa tual framework that posits that a fertility Indonesian: Orde Lama) is the term that decline would slow down population refers to the period 1945-1965 in which growth and thus reduce poverty. This view Sukarno ruled the country. The term was was influenced by neo-Malthusian think- used by Suharto to contrast the previous ing, which has become part of the global administration with his administration, development debate since the 1950s and which was called the New Order era (1965- which gave birth to the term “population 1998) after he succeeded Sukarno in 1965. control”. Even though this view was chal- Despite an opposing view from some lenged by differing perspectives in the experts (Hull and Hull, 2005), the popular 1980s and 1990s, which claimed that view sees population policy in Indonesia as demographic considerations are largely being divided into two major types: pro- irrelevant to poverty reduction, research natalist during the Old Order and anti- does show that there are potential benefits natalist during the New Order. In the New of slower population growth. However, the Order era, economic development was the benefits depend on the timing and intensi- first priority, but President Suharto did not ty of demographic change (Merrick, 2002). think that population concerns would take The case of Indonesia might be the best care of themselves (Neihof and Lubis, example of how the concept became the 2003, p. 6). The technocrats consider pop- driving force behind the development of ulation to be an important variable in eco- population policies in the first 30 years after nomic development and are convinced that Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 127

there is an inverse relationship between people (40.1 per cent) classified as poor; population growth and economic growth this number decreased to 34 million (13.3 (Lubis, 2003, p. 32). Hence, the National per cent) in 2006. On average, the num- Family Planning Programme was ber of people living below the poverty designed to lower population growth and line declined by more than one million. It was given high priority during the New is very clear that the poverty alleviation Order. The Government heavily backed programme has played an important role the Programme. in reducing the rate of poverty, but it cannot be denied that the declining popula- Since economic development is the tion growth has also contributed to priority to accelerate economic growth in poverty reduction. At the very least, the order to improve people’s welfare, the declining population growth has made it performance of development during the easier to implement the poverty allevia- New Order era can be seen first from the tion programme. declining poverty rate. As shown in graph 1, the poverty rate decreased sig- During the period 1971-1980, the nificantly from 1970 to 1996 not only in annual population growth rate was 2.32 terms of relative but also absolute value. per cent and in the period 1990-2000, it In 1976, there were more than 50 million was 1.44 per cent, the lowest level in

Graph 1 Population living below the poverty line and the poverty rate in Indonesia, 1976-2010.

No. of people below poverty poverty rate (%) line (in millions) 60 60

50 50

40 40

30 30

20 20

10 10

0 0 93 00 981 999 1976 1978 1980 1 1984 1987 1990 19 1996 1998 1 20 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

No. of people below poverty line (in millions) Poverty rate (%)

Note: The poverty rate is calculated based on the national poverty line. Sources: Central Body of Statistics (Badan Pusat Statistik, BPS) (2009), p. 2; BPS (2010), p. 3; and Yulaswati (2009). 128 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Indonesian history. The decrease in pop- can be thought of as a revolution since ulation growth has been attributed to the the total fertility rate fell by more than family planning programmes that have half over a relatively short period (Hull, been in place and that have been a gov- 2005). The drop in the fertility rate of the ernment priority since the 1970s. Graph country is associated with the impressive 2 shows clearly that the total fertility rate performance of family planning. decreased by more than half, from 5.6 Contraceptive use (the contraceptive births per woman during the period prevalence rate) increased nearly five- 1967-1970 to 2.3 births per woman dur- fold, from 12 per cent in 1973 to 55 per ing the period 1996-1999. This decrease cent in 1997 (graph 2).

Graph 2 Fertility Rate Total fertility rate, 1967- 6 5.6 2007. 5 5.2 4.7 4 4.1

3.3 3 2.8 2.3 2.3 2.3 2

-1975 1984 -1989 -2004 1 6 1 1967-1970 197 1976-1979 1980- 198 1991-1994 1996-1999 200 2004-2007

Sources: Central Body of Statistics (Badan Pusat Statistik, BPS) (2006), p. 37, and Hartanto and Hull (2009).

Graph 3 70 Contraceptive 60 prevalence rate (as 58 57 a percentage), 55 57 50 52 1973–2007. 47 Contraceptive 40 44 Prevalence Rate (%) 30 23 20

10 12

0 1973 1977 1987 1991 1994 1997 2003 2006 2007

Sources: Mize and Robey (2006), p. 14; Adioetomo and Sarwiono (2009), p. 14; and the Central Body of Statistics (Badan Pusat Statistik, BPS), National Family Planning Coordinating Board (Badan Koordinasi Keluarga Berencana Nasional), Departemen Kesehatan, dan Macro International (2007), p. 72. Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 129

The decrease in the birth rate is live births. Over 30 years, that rate fell to meaningful because, at the same time, the 47 per 1,000 live births, a 70 per cent infant mortality rate also declined signifi- decrease in the rate. This can also be cantly (graph 4). In 1967, the infant mor- interpreted as another revolution outside tality rate in Indonesia was 145 per 1,000 the demographic revolution in fertility.

Graph 4 Infant 160 mortality rate, 140 145 1967-2010.

120 109 100

80 71 60 47 40 35 34 30 20

0 1967 1976 1986 1996 2000 2005 2010

Notes: Data for 1967-1996 are based on the 1971, 1980, 1990 and 2000 population censuses; data for 2000 and 2005 are based on the 2002-2003 and 2007 Demographic and Health Survey; and data for 2010 are based on the 2010 World Population Data Sheet.

Since the New Order era, population other Heads of State, signed the United policy has been perceived to be integral Nations Declaration on Population: World to national development. It is there- Leaders Statement in 1967. This was a fore interesting to observe how this poli- milestone for national population policy cy, especially the Family Planning and family planning in Indonesia and was Programme, has been implemented. This supported fully by the Government. case study aims to increase the under- In his address to Parliament in early standing of the implementation, chal- 1968, President Suharto clearly stressed lenges and achievements of the Family the need for community involvement in Planning Programme. From this under- the Family Planning Programme. He stat- standing, lessons can be drawn for use in ed that the Government would support replicating or adapting the experience. family planning activities conducted by the community with aid and guidance I MPLEMENTATION from the Government. The commitment of the Government to implementing an effective family planning programme was The Family Planning Programme began signalled by the establishment of the when President Suharto, together with 30 National Family Planning Institute 130 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

(Lembaga Keluarga Berencana Nasional) Programme to be a national programme. created following the President’s In the history of the Family Planning Instruction no. 26, in October 1968. The Programme in Indonesia, this pioneering main tasks of the Institute were to pro- period, 1950-1970 (Kantor Menteri mote family planning, to coordinate Negara Kependudukan dan BKKBN, family planning activities, and to advise 1995, pp. 37-46), is the first phase. the Government on population issues The second phase was the develop- (Sarwono, 2003, p. 29). Through ment period (1970-1990) consisting Presidential Decree no. 8 of 1970, the of the first four periods of the Five Institute was invested with full responsi- Year Development Plans (Rencana bility for the Family Planning Pembangunan Lima Tahun, REPELITA). Programme. This decree transformed the During this phase, the Government commission of the Institute from advice, pro- mitted to implementing the Family motion and coordination of family plan- Planning Programme. This commitment ning activities to that of being fully can be seen from the inclusion of the responsible for coordinating the Family Programme in the First Five Year Planning Programme. The new initiative Development Plan (1969/70-1973/74). was named the National Family Planning Thus, the Family Planning Programme Coordinating Board (Badan Koordinasi was an integral part of national develop- Keluarga Berencana Nasional, BKKBN).1 ment policy. The interesting point is that, It is important to note, however, that as stated in the Plan, the Programme was the establishment of the National Family not only important to lower population Planning Coordinating Board cannot be growth to support the economic devel- separated from the family planning pio- opment of the country but it was also neer, the Indonesian Planned Parenthood beneficial for the health of mothers and Association (Perkumpulan Keluarga the well-being of families. It had this dual Berencana Indonesia, PKBI), which was objective from the start (Lubis, 2003). founded in December 1957. This organi- During the initial phase, especially zation obtained legal status in 1967 in the during the First Five Year Development transition period from the Old Order to Plan, the Family Planning Programme in the New Order government. This implies Indonesia focused on the Java-Bali that it was not the Government that first islands. Performance of the Programme paid attention to the importance of fami- during this period (1969/1970-1973/ ly planning to control population but the 1974) was remarkable. In the first year of NGOs. Thus, family planning as a move- the Programme, there were only 53,103 ment existed long before the Government participants but this number increased to officially declared the Family Planning 1,369,077 by the end of the period

1Hull (2003, p. 69) argues that the National Family Planning Coordinating Board (Badan Koordinasi Keluarga Berencana Nasional, BKKBN) was much more than a coordinating agency because it took on more implementation. Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 131

(graph 5). This means that in the first five the total number of family planning par- years of the Programme, the number of ticipants was 3,201,458, which was more participants increased by more than than the targeted number of participants twenty-fold. During the whole period, (3,025,000).

Graph 5 Number of 1,400,000 participants in the National Family Planning 1,200,000 Programme, 1969/1970 1,000,000 to 1973/1974.

800,000

600,000

400,000

200,000

0 1969/1970 1970/1971 1971/1972 1972/1973 1973/1974

Source: Kantor Menteri Negara Kependudukan dan BKKBN (1995), p. 73.

Beginning in the period of the innovative approach of the National Second Five Year Development Plan, the Family Planning Coordinating Board Family Planning Programme expanded to (BKKBN). the outer islands of Indonesia, including Aceh, North Sumatra, West Sumatra, COMMUNITY - BASED FAMILY South Sumatra, Lampung, West Nusa P LANNING P ROGRAMME Tenggara, South Kalimantan, West The basic idea of the community-based Kalimantan, North Sulawesi and South family planning programme is to use Sulawesi. These 10 provinces were then villages as bases for the Family Planning known as the Outer Islands Group I. In Programme, to decentralize the Pro - the Second Five Year Development Plan, gramme and to give responsibility to vil- the Government also established the lage officials and volunteers. As Piet long-term goal of reducing fertility by 50 (2003, p. 86) stated, “village family plan- per cent from the 1971 figure by 2000. ning is an information, motivation and To achieve this goal as well as to cover a contraceptive services programme cen- wider area, the Government introduced tred on the village (desa) level and run by the community-based or village family village residents”. The key element of the planning programme. Piet (2003, p. 85) strategy is to make use of the trained argues that the village family planning family planning fieldworkers (petugas programme is the best example of the lapangan keluarga berencana, PLKB) and tra- 132 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES ditional village institutions to promote on information collected from household the concept of family planning and “small heads. Houses of IUD users are outlined family norm” (Lubis, 2003). The best in blue, those of pill users in red and illustration of the strategy is explained by those of condom users in green, while Lubis (2003, p. 38): houses of non-users are left blank”. ”In late 1974, BKKBN provincial Further, Lubis (2003) explains that authorities in Bali began a programme the strategy was applied differently in to promote family planning through the Java, where it was modified to match the banjar2 by training fieldworkers and character of the Javanese community, banjar heads. As a result, contracep- which is well known for its strong admin- tion became a regular topic at banjar istrative hierarchy. The Family Planning monthly meetings. Potential acceptors Programme was then implemented were identified in these meetings and a through a bureaucratic mechanism. For certain amount of peer group pressure example, officials were evaluated based encouraged non-acceptors to begin on family planning performance at each using some form of birth control. administrative level. In addition, the existing village structure and institution Since the introduction of this idea, were used as important vehicles of the increasing responsibility has been Programme. Some of them include arisan3 placed on the banjar to manage its own and the family welfare organization4 family planning efforts. For example, (pembinaan kesejahteraan keluarga, PKK). each head of household is required to publicly report the family planning These examples clearly show the and pregnancy status of every married active participation of the community in woman of reproductive age in the the Family Planning Programme. This is a household. Banjar registers are com- result of continuous efforts to encourage piled, listing all eligible couples, their community participation through strong location in the hamlet and their use of political commitment. contraception. The registers also con- Piet (2003) explains that this model, tain logistic information on pill and used both in Java and Bali, did not fit the condom supplies. The provision of sup- situation and condition in outer islands. plies has largely become banjar respon- The Programme was thus adapted to sibility and is another activity of the meet local needs, with the basic approach monthly meeting. Each banjar displays at the core of the Programme unchanged. a map of all houses in the district, based

2Traditional hamlets in Bali are grouped into banjar, of which Bali has more than 3,500. The banjar is a unit for mutual aid and cooperative work and the gathering point for recreation and ceremony (see Lubis, 2003, p. 39). 3Arisan is a common word in Indonesia that refers to a unique social gathering in which a group of friends and relatives meets monthly for a private lottery similar to a betting pool. 4A family welfare organization (pembinaan kesejahteraan keluarga, PKK)) is a social organization established soon after the New Order took over the government. PKK chapters were set up at the village level to follow a ten-point programme aimed at promoting the welfare of women and families. Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 133

Another important programme focus- which later became the Mobile Family es on village contraceptive distribution Planning Team (Kantor Menteri Negara centres. This programme was set up to Kependudukan dan BKKBN, 1995). This respond to the problem of discontinued programme has helped participants to use of contraceptives and the “drop out” obtain contraceptives more easily and to problem. Distance was the main factor prevent them from discontinuing contra- behind the problems of discontinuation ceptive use and dropping out. and drop out. To tackle these problems, With these new strategies, achieve- the Government established village con- ments during the Second Five Year traceptive distribution centres in 1975 as Development Plan (1974/75-1978/79) “full-fledged community family planning were much greater than during the previ- posts, which enlisted local volunteers ous period. The total number of partici- who would recruit and instruct participants in the Family Planning Programme pants as well as distribute pills and con- reached 10.24 million over the whole doms” (Lubis, 2003, p. 40). In addition, period. This was more than three times as the Government launched a mobile med- many as those who participated during ical team (tim medis keliling, TMK), the First Five Year Development Plan.

Graph 6 Number of registered 2,5000,000 participants in the Family Planning 2,,000,000 Programme during 1974/1975- 1,500,000 1978/1979.

1,000,000

500,000

0 1974/1975 1975/1976 1976/1977 1977/1978 1978/1979

Source: Kantor Menteri Negara Kependudukan dan BKKBN (1995), p. 73.

During the Third Five Year them from the Outer Islands I, the ten Development Plan, the Family Planning provinces included in the Second Five Programme expanded coverage to include Year Development Plan. The basic strate- all provinces in the country. The gy in this phase was similar to that during provinces included in this period were the Second Five Year Development Plan. called the Outer Islands II to distinguish A priority area for the Governement was 134 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES the need to educate people about popula- Muhammandiyah, have supported the tion issues and increase people’s participa- Family Planning Programme since its tion in the Family Planning Programme. beginning. As Widyantoro (2003) men- tions, Nahdlatul Ulama, through its In the development phase (1970- national council declaration in 1969, 1990), the Government intensified the accepted family planning as a means of Communication, Information and Education spacing pregnancies, with the focus on Programme (Komunikasi, Informasi, Edukasi, the well-being of mother and child. KIE). Activities under this Programme Meanwhile, the national council of were meant to: Muhammadiyah in 1971 ruled that fami- “.. push for the achievement of the ly planning was allowed and could be process of change transforming the practised to serve the well-being of fam- knowledge, attitudes and behaviour of ilies and society at large. However, oppo- society concerning the national family sition and questions concerning family planning programme toward self reliance planning practices were still undecided, in building small happy and properous with some religious leaders equating the family as the institutionalised and use of intrauterine devices (IUDs) with culturally accepted norm in society” “abortion” and prohibiting their use since (Kantor Menteri Negara to insert and control an IUD, one must Kependudukan dan BKKBN, look at a woman’s genitals (Kantor 1995, p. 47). Menteri Negara Kependudukan dan BKKBN, 1995, pp. 96-97). To acomplish these objectives, the Communication, Information and During this period when the scope of Education Programme was implemented the family planning movement was in various ways. This included providing expanded to cover all provinces, the num- information to be distributed via the ber of participants increased substantially. mass media, information that could be The Government claimed that, as before, distributed to groups, and information the targets were surpassed (graph 7). The that needed to be given face to face. The number of registered participants increased role of the fieldworker was very impor- from about 2.2 million in fiscal year tant. The fieldworkers travelled around 1979/1980 to 5.3 million at the end of the the region, explaining the Family period 1983/1984. Only in the 1982/1983 Planning Programme and persuading fiscal year were there slightly fewer partic- community and religious leaders to par- ipants than in the previous year. ticipate. This was vital because it was In the Fourth Five Year Development critical to have the support of religious Plan (1984/1985-1988/1989), the leaders and avoid opposition from reli- Government developed population poli- gious groups. It is important to note that cy in a more comprehensive way. The the two largest Muslim organizations population programmes focusd on (a) in Indonesia, Nahdlatul Ulama and Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 135

Graph 7 Number of registered 6000,000 acceptors of family 5,000,000 planning during 1979/ 1980-1983/1984. 4,000,000

3,000,000

2,000,000

1,000,000

0 1979/1980 1980/1981 1981/1982 1982/1983 1983/1984

Source: Kantor Menteri Negara Kependudukan dan BKKBN (1995), p. 73.

decreasing the birth rate, (b) improving to strengthen and institutionalize the maternal and child welfare, (c) increasing concept of “small and prosperous family life expectancy, and (d) decreasing mor- norm” (norma kelurga kecil, bahagia dan tality rates, particularly that of infants sejahtera, NKKBS). and children (Kantor Menteri Negara As can be observed in graph 8, the Kependudukan dan BKKBN, 1995). number of registered paricipants was During this period, the Government more than that of the previous period. focused on increasing the participation of New participants totalled as many as 4 to women and young people in population 5 million each year. Only in fiscal year affairs as well as the quality of human 1986/1987 were there fewer participants resources, both of which were introduced than in the previous fiscal year.

Graph 8 Number of registered 6000,000 participants in family 5,000,000 planning during 1984/1985-1988/1989. 4,000,000

3,000,000

2,000,000

1,000,000

0 1984/1985 1985/1986 1986/1987 1987/1988 1988/1989

Source: Kantor Menteri Negara Kependudukan dan BKKBN (1995), p. 73. 136 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The third stage, after the pioneering • improving the quality of life of the and development periods, was the institu- population. tionalization period, which begin in 1990. During this period, family planning was This period was marked by several transformed from being a programme into new programmes, among them the a “movement”. It became more complex Campaign for the Healthy Prosperous and needed a new approach. During the Mother (Kampanye Ibu Sehat Sejahtera, Fifth Five Year Development Plan (1989/ KISS), which later became Gerakan Ibu 1990-1993/1994), the basic strategy was Sehat Sejahtera (GISS); the Campaign for continued with the policies as follows the Prosperous Small Family (Kampanye (Kantor Menteri Negara Kependudukan Keluarga Kecil Sejahtera, KKS); and the dan BKKBN, 1995): Campaign for the Self-help Small Family (Kampanye Keluarga Kecil Mandiri, KKM). • restraining population growth to The number of participants during raise the quality of human the Fifth Five Year Development Plan was resources; about the same as that of the previous • decreasing the rate of fertility period (graph 9). The last period, directly through the family plan- 1993/1994, was distinguished by fewer ning movement and indirectly by participants when compared to other improving the welfare of the pop- periods. In the 1984/1985 to 1993/1994 ulation; period, the Government did not reach its • decreasing the rate of mortality, target number of participants, save for particularly infant, child and 1988/1989, when 114.7 per cent of the maternal mortality, and increasing target was realized. life expectancy; and

Graph 9 Number of registered 5,000,000 participants during 4,500,000 1989/1990-1993/1994. 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1989/1990 1990/1991 1991/1992 1992/1993 1993/1994

Note: Data for 1993/1994 were for the period up to December 1993. Source: Kantor Menteri Negara Kependudukan dan BKKBN (1995), p. 73. Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 137

During the New Order era, popula- stated that the declining fertility rate tion policy was transformed from a poli- from 5.6 births per woman in the early cy with demographic goals at its core to 1970s to 2.3 births in the late 2000s was a policy with a more social and econom- caused by more women using contracep- ic orientation. The happy, prosperous, tion. Other factors may also have con- small family programme (NKKBS) com- tributed to lowering the population bined these two policies. The family growth and should not be discounted. planning movement is meant not only to The decreasing population growth lower population growth but also to sup- has catalysed the poverty alleviation pro- port family welfare. The norm was set out gramme. Within this logical framework, in Law No. 10/1992 on Population it is reasonable to say that the decreasing Development and the Development of fertility rate has also contributed to the Happy and Prosperous Families, which declining poverty rate. states that a “prosperous family is based on the legal marriage which fulfils spiritu- The success of the Family Planning al and material needs, devoted to God Programme is attributable to the support Almighty, having harmonious and bal- of the community, NGOs and civil socie- anced relations with the family members, ty. From the beginning, the two largest the community and environment”. Muslim organizations in the country, Nahdlatul Ulama and Muhammadiyah, In addition, the family-planning ter- showed their support for the implementa- minology changed from “programme” to tion of the Programme. Since Indonesia is “movement”. This implies that the Family also the world’s largest Muslim country, Planning Programme has also been trans- their support has meant a great deal. formed from a government (programme) However, their support does not mean to a community responsibility. This is the that all opposition from Islamic organiza- reason why the involvement of religious tions has been automatically removed. leaders, civil society and NGOs is crucial. The contribution of NGOs is also important. The establishment of the National R ESULTSAND Family Planning Coordinating Board A CHIEVEMENT (BKKBN) cannot be separated from the role of the Indonesian Planned Parenthood Association (PKBI), which Data on fertility, infant mortality and the was founded earlier. PKBI continues to poverty rate show that the population support the implementation of the Family policy of Indonesia has successfully Planning Programme even today (see reduced these three important develop- Widyantoro, 2003). Civil society groups ment indicators. Focusing on fertility such as the family welfare organization decline, it could be argued that family (PKK) and the Indonesian Association for planning has contributed to declining Secure Contraception (Perkumpulan fertility. Adioetomo and Sarwiono (2009) Kontrasepsi Mantap Indonesia, PKMI), to 138 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES mention only two, are very active in pro- rate and the contraceptive prevalence rate moting and providing family planning are relatively constant. Since the econom- services. ic crisis was followed by a multidimensional crisis that hit Indonesia in 1998, the The Family Planning Programme in capacity of the Government to subsidize Indonesia has shown how government contraceptives declined. The economic has been successfully working hand in crisis also lowered the purchasing power hand with the local community to imple- of the population. At the same time, the ment the Programme. The change in price of goods, including contraceptives, terminology from “programme” to “move- skyrocketed. These factors working ment” implies the transfer of responsibili- together increased the incidence of ty from government to community. The poverty (see graph 1). In terms of family success of self-reliance in family planning planning, such conditions made it very is also an example of how the community difficult for the poor to afford contracep- has already taken on more responsibility tives. In the end, the crisis reduced com- for the Family Planning Programme. munity participation in family planning. Declining community participation A SSESSMENTAND was also caused by the shift of govern- E VALUATION ment from a centralized to a decentralized model. Originally, the central Successful family planning and the pro- government had enormous power; after gramme to alleviate poverty were impact- decentralization was implemented, these ed by external factors: the economic powers weakened. The National Family crisis in 1997-1998 and political unrest Planning Coordinating Board (BKKBN), that led to governmental change. This in which had been a very powerful organi- turn affected two important aspects of the zation under the New Order, was decen- implementation of the Family Planning tralized in 2003. It consequently lost Programme: the weakened capacity of the much of its influence at the district level. Government to subsidize the Programme, As a result, the Government lost the abil- and decentralization, which resulted in a ity to direct family planning policies as it gap between national and local (district) had done in the New Order era. population policy. These two issues high- Decentralization also led to less govern- light the importance of community par- ment attention at the central and local ticipation in the Family Planning levels to population issues in general and Programme. The model must be adapted family planning in particular. This result- to take into account a new social, eco- ed in the implementation of family plan- nomic and political environment. ning programmes that weakened existing family planning programmes. Graphs 2 and 3 show the effects of the economic crisis in 1997. For family To respond to this situation, the planning programmes, the total fertility Government has revitalized the Income- Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 139

generating Activities for Prosperous Income-generating Activities for Families (Usaha Peningkatan Pendapatan Prosperous Families (UPPKS) Programme. Keluarga Sejahtera, UPPKS) Programme, Capital assistance provided for these which was initiated in 1976. This UPPKS groups ranges from 2.5 million to Programme has been considered a suc- 5 million rupiah. However, the groups cessful programme, with a large number must meet predetermined criteria: they of families enrolled and about 13.5 mil- should be groups that are not able to lion members involved in it (Ismawan, provide collateral, that already have eco- 2009). By Instruction of the President, nomically productive activities, and that trillions of dollars have been collected participate in family planning. In 2006, the from a 5 per cent tax on company profit National Family Planning Coordinating that is later used as a revolving fund for Board (BKKBN) recorded 2,412 UPPKS UPPKS groups. In this phase, the role of groups that had received capital assistance the private sector becomes stronger. amounting to 10 billion rupiah (see Dawam, 2008). According to Dawam In the beginning, the Income-gener- (2008), in 2005, there were approximately ating Activities for Prosperous Families 350,000 UPPKS groups. This was a signif- Programme (UPPKS) had a very signifi- icant drop from 557,942 groups in 2002 cant role in supporting the Family and 741,206 groups in 1999. In 2007, with Planning Programme by increasing fami- the launch of the new policy, there were ly income. However, owing to the eco- 30,410 UPPKS groups. This number nomic crisis and the implementation of increased dramatically by 2009 to 42,650 decentralization, the Programme tended UPPKS groups with a total of 759,864 to weaken. Similarly, other programmes family members. relating to community participation, economic crisis and decentralization have The Income-generating Activities for led to the decline in its performance. Prosperous Families (UPPKS) Programme Therefore, the revitalization of the played an important role when the influ- Income-generating Activities for Prosperous ence of the Government declined in Families Programme is important in fami- terms of ability to influence outcomes ly planning programmes in Indonesia. and to provide funding. It is becoming an alternative to help poor families afford The Medium Term Development contraception and, it is hoped, to Plan (RPJM) 2004-2009 states that there increase the number of people participat- is a need to increase family incomes, ing in the Family Planning Programme. especially of families in the categories of pre-prosperous and first prosperous family. In response, the National Family L ESSONS L EARNED Planning Coordinating Board (BKKBN) has launched a more intensive economic The success of the Family Planning empowerment programme for poor fami- Programme in Indonesia in the New lies by providing capital assistance to the 140 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Order era must be seen in the bureaucrat- P OTENTIALFOR ic political context. The Programme is a R EPLICATION national programme that is supported by strong government that has been able to The first and most important requirement develop political commitment to the for replication is the strong and sustained Programme. This is reflected in the full political commitment of the Government. backing of the Family Planning Programme by the President and the The problems surrounding communi- Parliament through the establishment ty involvement in any family planning of the National Family Planning programme such as opposition based on Coordinating Board (BKKBN), a special religion or belief, misunderstanding of body responsible for family planning the programme, and low social and eco- implementation. nomic status exist in any country. The Indonesian model and approach can According to Piet (2003, p. 88), the show other countries how to navigate success of the Programme is due to “the these issues. unusually effective administrative structure for a developing country that facili- Population policy development togeth- tates communication and mobilization of er with strategic planning is needed. action at the grass root level for a wide The programme should include three range of development activities”. important stakeholders: the State, the Piet (2003) has also pointed out that private sector and civil society, with a the flexible and innovative approaches clear definition of responsibilities. are key elements of the success of the Programme. For example, village family planning is an innovation that was fol- A CKNOWLEDGEMENTS lowed immediately by expansion without lengthy planning. In preparing this case study, I received support from many parties. I would espe- External factors such as the Southeast cially like to acknowledge the support of Asian economic crisis were unanticipated the National Family Planning and became a threat to the continuation Coordinating Board (Badan Koordinasi of the Programme. However, there was Keluarga Berencana Nasional, BKKBN). no immediate impact of the economic From BKKBN Jakarta, I would like to crisis in terms of withdrawal of the fami- express my thanks to Dr. Sugiri Syarief, ly planning acceptors, as evidenced by MPA; Dra. Kasmiati, MSc; and Drs. Eddy the high number of people participating N. Hasmi, MSc, and M. Dawam, who in the Family Planning Programme. provided valuable input as well as support for me to finish this work. I also wish to offer thanks to Dr. Samijo, MSc, from Importance of Community Participation in the Implementation of the Family Planning Programme – Indonesia 141

UNFPA, who was willing to read and www.prb.org/pdf10/10wpds_ eng.pdf>. provide comments on my earlier draft. Hull, T.H. and Hull, V.J. (2005). “From family planning to reproductive health care: A brief history”. In Terrence H. Hull R EFERENCES (ed.), People, Population, and Policy in Indonesia. Jakarta: Equinox Publishing Adioetomo, S.M. (2009). “Kontribusi pro- (Asia) Pte. Ltd. gram KB terhadap Penurunan Fertilitas Indonesia (1970-2000)”. In Warta Ismawan, B. (2009). “Pemberdayaan Demografi, vol. 39, No. 2, pp. 12-21. Masyarakat Melalui Dana Bergulir”. In Buletin Bina Swadaya, No. 59/Tahun Central Body of Statistics (Badan Pusat XIV/March-April. Statistik, BPS) (2009). Berita Resmi Statistik No. 45/07/Th. XIII, 1 Juli 2010: Profil Kantor Menteri Negara Kependudukan Kemiskinan di Indonesia Maret 2010. Jakarta: dan BKKBN (1995). 25 Years Family BPS. Planning Movement. Jakarta: Kantor Menteri Negara Kependudukan dan BKKBN. ______(2009). Berita Resmi Statistik No. 43/07/Th. XII, 1 Juli 2009: Profil Kemiskinan Lubis, F. (2003). “History and structure of di Indonesia Maret 2009. Jakarta: BPS. the National Family Planning Programme”. In A. Neihof and F. Lubis (eds.), Two Is ______(2006). Estimasi Parameter Enough: Family Planning in Indonesia under the Demografi, Mortalitas, Fertilitas dan Migrasi. New Order, 1968-1998. Leiden: KITLV Jakarta: BPS. Press, pp. 31-55. Dawam, M. (2008). Evaluasi Kelompok Lubis, F. and Neihof, A. (2003). UPPKS Tahun 2008. Jakarta: Pusra (Pusat “Introduction“. In A. Neihof and F. Lubis Penelitian dan Pengembangan Keluarga (eds.), Two Is Enough: Family Planning in Sejahtera), National Population and Indonesia under the New Order, 1968-1998. Family Planning Board (BKKBN). Leiden: KITLV Press, pp. 1-18. Hartanto, W. and Hull, T.H. (2009). Merrick, T.W. (2002). “Population and Provincial Adjusted Fertility for Under- poverty: New views on an old controver- Recording of Women in the SDKI 2002-3 and sy”. In International Family Planning 2007. Jakarta: Directorate, Population and Perspective, vol. 28. No.1, pp. 41-46. Labour Statistics, BPS-Statistics Indonesia, and The Australian Demographic and Mize, L.S. and Robey, B. (2006). A 35 Year Social Research Institute, The Australian Commitment to Family Planning in Indonesia: National University. BKKBN and USAID’s Historic Partnership. Baltimore: Johns Hopkins Bloomberg Haub, Carl (2010). 2010 World Population School of Public Health/Center for Data Sheet. Washington, D. C.: Population Communication Programs. Reference Bureau. Available at

Piet, D.L. (2003). “The significance of foreign assistance to the Indonesian family planning programme”. In A. Neihof and F. Lubis (eds.), Two Is Enough: Family Planning in Indonesia under the New Order, 1968-1998. Leiden: KITLV Press, pp. 83-106. Sarwono, L. (2003). “Family planning in Indonesia under the Old Order”. In A. Neihof and F. Lubis (eds.), Two Is Enough: Family Planning in Indonesia under the New Order, 1968-1998. Leiden: KITLV Press, pp. 19-30. Widyantoro, N. (2003). “NGO involvement in family planning”. In A. Neihof and F. Lubis (eds.), Two Is Enough: Family Planning in Indonesia under the New Order, 1968-1998. Leiden: KITLV Press, pp. 107-118. Yulaswati, V. (2009). “Isu Strategis dan Arah Kebijakan Penanggulangan Kemiskinan RPJMN 2010-2014 dan RKP 2010”. Bahan Prrsentasi TKPK [Tim Koordinasi Penanggulangan Kemiskinan] Provinsi [material presentation for the Provincial Coordination Team for Poverty Alleviation].

