EARHN. NEWSletter. Inside; Repositioning Reproductive Health & Family Planning in Eastern Africa. Message from EARHN Chairperson HIGHLIGHTS

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1 HIGHLIGHTS Message from EARHN Chairperson Dr. Teodros Bekele Chairperson, Eastern Africa Reproductive Health Network (EARHN) & Director General, Federal Ministry of Health Government of Ethiopia Pg. 1 The triple tragedy of fistula: The Scourge Destroying Women s Lives My recent visit to the anti-natal care-outpatient Clinic in Mulago National Referral Hospital was so revealing. I purposely wanted to know more about fistula and its management. Over 25 women (some where fistula patients) sat on a queue waiting to see the gynecologist. Pg. 29 EARHN Issue: 002 / 2013 NEWSletter Inside; Statement from Regional Director, PPD ARO, Dr. Jotham Musinguzi Over view of EARHN pg.2 pg.4 Progress on Family Planning Building on our own success: Family Planning Program in Ethiopia Addressing family planning challenges in Uganda Repositioning Family Planning in Burundi pg.6 pg.9 pg.12 Advocacy on RH/FP Ethiopia on truck to achieving MDGs Kenya s 10th Parliament Adopts Population Policy Budget support pg.19 pg.22 pg.27 Repositioning Reproductive Health & Family Planning in Eastern Africa Service delivery Responding to Sexual reproductive health services for young people in Rwanda pg.28 MDGs and other related topics Uganda s progress on MDG 5: A case of promoting Safe Motherhood in Uganda pg.38 Population growth and Climate Change pg.39

2 Editorial team Publisher: Eastern Africa Reproductive Health Network (EARHN) Editor: Mr. Ahmed Emano Mustafa Director, Public Relation & Communication Directorate, Federal Ministry of Health, Ethiopia Line Editors: Mr. Sintayehu Abebe Assistant director Urban Health Promotion and Disease Prevention and Focal Person for FP, Federal Ministry of Health, Ethiopia Dr. Betty Kyaddondo Head, Family Health Department Population Secretariat Ministry of Finance, Planning and Economic development, Uganda Dr. Juma Ndereye, Burundi National RH Coordinator Ministry of Health, Burundi Ms. Lucy Kimondo Senior Population Programme Officer for Advocacy & Communication National Council for Population and Development, Kenya Co-ordinating Editors: Diana Nambatya Nsubuga Partners in Population and Development Africa Regional Office Program Officer & Ethiopia Focal Person on PPD ARO/HPP Activities Stella Kigozi Makumbi Senior Program Officer Population Secretariat Ministry of Finance, Planning and Economic development, Uganda

3 Message from EARHN Chairperson Dr. Teodros Bekele Chairperson, Eastern Africa Reproductive Health Network (EARHN) & Director General, Federal Ministry of Health Government of Ethiopia Dear EARHN Members I am pleased to present to you the Eastern Africa Reproductive Health Network Newsletter for the year As you are aware, on September 2, 2011, the Government of Ethiopia was elected Chairperson of the EARHN Network. I thank the Government of the Republic of Uganda for passing on the mantle to the Government of Ethiopia to Chair this very important network. As you are all aware, Eastern African countries share similar social, political, demographic and geographic environments. The EARHN therefore builds upon the experiences of members within and outside of the network to build a collaborative effort to create positive change in both policy and programme implementation within Eastern Africa. Since our last meeting in Rwanda, May 21 25, 2012, Ethiopia with the support of Partners in Population and Development Africa Regional Office (PPD ARO) and funding from the Health Policy Project (HPP) has been able to develop a Family Planning Policy Brief which has been translated and printed in Amharic (Local language in Ethiopia). Dissemination of the Policy Brief was held alongside the Family Planning Symposium held in Bahir Dar, Ethiopia, November 26-28, We thank PPD ARO/HPP for the support to these activities. We specifically thank Ms. Diana Nambatya Nsubuga the Ethiopia Focal Person at PPD ARO for her efforts in developing, printing and disseminating the policy brief. As the Chairperson of the EARHN Network, I am honoured to have the opportunity to oversee the role, policy and operation of this very important network. I have strong determination to work and support member countries to realise the EARHN Vision, An Eastern Africa region free from sexual and reproductive health burdens. On this occasion, I would like to thank the member countries for their participation in EARHN activities over the past years. I call on us all to take advantage of the apparent improving political will, national ownership and prioritisation of SRHR refelected in member countries National Development Plans/ Frameworks, to advocate more effectively and enhance resource allocation to SRHR so as to achieve improved health outcomes. I also would like to reiterate my sincere appreciation to the Partners in Population and Development Africa Regional Office (PPD ARO) for the support to the Network. Without the PPD ARO support, our EARHN plans including this issue of the EARHN Newsletter among other EARHN activities could not be realized. In a special way, we thank Dr. Jotham Musinguzi (Regional Director, Partners in Population and Development Africa Regional Office) for his dedication and support to the work of the network since EARHN s existence. I am confident that EARHN will move further and attain greater success over the next many years. Lastly, and most importantly, I re-affirm on behalf of the Government of Ethiopia, my sincere support to the member countries of EARHN and PPD ARO in moving forward to greater advancement in the promotion of strategic partnerships, South-South Learning and Capacity Strengthening. EARHN_Newsletter 1

