Time of Changes in Turkey This Issue Is Co-Published with the EU Funded Reproductive Health Programme in Turkey

Time of changes in Turkey This issue is co-published with the EU funded Reproductive Health Programme in Turkey

THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No.65 - 2007 The European Magazine for Sexual and Reproductive Health Contents Entre Nous is published by: Reproductive Health and Research Programme Editor Special Issue: Evert Ketting WHO Regional Office forE urope Scherfigsvej 8 Foreword DK-2100 Copenhagen Ø By Prof. Dr. Recep Akdag˘, Minister of Health of Turkey 3 Denmark Tel: (+45) 3917 1602 Reproductive Health in Turkey Fax: (+45) 3917 1818 By M. Rifat Köse 4 E-mail: [email protected] www.euro.who.int/entrenous EU-Turkey: Perspectives on Reproductive Health Chief editor By Figen Tunçkanat 5 Dr Gunta Lazdane The Reproductive Health Programme in Turkey: Overview and Approach Editor By Ibrahim Acikalin, Mehmet Ali Biliker, Robert Gaertner, Demet Gural, Patrick Krause 7 Dr Evert Ketting Editorial assistant Health Seeking Behaviour Study Dominique Gundelach By Osman Hayran 9 Layout Sputnik Reklame Aps, Denmark. Making Motherhood Safer www.sputnikreklame.dk By Onur Karabacak, Ece Abay, Mohammed Mustafa, Selale Özmen, Ferit Saraçolu 10 Print Central tryk Hobro a/s Institutionalisation of SRH in-Service Training By Burcu Açıkalın,S¸evkat Özvarıs¸, Günes¸Tomruk, Gayane Dolyan-Descornet 12 Entre Nous is funded by the United Nations Population Fund (UNFPA), New York, with the Responding to Young People’s SRH Needs assistance of the World Health Organization By Ays¸egül Esin, Emel Özdemir S¸ahin, Ays¸e Akın, Hilal Özcebe, Evert Ketting 14 Regional Office for Europe, Copenhagen, Second Generation Surveillance of STI/HIV/AIDS in Turkey Denmark. By Peyman Altan, Levent Akin, Raphael Baltes, Kevin Fenton, Catharine Taylor 17 It is published three times a year. Present distribution figures stand at: 3,000 English, Strengthening SRH Pre-Service Training Capacity 2,000 Spanish, 2,000 Portuguese, 1,000 Bul- By Iffet Renda, Ayla Albayrak 19 garian, 1,500 Russian and 500 Hungarian. Public Sector and Civil Society: Forging a Powerful Partnership Entre Nous is produced in: in SRH and Rights in Turkey Bulgarian by the Ministry of Health in Bul- By Arzu Köseli, Seçkin Ataba, Serdar Esin, Mehlika Ulular, Poonam Thapa 21 garia as a part of a UNFPA-funded project; Hungarian by the Department of Obstetrics A Youth Story and Gynaecology, University Medial School By Selen Örs, Tunga Tüzer, Gökhan Yıldırımkaya, Fatma Hacıoğlu, of Debrecen, PO Box 37, Debrecen, Hungary; Nezih Tavlas, Zeynep Bas ¸arankut 25 Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, Service Standards Implementation P-1056 Lisbon, Portugal; By Gönül Kaya, Fatma Uz, Jean Robson, Yusuf Sahip 26 Russian by WHO Regional Office for Europe Turkey National Maternal Mortality Study Rigas, Komercfirma S & G; By Sabahat Tezcan, Banu Ergöçmen, Ahmet Sinan Türkyılmaz, Spanish by the Instituto de la Mujer, Minis- Rudolf Schumacher, Levent Eker 28 terio de Trabajo y Asuntos Sociales, Almagro 36, ES-28010 Madrid, Spain. Selected RHP Publications The Portuguese and Spanish issues are dis- By Evert Ketting 30 tributed directly through UNFPA representatives and WHO regional offices to Portuguese and Spanish speaking countries in Africa and South America. The Entre Nous Editorial Advisory Board Material from Entre Nous may be freely trans- lated into any national language and reprinted Dr Assia Brandrup- Jane Cottingham Ms Nell Rasmussen in journals, magazines and newspapers or Lukanow Coordinator, Gender, Repro- Senior Consultant, Danish placed on the Web provided due acknowl- Senior Adviser to the Health ductive Rights, Sexual Health Centre for Research on Social edgement is made to Entre Nous, UNFPA and Matrix Network and Adolescence, Vulnerability the WHO Regional Office forE urope. WHO Headquarters, Geneva WHO Headquarters, Geneva Dr Peer Sieben Articles appearing in Entre Nous do not Mr Bjarne B. Christensen Dr Helle Karro UNFPA Representative and necessarily reflect the views of UN- Secretary General, The Danish Professor, Head Country Director, Romania FPA or WHO or the EU. Please address Family Planning Association Department of Obstetries and Dr Robert Thomson enquiries to the authors of the signed Ms Vicky Claeys Gynaecology Adviser on Sexuality, Repro- articles. Regional Director Medical Faculty ductive Health & Advocacy, For information on WHO-supported activi- International Planned Parent- University of Tartu UNFPA Country Technical ties and WHO documents, please contact the hood Federation, European Estonia Services Team for Europe, Family and Community Health unit at the Network, Brussels Dr Evert Ketting Bratislava address given above. Senior Research Fellow Please order WHO publications directly from Radboud University Nijmegen the WHO sales agent in each country or from Department of Public Health Marketing and Dissemination, WHO, CH-1211, Geneva 27, Switzerland

ISSN: 1014-8485

Editorial Recep Akdag˘

Turkey has gone through a comprehensive health also widened the scope of our services, that originally only targeted women of transition. Enhancing and scaling up services and reproductive age, to cover adolescents, adopting continuous quality improvement at all levels young people, elderly people and men. I would like to share with you some are milestones of this transition, in the context of health results in Turkey shown by reproductive systems reform. Since the foundation of the Republic health indicators: Our infant mortality rate, which was of Turkey, health has always been a priority, but health 200 per 1,000 in 1960, progressed to indicators did not immediately reflect economic progress. 20 per 1,000 now. We decreased our maternal mortality rate from 200 per I would like to present a summary of 100,000 in 1970 to 28.5 in 2006. We can some of our latest achievements. With the now provide antenatal care for more than aim of unifying our resources and main- 80% of pregnant women, whereas this streaming services, we brought together was only 43% fifteen years ago. Similarly, all public health facilities under the roof 83% of deliveries are currently performed of the Ministry of Health, giving priority under healthy conditions. to second level hospitals, but excluding While noting our achievements, I universities. would like to state that reproductive We developed a performance based health services will continue to be our payment model for the health priority until no preventable infant or staff. Regarding the physician per maternal mortality is left. number of population ratio, we The contribution of the Reproductive are lagging behind European Health Programme in Turkey, funded by countries, according to the an EU grant under the MEDA Pro- World Health Organization gramme and in-kind contributions of our (WHO), but we are taking country, is apparent in the realisation of action in order to increase the our national objectives. Our cooperation number of physicians. with the civil society organisations, sup- An important basis of the ported with a grant of 20 million Euro, transition programme is the facilitated our job through increasing introduction of General Health awareness within the community and Insurance, which is in its final stimulating the demand for services. stage. We will start implementa- We are determined to scale up service tion on 1 January 2008. In addi- delivery, sustain the new approaches and tion to this, family physician pilot meet the increased demand for services projects have been initiated in 21 of the generated under this Programme. 81 provinces. We have also introduced new employ- Prof. Dr. Recep Akdag˘, ment models for health staff. We are Minister of Health of Turkey employing contractual staff and midwives where we have health staff shortages. In this way, our services have been strengthened and their quality improved. Reproductive health services are among the main priorities of our Ministry. In line with the definition and scope of reproductive health services, we extended maternal health and family planning services. We adopted the WHO framework and in accordance with it we integrate a life cycle reproductive health approach in the overall health care system. We have

No.65 - 2007 M. Rifat Reproductive Health in Turkey Köse

Reproductive health servic- Turkey attended the International Confer- and civil sector) programme, RHP was ence on Population and Development in launched in 2003. es in Turkey date back to the 1994 in Cairo and adopted its Programme The main idea adopted for the con- foundation of the Republic of Action. Turkey then developed the ceptualisation of RHP is very simple National Strategic and Action Plan for and clear: The Programme should be itself. The services, then Women’s Health and Family Planning conducted through service provision and marked by pro-natalist poli- and thus extended the range of maternal community information activities that health and family planning services. The will affect and develop each other. The cies, were delivered through plan covered service delivery, in-service Programme, based on this dual struc- vertical channels by Mater- training, IEC, management, logistics and ture, improved service quality through improving women’s status. Similarly, a activities targeting infrastructure and nal and Child Health Centres “Population and Development” chapter service providers on one hand and on in the 1950s and Health with broad topics on sexual and repro- the other hand it promoted services for ductive health and rights was included in the disadvantaged groups who are not Centres in the 1960s. In the the 8th 5-Year Development Plan (2001). aware of their own service needs or have 1980s, efforts were intro- The National Strategic and Action Plan difficulty to reach services. It encour- was reviewed and updated within the aged these groups to seek services and duced to reduce high fertil- framework of reproductive health. Fol- help them utilise preventive reproductive ity and mortality through lowing an evaluation process which took health services. into account the post-Cairo conference The Programme ensured that central integrated family planning country programmes of action, millen- and provincial level units of the Ministry (FP) programmes which nium development goals and interna- enhanced their experience of working tional perspectives such as the 21 goals in with civil society in harmony, in-serv- were determined by anti- health together with national objectives ice training in the field of reproductive natalist policies. In the past and priorities, four main reproductive health was institutionalised, youth health health topics were selected as the inter- centres were strengthened and increased three decades, the MCH/FP vention areas of the Reproductive Health in number, pilot implementations of General Department was Programme: pre-service reproductive health curricula were finalized, the Turkish Demographic established, and fertility 1. Maternal mortality rates are still high and Health Survey 2003 was supported, and mortality declined, to despite the declining trend, researches were carried out such as on 2. Unintended pregnancies continue to STI surveillance, health seeking behaviour which both routine services be a problem, and maternal mortality. and specific projects and 3. Sexually transmitted infections and Considering its short implementation HIV/AIDS: The diseases are increas- period, the RHP in Turkey has provided programmes contributed, ing. important contributions, as expected, although issues of regional 4. Sexual and reproductive health and to the process of achieving reproductive rights of young people: The young health targets stated in the National Stra- discrepancies, quality and population which is quite big can not tegic and Action Plan of Turkey. access remained. adequately utilise sexual and repro- I would like to extend my thanks to all ductive health services. parties, organizations and those who made great efforts to initiate and imple- Within the framework of the “Health for ment the Programme. All” approach of the Ministry of Health, reproductive health, coverage of services, M. Rifat Köse reducing regional discrepancies and Director of the Department of MCH/ dealing with gender issues have become FP of the Ministry of Health visible in the Ministry’s perspectives in the 1990s. Parallel to this, negotiations with the EU, which was willing to directly invest in the civil sector, were started in the first half of the 1990s. As parties finally agreed on a two-strand (i.e. public EU-Turkey: Figen Tunckanat Perspectives in Health - Reproductive Health Programme in Turkey

The European Commission (EC) is the major international donor in the health field in Turkey. EC support began in the early 1990s with a policy aimed at poverty reduction and reflecting a clearer understanding of the links between health and poverty. It focussed on a number of key issues including improving access to reproductive health services, reduction in maternal mortality rate and in the incidence of HIV/AIDS.

Within the scope of this policy, sev- been supported by a technical assist- in-service training programmes to short- eral projects in Turkey were supported ance team (TAT)1, both at central and term refresher trainings and will lead between 1992 and 1997 from the special local level, attaching great importance to significant savings in the amount of budget lines of “HIV/AIDS” and “Popula- to strong management capacity in the resources allocated for that purpose. tion Actions”. The volume of health efficient and effective provision of health Due to the importance of timely and related EC funding increased substan- services. Equally important for the regular utilisation of health care services tially from 1995 with the adoption of the efficient use of resources has been the in the prevention of maternal mortal- Euro Mediterranean Partnership (MEDA) cooperation fostered by this programme ity, all activities related to improving which stressed the human aspect of the between the Ministry and all stakehold- service provision have been coupled with relation between the two regions. After ers, including civil society organisations measures aimed at increasing demand for becoming a candidate country from 2002 (CSO) and with international organisa- the services6. This has constituted a high- onwards, Turkey started to benefit from tions, UNFPA, UNICEF and WHO. profile awareness raising not only in the pre-accession funds. public at large, but also in the media on As a result, EC’s health portfolio in Major Programme Components maternal and infant mortality issues. Turkey evolved from thematic and indi- Training has been a cornerstone of the Under the supply component of the vidual projects to sector wide programme programme in order to build institutional programme 15 million worth of medi- under social development with MEDA capacity and equip health care personnel cal supplies and equipment have been and to institutional building with the pre- with adequate knowledge and skills on provided to support the improvement in accession funds. SRH issues, thereby enhancing the quality the quality of services. This has included The Reproductive Health Programme of services on offer. the refurbishment of units offering youth- in Turkey (RHP) was one of the main A pool of trainers created at central lev- friendly services as well as the provision recipients of MEDA funding in Turkey, el2 of the MoH have disseminated at local of training aids and equipment for the with an EU budget of € 55 million over level the skills and knowledge they have centres where in-service and pre-service a six year period. The objective of the acquired, through a network of Regional training is carried out. The provision programme is to improve the sexual and RH Training Centres and Provincial of the supplies and their distribution to reproductive health (SRH) of the popula- RH Training Centres3. A service model the end users has been performed by 12 tion in general, but particularly of women is developed for basic/comprehensive companies under different contracts7. and young people. The programme takes emergency obstetric care (EMOC) and Among the surveys carried out to a two pronged approach by improving effective first aid/referral4, incorporating provide comprehensive and reliable data the quality of health services on the one the standards recommended by WHO. on SRH, the programme has co-funded hand and boosting demand and utilisa- This model has now been included in the the “Turkish Demographic Health Survey tion of these services on the other. Health Ministry’s 2005-2015 SRH Action 2003 (TDHS2003)”8. The findings of the In its drive to improve the health serv- Plan and will be disseminated gradually survey are reflected in the 2005-2015 SRH ices on offer, the programme has directly throughout the country. Action Plan of the Ministry. supported the activities and policies of The training component also acceler- A survey conducted in cemeteries the Ministry through several compo- ated efforts to harmonise SRH educa- on burials of female deaths9 gathered nents which provide technical assistance, tion offered by medicine, nursing and information on maternal mortality which training, equipment, as well as support to midwifery departments of universities5 makes comparisons on an interregional, research and policy development through with the EU curriculum, emphasising the urban/rural as well as international level 10 service, 19 supply contracts signed “higher education quality management” possible. The study has resulted in a shift within the scope of 11 service and 8 sup- principles of the Bologna Declaration. In to a permanent, systematic and sustain- ply tenders. the long run these efforts will result in able registration and reporting system The Ministry of Health (MoH) has converting Ministry’s current long-term for the future. Whereas the findings of