Project Contact Badan Koordinasi Keluarga Berencana Nasional (BKKBN) Pusat Jl. Permata No. 1 Halim Perdana Kusuma Jakarta Timur 13650, P. O. Box 1314 JKT 13013 Indonesia Tel.: +021 8008018, +021 88009029 Fax: +021 8008554 Website: http://www.bkkbn.go.id An Innovative and 6 Integrated Initiative to Kenya Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme

Dr. Lawrence D. E. Ikamari

Summary

The initiative described in the present case study was undertaken in order to reintroduce the intrauterine device (IUD) into the contraceptive method mix and to increase its uptake in Kenya. The use of IUDS was declining despite the safety, effectiveness, convenience and low cost of the device. At the same time, the use of expensive, modern family planning methods such as injectables was on the increase. The percentage of women in Kenya who used IUDs for contraception dropped from 21 per cent in 1989 to 15.4 per cent in 1993 and to 7.6 per cent in 2003. The underuse of IUDs and other long-acting and permanent methods became a cause of concern to the Government of Kenya and those who make health policy. Overreliance on relatively expensive methods burdened the National Family Planning Programme, which was already faced with budget cuts as resources were increasingly direct- ed to HIV/AIDS programmes, and limited women’s access to a full range of contraceptive options. At the same time, Kenya was undergoing serious challenges in ensuring family- planning commodity security, with recurrent stock-outs. HIV/AIDS was attracting all the focus of all the players, including the bilateral partners. It became necessary to reintroduce a method whose safety and cost benefits were well established even in the era of HIV/AIDS.

143 144 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Information on the Author Dr. Lawrence D. E. Ikamari, faculty member, Population Studies and Research Institute, University of Nairobi, Nairobi, Kenya.

I NTRODUCTION implementing an integrated maternal and child health/family planning programme to The initiative described in the present case reduce its high population growth rate and study was started to help to create demand to improve the welfare of women and chil- for intrauterine devices (IUDs), enhance dren. The high population growth in the the quality of services, increase easy access country was influenced mainly by high fer- to IUDs, reduce reliance on the relatively tility and declining mortality. Until recent- expensive methods that burdened the ly, the performance of the family planning National Family Planning Programme, and components had been rather poor. For increase women’s access to a full range of instance, between 1978 and 1998, the pro- contraception options. portion of married Kenyan women using modern contraceptive methods rose from only 9 per cent to 39 per cent (graph 1). It B ACKGROUND : O RIGIN , reached a plateau between 1988 and 2003, D ESIGNAND O BJECTIVES indicating a significant unmet need for family planning. Contraceptive commodity OFTHE I NITIATIVE stock-out was a serious challenge. Fertility remained relatively high at about 5 children O RIGINAND G ROWTH per woman. Since 1967, Kenya has been promoting and

Graph 1 Trends 35 in the use of modern contraceptives 30 in Kenya. 25 20 15

Percentage 10 5 0 1984 1989 1993 1998 2003

Source: Kenya Demographic and Health Survey 2003. An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 145

Moreover, the use of the IUD – one Kenyan women did not have access to a of the most reliable and cost-effective full range of contraceptive methods. methods – dropped from 31 per cent of Kenya as a country was experiencing an the modern method mix in 1984 to about increasing disease burden from the 8 per cent in 2003 (graph 2). At the same HIV/AIDS pandemic (graph 3), and the time, Kenyan women began to rely ability of the Ministry of Health to pro- almost exclusively on short-term meth- vide services was under a great deal of ods, with more than 70 per cent of pressure. All the players, including the women who used modern contraception bilateral partners, were focusing only on using injectables or pills, methods that are HIV/AIDS. Amid all the challenges, an more costly than IUDs. In addition, IUDs increased number of Kenyans were reach- have proven to be safe, effective, accepting reproductive age and requiring servi - able, and low in cost, and therefore suit- ces, furthering demand for contraceptives. able for most women in a resource setting In addition, research on IUD service such as Kenya. Also, the World Health delivery in Kenya showed that a combi- Organization has shown that IUDs are nation of factors contributed to the also suitable for women with HIV/AIDS. decline in the uptake of the IUD. These At the same time, the Ministry of included: Health was facing several challenges to its reproductive health programme. For • poor quality of care; example, it was facing serious challenges • fear of HIV transmission; in ensuring family-planning commodity • misconceptions and myths about security, with recurrent stock-outs. IUDs;

Graph 2 Trends in the contraceptive method mix in Kenya.

16 14 12 10 1993 8 1998 6 2003 Percentage 4 2 0 Pill IUD Injectables Condoms BTL

Note: BTL= bilateral tubal ligation. Source: Kenya Demographic and Health Survey 2003. 146 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Graph 3 12 HIV prevalence among adults 10 in Kenya.

Percentage 4

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: Adjusted from the Sentinel Surveillance System.

• provider bias or preference (e.g., planning programme, increase client concerns about the time and skill choice, and reintroduce the IUD into the required to offer IUDs); Kenyan contraceptive method mix. • shifting client preferences; The initiative was phased in well. It • lack of expendable commodities; started in two provinces – the Western and and Coast provinces – and gradually • availability of Norplant and depot some of the activities were extended to medroxyprogesterone acetate the six other provinces. The Ministry of (DMPA). Health AMKENI1 Project, a service delivery project supported by the United Concerned about a contraceptive States Agency for International method mix skewed towards short-term Development (USAID), was already methods (the most costly) and about pro- operating in these two provinces and thus viding a wide range of contraceptive integrated the IUD reintroduction efforts options to Kenyan women and a more into its activities. balanced and sustainable method mix, the Ministry of Health decided to rein- Based on the fact that the barriers to troduce or rehabilitate the IUD. In 2001, IUD use in Kenya were many, the initia- the Ministry, in collaboration with sever- tive focused on and addressed four al local and international partners, strategic areas: consensus-building and launched the initiative to promote a bal- advocacy; building capacity and improv- anced and sustainable national family ing service delivery; creation of demand;

1A Swahili word meaning “awakening”. An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 147

and monitoring and evaluation and oper- Gynecological Society to discuss ations research. IUD usage in Kenya. The members agreed that there was a need O BJECTIVES to convene a national stakeholders meeting to discuss matters relating The objectives of the initiative were to: to the IUD. • increase support for the IUD • Several months later, Family among policymakers, service Health International organized a providers and clients; stakeholders meeting to bring together government leaders, rep- • improve the quality of IUD services; resentatives from non-governmen- • enhance demand for IUDs; and tal organizations (NGOs) and • monitor and evaluate programme providers. The meeting served as a performance. venue for presenting the most current IUD research and discussing a way forward. The stakeholders M AJOR ACTIVITIES proposed the formation of the Although the activities followed a devel- IUD Task Force, which the opmental sequence, they were in reality Ministry of Health adopted. carried out more or less simultaneously • In March 2002, the IUD Task once the stakeholders had agreed on the Force, with the Ministry of Health importance of the project and the imple- as chair and Family Health mentation mechanisms. International as secretariat, met to develop a revitalization strategy Consensus-building Activities and work plan for the reintroduc- At the onset, the Ministry of Health tion of IUDs. In subsequent undertook several activities to cultivate quarterly meetings, the group ownership and consensus among various developed a work plan outlining groups, including researchers, trainers, goals, activities, indicators of suc- programme mangers, service providers, cess and a timeline. professional associations, funding agen- • The national IUD revitalization cies and clients. This cluster of activities strategy was launched at the annu- occurred in several steps over the course al conference of the East, Central of approximately two years from late and Southern Africa Association of 2000 to 2002: Obstetrical and Gynaecological Societies (ECSAOGS). • In early 2001, the Ministry of • The IUD Task Force transitioned Health and Family Health to a more streamlined implement- International hosted a panel ses- ing body under the chairmanship sion at the annual meeting of the of the Department of Kenya Obstetrics and 148 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Reproductive Health in the al reproductive health conferences. Ministry of Health. The In summary, the advocacy and sensi- Department adopted a systematic approach of quarterly meetings tization activities included the following: and regular progress reports. The • A public call-in radio programme Ministry of Health led this group, aired featuring IUD advocates, sat- which consisted of representatives isfied users and providers. During of the Ministry, Family Health some of these programmes, International, the AMKENI professionals answered some of Project, Jhpiego (an international the frequently asked questions non-profit health organization) about IUDs. Some of the IUD and several medical professional clients shared their experiences associations. with other potential clients.

Advocacy and Sensitization Activities • A package of IUD advocacy briefs targeting providers and policy- Based on research findings about the makers was developed by the causes of the decline in the use of IUDs Ministry of Health, Family Health in Kenya, the Task Force recognized that International and representatives the revitalization strategy would require a from all the major medical profes- strong advocacy component to combat sional associations in Kenya. In provider bias and misinformation. Family non-technical language, these Health International was responsible for briefs addressed the issues of con- developing the advocacy strategy. cern identified in the IUD assess- Throughout the process, it maintained ment and stakeholders meeting: strong partnerships with professional safety, efficacy, cost, convenience organizations and local NGOs whose for clients and providers, eligibili- members work closely with providers or ty criteria and potential as a safe are providers. method for HIV-positive women. The advocacy activities included a • The Ministry of Health hosted review of Ministry of Health policies and district-level meetings of public- the development of various communica- sector providers, health facility tion efforts to raise awareness among managers, and policymakers in all providers, clients and the general public. eight provinces. The purpose of As of 2004, over 2,600 advocacy briefs the meetings was to disseminate had been distributed, 400 programme the revitalization strategy and the briefs and to review information managers and family planning service about the IUD. providers had been sensitized in meetings in all eight provinces in Kenya, and hun- • Private-sector providers across the dreds of others had been encouraged to country were invited to sensitiza- take a new look at the IUD during radio tion meetings as part of their con- programmes and presentations at region- tinuing professional development. An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 149

Participants were certified and the • With leadership from the sessions were recognized as part of AMKENI Project, the Ministry of their continuing medical education Health and the rest of the IUD by their respective professional Task Force revised the national bodies. The materials for continu- reproductive health curriculum. ing professional development were Previous training materials were adapted and used to train pre-serv- piecemeal and out of date. The ice trainers from universities and new curriculum was standardized, medical training colleges. with updated information about reproductive health and family Capacity-building and Service-delivery planning. Activities • The AMKENI Project held facility- Capacity-building and service-delivery level orientation meetings to intro- activities were implemented primarily by duce IUD revitalization in 10 Ministry of Health teams and the districts in the Coast and Western Ministry of Health AMKENI Project, provinces. These meetings includ- which was USAID-funded. Concerted ed the entire staff of the facilities, efforts were made to improve the provi- not just the providers. This gave sion of quality IUD services by establish- all the staff an opportunity to ing a training system for IUD services understand the programme and and creating a cadre of trainers to reach their future roles in it. IUD providers in the public and private • The AMKENI Project provided sectors. The cluster of activities was car- clinical, in-service training and ried out to enhance supervision capacities refresher courses to public and within the existing Ministry of Health private providers in eight districts structures, to ensure the provision of on all aspects of IUD service equipment and expendable supplies to provision. AMKENI-supported clinics, to improve • The AMKENI project also distrib- the infrastructure of facilities and to uted nearly 600 kits for IUD inser- address infection-prevention techniques tion and removal to trained in clinics. providers and it continues to work with the USAID-supported The AMKENI Project worked to DELIVER PROJECT implemented improve reproductive health service by John Snow, Inc. to make sure delivery at 97 Ministry of Health-sup- that sufficient numbers of IUDs ported sites in the Coast and Western and related supplies are available provinces. To fit the revitalization effort at the facilities. into the AMKENI work plan, pilot facilities in these two provinces were selected. • Family Health International devel- Activities included the following: oped a checklist to help providers to determine if clients are medically eligible to use the IUD. The 150 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

checklist was partially field-tested AMKENI incorporated a new IUD in Kenya. During four focus-group emphasis into its existing behaviour discussions with providers, change communication (BCC) pro- Kenyan providers reviewed and gramme. It trained more than 500 BCC endorsed the use of the checklist. agents, mostly volunteers who live in the communities that they serve, to provide The newly formed, decentralized, information about the IUD and family reproductive-health training and supervi- planning in general. The BCC agents met sion teams of the Ministry of Health con- with village health committees, women’s tinue to provide supportive supervision. groups, men at worksites, youth groups Their goal is to ensure that facilities have and families. They distributed the IUD sufficient training, commodities and sup- and general contraception pamphlets. plies to offer IUDs to their clients. The AMKENI behaviour change Demand-creation Activities communication (BCC) strategy worked The IUD suffered from a poor reputation with communities around the targeted among family planning clients, who were health facilities to increase demand for rarely offered the method and often dis- services, foster women’s empowerment couraged from using it by persistent and participation in reproductive rumors about its safety and by providers’ health/family planning decisions, and attitudes. The providers’ attitudes were promote healthy behaviour. A hallmark influenced by many factors: lack of infra- of the AMKENI approach was to engage structure, provider skills, equipment and the community surrounding each facility supplies. The IUD Task Force (mostly to put people “in the driver’s seat” for implemented by AMKENI) undertook a bringing about desired change. AMKENI campaign in the two focus provinces of mobilized 754 villages to form village AMKENI to dispel myths and to inform health committees or health-facility man- potential clients about the benefits of the agement boards. More than 2,218 volun- IUD and all modern family planning teer field agents were trained to provide methods. information and mobilize community involvement in reproductive health/fami- Under Family Health International ly planning. Approximately 51,000 mem- leadership, Task Force members devel- bers from over 2,700 community groups oped two brochures (each produced in were engaged in regular BCC activities, English and Swahili) for clients of repro- reaching more than 2.8 million people. ductive health services. One brochure discusses the IUD, explaining what it is, In summary, clients’ awareness of the who can use it, and its benefits and side existence and advantages of the IUD was effects. The other brochure provides a major determinant of demand. Research information about all modern family showed that often clients were not aware planning methods, including the IUD. of the IUD as a contraceptive option or they had misconceptions about the An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 151

method. To raise awareness, the initiative target goals and the partners developed information, education and responsible for collecting data on communication materials and initiated progress. public education campaigns through the • Family Health International also extensive network of field agents of the coordinated and documented the AMKENI Project. As of March 2004, IUD Task Force meetings and pre- nearly 12,000 community members had pared quarterly reports with updates been reached through educational ses- on progress and results. The sions on the IUD. AMKENI Project is collecting data in two provinces on the increase in Documentation IUD users, which will be an impor- The process of documenting all the activ- tant indicator of success. ities of the initiative was put in place as part of facilitative support supervision. Data and information were available in I MPLEMENTATION the implementing facilities. The documentation enabled participants to share The initiative was a collaborative effort that programme information and made it easy involved the Ministry of Health (prime to monitor and evaluate the progress and mover), EnGender Health, Family Health success of the programme based on the International, IntraHealth International and initial baseline survey. the Program for Appropriate Technology in Health (PATH). Monitoring and Evaluation and Operations Research The Director of the Division of From the start, monitoring and evaluation Reproductive Health had the overall were considered vital to implementing coordination role and ensured that the the initiative and gauging its success. resources needed for the various activities Family Health International was desig- were made available to the implementers. nated to lead the monitoring and evalua- Involvement of professional health tion process. During the monitoring and associations and training institutions in evaluation planning, it put measures in the project activities was ensured place to ensure appropriate documenta- throughout the life of the project. In tion of all activities throughout the life of addition, private-sector providers across the project. These measures included the the country were invited to sensitization following: meetings as part of their continuing professional development. Participants were • Family Health International devel- certified and the sessions were recog- oped a monitoring and evaluation plan that listed project objectives nized as part of their continuing medical and the activities required to meet education by their respective profession- them, indicators to be measured, al bodies. The materials for continuing professional development were adapted 152 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES and used to train pre-service trainers from R ESULTSAND universities and medical training colleges. A CHIEVEMENTS Each partner had a clearly defined role based on its comparative advantage The results described in the following sec- and was responsible for implementing tions are based on the project documents the assigned project activities in close as well as assessment and evaluation. collaboration with other stakeholders. Joint planning and review meetings S USTAINABILITY were held by a representative task force. The initiative was sustainable because it During these review meetings, progress was mainstreamed into the Ministry of was assessed, challenges were discussed, Health Family Planning Programme and and, in certain instances, workplans were into each partner’s programme activities. modified to reflect the reality on the ground. I NCREASED U TILIZATIONOF THE IUD Funding was provided by USAID and the Government. Under the Ministry of Health AMKENI Project, which ended in 2005, the num- Supervisory teams from the Division of ber of new users in the 97 facilities sup- Reproductive Health of the Ministry of ported by AMKENI increased from 151 Health were formed. As indicated earlier, per quarter at the baseline in early 2003 these teams ensured that all the facilities to 373 per quarter in early 2005. The had sufficiently trained staff, adequate cumulative number of IUD users in IUDs and other contraceptive commodi- AMKENI Project sites over the two-year ties to offer to clients. They also ensured intervention period was approximately that all the facilities had the checklists 2,800 women. and that high standards were being followed and maintained. AMKENI Project achievements have had a significant impact on the Family Health International had access to, quality of, and use of repro- developed a monitoring and evaluation ductive health services in the Coast and plan that listed all the project objectives Western provinces. People now can and the activities required to achieve choose from an increased range of fam- them, indicators to be measured, target ily planning methods, and more people goals and the partners responsible for are using more methods. At the base- collecting data on progress. The imple- line, most facilities could offer only mentation of the project activities was short-term methods, such as the pill, closely monitored and all the activities injectables and condoms, and the num- were documented throughout the life of ber of clients was low. the project. An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 153

I NCREASED ACCESSTO Q UALITY S TANDARDIZATIONOF FAMILY P LANNING S ERVICES R EPRODUCTIVE - HEALTH AMKENI enabled the facilities to pro- T RAINING M ATERIALSAND vide a range of methods, strengthening T HEIR U SEIN T RAINING the capacity to provide long-acting and S TAFF permanent methods in particular. For example, the number of facilities that The staff had their knowledge and skills could provide IUDs rose from 5 per cent updated using standardized training man- at the baseline (2001) to 35 per cent by uals. The project also included pre-serv- the end of 2005, and reported IUD inser- ice trainers from various Kenyan medical tions rose from 510 in 2001 to 1,169 in training colleges in its training support. 2005. During the same period, accept- This assistance created a large reserve of ance of all long-acting and permanent high-quality, local experts in training and methods rose by 152 per cent, and the in supervision. number of new family planning users increased by 65 per cent. AMKENI Project staff formed a true L ESSONS L EARNED partnership with Ministry of Health staff, jointly planning and implementing pro- The following lessons were learned in the jects in eight provinces, and this was course of implementing the project: piloted successfully down to the health- facility level in two districts. The • High-level political commitment is Ministry of Health intends to roll out the crucial for successful programme system nationwide. implementation. Programme commitment to intervention by the Ministry of Health and all the E FFECTIVE S UPERVISIONOF partners is essential for successful S ERVICE D ELIVERY implementation and its sustainabil- By the end of the project in 2005, each of ity. In addition, leadership by the the eight provinces in Kenya and the 10 Ministry ensured a commitment districts within the AMKENI Project area by all involved to undertake nec- had members of the reproductive-health essary policy and programmatic training and supervision team who had changes. been updated in their clinical skills, • Building activities on evidence exposed to supportive supervision proce- (especially synthesis and discus- dures, and instructed in clinical training sion of local evidence) is more skills and on-the-job training techniques. effective than not using an evidence-based approach. Synthesis and incorporation of valid research 154 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

findings are required to inform common goals, are coordinated action. Succinct and accessible and bring a variety of skills to the evidence makes busy policymak- project. ers, programme managers and • Credible spokespeople are impor- service providers take notice. tant advocates in that they can • A review of existing policy and help to bridge the worlds of guidelines to ensure appropriate research, policy and programmes. content is necessary. For instance, the guidelines on family planning C HALLENGES were revised and a new Kenya Family Planning Guidelines for Service During the course of implementing the Providers was issued, which now programme, several challenges were includes the new medical eligibility encountered: criteria for the IUD and all other contraceptive methods. • weak health infrastructure; • Partnerships with key stakeholders • bureaucracy in the decision- at all levels of implementation are making process of government critical. Each partner should be agencies; assigned responsibilities based on • inadequate and erratic supplies of its comparative advantage and contraceptive commodities; track record. The assignment of • inadequate support by service responsibilities should be done in providers; a democratic and transparent manner. Collaboration leads to owner- • competition from other short-act- ship and more effective project ing contraceptives (e.g., DMPA); implementation. • lack of continuity in facilities’ • Community initiatives and part- commitment to the IUD and the nerships are key to service and provision of IUD services; and commodity uptake. Village-based • insecurity among clients as to health structures such as village whether the services would be health committees are essential for maintained. reaching people with appropriate information and for creating demand for health services and are S UITABILITYAND critical for ownership and sustain- P OSSIBILITYOF S CALING ability of health initiatives. U P (R EPLICABILITY ) • Collaboration and leveraging of resources by implementing agen- The model according to which the initia- cies are feasible. Organizations tive was executed has been replicated both can effectively cooperate and con- locally (in the country) and internationally. tribute resources when they share An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 155

• The initiative has been scaled up concerns regarding family plan- and is being implemented in all ning services and for providers to eight provinces of Kenya. As was meet. They resulted in increased indicated earlier, the Ministry of use of IUDs between 2005 and Health teams trained family plan- 2006 in Kisii District. ning staff of all the major health Remarkable progress in IUD inser- facilities in the eight provinces to tions was recorded by the AMUA3 provide IUDs among other family Project. This social franchising planning methods. A number of project targeting the rural private health facilities have also been sector with particular emphasis on upgraded and strengthened to pro- long-acting and permanent meth- vide a variety of family planning ods was conducted in Rift Valley methods including IUDs. IUDs are Province from 2004 to 2007 using now routinely included in the con- some of the lessons from the traceptive commodities supplied to AMKENI Project. all the health facilities in the country. This is clear evidence that the • The Population Council adopted initiative has been incorporated into and produced 500 copies of the national health decision-making IUD advocacy kit for Ghana and planning processes. Health Services (i.e., the Ghana • The implementation of project Ministry of Health) at a cost of activities was closely monitored approximately US$1,500. and all the activities were docu- • Ghana Health Services used mented throughout the life of the advocacy kits to help to sensitize project. The lessons learned in the 153 Family Planning Programme project have been used in the managers and service providers. AMUA and ACQUIRE Projects to increase the usage of IUDs. In Kisii District, with support from R ECOMMENDATIONS ACQUIRE2 and using lessons learned from the AMKENI Pro- The recommendations listed below should ject, the Ministry of Health held be followed to successfully reposition the community linkage meetings to IUD or any similar initiative in Kenya or bring together providers and com- in countries with similar conditions: munity members. These meetings provided an opportunity for com- • Partners and stakeholders who munity members to express their support the Ministry of Health of

2The ACQUIRE Project (Access, Quality, and Use in Reproductive Health) is a global initiative supported by USAID and managed by EngenderHealth in partnership with the Adventist Development and Relief Agency International (ADRA), CARE, IntraHealth International, Inc., Meridian Group International, Inc., and the Society for Women and AIDS in Africa (SWAA). 3Meaning “decide” in Swahili. 156 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Kenya should work within the The initiative worked well because of existing structures of the Ministry. the innovative design and strategy imple- • Stakeholders on a project should mentation that entailed wide consultation consult with one another regularly. among key stakeholder, use of research, consensus-building and advocacy, strong • Advocacy, sensitization and government commitment and leadership, consensus-building should be capacity-building, involvement of careful- encouraged. ly selected implementing partners that • Regular supportive supervision were assigned responsibilities democrati- should be maintained. cally and on the basis of comparative • Advocacy should be undertaken advantage and proven track record, and for inclusion of the project in the well-thought-out monitoring and evalua- annual operating plan of the tion arrangements. It further involved a Ministry of Health. well-coordinated flow of resources from • Advocacy should also be undertaken USAID, the Government of Kenya and a for a line in the Ministry of Health variety of other development partners and budget covering all the components integration of the initiative activities into of IUD services to ensure that they ongoing activities of the implementing will be continuous. partners.

C ONCLUSION A CKNOWLEDGEMENTS

This initiative was a best practice because I wish to express my profound apprecia- it increased the uptake of IUDs in the tion and gratitude to the Division of project provinces as shown by the service Reproductive Health of the Ministry of statistics; it contributed to the strengthen- Health and Family Health International ing of the capacity of various stakeholders (Kenya) for allowing me to have access and health facilities; it built strong part- to the documents of the initiative. nerships; and it was sustainable (use of Second, I would like to thank the existing health facilities and local National Coordinating Agency for resources, community participation). In Population and Development for nomi- addition, it is replicable (it has already be nating me to undertake this assignment used to reintroduce the IUD in all eight for Partners in Population and provinces of Kenya and has been used in Development (PPD). Finally, I wish to Ghana). Furthermore, the initiative was thank the PPD secretariat for the invalu- based on research and it integrated oper- able assistance that I received during the ations research and involved professional exercise. associations in a very innovative way. An Innovative and Integrated Initiative to Reposition Intrauterine Contraceptive Devices in the National Family Planning Programmme – Kenya 157

R EFERENCES Uzazi, P. (2005). Family Planning Guidelines for Service Providers. Nairobi: Division of Central Bureau of Statistics (CBS), Reproductive Health, Ministry of Public Ministry of Health (MoH) and ORC Health and Sanitation. Macro (2004). Kenya Demographic and Health Survey 2003. Calverton, Maryland: Contacts CBS, MoH and ORC Macro. Division of Reproductive Health, Information on the Project Ministry of Public Health and Sanitation Director (2009). Best Practices in Reproductive Division of Reproductive Heath Health in Kenya, August. Ministry of Health Fischer, S. (2005). Translating Research Government of Kenya into Practice: Reintroducing the IUD in P. O. Box 43319 Kenya. Research Triangle Park, NC: Nairobi, Kenya Family Health International. Information on the Drafting Team Klistch, M. (2008). “Revitalizing under- Dr. Lawrence D. E. Ikamari utilized family planning methods using Faculty Member communications and community engage- Population Studies and Research ment to stimulate demand for the IUD in Institute Kenya”. In Acquiring Knowledge: Applying University of Nairobi Lessons Learned to Strengthen FP/RH Services, Nairobi, Kenya No. 7. ACQUIRE Project/Engender- Health. Rajani, N. and Archer, L. (2006). “The AMKENI model: Learning global lessons from improving family planning, reproductive health and child survival in Kenya”. In Acquiring Knowledge: Applying Lessons Learned to Strengthen FP/RH Services, No. 4. ACQUIRE Project/Engender- Health. United States Agency for International Development (USAID) (2007). AMKENI Integrated Model in Reproductive Health Programming in Kenya: A Promising Practice Model. Extending Service Delivery Project Best Practices Series Report #2. Washington, D.C.: USAID and Extending Service Delivery, June. 158 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES A System Approach to 7 Training in Population, South Africa Environment and Development

Prof. Cornelius J. Groenewald

Summary

Population trends are intimately interacting with environmental sustainability and the need for development in order to sustain or increase people’s quality of life. This interaction has become a major factor in the process of development planning and implementation on all levels: global, regional, national and local. The multiple interactions among the three primary fields – population, environment and development – may be described as a nexus of interrelationships. Few development policymakers and planners have a solid understanding of this nexus and are therefore inclined to neglect or underestimate the systemic effect of their accumulated interactions when crafting development policies, plans and programmes. As a result, sustainable human development is not achieved. The need, therefore, is to build the capacity among policymakers, managers and planners to engage on an intellectual level (i.e., in addition to technical competencies) with the population, environment and development nexus, which has become an imperative for attaining sustainable human development.

Due to the fact that leaders, policymakers, managers and planners are not available to attend lengthy training courses, the Government of South Africa, in line with the mandate of its Population Policy, crafted a short course that varies between five and eight days, depending on the specific need, to address this capacity gap and accelerate the mastering

159 160 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

of an intellectual understanding of the systemic nature and implications of the population, environment and development nexus for development planning and implementation. This understanding would strengthen personal and institutional leadership in guiding policies, plans and programmes towards sustainable human development. According to the human development index (HDI), South Africa is not currently making strong inroads in attaining sustainable human development.

This case study introduces a short-course training programme, “Leadership Training in Sustainable Development: The Population, Environment and Development Nexus” (in short, the “LEAD-PED Nexus Training Programme”) that has been implemented since 2005 to this effect and reviews its outcomes, impact and future potential.