4 Statement from Regional Director, PPD ARO Dr. Jotham Musinguzi, Regional Director, Partners in Population and Development Africa Regional Office to provide a platform for the promotion of and resource mobilization for Reproductive Health and Population and Development in Africa through three key mission elements: policy dialogue, networking and building strategic partnerships in the region and sharing of experiences and good practices. I would like to thank the Chairperson of EARHN, Dr. Teodros Bekele, Director General, Federal Ministry of Health, and Government of Ethiopia for the strong and committed leadership since September 2, 2011 when the Government of Ethiopia was elected Chairperson of the EARHN Network. As you are aware, it was during the landmark International Conference on Population and Development (ICPD) in Cairo that countries of the South came up with the idea of South-South cooperation in the field of Reproductive Health, Population and Development. The Eastern Africa Reproductive Health Network (EARHN) was initially established as a south- 2 EARHN_Newsletter

5 south partners initiative of Uganda, Kenya and Tanzania to enhance collaboration in addressing population and development issues among the three countries. EARHN has now encompassed other countries to include Burundi, Ethiopia, Rwanda and collaborating countries including Malawi and South-Sudan. Uganda is host to the PPD Africa Regional office which was opened in February 2007 in order to help reinvigorate south-south collaboration within Africa. The PPD Africa office was established to ensure an improved sexual and reproductive health environment and better coordination of south-south collaboration activities and programs in Africa. The Vision of PPD Africa is a continent that meets its Reproductive Health needs, promotes the Population and Development agenda and thereby addresses poverty, through South-South Cooperation. Its Mission is to provide a platform for the promotion of and resource mobilization for Reproductive Health and Population and Development in Africa through three key mission elements: policy dialogue, networking and building strategic partnerships in the region and sharing of experiences and good practices. PPD therefore strongly associates and supports initiatives of EARHN because they are in tandem with one of our core strategic thrust of networking and building strategic partnerships in the region. PPD believes that networking and formation of strategic partnerships will broaden the resource base (financial and human) for addressing Sexual and Reproductive Health and Rights (SRHR) as well as help diversify the experiences and pool expertise for sexual and reproductive health, population and development issues. In this regard, PPD is very supportive of EARHN. We have already started replicating our experience with EARHN to other regional economic communities in Africa. As part of PPD ARO s programme to promote SRHR, Population and Development in the Africa region, PPD ARO, in collaboration with National Population Council (NPC) of Ghana supported in August 2009 the development of the Strategic Plan for the West Africa Reproductive Health Network (WARHN) to guide its work in promoting SRHR, Population and Development in the region. We are also working towards the re-invigoration of the RH network crafted around the Southern Africa Development Community (SADC). I am hopeful that newsletter will provide an opportunity for us all to have a critical look at interventions and innovations in the different countries as well as areas where we can learn from each other in our future advocacy work, networking and sharing of experiences. I am also hopeful that this newsletter will further help to lay and cement a strong foundation for long lasting and mutually beneficial partnerships and collaborating arrangements among countries and regional networks in addressing FP/RH, population and development, which we have already embarked on. On behalf of PPD Africa Regional Office, I would like to assure you that we appreciate the work already done by the Government of Ethiopia as chairperson of EARHN. I would like to thank the member countries for their participation in EARHN activities over the past years. I am also thankful to my staff at the Africa Regional Office for their support. I am convinced that PPD ARO will remain a forerunner in the promotion of South-South Co-operation in the field of Reproductive Health, Family Planning, Population and Development. EARHN_Newsletter 3