No.65 - 2007

a qualitative study on health seeking necessity to prioritize improvements in the Consortium with Sofreco and behaviour10 has provided meaningful the overall management capacity of the DeLeeuw International. replies to the “whys” and “hows” raised Ministry of Health through training of 5. “Strengthening SRH pre-service by the quantitative data from the “TDHS health personnel at different levels so that training capacity” project by EU- 2003” and “National maternal mortality policies can be effectively converted into ROMED sprl, leading partner of the survey”. And finally, a second generation action plans. Consortium with Ada Mühendislik surveillance study on sexually transmitted The studies undertaken have filled in ve Yazılım Hizmetleri Tic. Ltd. Sti and infections11 was conducted in coordina- the information and data gaps in the International Centre for RH Ghent tion with the EU-funded Project on the fields of organization and management of University “Control of Communicable Diseases and health services. Their findings and result- 6. “Mass media campaign on awareness Strengthening of the Surveillance System”, ing proposals will provide a sound basis building on maternal and neonatal as a basis for the restructuring of the for decision making and for the more health” project by Excel Communica- response mechanism to potential health effective use of resources. tions Consultancy leading partner threats as foreseen in WHO “Interna- An effective cooperation has been of the Consortium with Health tional Heath Regulation”. established with the CSOs in terms of Focus GmbH and Hill & Knowlton In order to boost demand and utilisa- increasing public demand for reproduc- Communications GmhB & Co. KG tion of health services, direct financial tive health services. Mass media has been and Mother and Child Education support of 20 million has also been effectively used to inform public opinion, Foundation (ACEV) granted to Civil Society Organisations raise awareness of public health services 7. AJZ Engineering GmbH; ALTAY (CSO). Funding to CSOs has followed and influence patterns of behaviour and Scientific SpA; AMS Tıbbi Cihaz competitive procedures through well demand. Imalat Ithalat Ihracat Ltd. S¸ti.; Bimsa publicised “open calls” inviting a wide At the macro level, the RHP has aligned Uluslararasi Is, Bilgi ve Yonetim Sis- range of organisations to submit innova- measures undertaken in Turkey with temleri A.S; Caner Medikal Ltd. S¸ti; tive projects which respond best to the the mother-child, health care and family D.R.C.b.v.; Globe Corporation BV; priorities of the programme as well as to planning targets established at the Cairo Meteksan Sistem A.S¸.; Seha Muhend- local needs. Following stringent evalua- International Conference on Population islik Musavirlik Tic. ve Makina San. tion procedures of two successive calls for and Development (ICPD) as well as at its Ltd Sti; Simed International bv; Spare proposals, the best projects were selected subsequent ICPD +5 and +10. The ambi- S.A.; YONSIS Bilgisayar Sistemleri and 88 grant contracts were signed to tious and multi faceted RH programme San. Tic. A.S conduct nation-wide information, educa- has succeeded in placing sexual and 8. Conducted by Hacettepe University, tion and communication activities. In the reproductive health firmly within the Institute of Population Studies process the CSOs have been encouraged sphere of fundamental health rights. 9. “National maternal mortality study” to establish effective strategic relations project by ICON Institut Public with local authorities and other stake- References Sector GmbH leading partner of the holders, and to institute intersectoral 1. “Technical Assistance Service Con- Consortium with Hacettepe Univer- and multidisciplinary approaches in tract” by EPOS Health Consultants sity - Institute of Population Studies addressing health issues. The results so leading partner of the Consortium and BNB Ltd. far indicate that durable and fruitful col- with Options Consultancy Services 10. “Health seeking behaviour study” laboration between the public sector and Ltd and Willows Foundation project by Conseil Sante S.A leading civil society is set to continue in this field 2. “Strengthening SRH in-service train- partner of the Consortium with Sofreco with the CSO network built under the ing capacity of the MoH” project by and Eduser Consultancy Services Co programme. SOFRECO, leading partner of the 11. “Operations Research on key STIs/ Consortium with, Conseil Sante SA HIV in Turkey” project by ICON Conclusion and Stars Crescent Assistance Institut Public Sector GmbH leading In the long run, the Reproductive Health 3. “Logistic support for the training partner of the Consortium with Programme is expected to reduce mater- of health care personnel” project by Institute of Tropical Medicine and nal mortality rates and eliminate regional Figür Kongre & Organizasyon Ltd., Hacettepe University-Department of disparities in reproductive health indica- leading partner of the Consortium, Public Health/Faculty of Medicine tors. It has focused on measures that are Lidea E˘gitim ve Danıs¸manlık Ltd. and replicable, realistic, and cost-effective and Figür Turizm & Organizasyon Figen Tunckanat (Ph.D) specific in terms of gender, age group, 4. “Strengthening emergency obstetric Sector Manager for Health geographical regions and local conditions. care (EMOC) services” project by EC Delegation to Turkey The programme has shown the Conseil Sante SA, leading partner of [email protected]

The Reproductive Health Programme in Turkey: Overview and Approach By Ibrahim Acikalin, Mehmet Ali Biliker, Robert Gaertner, Demet Gural, Patrick Krause

t the mid-term date for achieving nity awareness of sexual and reproductive hood (SM), family planning (FP), STIs- the Millennium Development rights, increase service utilization and en- HIV/AIDS and youth friendly sexual and AGoals (MDGs), the goals and hance the existing infrastructure in order reproductive health services (YFS). The targets set by 189 states in September to improve service delivery. The expected focus on a reduction of maternal mortal- 2000 are high on the agenda again. A outcomes of the Programme include: ity, as a long-term objective, required survey recently conducted by the Euro- • Increased use and scope of services attention to the availability of antenatal pean Commission (EC) among European • Increased service accessibility (geo- care, skilled attendance and emergency Union (EU) citizens showed broad public graphical, economical, cultural etc.) obstetric care (EmOC). Increased access support to the achievement of the MDGs • Increased quality of RH services to a wide range of contraceptive choices and EU’s assistance in the process. The • Increased sexual and reproductive aimed to improve birth spacing and EU funded Reproductive Health Pro- health awareness among adolescents reduce frequency, better meeting current gramme in Turkey (RHP), which com- • Increased awareness among decision preferences of women and couples. In- menced activities in January 2003 and makers, parliamentarians and policy vestments in the quality of care had to be came to an end with a final conference in makers in order to support reproduc- accompanied by major interventions to September 2007, contributed directly to tive health and rights raise awareness among women and their four of the eight goals identified. Gender • Reduced geographical discrepancies families about available services (See ar- equality and women’s empowerment, in reproductive health indicators. ticle in this issue of Entre Nous; hereafter maternal and child health, and combating “The Millennium Development Goals referred to as “See article”). STIs and HIV/AIDS were at the core of its … cannot be achieved if questions of According to MoH data, 1,123 people aims and objectives. population and reproductive health are were infected with HIV in 2003. In A grant from the EU of € 55 million not squarely addressed. And that means recognition of inadequate case detection and a contribution of an additional € stronger efforts to promote women’s and reporting, the Programme targeted 8 million from the Ministry of Health rights, and greater investment in educa- to improve the available data, as the basis (MoH), makes the RHP not only the tion and health, including reproductive for effective prevention and treatment ef- largest EU funded intervention in the health and family planning.” forts. Wider and deeper public knowledge health sector in Turkey, but very likely (UN Secretary-General, Kofi A. Annan, about STIs and HIV/AIDS across all the most comprehensive of its kind in the Bangkok, December 2002) layers of Turkish society was aspired to. world. Nearing EU standards and levels The Programme aimed to contribute to a The National SRH Strategy document of of development have been the guiding reduction in maternal deaths by 75% by the MoH clearly recognises young people principle for the MoH throughout the im- the year 2015, a reduction in the age spe- in need of particular attention especially plementation of the Programme, fostered cific fertility rate and most importantly with regard to protection from STIs and by the start of the accession negotiations a reduction in the regional discrepancies HIV/AIDS. The Programme has given between the EU and the Government of within the country by increasing the uti- due importance to addressing the needs Turkey in October 2005 and the built up lisation of sexual and reproductive health of young people regarding access to to it. services. information about SRHR and appropri- MDG 3: Promote Gender Equality and To achieve its purpose the Programme ate counselling and health services (See Empower Women followed a two-fold strategy. Through article). MDG 4: Reduce Child Mortality direct support to the MoH, it aimed to MDG 5: Improve Maternal Health strengthen institutional capacity and Summary of Main Results MDG 6: Combat HIV/AIDS, Malaria and quality of services on the one hand, With a separate research budget, the Other Diseases including training of health personnel, initial design of the RHP gave due impor- This article provides an overview of the upgrading of health facilities and the tance to the collection of accurate data Programme, explaining the need for introduction of quality management as a prerequisite for policy development reproductive health in Turkey, the choices mechanisms and service standards. On and advocacy, the definition of appropri- made during its implementation and the the other hand, the Programme aimed to ate interventions and most importantly main activities and results to date, point- advocate for reproductive rights, increase to monitor and evaluate results from ing at other contributions in this Special awareness and strengthen appropriate be- the process. Research priorities of the Issue. We are ending on main challenges haviour patterns and demand for health Programme were: the TDHS, maternal ahead for sexual and reproductive health services among the population through mortality, STIs-HIV/AIDS and health and rights (SRHR) in Turkey. support to interventions and activities of seeking behaviour (See summary of HSBS civil society organisations (CSO). on page 9). Priorities of the Programme Four main areas were selected as While estimations of maternal mor- The RHP was designed to raise commu- Programme priorities, i.e. safe mother- tality at the national level have been

No.65 - 2007 Mehmet Ibrahim Demet Ali Biliker Ac¸ikalin Gural

made at several points in time, different Engender Health and applied to more ties. Furthermore, a pilot project was con- methods were used and results were not than 40 facilities in the North-eastern ducted to organize EmOC services and comparable over time or internationally. provinces of Turkey with remarkable support hospitals with necessary supplies The National Maternal Mortality Study results (See article). Quality of care and and equipment, which is expected to have conducted under the Programme, is provider needs are taken seriously at the a major direct impact on maternal deaths. the first of its kind in Turkey estimating facility level after the introduction of The RHP envisioned increasing de- the maternal mortality ratio at 28.5 per service standards. Through client orienta- mand for SRH services mostly through 100,000 live births in 2005, with the high- tion in the process a dialogue is initiated, the CSO component. CSOs had already est levels in Northeast Anatolia and East which leads to a better exchange and prior to the Programme proven to be Black Sea (See article). understanding, and ultimately to services able to successfully develop innova- Lacking data on STIs and HIV/AIDS better targeted to the needs of clients. tive programming in awareness-raising, was addressed by initiating a consensus In accordance with the service stand- community based activities, advocacy, re- building process on surveillance and ards, the provision of training at all levels search and training, targeted particularly conducting an operations research on key to built capacities of managers and service at hard to reach groups. Under the RHP STIs and HIV/AIDS in Turkey. The project providers, and more importantly the two calls for proposals were conducted, developed tools for second generation strengthening of training systems have contracting a total of € 18.94 million to sentinel surveillance and applied these in been a major priority for the MoH. 12 88 CSO projects, involving 107 CSOs. Ad- five major cities in Turkey (See article). A in-service training modules have been ditionally to the EU funding, CSOs have comprehensive qualitative study, target- developed and applied under the RHP added another € 3 million of their own ing health seeking behaviour of women (see overview on pages 30/31). More than resources. The guidelines developed for in relation to pregnancy, was finalised 9,000 service providers and managers were the calls clearly outlined the main priority in March 2007, clearly recording facts trained, focusing on in-service training in areas of the Programme for which pro- obtained through focus group discussions primary care, EmOC services, YFS, the in- posals were welcomed. CSOs were active and in-depth interviews (See article). troduction of service standards and quality in 55 out of 81 provinces, reaching almost A training needs assessment, con- oriented health care management training. every corner of the country. The figure ducted in the inception phase of the RHP, Particular importance was attached below shows that the largest part of the acknowledged that almost all internation- to provide a structure and ensure the resources, i.e. € 9.6 million, was spent on ally recognised SRH services are currently sustainability of SRH trainings in order to the three Western regions, followed by the available in Turkey, but pointed to the ensure high quality services. In that sense, three Eastern regions with € 6.7 million absence of nationally binding standards. in-service trainings were institutionalised and very little in between. The CSO com- Based on these findings the RHP devel- in provincial and regional training cen- ponent has contributed tremendously to oped the Framework for SRH Services tres, providing sustainable and continu- the overall visibility of the RHP, putting in Turkey, providing an agreed structure ous training of trainers, and training of SRHR issues on the agenda across the against which responsible senior, mid and service providers, accompanied by effec- country (See article). line managers can target improvements tive supervision and monitoring systems in SRH services, manage performance (See article). Also 19 Youth Counselling Challenges Remain by providers, improve facility standards, and Health Service Centres (YCHSCs) Overall, the Programme has delivered and increase overall access and utilisation catering for special needs of young people remarkable outputs, fully matching the of services. Based on the priorities set by in the age group 10 – 24 have been estab- remarkable resources provided. The Pro- the Programme, the Framework sets out lished, with RHP support. gramme contributed well to the establish- primary activities and the associated com- Furthermore a project was conducted ment of national standards for SRH in petencies (knowledge, skills and attitudes) for 3 groups of health professionals Turkey. Short-term results can be observed required by a wide range of service pro- (physicians, nurses and midwives) with with a view to improved knowledge and viders, with an emphasis on primary care. a view to developing pre-service SRH skills among service providers and manag- The document provided the basis for curricula and adapting these curricula to ers, the sustainability of training and youth the subsequent development of all train- the schools education programmes ( See centres, attracting clientele and conducting ing activities, the development of service article). trainings, increased awareness and under- standards, assessment of equipment Almost 15 million were spent on up- standing of SRHR issues among vulner- needs, quality improvement, the revision grading of health facilities and pre-service able groups. The co-operation between of job descriptions, and the introduction training institutions. Equipment was CSOs and the public sector is on an un- of performance management. procured for 500 health centres, 161 hos- precedented level. This, however, needs to Service standards were adjusted to the pitals, 75 MCH/FP centres functioning as be transformed into changes in behaviours Turkish context from the Client Oriented training centres, 19 youth centres and 9 and access of the most vulnerable groups Provider Efficient (COPE) approach by faculties and health schools of 3 universi- in Turkish society to quality services.