Due to its focus and approach (the application of a systemic understanding of the interactions among the key population, environment and development components in sustainable human development and a unique adult learning methodology), the “LEAD-PED Nexus Training Programme” is assessed to be an innovative practice that is portable, replicable and successful in addressing local development planning and implementation.

Information on the Author Prof. Cornelius J. Groenewald, Professor Emeritus, University of Stellenbosch, South Africa.

I NTRODUCTION tion, soil erosion, desertification, and increasing levels of air and water pollu- “Our environment provides us with a tion. In other words, the increasing pace range of goods and services that are essen- of human-induced environmental change tial for human survival, well-being, cul- is altering the ability of the environment to tural diversity, and economic prosperity. provide essential goods and services, Human activities are, however, having which in turn impedes progress towards significant impacts on the environment, sustainable development.” ranging from the local to the global scale. These words are the opening sentences For example, growing human populations of the South Africa Environment Outlook are consuming resources and discarding (Government of South Africa, 2006, p. xv), a wastes at rates that we have not experi- comprehensive report on the state of the enced in the past. The ability of the earth environment in the country. They provide a to sustain us is therefore diminished by, concise description of how population trends for example, accelerated rates of deforesta- are intimately interacting with environmental A System Approach to Training in Population, Environment and Development – South Africa 161 sustainability and the need for develop- level (i.e., in addition to technical compe- ment in order to sustain or increase the tencies). As a result, government agencies quality of life of people. This interaction – (but also non-governmental organizations the interplay among population, environ- (NGOs) and businesses) are challenged to ment and development – has become a equip managers and planners, in the short- major factor in the process of development est time possible, with the necessary planning and implementation on all levels: knowledge and skills to understand this global, regional, national and local. The nexus and to guide and direct policymakers intricacies involved in the multiple interac- and implementers to increase the potential tions among the three primary fields may for sustainable human development. be described as a complex of links and con- The problem addressed in this case nections, tied into a connected series of study is, therefore, the need to under- bonds that may be called a nexus (Barnhart stand the population, environment and and Barnhart, 1982, p. 1401). The experi- development nexus as an essential aspect ence is, however, that few development in development planning and implemen- policymakers and planners have a solid tation in order to provide leadership in understanding of this nexus sufficient for the process of attaining sustainable translating their knowledge and skills human development. regarding the three primary aspects of sustainable human development (i.e., popula- Published figures of the South Africa tion, environment and development) into human development index (HDI) (Human effective development policies, plans and Development Report 1997, 1998, 1999, 2002, programmes. Therefore, the need is, 2007/2008) show a decrease in the health among others, to build the capacity to indicators of the HDI despite progress in engage with the population, environment the economic and education indicators of and development nexus on an intellectual the index (table 1). This means that the

Table 1 Yearly human development index (HDI) values for South Africa, 1994 to 2005, selected years.

GDP Per Rank/Total Life Education Capita Year No. of HDI Expectancy GDP Index Index Rank Minus Countries Index HDI Rank

1994 90 / 175 0.716 0.64 0.81 0.69 -10

1995 89 / 174 0.717 0.65 0.82 0.68 -9

1997 101 / 174 0.695 0.50 0.87 0.72 -47

2000 107 / 173 0.695 0.45 0.88 0.76 -56

2005 121 / 177 0.674 0.43 0.806 0.786 -65

Sources: Human Development Report 1997, 1998, 1999, 2002, 2007/2008. 162 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Table 2 Human development index (HDI) values for South Africa at 5-year intervals, 1975-2005.

1975 1980 1985 1990 1995 2000 2005

0.650 0.670 0.699 0.731 0.745 0.707 0.674

Source: Human Development Report 2007/2008. overall value of the index has been BACKGROUND, decreasing since 1995 (table 2). JUSTIFICATION, ORIGINAND In the case of South Africa, the quality HISTORYOFTHE PROGRAMME of life of the population, as measured by the HDI, is affected significantly by major B ACKGROUNDAND J USTIFICATION health challenges such as HIV/AIDS, The interplay between population and tuberculosis, cholera and malaria that are environment has been a challenge since all diseases intimately affected by environ- long before Thomas Malthus, in the mental, developmental and socio-cultural eighteenth century, explained the strik- factors. Understanding how these differing difference between arithmetic and ent sets of factors interrelate, apart from exponential growth in food production their individual effects, has become a and population growth, respectively major challenge in producing successful (Malthus, 1976/1798). Sam Gaisie human development policies, plans and (2008), in an essay on population and programmes. development interrelationships, high- This case study introduces a short- lights the ways in which ancient Chinese, course training programme as a fast-track- Greek and Roman philosophers grappled ing mechanism for building intellectual with these issues, recommending policy capacity in systemic understanding of positions on population growth and size, this nexus: “Leadership Training in sometimes arguing for population Sustainable Development: The Population, increase in support of military or political Environment and Development Nexus” considerations. Debates in the 1960s and (in short, the “LEAD-PED Nexus 1970s took an alarmist view of popula- Training Programme”) that was initiated tion growth (e.g., Erhlich, 1968), arguing in 2005. Based on its sustained, growing strongly for strict population control. and successful track record, its innovative A turning point was forthcoming at and distinctive features, and its proven the United Nations Conference on impact, the programme may be regarded Environment and Development in Rio de as a best practice that is portable and Janeiro in 1992 when the international replicable. community agreed on objectives and A System Approach to Training in Population, Environment and Development – South Africa 163 actions aimed at integrating environment raised and the population strategies that and development in pursuit of the idea of it proposed. sustainable development, i.e., develop- To give focused expression to this ment that generates an increase in human strategic area, the Chief Directorate: productivity that is sustainable and Population and Development of the enhances, rather than damages, the qual- Department of Social Development ity of life of both humans and the draws attention to the strategic impor- environment (Gaisie, 2008, p. 224). The tance of the area and performs relevant linkage among population, environment activities within the field (Government of and development was explored in more South Africa, 2004b). It defines the inter- depth at the International Conference on play of the three principal factors – popu- Population and Development of 1994 in lation, environment and development – as Cairo, leading to the acceptance of reso- a nexus, in the sense explained earlier. lutions and a plan of action regarding sus- Population, environment and develop- tainable human development (United ment comprise a complex field that needs Nations, 1994a, 1994b). proper multi- and intersectoral under- Following these resolutions and the standing, cooperation and planning plan of action, the Government of South among all relevant stakeholders across Africa in 1998 adopted the Population departments, programmes, plans and Policy for South Africa (Government of projects. It requires so-called triple-bot- South Africa, 1998). This Policy envis- tom-line accounting, which means that ages a society that provides a high and development includes social and environ- equitable quality of life for all South mental factors in addition to economic Africans and in which population trends considerations. This triple bottom line is are commensurate with sustainable socio- needed to attain sustainable development economic and environmental develop- (Mpumalanga Provincial Government, ment. The goal of the Policy is, therefore, n.d.). One of the programmatic activities to bring about changes in the determi- in this area is the “LEAD-PED Nexus nants of the population trends of the Training Programme”. country so that these trends are consistent with the achievement of sustainable human development. The Government O RIGINAND H ISTORYOF has thus accepted that it is of strategic THE P ROGRAMME importance for the future of its population to attend to the interrelationship The “LEAD-PED Nexus Training between population, environment and Programme” originated from a partnership development (Government of South between the Department of Social Africa, 2004b). The Population Policy Development of the Government of South mandated such a focus in terms of its cen- Africa, represented by its Chief tral goal, the population concerns that it Directorate: Population and Development, 164 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES with its base in Pretoria, and Leadership for Mandela Metropolitan University. A Environment and Development (LEAD) Memorandum of Understanding with Southern and Eastern Africa (SEA), based at each university regulates its participation the University of Malawi.1 These two par- in the Programme. In practice, the uni- ties piloted the first concept of the pro- versity provides the venue, the main gramme during March 2005 in Kempton intellectual input and logistical infrastruc- Park, South Africa. Six months later during ture for the training course while the September 2005, the Programme was offi- other partners assist financially and intel- cially launched in Mohale, Lesotho, to lectually. Although the Programme has a serve as a regional Southern African proj- general theme and framework – sustain- ect driven by the Government partnership able human development within the con- with LEAD SEA. The “LEAD-PED Nexus text of population, environment and Programme” training is accredited with development – universities bring a spe- LEAD, and participants can continue to cialized focus according to their field of attend other courses of the LEAD Associate expertise. For instance, Nelson Mandela Programmes at any of the LEAD member Metropolitan University focuses on the programmes worldwide to qualify for fellow- integration of population, environment ship training.2 and development within the context of the municipal integrated development Since the launch, the Programme has planning processes in order to serve the been implemented initially as an eleven- need at the local community and district day3 training course in various parts of South levels where expertise is lacking. The Africa governed by a Project Document course title is “Population, Environment (2005) between the Government of South and Development in Integrated Africa and the United Nations Population Development Planning Processes”. Fund (UNFPA), which became the third partner in the Programme according to the mandate of its Second Country Programme G OALSAND P RINCIPLES for South Africa (2002-2005). AND D ESCRIPTIONOFTHE A number of South African universi- P ROGRAMME ties are involved in the “LEAD-PED Nexus Training Programme”, including O UTCOMESAND I MPACT the University of the Free State, the University of Cape Town and Nelson The “LEAD-PED Nexus Training

1LEAD SEA is a subsidiary of LEAD (Leadership for Environment and Development), which is an international NGO that focuses on capacity-building in leadership and sustainable development. References below to LEAD are to the worldwide NGO while LEAD SEA will refer to the Southern and Eastern African initiative of this NGO. 2In 2010, LEAD is bringing its International Training Session to Nelson Mandela Bay Municipality in Port Elizabeth, Eastern Cape Province, South Africa, as the final training of 210 Associates from about 50 countries to qualify as Fellows. The theme is “Leadership and Climate Change: Population, Environment and Development”. 3The length of the course is adapted according to the needs and circumstances of specific target groups. It varies between five and eight days, as will be explained later, but can vary even more. A System Approach to Training in Population, Environment and Development – South Africa 165

Programme” envisages a number of out- environment and development to comes for course participants (Government share information and experience. of South Africa, n.d. c, p. 6): Furthermore, as far as impact is con- • an understanding of the concept cerned, it is expected that the training of “sustainable development” and will raise awareness and build capacity to the role that participants can play make valuable contributions in the in their work individually and process leading to decisions on planning, within organizations in achieving development, implementation, monitor- sustainable development; ing and evaluation of policies on popula- • an understanding of the key sus- tion, environment and development in tainable development challenges order to improve the living conditions and their potential solutions at the and the quality of life of all South global, regional and local levels; Africans. It is envisaged that participants • needed skills to analyse and will develop and increase interest in pop- address global, regional and ulation, environment and development national population, environment issues to pursue careers that centre on the and development issues; population, environment and development nexus. Participants will increase • solid knowledge of the population, their capacity to identify key population, environment and development environment and development interrela- interrelationships; tionships and integrate them into policies • improved skills in policy analysis, and programmes on sustainable develop- including multisectoral policy ment (Government of South Africa, n.d. analysis, and in programme man- c, p. 6). agement, including programme formulation, implementation, These outcomes and the expected monitoring and evaluation; impact assume fairly sophisticated learn- • enhanced leadership skills in con- ing results. They contain three major cat- flict resolution, systems thinking, egories of outcomes in comprehensive change management and commu- learning: (a) a change towards a positive nication, especially as they relate attitude and values regarding sustainable to population, environment and development; (b) an increase in knowl- development interrelationships; edge that will lead to critical understanding of abstract concepts and complex • the ability to develop solutions that are both environmentally relationships and processes; and (c) the sustainable and socially equitable acquisition of sophisticated skills in lead- within the workplace and commu- ership, awareness-raising, and direction- nities; and giving and decision-making regarding policies, programmes and projects. • the initiation of a network of Understanding population, environment professionals involved in population, 166 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES and development interrelationships and dynamic and complex condition, it is their integration into policies and pro- necessary to understand the interrelation- grammes on sustainable development ships among the constituent factors of would require training in mastering high- the nexus of population, environment ly sophisticated intellectual tools and development and to acquire and (Government of South Africa, n.d. c, p. apply the knowledge and skills that this 5). One of these intellectual tools refers understanding must bring to design and to systems thinking, which is described in manage new complex eco-social systems. the following section. It should be understood that once a new eco-social system has been designed and S YSTEMS P ERSPECTIVE implemented, it will need to be redesigned and adapted continuously to Since the International Conference on remain sustainable. This means that Population and Development of 1994, information systems, including monitor- the challenge of sustainable human ing and evaluation systems, will need to development has become a globally rec- be designed and implemented as an ognized problem for all levels of policy ongoing activity to feed population, envi- design and implementation. This chal- ronment and development and related lenge is also recognized in the Population data into the decision-making systems in Policy for South Africa (Government of order to redesign and implement updated South Africa, 1998) that was adopted in and upgraded models of sustainable 1998. The challenge can be stated as fol- human development. lows: How can sustainable human development be achieved and maintained The key concept describing this given the reigning population and envi- extremely dynamic and complex situa- ronmental realities of the country? tion is integration. “Integration” refers to a process and ongoing activity that link The answer to this challenge is to be various elements to achieve higher levels found in the acceptance of the fact that of synergism or interrelationships that population dynamics need to be factored create new combinations and, according- into all development planning and imple- ly, new types of outcomes. In the present mentation in order to conserve natural context, this refers to the integration of resources for use by future generations, to population and environment in such a restore the degraded environment, to way that sustainable development would stop further environmental degradation, be possible and in fact materialize. to modify destructive consumption patterns to manageable levels for both devel- Integration is a process that regulates oped and less developed communities, to the functioning of systems by recombin- temper the demand on natural non- ing existing and new units and functions renewable resources, and to increase the to create even higher-order functions. In quality of life of all and the standard of human systems, this process is assumed living of the poor. To achieve this to be driven by human values, or value A System Approach to Training in Population, Environment and Development – South Africa 167 generalization. “Value generalization” Department of Social Development and refers to the process of the evolution of the United Nations Population Fund values to a higher order, i.e., of having a (UNFPA) in South Africa that attempted more generalized authority that will to develop insight into the integration of function as new forces of (more effective) population and development factors did integration of the units within the overall not make this explicit up until 2005. system.4 Globalization is an example in Laudable attempts have been put in place the sense that it refers to universal to develop an increased understanding of (transnational) values in human develop- the relevant interrelationships but the ment, such as the Bill of Human Rights.5 “LEAD-PED Nexus Training Programme” In the South African system, this is is the first to claim explicit training in sys- embodied in the Constitution of South tems thinking and the first that attempts Africa (Government of South Africa, to apply systems-thinking skills to the 1996), which is one of the major results topic. In this respect, the Programme is a of incorporating South Africa after 1994 unique and innovative venture. (i.e., since the abolition of apartheid) into The training in and application of the world system. The Mafikeng systems thinking in various fields general- Declaration on Population and ly has had the result that participants Development in Africa of 2007 sub- developed an enhanced insight into the scribes to general values and principles in relevant field. Systems-thinking applica- topics pertaining to population, environ- tions are, of course, without boundary or ment and development. restriction. Systems thinking is excep- A simple description of a system tionally suitable for applications where depicts it as a unit where its elements are one needs to think and work in a transdis- interrelated and where this interrelated- ciplinary and interdisciplinary way. It is ness has the effect that the whole (the furthermore essential as a tool in problem- system unit) is more than the sum of its solving. parts. The parts synergized to create a It is important that managers and higher energy output than the sum of leaders acquire these competencies to be each one’s individual output.6 able to design scenarios for alternative Understanding the population, envi- futures and to nurture vision. The leader- ronment and development nexus requires ship qualities that are critical in this a sophisticated knowledge of systems regard include capacity in interpretation, thinking. Training initiatives by the envisioning, explicating new values,

4Insights used here were drawn, inter alia, from the following sources: Parsons (1966, 1971) and Laszlo (2001). 5Other relevant examples are international declarations on topics relating to population, environment and development such as the Dakar/Ngor Declaration on Population, Family and Sustainable Development (1992), the Plan of Action of the ICPD (1994), and the United Nations Millennium Declaration and its eight Millennium Development Goals (2000). 6This is, of course, true only of dynamic (open) organic systems; in closed mechanical (e.g., a petrol engine) or steady-state systems, this is not true. See also Bailey (1998). 168 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES building synergy, and mobilizing The three partner universities follow resources and people towards reaching this outline to a large extent but amend it new ends. according to their own individual emphasis and special strengths. D ESCRIPTIONOFTHE P ROGRAMME As noted earlier, the course initially The core activity of the “LEAD-PED lasted 11 days and consisted of a series of Nexus Training Programme” is, of course, active and intensive learning activities training. The initial design of the preceded by a pre-course phase. The Programme is written up in a prospectus, duration of the course is now shorter: in called the Course Outline, which speci- the case of the University of Cape Town, fies the curriculum, the teaching and it is six and a half days; for the University learning approach, pre- and post-course of the Free State, it is eight days; activities, selection of participants and and for Nelson Mandela Metropolitan related topics (Government of South University, it is five days. Africa, n.d. c). These aspects are to be None of the universities are using the considered as the planned Programme pre-course phase that was initially pro- content and activities. However, in view vided in the Course Outline. According of experience gained and the differential to the Course Outline, the pre-course needs of target groups, amendments are phase was to be used to select the made along the way. The Course Outline participants and to provide them with serves as a framework according to which pre-course reading work that they were needs of specific institutions and target supposed to study and on which they groups are addressed in line with the would be tested. This would have had basic design. This design is introduced in two important functions: to introduce the table 3. participants to the field of study and to The main theme is population, envi- ensure that they would be on an equal ronment and development for sustainable footing when entering the active lectur- development. The accompanying themes ing part of the course (Government of are: environment and development; pop- South Africa, n.d. c, pp. 9-10). ulation and development; population and Apparently, owing to late registrations, environment; and competencies in lead- none of this is possible at present, which ership and management. Site visits and/or is a pity particularly because facilitators local case studies are important learning observe different levels of pre-course tools, and discussions and group work are knowledge among participants and the essential elements in the presentations. A need to introduce baseline material dur- variety of themes is addressed according ing the course. Provision should be made to the following topics although amend- for correcting this practice by going back ments and adaptations are made at each to the original idea or providing pre- university. study time to participants. A System Approach to Training in Population, Environment and Development – South Africa 169

A facilitator conducts daily monitor- introduced and discussed according to a ing of course activities. Presentations and conventional lecturing style while others learning activities vary. Some topics are are addressed in a workshop. Case studies

Table 3 Population, environment and development topics as per the Course Outline.

Population, Environment and Development for Sustainable Development

• Overview of key population, environment and development concepts and indicators; international agreements; • Systems thinking; • Simulations; • The role of indigenous knowledge systems in sustainable development; public participation; • Globalization, trade and sustainable development; and • Provincial growth and development strategies.

Environment and Population and Development Population and Environment Development • Population, gender and • Land tenure and human • Ecosystems and global development; settlements; change; • Reproductive health and • Agriculture and food • Ecological footprint; development; security; and • Resource utilization; • Social and economic impact • Disasters and vulnerability. • Health and environment; of HIV and AIDS; and • Environmental policies • Migration and urbanization. and tools.

Competencies in Leadership and Management

• Communication skills; • Conflict-resolution negotiation and decision-making; and • Change management.

Site Visits and/or Local Case Studies

These may include: • Sustainable commonage management; • Poverty alleviation and Working-for-Water/Working-for-Wetlands initiatives; and • Sustainable human settlements and land reform.

Source: Government of South Africa, n.d. c, pp. 11-22. 170 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES and simulations are used to ensure practi- The courses targeted professionals cal and applied learning and group work and managers who work in a sector that is encouraged and implemented. is concerned with development, such as international, national, provincial and After the course, participants are local government, NGOs, trade unions expected to develop networks among and the private sector, and high-level pol- themselves, the facilitators and the pre- icymakers. senters. This networking is used as a means of mentoring among individuals to The courses drew more participants assist one another at work. This is regard- from national and provincial government ed as a long-term benefit of attending the departments than from local government. course. The “Population, Environment and Development in Integrated Development The in-class training course content Planning Processes” course did not suc- focuses on a number of topics including ceed in drawing majority numbers from awareness creation and capacity-building local governments. Up until 2009, 85 regarding the population, environment and local government officials had attended, development nexus in sustainable develop- which represents less than a third of the ment, and leadership and management of total number of municipalities (local gov- population, environment and development ernments) in South Africa. issues in sustainable development. On the other hand, some municipalities sent more than one trainee and in I MPLEMENTATIONOFTHE some cases quite a number of them. It is a P ROGRAMME fact, however, that while local government managers and planners, especially Altogether 17 courses with a total enrol- those responsible for the integrated devel- ment of 452 participants were conducted from April 2005 to April 2010 under the Unemployed youths have become a target Programme. The second course, in for the Programme. Principles of systems Lesotho, was much shorter than other thinking are being introduced by Prof. courses as it served as the launching event Sosten Chiota from LEAD SEA. of the Programme. “Population, Environment and Development in Integrated Development Planning Processes” was first presented in October 2008; since then, another two courses have been given. Most of the courses were presented by the University of the Free State (7 courses) and the University of Cape Town (3 courses). A System Approach to Training in Population, Environment and Development – South Africa 171

Table 4 Courses given and distribution of course participants.

Course Participants South South South Non- South Africa Africa Africa South Africa Course Presented Total Nat. Prov. Local Africa Other Govt. Govt. Govt. (Africa) (NGOs) 03-15 Apr. 2005, Kempton Park 2 13 441 24 26-27 Sept. 2005, Lesotho 01210 0 13 21 Nov.-02 Dec. 2005, Africa Centre, KZN 10 710018 05-17 March 2006, Cape Town 9712 00 28 03-14 July 2006, Bloemfontein 8 11 720 28 16-27 Oct. 2006, Port Elizabeth 5483525 11-22 Feb. 2007, Kimberley 6603318 13-21 Sept. 2007, Bloemfontein 11 4217 0 34 25-31 Aug. 2008, Cape Town 15 26112 36 13-17 Oct. 2008, Port Elizabeth (“Population, Environment and Development in Integrated Development Planning Processes”) 12 260020 11-19 Sept. 2008, Bloemfontein 4 18 9 14 2 47 17-21 Nov. 2008, Port Elizabeth (“Population, Environment and Development in Integrated Development Planning Processes”) 9120517 04-12 June 2009, Bloemfontein 7623018 15-23 Sept. 2009, University of the Free State, Bloemfontein 8 11 821 30 01-07 Nov. 2009, Cape Town 4 11 750 27 07-12 Dec. 2009, Port Elizabeth (“Population, Environment and Development in Integrated Development Planning Processes”) 6 14 503 28 15-23 Apr. 2010, Bloemfontein/Golden Gate 20 6411 0 41 Total 136 124 85 75 32 452 % per government sphere, etc. 30.1 27.4 18.8 16.6 7.1 100

Sources: Government of South Africa, 2009a; Government of South Africa, 2010. opment planning process, are the target ments responsible for servicing local gov- for the Programme, it is not succeeding in ernment needs did respond favourably in attracting a majority to attend from this attending the Programme and were in source. It should be noted that depart- that sense answering the call to attend to ments in national and provincial govern- local planning and development needs. 172 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

P OST - TRAINING O PPORTUNITIES agents globally and within their own countries and regions. One expects, there- One of the major features of the “LEAD- fore, a continued impact among manage- PED Nexus Training Programme” is the ment and leaders regarding population, post-training opportunities that offer environment and development issues due unique possibilities for the further devel- to the increased awareness and knowledge opment of selected participants. improvement gained in the course. The available options include the Support was provided to four local completion of the entire LEAD Associate government participants to undergo programme, internships at relevant United United Nations Economic Commission Nations agencies, exchange programmes for Africa internships with a focus on between countries and progression to a population, environment and develop- post-graduate programme. Post-training ment in the work place and on gaining a support is provided through a network of population, environment and develop- participants with a tutor. This means that ment orientation to plough back into participants, on their return from the their local situation. course to their workplace, may discuss questions among themselves with techni- Some evidence was forthcoming that cal support from tutors. Participants will exposure to training according to the also be subscribed to the Population and model of the “LEAD-PED Nexus Environment Research Network of the Training Programme” might be beneficial International Union for the Scientific for finding job opportunities among Study of Population. unemployed youth. At least one such pilot was conducted with a measure of All the participants will become success.7 As this example demonstrates, LEAD Associates. In addition, a limited the Programme is showing potential for number of participants have an opportu- vertical portability by including and ben- nity to join LEAD training to receive efiting a variety of target groups. detailed training in leadership in sustainable development. This would enable Finally, participants have an opportu- participants to become LEAD Fellows. nity to continue post-graduate population, environment and development studies at The “LEAD-PED Nexus Training partner universities depending on the Programme” produced more than 40 requirements of the universities. One of LEAD Fellows until the end of 2009 and the partner universities (University of the doubled the number of LEAD Fellows in Free State) is recognizing LEAD popula- South Africa. LEAD Fellows act as change tion, environment and development

7In this case, the Department of Environmental Affairs and Tourism requested a pilot LEAD population, environment and development course among unemployed youth, which was presented by Dr. Anton de Wit from Nelson Mandela Metropolitan University, with the result that participants received job placements within six months after completing the course. The roll- out of this version of the course on a larger scale is now under consideration (Government of South Africa, 2010). A System Approach to Training in Population, Environment and Development – South Africa 173 training in its master’s degree programme ter. People responsible for the publica- in Development Studies. tion have been trained in the “LEAD- PED Nexus Training Programme”. The N ETWORKINGAND S UPPORT newsletter serves as an advocacy instrument, appears twice a year and has a cir- There is a need for networking and mutual culation of about 5,000 (Government of support in the post-training phase as indi- South Africa, 2010). cated earlier. Various mechanisms have been created for this purpose, notably the The Department of Social Development printed Population, Environment and Development maintains a Population and Development News and an e-driven information service run Information and Knowledge Centre, by the Department of Social Development. which serves the population and development community, among others, through Population, Environment and Development an e-driven subscribers’ information serv- News is a collaborative venture by the ice. The service includes an environment Department of Social Development and list with subscribers to whom information an NGO, Bethelsdorp Development messages (about publications, conferences, Trust (BDT). The aim is to provide a courses, etc.) are sent. Items are linked communication channel for population, or can be requested directly from the serv- environment and development (PED) ice. Items are also added to the trainees to share information, news and population.gov.za website where they are ideas about, within and among communi- downloadable. The service provides a rich ties within South Africa and the region. and up-to-date source of data and informa- The information is generated from a tion on issues relating to population and community base and is not moderated the environment. by the Government although the Government acts as a facilitator. In its Population, Environment and first edition, December 2006, the lead-in Development Research and Case article states that “This newsletter should Studies always have a distinctly local ‘flavour’. It Information on population, environment must contain news and stories of local and development issues serves to community activities from across Africa, enhance interest in as well as the level of like those of the BDT. You, the reader, insight into the interrelationships among have an important role to play to ensure the core components of the nexus and that your own PED stories also get told how they are affecting not only the con- herein, so that others can read them.” stituent parts and system but also the The Bethelsdorp Development Trust is wider and outer systems. Often these regarded as a successful population, envi- intricate systems are best understood by ronment and development initiative. It is having access to in-depth case material operating in the Nelson Mandela Bay that demonstrates the dynamic processes municipal area and hosting the newslet- in real-life situations. The “LEAD-PED 174 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Nexus Training Programme” stimulates be from the “LEAD-PED Nexus Training not only a need for case studies but also Programme”. Pre-courses are offered in initiatives to conduct such studies. Two South Africa, the United Republic of unpublished volumes contain the result Tanzania and Malawi, which creates a of these studies, which are collaborative basis for a regional network in PED train- efforts by individual researchers and ing. The LEAD International Training research institutions with the Session is held in one of the poorest Department of Social Development. The provinces of South Africa, which is pro- first volume includes papers that provide viding financial, intellectual and net- information on the policy and legal working inputs to the province and city. framework of population, environment Six areas are identified for continuation and development interrelationships; the of case study research, with consideration theoretical and international debates on of the theme of the international session, this topic; the various thematic aspects of namely, “Population, Climate Change the interrelationships; women and popu- and Development”. lation, environment and development; technology; economics; and training and Climate Change partnerships. This volume may serve as a Climate change is the most significant theoretical and contextual introduction emerging issue in international population in population, environment and develop- and development discussions, as reflected ment training (Government of South in resolutions adopted by the United Africa, n.d. a). The second volume Nations Commission on Population and includes six real-life case studies on pop- Development in 2008 and 2009 and in ulation, environment and development the Kampala Declaration of the Partners interrelationships in South Africa in Population and Development (PPD) (Government of South Africa, n.d. b). (Government of South Africa, 2010). The “LEAD-PED Nexus Training Climate change as an acute environ- Programme” has therefore stimulated mental issue in relation to population and in-depth research into population, envi- development has therefore become an ronment and development interrelation- urgent challenge. In the 15-year review ships. Further research, training and of the International Conference on regional networking are encouraged by Population and Development within the the fact that LEAD is conducting its Southern African Development Community Cohort 15 International Training Session (SADC) region, it is recommended that in Eastern Cape (Nelson Mandela Bay the impact of environmental degradation Municipality, Port Elizabeth), South and climate change on sustainable devel- Africa, during 2010. Participants in this opment and the need to strengthen training qualify as LEAD Fellows. In capacity to address this impact be recog- order to qualify for enrolment, pre-cours- nized (Government of South Africa, es must be completed, one of which may 2009b, pp. 18 and 58). The above- A System Approach to Training in Population, Environment and Development – South Africa 175 mentioned International Session on of view, in an adult learning setting, with Population, Climate Change and time restricted, it is imperative that learn- Development and its associated activities ing situations be well planned, well therefore seem to be a timely response to resourced and facilitated by well-pre- this call. The “LEAD-PED Nexus Training pared, knowledgeable and experienced Programme” has provided the necessary instructors. It should furthermore be institutional link for bringing this input to understood that the trainee audience is the country. mixed and varied in terms of academic background, professional experience, and cultural, age and gender composition. A SSESSMENTAND The minimum academic entrance qualifi- E VALUATION cation is a bachelor’s degree. Given this background as a description of the teach- I NNOVATIVEAND D ISTINCTIVE ing challenge, participants have observed A SPECTS the following as innovative and distinctive aspects of their learning experience The “LEAD-PED Nexus Training in the Programme. Programme” may be regarded as a bold innovation in teaching a complex topic, First of all, one participant observed distinguishing itself from other pro- that “it is the interrelatedness of the three grammes in the population capacity- topics that makes it both a challenge and building field. Programme facilitators and the key for human prosperity”. It seems past participants testify to the extent to that this participant recognizes the sys- which they have experienced the temic nature of the study topic and Programme as an innovation and distinc- gained insight from this fact. Other par- tive venture.8 This section provides per- ticipants concur by pointing out how spectives and findings on this question. well the Programme succeeds in making the complexity understandable through From a general perspective, the topic well-designed teaching and demonstra- of population, environment and develop- tion settings, well-prepared facilitators, ment interrelationships itself is multifac- bringing theory and practice into imme- eted and complex and therefore extremely diate relationship with one another, and challenging to teach. It requires a using cases studies, field trips, the natural multi- and inter-disciplinary approach, environment and practitioners. explaining the theoretical concepts and models for understanding this complexi- In addition, participants mentioned ty and providing hands-on illustrations in that they found the coverage of a rather practical situations to grasp the theoreti- wide range of topics from different angles cal underpinnings. From a teaching point and vantage points to demonstrate the