6 Overview of EARHN The Eastern Africa Reproductive Health Network (EARHN) is a South-South network comprised of government ministries addressing population issues. Its geographical coverage includes Burundi, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda. EARHN was founded in 1996 by members in Kenya, Tanzania, and Uganda. In December 2007, the Eastern Africa Reproductive Health Network met to re-invigorate its work and develop a Strategic Plan for Eastern African countries have extensive experiences in SRHR; these good practices and experiences offer a set of known lessons on which to build a new, collaborative effort to initiate change in-country and regionally, in order to improve the health and rights of all people, and in particular, the SRHR status of women and youth. EARHN will build upon the experiences of members within and outside of the network to build a collaborative effort to create positive change in both policy and programme implementation within Eastern Africa. EARHN meeting, 2008, Kampala, Uganda, EARHN s vision is an Eastern African region free from sexual and reproductive health burdens. The mission of EARHN is to Promote sound sexual and reproductive health policies and programmes across borders through strategic partnerships, effective coordination and sharing of best practices. EARHN works through strategic partnerships, effective coordination and sharing of critical information, experiences and expertise. In order to attain its vision, carry out its mission and fulfil its mandate, EARHN has agreed on three areas of strategic focus: Advocacy and Coalition Building; Programme Development and Expansion; and Institutional Strengthening. 4 EARHN_Newsletter

7 Selected Demographic and Reproductive Health Indicators for EARHN Member And Collaborating Countries Country Population (M) Population Growth Rate (%) Total Fertility Rate Infant Mortality Rate Maternal Mortality Ratio Contraceptive Prevalence Rate (Modern methods) (%) Unmet need for FP (%) HIV/AIDS Prevalence (%) EARHN Member Countries Burundi Ethiopia Kenya Rwanda Tanzania Uganda EARHN Collaborating Countries Malawi South Sudan (Source: Country Reports, February 2013) The mission of EARHN is to Promote sound sexual and reproductive health policies and programmes across borders through strategic partnerships, effective coordination and sharing of best practices. EARHN_Newsletter 5

8 Progress on Family Planning Building on our own success: Family Planning Program in Ethiopia Dr. Tewodros Bekele Director General, Federal Ministry of Health, Ethiopia and EARHN Chairperson Ethiopia has seen a sustained 3 percent annual increase in the rate of contraceptive prevalence since In the first national survey in 1990, the CPR in Ethiopia was only 3%. Twenty years down the line CPR has now reached 28.6%. 6.3% of married Ethiopian women had reported use of modern methods in 2000 which increased to 14% in 2005 and nearly doubled by How did Ethiopia succeed in going from just a 3 percent contraceptive prevalence rate to nearly 30 percent in just 20 years? Here is a synthesis of lessons from Ethiopia regarding the prime success factors that contributed to the dramatic shift in access to family planning services. Doing at scale: In Ethiopia, plans are set ambitiously, and done at scale. The current five year strategy of the health sector, HSDP IV ( ), targets to reach CPR of 66% by Use of family planning in Ethiopia has traditionally been limited to short-acting methods such as pills due to 6 EARHN_Newsletter