Demet Patrick Robert Gural Krause Gaertner

Georgia closing, Turkey will be most unlikely to Istanbul Bati Marmara 350000-750000 3,9 0,3 0,6 meet the MDG for gender equality by 0,4 Bati Karadeniz Dogu Karadeniz Armenia 2015. Gender continues to be a major 0,9 2,0 Dogu Marmara 750000-1500000 Kuzeydogu Anadolu cause of inequality in reproductive health, 0,4 Iran with large variations in human develop- Orta Anadolu Ortadogu Anadolu Ege 1,6 1500000-2500000 ment levels between men and women. 4,4 2,2 Güneydogu Anadogu Bati Anadolu The health sector alone cannot achieve 3,1 2500000-3500000 Akdenla a marked improvement on this issue. It Iraq 1,2 Syria requires attention to legislation, political 3500000-4500000 empowerment, economic participation and educational attainment, fostered by Figure 1: Distribution of CSO Grant Scheme in Million inter-sectoral collaboration. It is too early to talk about the impact attention and investment is necessary. of the Programme. Even though the time Senior and mid-level managers at central Ibrahim Ac¸ikalin span between the previous TDHS in 2003 and provincial level need to be further Deputy GD, MCH/FP MoH and the one scheduled for 2008 covers strengthened in their capacity to priori- [email protected] almost exactly the RHP implementation tise, convert policies into strategies and Mehmet Ali Biliker, period, the data gathered in 2008 will not action plans and implement them. Deputy GD, MCH/FP MoH yet assess the full impact of the Pro- 2. Public – CSO Partnership gramme. The success of the Programme The Programme has greatly contributed Robert Gaertner, also needs to be judged against the ability to bridge the gap between public and MD of EPOS to keep SRHR on the political agenda CSO sectors, working jointly on the and mobilise resources as there are major achievement of a common goal. Espe- Demet Gural, challenges ahead: cially for vulnerable groups this partner- ED of Willows 1. Management ship needs to be continued and intensi- According to the National SRH Strategy fied. Also the provision of quality health Patrick Krause one of the weaknesses in the Turkish services to hard to reach groups by CSOs Programme Co-Director, health care system is limited manage- should be further explored. RD Europe of EPOS patrick. [email protected] ment capacity. The RHP has contributed 3. The Gender Gap with its activities in this respect, but more Even though its gender gap has been Health Seeking Behaviour Study

The study was designed as a qualitative study Perception of pregnancy Barriers to ANC services to explore and describe the perceptions Pregnancy was perceived as a natural process, According to pregnant women and their rela- and health-seeking behaviours related to even as a process giving a sense of happiness tives, there were many and serious obstacles pregnancy and childbirth in selected urban and fulfilment in general and it was found impeding access to ANC services. The most and rural sites in Turkey, in order to design unnecessary to attend a health care institu- common and highly-rated obstacle was interventions contributing to increased tion in the absence of any severe complaint. ‘lack of interest and negative behaviour of utilisation of antenatal care (ANC) and skilled Concern and anxiety observed in some the health personnel’. Inattentiveness, bad birth attendance. It was conducted in Adana, pregnant women were related to childbirth practice, and miscommunication at health Afyon, and Van provinces (in parts of these and the health of the baby rather than the care institutions were important determining provinces where problems regarding ANC pregnancy itself. factors of under-utilization of existing ANC and skilled birth attendance are observed) services. among pregnant women who have never A feeling of ‘shame/embarrassment’ was attended or discontinued ANC services, and present in almost all pregnant women inter- Other common obstacles were lack of health relevant others. The study group was selected viewed and it is understood that this feeling insurance and economic problems. These by purposive sampling and snowball method. negatively affects obtaining information and emerge along with lack of education, and accessing ANC services. gender problems. Low education level and Data were collected through in-depth living in an extended family, where permis- Symptoms like vaginal haemorrhage, immo- interviews and focus group discussions with sion of the mother-in-law and husband is bility of the foetus, severe pains and nausea 239 participants, of whom 111 were pregnant required, seriously impeded women access- increased risk perceptions as did previous women, the remainder (128) being peers, ing information and services. relatives, health care personnel, and commu- experience of miscarriages, stillbirths, babies nity leaders. 60.4% of the pregnant women with deformities, and babies with serious Inadequate ANC at primary health care were in the 20-29 age group, 59.1% resided in diseases, in their proximity. institutions, insufficient personnel, and the occurrence of organizational and administra- urban areas, and 98.2% were either illiterate Although pregnant women and their relatives tive problems, were important obstacles in or elementary school graduate. Furthermore, stated that attending ANC is a good thing, the utilization of services. 57.4% were from extended families. they could not give satisfactory explanations as to why it was. Osman Hayran MD, Professor, HSB Team Leader

No.65No.61 - 20072005

Onur MAKING MOTHERHOOD SAFER Karabacak

The National Maternal Mortality Study has proven that despite good progress, making pregnancy and childbirth safer is still a priority for Turkey (1). Special attention was required for the north-eastern part of the country, where the maternal mortality ratio (MMR) was 68.3 compared to a national average of 28.5 per 100,000 live births. Based on the three-delays model the Programme aimed to increase quality of care and awareness and utilisation of services.

In 2004-2005 detailed situation analyses PHC Training together with IEC materials. The MOH were conducted in five pilot provinces of A training module for SM was developed developed a website providing infor- Agri, Ardahan, Erzurum, Igdir and Kars. covering antenatal care (ANC), delivery mation on the first, second and third The focus was on infrastructure, supplies, and postnatal care. The module was used trimesters of pregnancy. Danger signs and human resources, knowledge and skills of for the training of approximately 3,500 changes to be expected are extensively staff of primary health care (PHC) facili- service providers in PHC in 67 provinces. publicized (2). ties, basic and comprehensive emergency It was also shared with Civil Society obstetric care (EmOC) facilities, blood Organizations (CSOs) for additional Mass Media Campaign centres and emergency services. The key trainings and briefings. In February 2007 the Ministry of Health findings were: (MOH) started with the development of (1) Some north-eastern provinces lack EmOC Training a national mass media campaign, with basic 24-hour EmOC services. Issues EmOC in-service training modules were some specific activities in 15 provinces included staff shortages, especially of developed. A systems’ perspective, the with similar demographic backgrounds. midwives at PHC level in rural areas; team approach and clients’ rights/pro- The campaign aims to increase aware- limitations in clinical skills; lack of equip- viders’ needs were at the core of these ness on EmOC and to boost utilization of ment and supplies; weak team work and modules, which targeted PHC service SM services. Local women were actively management capacity. providers, first aid and referral, basic and involved in the creation of appropriate (2) The blood transfusion services comprehensive EmOC facilities and the messages. Women did not want to hear required standardisation of blood collec- management level equally. The modules messages from well known female artists, tion, care and storage. include clinical practice updates and but they wanted messages from ‘women (3) Referral protocols were not in place standards, emphasised a teamwork ap- just like them’. They also did not want to and emergency services (112) needed proach and inter-sectoral cooperation. involve their mothers-in-law or their own upgrading. Extensive trainings in EmOC within husbands, because they felt that “Preg- (4) Difficult topography and weather the five pilot provinces are completed nancy and related conditions are special conditions produced delays in accessing under the Programme and will be further to the mother and no other persons have services. expanded (Table). to be involved if women are empowered”. (5) Low levels of awareness due to poor In a ‘Road Show’ a van displayed a poster female literacy rates and a lack of empow- Clinical Protocols showing well known national figures 10 erment reduced access to maternal health Clinical protocols for pre-marriage stating: “Regular antenatal visits - healthy services. counselling, preconception, ANC, birth, mother and healthy baby - prevent Acting on the findings and utilising the postnatal care and EmOC were prepared, deaths” or “My baby stay alive, a baby’s three-delays model as a framework, the Table: EmOC Training Programme aimed to: 1. Increase awareness and utilization of Type and Target Group Focus SM services. Health managers training: central and provincial health admin- Facilitative management 2. Increase the quality of SM services. istrators, health group heads; hospital administrators, hospital Supportive supervision head nurses Teamwork 3. Provide essential equipment and supplies. 1st level health services personnel: doctors, nurses, support Awareness of EmOC and SM staff, 112 emergency personnel, ambulance drivers, safe blood Teamwork Delay 1 - in recognising a complication technicians. Roles and responsibilities and seeking help. Clinical training: obstetricians/gynaecologists, paediatricians, Competency based clinical training Delay 2 - in reaching appropriate health anaesthesiologists, emergency service personnel, blood drive Patients’ rights/providers’ needs care centres. personnel, midwifes, nurses Teamwork Delay 3 - in receiving appropriate care Neonatal resuscitation: Doctors, paediatricians, anaesthesiolo- Cardio pulmonary resuscitation and treatment at the facility. gists, midwives and nurses Onur Ece Mohammed Selale Ferit Karabacak Abay Mustafa Özmen Saraço˘glu

life is connected to the mother, the moth- tion of Provincial and District Governors administered. The woman was immediately er’s life is connected to baby” and Mayors, Religious Affairs, Rural taken for caesarean section. Both she and Affairs, National Education, Popula- the baby survived. Educational Materials tion and Citizenship, Turkish Armed The implementation of national service A variety of IEC materials were designed Forces, Provincial Private Administration, standards for EmOC is scaled up by the by the MOH to enhance utilization of SM Highways Administration, Electricity MOH, including further development of clinics. The handouts state that antenatal and Agriculture administrations and referral protocols in line with interna- visits decrease mother and newborn mor- Provincial Health Directorates in the five tional guidelines. tality and increase postnatal survival. The pilot provinces. Based on the three-delays WHO recommends one comprehensive message is based on evidence from the model, action plans and reports were and 4 basic EmOC units for every 500,000 Turkish DHS 2003 data (3), that the fre- developed, followed up on a 3-monthly population. The north-east of the country quency of ANC has an impact on where basis. The co-ordination has resulted in is sparsely populated. High altitude and the mother will deliver. If the mother new and innovative approaches, including limited road access in winter time means attends ANC four or more times, 96% of the following: low demand for EmOC and a high MMR. deliveries will be in a hospital, compared (1) To overcome the harsh winter condi- To increase coverage, every province is to only 50% of mothers who have not tions the councillors from Ag˘rı and Ig˘dır establishing one comprehensive and two attended ANC. created a winter guest house project for basic units, although their populations expectant mothers and one accompa- are below 500,000. CSOs nying family member. The guesthouse 15% of the CSO projects awarded under is used for the last four weeks before References the Programme’s grant scheme aimed at delivery. 1. Turkish National Maternal Mortality increasing awareness and utilization of (2) In Ardahan a statement is being Study. Hacettepe University Institute SM services. The projects in the eastern printed at the bottom of electricity bills: of Population Studies, Ankara, 2005. provinces of Turkey were mainly focusing “The interval between deliveries should 2. http://sbu.saglik.gov.tr/tusp/turkce/ on increasing literacy, providing infor- be at least two years and the maternal age mudahale_alanlari/index.asp. mation about reproductive rights and at delivery should be 20 – 35 years old.” 3. Turkish Demographic and Health emphasizing the importance of ANC and (3) In religious gatherings the importance Survey, 2003. Hacettepe University facility delivery. Literacy trainers provided of ANC is emphasised. Institute of Population Studies, An- SRH knowledge and information. In (4) Local TV Kars region has broadcast a kara, 2004. many cases the change in women’s at- programme about EmOC. titudes could be seen immediately after (5)The military offered to clear snow the training. covered roads and provide assistance by Onur Karabacak specialized vehicles or helicopter if ambu- M.D. Professor Ob/Gyn at Gazi Uni- I never received ANC for any of my lances fail due to weather conditions. versity SOM, Turkey pregnancies, but I will definitely guide my (6)112 emergency services will include ([email protected]) daughters and daughters-in-law to have SM in their routine training. Ece Abay proper ANC M.D. Public Health specialist, Depart- Conclusion Trainee in Erzurum ment of MCH/FP; Head EmOC Sec- Multi-sectoral approach is already bring- tion, Ministry of Health, Turkey 11 If women are not cared for properly they ing results. The case study below dem- refuse to go for another visit. onstrates how improvements in EmOC Ferit Saracoglu CSO trainer services are already in place and saving M.D. Associate Professor Ob/Gyn in women’s lives. Numune Hospital, Turkey. Local CSOs gained excellent support from A lady was admitted ‘fitting’ at 36 weeks of provincial governors, the health directorates pregnancy; she was immediately diagnosed Selale Ozmen and other sectors such as the military dur- as having eclampsia. The midwife prepared M.D. Specialist Ob/Gyn; Consultant at Willows Foundation, Turkey ing the implementation of their projects. an infusion of Magnesium Sulphate, having Representative of a National CSO been taught about the benefits of this treat- Mohammed Mustafa ment during her training. When the doctor M.D. Specialist in Ob/Gyn, Cairo, Inter-sectoral Collaboration arrived he prescribed Diazepam. The mid- Egypt. The Programme effectively initiated inter- wife refused to administer the Diazepam sectoral collaboration mechanism under and explained the use of Magnesium Sul- the leadership of the MOH. The process phate. She had to convince the doctor, but commenced with the active participa- in the end the Magnesium Sulphate was

No.65 - 2007 INSTITUTIONALISATION OF SRH IN-SERVICE TRAINING By Burcu Açıkalın, S¸evkat Bahar-Özvarıs¸, Rukiye Gül, Gayane Dolyan-Descornet, Hacer Boztok, Dilek Özdemir, Günes¸Tomruk, Güldalı Aybas¸

uring the last decade the Min- organized for national trainers and serv- istry of Health (MoH) worked Box 2. Training equipment and models ice providers. As a strategy, 5 candidate Dtowards developing sustainable • female Pelvic Organs Model trainers from regional RHTCs and 3 and effective SRH training programmes • master Set of Human Reproduction from general RHTCs were selected for in all provinces of Turkey. In 2005-2007 • gynaecological Model (Zoe) a TOT. Priority was given to volunteers comprehensive and complementary work (midwifes, nurses and physicians with • childbirth model was done by MoH staff, national and experience). Candidates were trained dur- • episiotomy Suturing Simulator international experts, within the RHP ing a 20 days course by master trainers (5 • embryo/Foetus Development Poster framework, in order to further strengthen modules and TS together), using modern the system. The main project objectives • Pregnancy Cards with Apron methodologies. They acquired knowledge are presented in Box 1. • empathy Pregnancy Apron and training skills on clinical approaches, • Baby Examination Model adult learning techniques, creating a posi- Box 1. Overall and specific objectives • female Condom Model tive atmosphere, interactive techniques, Overall Objective • Breast Self Examination Model preparing and using audio-visual tools, To improve MoH in-service SRH training • Testicular Self Examination Model facilitation, demonstration and coaching, capacity nationally both in training skills and SRH programme areas and ensure the • Penis Model for Condom Training developing sessions and action plan. By sustainability through institutionalisation of the end RH trainers were fully equipped • Blood Pressure Training System in-service trainings with all the necessary modules, CDs and • arm model for intravenous injection Specific Objectives relevant materials for conducting train- • To strengthen the training centres; • intramuscular injection simulator ings at the provincial level. In total 247 • To develop and revise training materials on RH trainers were trained and are MoH the basis of sound pilot testing; tres are responsible for selecting training certified “RH trainers”. They have started • To strengthen SRH training capacity of participants according to predetermined to work as trainers in RHTCs and re- selected trainers in training skills and SRH programme areas (safe motherhood, criteria, collecting participant informa- gional RHTCs. In total 6159 primary level emergency obstetric care, family planning, tion, preparing the courses, revising as RH service providers were subsequently STIs, HIV/AIDS, and SRH services for young necessary, preparing materials and equip- trained in RHTCs and regional RHTCs people); ment, selecting trainers, preparing the on the different modules, selected accord- • To strengthen SRH training capacity of selected trainers in advanced training, TOT, rooms and carrying out the sessions. ing to the needs in each province. follow-up, and M&E skills; Majority of participants were either • To establish/strengthen a monitoring and SRH in-service training modules midwives (41.8%) or doctors (39.0%). evaluation system for SRH in-service train- and materials At the end of training, participants were ing; Prior to 2005, in-service training for tested on professional knowledge and • To ensure dissemination of the in-service clinical health personnel focused mainly training skills, using special multiple training results to policy makers and plan- ners. on family planning. The new training choice test forms. The results demonstrat- programme is the first experience for ed high achievements in all 5 modules the MoH in developing and introduc- reaching on average a 93.8±7.8 score as Strengthening of training centres ing integrated national SRH trainings shown in Graph 1. At the end of 2004, 75 Reproductive country-wide. Training modules were After the training sessions participants 12 Health Training Centres (RHTC) were developed jointly by national and inter- were evaluated on their learning abil- strengthened in 67 of the 81 provinces. In national experts. Eight different modules ity, active participation, knowledge on 2005-2007 all centres were equipped as cover the areas of Reproductive Health the subject, and their communication, shown in box 2 General Issues (RH), Family Planning coaching and facilitation skills. In general, According to sustainability plans of the Counselling (FP), Safe Motherhood and participants demonstrated a high motiva- MoH, 75 general (provincial) RHTCs will Emergency Obstetric Care (SM/EmOC), tion and high personal evaluation scores. be responsible for SRH in-service training STI/HIV/AIDS, SRH for Youth, Train- Training skills and attitudes of master of service providers. This includes 12 ing Skills (TS), Advanced Training Skills trainers were anonymously evaluated by Regional RHTCs that will also provide (aTS) and M&E Skills. All modules are participants and the former demonstrated training of national trainers (TOT). tested, revised and published. high quality job performance. Training sessions were organized according to the needs per province, as identi- Strengthening SRH training capac- Advanced and M&E trainings fied by Provincial Health Directorates ity of national trainers and RHTCs One hundred and sixty most success- (PHD), in collaboration with the MoH In 2005-2006, integrated training courses ful trainers, who had gained training MCH/FP General Directorate. The cen- on the above-mentioned modules were experience at field level, were selected for S¸evkat Günes¸ Gayane Bahar- Tomruk Dolyan- Özvarıs¸ Descornet

able. A “team approach” should be en- Trainees Test Scoring in Respective Course Modules couraged, because if local managers own 100 the training and realize the importance of 96,7 97,6 94,3 95,1 it, usually the activity is carried out more 90 91,0 89,0 successfully. Managers’ awarding systems 80 and events (e.g., acknowledgment letter,