8A special investigation to this effect was conducted by the author of this case study. 176 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES linkages among population, environment a real-life context. The field visit enables and development as a distinctive aspect. participants to integrate theoretical con- It is not only different approaches that cepts and practical experience within a are making the distinction but also the natural environment.” fact that the Programme draws from dif- The total mix of the various elements ferent countries, cultures, professions of the teaching experience was also val- and age groups. “This makes for a great ued: “The balanced use of a variety of learning experience”, said one partici- adult learning methods including the pant. Another participant appreciated the emphasis on cross-cultural experience multidisciplinary approach: “So many and exchange of expertise” is a distinctive disciplines form part of the course, which feature. means that your horizons are broadened.” The creation of networks also was The methodology of teaching was seen as a special feature. As a participant also experienced as innovative and dis- stated, “The programme teaches a philos- tinctive. Case studies, group projects and ophy and approach to sustainable devel- group presentations were appreciated in opment rather than mere facts that will this regard. A participant testified that be reinforced for many years to come by “The interactive setting highlighted key strong networks and support for further concerns and challenges. Issues that I had learning. I have found the interaction read and studied before and during the with fellow group members helps to keep session from books were brought to life me motivated and involved.” through carefully crafted and finely observed practical applications.” The dis- Some participants and even tinctive element therefore was “the focus Programme facilitators alluded to the fact on interactive learning and practical that they were not aware of other pro- application in group context and using grammes in this particular field and there- case studies”. fore regarded this Programme as unique in itself: “The venture itself and the topic An example of how one university are a unique intervention within the (University of the Free State) attempted South African context.” to bring a real-life situation into the teaching setting was the bringing on Finally, the University of Cape Town board of South African National Parks saw the innovative aspect of this (SANParks) as a partner. The innovative Programme as the fact that the nexus of aspect was the involvement of a second- population, environment and develop- ary partner, SANParks, which “has ment is regarded as a teaching topic. ensured the programme of a sustainable Furthermore, it found the partnership case study and the incorporation of between the public sector, civil society inputs of practitioners working in the and particular academic organizations to PED context. Participants were given be innovative. practical exposure to the PED linkages in A System Approach to Training in Population, Environment and Development – South Africa 177

S TRENGTHSAND W EAKNESSES environment and development nexus, have since been identified and developed A mid-term evaluation of the “LEAD- (Government of South Africa, 2009a). PED Nexus Training Programme” was commissioned by UNFPA and the Although no further evaluation was Department of Social Development and subsequently undertaken on the same conducted in 2006 to assess the first scale as the mid-term review of 2006, group of courses and the experience of post-course assessments were conducted participants and to make recommenda- by the various universities. These assess- tions for future application (Gaisie and ments covered all sessions/presenta- Groenewald, 2006). tions/exercises in each course. The findings from these assessments do not This evaluation found that most par- differ significantly from those of earlier ticipants viewed the Programme as a suc- assessments and the mid-term evaluation cess. The apparent reason for its value lay and in fact support the findings of those in the mix of the course elements and the assessments. With respect to one univer- foundational value of systems thinking to sity (University of the Free State), a sig- which participants had been introduced. nificant improvement in the participants’ The evaluation concluded that to main- ratings was observed over the period tain a lasting effect, the course module from 2006 to 2008. Participants were needed to be followed up by further sim- responding generally positively to the ilar but reinforcing modules and accredit- Programme. At another university ed with the South African Qualifications (University of Cape Town), nearly all Authority so as to affirm its high stan- participants confirmed consistently over dard. The course could be redesigned to three courses that they felt that the cater to homogenous levels of seniority course contributed to their capacity to do groupings of participants to facilitate the work and that they had gained new institutionalization of the course on post- knowledge and skills. graduate levels where the need might arise. The course needed to be seen as a Weaknesses noted in the mid-term template for developing a series of short evaluation (Gaisie and Groenewald, 2006) courses on different levels that all fit the include the following: population and development interaction framework. • No pre-course learning activity seems to be required, which has a This recommendation by the mid- negative effect on starting the term evaluation of the “LEAD-PED Nexus course on an equal footing. Training Programme” received a positive • Some course attendants are diverse response by the Government’s Directorate in terms of their level of knowl- for Population and Development. Various edge and experience and seniority training initiatives of different kinds and level, which slows down the pace formats, all related to the population, of group exercises and contributes 178 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

to increased frustration among the local courses are accredited with the participants. international LEAD programme (LEAD, • Apart from the accreditation by 2010). the LEAD fellowship programme, On the level of the individual partic- there seems to be a need to have ipant, trainees provided generally posi- the Programme registered with the tive responses about the course, as South African Qualifications already indicated. Numerous comments Authority. One university has listed in the formal evaluation by the uni- accredited the Programme within versities confirmed this. Participants a post-graduate Programme. grasped the idea and an understanding of • Targeted selection of prospective key population, environment and devel- trainees should receive more atten- opment interrelationships and developed tion, particularly among groups the skill to integrate them into policies where the need for population, and programmes on sustainable develop- environment and development ment (Gaisie and Groenewald, 2006). knowledge is apparent, such as Generally, it seems that this outcome has among local government managers been accomplished. and planners. Some participants were encountered who did not acquire the desired knowl- E NHANCEMENTOF PARTICIPANTS ’ C APACITY edge and skills but the evaluation concluded that the courses were successful in The partnership of the Programme with accomplishing the main objective of LEAD brings numerous advantages, as acquiring integrative skills. has become clear from the overview above. Using case studies as a learning In the recent inquiry,9 participants strategy has proven to be highly success- were asked to indicate whether in their ful. LEAD has applied a case-study experience the course had enhanced the approach worldwide for the past 18 capacity to do their work. Nine out of ten years. The LEAD Network has 14 region- participants answered in the affirmative. al offices that each provides capacity The participants were also requested development courses and activities. The to provide examples of how, or where, “LEAD-PED Nexus Training Programme” they had applied, with a measure of suc- in South Africa is already linked regional- cess, insights, knowledge or skills ly to the LEAD Network. The concept acquired in the course. Examples of appli- has been applied elsewhere in Africa, cations include the following: which is an indication of the portability of the Programme also into countries of • A participant was able to run a Francophone Africa. As mentioned earlier, programme on the social and

9As noted earlier, the inquiry was specifically conducted by the author for the purposes of this case study. A System Approach to Training in Population, Environment and Development – South Africa 179

economic impact of HIV/AIDS. • A participant was involved in • A participant used the Gender and course designs regarding a training Access to Resources module to manual on integrating population manage a poverty-relief project issues into development policies and to recognize the role that and plans and the Allied gender is playing in this regard. Population Sciences Training and Research (APSTAR) manual. The • A participant had to compile socio- participant was able to give inputs economic profiles for the munici- regarding the importance and palities in the province and was need to address the integration of able to link local government policies population, environment and and accompanying budgetary development in both the courses. documentation to the exercise. • A participant had to critique a • A participant worked with paper on population, environment engineers from Infrastructure and development linkages in Development (which, according to addressing environmental sustain- his/her perception was “always ability. The training made it possi- developmental”) as well as the ble to review the author’s views Social Facilitation section. With and perspectives and to (re-)shape the population, environment and policy perspectives in this respect. development knowledge, he/she could now ensure “that a balance These examples show that a wide is achieved between development, variety of applications is indeed possible people and environment”. for participants who have acquired • A participant said that he/she had knowledge and skills as intended through the opportunity to use knowledge the training. It can therefore be conclud- gained from the course in advocacy ed that the Programme succeeds in pro- and capacity-building sessions that viding the desired outcomes. the office was conducting with district and local municipalities. I MPACT • A participant used the acquired The course outcomes are important and knowledge and skills in running a critical in establishing impact among par- campaign of early childhood ticipants, in society and on the physical immunization against measles and environment. other diseases. • A participant used insights and With respect to the participants, their knowledge from the course when capacity to perform their work and duties, writing a synthesis report on the and their work situation, evidence has implementation of the Population been provided to reach the following con- Policy between 1998 and 2008. clusions in line with the expected outcomes, that is, the majority of participants: 180 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

• seem to have an understanding of It could be expected that the major the concept of “sustainable human overall societal impacts to follow from development” and the role that these outcomes would be enhanced sus- they can play in their work indi- tainable human development, a more vidually and within organizations; equitable and harmonious society, • seem to have an understanding of improved quality of life, a population less key sustainable development chal- vulnerable to natural and man-made dis- lenges and of how to address them asters, and informed and empowered at global, regional and local levels leadership. Because it would be impossi- in so far as this is related to their ble to measure and demonstrate empiri- work situation; cally links between these expected • have developed insight into the impacts and the specific inputs of a singu- skills needed to analyse and lar programme, one may only assume, on address global, regional and reasonable grounds, that the “LEAD-PED national population, environment Nexus Training Programme” does have a and development issues; contributing effect in the above-men- • have acquired improved knowledge tioned respects. of population, environment and The impact on the physical environ- development interrelationships; ment, for example, may result from • have developed insight into the changes in individual behaviour, which skills needed to perform policy will only have a significant impact when analysis and undertake programme a large enough number of individuals management, formulation, imple- change their behaviour to environmen- mentation, and monitoring and tally friendly patterns. This means that evaluation; impact from the Programme possibly will • have developed insight into the only be significant as a result of aware- skills needed in conflict resolution, ness and advocacy, making use of suitable systems thinking, change manage- information, communication and educa- ment and communication as they tional action. On the assumption that the relate to population, environment Programme is reaching leaders and man- and development interrelationships; agers who have a wide range of influence, • have enhanced their ability to one can expect measureable impact develop solutions that are both although demonstrating causal linkages environmentally sustainable and will remain a difficult methodological socially equitable within the task. One therefore must opt for an workplace and communities; and impact argument that assumes causality • have formed networks with profes- as a result of critical mass, perhaps result- sionals involved in population, ing in public measures (e.g., policy and environment and development to legislation) and public opinion that pro- share information and experience. mote environmental rehabilitation and A System Approach to Training in Population, Environment and Development – South Africa 181 conservation in the broadest sense of the and parcel of the existing development word. In this respect, the Programme is policy (in this case, the Population assumed to be on the right track. Policy) of South Africa. The final question regarding impact On the other hand, because of the is whether the Programme has in fact status of the Programme as a develop- resulted in changes in public policy meas- ment measure, it has been considered as a ures and public opinion that would pro- special tool in facilitating local develop- mote sustainable human development ment planning. Local development plan- based on a sound understanding and res- ning is a formal, legally sanctioned process, olution of population, environment and under the auspices of local government, development issues. which, according to the Constitution of South Africa (Government of South In this regard, it should be noted that Africa, 1996), has full responsibility as the Programme is a result of such public well as the obligation to take care of local measures and public opinion in so far as community development. these measures and opinions are already in existence. It has been argued exten- The Municipal Systems Act sively in this case study that there is a (32/2000) provides the legal provisions global consensus regarding the strategic for local government to fulfil its importance of the population, environ- Constitutional obligations and responsi- ment and development interrelationships bilities. In this regard, development at the and about the critical nature of popula- community level must answer to so- tion, environment and development called “triple bottom-line accounting”, issues (for example, climate change being which refers to the need to incorporate a particularly important issue at present). population (the social component), envi- The case study has indicated that South ronment and development into local Africa has indeed bought into this argu- development (Mpumalanga Provincial ment, among others, by endorsing the Government, n.d.). global consensus and concerns and by Government, through the Chief adopting a Population Policy that under- Directorate: Population and Development, scores the concerns and issues. In this identified the need to build capacity case study, the route has been traced by among local government institutions which the “LEAD-PED Nexus Training (municipalities) and personnel to perform Programme” has come about as a specific their responsibilities in formulating and venture, among others, to address (some implementing integrated develop plans. of) these concerns and issues. The case These plans, once adopted, will become study has also shown how the the legally binding instrument for perform- Programme has expanded in terms of par- ing the development process for the local ticipant numbers and institutional government area of jurisdiction. By train- response. It may therefore be correct to ing integrated-development-plan and assert that the Programme is already part 182 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES related managers of local government, the PED Nexus Training Programme” is pro- “LEAD-PED Nexus Training Programme” viding some lessons learned and guidelines is becoming a real, direct influence in the in considering these issues. integrated-development-plan process, as examples of the application of knowledge • The implementation of the and skills acquired in the training have Programme in South Africa was demonstrated. informed and supported by training sessions conducted by LEAD A specific instrument has been elsewhere in Africa and developed designed to assist the “LEAD-PED Nexus in close collaboration with LEAD. Training Programme” in fulfilling this task. In fact, some academic content This instrument is a guideline titled Taking used in the present implementa- Population Seriously in Your IDP: A Guide for tion was developed by LEAD and Integrating Population Information into Integrated is still applied in sessions by LEAD Development Planning. This guideline has locally and elsewhere. Some been submitted to the Chief Directorate: presentations are made by LEAD Population and Development and has personnel. This points to an been used already in the training of partic- important principle and in fact a ipants in the Programme on two occasions requirement for the successful (Groenewald, 2010).10 In this way, the transfer of a programme such as “LEAD-PED Nexus Training Programme” this, namely, that close collabora- has become institutionally integrated into tion is maintained between the the development policy and planning sending agent and the receiving agent. Part of the success of the process at the local level of governance. It Programme in South Africa can be may therefore be concluded that the ascribed to the adherence to this Programme is impacting on development principle. policy, planning and implementation. • The Programme has the potential for portability. Transference geo- L ESSONS L EARNEDAND graphically from one region/coun- R EPLICATION try to the next has taken place successfully and is an example of horizontal transference. In this An important question remains whether case study, it has also been shown the Programme has the potential to be that vertical transference is possi- replicated in another country. What ble, namely, from one target group would be the requirements for and poten- to another. In both cases, adapta- tial stumbling blocks in such a move? The tion to the needs of the new envi- experience in establishing the “LEAD- ronment/target group is necessary

10 The research and writing of the guideline were commissioned by the Department of Social Development and introduced on two occasions to participants at the University of Cape Town course in November 2009 and the Nelson Mandela Metropolitan University course in December 2009. A System Approach to Training in Population, Environment and Development – South Africa 183

and changes should initially be there is sufficient capacity, interest piloted before new content, struc- and enthusiasm on the part of the tures and practices are established. local academic partner. Home • Institutionalization is a strong if institutions should have at their not essential principle and process disposal adequate and suitable to ensure sustainability in the ven- resources and infrastructure for ture. This is valid for the present implementing the Programme. Programme as well as new pro- • A dedicated and experienced grammes. “Institutionalization” group of presenters should be means that the programme can be recruited and maintained to pres- seen as a function of the relevant ent a series of courses that are organization or organizations committed to the population, within a framework of agreed part- environment and development nerships. A strong institutional idea and the Programme. foundation, with partnerships as • Financial responsibility should be the basis, is therefore recommend- shared among the partners. ed. The relationship among part- Dependency on single-party fund- ners and their individual roles and ing is risky and unsustainable. obligations should be regulated Each partner should be clear on its according to memorandums of financial input into the running of understanding and agreement. the Programme. In this respect, • Implementing agencies should the South African Programme sees have a clear understanding of what the UNFPA role as that of an incu- is involved in implementing the bator that enables the start-up of Programme. In other words, they the Programme (memorandums of should know the requirements, understanding for funding, cur- both scientifically and logistically, riculum writing, pilot courses, etc.) and preferably have hands-on and not as responsible for subsi- experience in the implementation dizing the Programme as a whole. of projects. The Chief Directorate: Population • From the point of view of imple- and Development claims that this mentation, there is a need for a is an innovative engagement of champion of the Programme, i.e., UNFPA that is actually making the someone to drive the Programme Programme more self-sustaining at each of the home institutions owing to the institutionalization of (programme coordinator); this also role expectations at the partner and particularly applies to govern- level (Government of South ment. Without key champions at Africa, 2010). key partner institutions, the • The Programme would need a Programme is doomed to failure. fully designed curriculum includ- To act as a champion implies that ing a course outline and study 184 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

guide together with suitable study added to this and was a key in the forging material. Standards and norms of the partnership between the should be specified. Government of South Africa and • The most suitable replication UNFPA. The involvement of LEAD may model should be investigated. The have been motivated by the fact that key following are options but combi- role players were LEAD Fellows who nations would also be possible: upheld the values of leadership and environmental sustainability. The inclusion of – the course may be transferred as a universities should be regarded as a delib- package deal; erate policy directive to involve stake- – participants are transferred from holder communities in planning and the area of need to the site of development. presentation; The role players mentioned above – presenters are shared between the progressively plan and execute the institu- existing and the new Programme; tionalization of the Programme. First, – existing implementing agents are there was an agreement between the shared with the new Programme; Government of South Africa and UNFPA – capacity is built in the new envi- to collaborate on this venture. This was ronment in order to enable the followed by a Project Document with new presenters to become expanded agreement conditions and equipped for their task. This will parties, involving LEAD. Universities stimulate self-sufficiency in the were consulted and formally included long run. through memorandums of understanding. Secondary and other partners were included along the way. The following T HE F UTURE : C ONDITIONS partners may be mentioned: SANParks FOR D EVELOPINGAND (Golden Gate Highlands National Park in E XPANDINGTHE Free State, Addo Elephant National Park P ROGRAMME in the Eastern Cape), the Africa Centre in KwaZulu-Natal, Coega Industrial The process of crafting this Programme Development Zone in the Eastern Cape, was elaborated earlier. In South Africa, Bethelsdorp Development Trust in the the Population Policy for South Africa Eastern Cape, Nelson Mandela Bay (Government of South Africa, 1998) Municipality in the Eastern Cape and the served as a major rationale for the idea of Bus Rapid Transport System. a training and capacity-building pro- The role players represent a wide gramme to deal with population, envi- spectrum of stakeholders and interests ronment and development issues. The ranging from international (UNFPA, country programme of UNFPA, especial- LEAD), regional (Southern African ly its Population Development Strategy, Development Community, Southern A System Approach to Training in Population, Environment and Development – South Africa 185

African Ministers’ Conference on Municipality were trained in the “LEAD- Population and Development), national PED Nexus Training Programme”. These (Government of South Africa, Department leaders encouraged colleagues to be of Social Development, Chief Directorate: trained and, as a result, the awareness and Population and Development) and provin- knowledge level regarding population, cial (Provincial Population Units) to local environment and development issues players (e.g., Nelson Mandela Bay increased significantly and a centre of Municipality) as well as various universities gravity started to develop regarding pop- (University of Cape Town, University ulation, environment and development of the Free State, Nelson Mandela interrelationships. For example, a local Metropolitan University) and specialist municipal policy and implementation organizations and businesses, as listed process began with respect to the so- above. The active engagement of the vari- called “green economy”. It provided for ous institutional spheres through the hosting the LEAD International Session mechanism of the memorandums of under- on Population, Climate Change and standing and the sustained involvement Development, which spurred a range of of participants in the post-training phase activities relating to population, environ- through the LEAD Associate and ment and development interrelation- Fellowship Programmes ensured a high ships: public seminars; a university level of community engagement. course; scholarships for training in population, environment and development However, in a recent follow-up issues; network-building, etc. inquiry by the author,11 it was observed that a substantial number of participants Local institution-building is one of could not be traced through the address the prerequisites for sustainability in pro- system on record. This shows that the grammes. It depends on visionary leader- alumni system could be upgraded and ship. It is therefore extremely important kept in better condition than it is at pres- to nurture leadership through the train- ent. By keeping alumni on an active and ing and capacity-building processes of up-to-date circulation list, networking the Programme, to develop and build could be more effective and the circula- effective communication processes to tion of Population, Environment and spread the message and to anchor these Development News could be better targeted. efforts within an institutional framework. A good example is the development of Attempts are made to build and Population, Environment and Development strengthen local institutions. One exam- News and its anchoring in the Bethelsdorp ple is strengthening and supporting Development Trust. This venture is nur- Nelson Mandela Bay Municipality. The turing leadership (an editor from the process started when leaders from the Trust), a communication channel and

11 The inquiry for this case study. 186 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES mechanism (Population, Environment and build capacity in this regard that may Development News) and institution-building impact constructively on development (the Trust has become a platform for policy, planning and implementation. news, information and interpretation). The case study provides evidence of a The training programme and the ses- best practice and innovative and distinc- sions are accredited with the international tive approaches in the implementation of LEAD Programme. Participants can con- this Programme in terms of its design, tinue to attend other courses of the LEAD development and expansion. It has been Associate Programme at any of the 14 argued that the topic itself, the inputs LEAD member programmes worldwide. into the implementation of the The various universities involved are in the Programme, the methodologies fol- process of gaining recognition for the lowed, the quality of the facilitators, the course within the various university struc- management of the Programme, the tar- tures according to the procedures for get group, the partnerships, and the fol- accreditation by the South African low-up networking of participants all Qualifications Authority or the South contributed to its best-practice status. African Council on Higher Education. The case study shows that the Such accreditation will carry recognition Programme has strong portability poten- throughout the university system of South tial and that it should be possible to repli- Africa. This will enhance the credibility cate the model in other environments. A and sustainability of the Programme. list of requirements, based on lessons learned, is provided for this purpose.

C ONCLUSION Finally, the Programme is considered as a product of development policy and planning and a contributor to the more This case study on the “LEAD-PED effective implementation thereof as well Nexus Training Programme” has shown as a direct stimulus for the further that understanding interrelationships advancement of development policy and between population, environment and planning, particularly in the area of inte- development is an urgent and important grated development planning in South issue for South Africa and beyond, as Africa. confirmed in international and national discourse. In particular, climate change has become a matter of grave concern A CKNOWLEDGEMENTS regarding the future quality of life of people and in poverty alleviation. Awareness- I would like thank the following people raising, knowledge enhancement and who assisted in providing information: skills development are measures neces- Prof. Sosten Chiota, Director, LEAD sary to address the issue. The Programme Southern and Eastern Africa, University of introduced in this case study aims to Malawi, Zomba, Malawi; Dr. Anton de A System Approach to Training in Population, Environment and Development – South Africa 187

Wit, Department of Geography, Nelson Gaisie, S. (2008). “Population and develop- Mandela Metropolitan University, Port ment interrelationships: Global perspec- Elizabeth; Prof. Ralph Hamann, Associate tives”. In: R. Marindo, C. Groenewald, and Professor and Research Director, Graduate S. Gaisie, (eds.), The State of the Population in School of Business, University of Cape the Western Cape Province. Cape Town: HSRC Town, Cape Town; Ms. Carol Lombard, Press, pp. 221-237. Population and Development Information Gaisie, S. K. and Groenewald, C. J. (2006). Centre, Chief Directorate: Population and Building Capacity of Government Officials to Development, Department of Social Integrate Population Factors into Development Development, Pretoria; Ms. Eunice Policies, Programmes and Activities: A Review of Nchoe, Chief Directorate: Population and the LEAD-PED Nexus Training Programme Development, Department of Social 2005-2006. Commissioned by the Development, Pretoria; Ms. Lynn O’Neill, Government of South Africa and the University of Cape Town, Cape Town; United Nations Population Fund, Vol. 4. Prof. André Pelser, Department of Pretoria, July. Sociology, University of the Free State, Government of South Africa (2010). Bloemfontein; Ms. Nola Redelinghuys, Interview with and information received Department of Sociology, University of from Mr. Jacques van Zuydam, Chief the Free State, Bloemfontein; and Mr. Director, Population and Development, Jacques van Zuydam, Chief Director, Department of Social Development. Population and Development, Department Pretoria, May. of Social Development, Pretoria. ______(2009a). Progress Report: Population I would also like to express my appre- and Development Capacity Building Initiatives. ciation to the trainees who responded to Pretoria, June 2009. Department of my inquiries and provided qualitative Social Development, Chief Directorate: answers to the questions. Population and Development. Unpublished. ______, (2009b). Review of the Fifteen Years R EFERENCES of the International Conference on Population and Development (ICPD) Programme of Action Bailey, Kenneth D. (1998). ”Social ecolo- (POA) in the Southern African Development gy and living systems theory”. In Systems Community (SADC) Region. SADC Research and Behavioral Science, vol. 15, No. Ministers’ Conference on ICPD + 15, 5, pp. 421-428. John Wiley & Sons, Inc. 2009. Department of Social Development, Chief Directorate: Communication. Barnhart, C. L. and Barnhart, R. K. (eds.) Pretoria. (1982). The World Book Dictionary. World Book-Childcraft International, Inc. ______(2006). South Africa Environment Outlook. A Report on the State of the Ehrlich, P. (1968). The Population Bomb. Environment. Department of Environmental New York: Ballantine Books. Affairs and Tourism. Pretoria. 188 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

______(2004a). Report of the Southern Groenewald, C. (2010). Taking Population African Ministers’ Conference on Seriously in Your IDP: A Guide for Integrating Population and Development held in Population Information into Integrated Maputo, Mozambique, on 7 May 2004. Development Planning. Commissioned by Department of Social Development. the Chief Directorate: Population and Pretoria. Development, Department of Social Development. Pretoria. ______(2004b). Strategy on Population and Development 2004-2009. Laszlo, A. (2001). “The epistemological Department of Social Development. foundations of evolutionary systems Pretoria. design”. In Systems Research and Behavioral Science, vol. 18, pp. 307-321. John Wiley ______(2002). Strengthening Sustainability and Sons, Inc. in the Integrated Planning Process. National Framework Document, final Leadership for Environment and draft. Department of Environmental Development (LEAD) (2010). Interview Affairs and Tourism. Pretoria. with and information received from Leadership for Environment and ______(2000). Municipal Systems Act (Act Development Southern and Eastern No. 32 of 2000). Africa, Prof. Sosten Chiota, Director. ______(1998). Population Policy for South University of Malawi, Zomba, May. Africa. Pretoria. Mafikeng Declaration on Population and ______(1996). Constitution of South Africa, Development in Africa: Research and Act 108 of 1996. Pretoria. Policy Dialogue for Action (2007). Adopted at the conference on ______(n.d. a). Vol. 1: Theoretical Debate on “Population and Development in Africa: the Interrelationships between Population, Research and Policy Dialogue for Environment and Development in the Context of Action”, held in Mafikeng, South Africa, Sustainable Human Development in South Africa. 5-8 March 2007. Department of Social Department of Social Development. Development. Pretoria. Unpublished. Malthus, T. R. (1976 [original 1798]). An ______(n.d. b). Vol. 2: South African Case Essay on the Principle of Population, P. Studies Illustrating the Population, Environment Appleman (ed.). New York: W. W. and Development Nexus at Local Level. Norton and Company. Department of Social Development. Unpublished. Mpumalanga Provincial Government (n.d.). Population, Development and ______(n.d. c). Course Outline. Leadership Environment. Department of Health and Training in Sustainable Development: The Social Services, Population Unit, Population, Environment and Development Nexus. Nelspruit. Department of Social Development. Pretoria. Parsons, T. (1971). The System of Modern A System Approach to Training in Population, Environment and Development – South Africa 189

Societies. Englewood Cliffs, New Jersey: World. New York and Oxford: Oxford Prentice-Hall, Inc. University Press. Parsons, T. (1966). Societies: Evolutionary ______(1999). Human Development Report and Comparative Perspectives. Englewood 1999: Globalization with a Human Face. New Cliffs, New Jersey: Prentice-Hall, Inc. York and Oxford: Oxford University Press. Population and Development Information Centre (2010). Information received from ______(1998). Human Development Report Ms. Carol Lombard, Deputy Director, 1998: Consumption for Human Development. Chief Directorate: Population and New York and Oxford: Oxford Development, Department of Social University Press. Development. Pretoria. ______(1997). Human Development Report Population, Environment and Development 1997: Human Development to Eradicate News (2006). Bethelsdorp Development Poverty. New York and Oxford: Oxford Trust and Department of Social University Press. Development. Port Elizabeth, December. University of Cape Town (2010). Pre-project Document between the Information received from Prof. Ralph Government of South Africa and the Hamann (Programme Coordinator/ United Nations Population Fund (2004). Facilitator) assisted by Ms. Lynn O’Neill. Unpublished. Cape Town, May. Project Document between the University of the Free State (2010). Government of South Africa and the Information received from Programme United Nations Population Fund (2005). Coordinator and Facilitator, Prof. André Unpublished. Pelser. Bloemfontein. United Nations (1994a). International Conference on Population and Development Contacts (ICPD), Cairo, Egypt. Enquiries Regarding the LEAD-PED United Nations (1994b). Population Plan Nexus Training Programme of Action, Cairo, Egypt. Mr. Jacques van Zuydam United Nations Development Chief Director Population and Programme (UNDP) (2007). Human Development Development Report 2007/2008: Fighting Department of Social Development Climate Change: Human Solidarity in a Private Bag X901 Divided World. Houndmills, Basingstoke, Pretoria 0001 Hampshire and New York: Palgrave South Africa Macmillan. Tel.: +27 12 312 7961/7953/7500 ______(2002). Human Development Report Fax: +27 12 312 7710/7932 2002: Deepening Democracy in a Fragmented E-mail: [email protected] [email protected] 190 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Website: www.population.gov.za

Enquiries Regarding the Case Study: Prof. Cornelius Groenewald University of Stellenbosch P.O. Box 193 Capegate 7562 South Africa Tel./Fax: +27 21 9820173 Mobile: +27 82 444 0205 E-mail: [email protected] Experience in 8 Addressing Mother- Thailand to-child Transmission of HIV/AIDS within a Community Framework Mrs. Nareeluck Kullurk

Summary

In 2000, the Ministry of Public Health of Thailand issued a policy that aimed to prevent the transmission of the human immunodeficiency virus (HIV) from mothers to their children. The national policy combined core services in preventing mother-to-child HIV transmission with existing care for mothers seeking prenatal care at all government and some private hospitals. These services should have included general care and psychosocial help and they should have stressed the linkages between hospitals and communities. The national policy and guideline did state, however, that HIV-infected mothers and their children should receive a continuum of HIV care to improve their health and receive other appropriate treatment and care whenever needed.