9 Progress on Family Planning The Health Extension Program was initiated with the aim of training and deploying over 30,000 Health Extension workers (HEWs) in each of the villages across the country. limited access to Long-Acting FP (LAFP) methods as a result of shortages of commodities, and lack of skilled health care providers to offer services at the community level. Of the 6.3% married women using any modern contraceptive method in 2000, 2.5% were using the pill, and 3% were using injectables, a number which dramatically changed to 20.8% injectables use and 2.4% implants in This was a result of Government s plan to expand contraceptive method mix by setting out a comprehensive community based and facility base family planning program. The launching of the flagship community based Health Extension Program by the Government in 2004 created a landmark opportunity for scaling up access and demand for family planning services in Ethiopia. The Health Extension Program was initiated with the aim of training and deploying over 30,000 Health Extension workers (HEWs) in each of the villages across the country. There are currently more than 39,000 Health Extension Workers in the payroll of the government delivering promotive, preventive and a small number of selected basic curative services in the community. These Health Extension Workers have become backbones of the village health care delivery system as they were all trained to provide health education and basic primary health care, including education on family planning, counseling and delivery of short acting contraceptives like condoms, pills and injectables. A major policy decision was made in April 2009 to use the HEWs to provide Implanon insertion at the community level. A decision regarded as practical and appropriate method for addressing the lack of human resources for health. It was believed that the provision of Implanon at the community level through task-shifting by HEWs would be more effective in reaching younger women who have more limited access to services through health centers. Results also showed that the majority of family planning users who were getting their methods from the health centers five years ago are now obtaining them from the health posts (about 60% of them get the service from HEWs). As the services have come closer to the people the strategy is now reaching women with the highest levels of unmet need, particularly those between the ages of reducing barriers to access for these women. The ministry is also currently scaling EARHN_Newsletter 7

10 Progress on Family Planning up IUCD services to contribute to the overall increase in CPR. IUCD is one of the most economically sustainable methods as it costs cheaper compared to implanon. Advocacy communication and social mobilization activities are being undertaken harmonized with massive trainings to build the skills of health workers. Building capacity of health facilities and health professionals is also being done to expand access to permanent family planning methods in Ethiopia. Country commitment and ownership: Political will is a key ingredient to improve the reproductive health status of women, particularly in countries such as Ethiopia where long-held traditions and customs put women at high risk. With increased Government efforts to expand family planning services in Ethiopia, more women were reached, saving their lives and giving women and their families greater hope. Starting from policy makers to local authorities, the commitment from the leadership of the health sector in Ethiopia was crucial for the success in Family Planning program. The political leadership at different levels of the system is highly engaged and committed for the success of the national program. Many of the senior leadership in the Government, including the Prime Minister and Minister of Finance are closely involved in population matters of the country. The leadership of Federal Ministry of Health plays key role in setting a clear vision, leading program implementation and providing support and monitoring throughout the process. Family Planning service is a constitutional right in Ethiopia as stipulated in Article 35/9 of the constitution. Moreover, the Government of Ethiopia has made a number of various global commitments related to family planning over the last decade. Ethiopia s five-year blue print, The Growth and Transformation Plan, has given due emphasis for improving access to family planning services in the country setting an ambitious goal of increasing CPR to 66%. This takes account of various Government commitments such as allocation of additional budget for family planning by both the federal and regional governments, removal of all duties and taxes on imported contraceptives and fulfilling the required infrastructure as well as human resource needs for the program. Health System Building: Ethiopia has been expanding access to basic health services through a major governmentled effort to rapidly increase the number of well-equipped health facilities throughout the country. The Accelerated Expansion of Primary health Care Program has been successful in expanding infrastructures through construction of more than 2,500 health centres, equipping health centres and health posts, and massive training of mid level health work forces during HSDP III period ( ). A considerable amount of investment was also made in strengthening the health information system, and establishing an effective...the complementary role played by the private sector, as well as technical support received from development partners in filling the gap related to commodity quantification, planning, procurement and distribution are among the major factors that contributed to the overall improvement. 8 EARHN_Newsletter