70 remembering special days -midwifery and nursing week, festival of medicine and 60 organizing business meetings) motivate Family Reproductive Safe Sexual & STI, HIV, Training Planning Health Motherhood Reprod. AIDS skills trainers to improve their performance Health Youth in training courses. In-service trainings Graph 1 require an effective and sustained system. The in-service training project established additional 5-day course on “Advanced sustainability of centres, activities, atmos- important benchmarks for the future: an Training Skills”. They acquired more skills phere, materials, and capacity. efficient physical infrastructure, master in course facilitation, group dynamics, Most of centres were sustainable, but trainers; relevant materials and a support- problem solving, dealing with difficult 36% needed additional support to be- ive M&E process. situations and all aspects of develop- come sustainable. During the visits some ing training modules, thus becoming field training sessions were also evaluated “Advanced Trainers”. Sixty RH trainers and facilitative supervision was provided. Burcu Açıkalın were trained during 5-day “M&E Skills” Results, including short-term and long- MD, MOH MCH/FP General Directo- course, where the main steps for training term recommendations, were shared with rate activities were introduced and exercised, MoH, PHDs and RHTCs. S¸evkat Bahar-Özvarıs¸ including guidance and support to train- (Lead Author) MD, Prof. Dr., Hacet- ees before, during and after the training, Dissemination of in-service training results tepe University, Faculty of Medicine, and skills on performance evaluation. Dept. of Public Health, During follow-up activities, master Publication and dissemination of the [email protected] trainers provided support to regional and activities is important for continuation; local RHTCs at all levels of training. In it sets examples for the future activities; Günes¸ Tomruk the first follow-ups conducted of newly sheds lights on new studies and helps the MD, TAT Long term expert trained health personnel, the aim should contributors of the project recognize their be for both supporting and strengthening share in the success. Hence results of this Gayane Dolyan-Descornet health personnel’s skills acquired during project were disseminated in a conference MD, Prof. Dr., Team Leader SOFRECO/ the trainings and early detection and organized with participation of central Conseil Sante solving of problems that might prevent MoH and provincial managers, training Boxes: successful implementation. Some RH institutions and other public agencies. Güldalı Aybas¸, PhD, TAT Long term expert trainers stated that after initial support Hacer Boztok, Conclusion Rukiye Gül, MD, Dilek Özdemir , MOH MCH/FP in two trainings they could carry out the General Directorate third one on their own. Fully equipped and trained health per- 13 sonnel must receive periodic follow up Monitoring and evaluation to integrate new advancements in health, Recognizing the importance of continu- self -evaluate and remain motivated. Fol- ous M&E for sustainable and effective low-up then becomes part of an activity in-service training institutions, an between master trainers and SRH in- M&E strategy, tools and guidelines were service trainers. It helps trainers use the developed, tested and fully implemented lessons they have learnt during training at field level. Before field visits, a one more effectively. Within the evaluation day orientation meeting was held for the process, “corrects instead of wrongs” and M&E Team and visits were standardized. “achievements instead of failures” should In total 12 visits were made to the 12 be focused on. It should not be forgotten Regional RHTCs by master trainers and that “acknowledgement and approval” is MoH representatives. In general five main the most powerful approach that makes components of training were evaluated: people and teams effective and sustain-

No.65 - 2007 RESPONDING TO YOUNG PEOPLE’S SRH NEEDS

oung people’s SRH is one of the services for young people, aged 10-24, noted that almost all these sexually active main intervention areas of the also became one of the priorities of students were unmarried. Every 9 out of YReproductive Health Program EU-funded RHP in Turkey. It not only 10 students claimed they either needed or (RHP) in Turkey. The main focus has increases the number of youth friendly wanted to receive SRH services. been the establishment of 20 Youth centres from 18 to 38, but it particularly Counselling and Health Service Centres improves the skills and expertise of the How did we achieve what we did? (YCHSCs). These comrehensive youth- staff, in line with international standards. The process friendly centres provide quality clini- In the inital RHP it was planned to open cal and non-clinical services for young What does the data on youth in 16 YCHSCs under the MoH; however, people. Service delivery has begun, but Turkey tell us? upon request from many young people the centres still need more guidance from In the past decade several studies on and Provincial Health Directorates, actu- the Ministry of Health (MoH), intensive youth SRH were completed. Box 1 sum- ally 20 centres were established. youth-adult partnerships and support of marises major outcomes of the 2003 Implementation of the RHP Youth other stakeholders in order to become Demographic and Health Survey. Component began in 2004 with a Situ- more effective and sustainable. ational Analysis that provided a more Box1: Basic facts on youth and SRH in accurate picture of the real needs of youth Turkey (3) Why youth as an RHP intervention (6). The first part identified gaps in the area? • young people aged 10-24 years make up one third of the country’s population. provision of information for youth, their The MoH of Turkey puts a high priority • one in every five women reaching the age level of SRH knowledge, and an updated on safeguarding young people’s health of 19 is either mother or pregnant. demand for services. The second part was and rights, promoting gender equality • one quarter of all pregnancies under the an evaluation of 27 health facilites, that and supporting the transition of youth to age of 20 do not receive any antenatal were potential candidates for establishing care. adulthood. The recommendations of the youth-friendly services. Box 2 presents International Conference on Population • one sixth of these births are not attended some views of young people from the by health personnel, and one fifth take and Development (1) are reflected in the place at home. Situational Analysis. targets and strategies of Turkey’s 8th Five • contraceptive prevalence of married Year Development Plan, which provides women within the youth age group is only Box 2: Opinions of Youth as Stakehold- ers of Centres opportunities for young people to receive 44%. “Turkish society doesn’t have much aware- information, education and services ness. They don’t know about prevention. related to sexual and reproductive health In 2002 a study among first year univer- Girls and boys get married before accessing (SRH) and rights. sity students was conducted by Hacettepe correct SRH information” (22 years male). In 2002, the MoH established a University, Department of Public Health, “Will it provide a continuous service where I can ask for help for a psychological problem National Service Provision Model to im- a WHO Collaborating Centre (4). Health that I can’t discuss with my parents? Usually, prove adolescent health. In the following personnel who should provide services to people in such places only work two days a few years, with the cooperation of MoH, this group found that their SRH knowl- week” (21 years male). UNICEF, UNFPA and various Civil So- edge and experience was rather insuf- “They should provide counselling and also examinations. Eye contact is good but I think ciety Organisations (CSOs), 18 YCHSCs ficient. 71% had not received any training the main issue is examination and treatment. have been established. on adolescents; only 33% of those who (22 years male) 14 The importance of youth SRH was had some training felt competent to work “My family wants to learn what is happening; strongly emphasized in 2005, in the with adolescents. The study was the start- I should trust a doctor that s/he does not tell National Strategic Action Plan (NSAP) ing point for the creation of the very first anything to my family, otherwise I won’t go there ever” (22 years male). of the MoH, where young people were university based students SRH centres, “It should not look like a hospital; then defined as one of the five priority areas in of which there are already 13 now, partly young people might not want to come” (22 SRH (2). This NSAP provides a system- created as a result of the CSO component years male). atic overview of analyses, strategies and of RHP. “It should have computers, internet etc., so objectives during the period 2005-2015. In 2006, another study was conducted people will come to see each other apart A key recommendation on youth in the by the International Children’s Centre from seeking treatment” (21 years male). NSAP is: (ICC) among first year students of eight “If it is free of charge, quality of services will be poor. There should be a price for services, “Access to Youth Friendly SRH services universities. The data shows 12.4% of but it should be low” (22 years female). will be increased to have one unit provid- students had sexual experience with inter- ing these services for every 150.000 young course and 6.8% without (5). Experience people by the year 2015”. with intercourse was 6% among females Increased demand and supply of SRH and 33.1% among males. It should be Ays¸egül Emel Ays¸e Hilal Evert RESPONDING TO YOUNG PEOPLE’S SRH NEEDS Esin Özdemir Akın Özcebe Ketting S¸ahin

Comprehensive training pro- Youth participation in all phases of the grammes on youth-friendly services Programme is not an option but a neces- Two different training curricula were sity, if the needs of young people are re- developed. The first module is for health ally and truly to be met. Service providers professionals working in general primary have learned about the importance of health care services, and aims to raise engaging youth wherever they can, and awareness on SRH and young people. managers must ensure that the practice is The second, comprehensive module kept up beyond RHP. was for service providers , and this is Picture 1: Outreach work by young volunteers largely based on the “RAP rule”: Outreach activities and youth par- Youth component of RHP goes • Rights-based approach, ticipation international • Acceptance of young people’s sexual- An “Outreach Guide” for youth-friendly A major success has been the hosting of ity, and service provision was developed with the an International Symposium on “Youth • Participation of young people. aim of giving practical advice on planning Friendly SRH Services”, in Ankara, The training topics intend to stimulate activities, reaching out to target groups 2006 (9). More than 200 young people, providers to reconsider their attitudes and in the community and creating more specialists from national and interational approaches to young people. demand for the services offered at the agencies, health policy makers, and some An overall theme of this training is to centres (8). Providers have also learned in parents joined forces to discuss how create greater trust and understanding practice that they can better reach young SRH services can be made more acces- between youth and health care providers. people if they work outside their centres sible, acceptable and relevant to young Towards this end, the trainings also share in places where young people hang out, people. Representatives of Turkish CSOs, experiences of both sides, best practices like youth and sports clubs, café’s and WHO, UNFPA, UNICEF, ICC and IPPF and lessons learned by YCHSCs. fairs, or schools and work places. also provided expert advice and practical It was one thing to train health care examples of youth friendly services. A providers, but quite another to draw in Box 3: Various initial activities of major result of the symposium has been YCHSCs managers on a continuous basis. They too that youth-friendly SRH services are now are very important owners. A Manage- Outreach activities are the main part of firmly on Turkey’s health agenda and this the work of YCHSCs! ment Guide for Youth Friendly Services 1-Opening ceremony: This was organised agenda has the full support of many ac- has therefore been developed (7). The aim with painting and composition competitive youths. The Proceedings of the sym- of the Guide is to explain to managers of tions. Brochures, posters and T-shirts were posium include more than 200 recom- distributed by service providers and young YCHSCs in more detail the purpose of people. A concert was given by young mendations on various aspects, which are establishing a youth centre, the variety people during the ceromony. planned to be followed up by the different of youth related services, how to publicly 2-Working with police department: A participating agencies. Keeping in mind promote the centre, share the functions of YCHSC’s psychologist is working with the the “RAP rule” these recommendations police department, doing interviews dur- the centre and the “Services Framework ing interrogations. She has meetings with focus mainly on: for Youth” with personnel, inform them suspect criminal youth beforehand. She • Ways and means to lower barriers to on registration and reporting forms and also works with adolescents in the prison youth friendly health servies, or police department. provide instructions for their use in the • Priorities for developing information centre. 3-Ideas box and client exit survey: Almost and education materials for young all YCHSCs have placed an ideas box for 15 In the interest of sustainability it was young people to write down and deliver people, planned from the start that the cent- their thoughts about youth centre. • Methodologies and utilisation of peer ers will be part of existing primary level 4-School activities: YCHSCs prepared and education, health facilities, and not be separate gave presentations which were used to • Identifying the main stakeholders for promote their centres during school visits. organisational structures. The ultimate inter-sectoral collaboration and co- objective of the MoH in this respect is 5-Centre promotion on a tourism festival: ordination. Service providers of one YCHSC produced to ensure that all health facilities acquire 3000 caps, T-shirts, brochures and posters It should be stressed that CSO projects skills for a youth-friendly approach together with young people, which were have strongly contributed to putting through a common policy and service exhibited in a youth stand on the Alanya youth SRH firmly on the agenda; more Tourism Festival. The centre worked with a delivery standards. young professional group. News about the than 30 CSO projects addressed this youth centre was published in local and subject! national newspapers and television sta- tions. A video clip was made, to be used as a good outreach example for other centres.