The medical and related health services for mothers and children are part of the government mainstream health service facilities, which are found at all levels of administration and in all geographical areas. Government health-service providers in these facilities are often overburdened with a heavy workload and might not always have been able to spend sufficient time with patients, in particular with HIV-infected patients who require psychological support in addition to medical services. As a result, peer leaders of people living with HIV/acquired immune deficiency syndrome (AIDS) were called upon to provide assistance to the health-service providers in the government hospitals. In Thailand, the people living

191 192 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

with HIV/AIDS have played an important role and have been active in self-help groups for people living with HIV/AIDS. Many of these people have become peer leaders and have been recruited and trained by non-governmental organizations to work closely with the staff in the communities. The community network is yet another important mechanism that has helped and encouraged HIV-infected mothers to bring their children for follow-up. Coordination among health-service providers in hospitals, peer leaders of people living with HIV/AIDS and the community network needed to be strengthened in order to increase the access to support and help.

In 2005, a project to provide care and support for HIV-infected mothers, their partners and children was developed and set up in 41 provinces. The project was implemented by the Department of Health with collaboration and coordination from the Thai National AIDS Foundation. The Foundation brought in its network of peer leaders of people living with HIV/AIDS to work closely with the government service providers in clinics for maternal and child health/prevention of mother-to-child HIV transmission. The project offered HIV treatment and care for infected mothers, their children and spouses; follow-up of HIV testing and antiretroviral treatment (ART); supportive ongoing counselling; and psychological support for children infected with or affected by HIV. It organized peer support groups in hospitals and communities, campaigns for the better understanding of HIV/AIDS in the community, policy advocacy for a reduction of stigmatization and discrimination, health education for school teachers and effective community-based networks. It also aimed at strengthening the linkage between health-care facilities and communities as well as the capacity of groups of people living with HIV/AIDS to provide holistic care for HIV-infected mothers and their children. These project activities encouraged the mothers to remain with the project and to come back for regular medical check-ups.

This case study describes the successful implementation of the above-mentioned project initiated in 2005 whose activities were qualified as best practices in seven of the 41 provinces. The project was a successful service model in that it helped HIV-infected women, their children and families to receive a continuum of HIV/AIDS care and remain in the HIV care programme. Furthermore, the number of diagnosed children born to HIV-infected mothers also increased and they could be given timely and appropriate care. There was also an increase in the number of husbands participating in the HIV care programme.

Information on the Author Mrs. Nareeluck Kullurk, Head, Mother and Child Health/AIDS Working Team, Bureau of Health Promotion, Department of Health, Ministry of Public Health. Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 193

B ACKGROUND In 2000, the Ministry of Public Health launched a policy aiming to pre- The Thailand human immunodeficiency vent the transmission of HIV from moth- virus (HIV) sentinel sero-surveillance sys- ers to their children. In 2001, the core tem, which was started in 1989, detected component services of the policy were a median rate of HIV infection of 0.8 per combined with routine prenatal care in cent among pregnant women in 1991. hospitals. These services, however, did The trend increased to 2.3 per cent in not put any emphasis on psychosocial 1996, began to decline in 1997 and support, holistic care or linkages between remained constant at around 1.2 per cent communities and hospitals. until 2000. In 2000, the prevalence rate The programme on the prevention of of HIV infection among pregnant mother-to-child transmission was women was 0.7-1 per cent. launched in all government hospitals and The HIV transmission rate from some private hospitals all over the coun- mothers to children was reduced from try, in total 954 hospitals in 76 provinces, 30-40 per cent to 25 per cent by including regional, provincial and district providing formula milk to babies born (community) hospitals. The services for to HIV-infected mothers. The national prevention of mother-to-child transmis- programme for prevention of mother-to- sion were integrated into maternal and child HIV transmission using oral short- child health services: antenatal clinics, course zidovudine (AZT) started in 2000 delivery rooms, postpartum wards and and resulted in a diminishing number of well-child clinics. The infected mothers, cases of acquired immune deficiency syn- their husbands, and their children who drome (AIDS) in children under two needed antiretroviral treatment (ART) years of age. were to be referred to ART clinics. Each year, around 800,000 babies are The programme on the prevention of delivered in health-care facilities. Out of mother-to-child transmission was a suc- these, 6,000-8,000 (0.7-1 per cent) are cess but new issues had to be addressed. born to HIV-infected women. Without For example, the number of orphans was any intervention, it is expected that around becoming a serious problem and HIV- 1,500-2,000 of these children would be infected mothers often had the first infected with HIV (a 25 per cent transmis- symptoms of the illness two years after sion rate). Thanks to the programme on delivery. In 2002, a project entitled the prevention of mother-to-child trans- “Enhancing Care and Support for HIV- mission, which has implemented various infected Mothers, Their Children and intervention strategies to prevent HIV Families” was initiated in four provinces transmission from mother to baby, the as a pilot model. The project focused on number has been reduced to 300-400 chil- the follow-up of HIV-infected mothers, dren (a 5 per cent transmission rate). their children and their husbands. It was implemented by the Department of 194 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Health, which coordinated HIV-care school teachers, affected parents and care- activities among governmental organiza- givers, and health-service providers. The tions, non-governmental organizations activities included enhancing HIV-related (NGOs) and community-based organiza- care and treatment and the provision of tions. The programme activities includ- antiretroviral treatment in hospitals, peer ed: supportive ongoing counselling; support groups in hospitals and communi- disclosure counselling for husbands; pro- ties, campaigns promoting better under- vision of HIV treatment and care for standing of HIV/AIDS in communities, HIV-infected mothers, children and hus- policy support for the reduction of bands; follow-up of children for HIV stigmatization and discrimination, health testing and referral of HIV-infected chil- education for school teachers, and effec- dren to HIV treatment and care pro- tive community-based networks. grammes; and caring for HIV-affected and HIV-infected children in an attempt P ROJECT A REAS to offer them a better quality of life. The project areas comprised 71 commu- Finally, in 2005, with the support of nities of 15 districts in 7 provinces the Global Fund to Fight AIDS, spreading over 4 regions of the country: Tuberculosis and Malaria, the project, the Northern region (Payao and “Enhancing Care and Support for HIV- Lampoon); the Northeastern region infected Mothers, Their Children and (Sakolnakorn and Khonkaen); the Families”, was expanded to 41 additional Southern region (Nakorn Sri-Thammarat provinces in order to develop good prac- and Pattalung); and Cholburi in the tices in providing more comprehensive Central region. The Northern region is holistic care that included psychosocial an area with a high prevalence rate of support for HIV-affected children and HIV infection. The Northeastern region HIV-infected women, their husbands/ has a low HIV prevalence rate as does the partners and families as well as strength- Southern region. The central province of ening the linkage between health-care Cholburi has a high HIV prevalence rate. facilities and community-based networks. P ROJECT O BJECTIVES I MPLEMENTATION The project focused on: • providing a continuum of care and This case study describes the successful services for HIV-infected mothers, implementation of the project that was their children and families through identified as a best practice in seven well-planned collaboration and provinces in four regions of Thailand. The coordination among government project focused on coordination and par- organizations, NGOs and communi- ticipation of networks of people living ty-based organizations in the health with HIV/AIDS, community leaders, facilities and communities; and Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 195

• promoting awareness and a wider For example, children of HIV-infected understanding of HIV/AIDS with- mothers were not allowed to attend child in the communities through care centres in the villages. For this rea- providers of health services and son, many HIV-infected mothers did not leaders of people living with want to use the services from local hospi- AIDS. The aim was to reduce tals since they were afraid that their stigmatization and discrimination illness would be disclosed to their neigh- against HIV-infected mothers, bours. The reduction of stigmatization their children and their families. and discrimination would enhance the Increased awareness and better quality of life of HIV-infected mothers, understanding could then lead to their partners and their children. policy formulation.

S TRATEGYAND I NTERVENTIONS The Continuum of Care In this project, “continuum of care” meant Developing the Network all the services provided to HIV-infected At the beginning of the project, a work- mothers, their children, husbands and ing group was set up, which consisted of families. These comprehensive services health-service providers from provincial included prevention, care, treatment and and district hospitals, groups of people support and were available to patients in living with AIDS, community members their homes, in the communities where and NGO staff. The working group car- they lived and in the health-care facili- ried out an analysis of the situation and ties. Those involved in the services held discussions to identify the problems included government health-care and the needs. Programme activities were providers, NGO representatives, people then developed to address those needs. living with AIDS, and other stakeholders All stakeholders were engaged in the such as community leaders and school development of the work plan. Training teachers. The continuum of care enabled courses were developed to train providers more people to have access to services of health services and leaders of people and helped them to accept and adhere to living with AIDS to ensure that they were antiretroviral treatment. It ultimately well informed and prepared for the pro- improved the quality of life of HIV- ject implementation. infected mothers, their children and their families. Building Capacity Training Stigmatization and Discrimination Stigmatization and discrimination were Training sessions using the standard cur- the barriers hindering the access to care, riculum were conducted in regional, treatment and support of HIV-infected provincial and district hospitals and in mothers and their families. Discrimination subdistrict health stations for maternal occurred mainly within the community. and child-health and prevention-of- 196 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES mother-to-child-transmission clinic staff group for people living with AIDS in hos- and other related staff. The aim was to pitals, and home visits by peer leaders of enable these medical structures to offer people living with AIDS who were in the counselling and HIV testing in antenatal community. clinics and in the delivery room, disclosure and risk-reduction counselling, and Family Camps holistic care for HIV-infected mothers and their families. The community lead- Family camps were arranged for family ers of people living with AIDS attended members of HIV-infected mothers. The separate training courses. They were three-day camps aimed to encourage par- trained in all aspects of the project and in ticipants to share their knowledge of and their expected role and responsibilities, experiences in HIV/AIDS prevention and which included: knowledge of HIV/ care. Through various activities run by AIDS and prevention of mother-to-child health-service providers and people liv- transmission, home-based care, commu- ing with AIDS, key issues were discussed, nities/network activities, reproductive such as health-care support, dealing with health, child rights, opportunistic infec- loss in the family and communication tion, antiretroviral treatment and peer among family members. counselling. These training sessions were run by the Thai National AIDS Camps for Children and Foundation. After the course, the trainees Parents/Caretakers met to map out an action plan and organ- Camps for affected and infected children ized appropriate activities in clinics and under 12 years of age were organized. within the communities to ensure that Caretakers or parents also participated. interventions relating to treatment, care Child care, child growth and develop- and support of HIV-infected mothers, ment, life skills, HIV prevention and their children and families were effective. treatment, and positive living with per- The action plan would serve as a guide- sons with HIV/AIDS were the main top- line and would ensure collaboration and ics of these camps. The camps also cooperation. offered psychosocial support for both the For the group of people living with children and the caretakers. People living AIDS, the capacity-building activities with AIDS and health-service providers aimed to provide HIV-infected mothers collaborated to organize these camps and their families with the appropriate twice a year. knowledge and the essential skills to improve their quality of life and enable Community Campaigns them to live together like other normal Exhibitions and mass media campaigns families in the community. The activities on HIV/AIDS/prevention of mother-to- included: family camps, child-parent child transmission and care were organ- and/or caretaker camps, a peer support ized on special occasions and important Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 197

national holidays to provide information tributed to various activities relating to and to build the capacity of NGO and HIV/AIDS/mother-to-child-transmission community-based-organization staff in prevention and care. the communities. The campaigns and exhibitions conveyed messages on a Developing and Strengthening broad range of topics, such as prevention Comprehensive Services of HIV/AIDS, prevention of mother-to- HIV-infected pregnant women received child HIV transmission, antiretroviral care and treatment starting from the ante- treatment, reproductive health, gender natal period. They received counselling issues, peer-to-peer counselling, child to help and encourage them to disclose care, psychosocial support, and reduction their HIV status to their partners. Once of stigmatization and discrimination. the partners had been informed, they, in They helped community members and turn, were encouraged to participate in their leaders to have a better understand- the programme. ing of HIV/AIDS and prevention of mother-to-child transmission so that they Support Group in Hospitals could, in their capacity, support and work A support group meeting for people liv- with HIV-infected women and HIV- ing with AIDS was arranged on a month- affected children in their communities. ly basis at the antiretroviral treatment clinic after the patients’ scheduled Training for Networks of Community- appointments to receive their drug sup- based Organizations ply. This was the time when people living From time to time, the community net- with AIDS would discuss their problems, works, namely, village health volunteers, share experiences and seek advice from women’s groups, breast-feeding support the peer leaders. The health-service groups, youth clubs and groups of people providers were also present to give moral living with AIDS, were offered one-/two- support. Problems shared by people liv- day training courses. The topics of the ing with AIDS ranged from health, side courses varied depending on the needs. effects and adherence to antiretroviral They included: self-health care for HIV- drugs to personal and family-related infected mothers and family, general issues such as safe sex, condom use, health care, follow-up for adherence to reproductive health, and social and eco- antiretroviral drugs, peer-to-peer coun- nomic concerns. Usually 10 to 12 people selling, and care for HIV-affected and living with AIDS would participate in HIV-infected children. As a result, the such a support-group meeting. community networks were able to use the acquired knowledge to provide coun- Peer Leaders of People Living with selling, care and support to the people in AIDS Collaborating with and need. On many occasions, the communi- Assisting Health-service Providers ty networks participated in and con- One of the important roles of the selected 198 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES and trained peer leaders of people living their affected children. The peer leaders with AIDS was to assist health-service usually made home visits in pairs on a providers at antenatal and antiretroviral monthly basis. All home visits were clinics. They shared their knowledge on recorded by peer leaders of people living self-health care, prevention of mother-to- with AIDS in their monthly report to child HIV transmission, physical and their central office (Thai National AIDS psychosocial care, food and nutrition, Foundation) and funding agency. exercises, adherence to the antiretroviral drug treatment and prevention of oppor- Collaboration of Peer Leaders of tunistic infections. They also provided peer People Living with AIDS with counselling, moral support and advice on Community-based Organizations and various matters. The assistance of these Administrative Organizations of Local trained peer leaders was helpful to both the Authorities health-service providers and the people living with AIDS who were patients. It less- Throughout the project, peer leaders of ened the workload of the health-service people living with AIDS acted as coordi- providers and the patients felt more at ease nators between the administrative organi- talking to someone who had had a similar zations of the local authorities, experience and was familiar with clinical community-based organizations and settings and procedures. people living with AIDS on matters concerning child care, child education, child support and career training. In addition, Home Visits they coordinated with teachers and The main persons making home visits school authorities to discuss the children’s were peer leaders of people living with education and fellowship opportunities AIDS. Health-service providers used and to prevent potential discriminatory their routine postpartum home visits (one treatment towards the children. On some visit per case) to visit HIV-infected moth- occasions, the peer leaders would ers to avoid any potential discrimination approach these local authorities to ask for of the mother in the community. The their cooperation in the interest and sup- peer leaders of people living with AIDS port of the infected mothers and affected were trained and had a basic knowledge children and families. of most aspects of antiretroviral drugs, adherence and side effects; self-health Policy Advocacy care; reproductive health care; and well- HIV/AIDS campaigns were conducted at child care. Regular home visits by these least twice a year on the occasion of spe- peer leaders were made only to those cial festivals and on World AIDS Day. In who disclosed their HIV status and who the communities, campaign activities had given their prior consent. Home vis- were arranged by NGOs and groups of its provided regular care and psychoso- people living with AIDS, with support cial support to HIV-infected mothers and from the government health personnel. Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 199

Community leaders and members of the ensured a comprehensive array of services. public participated in the campaigns, NGOs in particular played a crucial role in which aimed to provide knowledge about facilitating access to the target population HIV/AIDS and its prevention and pro- at the community level and to those who mote better understanding among the might otherwise be difficult to reach. community members on HIV/AIDS and the prevention of mother-to-child trans- C APABILITYOF H EALTH - SERVICE mission in order to reduce stigmatization P ROVIDERS and discrimination. The project evaluation collected data in Evaluations done after the campaigns the sample area and found that every revealed that the community members large hospital had at least five to six per- and their leaders gained a better under- sons trained and working as counsellors standing of issues such as HIV/AIDS or mediators. Small hospitals had two to transmission and prevention, mother-to- three counsellors. Each of the hospitals child transmission, living life with others had two to three persons from the net- in the community, having a positive atti- work of people living with AIDS trained tude towards people living with AIDS, as counsellors and resource persons. In safe sex and condom use. The communi- some areas, service providers of the net- ty leaders expressed their wish to set up work of people living with AIDS were additional activities to prevent HIV/ recognized as effective counsellors and AIDS in their own areas. Suggested activ- resource persons, meeting regional and ities were: organizing campaigns to national standards of performance. promote condom use for sexually active In addition, members of the network people and to encourage people living of people living with AIDS built their with AIDS to make use of the easier capacity to the extent that they could access to the antiretroviral treatment as transition from service recipients to serv- well as setting up supportive measures for ices providers and become effective focal persons affected by AIDS. points for AIDS activities at the community level. They contributed to an R ESULTSAND increased awareness and understanding of AIDS and helped to reduce stigmatiza- A CHIEVEMENTS tion among various groups in the community such as young people, women COLLABORATIVE E FFORTBETWEEN and local leaders. THE P UBLIC S ECTORSAND NGO S Results from the project progress Cross-institutional collaboration was nec- report showed that peer leaders of people essary; it helped to build the capacity of a living with AIDS had well-developed range of service providers in the public capacity and achieved good results. They sector, NGO agencies and networks of helped approximately 957 HIV-infected people living with AIDS, which in turn 200 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

mothers and 852 affected children to S ITUATIONOFTHE HIV- INFECTED access the support services through coor- M OTHERSAFTERTHE dinated and hence more effective con- I MPLEMENTATIONOFTHE tacts with 71 subdistrict administrations P ROGRAMME and municipalities in 7 provinces. A total of 972 HIV-infected mothers went to the hospital for follow-up COMPREHENSIVE S ERVICES : appointments on a continuous basis. H OSPITAL - BASED P OST - PARTUM Most of them received information on C ARE antiretroviral drugs and drugs for oppor- Over 90 per cent of the HIV-infected tunistic-infection prophylaxis. They were women received post-partum care, which able to take care of their health and included information on hospital services remain in good health. They could con- and advice on infant formula feeding; 81 tinue to work, for example as factory per cent received self-care counselling; workers. They had easier access to avail- and 77 per cent received family-planning able social services such as a monthly counselling. Over half (57.9 per cent) of allowance and funds from the social the husbands/partners of HIV-infected development and human security office. women came for HIV counselling and The HIV-infected mothers gained screening; 61 per cent joined support knowledge and a better understanding of groups, groups of people living with safe sex, sexually transmitted diseases AIDS, friends-help-friends groups or and other important issues such as repro- other related associations. ductive choice. They acquired better negotiation skills to urge their hus- Peer leaders of people living with bands/partners to use condoms. The AIDS made 1,709 home visits to HIV- HIV-infected women in the programme infected mothers and their children. were able to lead their lives as normal Post-partum home visits to HIV-infected persons in the community. Most of them mothers were still problematic in cases did not experience discrimination by where the women had not yet revealed other community members. A majority their serostatus to their husbands or (80 per cent) of HIV-infected mothers immediate families. During the project, disclosed their HIV status to their spous- HIV-care home visits were paired with es/partners and/or family members. visits for other diseases or health services. Usually, a local health volunteer and S ITUATIONOFTHE HIV- INFECTED a peer leader assisted with the home AND HIV- AFFECTED C HILDREN visitation. Among the 182 HIV-infected children in In addition, 1,377 group meetings for the programme areas, 153 received anti- HIV-infected pregnant women and retroviral drugs for treatment. The infected mothers took place in hospitals and 724 children were referred to 15 community family and child camps were organized as hospitals for their antiretroviral treatment. well as 5,071 community campaigns. Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 201

The children who did not receive anti- Routine supervision and monitoring retroviral treatment were followed up by a activities at all levels of service facilities paediatrician on a regular basis. Children’s helped to strengthen the project. camps were conducted for these children. At these camps, the affected children W EAKNESSES learned how to interact with their friends, It remained difficult for HIV-infected how to participate in a group and what mothers to agree to disclose their HIV their responsibilities were. After partici- status and this reluctance proved prob- pating in the camp’s activities, the lematic when trying to work with them. children felt more confident. The programme staff were not able to access a number of people in the target S TRENGTHSAND group because they feared stigmatiza- W EAKNESSESOFTHE tion and discrimination. As a result, they refused to come forward to receive ser - P ROGRAMME vices provided by the government organizations or the NGOs. S TRENGTHS As explained earlier, the collaboration ONITORINGAND between the public sector and NGOs was M one of the programme’s main strengths. E VALUATION The project provided a chance for all stakeholders to learn and participate in P ROGRAMME M ONITORING the community’s activities. All the com- Programme monitoring was carried out munity organizations and persons by the programme staff at the communi- involved joined hands and participated in ty level on a monthly basis throughout the programme with their full potential the duration of the programme. A well- and expertise. The assigned staff from the designed and tested programme record local authority administrations, the form was used to record the information schools, the public health sector, govern- needed. Data were compiled to prepare ment organizations and NGOs devoted a quarterly reports of programme activities, great deal of their time to carrying out outcomes and achievements. The reports activities for the vulnerable people in the were then analysed and discussed among communities, especially HIV-infected the project team members. Suggestions pregnant women and children. and recommendations were duly consid- The programme on prevention of ered for problem-solving and appropriate mother-to-child transmission of HIV/ programme adjustments. AIDS resulted in a good maternal and child health service system, which was integrated into the programme. 202 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

E VALUATION primary education; one fourth had completed high school. Also, 83 per cent External Evaluation were living with their husbands at the External evaluation was carried out with time of the interview. By occupation, 54 the objective of evaluating the overall per cent were employed in low-wage programme. The conceptual framework labour jobs; one third were housewives; of the programme, the input, the process and one woman was a full-time student. and the output variables that contributed More than half the women stated that to the outcomes and the impact of the they did not have enough income; only programme all were evaluated. 15 per cent had enough to meet their needs and for saving. Evaluation Results The summary of the evaluation report Among this group of women, 39 per states that the project was able to build cent knew of their serostatus before their the capacity of health-service providers last pregnancy; 58 per cent learned that at all levels of implementation by encour- they were HIV-positive during the last aging them to make the project services pregnancy; and three only learned their part of their routine occupational func- serostatus at the time of delivery. The tion. The project strengthened the (estimated) duration of infection among health-service system and advocated those who knew their serostatus before for policy and activities to combat the current pregnancy was between 10 stigmatization and discrimination. The months and 15 years. Approximately one implementation plan of the project was half of this group had taken antiretroviral consistent and was integrated into the drugs previously. Among those who national AIDS plan. It included the par- learned their serostatus during their last ticipation of AIDS subcommittees at the pregnancy, the time of diagnosis ranged provincial level that received policy from 2 to 32 weeks of pregnancy. directives from the national AIDS com- The availability of antenatal-care mittee. The pro ject also worked closely services at the health-centre level with agencies in the private sector includ- enabled the referral of HIV-infected ing the Thai National AIDS Foundation. women to local, district or provincial The project was fully endorsed by the hospitals. At the district hospital, the local administrative organization. women were encouraged to join the peer The study population for the evalua- support group for people living with tion report consisted of 95 HIV-positive AIDS. Approximately half of the women women who had recently had a baby. had initiated antiretroviral therapy The women were between 19 and 47 because their CD4 cell level had declined years old, most of them (56 per cent) to below 200, which qualified them for were 25 to 34 years old, and only 16 per the antiretroviral therapy. Antiretroviral cent were 19 to 24 years old. Slightly therapy was given continuously during over half of the women had completed pregnancy, delivery and post-partum Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 203

periods. As long as the infected patient monitoring, follow-up and access- was registered and remained in the proj- ing hard-to-reach groups such as ect system, she, her partner and her chil- non-Thais, displaced persons, dis- dren benefited from continuous medical advantaged groups, and persons in follow-up even after they returned to challenging socio-cultural circum- their home community. stances that make it difficult for them to access services. In most cases, infants were scheduled • A coordinating agency established for treatment and care at paediatric clin- in the community played an ics. To avoid the hassle of several trips important role in the success of and ensure group attendance, the the programme as a result of its appointments were made for the HIV- role in encouraging capacity- infected women and their babies on the strengthening of the field staff to same day. The Day Care Department enable them to gain knowledge continued to provide care and monitor- from the learning process. ing for them for one year post-partum. • Groups of the HIV/AIDS network in the community that help in giv- L ESSONSLEARNED ing support to the HIV-infected pregnant women, children and their families are essential and From the evaluation results and the needed for their better quality of progress report, it was learned that: life. Health care and psychosocial • A great deal of experience was support extended to the mothers, gained by working in a model of their children and families need to collaboration and partnership be provided on a continuing basis. between the government, NGOs, • The role of people living with peer networks of people living AIDS is to provide assistance and with AIDS, local administrators work for HIV-infected mothers, and the community. The project their children and families. It is goals required a modality of important that the people living implementation that went beyond with AIDS gain not only knowl- public health and extended to edge and skills but also more cultural, social and community experience and self-confidence dimensions of the local context. and achieve better teamwork. Thus, it was necessary to involve Drawing from their personal expe- private-sector organizations in rience, people living with AIDS order to achieve full coverage and can assist health personnel in how continuity of services. to inform patients of the result of • The government and NGO sec- the HIV test. Having gone tors learned more about better through the same situation, they ways of providing care, treatment, are fully aware of the psychological 204 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

effect that the news can have on R EPLICABILITYAND the patients. S CALABILITY • Encouragement by and participation of the local authority are vital S UGGESTIONFOR R EPLICATION for the sustainability of the pro- AND S CALABILITY gramme. Accurate knowledge and a full understanding of HIV/AIDS Three major activities are needed for the among community leaders con- programme to be successful: community tribute to the success of the situation analysis and preparation, collab- programme activities. Working oration of the community in programme effectively and efficiently at the planning and implementation, and super- local level requires the support of vision and monitoring by the technical all relevant organizations from assistant. the horizontal and vertical lines of management. Community Situation Analysis and Preparation • Working with HIV-infected children requires a sound understand- A situation analysis should be done ing of children’s psychosocial before starting the programme.The infor- development. A good relationship mation gathered would include target based on trust is essential for populations and their characteristics, working with children. Children health problems, local diseases, the epi- need encouragement and support demiology of HIV/AIDS and other dis- to develop their self-confidence. eases, social norms, cultural practices and values, local wisdom, community beliefs • NGOs involved in the project need to have a high level of technical and way of life, and available community skills in order to provide effective resources that can support and facilitate support to affected families. the programme. Community preparation can be done through meetings that need • Some of the service providers in the participation of all parties and sectors the project restricted their partici- involved that represent people’s interest pation to routine activities, groups, organizations and various net- ignoring the added benefit to the works in the community. The data analy- target population that could be sis provides useful information about the achieved through greater effort. Improvement and adjustment of community that will be made known to the overall project management those involved and form a basis for which and coordination must be main- interventions/activities can be planned tained throughout the duration of accordingly. A needs assessment of the the project. community should also be conducted in order to find out its real needs so that the programme plan can be appropriately Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 205

drawn up to serve and address the prob- Having all parties work together in a lems and needs of the community. coordinated and collaborative manner to implement the programme activities Collaboration of the Community in according to the plan is a powerful strat- Programme Planning and egy for achieving the desired results. Implementation Meetings can be arranged for involved A meeting to plan the programme activi- community members to provide them ties should be organized for all stakehold- with information for a better understand- ers in the community, which include ing of the programme implementation. target populations (HIV-infected moth- Such meetings can also be venues for ers, husbands, affected children and their clarifying and clearing up misunderstand- families), community leaders (people ings while ensuring that everyone living with AIDS/youths, housewives, involved is well informed. etc.), community administrators (head of the village, tambon leaders), religious S UPERVISIONAND M ONITORING leaders, community government officers (school teachers, staff of day-care centres, Supervision and monitoring regularly by health-centre staff, tambon administra- a technical assistant can be done through tors, municipal staff) in order to devise a field site visits so that the programme fol- plan for activities that suit the community low-up and coordination with communi- situation and context. The meetings can ty networks are closely monitored. be arranged for each group or for all Besides fieldworkers and the participating groups together, as appropriate. This community, people were made aware that meeting also helps to encourage commu- their work in the field was an important nity members to participate, take full part of the programme. responsibility for dealing with their Regular follow-up meetings can be community problems and help to find a arranged for the working team at three- solution to such problems. Some commu- month intervals in order to monitor the nities may need funds for implementing progress of the programme, provide sup- the programme. Fund-raising events can port to activities in the community by the also be organized to raise funds and technical assistant and the Thai National resources available in the community with AIDS Foundation, make appropriate the collaboration of government organi- adjustments to the planned activities and zations and NGOs. Such events, when troubleshoot problems that might occur. organized to coincide or tie in with the Through such meetings, the programme local social, cultural or religious events, activities can be closely monitored on a can also increase responsibility and the regular basis, allowing timely and appro- sense of ownership of the programme priate programme adjustment and prob- among members of the community. lem-solving. 206 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Documentation of activities imple- and care for HIV-infected mothers mented by reporting on the progress of and their families; and the programme every three months will • policy advocacy against stigmati- enable the programme to become more zation and discrimination of HIV- accountable and measurable against the affected people in the community. plan in addition to keeping those involved informed. Lessons learned at the local and Contacts central levels can be identified to ensure that they are well documented for Nodal Institutions wider dissemination and replication. Programme evaluations should be con- Bureau of Health Promotion ducted to learn about the specific results • Director of interventions/activities as well as the Address: Tiwanon Road, Mueng overall outcome of the programme for the District, Nonthaburi 11000, Thailand adjustment of the future health service Tel.: +66 2590 4417, +66 2590 4418 system, legislation and policy advocacy. Fax: +66 2590 4427, +66 2590 4432 E-mail: www://anamai.moph.go.th

F UTURE P LANS Thai National AIDS Foundation (TNAF) • Ms. Yenjit Somphoh, Director Programme planning for the future Address: 191 Phaholyothin Soi 11, includes the following: Samsennai, Phayathai, Bangkok 10400, Thailand • enhancement of the care and Tel.: +66 2279 7022 3, +66 2279 1951 treatment for affected children in Fax: +66 2618 4748 the community. A data reporting E-mail: [email protected] system regarding affected children Website: www.thaiaids.org will be developed at the community and provincial levels. The coverage of affected children who Drafting Team have received care should be Bureau of Health Promotion, Department increased; of Health, Ministry of Public Health • policy advocacy by local adminis- • Mrs. Nareeluck Kullurk trative offices to support HIV- Head, Maternal and Child infected mothers and children and Health/AIDS Working Team for community participation in the Tel.: +66 2590 4417 prevention and control of Fax: +66 2590 4432 HIV/AIDS; E-mail: [email protected] • increased capacity of people living with AIDS to work on prevention Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 207

• Dr. Nipunporn Voramongkol Technical Assistants Chief, Maternal and Child Health Raks Thai Foundation Group • Mr. Promboon Panitchpakdi, Tel.: +66 2590 4418 Executive Director, Suratthani Branch – Fax: +66 2590 4432 Southern E-mail: [email protected] • Mr. Prasan Sathansatid, Programme Manager • Mrs. Mukda Tagrudthong Prevention of Mother-to-child Transmission Team Member Phayao Development Foundation – Northern Tel.: +66 89 995 0558 E-mail: [email protected] • Mrs. Supaporn Thinwattanakul, Director Thai National AIDS Foundation (TNAF) Net Foundation, Surin Province – • Ms. Yenjit Somphoh Director Northeastern Tel.: +66 2279 7022 3, +66 2279 1951 • Mr. Chakrit Hankhampha, Director Fax: +66 2618 4748 E-mail: [email protected], Migrant Workers and Their Families [email protected] Organization – Central Website: www.thaiaids.org • Mr. Pinyo Verasuksawat, Director

• Ms. Pintong Lekan Tel.: +66 2279 7022 3, +66 2279 1951 Subproject Team Fax: +66 2618 4748 Phayao Province [email protected] E-mail: • Mr. Khongsak Khamon, Phayao Website: www.thaiaids.org Persons with HIV/AIDS (PHA) Network Project Team • Mrs. Kanjana Somrit, Raks Thai Foundation Programme Management Organization • Mr. Sittiphong Anatrakul, Institute of Thai National AIDS Foundation Active Community Development • Ms. Yenjit Somphoh, Director Lampoon Province Department of Health, Bureau of Health • Mr. Thanu Watthana, Lampoon PHA Promotion Network • Mrs. Nareeluck Kullurk • Mrs. Nipa Chomphupa, Raks Thai • Dr. Nipunporn Voramongkol Foundation, Chiangmai • Mrs. Chailai Lertwanangkool 208 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Khon Kaen Province Province; Ms. Thisopin Thongthai, • Mrs. Wanida Suchitaphan, Peun responsible for Khonkaen Province; Ms. Nampong Group Laksami Manowong, responsible for Payao and Lampoon Provinces; Ms. Sakol Nakorn Province Thaworn Pumauim, responsible for Nakonsrithamrat Province; and Ms. • Mrs. Pranee KeaKlom, Mother-child Wanida Sukki, responsible for Pattalong Relations Group Province); and Ms. Thananda Naiwattanakul, Technical Officer from Cholburi Province the Thai-United States Centers for • Miss Natnatee Sukkee, Parnthong- Disease Control and Prevention peuntae Group Collaboration.