11 health commodities supply and logistics system. Efforts to improve quality of service delivery also continued through addressing skill gaps and management competencies, and strengthening supportive supervision and monitoring capacities. In addition to massive investments in infrastructure and human resources in order to get services out to the doorstep, the Ministry of Health also revamped the supply chain management in an effort to ensure uninterrupted supply and availability of contraceptives in health facilities. Recent reports indicate that the percent of facilities reporting a contraceptive stock out had decreased to 5% in 2011 from 40% in Hence, the increase in the amount of budget allocated for commodity security by the public sector, the complementary role played by the private sector, as well as technical support received from development partners in filling the gap related to commodity quantification, planning, procurement and distribution are among the major factors that contributed to the overall improvement. Partnership: Partnership with local and international institutions existed in Ethiopia even long before adoption of the Population Policy when the Family Guidance Association of Ethiopia (FGAE), an International Planned Parenthood Federation affiliate founded the delivery of modern family planning services in Ethiopia in 1960s. Working in collaboration with its development partners and using the coordination platform of the FP technical working group, the FMOH gradually expanded the national family planning program across the country. The FMOH and Regional Health Bureaus closely coordinate with Development Partners to ensure that support to family planning goes where needed without duplicating efforts and resource allocation. There is strong collaboration between Partners and Government on the platforms of Regional and National Family Planning Technical Working Groups under the leadership of the FMOH. In addition, franchising for profit FP services, social marketing of contraceptives and NGO clinics play key role in meeting demands of the community. In conclusion, the experience in Ethiopia shows that strong leadership and commitment at the country level are absolutely key in advancing primary health care across nations in general and expanding family planning programs in particular. Despite the sobering numbers and the great challenges it still faces, Ethiopia is registering real progress in family planning and this is mainly due to the firm commitment of the Government, the steadfast support of our diverse partners and the meaningful engagement of the community. Progress on Family Planning Addressing family planning challenges in Uganda Prioritising family planning in district planning and budgeting processes Dr. Betty Kyaddondo Head, Family Health Department Population Secretariat, Uganda Introduction Family planning is a fundamental aspect of development and poverty reduction. Having noticed the urgent need for governments to be proactive and ensure the security of commodities as well as creating demand for family plan- EARHN_Newsletter 9

12 Progress on Family Planning ning services, together with Partners in Population and Development Africa Regional Office, Advance Family Planning and Ministry of Local Government, Population Secretariat supported two districts (Mukono and Mayuge) to prioritize family planning in district planning and budgeting processes. The aim was to mainstream family planning into departmental and local government planning and budgeting processes. This led to increased advocacy, community awareness and mobilization, commitment of additional resources to family planning interventions and integrated planning by all stakeholders involved in family planning delivery in the two pilot districts. To do this effectively, teams from POPSEC, MOLG and PPDARO worked closely with district technical and political big wigs to lobby for more budget allocation to the work of providing family planning and reproductive health services and ensure that family planning activities were rolled out in rural areas to ensure the attainment of MDGs. The districts were selected based on performance measures and location (rural and urban based). Previously, POPSEC had partnered and supported Mayuge district to integrate population variables in District Local Government Plans. Courtesy calls were undertaken by staff of MOLG, Population Secretariat and PPD ARO. During the initial visits, the visiting ams reviewed the District Local Government Plans and found that family planning was vividly missing in the plans, although, it was highlighted as a challenge in the situation analysis in both districts. Based on this finding, awareness creation meetings were organized with the politicians and technical officers at district and Sub county levels. The meetings emphasized the benefits of family planning and the need for districts to prioritize family planning in all sector departments as was clearly emphasized in the National Development Plan. The prioritization was based on in-depth analysis that identified effective interventions that each department could undertake within the available resources. The process that kicked off in 2011 and run through 2012 revealed that district and lower local government heads of departments sought to ensure that the collection and allocation of public resources is carried out in ways that are effective and contribute to advancing women s empowerment and increasing utilization of family planning services. Each district developed a monitoring and evaluation framework with specific targets and indicators for measuring progress as well as tools to assess the different needs and contributions of men and women, and boys and girls within the existing revenues, expenditures and allocations and this later called for adjusting budget policies to benefit all groups. Individual Sub county work plans were developed and were the basis for the general district family planning work plan that was incorporated in the District Development Plans. The review of the District Local Government Plans in mid September 2011 revealed that family planning issues had been clearly prioritized with activities and budget items for each department including health, education, production, Works, administration, community development and planning units. The comprehensive budgets took into consideration the activities that are not funded (Unfunded priorities), as basis for resource mobilization from development agencies and partners. By Mid of the FY 2011/12, Mukono and Mayuge Local Government Councils adopted the Family Planning Decalration (2012) with primary goal of increasing advocacy, community awareness and a commitment to raise resources for family planning. Mukono district council in its budget of FY 2012/13 allocated shs. 12,000,000 (Twelve million shillings) out of its locally raised revenue. The funds will enable the district health office carry out mentorship of family planning mainstreaming in district departments and the 15 lower local governments and also carry out the quarterly review meetings and provide technical support to departments and lower local governments during the development of district family planning work plan for FY 2013/14. The family planning declaration enabled the district executive committee at its sitting to prioritize and commit funds for family plan- 10 EARHN_Newsletter