No.65 - 2007 Achieving youth-adult is essential that: risk taking behaviour and level of partnerships • Issues related to youth stay on top of knowledge on SRH of first year stu- In this component youth, parents, service the health agenda of Turkey; dents of seven universities in Turkey. providers, managers, CSOs and the MoH • Number of youth centres is increased ICC, Ankara, 2006. embarked on a journey together. In this according to the targets of the SRH 6. Esin A. The Situational Analysis travel they acted, re-enacted, learned NSAP; Report on Sexual and Reproduc- and achieved together. Some important • Intersectoral cooperation and tive Health Counselling and Health achievements have been: multidisciplinary approaches are Service Centres For Youth for Sexual • Increased awareness in society about employed; and Reproductive Health in Turkey. needs and rights of young people. • In all programmes youth involvement Ankara, 2004. • Services are delivered in a non-judg- is ensured; 7. Esin A, Ketting E. A Management mental manner by health personnel • New researches and studies on adoles- Guide for Youth Friendly Services. who care about privacy and confiden- cent/youth sexuality are done and Ankara, 2007. tiality. the results are shared with relevant 8. Esin A, Ketting E. Outreach Guide for • Physical and other infrastructure agencies, communities and the media; Sexual and Reproductive Health in features of the 20 centres comply with • International collaboration and coop- Turkey. Ankara, 2005. internationally accepted standards of eration is continued. 9. Ministry of Health of the Republic of youth friendly outlets. One of the most critical issues is to Turkey. The International Symposium • Service providers use youth participa- prepare youth more consciously for the on Youth Friendly Sexual and Repro- tion in outreach activities with great future. Turkey has to attach special im- ductive Health Services; Symposium success. portance to describing the problems and Proceedings Book. Ankara, 2006. risks for youth, and subsequently develop Box 4: Quantitative Results effective strategies and action plans ac- Overall output achievement of the cordingly and implement them. Ays¸egül Esin Youth Component within RHP: We have overcome many obstacles, MD, Public Health specialist; national • a situation analysis on SRH YCHSCs and a there are still several barriers, but the youth expert of RHP Service Delivery Framework. Youth Component of RHP has been a ([email protected]) • a module for training primary health care very good start in taking youth SRH seri- providers, and 785 of them trained. Emel Özdemir S¸ahin ous in Turkey. • a comprehensive training module on MD, MoH GD Mother and Child Health Family Planning, Youth result youth friendly SRH services for YCHSC staff References and 122 of them trained. Follow-up train- leader of RHP, MoH ings were completed. 1. Programme of Action adopted at the ([email protected]) • an Outreach Guide and a Management International Conference on Popula- Guide for YCHSCs. tion and Development. New York, Ays¸e Akın • 20 new YCHSCs established. United Nations, 1994. MD, Professor of Public Health, • an International Symposium on “Youth 2. Ministry of Health of the Republic Hacettepe University Friendly SRH Services”, in 2006. of Turkey, Sexual and Reproductive ([email protected]) • number of clients in 38 YCHSCs was 26,332 Health National Strategic Action Plan in 2006, and 12,474 in the first half of 2007. Hilal Özcebe 16 For Health Sector 2005-2015. Ankara, MD, Professor of Public Health, • 75% of clients were pupils and students, 2005. and 8.5% were working adolescents. Hacettepe University 3. Hacettepe University Institute of • 44% of clients were 10-14, 38% were 15-19, ([email protected]) and 18% were 20-24 years old. Population Studies, Macro Inter- national Inc, Ministry of Health Evert Ketting General Directorate of MCH/FP, State PhD, International SRH consultant; Planning Organisation and European international youth expert RHP Future challenges Union. Demographic and Health ([email protected]) It is to be expected that in the next Survey. Ankara, 2003. decade, the issue of “Adolescent SRH” 4. Akın A, Özvarıs¸ S¸B. Factors affecting will become much more pronounced and the SRH of Adolescents/Young People pressing in Turkey. In order to meet the Report. Hacettepe University, Public rapidly changing SRH needs of young Health Department, UNFPA, Ankara, people, and to sustain the momentum 2004. created by the RHP Youth Component, it 5. Bertan M, Özcebe H, Dog˘an BG. The SECOND GENERATION SURVEILLANCE OF STI/ HIV/AIDS IN TURKEY By Peyman Altan, Levent Akin, Raphael Baltes, Kevin Fenton, Catharine Taylor

econd generation surveillance drug users (IDU) was conducted as part rhoea, chlamydia, Hepatitis B) and HIV (SGS) of HIV/AIDS is the regular, of the RHP in November 2004. The RA among pregnant women attending Ssystematic collection, analysis and aimed to identify groups most at risk of antenatal clinics (ANC). In addition, the interpretation of information used in STI/HIV and to determine which behav- cities of Ankara, Istanbul and Izmir were tracking and describing changes in the iours commonly put them at risk and to chosen as sentinel sites for MARPs (Most HIV/AIDS epidemic over time. It gathers determine the links between these high- at Risk Populations). information on risk behaviours, using it risk groups and the general population. to explain changes in infection rates. In Results suggested that there was a need to Implementing the ORKSH addition to HIV surveillance and AIDS continue efforts to improve knowledge, Key ORKSH activities were: case reporting, SGS includes surveil- raise awareness and promote safe sexual 1. Preparation of research documents lance of Sexually Transmitted Infections practices among the high-risk groups. (protocols, questionnaires, forms) (STIs), to monitor the spread of STIs in In February 2005 a National Consensus 2. Meeting with the Provincial Health populations at risk of HIV and behav- Building Meeting (NCBM) was con- Directorates staff to establish local ioural surveillance to observe trends in ducted with the participation of major coordination and collaboration risk behaviours over time. These different and relevant stakeholders in the field. The 3. Review of training modules for: components are more or less significant, NCBM discussed the results of the previ- counsellors, laboratory experts, peer depending on the surveillance needs of ous workshops and the situation analysis, recruiters a country, determined by the level of the including the RA. Speakers and panellists 4. Identification of NGOs and peer epidemic: low, concentrated or general- alike agreed that STI/HIV surveillance recruiters to work with groups at risk ized level (1). In low HIV prevalence needed improving and that an effective 5. Training of peer recruiters to mobilise countries like Turkey, where relatively surveillance system required the use of target groups few HIV-cases are found in any group, existing tools and mechanisms, in addi- 6. Training of counsellors, on voluntary surveillance systems focus largely on tion to behavioural studies and sentinel counselling and HIV testing (VCT), high-risk behaviours, looking for changes surveillance. and laboratory staff in behaviour which may foster a rapid 7. Pre-testing of questionnaires spread of the infection (2). Operations Research on Key STIs 8. Ordering and supplying tests and and HIV in Turkey (ORKSH) laboratory materials Steps taken to introduce SGS in Following the recommendations of the 9. Data and sample collection of ANC Turkey NCBM an Operations Research on Key patients and MARPs A number of different project activities STIs and HIV in Turkey was designed. 10. Laboratory testing of collected sam- were implemented from 2005 to fulfil The study aimed to contribute to the ples the requirements for SGS in the ongoing epidemiological knowledge of key STIs 11. Quality control surveillance system. A series of workshops and HIV among the general population 12. Data entry & analysis were conducted in 2004 as part of the Na- and among high-risk groups, and to assist 13. Final Conclusion Meeting with all tional AIDS Action Plan and a joint work in the development of a national SGS participants plan of the Ministry of Health, RHP and system. 14. Dissemination of the results UN Theme Group on HIV/AIDS. The The research enabled the MoH to workshops were conducted in the areas prepare specific interventions concern- The selection of the sentinel sites was of surveillance, laboratory practice, diag- ing sentinel surveillance in the field of on the basis of convenience (accessibil- 17 nosis and treatment of HIV and groups STIs and HIV. The research was imple- ity) rather than on the recommended at high-risk of STI/HIV. The workshop mented by a consortium, consisting of representative sample for the country’s had two outputs: providing an opportu- ICON Institute Public Sector GmbH, target population. Given the anticipated nity for policy makers, practitioners and Public Health Department of Hacettepe low HIV prevalence rate (below 1%), academics to discuss issues and creat- University and Royal Tropical Institute the planned number of HIV tests to be ing a basis for a situation analysis on in Antwerp, starting in March 2006 and conducted within the research was too STI/HIV/AIDS. As recommended for the finalized in April 2007. low to have reliable confidence intervals. establishment of SGS, a situation analysis The cities of Ankara, Istanbul, Trabzon Therefore, the research findings only was carried out in 2004 as part of the STI and Gaziantep were selected as sentinel provided information on some aspects surveillance component of the RHP (3). sites in order to develop the methodology of the current situation related to STIs, A Rapid Assessment (RA) of sub- for establishing future SGS programmes. including HIV, in pregnant women and groups including unregistered com- It aimed to estimate the prevalence and some of the MARPs. The epidemiological mercial sex workers (CSW), men having associated demographic and behavioural value of the expected results of the study sex with men (MSM) and intravenous correlates of key STIs (syphilis, gonor- is limited.

No.61No.65 - - 2005 2007 Peyman Levent Raphael Kevin Catharine Altan Akin Baltes Fenton Taylor

Table 1: HIV and STI incidence among MARPs and ANC clients Moreover, implementation of a well CSW MSM IDU ANC developed surveillance system should be Number % Number % Number % Number % completed and quality control should include systematic information about HIV 2 0.8 3 1.8 1 1.5 quality. This process should start with Hepatitis B 6 2.4 6 3.6 2 2.9 4 2.3 the diagnostics of the disease through Syphilis 19 7.5 18 10.8 1 1.5 3 0.1 improved reliability of the reporting Gonorrhoea 7 2.8 5 3.0 1 1.5 10 0.5 process at all stages until the data entry Chlamydia 3 1.2 4 1.8 2 2.9 19 0.9 and processing.

Antenatal Clinic Findings MARPs findings References The educational level of many of the Among MARPs, the refusal rate to par- 1. World Health Organization and Joint pregnant women participating in the ticipate in the study was highest in the United Nations Programme on HIV/ research was low; most of them were group recruited in health care settings AIDS. Guidelines for Second Generation unpaid family workers/housewives. Their at 33%. Within the MARP groups, 0.8% HIV Surveillance. WHO, UNAIDS 2000. low social status was an important barrier were found to have HIV positive status 2. Ministry of Health of Turkey. Final in obtaining information on health and among CSWs, 1.2% among MSM and Report on Operational Research on Key health care services in general. Out of 1.5% among IDUs. Only 29.5 % of MSM STI’s and HIV in Turkey: Ministry of 2,089 women approached in ANC clinics, declared always using a condom during Health, Ankara 2007. only 29 refused to participate in the study. sexual intercourse, while this was 36.1% 3. Ministry of Health of Turkey. Situational Knowledge related to condoms and among CSWs and 44.1 % for the IDU Analysis on Sexually Transmitted Infec- their use was lower amongst the pregnant group. Pharmacies were most often used tions and HIV/AIDS in Turkey. Ministry women, than expected. 13.8% stated by MARPs to receive services (condom, of Health, Ankara 2007. they had not heard of the male condom, medicine, injectors, etc.). 4. Hacettepe University Institute of Popula- while the majority of the participants tion Studies, Macro International Inc, (75.3%) had not heard of the female Conclusion and Recommendations Ministry of Health General Directorate condom. During last sexual intercourse Since Turkey is still considered a low MCH/FP, State Planning Organisation 81.4% of pregnant women had not used prevalence country, there is no need yet and European Union. Demographic and a condom. The major reasons for not for SGS on HIV to be introduced in the Health Survey. Ankara 2003. using condoms were stated as: “thought it general population. However, SGS can was unnecessary (20.8%)”, “their partner be considered appropriate for the most Peyman Altan did not want to use it (19.9%)”, and at risk populations. This would provide MD, Head/Director STI Department, “used another method (13.4%)”. Women an early indication of the magnitude of National AIDS Programme who had not used a condom during last the risk factors for HIV transmission. Ministry of Health of Turkey ([email protected]) sexual intercourse responded that they Therefore, both sentinel and behavioural considered the condom as a contracep- surveillance in selected sentinel sites Levent Akin tive, which indicates that they are not should be periodically carried out. Fur- MD, Professor, Dept. of Public aware that condoms can protect against thermore, more sentinel sites should be Health, Faculty of Medicine at Hacet- 18 sexually transmitted diseases. Those who in place based the location and size of the tepe University, Ankara use condoms mainly obtain them from MARPs population. ([email protected]) pharmacies, followed by primary health Due to limited numbers of MARPs and Raphael Baltes care units. pregnant women included in the ORKSH, MD, Public Health Specialist, ICON As is commonly found in Turkey (4), information was collected on only some Institute Public Sector AIDS awareness was higher than HIV aspects of the current situation related to Kevin A. Fenton awareness within the study population. STIs, including HIV, in pregnant women MD, PhD, FFPH, Director, National Only 28.6% participants replied as having and some MARPs. Therefore, to carry Center for HIV/AIDS, Viral Hepatitis, heard of HIV, whereas 93.2% indicated out surveillance effectively, the numbers STD, and TB Prevention, Centers for having heard of AIDS. The laboratory of members in each risk group, as well as Disease Control and Prevention, results of HIV and STIs testing through their distribution in the country and the Atlanta, USA VCT with MARPs and ANC clients are way to access them has to be estimated. Catharine Taylor presented in Table 1. On the basis of this information, reliable Lead Specialist Maternal and New- sentinel surveillance studies for risk born – HLSP, UK populations should be planned. STRENGTHENING SRH PRE-SERVICE TRAINING CAPACITY By Iffet Renda and Ayla Albayrak

The two-year project in Turkey had two aspects: to Main Activities of the Project strengthen pre-service SRH education in medical fac- Education Monitoring and Accessibility and SRH Curriculum ulties, and in nursing and Capacity Evaluation Dissemination midwifery departments of • Development • Training of • Web Site Schools of Health; and to • Implementation Trainer’s • Forum harmonise SRH education in line with EU regulations. The Figure 1. Key activities of the projekt The medical, nursing and midwifery the schools not only to examine the SRH universities were motivated coordinators of the Technical Assist- component but also to review their com- to adopt revised SRH cur- ance Team (TAT) of the project visited 8 plete curricula. universities and selected 9 departments The integrated SRH curricula of ricula, improve their skills (medicine, nursing, and midwifery) of the pilot schools were approved by the laboratories, focus on the Istanbul, Mersin and Kayseri (Erciyas) university senates, and recommended for Universities for a pilot project. adoption by the Inter-university Health teaching skills of their aca- and Medical Sciences Education Council. demic staff, and to realise SRH curricula The midwifery curricula were used as a The TAT assessed the SRH curricula of reference document during the develop- the significance of feedback the pilot universities, and established ment of core curricula for the midwifery from in-service graduates core and advisory expert working groups schools. The revised SRH curriculum for to revise the curricula for the three midwifery was promoted at the midwife- for their programmes. The disciplines and establish comparative ry annual national conference. project resulted in a cata- standards. The content ensured consist- ency between the pre- and in-service Competency-based training lytic and continuous reform components of the RHP and harmonisa- The project trained 53 instructors from for the universities. tion with EU directives. The SRH subjects the three pilot universities in compe- of violence, sexual abuse, gender issues, tency-based (learning by doing) train- The needs assessment survey (2003) for vulnerable groups, and SRH needs of ing courses. These trained academics RHP in Turkey, by the Ministry of Health the elderly were also included to provide on return set up clinical skills training (MoH), revealed weaknesses in SRH with comprehensive coverage. courses in their schools for the other staff. regard to pre-service education. It made The integration of the revised SRH Some schools established multidiscipli- recommendations for the improvement curricula into the programmes of the nary new-skills laboratories to support of curricula formats and contents, train- pilot schools revealed numerous cases of the training of students in clinical skills ing of teachers, standardisation and har- repetition of the same topic in different and others increased the capacity of their 19 monisation with international standards, courses and years. Learning objectives laboratories. and for monitoring and evaluation of the and assessment techniques were identi- overall SRH curricula. fied. Schools moved several SRH subjects Monitoring and Evaluation (M&E) This article describes the response by to earlier years of study, and they ensured To assess the integrated and implemented the project for strengthening SRH pre- vertical and horizontal integration of SRH curricula of the pilot schools, an service training capacity that ended in subjects. The approach to teaching from M&E model was developed in line with August 2007(Fig.1). The overall objec- illness to health and from an understand- the Bologna process (on academic degree tive of the project was to contribute to ing by the students of his or her personal standards throughout Europe) and strengthening pre-service SRH education SRH needs to an understanding of the the university strategy plans. TAT gave in line with EU regulations in medical family and the community was adopted. regular technical assistance and designed faculties, and in midwifery and nursing The actual SRH content of the curricula two workshops where schools shared departments of Schools of Health (SoH), was already well covered in the pro- experience and exchanged information. in universities. grammes of the schools; the project then The implementation of the M&E model offered an opportunity for made it feasible for schools to measure

No.61No.65 -- 20052007 Iffet Renda

the response of students and staff to their Dissemination visits The HEC is an autonomous body with integrated SRH curricula. The schools In the extension period of the project, legal authority governing all higher edu- also realised that taking up contact TAT made presentations at a further cation activities. For the newly developed and strengthening relations with their 9 selected universities to outline the SRH curricula for medical faculties, graduates will provide valuable informa- project, its results and distribute relevant nursing and midwifery schools to have tion concerning the credibility of their documents and CDs. Almost all of the a national impact, consistent support of programmes. universities set up curricula study groups both the HEC and MoH is paramount. Measurement techniques that the to examine their SRH curricula. They also Such support is not at a desirable level at model offered had a high acceptance started looking into ways of initiating or present for various reasons. The project rate. Focus group meetings were used extending their competency-based train- therefore offers an alternative for improv- extensively to measure attitudes of staff ing programmes and investing in skills ing and strengthening communication and students with regard to SRH cur- laboratories. Twenty four instructors and relationships with the other layers ricula. The SoHs started testing both the from six SoHs of the 9 universities visited of stakeholders in order to overcome validity of examination questions and were trained in clinical skills. Presenta- difficulties. developed question banks with a view tions contributed further to the institu- The TAT’s interaction with the man- to sharing these with other SoHs. This tionalisation of the SRH project outputs. agement of the 17 universities visited process will gradually contribute to the for pilot project selection, pilot work, standardisation of education in nursing Communication strategy and dissemination purposes, and with and midwifery. The communication map shown in Fig- professional organisations, was posi- ure 2 places the MoH at the centre, and tive. No contact was established with the Staffing problems in Schools of its closest partner at the interface with the private health sector that is claiming a Health health sector is the HEC. larger share of service and is progressively Schools of health are overwhelmed with becoming a desirable employer of health long hours of teaching and a shortage Figure 2 workers. of trained senior staff. Table 1 shows A website of the project, www.tuspmoe. the distribution of senior staff in SoHs Communication Map gen.tr, was activated in April 2007. A fo- compared with medical faculties in the rum now exists for the use by all the con- pilot universities. Since 1996 midwifery Public tributors and participants in the activities ernational education is mainly the responsibility of Int or of the project. The discussion forum has g. dem academic nurses. There are just three MSc Aca ics not yet been used, possibly because it is a programmes for midwifery and only 15 iversit new medium or because SRH education . n ie s * o U

midwives have MSc degrees in Turkey. MoH i is not yet a subject of great interest.