Nakorn Srithamarat Province R EFERENCES • Mrs. Nimnual Paengaosuk, Konkorn Network Government of Thailand, Ministry of • Mrs. Sirilak Chauchangkaen, Public Health, Department of Health Peun-Rak-Peun-Toongsong Group, (2009). Evaluation of Enhancing HIV- Toongsong Hospital related Care and Treatment for HIV- • Mrs. Mayurate Phonsuwan, Maharaj- infected Mothers, Their Partners and Nakorn Srithamaraj Group, Maharaj Children Project. Final Report, July. Hospital Government of Thailand, Ministry of Pattaloong Province Public Health, Department of Health, Bureau of Health Promotion. Enhancing • Miss Kanda Poonsong, Pattaloong PHA Network HIV-related Care and Treatment for HIV-infected Mothers, Their Partners and Children. Annual Report 2007-2008.

A CKNOWLEDGEMENTS ______(2008). Report on PHIMS [Perinatal HIV Intervention Monitoring The author would like to acknowledge Surveillance System]. the support of the following: Dr. Somsak National Committee for Prevention and Pattarakulwanich, Deputy Director Control of HIV/AIDS, B.E. 2550. National General, Department of Health; Dr. Strategic Plan for HIV/AIDS Control B.E. Sompong Sakulisaliyaporn, Director, 2550-2554 (2007-2011). Bureau of Health Promotion; public health technical officers from regional Scaling Up the Continuum of Care for health promotion centres of the People Living with HIV in Asia and the Department of Health (Ms. Rattana Pacific: A Toolkit for Implementers Petchpun, responsible for Cholburi (2007). Bangkok: United States Agency Experience in Addressing Mother-to-child Transmission of HIV/AIDS within a Community Framework – Thailand 209

for International Development (USAID) and Family Health International. Suntrajarn, T. et al. (2005). Health Promotion: The Challenge in the Prevention and Control of HIV/AIDS. 210 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Women’s 9 Empowerment Tunisia and Reproductive Health Dr. Ridha Gataa

Summary

The topic of women’s rights remains one of the most difficult issues to be addressed in the Arab world. Successful progress of women’s empowerment in Tunisia can serve as a model for the region and elsewhere. Within a human rights framework, women in Tunisia have been empowered politically, economically and socially and this empowerment has benefited the Tunisian society.

During the 1950s, before Tunisia’s independence, women in the country were largely poor and illiterate. Under the pretext of Islam, women were repressed and treated as second- class citizens. In the lead-up to Tunisian independence in 1956, however, there were calls from high political levels to ensure fundamental rights for women.

Some important changes took place following independence, including a ban on polygamy as stated in the Code of Personal Status and the entrance of women into the economic life of the community and the country, attaining nearly universal education, improved health care and better access to family planning and reproductive health services.

Tunisian women have benefited from a tremendous improvement in reproductive health, and their rights to control their fertility have been recognized. Family planning programmes and important strides in health have considerably lowered the birth rate and lengthened the average life expectancy for women. The life expectancy at birth of 51 years

211 212 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

in 1966 increased to 74.2 years in 2007; the overall mortality rate of 15 per cent in 1967 was reduced to 5.7 per cent in 2007; the infant mortality rate declined from 138.6 per cent in 1966 to 18.5 in 2007, maternal mortality from 140 deaths per 100,000 live births to 68.9 in 1994 and to 36.5 in 2006; and the immunization rates of children improved and exceeded 95 per cent in 2007 against 70 per cent in 1984. The contraceptive prevalence rate has reached 60.2 per cent currently against only 10 per cent in the 1960s. In addition, the gap between urban and rural environment has been minimized through services provided in rural areas by mobile teams, mobile clinics and special programmes in the remote areas since 1994.

Measures to empower women in Tunisia have benefited not only women but Tunisian society as well, with significant shifts in men’s attitudes towards women’s rights and roles in the society. The discussion of women’s rights should take place within the broader context of human rights. Women’s rights should not be seen as a zero-sum-game between male and female rights but rather from the perspective that everyone gains when all citizens have equal rights and can use them to expand their opportunities and achievements to benefit their societies.

Tunisia has changed for the better in the last several decades. With a history of strong and influential women, the country is a beacon for other Muslim societies in terms of its open- ness and progressive stance on women’s rights, viewed as an affair of state for Tunisia. However, Tunisia will have to face other challenges in the years to come that are as important, particularly as regards employment, social security and better integration of women into social and economic sectors, in order to fully achieve the United Nations Millennium Development Goals.

Information on the Author Dr. Ridha Gataa, Consultant, National Bureau of the Family and Population (Office national de la famille et de la population, ONFP). Women’s Empowerment and Reproductive Health – Tunisia 213

I NTRODUCTION ted itself, since independence, to an ambitious policy. It has succeeded, The strategy adopted by Tunisia since its through sustained efforts in the fields of independence in 1956 has, over the education, health and family planning, to years, reinforced the principle of equality progressively control the demographic between men and women as citizens and pressure and reach a significant level of in the eyes of the law. This has enabled family and social welfare. the country to thrive, to achieve social The successful example of Tunisia and economic development, to strength- documented here is neither a pilot study en the bonds within families and to fully nor an experimental effort like many participate in the construction of a mod- other innovative practices. This is a ern society. national development strategy that has The Code of Personal Status, prom- largely contributed to the development of ulgated in 1956, codified the relations the whole country and that continues to between the different family members. It act on all socio-economic and health aimed at promoting the status of women components in order to achieve the and at preserving social equilibrium. The Millennium Development Goals by 2015. Code comprised a series of measures that consolidated women’s rights and consid- B ACKGROUND ered these rights as an integral part of human rights. It advocated women’s active participation in the development FAMILY S TRUCTUREAND W OMEN ’ S process of the country and encouraged S TATUSIN T UNISIAN S OCIETY the use of their capacities. It also strived BEFORE I NDEPENDENCEIN 1956 to achieve a balance between the asser- Before independence in 1956, the family tion of women’s status, the strengthening model in Tunisia was the extended family of family ties and the family as a basic model in which grandparents, uncles, unit of society. aunts and cousins were integral parts of an individual’s daily life. In general, the Inspired by the achievements of the family and society were patriarchal. This Code of Personal Status and taking into social system extended beyond the home consideration the need to regulate its into the organizational framework of the population growth and fertility indica- country’s political system and workforce. tors, Tunisia has adopted a strategic vision for population management, based In addition to living together, the primarily on this ground-breaking legisla- family retained its influence on its tion on women’s rights. Aware of the younger generation by practising challenges linked to the promotion of arranged marriages. Traditional marriages human resources in the development were often endogamous, with a prefer- process, the country has firmly commit- ence for marrying one’s parallel cousin, 214 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES which also increased parental control Islam, in which he advocated girls’ educa- over daughters and sons. Both men and tion. Fifteen years later, Abdelaziz Thâalbi, women were under the influence of their César Benattar and Hédi Sebaï published families in relatively similar ways. In a The Koran’s Liberal Spirit, which also empha- study that was undertaken in five villages sized the need for girls’ education. in the southern region of Tunisia, 98 per The roots of Tunisia's pioneering role cent of men and women who were mar- in women's issues reach back to the ried between 1940 and 1945 did not beginning of the twentieth century, when choose their spouse (Betgeorge, 2010). an Islamic reformer, Tahar Haddad, a Women’s behaviour was closely mon- scholar of Tunisia's Great Mosque of the itored. The primary domain of women Zitouna (in Tunis), demanded that was the domestic one, and women’s social women be freed from all their traditional interactions with the outside world were bonds. He demonstrated, in a book enti- few. Since females were the family’s indi- tled Our Women in the Shari ‘a and Society cators of honour, to protect them was to published in 1930, that Islam was com- preserve the family’s reputation in socie- patible with modernity. He advocated ty. These customs were influenced by a formal education for women and main- mix of culture and Islamic law. tained that over many years, Islam had been distorted and misinterpreted to such Before independence, polygamy was an extent that women no longer were legal and a man could take additional "aware of their duties in life and the legit- wives. Polygamy diminished the status of imate advantages they could expect”. In each wife, filling the one position parallel the name of Islam, Tahar Haddad to the husband with up to four women. denounced abuses against women such as repudiation, whereby a husband could W OMEN ’ S R IGHTSASAN A FFAIR divorce his wife without grounds or OF S TATEFOR T UNISIA : A N E ARLY explanation, send her back to her family R EFORMER or leave her for another wife. Refuting Since the nineteenth century, many assertions that such conduct is permissi- Tunisian thinkers and writers have had ble for Muslims, the reformer declared in the merit to begin a very positive reflec- his book that "Islam is innocent of the tion on the modernization of Islam and oft-made accusations that it is an obstacle the rights of women. In 1868, a reformer, in the way of progress”. Kheireddine Pasha, explained in his book Even though Haddad’s proposals written in Arabic, The Surest Way to an were condemned in his time by the Understanding of the State of Nations, that the future of the Islamic civilization was Conservatives, almost all his appeals were linked to modernization. In 1897, Sheikh taken into account by the first President of Tunisia, Habib Bourguiba, in the draw- Mohammed Snoussi published The ing up of the Code of Personal Status such Flower’s Blooming or a Study of Woman in as the obligatory consent for marriage, Women’s Empowerment and Reproductive Health – Tunisia 215 the establishment of a procedure for high underemployment of the popula- divorce and the abolition of polygamy. tion, given that 70 per cent of the active workforce was employed in agriculture. N EEDS T HAT H AVE P RESSEDTHE COUNTRYTO TAKE CONCRETE ACTIONSTOWARDS F ERTILITY I MPLEMENTATIONOFTHE R EGULATION P RACTICE In the aftermath of its independence, Tunisia inherited a pronatalist colonial The practice could be defined as the policy as well as an archaic legal and national strategy of promoting women’s administrative system. It was faced with status as a basis for implementing a com- two major events: independence on the prehensive fertility and population pro- one hand and the peak of the population gramme in order to ensure the country’s boom on the other (the birth rate was economic and social development. close to 50 per 1,000) in a context of very limited economic resources. P ROMULGATIONOFTHE CODEOF P ERSONAL S TATUS Before independence, in the late 1950s, according to the classical pattern The Code of Personal Status (First of demographic transition, the decline of Version) mortality as a result of advances in health The Code of Personal Status, promulgat- care preceded that of fertility, paving the ed on 13 August 1956 (five months after way for a rapid population growth. At independence), has laid the foundation that time, Tunisia was characterized by a for codifying the relations between fami- very young population (49 per cent under ly members. This foundation is based on 15 years of age), a natural fertility status mutual respect between spouses, on shar- (crude birth rate of 50 per 1,000) and a ing burdens and responsibilities, and on total fertility rate that exceeded 7 children guaranteeing individual rights while per family. The mortality rate was high (a ensuring respect for children’s interests. crude death rate of 25 per 1,000 and an The Code gives women a unique place in infant mortality rate of 200 per 1,000), Tunisian society and in the Arab World in and the life expectancy at birth was not general. Since then, the date of 13 August more than 47 years. The rural population has been set aside to celebrate the was large, exceeding two thirds of the anniversary of the Code in the context of total population. In addition, illiteracy National Woman’s Day, which is a public was widespread: it was estimated that 85 holiday in Tunisia. per cent of the population 10 years old This Code of Personal Status includes and over and 99 per cent of the female many measures that promote the status of population were illiterate. This situation women and strengthen their rights. was made worse by unemployment, with Among them are abolition of polygamy, a gross rate of around 34 per cent, and legal regulation of divorce, permission of 216 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES marriage only with the mutual consent of receipt of a pension and income both spouses and the prohibition of early after trial. In case of non-compli- marriage. At the beginning, the minimum ance with this ruling, debtors are age for marriage was set at 18 years for liable to State prosecution; men and 15 years for women. However, • the right of a mother to give her it was increased by two years for both nationality to her children who are spouses in 1964. born of a foreign father; and • full legal capacity of a woman at Evolution of the Code of Personal Status (New Measures) the age of majority (18 years). A woman has the same access to The Code of Personal Status is not con- legal services as any man. For the sidered as a static reform nor is it only a preservation and cohesion of the set of legislative texts aiming to improve family, domestic violence is pun- women’s status in Tunisia. The women’s ishable by law. liberation movement has continued to receive significant political support and Operationalization of the Code of assistance from decision makers at the Personal Status highest level. The main goal of the Code of Personal In 1992, new measures were Status is to “remove all injustice” and pro- announced. These measures provide mote “laws rehabilitating women and women and the family with new privi- conferring upon them their full rights”. leges and gradually give the mother Since the promulgation of the Code, greater responsibilities within the family: polygamy has become a crime sanctioned by a fine and imprisonment, a unique • the right of a woman to guardian- development in the Arab World but one ship not only in case of the father’s patterned on a similar interdiction previ- death but also during his lifetime ously adopted by Turkey. Many reforms if it is proven that he is unable to incorporated into the Code were based meet family responsibilities; on the Islamic practice of ijtihad, the • the right of a divorced woman process of legalizing judgments reached with custody of children to obtain by consensus and by applying the under- the prerogatives of guardianship; lying principles of Islamic jurisprudence • replacement of the notion of the to changing and modern situations. wife’s obedience to her husband Other reforms incorporated into the by the obligation for both spouses 1956 Code of Personal Status abolished to have a relationship based on the right of fathers to force their daugh- mutual respect; ters to marry against their will. • creation of an alimony pension Nowadays, marriage in Tunisia can only fund guaranteeing divorced take place with the consent of both par- women and their children the ties. The Code set the legal age for mar- Women’s Empowerment and Reproductive Health – Tunisia 217 riage at 20 years for men and at 17 years The change from tradition to the for women, with marriage below those Code of Personal Status has shattered ages permitted only with the consent of some other stereotypes. Formerly, a both parents and the decision of a judge. woman was treated by the law as a minor Unilateral repudiation was abolished and until two years after her marriage. Now, the husband no longer has the right to under Tunisian law, men and women alike simply terminate the marriage without gain full adult rights when they reach 18 explanation. years of age. They acquire exactly the same rights to vote, to enter into contracts Today, either a husband or a wife can and to buy and sell property and goods. initiate divorce proceedings. However, a divorce can be granted only by a judge Penal law also applies equally to men who has exhausted all efforts to reconcile and women. The penal code, as amended the two parties. Women may also be on 8 March 1968, stipulates that adultery granted a financial settlement under the is a crime and lays down equal sanctions law, and the Government has set up a for a wife or for a husband judged guilty fund to pay the divorced husband's obli- of adultery. gations to his former wife if he fails to do Penalties for rape also have become so himself. Also abolished was the custom increasingly severe. A March 1985 law of awarding custody of children – from allows the death penalty in cases of rape the age of seven in the case of boys and where violence and armed threat are used nine in the case of girls – automatically to and where the victim is under 10 years of the father. Custody arrangements are now age. The penalty for all other kinds of worked out on a case-by-case basis by the rape is imprisonment and hard labour. court as part of the civil divorce procedure. Similarly, where previously widows did not automatically retain custody of T HE S UPPORT S TRUCTURESFOR THE P ROMOTIONOF W OMENIN their children, the Code of Personal T UNISIA Status now states that a surviving parent, regardless of sex, remains the principal Tunisia has established operational struc- guardian of minor children. Inheritance tures to allow the proper integration of laws, too, were overhauled to improve the women into the process of sustainable protection of women’s interests. development. The main structures that facilitate the involvement of women in Tunisian law also gives women the decision-making and at the highest polit- right to contraception and to abortion. ical and societal levels are: the Ministry As Betgeorge (2010) states, "The right to of Women’s Affairs and the Family decide whether to give life and decide (Ministère des affaires de la femme et de the number of children she would like to la famille, MAFF), the National Council have is the essential element in woman's for Women and the Family (Conseil emancipation”. national de la femme et de la famille, 218 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

CNFF), the National Commission on participation in strategic development Women and Development (Commission planning and at mainstreaming gender nationale “Femme et développement”, equality in development policies and pro- CNFD), and the Centre for Research, grammes. This Commission is responsi- Studies, Documentation and Information ble for the annual monitoring of the on Women (Centre de recherches, objectives of the Plan as regards women’s d’études, de documentation et d’informa- advancement. tion sur la femme, CREDIF). Centre for Research, Studies, Ministry of Women’s Affairs and Documentation and Information on the Family Women Created in 1992, the Ministry of Defined as the scientific body of MAFF, Women’s Affairs and the Family (MAFF), the Centre for Research, Studies, now renamed the Ministry of Women’s Documentation and Information on Affairs, Family, Children and the Elderly Women (CREDIF) has the responsibility (MAFFEPA), has the primary duty to of undertaking studies and research on develop and coordinate the policy of the women. In order to facilitate decision- Government regarding the status of making, it collects data on women’s social women and the family. It also must ensure and economic situations, disseminates all that women’s rights are respected and it the information collected within this strives to preserve the balance and stabil- framework and establishes periodic ity of the family. reports on the evolution of women’s conditions. It also analyses, observes and National Council for Women and assesses women’s status and is the inter- the Family face between civil society and the The National Council for Women and Government. The Centre has several the Family (CNFF) is the advisory body achievements to its credit, including the of MAFF. It assists the Ministry in the creation of the Observatory on Women’s implementation of major policy guide- Status, which provides policymakers with lines for the advancement of women and statistical data and relevant information coordinates actions between the various for the consideration of gender equality governmental and non-governmental in policy formulation and programme stakeholders. implementation.

National Commission on Women and Development R ESULTSAND The National Commission on Women A CHIEVEMENTS and Development (CNFD) was founded in 1991 in the context of the preparation The recent growth and development of of the Eighth Development Plan (1992- Tunisia compared to the growth and 1996). It aimed at strengthening women's development of other countries in the Women’s Empowerment and Reproductive Health – Tunisia 219 region and countries of similar develop- increased from 52 per cent to over 94 per ment levels in other parts of the world, cent over the same period. More impres- particularly in sub-Saharan Africa, have sive is the increase in female literacy. In been remarkable. An analysis of the coun- 1970, the female literacy rate was about try’s path to development reveals that its 15 per cent while the male literacy rate development strategy relied primarily on was 41 per cent. In 2004, these rates were diversifying its production and trade and about 77 per cent and 85 per cent, on enhancing its human capital, with respectively. The proportion of girls in emphasis on women’s empowerment. primary schools rose from 38.6 per cent in 1974-1975 to 47.7 per cent during the The enhancement of women’s auton- year 2002/2003. In secondary schools, omy, the free access to education and this proportion rose from 32.4 per cent in women’s access to the labour market as 1975/1976 to 53 per cent in 2003/2004 well as the implementation of family while in the universities, the rate of planning programmes that have caused young female students reached 57 per fertility to decline significantly are the cent by 2004/2005. main human development factors of the development strategy of Tunisia. It seems that this strategy is currently paying off and contributing significantly W OMEN ’ S E DUCATION to the development of Tunisia. During the last 20 years, the country more than Tunisia has always viewed public educa- doubled the rate of its spending on pub- tion as a national priority and a right for lic education, increasing it from 6 per both sexes without discrimination. Since cent of its gross domestic product (GDP) 1958, the education reform has stipulated in 1991 to 14.2 per cent in 2005. that access to education is free and compulsory from the age of six. The comprehensive 1991 reform of the educational ECONOMIC INVOLVEMENTOF WOMEN system made attendance for both girls The right to employment is defined in and boys compulsory from 6 to 16 years the Labour Code as a fundamental right of age, resulting in a dramatic increase in for a woman and the true guarantor of her the enrolment rates in secondary schools. citizenship. Law No. 66/27 of 1966 con- Thanks to these measures, dropout rates, tains many articles in relation to women's especially among girls, have decreased work: gender equality, maternity leave, steadily. Achievements in education have unpaid leave, part-time work and specific not only helped to reduce poverty but provisions as regards the retirement plan have also created an increasingly educat- for women. ed and productive workforce. Under the current legislation, women Adult literacy rates increased from have the same rights as men concerning 27.4 per cent in 1970 to over 73 per cent economic matters. They have the right to in 2002, and the literacy rates of youths own property, and once they reach adult- 220 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES hood at the age of 18, they can open a municipal councils are women compared bank account, take out a loan, and enter to 1.3 per cent in 1957, and 11 per cent freely into business and financial con- of board members from the socio-eco- tracts and transactions. nomic sector are women. Tunisian women are thus represented at the high- Tunisian women have gained access est decision-making levels and therefore to various working sectors, including may push the improvement of women’s those traditionally closed to women, such status and rights even further. as the judiciary, the army, engineering and medicine. The female labour force Tunisian women are represented at accounted for 25 per cent of the total several international forums and organi- workforce of Tunisia in 2007. Following zations, such as the United Nations the efforts made in the educational sec- Committee on the Elimination of tor, women now represent 51 per cent of Discrimination against Women, and the primary school teachers, 48 per cent other international bodies. of the secondary school teachers and 44 per cent of the university teachers. W OMEN ’ S R IGHTSAND F ERTILITY Furthermore, 29 per cent of the judges, CONTROL 42 per cent of the lawyers, 42 per cent of All the steps that preceded the develop- the medical staff, 72 per cent of the phar- ment of an explicit population policy and macists and 44 per cent of those working fertility control strategy in Tunisia were in the media sector are also women. aimed at preparing the ground for this In practice, however, women remain policy by focusing primarily on improv- underrepresented in the workforce and ing women’s conditions to encourage face gender-based salary inequity and their active and effective participation in obstacles in career advancement, notably the process of fertility control and their in the private sector. adherence to this policy in a responsible and rational manner. POLITICAL INVOLVEMENTOF WOMEN Tunisian women have benefited from The Tunisian Constitution of 1959 gave a tremendous improvement in the field of both men and women equal rights and reproductive health. Their own interest duties without discrimination. Women, in better reproductive health has like men, are eligible to vote in all public increased and their rights to control their elections. fertility and to have access to modern contraception have been recognized. In 2010, five women were part of the The integration of reproductive health Government of Tunisia: one Minister and into the Tunisian health policy reflects four Secretaries of State. Women com- the desire to go further in this direction. prise 22.7 per cent of the Chamber of Deputies and 24 per cent of the diplo- In 1961, the French law of 1920 pro- matic corps. In addition, 27 per cent of hibiting the importation, sale and adver- Women’s Empowerment and Reproductive Health – Tunisia 221 tising of contraceptives was repealed and tion policy initiated in the aftermath of replaced by the Act of 9 January 1961, independence. The remarkable achieve- which legalized contraception. However, ments in controlling the population the passage of this law was not easily growth rate are to be placed in the broad- achieved and parliamentary debates were er context of development strategies and very intense. Since 1961, Tunisian of global and intersectoral dynamics women have had free access to contra- adopted after independence. The main ception and they have been able to make achievement of this strategy was the cre- their own contraceptive choices. ation in 1973 of the National Bureau of the Family and Population (ONFP), Tunisia was the only Arab and which was responsible for implementing Muslim country to legalize abortion. the national policy of family planning Enactment of the Law of July 1965 stated and population with two fundamental that induced abortion is permitted when objectives, aiming at reducing the growth it occurs within the first three months of of population and protecting the health pregnancy in a hospital or a recognized of women and their families. As a second health facility and is performed by a step, the Superior Council of Population physician lawfully exercising his profes- was created in 1974. The Council sion and when both spouses have at least brought together different ministries and five living children. Abortion can also be national organizations under the chair- performed if the health of the mother or manship of the Prime Minister and had the child's mental health could be jeop- the responsibility of defining the general ardized by the continuation of pregnancy guidelines for the population policy. or when the unborn child might suffer from illness or a serious infirmity. In Many demographic analyses have 1973, abortion became permitted under shown that one third of the decline in these same conditions but regardless of birth rates in Tunisia in 1968 could be the number of children. However, it is attributed to the national family planning worth noting that abortion, despite its programme. Raising the minimum legal inclusion in the reproductive health serv- age of marriage and empowering women ices, has never been considered as a seem to have contributed to what Fargues method of family planning. Unwanted (1989) calls “marriage transition”. The pregnancies are considered as contracep- author argues that this transition is associ- tive failures. The use of modern and ated with two important changes: an edu- effective contraception methods must cational transition (more women gained still be promoted through educational access to education) and increased female messages in order to further reduce the participation in the labour force. Both of number of abortions. these changes have taken place in Tunisia. Indeed, Fargues (1989) notes that “Tunisia Fertility Control Strategy and is a striking example of what can be Reproductive Health Services termed a real ‘educational transition’”. Tunisia is known for its successful popula- 222 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

The National Bureau of the Family the infant mortality rate declined from and Population (ONFP) currently offers 138.6 per cent in 1966 to 18.5 per cent in its services in 44 family planning/repro- 2007, maternal mortality from 140 deaths ductive health centres; 410 primary per 100,000 live births in 1966 to 68.9 in health centres are visited by its mobile 1994 and to 36.5 in 2006; and the immu- teams. It has 13 mobile clinics that cover nization rates of children improved and 211 remote areas and 24 youth centres exceeded 95 per cent in 2007 compared located in all the governorates of the to 70 per cent in 1984. country. In terms of allocation of human Qualitative changes that occurred in resources, the Tunisian programme the lifestyle of Tunisian citizens are records one midwife per 1,000 inhabi- reflected in the improvement of the fol- tants (the density was 1/10,000 in 1966) lowing indicators (table 1-4), taking into and one doctor per fewer than 1,000 account that the poverty rate is the num- inhabitants. ber of people living below the poverty The contraceptive prevalence rate is threshold. currently 60.2 per cent compared to only 10 per cent in the 1960s. In addition, the gap between the urban and the rural envi- Table 1 Poverty rate (as a percentage). ronment has been minimized through 1967 1975 1985 2005 services provided in rural areas by mobile teams, mobile clinics and special pro- 33 22 7.7 3.8 grammes in the “gray” (remote rural) areas since 1994. Table 2 Gross national product, per capita (in dinars). I MPACTONTHE H EALTHAND S OCIO - ECONOMIC I NDICATORS 1966 1986 2001 2007 Through the implementation of its 117 960 3,000 4,400 human and social development programmes, Tunisia has managed to contin- The various components of the pop- uously improve its health indicators: the ulation policy, such as those promoting life expectancy at birth of 51 years in schooling for girls, the better integration 1966 increased to 74.2 years in 2007 (life of women into the labour market, and the expectancy after the last child has emphasis on health programmes for increased from 15 years in 1966 to about mothers and children have reduced the 40 years at present, enabling a woman to population growth rate to only 1.09 per be healthy, to participate as long as pos- cent in 2007 compared to 3 per cent in sible in the labour market and to ensure 1966. The total fertility rate fell from 7.2 the well-being of the whole family); the children per woman in 1966 to 2.03 chil- overall mortality rate of 15 per cent in dren in 2007. 1967 was reduced to 5.7 per cent in 2007; Women’s Empowerment and Reproductive Health – Tunisia 223

authorities at a time when Tunisia was Table 3 Population growth rate trying to escape poverty and underdevel- (as a percentage). opment so characteristic during French 1966 1987 2007 colonialism. 3 2.3 1.09 A strong will to adopt a population policy as part of the overall development of the country Table 4 Population size. The Tunisian population policy is distin- 1966 2002 2007 guished by its comprehensiveness and its integration into the overall development 4,583,200 9,781,900 10,225,400 process. It is a dynamic, multidimensional and progressive policy that aims at S UCCESSESAND L ESSONS achieving a balance between population L EARNED growth and economic growth in order to ensure the well-being of the population. Its originality stems from the way in S UCCESSES which it was applied. Modernization of cultural and religious attitudes and behaviour L ESSONS L EARNED related to fertility control Since the adoption of the population pol- Improving the status and rights of icy, based primarily on fertility control women is fundamental to successful through family planning as a basic strate- fertility regulation. gy, Tunisia has met with resistance from It is very difficult to build up a fertility various groups including religious groups. control programme in a population The aggressive media campaign carried where women have no status. Indeed, if out in the beginning provoked some women have no natural and socially opposition and rejection, but all this attributed roles and if they do not occu- remained marginal. Indeed, these resist- py a privileged position in their family, ance efforts were not of a collective no population and development pro- nature but rather cases of individual gramme can succeed. resistance, emanating mainly from males The Tunisian example is an interest- and from rural areas. The political deci- ing illustration of how fertility control and sions have been gradually integrated into the socio-economic development of a the society, and family planning has country are intrinsically linked to the come to be accepted and internalized by improvement of women’s status. The the people. This was achieved thanks to a Code of Personal Status, the liberalization communication strategy that was well of the sale of modern contraceptives and adapted to the culture of Tunisia and that their use, and the right to abortion are all emanated from the highest political key elements of women’s emancipation. 224 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