13 Progress on Family Planning ning mainstreaming, a meeting not attended by the District Health officer is a manifestation that family planning issues are now high on the political agenda in the two ditsritcs. This is a clear manifestation that family planning mainstreaming concept enabled raising of the profile of family planning in district local government structures whereby the politically endorsed declaration is used as a measure of adherence to commitments by the current political leaders in the office. The Declaration has been shared with other programs and is seen to be a good practice. A similar declaration is being considered for addressing child survival programs in the district by using the experience gained while developing the family planning declaration. The funding gaps for family planning delivery in the district e.g. inadequate family planning providers to insert and remove IUDs, family planning permanent methods improvement of DHT capacity to carry out performance improvement support supervision to health units have been shared with other development partners for support. As a result of the interventions, the health departments experienced increased demand for family planning methods especially the long acting family planning methods. To be able to cope with this demand, the health departments strategically made plans to increase geographical access by opening additional outlets that could provide long acting family planning methods. Only few Health Centres were able to the long acting family planning methods. The districts relied on staff at H/C IVs and the outreach camps organised biannually by Maries Stoppes Uganda for the case of Mukono and Strides in Mayuge district. These were not adequate to provide optimal services to clients that needed the methods and were limited in coverage, creating a big missed opportunity for the demanding clients. To ensure that the districts build own systems and capacity to provide the long acting FP methods, Partners in Population and Development Africa regional Office supported the training of service providers in provision of implants and intra uterine devices and update on depoprovera provision. This resulted in the training of additional family planning providers coupled with supplementary procurement of 5,000 rods of implanons from National Medical Stores. This widened the scope of reach and coverage and translated into a family planning boom for the districts. Performance The districts have so far registered a 3 fold increment of both implants and injectables dispensed in Quarter 4 compared to the other 3 quarters before training of the service providers. See bar graphs for implants and injectables comparing FY 2010/11 and 2011/12. Prioritisation and getting all sectors to appreciate did not only improve the policy environment for family planning in the districts, it also raised the demand of clients, enabling enrollment of many clients and hence an opportunity to increase uptake of the long acting family planning methods in the district. This will eventually lead to reduction in Maternal Mortality Rate (MMR), eventual improvement in the standard of living of the and also contribute to the attainment of the millennium development goals. EARHN_Newsletter 11

14 Progress on Family Planning Dr. Bigayi Theophile Chief of Clinical Provisions National Program for Reproductive health, BURUNDI Introduction of the No-Scalpel Vasectomy Burundi, an East African Community country, is one of the most densely populated countries in sub-saharan Africa. The country covers an area of 27, 834 km2 with a population of over 8 million inhabitants. The country population growth rate is that of 2.4% with a population density that is considered among the highest in sub-saharan Africa with average of 310 inhabitants/km2 (National census, 2008). The TFR (Total Fertility Rate) has been persistently high, remaining above 6 children per women from 1965 to 2010; a recent demographic and health survey shows a TFR of 6.4 children per woman (DHS, 2010). Burundi initiated its family planning program in 1987 but the use of modern contraceptive methods hadn t increased significantly over 20 years. The CPR (Contraceptive Prevalence Rate) remained below 10% until 2007 when the CPR reached 9.4%. Since 2008 the CPR began to increase slowly from 11.4% in 2008 to % in This increase was a result of sensitization on population issues and the subsequent training in family planning in all health centers. Generally, family planning services are delivered in health centers but since the Ministry of Health initiated the performance based financing, some district hospitals have 12 EARHN_Newsletter