* . The training of senior staff for SoHs H E C Conclusion should be priority for the policy makers, Students the Higher Educational Council (HEC), NGO The project was not designed as a one- and the MoH. Unless urgent steps are time reform of the SRH programme in taken, the quality of SRH education in the universities but as a motor of ongo-

Turkey will be seriously undermined. * Pri. = Private Sector ing change. Its value will be apparent 20 * Pro.= Professional Bodies (Medical, Nursing and Midwifery) if it motivates universities in Turkey to Table 1 evaluate regularly all aspects of their SRH programmes and introduce appropri- Number of students per senior staff member in ate changes. The curriculum, clinical Medical Faculties and Schools of Health skills of the academic staff, evaluation of their programmes, and incorporation of Pilot University Medical Faculties Schools of Health feedback from former students working in SRH fields will all play their role. Pilot University 1 5,8 92,1 Iffet Renda Ph.D. Nursing ([email protected]) Pilot University 2 3,8 74,1 Ayla Albayrak Pilot University 3 2,2 49,8 Ph.D. Nursing (Ayla.Albayrak@medicine.ankara.edu.tr) Iffet Public Sector and Civil Society: Renda FORGING A POWERFUL PARTNERSHIP IN SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS IN TURKEY

The article explores the creative potential of moving from an international co- operation to establishing a national partnership between the Ministry of Health (MoH) and Civil Society Organisations (CSOs) within the Reproductive Health Programme (RHP) in Turkey. The dynamics between two different sectors; the natural conflicts, the underlying interests of funding a portfolio of 88 projects, co-ordinating 107 civil organisations within a multi-stakeholder programme is analysed as a resource in itself. The result is a doorway into a rich and transformative opportunity for change and future growth in the provision of quality SRH services in Turkey.

Turkey at the cross roads of underscored the potential partnership: 2). The two Programme strands were the health millennium 1 Turkey had become a middle income divided into 9 interlinked result areas, of Neither a revolution nor a counter country: “Feminisation” of the bureauc- which the CSO strand is Result 6. A CSO revolution racy and rapid private service sector Team was established within the MoH From the late 1980s to the mid 90s there development including health were taking to oversee the CSO Grant Scheme. The were the winds of health reform and a place. Team worked in collaboration with the variety of multi-lateral, bi-lateral and 2 Crisis in health and successful advocacy: Technical Assistance Team (TAT). non-governmental donors co-oper- RH indicators were beginning to plateau. There were two calls for CSO project ated with the public health sector and The Group for Establishing Support for submissions, in 2004-5. Twenty seven civil society. As the donors moved on or Women (KIDOG) with strategic support proposals were contracted in the first call. downsized, Turkey was left with many from MoH convinced the government Financial support was given for a period documents that the public had only to fund contraceptives from the general of 12-24 months, and approximately rare access to. Within the hierarchy of budget. €7.1 million was committed and distrib- public institutions only a select few 3 ‘The Force’ of the Acquis: The objective uted. Under the second call another 61 managers understood these co-operative of this crucial EU accession document projects were awarded. The maximum documents, many of which contained made it possible that a €55 million grant project duration was 12 months and the progressive ideas and know-how. Between was provided by the EC for SRH; 36% (or funds committed were approximately € ICPD Programme of Action (1994) and €20 million) of which was earmarked for 12 million. The Grant Scheme represents Millennium Development Goals (2000), direct funding to CSOs. involvement of 107 organizations, which there have also been shifting perceptions 4 New Regime Creation in SRH: The Na- also included CSO-CSO co-operation. regarding quality of care and the added tional Strategy for Women’s Health and value of a rights based perspective to Family Planning provides the framework Dynamic 1: state of affairs sexual and reproductive health (SRH). within which the RHP operates. A financ- A civil sector review of Turkey (2004), In the many interpretations that have ing agreement was reached in 2001. From using a Situational Analysis Model, was followed these international agreements then on, the negotiation was episodic conducted. The Review casts a wide net and translations that were done, people until implementation began in early 2003. through an inventory of 330 CSOs, notes 21 applied their own reductions. The end It culminated with the National Strategic their perspectives and elaborates on how result - there was no collective ethos on Action Plan of the MCH/FP Directorate these organisations have and can contrib- the subject of SRH. The CSO Situational (2004). ute to SRHR in Turkey. Analysis for Turkey (2004) shows that This was followed by a Stakeholder many women’s groups do not equate gen- Dynamics of the civil society strand Analysis (2004) which identified 24 der equity and empowerment to sexual of RHP potential partnerships among 3 sectors and reproductive rights (SRR). There are two main components (or (public, CSO, private) and analysed them strands) of the RHP in Turkey: the according to characteristics, interests and From confusion to evolution public health sector, committing itself expectations, sensitivity to and respect for A decade long set of circumstances in to improving the quality of service and SRHR and capacity to resolve anticipated Turkey created the present public – CSO strengthening institutional capacity problems. co-operation and some of the perils and (Strand 1) and CSOs committing them- The Strategic Choices (2004) docu- opportunities of economic co-operation selves to increasing demand and utilisa- ment of RHP facilitated a mapping route and the social development of a country tion of public health services (Strand for the Grant Scheme using the 3 level

No.65No.61 - - 2007 2005

By Dr Arzu Köseli, Dr Seçkin Ataba, Dr Serdar Esin, Ms Mehlika Ulular and Ms Poonam Thapa

development concepts in Turkey; regional terms of giving priority to Programme in- same time Provincial Health Directorates disparities in access to services, migration tervention areas by working with 68 lead (PHDs) had doubts and questions about areas and other issues. The consultative CSOs. Figure 2 represents the resource CSOs and whether resources should be process showed a willingness to learn and distribution. given directly to CSOs or to themselves. exchange opinions about a possible future together for the two sectors. This did not Resource distribution by programme Areas “Co-operation is uncommon and CSOs mean there were no obstacles or difficul- 13 % are not strong as a sector… They are too 37 % ties in the process. different… two conflicting… CSOs have 15 % their own independence... Concepts are Dynamic 2: Transforming the also different…. Civil society is nascent support for RHP into a ground swell and MoH should view the co-operation as a mentor…will they accept? We would like Key Message: 16 % 3 % CSOs to promote what we believe in…. “Protecting mother and child is in the 16 % Civil society is not obliged … “ Constitution of the State….Turkey has Safe morthud Youth SRH STI-HIV/AIDS Representatives of made great strides in health…but some FP Cross-Cutting SRH Provincial Health Directorate provinces have started from behind… Some women say ‘no more’ and they Fig 2 Dynamic 4: Getting over stereotypes get pregnant…this is our collective fail- Dynamic 3: Dilemma of duality ure… Fertility planning is not fertility There is recognition within MoH that Key Message: limitation…” there are no legal barriers to CSOs “We bring the power we have in being General Director, MCH/FP, MoH becoming involved directly in service together to reach all our objectives in the delivery. The RHP design that is based Programme. We are grateful for the sup- 5% on the public sector being involved solely port received from MoH. CSOs are tak- 4% on the supply side and civil sector only ing seriously their responsibility to the 5% in creating demand was seen as a policy Ministry and themselves. We underscore shortcoming, an artificial division and expectations on all sides …” an example of a top-down approach by Representative of ECD some, especially CSOs. In the interest of creating a balance “…when creating the demand, MoH between two critical forces the follow- 86% should think how much of this demand ing was decided by MoH. For reasons of Primary Key CSOs can meet. People move from the state cost-effectiveness, work proceeded with Secondary Multi hospitals to the private sector. I believe that PHDs; for efficiency in finding clients for Fig 1 Distribution of CSO projects by there are important gaps in public service health centres and dealing with sensitive stakeholders groups delivery; they (MoH) should have made an SRH issues, a great variety of CSOs were The 88 Grant Scheme projects closely internal plan. Most of the people in the field included. The CSOs in the Grant Scheme reflect the Strategic Choices as illustrated complain … “ National CSO were represented by foundations (43%); 22 by Figure 1. It shows that reducing in- associations (41%) and the remaining equalities effectively meant CSO projects For the MoH, however, there was also an ones were unions, clubs and chambers. worked directly with a variety of stake- over-riding responsibility for improving Nevertheless, a palpable opposition from holders but mostly with primary benefici- the status of SRH, increasing demand for both PHDs and CSOs continued, but aries i.e. the end users of services, many of its services, strengthening its RH centres MoH and TAT advocated appropriately whom are vulnerable and disadvantaged and assuring their quality, continuity at this stage. The Grant Scheme ensured women, men and youth and high risk and sustainability. Furthermore, the state that awarded projects would maintain co- groups. Thirty percent of the projects are could only take responsibility for quality operation. Capacities were built through located in North Eastern and South East- standards of its own service delivery joint public – CSO meetings and contin- ern Turkey and 50% in high migration institutions and not that of CSOs. On the ued during the process of implementa- areas where poor indicators for RH are other side, initial criticism from CSOs did tion in forming partnerships as shown in found in women with low education level, not manifest itself as a resistance to the figure 3. irrespective of their residence (but mostly supply and demand model; there was no residing in gaecokundu or urban squatter concerted effort on their part to provide “Third party mediation often works…Lo- settlement). The 88 projects of the CSO alternative strategies to the design or cal representative of CSO asked to invite Grant Scheme also makes a statement in distribution of the Grant Scheme. At the health staff to a training programme and The gap in monitoring has been Distribution of CSO Projects By Forms of Partnerships Key Statement: leveraged by a call from MoH and TAT 66% 29% “The Network (of CSOs) seeks to strike for an independent process evaluation. 66% a balance between a healthy sexual This evaluation limits itself to assessing and reproductive life and sustainable the execution and implementing role of development. The Network will organize Programme Unit in the implementation itself to promote knowledge and training of the Grant Scheme and response of the skills; building capacities both at home CSOs in adapting to the process. Prelimi- and abroad to actively generate different nary findings from the evaluation show funds from a variety of sources to carry the following: CSO - CSO CSO - Public Sector out activities in the interest of its mis- CSO - Private Sector sion and members.” • A wide agreement among interview- Interim President on behalf of ees that the areas of intervention, Fig 3 Network Founding Members methods and selected projects were was turned down by PHD. Such refusals relevant and in balance. Many also happened often and I had to act as a bridge By moving beyond the grants/donations agree that it is too early to comment more than a few times. We organised many paradigm to experience a huge range of on the benefits of the Grant Scheme confidence building meetings between the funding ideas and examples from around for the people of Turkey. two parties… for relationship that is ben- the world, CSOs began to visualise the • 95% of the allocated funds are eficial now and in the future….” network as a “philanthropic exchange” contracted to CSOs showing a high TAT staff, Field Office and vibrant marketplace for CSOs, level of efficiency in the disburse- donors and investors. At the close of the ment of funds. There is criticism (not Dynamic 5: On the threshold of a training, a constitution was established from CSOs) that human resources partnership and a three-year action plan devel- (national and international) were not A Sustainability Initiative aimed at em- oped. The establishment of “Ağ Cevap”, appropriately allocated for capacity powering CSOs within the Grant Scheme (in English: Net - Response) therefore building and were under-utilised for to understand, support and practise sus- represents a leap of faith on the part of field monitoring during the imple- tainable development of their organisa- the “founding fourteen” to develop their mentation phase. tions was organised in 2006-7. The Initia- own partnership among each other, with • A general agreement that the Grant tive demanded the energy, commitment MoH and other interested partners. Will Scheme made an effective contribu- and creativity of the CSOs, as well as the the network live on to tell its own success tion to the expanding SRH proc- support and encouragement of the CSO story? Only leadership, endeavour and ess and enhancing individual CSO Team, TAT and ECD throughout the con- time will tell. capacities. Many CSOs state that they duct of four building block workshops. were not made fully aware of the Support was sought from international Dynamic 6: In the interest of complimentary roles of Programme experts who specialise in CSO fundraising accountability Unit in execution, implementation beyond grant schemes, with knowledge The RHP has a Monitoring Plan and management. of unique circumstances of EU accession (Progress Report, February 2005). A • Most respondents noted that while and experiences of emerging markets formal mechanism to follow-up CSOs methods of intervention were tra- 23 such as Central and Eastern Europe. during the implementation phase was ditional to many other parts of the Initially the CSOs had a limited not fully discussed and negotiated and world, they were innovative to Turkey. understanding of the role and function accepted within the Programme Unit As SRH is now easier to discuss, many of a network. Most of them had not (MoH, TAT and ECD). Since mid 2005, other sensitive issues can be better worked together before, and many had monitoring responsibility reverted solely integrated in the future. incomplete knowledge of the practices to ECD as part of contract management. • Some CSOs have integrated SRH into of fellow organisations working in the There have in the last two years been at- their core programme but require field, or MoH for that matter. Through tempts at monitoring by TAT on a limited new funds for sustainability of project team-building exercises, analysis of case scale. There have also been joint meet- activities within the Programme. It studies, simulation activities, role-play ings between MoH and ECD with CSOs is still too early to speculate on the and real-life fund raising exercises the in Izmir and other provinces. In a novel development of the Network. CSOs in workshops unlocked the potential for way the MoH has made it beholden for Turkey largely remain within a charity effective co-operation between CSOs CSOs to increase their visibility beyond model, anticipating grants rather than and potential partners in the public and the contract requirement. A qualitative pro-actively generating their own private sectors. Monitoring Map has been prepared. products and services; income