P OSSIBILITIESOF Women are by far less educated R EPLICATINGTHE than men and participate to a less- er extent in the labour market or P RACTICE in schools. This situation perpetu- ates the domination of men while While the experience of Tunisia with the women retain their traditional role practice has demonstrated some success- as mothers and housewives serving es and has generated lessons learned, the their husbands and their families. potential for its replication elsewhere would require an enabling environment. These factors are not the only ones Factors to consider include the following: influencing the birth rate in the Muslim world. Other relevant fac- • It is first necessary to have a tors include: the survival of social progressive policy vision and traditions and customs (such as val- courage in decision-making. To ues attached to masculinity and achieve an effective population reproductive virility or the impor- policy, a family planning pro- tance of giving birth to a boy); gramme on its own is not enough. political factors (opposing Western The Tunisian experience has influence); and more specifically, shown that politicians and civil socio-economic under-development society organizations must first (illiteracy, mode of agricultural pro- raise the status of women. The duction, low living standards and abolition of polygamy and repudi- unequal income distribution). ation has had an impact on the There is a need to change the reli- birth rate and, contrary to com- gious and cultural factors encourag- mon belief, it has increased family ing reproduction and that exist stability. throughout the Muslim world by The results achieved by Tunisia in adopting advocacy and mobilization matters of fertility control, health strategies within the religious com- and socio-economic development munity and at political levels. It has stem from a visionary policy deci- been demonstrated in several coun- sion and courageous leadership tries, including Tunisia, that a signif- based on simple communication icant change, even a radical one, strategies and convincing speeches would occur in the demographic targeting all social strata. trend if Muslim women had the • Islam is not against family plan- same opportunities as men in the ning and fertility control: the fields of education and employment, population policy may be part of had access to modern facilities and a dynamic interpretation of Islam. social services, and could fully bene- In practice, in most Muslim coun- fit from economic opportunities in tries, the women’s situation has an environment of responsible free- not undergone many changes. dom and family empowerment. Women’s Empowerment and Reproductive Health – Tunisia 225

A CKNOWLEDGEMENTS 1999, No. 9, Women of the Maghreb, pp. 93-105, posted online on 22 May 2006. . to all those who gave me the opportunity to accomplish this assignment, in par- Betgeorge, A. (2010). Society’s Views and ticular to the National Bureau of the the Personal Status Code: A Discussion Family and Population of Tunisia, which of Tunisian Men and Women’s Roles in nominated me, in my capacity as Marriage and Divorce. Global Studies Consultant, to carry out this research. student papers. Province College. The confidence that it placed in me will Boukhris, M. (1992). The Population in remain a personal source of pride. Tunisia: Realities and Perspectives. Tunisia: The execution of this assignment rep- National Bureau of the Family and resented a wonderful opportunity to Population, November 1992. meet and talk with many persons from Châabouni, H. (2006). “The Tunisian countries participating in the drafting of woman, 50 years after the enactment of reports on “National Innovative Practices the Code of Personal Status”. In Info- and Successful Approaches in the Field of CREDIF, no. 34. Tunis, August 2006. Population and Reproductive Health”. Fargues, P. (1989). “The decline of Arab Each person has, to varying degrees but fertility”. in Population: An English Selection, with equal kindness, made a positive con- 4(1):147-175. tribution to the finalization of this study and I would like to express my thanks to Gastineau, B. Providing Care, Healthcare them all. Utilization and Women’s Health in Tunisia. Centre de recherche, populations et sociétés (CERPOS) D321, Université de R EFERENCES Paris X, Nanterre, France. Gastineau, B. and Sandron, F. Family and Abdennebi-Abderrahim, S. Sexual and Socio-Economic Development in Tunisia: An Reproductive Health and Women’s Status in Integrated Family Planning Policy. IRD Tunisia. Tunisian Association of Family [Institut de recherche pour le développe- Planning. ment] Documentary Fund, A* 37031 Ex:2. Baliamoune-Lutz, M. (2009). Tunisia’s Gueddana, N. (2009). Statement to the Development Experience: A Success 42nd Session of the Committee on Story. United Nations University World Population and Development. Permanent Institute for Development Economics Mission of Tunisia to the United Nations. Research (UNU-WIDER) Research New York, March 2009. Paper No. 2009/32, May 2009. ______(2006). “Men, family planning Bessis, S. (2006). “Institutional feminism and reproductive health”. In Info- in Tunisia”. [Article in French]. In Clio, CREDIF, no. 34. Tunis, August 2006. 226 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

______(2002). The Promotion of Female Ministry of Women’s Affairs, the Family and Human Resources in Tunisia: The Foundations of Children, Department of Communication Sustainable Human Development. International and Information (2004). Reply of Tunisia to Women’s Day 2002. Tunis, 2002. the Questionnaire addressed to Governments on the implementation of the Beijing Platform for Hamza, N. (2002). Models of Social Policies: Action (1995) and the outcome of the 23rd Lessons from the Tunisian Experience. Social Special Session of the General Assembly Policy Series No. 2. Economic and Social (2000). Tunis, May 2004. Commission for Western Asia. New York: United Nations. Rahmouni, S. (2006). “Tunisian women: An overview of reforms from 1956 to Ministry of Public Health, National 2006”. In Info-CREDIF, no. 34. Tunis, Bureau of the Family and Population August 2006. (2009). Journal of the Family and Population, Series No. 6-7. Tunis, June 2009. United Nations Population Fund (UNFPA) Tunisia (2009). LINKS, the ______(2008). UNICEF. Survey on the Official Newsletter of the United Health and Well-being of Mother and Child Nations Population Fund Tunisia. Tunis, MICS [Multiple Indicator Cluster 3 November and December 2009. Survey]. Tunis. Vallin, J. and Locoh, T. Population and ______(2007). The Circles of Population Development in Tunisia: The Metamorphosis. and Reproductive Health. Masculine-feminine: National Institute of Demographic The Laws of Gender on Health. Document Studies, Paris, and Ministry of Economic No. 1. Tunis, January 2007. Development, Tunis, published with the ______(1974). Tunisian Legislation and assistance of UNFPA by Presses universi- Policy on Population: Analysis and Perception. taires of France. Published following the Symposium on Websites: www.onfp.tn (in Arabic, International Law and Population, Tunis, English and French); www.unft.org.tn (in 1974. Arabic); www.unfpa-tunisie.org; www.tn. Ministry of Public Health, National undp.org in French); www.cawtar.org; Bureau of the Family and Population, and www.credif.org.tn (in Arabic). League of Arab States (2006). Pan-Arab Project for Family Health. The Socio- Contacts Demographic Characteristics of the Tunisian Family: Extensive Analysis of the Results of Ministry of Public Health PAPFAM [Pan-Arab Project for Family Address: Bab Saadoun 1006 Tunis, Tunisia Health] Investigation. Tunis. E-mail: [email protected] Website: http://www.santetunisie.rns.tn Women’s Empowerment and Reproductive Health – Tunisia 227

National Bureau of the Family and Population (ONFP) Address: 7, rue 7051 centre urbain nord, 1082 Tunis, Tunisia E-mail: [email protected] Website: www.onfp.nat.tn Ministry of Women’s Affairs, the Family, Children and the Elderly Address: 2, rue d’Alger, 1000 Tunis, Tunisia E-mail: [email protected] Website: http://www.femmes.tn Centre for Research, Studies, Documentation and Information on Women (CREDIF) Address: Avenue le roi Abdelaziz Al Saoud, rue Farhat Ben Afia, manar 2, 2092 Tunis, Tunisia E-mail: [email protected] Website: www.credif.org.tn Staff of the technical cooperation unit at the National Bureau of the Family and Population Dr. Ridha Gataa Consultant National Bureau of the Family and Population (ONFP) E-mail: [email protected] 228 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES Involving 10 Parliamentarians Uganda as Advocates for Reproductive Health Mr. Hannington Burunde

Summary

Uganda has involved its Members of Parliament in promoting reproductive health and family planning issues among the decision makers using evidence-based advocacy as a strategy to influence policy decisions. This approach has transformed a large proportion of the Parliamentarians into active advocates of reproductive health and family planning issues, committed to influencing other decision makers both in Parliament and elsewhere to take actions that bring about desired change in terms of policies, programmes, strategies and allocation of resources.

Evidence-based advocacy as an approach seeks to equip selected advocates with data and information to be used in drawing the attention of decision makers to socio-economic realities on the ground. The aim is to inform them, motivate them, persuade them and prompt them to take actions that address the issues so identified.

A comparative analysis of the situation before and after the introduction of this evidence- based advocacy initiative indicates that Uganda has, through this innovation, managed to put population and development issues in general and reproductive health and family planning issues in particular high on the policy, public and media agendas. Key indicators used as evidence included low life expectancy, a high population growth rate, a high total fertility rate, a high maternal mortality ratio, low contraceptive use, a high unmet need for family planning, and high incidences of unintended pregnancy and induced abortion as well as high levels of poverty.

229 230 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Summary (continued)

The link between these indicators and the overall socio-economic development was also highlighted. The implications of these indicators for the provision of social services such as health, education, water and sanitation, employment and housing and for the government efforts to eradicate poverty and to achieve the national vision of social transformation were also highlighted to emphasize the need for policy action.

Apparently these implications had, in the past, not been brought to the attention of Parliamentarians and other decision makers so that they would be sufficiently informed, motivated, persuaded and prompted to take appropriate policy actions. As such, reproductive health and family planning issues had remained largely unattended to and were placed low on the policy and funding agendas.

Evidence-based advocacy as a practice was therefore conceived as an appropriate strategy primarily to create a substantial number of Members of Parliament who would be convinced and committed to bringing these issues onto the floor of Parliament in order for other Parliamentarians to appreciate the realities on the ground and to take policy actions that would bring about desired change. The Parliamentarians were also prepared and equipped to take the message to other decision makers at national and subnational levels who might not be members of Parliament but who were in positions of leadership.

An elaborate implementation modality was put in place and tools and materials were developed to guide the entire initiative. These included the development of the Advocacy Subprogramme as part of the Country Population Programme and the formulation of the National Advocacy Strategy and the Media Advocacy Strategy within the framework of the National Population Policy. The Advocacy Training of Trainers Curriculum and Manual in Support of Population Programmes was also developed to guide the capacity-building process.

The Members of Parliament were then identified and recruited, sensitized and equipped with advocacy skills and instruments to prepare them to become actively involved in advocacy-based events and to assist them to use various forums to advocate for reproductive health and family planning issues whenever opportunities arose.

After a period of about ten years, there are new developments to show that evidence-based advocacy through Parliamentarians is a good practice that can influence a policy agenda in great measure. Statements by decision makers show that the messages of the Parliamentarians have been taken on board and are the basis for a number of decisions in various sectors and at various levels including district and lower levels. The integration of population factors into the development plans at national and district levels are a clear manifestation of this initiative.

The practice has to a great extent become self-sustaining, with decision makers expressing concern over the people-centred issues and calling for quick action to address them.

Despite the challenges encountered, it is apparent that the replicability and spreadability of this practice can benefit many other countries and institutions as a lesson from which to draw in their effort to promote reproductive health and family planning as well as prompt policy action and resource allocation. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 231

Information on the Author Mr. Hannington Burunde, Head, Information and Communication Department, Uganda Population Secretariat.

I NTRODUCTION Members of Parliament from mere politicians into active advocates of reproduc- Uganda has been implementing evidence- tive health and family planning issues and based advocacy through Parliamentarians to have a strong lobbying group in since 2001 to influence decision makers Parliament to champion population and at various levels to advocate for putting in development concerns of the country. place policies, programmes and strategies Evidence-based advocacy was con- that address reproductive health conceived as the best practice for promoting cerns of the country and to mobilize the population and development issues in gen- necessary resources and prioritize their eral and reproductive health issues in par- allocation for implementation of the ticular after it was realized that these were interventions. not priorities on the policy, public, media The main target has been the mem- and development partners’ agendas. It was bers of the country’s legislative body: the introduced to influence government poli- Parliament. Parliamentarians make policies and programmes to address popula- cies and endorse decisions that guide tion trends and patterns and to mobilize government implementing agencies and and allocate resources to implement them. other stakeholders in addressing the Uganda has one of the highest population socio-economic needs and the manage- growth rates in the world and the root ment of society. In addition to legislation, cause of this is linked to the lack of priori- Parliamentarians represent the views of tization of reproductive health issues in their constituencies, which cut across government policies and programmes. sectors of the population, including the Population and development factors cover grass-roots level. They are elected lead- a broad spectrum of issues that include ers, they are trusted and they are seen to reproductive health, gender and demo- represent the desires, aspirations and graphic challenges. Evidence-based advo- interests of the majority of their con- cacy is a cross-cutting intervention that stituents. They also play a central role in aims at attracting the attention of decision budget appropriation and oversight. makers at various levels not only to be informed about such issues but to also Over time, evidence-based advocacy develop an interest in them and become as a practice has enabled Uganda to convinced enough to take the necessary transform a large proportion of the investment and policy actions. 232 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

A comparative analysis of the situa- advocacy and in the mobilization of tion before and after the introduction of resources and the masses, with a special this type of advocacy intervention shows emphasis on achieving the Millennium that, indeed, after a period of sustained Development Goals (MDGs). Every campaigning using this approach, country was required to domesticate the Uganda has managed to put population resolutions of the ICPD and this situation and development issues on the policy called for favourable legislation that agenda and in the public domain. Media could put in place appropriate policies, coverage of these issues has increased effective and focused programmes, good tremendously, implying that such issues strategies, and suitable mechanisms for have become topics for public debate. resource mobilization and allocation to address them. Over 200 Parliamentarians out of the 333 who constitute the whole of the A general overview of the health situa- Ugandan Parliament have been enrolled tion in Uganda over the years shows that in voluntary parliamentary associations for a long time, the health status of the involved in advocating for improved population has been poor, with life population programmes that they are expectancy at birth standing below 50 convinced will bring about a positive years in 2002. The infant mortality rate change in the country. This has helped in was at 88 per 1,000 live births in 2000 increasing the visibility of reproductive (Uganda Demographic and Health Survey health and family planning in particular 2001/2002) and the maternal mortality ratio and of population and development issues had stagnated at the unacceptably high fig- in general in Parliamentary debates. ure of 505 per 100,000 live births (ibid.). In addition, reproductive health serv- B ACKGROUND , I NCLUDING ices remained inadequate yet the popula- THE D ESIGNOFTHE tion, according to the 2002 National Population and Housing Census, was P RACTICE increasing at the very high rate of 3.2 per cent per year. The total fertility rate N EEDFORTHE I NNOVATIVE stood at 6.9 children per woman in 2000, P RACTICE making Uganda the country with the Following the International Conference highest fertility rate in sub-Saharan on Population and Development (ICPD) Africa. Contraceptive use stood at a mere held in Cairo, Egypt, in 1994, it was iden- 18.6 per cent in 2000/2001. The unmet tified that Parliamentarians play a crucial need for family planning had been role in changing communities, given increasing from 7.8 per cent in 1995 to their unique roles and the fact that they 38 per cent in 2001 and to 41 per cent in have the support of the majority in their 2006, implying that many more women communities. It became imperative to wanted to use family planning but were emphasize the role of Parliamentarians in not doing so for various reasons, includ- Involving Parliamentarians as Advocates for Reproductive Health – Uganda 233

Growth of the population of Uganda.

60 53.7 50 36.8 40

30 21.8 20 16.7 12.6 9.5 10 5.0 6.5 Population (in millions) Population 0 1948 1959 1969 1980 1991 2000 2015 2025 ing low level of knowledge, limited avail- Advocacy should be a subprogramme to ability and access, and issues of afford- support Reproductive Health and ability as well as side effects, myths and Population and Development Sub- misconceptions. programmes. A total of 10 per cent of the funds for the Country Programme were Most of the above-mentioned issues therefore allocated to Advocacy as a and their socio-economic implications stand-alone subprogramme. This provid- had not been brought to the attention of ed an opportunity for the implementing decision makers, especially the legislators institutions and organizations to build and those in leadership positions, so capacity in advocacy as an intervention that they would become sufficiently and to come up with strategies for influ- informed, motivated and persuaded to encing various agendas, with special address the situation in terms of appropri- emphasis on decision makers at various ate legislation. As such, reproductive levels. health issues had largely remained unattended to and were placed low on the In the Government of Uganda/ policy and funding agendas. The advoca- UNFPA Fifth Country Programme cy intervention was therefore designed (2001-2005), Advocacy was again made a with the above-mentioned issues and subprogramme, which provided a chance requirements in mind, with the mission of for Uganda to consolidate the achieve- bringing about policy change. ments made under the previous Country Programme. The intervention has since D ESCRIPTIONOFTHE P RACTICE , become a permanent cross-cutting inter- I NCLUDING I TS D ESIGN vention supporting Reproductive Health, Population and Development, and During the development of the Gender Subprogrammes and targeting Government of Uganda/UNFPA Country decision makers including Members of Programme 1997-2000, it was agreed that Parliament. 234 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Evidence-based advocacy is a type of based advocacy intervention is premised advocacy that aims at bringing about a on the realization that unless the attention better understanding of issues among of decision makers is drawn to the realities decision makers using evidence (scientific on the ground, the decision makers may data) to prove the real situation on the not appreciate them enough to be able to ground and justifying the need for urgent take policy actions aimed at meeting the practical solutions. As such, its primary socio-economic challenges of the popula- target is those holding positions of tion. The design of the intervention fol- authority where they influence policy lowed the steps in the advocacy process decisions that affect society. An evidence- presented in the following table.

Steps in the advocacy process.

1. Collecting Data Gathering, analysing and using appropriate quantitative and qualitative information to provide supportive evidence for identified issues. 2. Identifying Issues Identifying problems that require policy action through changes in policies, programmes, strategies and resource allocation. 3. Developing a Setting out the overall aim, ultimate goal or purpose of the advocacy Mission Statement initiative. Advocacy Advocacy Strategy 4. Setting Goals Stating goals as the general results to be achieved over a specified length of time. 5. Setting Objectives Setting the objectives, that is, the incremental steps towards achieving each of the goals. Objectives should be specific, realistic, measurable and time-bound. 6. Identifying Target Identifying the policy makers, public institutions, community and Audiences religious leaders, politicians, development partners and organizations that need to be influenced to support the priority issues and to take positive action.

7. Identifying Activities Determining the specific actions to be taken in order to achieve the agreed advocacy objectives. 8. Message Developing statements tailored to different audiences that define the Development issues, suggest solutions and describe the actions that need to be Action Plan taken and the benefits. 9. Identifying Channels Identifying the means by which a message is delivered to the various of Communication target audiences, e.g., radio, television, flyers, press conferences and meetings. 10. Building Support Building alliances and networks with other groups, organizations or individuals committed to supporting the priority issues. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 235

Steps in the advocacy process (continued).

11. Fundraising Identifying and attracting resources (money, equipment, volunteers and supplies) to implement the advocacy initiatives. 12. Implementation Carrying out a set of planned activities to achieve advocacy objectives (action plan).

Taking Action Taking 13. Monitoring Gathering information to measure progress towards the advocacy objectives. 14. Evaluation Gathering and analysing information to determine if the advocacy objectives have been achieved.

The starting point for evidence-based population regarding reproductive health advocacy as an intervention was to identi- and family planning issues. fy the policy issues and challenges that The Parliamentarians were expected needed to be addressed, set goals and to play an instrumental role in influenc- objectives, and establish who the main ing decisions not only on the floor of actors were and who had the best compar- Parliament but also in convincing the ative advantage to undertake specific tasks. general public about the need to demand The main goal was to have a substan- specific services from their leaders. It was tive number of Members of Parliament agreed that once converted as advocates who were convinced and committed to of population and development con- influencing policy decisions made by the cerns, they would bring these concerns legislative organ of Uganda aimed at onto the floor of Parliament and influ- bringing about positive changes. The ence funding and the policy environ- Members of Parliament debate and ment to address them. endorse decisions that shape the manage- An advocacy steering committee was ment and running of society. They repre- established to guide the implementation sent constituencies that cut across sectors of advocacy interventions. It comprised of the population. They are elected lead- representatives from line ministries, civil ers, are trusted, and are expected to society organizations, international and champion the desires, aspirations and bilateral and multilateral donors, and the interests of their constituents. Based on media. The coordinating organ was the these principles, a national advocacy Uganda Population Secretariat. strategy was developed, identifying Members of Parliament as one of the Advocacy Issues main actors that could influence policy The evidence-based advocacy pro- decisions and general perceptions of the gramme of the Uganda Population 236 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Secretariat selected six key broad issues Inadequate numbers of appropri- that needed to be addressed urgently ately skilled service providers to through advocacy efforts in order to offer a full range of quality static increase the access to and use of high- and outreach family-planning ser- quality reproductive health and family vices, including men-friendly and planning information and services in adolescent-friendly services; and Uganda. • Issue 6: Education for young people in the formal school • Issue 1: Public leadership and system and those not in school support Inadequate implementation of Inadequate promotion and support life-skills training and population for reproductive health and family education in school curriculums planning by leaders at all levels; and for youths out of school. • Issue 2: Access to information Inadequate support for information and communication programmes I MPLEMENTATION D ETAILS that address male involvement, rumours and misconceptions, the The Uganda Population Secretariat, as benefits of family planning, and the lead agency, established links with information on sources of family the Uganda Parliamentarians’ Forum on planning methods and services; Food Security, Population and • Issue 3: Availability of commodi- Development and other stakeholders to ties and supplies introduce evidence-based advocacy to Inconsistent availability of the the legislators. The implementation of right family-planning commodities the intervention required the mobiliza- and supplies in the right quantities, tion of stakeholders and the creation of at the right times and in the right partnerships and networks. It also called places at service delivery levels; for resource mobilization from develop- • Issue 4: Access to services ment partners and government as well as through integration capacity-building; the development of tools, guidelines, messages and materials; Inadequate policies, guidelines and and the organization of advocacy-based tools to support integration of events to raise the profile of population family planning services into exist- issues in general and reproductive health ing health services and pro- and family planning in particular. These grammes and into multisectoral community-based services and elements made the implementation of programmes; evidence-based advocacy in Uganda possible since they helped in harmonizing • Issue 5: Capacity for service the messages and speaking with one delivery voice. Particular Parliamentarians were Involving Parliamentarians as Advocates for Reproductive Health – Uganda 237 brought on board and equipped with evi- Figure 1 A flow diagram of the commu- dence data and information to back their nication model used in the innovative advocacy activities and to lobby and pro- practice in advocacy. pose solutions that called for policy actions. MOVE TO ACTION Some of the tools and materials included a national advocacy strategy in support of reproductive health, popula- PERSUADE tion and development programmes, which was developed in 2005 to guide stakeholders (including Parliamentarians) in implementing advocacy interventions. MOTIVATE The strategy was designed clearly spelling out reproductive health issues and the actions that needed to be under- INFORM taken by Parliamentarians as pointed out in the National Population Policy (1995 and 2008 versions). The sensitization of the members of The National Family Planning Parliament followed this model to equip Advocacy Strategy (2005-2010) was also them with information and data in order developed by the Ministry of Health in for them to be able to speak authorita- collaboration with the Population tively on reproductive health and family Secretariat as a subset of the National planning issues with ease and confidence. Advocacy Strategy to focus specifically The model also helped them to not only on family planning issues. give information and motivate their colleagues but also be able to persuade them The implementation process employed to take the required policy actions. the communication model (fig. 1) that aims at moving the target audience The model formed a basis for the for- (Parliamentarians) to action. It does so mulation of messages to be used by the through providing them with informa- Parliamentarians. The principles of mes- tion, motivating them, persuading them sage formulation were as follows: and ultimately influencing them to take necessary actions that would put in place • to state an issue and propose a real- appropriate policies, programmes and istic solution (policy, programme, strategy, resource allocation); strategies and mobilize and allocate resources to address the identified issues • identify the possible action and and converting Parliamentarians into a who should take that action cadre of advocates to sensitize others to (specific actor or decision maker); support this cause. and 238 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

• mention the possible benefits to sending negative messages that society as a result of taking that have undermined the advocacy action. The benefits also serve as campaign. motivational factors that would • The challenge of inadequate influence the targeted decision resources cannot be overempha- maker to act. sized, especially where the Parliamentarians had to be assisted C HALLENGES to go out to their constituencies to sensitize the people. A number of challenges were encountered during the implementation of the • Results and achievements of evi- evidence-based advocacy interventions: dence-based advocacy take a long time to achieve (ten years and • The recruitment of the legislators above). There was therefore a was not simple at the beginning need to exercise a great deal of since many Parliamentarians were patience and persistence while car- not interested in population and rying out this work, yet many development issues in general and partners would become frustrated reproductive health and family and leave the campaign before it planning issues in particular. created the required impact. • Some of those who had been con- • Some development partners are verted were not re-elected and the also unable to sustain a long cam- new entrants were not aware of paign whose results take years to the issues. Parliamentarians also achieve. have a very busy schedule, which • Time for elections has affected the makes it impossible to engage involvement of the Members of them for a long period. Parliament in organized campaigns • The implementation also faced since they are engaged in political challenges of lack of expertise in campaigns. However, several pop- advocacy since capacity was still ulation and development issues are low at the national level and worse being put on the candidates’ cam- at lower levels. paign and manifesto agenda. • There are cultural leaders in the communities who have been A DVOCACY S UPPORT TOOLSAND mobilizing communities, advocat- M ATERIALS ing for the advantages of having a A number of other advocacy support bigger population and for giving tools and materials were also produced to an incentive to families to have guide and equip the Parliamentarians more children. These views of the with knowledge and skills and to provide community leaders have been quick reference points whenever needed. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 239

They include the following: issues in the country in local languages. At first, they were being • An advocacy training-of-trainers paid for using donor resources but curriculum and manual were some radio stations later saw the developed whose purpose is to need to exercise corporate social ensure that advocacy as a concept responsibility by giving free air- is well understood and is time for such talk shows. In any employed as a strategic interven- case, the talk shows were seen to tion by the Parliamentarians, and a add quality to media house pro- series of training sessions was car- gramming since they turned out to ried out to equip the Members of be educational for the communi- Parliament with advocacy skills ties and informative, thus increas- and to try out role playing to ing their audiences. sharpen their skills. The main objective of the evidence- • A media advocacy strategy was based advocacy intervention was to drum also developed to influence the up support for reproductive health and media agenda to give coverage to family planning issues, to convince decision makers especially Parliamentarians to bring these issues Members of Parliament who speak onto the agenda of Parliament, and to about reproductive health and influence other stakeholders as well as family planning issues at various development partners to address the forums so that the message is issues. The implementation of the inter- widespread. Various interactive vention was carried out in phases (fig. 2). media talk shows (television and radio) were held in the country • Phase one aimed at sensitizing hosting members of Parliament to legislators to raise their level of deliberate on various population awareness and appreciation of

Figure 2 Phases of the implementation of the Sensitization and awareness creation PHASE I evidence-based advocacy intervention.