15 Progress on Family Planning 2025 Vision, the National Plan for Health Development, and the Strategic Plan for the Reproductive Health Program in Burundi. provided family planning services since Strengthening Human Resources in Family Planning Despite government effort, the CPR is still low with an unmet need in family planning estimated at 31% (DHS 2010). Capacity building of the district level healthcare providers in family planning remains one of the priorities of the Ministry of Health s projected goal. Currently, the Ministry of Health effort is being focused in promoting long acting methods such as IUDs (intrauterine devices) and implants. Permanent methods such as tubal ligation and vasectomy are still to be promoted. The Africa region IPPF (International Planned Parenthood Federation) has offered trough ABUBEF (Burundian Family Guidance Association) technical support to the Ministry of Health in building the capacity of 5 district hospitals and one ABUBEF clinic. The objective was to inform the clients of the full range of quality family planning methods. In each hospital, two healthcare providers were trained (a physician and a nurse) in the NSV (No- Scalpel Vasectomy) technique. The hospitals were also provided with the surgical training equipment and supplies. After the training, the six sites started delivering NSV; however three were discontinued due to the physician leaving the site. This increased the clients to be wait-listed who where 143 in ten months period. In that period, a total number of 190 cases of vasectomy have been performed. Five out of 190 cases developed minor complications which were successfully addressed. Surgical Method s Place in Family Planning In Burundi, surgical methods as family planning option are minor. Only 0.04% of contraceptive use is represented by surgical methods in This is partially due to the fact that surgical methods have not been as promoted as DIUs and implants. Vasectomy is one of the safest and most effective contraceptive methods and has advantages over tubal ligation. These advantages include a lower rate of postoperative complications, shorter recovery time, and increased male involvement in family planning. But no one has yet taken advantage of these benefits due to an extreme shortage of trained healthcare providers in the vasectomy procedure. Increasing Male Involvement in Family Planning One of the objectives of the community sensitization was to stimulate demand for vasectomy and to motivate men to travel to a health facility for vasectomy procedure. In the sensitization process, local leaders and community health workers played an important role in terms of policy support and orientating the potential clients. It is acknowledged that rumors deter a number of potential clients willing to undergo family planning methods; often one failed procedure is enough to impede the progress of the program. Conclusion Family planning is one of the top priorities of the Burundian government; this is reflected in numerous policy documents as seen in the 2025 Vision, the National Plan for Health Development, and the Strategic Plan for the Reproductive Health Program in Burundi. In order to achieve the goal of satisfying the demand for the 31% unmet need, the population must acquire a profound understanding that family planning is an investment for socioeconomic development. Vasectomy is simply another effective method to achieve family planning goals in individual families and in the country. EARHN_Newsletter 13

16 Progress on Family Planning Community leaders advancing Family Planning in Kenya Ms. Lucy Kimondo and Ms. Faith Abilla Ms. Kimondo works as a Senior Population Programme Officer at NCPD and Ms. Abilla works as an Advocacy Officer with Tupange Project ith county admin- about to Wistrations become a reality after the coming elections in Kenya, the family planning campaign has already seen its own devolution with local administrators being co-opted as advocacy champions. The National Council for Population and Development (NCPD), which is coordinating the advocacy initiative of a project known as Tupange, has trained and empowered local administrators in three main town Nairobi, Mombasa and Kisumu to help in reaching the public with family planning messages. The project is coordinated by Jhpiego and is aimed at re-invigorating a campaign that had achieved major gains in the 1980s, but whose momentum waned due to low investments in family planning programmes in particular and reproductive health in general. The Provincial Administration is the organ the central government depends on most as an interface with the citizens. Not only are they the most visible sign of government at the grassroots, but they also interpret and educate on various government policies and programmes. The Tupange advocacy strategy by NCPD is focusing on educating national and local policy makers on FP/RH issues to take advantage of their authority and reach. This approach will strengthen the policy environment at the national and operational levels by ensuring that relevant policies, guidelines, standards and protocols enable and encourage access to FP services for the urban poor, says George Kichamu, Assistant Director for Communication at NCPD. The Provincial Administration structure includes Provincial Commis- 14 EARHN_Newsletter