No.65 - 2007 through diversified sources and social The RHP in Turkey allowed the fol- or not, it is good to know that many NGOs enterprise investments. lowing: from various sectors were able to think, • Mainstreaming opportunities for develop and implement SRH projects”. The process evaluation takes careful various CSOs to get into SRH sub- Director, Willows Foundation, consideration of the recipient of ECD sector. Member of RHP Consortium funding, namely the CSOs at large. It • Programme integration and the prac- is however unable to speak confidently tical SRH link between demand and As Turkey boldly enters the Acces- about the impact of the RHP on those supply. sion process for European Union (EU) 86% primary stakeholders (the end users • Emphasis on public standards that membership, we continue to witness of services) that were beneficiaries of the highlighted importance of skilled remarkable transformations in society CSO funded activities. The amalgama- quality services. with unpredictable results in upholding tion of voices summarizes the basic and • Human resource development in sexual and reproductive health and rights. initial process in terms of public - CSO project development and manage- The international development policy of co-operation and the tensions in setting ment. the EU, including health, provides vital priorities, understanding quality service • Importance of bilingualism was leadership in the face of increasing op- and client rights, developing partnerships, stressed in all documents and interac- position to SRR from different directions. sustainability of CSOs and health centres tion. The more precise fulfilment of ICPD Pro- becoming client magnets. • Becoming a ‘stakeholder’ without gramme of Action continues to remain knowing and then consciously trans- a challenge. The pace of more change in “By coincidence, I saw an advertisement forming. future SRH programming within Turkey for maternity and new born training at can create new predicaments for the home by a CSO in a private hospital. A In moving from an international financial public sector as reflected in some parts of midwife… came to me to give 4 weeks co-operation (or collaborative aid) to a Europe but RHP will have made the pos- training after delivery. It was free of charge national partnership (joint venture en- sibility of finding appropriate solutions and very good quality. I learnt about infant terprise) it was normal that as a first step, that much easier. food…she asked about me… showed how MoH would look at RHP and CSOs from to breast feed properly without using the their own perspective. Understanding scissor method…things my mother and through practical experience, the differ- Dr Arzu Köseli grandmother don’t know ….how to sit on ence between power over civil society and MoH, General Directorate of MCH/ the chair (not the bed) and nurse… I was power to civil society was the second step. FP, Acting Head of Reproductive told about maternal care and psychol- Instead of seeking to control, the CSO Health Department; Leader of CSO Public Co-operation, RHP ogy…I mean everything…The free service Team became facilitator of CSOs over- ([email protected]) ended last year…” time. This experience needs to resonate Client of CSO Project, Izmir further within the public health sector Dr Seçkin Ataba “After checking the web address it was and beyond. MoH, General Directorate of MCH/ learned that a private company had started CSO partnership with the public sector FP; Member, CSO Team, RHP providing the same service and charging emphasises two parts – firstly, it has its fees”. own importance in advancing the col- Dr Serdar Esin 24 Expert, CSO Evaluation laboration and providing mutual support. MoH, General Directorate of MCH/ Secondly the partnership enhances the FP; Member, CSO Team, RHP role of CSOs in democracy as they are in- Conclusions: step by step creasingly engaged in the reform process, Ms Mehlika Ulular MoH, General Directorate of MCH/ building awareness on several issues on FP; Member, CSO Team, RHP Key Message: several fronts. The Programme may end “… you see how the Programme was but a form of partnership exists and will Ms Poonam Thapa born …we did not speak about CSOs in continue to play a valuable role in catalys- CSO Adviser, RHP and lead author the beginning … we only spoke of what ing new reforms and policy innovations ([email protected]) Ministry did/could do….we had full in health. rooms…half empty rooms in our meetings…there were many questions…many “Not just SRH CSOs or just the big experiences…..and today we speak of our ones but the whole sector was mobilised. partnership.” Although we cannot say now whether General Director, MCH/FP, MoH, 2006 mainstreaming activities will be sustained

A YOUTH STORY from left to right: Selen Örs, Tunga Tüzer, Gökhan Yıldırımkaya, Fatma Hacıog˘lu, Nezih Tavlas, Zeynep Bas¸arankut

UNFPA Turkey launched Turkey’s first youth-to-youth advocacy web campaign for young people’s sexual and reproductive health (SRH) and rights. The campaign aims to increase awareness of SRH among young people and create demand for sexual health education. Poster

“Before I visited your site, I did not know reach policy makers and create an ena- and awareness on SRH at local level, “A how to cope with my sexual health prob- bling environment for the integration of Youth Story” will empower young people lems. Many thanks …” comprehensive SRH education in school through a number of advocacy trainings. “I would like to learn how we can overcome curricula. These trainings will be carried out in the problems during adolescence, especially The campaign includes remarkable ele- seven cities with participation from 30 the psychological ones.” ments, which make it unique in Turkey. provinces. These young people will act Boy of 16 and girl of 15 express their feel- Firstly, “A Youth Story” is the original as advocates and reach their peers, policy ings on the web -(www.birgenclikhikaye- national youth SRH advocacy campaign, and decision makers to create awareness si.com) “A Youth Story”. being implemented by true youth-adult on young people’s SRH and rights. partnership. Young people have been Background involved since the planning phase and Hungry for knowledge Serious efforts have been made in Turkey a young coordinator under the direct After the launch of the website, we real- to meet the SRH information and service supervision of UNFPA is currently imple- ized how much young people care about needs of young people through UNFPA’s menting it. Secondly, UNFPA’s technical their sexual health and how many ques- technical assistance since 2000. The expertise was united with Levi’s and MTV tions they have that they could never ask Ministry of Health took the lead role, Turkey’s popularity among young people out loud. The diversity and content of the with support of international donors, and with a national network, one of the questions reveal the need for compre- in developing a youth friendly health biggest NGO working for young people’s hensive and in-depth research to better service model and integrating it into the participation in governance at local level. understand the socio-cultural factors existing maternal and child health and The website was chosen by a bank as affecting young people’s knowledge and family planning centres. Simultaneously, a one of the best corporate social re- attitude on SRH. similar model was developed for students sponsibility projects in Turkey and they In the first three months, “A Youth in selected universities. wanted to sponsor the campaign. Another Story” showed us how hungry young peo- Previous efforts, targeting the educa- innovative approach was to work with ple are for SRH knowledge. An integrated tion system, show that only through celebrities as role models. The lead singer approach including appropriate informa- effective advocacy, SRH education would of the Turkish rock band “Kargo”, Koray tion in formal education supported by be integrated in school curricula. A Candemir, and popular TV presenter behaviour-change techniques like peer potential action could only be successful Defne Sarısoy kindly accepted to become education and widespread youth-friendly if young people themselves demanded spokespersons for two years. health services providing necessary such a policy change; however, most of counselling and treatment are needed. 25 them are not aware of or empowered to Wherever young people are, “A “A Youth Story” is expected to be an advocate for their SRH rights. UNFPA Youth Story” is there… important step forward to this approach believes youth-adult partnership must be Website: “A Youth Story” created a virtual by mobilizing young people and creating an integral part in programmes targeting setting for youth, enabling them to spend an enabling environment for necessary youth, we have decided to work with and their leisure time with interesting inter- policy change. for young people to attain this goal. views and quizzes, fun videos, games, and music while they are learning about SRH. Selen Örs, A unique initiative The website was developed to help young Tunga Tüzer, An advocacy campaign was launched on people find answers to their questions Gökhan Yıldırımkaya, 12 April 2007 by UNFPA in collaboration without compromising confidentiality. Fatma Hacıog˘lu, Nezih Tavlas, with Levi’s, MTV Turkey and the Youth Events: “A Youth Story” has been car- Zeynep Bas¸arankut for Habitat Association. The short-term ried to 30 universities during the spring goal is to create awareness and demand fests and to three international music All authors are staff members of among young people for sexual health festivals in 2007. UNFPA Turkey. Correspondence: education. In the long run it aims to Training: In order to create demand Selen Örs, [email protected]

No.65 - 2007 SERVICE STANDARDS IMPLEMENTATION (SSI)

ervice Standards Implementa- staff to define whether the information on External facilitator training courses tion (SSI) is a model developed to clients is accurately recorded and whether The first SSI “External Facilitator” training Sincrease service quality. It aims to the clients receive appropriate services. courses were conducted in June 2005. In build capacity in sexual and reproductive 3. Client Interview Form, has questions Erzurum, 12 staff, including one partici- health (SRH) programme management; on clients’ rights that the staff use to learn pant from the Ministry of Health (MoH) developing and implementing policies, about opinions of clients on the services and 11 participants from the province. In service standards and job descriptions provided. Kars 11 health staff were trained as EFs. for service management. SSI tools enable 4. Action Plan: a written plan developed “Follow-up and Subsequent SSI” exercises clinicians, policy makers and clients to by the staff on solving problems identified of EFs were carried out in Erzurum and in make health care more uniform, reliable during the SSI process. Kars. Due to staff reassignments and some and efficient. SSI was initiated in 2004; An EF, internal facilitator (IF) and a SSI personal reasons, a total number of 15 EFs evaluation activities were carried out in committee play crucial roles in the intro- (65% from the initial cohort) participated. 2006 and based on its outcomes scaling up duction and institutionalisation of the Following the agreement on initiating activities started throughout the country process. The EF is the key person in the scaling up activities, in total 21 partici- in 2007. process and s/he is a health professional pants from Ag˘rı, Ardahan, Artvin, Ig˘dır For SSI, the period 2004-2007 was that has a role outside of, and higher than, and Erzurum were trained as EFs. In marked by planning and implementation. the facility level (preferably a manager in Ìzmir, where staff turnover is low, health The planning stage included develop- a Health Directorate). S/he takes care of staff with previous training skills were ment of service standards, development the introduction and guides the facility in selected and 20 EFs were trained in 2007. and testing of SSI tools and selection of 2 institutionalisation, supporting and fol- The total number of EFs trained has been project provinces and 19 health facili- low-up, and trains the internal facilitator. 64, which means a viable critical mass ties. It also included the development of The IF ensures the internalisation and in- nationally. an External Facilitators (EF) training stitutionalisation of the process within the programme and practice. The project facility, under the supervision of the EF. Pilot implementation implementation year in the provinces was The Committee consists of staff from all EFs initiated pilot implementation of 2005, when the service standards, SSI tools units, representing all professional groups, SSI in 19 facilities in Erzurum and Kars. and EF training programme were revised follows up and supports the implementa- Three exercises have been conducted in in line with local needs and national poli- tion of the Action Plan through regular each facility during the first year. At the cies. In 2007 roll-out activities started in 7 meetings. end of it, 9 EFs (39% of the initial cohort) provinces. The exercises are completed in 3 days continued their role as EF. High levels of on average, and consist of: 1. Preparations attrition in the two provinces is a concern, What is SSI? in the facility, 2. Introductory meeting, 3. but with national roll-out, these staff can The SSI Model, inspired by COPE (Client Group exercise, and 4. Action plan meet- be re-activated as EFs later in other places, Oriented Provider Efficient), originally ing. and are not lost to the system. developed by Engender Health, focuses both on client’s rights and staff needs. Implementation steps Evaluation activities These are, client’s right to information, The following steps were taken to develop SSI data collection activities were con- access, choice, safety, privacy and confi- service standards: ducted in 10 health facilities twice at 26 dentiality, comfort, dignity and expression 1. COPE project experiences in Turkey in the beginning and end of the project to of opinions and continuity of services. 1993-1994 were reviewed. measure the effectiveness and efficiency of Staff needs include facilitative supervision 2. SSI Self-Assessment Guide was devel- project exercises. During data collection, and management, information, training oped according to “SRH Service Stand- the Quality Measurement Tool, Client and development, supplies, materials and ards” and in line with the “SRH Services Interview Form, and Health Statistics infrastructure. Framework”. Form have been used. In addition to these, SSI is characterized by problem solving 3. Self-Assessment Guide was tested in Focus Group Questions, another tool, approaches, teamwork, and self-assess- health facilities in Ankara, Erzurum and developed for the focus group discussions ment. There are four SSI Tools used in this Kars (North-East Turkey). with managers and service providers. process: 4. SSI EF course programme was devel- 1. Self-Assessment Guide, used by service oped. Achievements providers to assess their own strengths 5. Ten health facilities in Erzurum and 9 Reliable tools: Through a rigorous design, and weaknesses. There is a standard list of facilities in Kars were involved. Turkey now has locally relevant and ap- questions and adapted to the “SRH Serv- 6. All managers from all levels were ori- plicable SRH quality assurance tools. A ice Framework” developed under the RHP. ented about the topic in the provinces. Self-Assessment Guide was adapted to the 2. Client Record Checklist Form used by 7. Candidate EFs were selected. SRH Framework Document, 5 train- Fatma Jean Gönül Yusuf Uz Robson Kaya Sahip

ing modules were prepared for priority towards both short-term and long-term Conclusion intervention areas of RHP and a “Client results. The tools and processes within SSI is a service model that increases Interview Form”, covering all questions the SSI initiative mean that managers can SRH service quality. In spite of some about client’s rights was developed. The work with service providers (and clients) constraints in practice, SSI as a human evaluation process led to changes in the in delivering more reliable and more oriented approach, proved to be useful tools, making SRH care more uniform efficient services throughout the country. for clients, providers and managers at all and more reliable and sustainable in the The evaluation revealed that one year after levels. However, it has been noticed that project provinces and facilities. the introduction of SSI, the following the SSI process should be supported by Sustainable and tested quality manage- improvements were observed: 1. better all managers for its efficient, effective and ment process: The Programme produced team work, 2. more cost-effective resource sustainable implementation. The MoH, the following experiences and adaptations utilization, 3. better problem identifica- in addition to showing its willingness to to the process used worldwide: tion and solving, 4. increased motivation, institutionalise SSI, has foreseen that it 1 Integrating “SWOT” into problem as- and 5. improved ownership of staff roles should be integrated within the facilities’ sessment process, and responsibilities. job descriptions and has decided to scale 2 Developing a (monthly, quarterly and Valuing client and provider empower- up SSI throughout the country, after some annual) “SSI Evaluation Pack”, ment: Although initially some unease was arrangements reflected both in EF train- 3 Using clinical protocols and flow charts created about centring the client within ing and practice and in the SSI process developed for intervention areas in SSI, SRH services, the tools and processes have that have been ongoing in 7 provinces by 4 Developing an SSI External Facilitator actually stimulated service managers and the first half of 2007. Training Module, service providers to work on this. This 5 Developing and piloting alternative is a value shift which has been achieved Recommended reading durations for EF courses (5 and 7-days), without displacing key managerial func- EngenderHealth. COPE® Handbook: A Process 6 Developing a standard “Facility SSI tions, and it is consistent with the wider for Improving Quality in Health Services, Revised Edition. 2003. Guide”, and sector reforms being promoted nation- http://www.engenderhealth.org/res/offc/qi/ 7 Integrating SSI into the quality oriented ally. The shift towards a client focus is not cope/handbook/index.html, (accessed 1 July “Health Care Management Training” of just about clients’ rights, but also about 2004). RHP. more emphatically giving clients a ‘voice’. The SSI experience in Turkey has dem- Clients now are realizing that they will EngenderHealth. Self-Assessment Guide for onstrated that it is possible for quality be heard, and that services can become Reproductive Health Services. 2003. http:// management, adapted to local needs and more responsive to their needs, but it also www.engenderhealth.org/res/offc/qi/cope/ priorities, to be incorporated into existing means increased client responsibilities. toolbook/pdf/cope_toolbook_self_assess.pdf, and possible new programmes of care at (accessed 16 June 2004). a cost and in a manner that allows quality Constraints services to be sustainable without further Inevitably there are some problems associ- SSI reports and training manuals in this issue of Entre Nous external inputs. The processes of quality ated with the introduction and mainte- management will not always be problem- nance of any quality assurance system. free, but managers and staff now have an The process requires time, new advocacy Gönül Kaya understanding of the process of maintain- skills, fresh attitudes and a willingness to MD, Women’s Health Section ing quality standards. change established roles and practices. The Director and leader of RHP 27 System-wide ownership of quality: The Programme, however, encountered the “Strengthening Management quality issue is now embedded within usual and universal problems that have to Capacities”, Ministry of Health of the service. The Programme has demon- do with management change (resistance Turkey, MCH/FP General Directorate strated that a sensitive issue like quality as- from ‘late adopters’), conflicting priori- ([email protected]) surance can be successfully tackled sector ties, and inadequate resources. Turkey wide, and with early positive results. Based also experiences persistent problems with Fatma Uz Field Coordinator of RHP on these results, the MoH has decided staff mobility, which renders new skills to roll out the SSI exercise to all SRH acquisition frustratingly inefficient as staff Jean Robson facilities across the country. Moreover, moves away before new practices have Lecturer and adviser, Centre for the rapid roll-out of the quality manage- been institutionalised. However, these Health Planning and Management, ment system has implications for health are not insurmountable problems. They Keele University programmes beyond the remit of RHP. can be managed within the framework of Enabling performance management: management change and managers’ sup- Yusuf Sahip The larger reform agenda in Turkey report. Staff enthusiasm is perhaps the key MD, Field Co-Director of RHP quires that health service managers work to achieving the results seen so far.