PHASE II Development of advocacy support materials

Involvement of Members of Parliament in PHASE III advocacy-based events

Assisting Members of Parliament to speak on PHASE IV reproductive health at various forums 240 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

reproductive health issues, using • Phase two involved the provision scientific evidence from credible of information kits, advocacy sup- sources both locally and interna- port messages and materials to tionally. The Members of enable Members of Parliament to Parliament were, for example, use evidence to advocate for shocked to learn that approxi- reproductive health issues. mately 6,000 women die in Materials were designed in such a Uganda every year owing to preg- way that they cater to the interests nancy-related complications. They of an average reader. were equally shocked to know that The legislators not only were every year, 297,000 induced abor- equipped with advocacy skills but tions are performed in Uganda. they were also given facts and fig- The sensitization phase also ures to enable them to back up shared experiences of other coun- their information and to convince tries for comparison purposes and their audiences with evidence. The to show that Uganda can achieve materials included fact sheets, what countries such as Thailand posters, reports, data sheets and and Malaysia and other Asian booklets (fig. 3). Tigers have achieved if it puts in place what is required. • Phase three entailed involving Members of Parliament in advoca-

Figure 3 Sample advocacy posters. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 241

cy-based events as chief guests, team as respected members of society at resource persons, discussants and both national and community levels and participants in order to equip them as legislators who bring and debate bills with advocacy skills for presenting in Parliament. issues in a convincing manner. Members of Parliament have always had the opportunity to also R ESULTSAND share personal experiences with A CHIEVEMENTS the communities so as to learn from them. The above-mentioned modalities have • Phase four involved assisting helped Uganda to register some modest Members of Parliament to use var- results and achievements in terms of the ious forums to advocate for repro- roles that the Members of Parliament are ductive health issues. The playing today in advocating for reproduc- Members organized workshops in tive health and family planning. The their constituencies to talk to the achievements can be categorized into poli- district and community leaders cies, programmes, strategies and resources. about such issues. Some managed Some of these are long term so that the to mobilize resources from gov- results may not be very visible in a short ernment, the private sector, NGOs period but it is possible to identify a few. and development partners in order to provide items such as ambu- At the national level, evidence-based lances, reproductive health and advocacy efforts have resulted in having a family planning commodities, and strong lobby group of legislators in the construction and renovation of Parliament. The membership of the health facilities as well as to offer Uganda Parliamentarians’ Forum on Food specialized reproductive health Security, Population and Development services such as cancer screening has increased over time and has become a and other outreach services. By strong advocate both in Parliament and the end of 2009, 69 out of 80 dis- outside for reproductive health and fami- tricts had had mobilization meet- ly planning issues and population and ings and some Parliamentarians development in general. The Forum has a decided to mount the campaign at membership of 199 Members of the county/constituency level. Parliament out of the total of 333 Many district leaders admitted Members from different political parties that reproductive health issues and representing various constituencies were issues to which they had in the country. This has helped in pro- given less attention and called for increased advocacy for them. jecting population issues as having no political, religious or tribal boundaries. The main aim was to have Members of Parliament be part of the advocacy The lobby group has generated 242 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES greater appreciation of reproductive Parliament, stated in August 2010 that health issues, mainly family planning and “poor health is one of the underlying maternal health issues, among all causes of poverty in Uganda and as such Members of Parliament and the Cabinet health is an essential prerequisite and an as well as among the members of the pub- outcome of sound economic develop- lic and the media. Some of the Forum ment”. Such statements indicate that members are ministers and ministers of through evidence-based advocacy, the State, indicating an influence in the exec- Parliamentarians in Uganda have influ- utive arm of government. This has also enced not only the policies and alloca- influenced the political agenda, with var- tion of resources to health issues but also ious manifestoes of aspiring candidates the perception of the decision makers including presidential aspirants listing regarding reproductive health issues in maternal health as one of the issues that general and maternal health in particular. need urgent attention. Reproductive health issues and family B UDGETSAND R ESOURCE A LLOCATIONS planning are now debated on the floor of Parliament and are part of the legislators’ The 2008/2009 national budget for the agenda. As such, the Cabinet, including first time included population, reproduc- the President, can now be heard making tive health and family planning issues as statements in their speeches that reflect budget line items. The appreciation of their appreciation of reproductive health Members of Parliament of reproductive and family planning issues. Statements health issues resulted in the Minister of such as “No woman should die while giv- Finance announcing an additional ing life” are common with the top leader- US$62,500 for reproductive health in the ship and the Parliamentarians at various 2008/2009 national budget. This implies a functions. 13 per cent increase in the budget line of that financial year. The 2009/2010 nation- The wife of the President, who is her- al budget also included the same issues, self a Member of Parliament and a minis- implying that this has now become an item ter, is advocating for safe motherhood in that will continue to feature in the future Uganda and stresses that “you cannot budgets, courtesy of the Parliamentarians. speak about safe motherhood without Similarly the allocation of funds to the promoting family planning”. She has health sector saw an increase from 7 per agreed to be a Goodwill Ambassador of cent in the 2007/2008 national budget to 9 Reproductive Health after appreciating per cent in the 2008/2009 national budget the impact of such issues on the well- and to 10.4 per cent in the 2009/2010 being of families in the country, and her national budget. work is influencing a number of policy decisions in Uganda. The Minister of The Parliamentarians’ advocacy efforts Finance, who is also a Member of have been successful in influencing the Ministry of Health to request a loan from Involving Parliamentarians as Advocates for Reproductive Health – Uganda 243 the Ministry of Finance for maternal tion of resources to have maternal mor- health issues, which has resulted in a tality addressed in Council budgets, and US$200 million fund specifically for held district leaders, local governments maternal health. Uganda is also begin- and health workers accountable to the ning to attract a great deal of attention population that they serve. from development partners with respect In addition, a number of policies, pro- to investing in reproductive health and grammes and strategies have been put in family planning. Donors such as the Bill place to ensure that reproductive health and Melinda Gates Foundation, UNFPA, and family planning service delivery is the United States Agency for integrated as an essential strategy to pro- International Development (USAID), the vide quality health services. World Bank and the World Health Organization have provided funds to Policies and systems have also been address reproductive health and family put in place to ensure that adequate planning issues in Uganda. In January quantities of reproductive health and 2010, Parliament refused to pass a supple- family planning commodities and sup- mentary budget for the financial year plies reach service delivery points. 2009/2010 until the World Bank loan on The National Policy Guidelines and maternal health that had not been passed Service Standards for Reproductive for the previous two years had been con- Health Services (2004) is being imple- sidered. The loan has now been secured mented to ensure that all health facilities and disbursed to the Ministry of Health in the country offer an appropriate range to improve the health system in the of family planning services. The same country, including reproductive health. policy requires that adequate numbers of The five-year National Development appropriately qualified and skilled service Plan (2010/2015) presented by the providers be in place in all levels of Uganda National Planning Authority has health-service delivery units to offer the for the first time ever included an entire entire range of quality, facility-based and section on population and development community-outreach family planning issues. This is an indication of the influ- services. ential role that the Members of These achievements may seem mod- Parliament play in the planning process. est but considering where Uganda is The Plan was presented to them for their coming from, the Parliamentarians have input and approval. played quite a commendable role. At the community level, the Parliamentarians, through the joint dis- PARTNERSHIPSAND N ETWORKING trict/constituency field visits, have sensi- The Members of Parliament have formed tized communities about maternal health partnerships with the Uganda Population issues, mobilized communities to use Secretariat and various stakeholders and health services, advocated for the alloca- 244 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES development partners. The development and the Eastern Africa Reproductive partners include Family Health Health Network. International, the Guttmacher Institute, In addition, the Parliamentarians Partners in Population and Development, have formed strategic partnerships and Population Action International, the networks with key Government line min- Population Reference Bureau, UNFPA, istries such as the Ministry of Health, the USAID and the World Bank. They have Ministry of Gender, Labour and Social provided financial, technical and material Development, the Ministry of Education, support to enable the legislators to carry and the Ministry of Finance Planning and out their advocacy activities. Economic Development as well as the Partners in Population and National Planning Authority, the Bureau Development in particular has been in of Statistics, the Makerere University the forefront in assisting Parliamentarians School of Public Health, and the African to play the advocacy role at local, nation- Peer Review Mechanism to mention but a al and international levels. It has funded few. Partnerships and networks have also regional conferences for Parliamentarians been formed with civil society organiza- and breakfast meetings meant specifically tions including faith-based NGOs and to discuss reproductive health and family cultural institutions, professional organi- planning issues as well as constituency zations such as Rotary International, and meetings where Parliamentarians discuss the media fraternity. These strategic part- reproductive health issues with commu- nerships have yielded a number of posi- nities. These efforts have enhanced the tive results. advocacy role of Parliamentarians and have increased their resolve to take I MPACTAND S USTAINABILITY reproductive health and family health The knowledge, information and advoca- issues to higher levels. Partners in cy skills imparted to the legislators have Population and Development has also enabled them to have a better under- provided a platform for decision makers standing of reproductive health issues to interface with communities to discuss and to champion, in the legislative these rather sensitive issues and to collect assembly debates, such issues as increased popular views to inform legislation. funding and tabling of bills as well as popularizing reproductive health issues in The Parliamentarians also network general at the national, district and lower through groups such as the Uganda levels (constituencies). Parliamentary Forum on Food Security, Population and Development (1996), the This has had a positive impact on the Network of African Women Ministers legislators’ ability to influence bills and to and Parliamentarians – Uganda Chapter see them passed by Parliament. (2006), the Uganda Parliamentary Forum Parliament has, for example, prioritized on Youth Affairs (2009), the reproductive health issues and passed a Parliamentary Social Services Committee number of pieces of legislation as a result. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 245

The legislators have continued to lobby enabled the sensitization of communities Parliament to increase health-sector about maternal health issues, mobilized budget lines and allocate more resources communities to use health facilities, and to reproductive health and family plan- persuaded community leaders to allocate ning. They have also extended the resources to maternal health in council resource mobilization and allocation and district budgets. campaign to development partners and At the national level, advocacy efforts the private sector, which now allocate of Members of Parliament have generat- resources directly to reproductive health ed greater appreciation of reproductive activities. health issues among all Members of Indeed, the percentage of the nation- Parliament, the Cabinet, the public and al budget allocation to the health sector the media and have added a strong voice has been on the increase from as little as to the reproductive health agenda in below 7 per cent in the 2006/2007 finan- Uganda. cial year to 10.4 per cent in the In May 2010, the World Bank 2009/2010 financial year. The challeng- approved a US$130 million loan to ing issue is to focus now on how this Uganda for improvement of the health increase benefits reproductive health and infrastructure on condition that govern- family planning. The Parliamentarians ment prioritizes maternal health. In a are at present taking up the matter media statement regarding this loan, the through the Social Services Committee World Bank country manager in Uganda of Parliament and the Ministry of Health said that the money is meant to strength- and are pushing for the national budget en the country’s health system and to allocate 15 per cent of the total budg- improve reproductive health care, includ- et to the health sector as recommended ing family planning services. While meet- by the Abuja Declaration and for the ing Members of Parliament, the Ministry of Health to prioritize repro- Permanent Secretary in the Ministry of ductive health in its allocation of the Health assured them that at least health resources. US$30 million of the funds will go The legislators have also mobilized towards improving maternal and repro- resources from outside the government ductive health services. budget for implementation of reproduc- Speaking after signing the loan agree- tive health and family planning activities ment with the World Bank in Kampala, and programmes, including the Road the Minister of Finance was quoted by Map for Accelerating the Reduction of the media as saying that “Uganda’s mater- Maternal and Neonatal Mortality and nal health was among the worst in Morbidity in Uganda (2007-2015). Africa”, and warning that “if the trend The involvement of and partnering continues, Uganda will not be able to with Members of Parliament have meet the Millennium Development Goal 246 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES of reducing 435 maternal deaths (2010) population issues as cross-cutting con- to 131 deaths per 100,000 live births by cerns for the attention of top leadership. the year 2015”. Statements of this nature This has resulted in the following: from top leadership show that reproductive health issues are beginning to get the • The commitment of district offi- attention that they deserve from big deci- cials in improving reproductive sion makers in the country. health services has been generated and many of these officials have The Parliamentarians are also influ- either committed funds or prom- encing policies, programmes and strate- ised to incorporate reproductive gies to address reproductive health issues health and family planning as pri- in Uganda. They have proved not only to ority issues into their development be strong advocates and lobbyists but planning activities. they have also taken on that role ably, • There has been increased male willingly and consistently. This has facil- involvement in reproductive itated the sustainability of evidence- health issues, which differs from based advocacy activities. The structures the situation in the past when that the Parliamentarians have put in women languished in labour wards place and the influence that they have without the support of their hus- had on how to handle reproductive bands. Several districts have come health and family planning issues in the up with an initiative that gives country have resulted in the entrench- incentives to husbands who escort ment of such issues on various agendas. their wives in antenatal wards/clin- There is an indication that such issues ics by having them attended to will remain on the policy, public and first and giving Mama Kits and media agendas in Uganda for a long time. mosquito nets to those husbands who are present when their wives are delivering. After a continuous I NTEGRATIONINTO D EVELOPMENT sensitization exercise, there has P OLICY, P LANNINGAND P ROGRAMMES been a continuous phasing out of the traditional birth attendants, Some of the issues being advocated for who have been a major source of have been integrated into policies, pro- labour complications. Training, grammes and various strategies as well as retraining and recruitment of into the national development planning health workers to handle maternal process, which also takes into account concerns are now on the increase. poverty reduction strategies in the coun- • Some districts have been empow- try. The National Development Plan has ered and gone ahead to establish now taken on population and develop- district task forces on reproductive ment issues as some of the items that need health and HIV/AIDS, e.g., to be addressed. Similarly, the African Bundibugyo, Gulu, Kanungu, Jinja Peer Review Mechanism has taken on and Mubende. These task forces Involving Parliamentarians as Advocates for Reproductive Health – Uganda 247

are lobby groups that would help and annual reports made by the imple- to roll out programmatic activities menting partners, who include Members to communities where most repro- of Parliament. ductive health cases originate. The reports refer to process, • Laws eliminating all forms of progress, performance and impact indica- domestic violence have been tors. The Monitoring and Evaluation enacted, e.g., the passage of the Framework is complemented by the Domestic Relations Bill, the strategies, goals and objectives stated in Marriage and Divorce Bill, the the National Population Policy, the Trafficking Persons Bill and the Reproductive Health Subprogramme and Bill outlawing Female Genital the National Advocacy Strategy, which Mutilation. clearly state the situation on the ground • There has been increased aware- and set the objectives that interventions ness of reproductive health issues are designed to achieve. It is against the and the empowerment of commu- objectives set out in the Monitoring and nities to demand reproductive Evaluation Framework that progress is health services as their right. assessed and challenges identified. The • The number of cases of violence National Advocacy Strategy is particular- (in any form) against women has ly handy in the evaluation of evidence- been reduced. based advocacy since it focuses on the policies, programmes and strategies put in place to address issues being advocat- E VALUATIONAND ed for and the resources mobilized and A SSESSMENT allocated to deal with such issues. Means of verification also included The implementation of evidence-based media reports, relevant statements made advocacy for reproductive health and by decision makers at various forums, the family planning is monitored through a statements made on the floor of coordination mechanism involving the Parliament as recorded by the Hansard Population Secretariat, the Ministry of (the official report of the proceedings Health, the Parliamentarians’ Forum on and debates of the Parliament), and indi- Food Security, Population and vidual in-depth interviews with selected Development, UNFPA and various other decision makers and other categories of development partners. A monitoring and respondents. Evaluation studies have evaluation framework was developed in been carried out by UNFPA and the 2006 by the stakeholders to guide the Guttmacher Institute and the reports monitoring of implementation and to put indicate that the advocacy role of the in place an agreed mechanism for evalua- Parliamentarians has contributed position. This tool has helped in document- tively to popularizing reproductive ing the achievements through quarterly health and family planning issues in the 248 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES country. However, there is a need to • legislators need to be equipped carry out a more comprehensive study of with information, tools and advo- this practice to assess the long-term cacy support materials; impact that it has had in Uganda, with a • legislators need to be given an view to duplicating it in other countries. opportunity to talk to the people Various surveys over the years have about reproductive health issues in order to use the feedback to pre- indicated a positive trend in the areas of pare themselves better; reproductive health and family planning in Uganda. The Uganda Demographic and • legislators need to be facilitated to Health Survey 2006, for example, indicated sensitize other leaders and the that contraceptive use had increased from public and to advocate for repro- 18.6 per cent in 2000/2001 to 24.4 per ductive health issues at various cent in 2006. Similarly, maternal mortali- forums; and ty had been reduced from 505 per • legislators need to be constantly 100,000 live births in 2002 to 435 in updated on the situation using sci- 2006 and unmet need was said to be at 41 entific findings and research infor- per cent, having increased from 38 per mation and regularly involved in cent in 2002. Fertility was also on the reproductive health and family downward trend although decreasing planning campaigns. slowly, from 6.9 children per woman in Uganda has also learned that having the 1990s to 6.7 in 2000/2001 and show- a strong, credible coordinating body with ing signs of dropping even further. These qualified, committed and consistent staff surveys have confirmed that evidence- is crucial to sustaining evidence-based based advocacy through Parliamentarians advocacy and to achieving positive made a substantial contribution to results. achieving these positive trends. The elaborate modalities, strategies and approaches put in place to enable L ESSONS L EARNED members of Parliament to implement evidence-based advocacy have helped The above-mentioned results, achieve- Uganda to achieve the following: ments and impact of evidence-based advocacy with Members of Parliament • They have increased the level of indicate that: awareness and appreciation among Members of Parliament regarding • involving and engaging legislators reproductive health issues and in reproductive health pro- enabled Parliamentarians to have a grammes deliver results; better understanding of the impli- • legislators need to be sensitized cations of such issues for the lives and made aware of the reproduc- of the people whom they repre- tive health issues affecting society; Involving Parliamentarians as Advocates for Reproductive Health – Uganda 249

sent and the need to promote fam- solving such issues, including ily planning as a solution. those affecting the people at the • The development of advocacy constituency level. support materials and information • The biggest achievement as a kits equipped the legislators with result of this partnership with the information, knowledge and scien- legislators is that they have tific evidence to back their state- become advocates of reproductive ments and arguments and to relate health issues and are now spread- them to the real situation on the ing the information largely on ground. The materials gave them their own. The Members of points of reference and enabled Parliament have now become a them to speak out confidently and cadre of advocates to advance authoritatively on such issues and reproductive health issues in to quote credible sources such as Parliament and outside, including the Uganda Bureau of Statistics at any international conferences. and the Population Reference As such, a change is beginning to Bureau. On several occasions, the be seen in the policies, pro- Parliamentarians and Cabinet grammes, resource allocation and Ministers have taken on top lead- decisions made at the national and ership and challenged it, especially lower levels in the country. The regarding the perception that awareness of the public is also Uganda needs a bigger population increasing, and with it, pressure is than it currently has. mounting on decision makers to • The involvement of Members of address reproductive health and Parliament in advocacy-based family planning issues. events enabled the Members of Parliament to try out the skills involved in presenting reproduc- R EPLICABILITYAND tive health issues to various audi- S PREADABILITY ences and to obtain feedback in order to perfect their arguments In spite of the challenges mentioned earli- and persuasion skills to convince er, it is possible to replicate and spread the their audiences. Uganda experience in using evidence- • Assisting Members of Parliament based advocacy in other countries to influ- to organize advocacy events and ence policy decisions. The lessons learned to participate in reproductive by Uganda indicate that evidence-based health activities provided them advocacy with Parliamentarians can bring with an opportunity to own repro- about desired change when dealing with ductive health issues and to high- reproductive health issues or any other light them in order to show their population and development concerns commitment and support to that need supportive policies, adequate 250 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES programmes, effective strategies, and in the draft and for providing inside mobilization and allocation of required information on the operations of the resources. Parliamentarians. The case of Uganda can therefore be Special gratitude goes to Dr. Jotham regarded as a good practice that could be Musinguzi, Regional Director, and his adjusted and replicated in other countries team at the Partners in Population and to address similar situations. Some of the Development Africa Regional Office in prerequisites for ensuring success in Uganda for their part in carrying out an involving Parliamentarians include the internal review of the document; Mr. establishment of a good working rela- Charles Zirarema, Acting Director, tionship with Members of Parliament and Uganda Population Secretariat; and Dr. a strong coordinating body with a good Betty Kyaddondo, Head of the Family knowledge of advocacy and communica- Health Department at the Population tion skills. This forms the basis for formu- Secretariat, for her input. lating strategies and mobilizing resources I am grateful to you all. needed to develop tools and materials and to facilitate the implementation process. R EFERENCES

African Peer Review Mechanism A CKNOWLEDGEMENTS (APRM), Uganda Chapter (2009). Republic of Uganda: APRM Country Review It is not possible to mention the names of Report No. 7, January 2009. Kampala. all individuals and organizations that in one way or another had an input into this Bureau of Statistics (2006). Uganda documentation of a best practice. Demographic and Health Survey 2006. Bureau However, we are very grateful to the of Statistics, Kampala, and Macro Chairperson of the Uganda International Inc., Calverton, Maryland, United States. Parliamentarians’ Forum on Food Security, Population and Development, ______(2002). Uganda Demographic and the Hon. Dr. Chris Baryomunsi, and, Health Survey 2001/2002. Kampala. through him, all the members of the Republic of Uganda (2010). National Forum, for reviewing the draft outline Development Plan (2010/11-2014/15). and providing the invaluable comments Kampala, 22 January 2010. and inputs that went a long way to adding value to the final document. We ______, Ministry of Finance, Planning also would like to thank the Coordinator and Economic Development. Approved of the Uganda Parliamentarians’ Forum, Estimates of Revenue and Expenditure Mr. Musa Wamala Buyungo and his team, (Recurrent and Development), FY 2007/2008. who took off time to include finer details Kampala. Involving Parliamentarians as Advocates for Reproductive Health – Uganda 251

______, Ministry of Finance, Planning ______. UNFPA/Government of Uganda and Economic Development, Population Advocacy Sub-Programme under Fifth Secretariat (2008). Media Advocacy Country Programme 2001-2005. Kampala. Strategy: Guidelines for Media Partners in “World bank gives Uganda Sh260 billion Support of Population and Development Issues health loan”, New Vision, 3 June 2010. 2008-2010. Kampala. ______, Ministry of Finance, Planning Contact Persons on the and Economic Development, Population Project Team Secretariat (2008). National Population Policy for Social Transformation and Mr. Hannington Burunde Sustainable Development. Kampala. Head Information and Communication ______, Ministry of Finance, Planning Department and Economic Development, Population Uganda Population Secretariat Secretariat (2005). National Advocacy P. O. Box 2666 Strategy in Support of Reproductive Health, Kampala, Uganda Population and Development Programmes E-mail: [email protected] (2005-2009): Towards a Healthy and Prosperous Population. Kampala. Dr. Jotham Musinguzi Regional Director ______, Ministry of Finance, Planning Partners in Population and Development and Economic Development, Population Africa Regional Office Secretariat (2003). Advocacy Training of P. O. Box 2666 Trainers Curriculum and Manual in Support of Kampala, Uganda Population Programmes. Kampala, August. E-mail: [email protected] ______, Ministry of Health, Health Mr. Patrick Mugirwa Promotion and Education Division, Programme Officer Reproductive Health Division, National Partners in Population and Development Family Planning Advocacy Strategy 2005- Africa Regional Office 2010. Kampala: Ministry of Health. P. O. Box 2666 ______, Parliament, website: www.parlia- Kampala, Uganda ment.go.ug. E-mail: [email protected] United Nations Population Fund Dr. Betty Kyaddondo (UNFPA). The Sixth Government of Head Uganda/UNFPA Country Programme, Family Health Department, Monitoring and Evaluation Framework Population Secretariat 2006-2010. Kampala. P. O. Box 2666 Kampala, Uganda ______. UNFPA/Government of Uganda E-mail: [email protected] Fifth Country Programme 2001-2005. 252 VOLUME 19: EXPERIENCESIN ADDRESSING POPULATION AND REPRODUCTIVE HEALTH CHALLENGES

Hon. Dr. Chris Baryomunsi Member of Parliament and Chairperson Uganda Parliamentarians’ Forum on Food Security, Population and Development P. O. Box 7178 Kampala, Uganda E-mail: [email protected] Mr. Musa Wamala Buyungo Programme Coordinator Uganda Parliamentarians’ Forum on Food Security, Population and Development P. O. Box 7178 Kampala, Uganda E-mail: [email protected] Mr. Charles Zirarema Acting Director Population Secretariat P. O. Box 2666 Kampala, Uganda E-mail: [email protected] U NITED N ATIONS D EVELOPMENT P ROGRAMME (UNDP)

The United Nations Development Programme (UNDP) is the UN’s global development network, an organization advocating for change and connecting countries to knowledge, experience and resources to help people build a better life. It is on the ground in 166 countries, working with them on their own solutions to global and national development challenges. As they develop local capacity, they draw on the people of UNDP and its wide range of partners.

World leaders have pledged to achieve the Millennium Development Goals, including the overarching goal of cutting poverty in half by 2015. UNDP’s network links and coordinates global and national efforts to reach these Goals. Its focus is helping countries build and share solutions to the challenges of:

• democratic governance; • poverty reduction; • crisis prevention and recovery; • environment and energy; and • HIV/AIDS.

UNDP helps developing countries attract and use aid effectively. In all its activities, it encourages the protection of human rights and the empowerment of women.

253 Special Unit for South-South Cooperation

S PECIAL U NITFOR S OUTH -S OUTH C OOPERATION (SU/SSC)

The Special Unit for South-South Cooperation, formerly known as the Special Unit for Technical Cooperation among Developing Countries (TCDC), was established by the United Nations General Assembly within UNDP in 1978. It carries out its United Nations mandate to mobilize international support for sustained South-South cooperation for development.

The Special Unit for South-South Cooperation:

• encourages developing countries to become important providers of multilateral cooperation; • fosters broad-based partnerships for supporting South-South initiatives; • supports the efforts of the South to pool the vast resources of Southern countries as a way of achieving common development goals; and • facilitates South-South policy dialogues.

Special Unit for South-South Cooperation United Nations Development Programme One United Nations Plaza New York, NY 10017 Tel.: +1 212 906 5737 Fax: + 1 212 906 6352

This monograph and other SSC documents are accessible on the Internet at http://ssc.undp.org.

254 PARTNERSIN P OPULATIONAND D EVELOPMENT (PPD)

Partners in Population and Development (PPD) is an intergovernmental initiative created specifically to expand and improve South-to-South collaboration in the fields of reproductive health, population and development. PPD was launched at the 1994 International Conference on Population and Development. Its mission is to assist member countries and other developing countries to address successfully the sexual and reproductive health and rights and population and development challenges through South-South collaboration. PPD carries out its mission by raising a common voice and sharing sustainable, effective, efficient, accessible and acceptable solutions considering the diverse economic, social, political, religious and cultural characteristics of member countries.

Partners in Population and Development Location Address: Mailing Address: IPH Building (2nd Floor) P. O. Box 6020 Mohakhali, Dhaka-1212 Gulshan 1, Dhaka 1212 Bangladesh Bangladesh Tel.: +88 02 9881882 +88 02 9881883 +88 02 8829475 Fax: +88 02 8829387 +88 02 9880264 E-mail: [email protected] Website: www.partners-popdev.org

255 U NITED N ATIONS P OPULATION F UND

The United Nations Population Fund (UNFPA) is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV, and every girl and woman is treated with dignity and respect. UNFPA works in partnership with governments, along with other United Nations agencies, communities, non- governmental organizations, foundations and the private sector, to raise awareness and mobilize the support and resources needed to achieve its mission. It works in some 150 countries, areas and territories and is a field-centred, efficient and strategic partner to the countries it serves.

United Nations Population Fund Technical Division 605 Third Avenue New York, NY 10158 USA Tel.: +1 212 297 5000 Website: www.unfpa.org

256 T HE G LOBAL S OUTH -S OUTH D EVELOPMENT A CADEMY

The Special Unit for South-South Cooperation has committed to transforming, consolidating and institutionalizing its current programme activities into integrated, mutually reinforcing components of an architecture that supports multilateral South- South cooperation. It is doing so by introducing an innovative approach aimed at strengthening social and economic cooperation among developing countries and the sharing of knowledge and best practices with the goal of actual transfers. The Special Unit is building this 3-in-1 architecture as a key contribution to the implementation of its fourth cooperation framework for South-South cooperation (2009-2011), guided by the vision of its director, Mr. Yiping Zhou. This architecture has the following three interlinked components:

1. The Global South-South Development Academy (GSSDA): to enable development partners to systematically identify, document and catalogue Southern development solutions for subsequent validation and mutual learning; 2. The Global South-South Development Expo (GSSD Expo): to enable development partners to showcase successful, scalable development solutions for visibility to the broader international development community in order to obtain feedback and build partnerships; and 3. The South-South Global Assets and Technology Exchange (SS-GATE): to enable development partners to list the most scalable solutions and technologies for partnership- building, resource mobilization and actual transfer.

The GSSDA is a platform for knowledge production, management and sharing for human development solutions. It offers knowledge products and tools to enable partners to research, document, publish and learn about effective practices. Among its many elements, the GSSDA includes a network of focal points; how-to training materials such as manuals, e-courses and workshops; rosters of experts; and publications. The knowledge produced, refined and catalogued through this platform will serve as the stepping stone to the other components of the architecture.

257 (continued from previous page)

The GSSD Expo is a marketing platform for showcasing Southern solutions to facilitate and promote their dissemination and replication. It focuses on presenting proven development solutions through poster and booth presentations at an annual exhibition. In addition, the GSSD Expo includes forums, round tables and an award competition for innovative development solutions in order to promote best practices and encourage and facilitate their transfer and replication.

SS-GATE is a transactional platform that enables the listing of Southern technologies and development solutions as proposals for social investment. It operates as an open, market-driven mechanism to attract social investment via coordinated but independent tracks to capitalize on different market segments with their distinctive dynamics and players. Current transactional tracks in the design, pilot or operational stage include:

• Track 1 – Technology Exchange: to increase trade of assets and technology among Southern countries and global markets. Phase: operational; • Track 2 – Human Development Investment Exchange (HDSX): to focus on social investment that will scale up successful development practices in Southern countries. Phase: design; • Track 3 – Creative Economy Exchange: to increase trade of creative products and services among Southern countries and global markets. Phase: design; and • Track 4 – New Energy and Energy-saving Technology Exchange: to facilitate the exchange of new energy and energy-saving technology among Southern countries and global markets. Phase: pilot.

With this novel architecture, the Special Unit is offering a service platform that can strengthen social and economic ties among developing countries and capitalize on best practices with the goal of their actual transfer.

258 259 260 Participants in the international workshop on population and development organized by Partners in Population and Development and the UNDP Special Unit for South-South Cooperation in Bangkok, Thailand, in August 2010. Other volumes in the series:

1. Examples of Successful Initiatives in Science and Technology in the South 2. Examples of Successful Initiatives in Small Island Developing States 3. Examples of Successful Economic, Environmental and Sustainable Livelihood Initiatives in the South 4. Examples of Good Practices in Social Policies, Indigenous and Traditional Knowledge, and Appropriate Technology in the South 5. Examples of Successful Initiatives in Agriculture and Rural Development in the South 6. Examples of Innovative Social Organizations and Practices in the South 7. Conservation and Wise Use of Indigenous and Medicinal Plants 8. Examples of Successful Uses of Renewable Energy Sources in the South 9. Examples of the Successful Conservation and Sustainable Use of Dryland Biodiversity 10. Examples of the Development of Pharmaceutical Products from Medicinal Plants 11. Examples of Successful Experiences in Providing Safe Drinking Water 12. Examples of Natural Disaster Mitigation in Small Island Developing States 13. Examples of Knowledge-sharing for Local Development in the South 14. Examples of Community-based Approaches to Recovery from Natural Disasters: Post-tsunami Experiences 15. Examples of Successful Public-private Partnerships 16. Examples of Successful Experiences in Coastal Community Development 17. Experiences in Developing Capacity for Sustainable Development 18. Successful Social Protection Floor Experiences

United Nations Development Programme One United Nations Plaza New York, NY 10017 www.undp.org May May 2011