No.65 - 2007 Sabahat TURKEY MATERNAL MORTALITY STUDY Tezcan

In 30 years, three estimates (1). medical causes of death and underlying The study was conducted between factors related to the community/family, of pregnancy-related mor- October 2004 and December 2006 and health facility and health personnel. tality were used in Turkey the objectives were to: First review of response data was 1. Determine MMR and ratios at the done by two physicians, followed by an but each had drawbacks. national level; for the 12 regions of evaluation from a epidemiologist. Final The Turkish National Mater- the country and for urban and rural decisions on the causes of death were areas; reached by a “Central Review Commit- nal Mortality study (2005) 2. Identify medical causes and under- tee” of relevant experts. Definitions of established the MMR at 28.5 lying socio-economic factors and WHO/ICD-10 were used. specify high risk categories with per 100,000 live births, but regard to maternal conditions; Outcomes there are significant rural- 3. Contribute to an improved registra- The two indices that are presented in this tion and reporting system for preg- paper are the MMR (number of maternal urban and regional differ- nancy related deaths; deaths per 100,000 live births) and the ences. 4. Increase awareness of administra- lifetime risk of dying from a maternal tors and health personnel on the cause (accumulated risk by the end of the Most maternal deaths in Turkey are importance of collecting uniform and reproductive period). considered avoidable and closely linked reliable information as a precondition to underlying socio-economic factors and to improve MMR Table 1: MMR and Lifetime Risk equity issues. Reducing maternal mortal- Several targeted approaches were used. A (1 in … ) in Turkey ity ratio (MMR) is one of the MDGs; yet prospective maternal mortality field study Region/ Life- it is a difficult indicator to monitor (1). was carried out; comparative analyses of Urbanisa- time Death underreporting is a countrywide existing recording and reporting systems tion level MMR Risk problem. The medical and underlying were accomplished. A model-based esti- socio-economic causes were not precisely mation of maternal mortality indicators Turkey 28.5 1536 known prior to 2005 and the robustness was made; and a qualitative study for Urban 20.7 2391 of the existing information was question- understanding the problems related to the Rural 40.3 869 able. While registration of vital events is data collection system was carried out. compulsory, the system is unsatisfactory. Region For 30 years, information on MMR in Prospective field study Istanbul 11.0 4876 Turkey was based on three estimates of The results of the 12 months prospec- West Marmara 42.1 1560 pregnancy-related mortality. The national tive field study are presented for 29 MMR was 208 per 100,000 live births for provinces that were sampled by using a Aegean 31.5 1764 the 1974-75 period (2) and 132 in 1981 weighted, stratified probability sampling East Marmara 21.7 2549 (3). The last of the 3 estimates comes method. The study covers 54 percent of West Anatolia 7.4 6947 from a hospital-based study conducted in the total population. The Reproductive 1998 by the Ministry of Health (MoH), Age Mortality Study (RAMOS) (5) data Mediterranean 25.1 1737 28 which was an estimate of 49 pregnancy- collection method was used. Information Central 11.9 3067 related deaths per 100.000 live births (4). on burials at cemeteries of all urban and Anatolia There were several drawbacks to these rural settlements was collected by using West Black Sea 26.8 1956 estimates. The first two were estimated primary informants (cemetery officials in through indirect methods and the latter urban areas and village/section headmen East Black Sea 68.3 883 one had the disadvantage of not covering in rural areas). Then, information on the Northeast 68.3 439 all hospitals and home deliveries. death of women aged 12-50 years was Anatolia An up-to-date and accurate National collected, using two methods. If death Central East 36.9 755 Maternal Mortality Study (TurkeyN- occurred in hospital, the health records of Anatolia MMS) was funded by the EU as part of the deceased woman were reviewed and the RHP. The study was undertaken by information was transferred to a “health South East 38.9 626 a consortium composed of Hacettepe facility form”. If death occurred at home, Anatolia University Institute of Population Studies a “verbal autopsy questionnaire” was ap- (HUIPS), Icon Institute Public Sector plied to the closest relative/friend of the The MMR for Turkey was 28.5 per (Germany) and BNB Consulting (Turkey) deceased woman in order to identify the 100,000 live births but there were sub- Banu Ahmet Rudolf Levent Ergöçme Sinan Schum- Eker Türkyılmaz acher

stantial residential and regional differenc- system. They were in close contact with References es (Table 1). The lowest ratio was found the people working in the mortality 1. Hacettepe University Institute of Popu- in West Anatolia (7.4) and the highest recording system. The qualitative study lation Studies, ICON-INSTITUT Public ones in Northeast Anatolia and East Black was revealing about social structure and Sector GmbH and BNB Consulting. Sea (68.3). A similar pattern in maternal process. For instance, the job descriptions National Maternal Mortality Study, mortality ratios was observed with regard of the persons responsible for registra- 2005. Ministry of Health, General to the lifetime risk of dying from mater- tion and reporting of deaths needed a Directorate of MCH/FP and Delegation nal causes. The risk of maternal death in thorough review. The high turnover rate of European Commission to Turkey, Turkey was 1 in 1536 women, but the risk of personnel and their lack of interest in Ankara 2006. in rural areas was 2.8 times higher than in record-keeping and partial coverage of 2. State Institute of Population Statistics urban areas. the causes of death are major problems. (SIS). Turkish Demographic Survey The MMR differs strongly by age. The Another significant finding was lack of 1974-1975. State Institute of Statistics, age structure of maternal deaths fol- coordination and cooperation between Prime Ministry of Republic of Turkey, lows a J-shaped pattern. In line with the health institutions and various govern- (SIS Publication No. 841) Ankara, 1978. international trends, the oldest and very ment organizations. 3. State Institute of Population Statistics young women are high-risk groups. The (SIS). 1989 Turkish Demographic Sur- lowest ratio was observed at 20-24 years Needed interventions vey. State Institute of Statistics, Prime (10.2) and the highest one at 45-49 years The national MMR in 2005 is lower than Ministry of Republic of Turkey, Ankara, (146.7). the earlier estimates but significant rural- 1993. Medical causes of maternal deaths were urban and regional differences remain. 4. Ministry of Health, General Directorate classified and the direct causes in order of Multidisciplinary and multi-sectoral of MCH/FP. Hastane Kayıtlarından importance were: haemorrhage (24.9%), prevention approaches are required in Anne Ölümleri ve Nedenleri oedema, proteinuria and hypertensive Turkey. Araştırması (Causes of Maternal Mor- disorders (18.4%), other specified direct Household and community play an tality in Turkey based on Health Facility causes (15.7%), unspecified direct causes important role in avoiding maternal Records). Ministry of Health General (10.1%), pregnancy related infections deaths. Health education, particularly Directorate of MCH/FP, Hacettepe (4.6%) and suicide (3.2%). Indirect in reproductive health is essential to University Faculty of Medicine Public causes were responsible for 21.2 percent change behaviour. Such education Health, World Health Organization and of maternal deaths; about half were dis- must start at an early school age and UNFPA, Ankara, 2000. eases of the circulatory system (47.8%), continue throughout life. Awareness 5. Maternal Mortality in 2000: Estimates and 13 percent were malignancies. in the community of maternal health developed by WHO, UNICEF and With regard to the time of maternal must be increased, using different UNFPA. WHO, Geneva, 2004. death, 37% occurred during the ante-par- channels of communication. The MoH tum period, 9 % died at delivery and 54% has the primary responsibility for both. Sabahat Tezcan in the post-partum period. Twenty one Appropriate and evidence-based policies Hacettepe University Institute of percent of maternal deaths were at home must be developed and applied. Planned Population Studies; and about 8% died in an accident. Sixty parenthood, high quality antenatal, [email protected] percent of deaths occurred at secondary delivery and postnatal care at all health Banu Ergöçme and tertiary level health facilities and 10.4 service levels must be provided in every Hacettepe University Institute of 29 percent died on the way to one. region. Special programmes should be Population Studies; Four categories of avoidable factors developed for high-risk regions and [email protected] (61.6%) contributing to all maternal for rural and peri-urban areas and deaths were: underprivileged high-risk groups. Ahmet Sinan Türkyılmaz 1. Household and community factors Accurate, complete and continuous Hacettepe University Institute of - 36.2%, surveillance system for all vital events Population Studies; 2. Health service providers - 13.7 % must be made operational. Furthermore [email protected] 3. Health service supply factors - 2.1%. the provision of high quality health 4. Other risk factors - 9.6%. services asks for special programmes on Rudolf Schumacher expert; [email protected] training, supervision and appropriate dis- Problems of the reporting system tribution of health personnel at all levels Levent Eker In–depth interviews and focus groups of the health care delivery system. Ministry of Health, MCH/FP; levent. were held with province project teams [email protected] who were using the existing recording

No.65 - 2007 SELECTED RHP PUBLICATIONS

Research and Symposium Publications

Turkey Demographic and Health Survey (TDHS - 2003) Hacettepe University. Ankara 2004 www.hips.hacettepe.edu.tr/tnsa2003eng/index.htm Provides information on levels of fertility, mortality, marriage patterns, FP, maternal and child health, nutritional status of women and children, and reproductive health. Results are presented at the national level, by urban and rural residence, and for each of the five regions in the country. Based on interviews with 10,836 households and with 8,075 ever-married women of reproductive age.

Operational Research on Key STI’s and HIV in Turkey ICON-Institute, Hacettepe University, ITM Antwerp. Ankara 2005 The main objective of the research was to assist the development of a national second generation STI/HIV surveillance system. For this purpose the necessary tools and methodologies were developed and piloted in Ankara, Gaziantep, Istanbul, Izmir and Trabzon, targeting pregnant women as a proxi for the general population, and groups at increased risk in Ankara, Istanbul and Izmir.

National Maternal Mortality Study Hacettepe University, ICON-Institute, BNB. Ankara 2006 Looks into main causes of maternal death, avoidable factors, verifying high risk population groups. Presents recommendations for the improvement of existing vital registration system. Data was collected by using Reproductive Age Mortality Study (RAMOS) data collection approach. The Maternal Mortality Ratio for Turkey was 28.5 per 100,000 live births; 20.7 for urban and 40.3 for rural areas.

International Symposium on Youth Friendly SRH Services – Symposium Proceedings EPOS Health Consultants, Options, Willows Foundation. Ankara 2006 http://www.gopa-group.com/prod/Documents.173.0.html This International Symposium was held in Ankara on 1-3 March 2006, under the leadership of the 30 Ministry of Health, MCH/FP General Directorate, and in co-operation with ICC, UNFPA, UNICEF and WHO. The Symposium Proceedings provide a summary including opening speeches, presentations, reports of working groups and recommendations for improving SRH of young people.

Health Seeking Behaviour Study Conseil Santé, Sofreco, EDUSER. Ankara 2007 A qualitative study exploring health seeking behaviour related to pregnancy and child birth, revealing perceptions at individual, family and community level. It also looks at responsiveness of primary care and MCH/FP services and needed interventions to increase utilisation of antenatal and delivery care. Inattentiveness and bad treatment by health service personnel and inadequacy of services are important service barrier factors. Evert Ketting

Training Manuals and Practical Guides All publications are available in Turkish at: http://sbu.saglik.gov.tr/tusp/index.asp or http://epos.eusrhp.org English versions are not available for all publications.

5 Training Modules on: 9 Pre-service Training Documents: • Introduction to Reproductive • Three SRH training curricula for the Health medical, nursing and midwifery fields. • Family Planning Counselling • Each of these three curricula for pre- • Safe Motherhood service education consists of: • Sexually Transmitted Infec- • SRH Medicine Curriculum; SRH tions Midwifery Curriculum, SRH Nursing • Youth Reproductive Health Curriculum Services • SRH Evaluation Guide and SRH Learn- These guides are developed for ing Guide for Medical Education, Nurs- in-service trainings of service ing Education & Midwifery Education. providers in primary health care. • Framework for Monitoring and Evalu- ation.

Youth Pack, Including 3 Publications: Emergency Obstetric Care (EmOC) Pack, Including: Sexual and Reproductive Health Training Emergency Obstetrics Care Clinician Module for Youth Counselling and Health Training. Services Centres; This training module was developed for EmOC in-service training for physicians, midwives, nurses, anaesthetists / anaesthe- sia technicians and “112” emergency care providers. Management Guide for Youth Counselling Manager Facilitator Orientation Training. and Health Service Centres, developed for the The aim of this module is to inform health Provincial Health Directorates and managers care managers on the specificities of EmOC and ensure that of youth centres established by the MoH. they acquire necessary knowledge and skills to plan, implement, coordinate and monitor provincial activities. Support Personnel Orientation Training . The module is developed to train support staff in first aid / re- Outreach Guide for Youth Counselling and ferral facilities about the main issues in the provision of EmOC Health Service Centres, aiming to provide services at their respective levels. guidance in the planning and implementation of youth outreach activities. Reproductive Health Programme in Turkey: Pro- gramme Booklet and CD-ROM The Programme Booklet is divided into three 31 sections. The first section provides a summary overview of the Programme, explaining the Service Standards Implementa- need for reproductive health in Turkey, the tion External Facilitators Train- choices made during its implementation, the ing Module approach taken and the main activities and re- These guides are developed to train sults to date. The second section is an annotat- facilitators who will first undertake and ed bibliography of publications, tools and resources produced then coordinate implementation of the under the Programme. The third section comprises a list of the standards at health facility level. The large number of contributors to the RHP. The Booklet is ac- term service standard is used to define companied by a CD-ROM, which contains all the publications decisions relating to service delivery mentioned in section two of the Booklet as electronic pdf-files. and organization. Standards are used With the Booklet and the corresponding CD-ROM the Pro- as a criterion to describe basic and desired comparisons. These gramme aims to share and disseminate the knowledge created descriptions emphasize clients’ rights and staff needs. during its 5 years of implementation as widely as possible.

No.65 - 2007 The European Magazine for Sexual and Reproductive Health

WHO Regional Office for Europe

Reproductive Health and Research Programme

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Denmark

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