17 Progress on Family Planning sioners (PCs), District Commissioners (DCs), District Officers (DOs) and Chiefs. Their main avenue is what is known as barazas or public gathering. At these for a, the administrators hold sensitization sessions supporting the national efforts to reposition family planning as the missing link to achieving the Millennium Development Goals and Kenya s Vision The existing provincial administration structure creates a cost effective platform to integrate FP advocacy with other issues affecting the community. This platform offers an opportunity for community leaders to disseminate FP information as well as demystifying myths and misconceptions that are rampant among the community. As most of the administrators are male, using them also promotes male involvement in FP. The chiefs help organise community forums and invite family planning providers and advocates to discuss the benefits of family planning and also serve as models and champions for family planning by practising family planning and making public statements about its benefits. They are also expected to facilitate implementation of national policies on provision of family planning by engaging other community leaders in their areas to mobilise support for family planning. Since the Tupange project started using the chiefs there has been positive reception for FP services in the outreach activities for the urban poor. Tupange is a five year project implemented by a consortium of partners led by Jhpiego, an affiliate of John Hopkins University, National Council for Population and Development (NCPD), Johns Hopkins University Centre for Communication Programs, Marie Stopes International, and Pharm Access Africa Limited. The goal of this program is to achieve a 20 percentage point increase in contraceptive prevalence rates in selected urban centres of Nairobi, Mombasa and Kisumu, specifically among the urban poor in Kenya. The trends in Family Planning use in Rwanda during the last 10 years Dr. Anicet Nzabonimpa FP/HIV Integration Coordinator, Ministry of Health, Rwanda Rwanda MCH conditions The 2000 Rwanda Demographic and Health Survey (DHS) reported a regression in most Maternal and Child Health (MCH) outcomes when compared to the 1992 DHS. This is largely due to the disruption of the health sector caused by the genocide of This conflict represented a step back for the country in terms of development and health. Health facilities needed to be created and, more importantly, staffed by professional health personnel. Additionally, the direct effects of the conflict on the health status of the Rwandan people such as injury and mental health lasted long after the conflict ended. In the ten years since the 2000 DHS was released, the government has prioritized improving health across the country, particularly MCH indicators. Maternal mortality rate and child mortality rate have both been reduced by more than 50% of their 2000 figures. Vaccination rates are increasing and the total fertility rate has dropped. These improvements are due to a commitment on all levels towards improving health outcomes as well as the use of innovative policies to reach as many people as possible. In this paper, the improvement in MCH indicators will be linked to the programs and policies that caused the change. This should serve to inform other countries struggling to improve their MCH health outcomes by providing them with interventions and strategies that have been proven effective. In addition, areas that have not improved will be identified for future strategic planning to continue the ongoing process of improving Rwanda's overall health. EARHN_Newsletter 15

18 Progress on Family Planning Background Rwanda is a small landlocked country, about 26,338 square kilometers. The country is largely mountainous with sharp valleys interspersed. The average elevation is 1700 meters above sea level. The economy is still largely agricultural, with over 80% of the population working in that sector. The per capita gross domestic product in purchasing power parity is $1,300. The population is quite young, with the median age around 19 years old. With over 10 million people, Rwanda is the most densely-populated country in Africa. 86% of the population is rural and has limited access to health services due to geographic access issues. In 1994, almost 1 million Rwandans were killed during 100 days of genocide. This conflict destroyed the economy and devastated the health care infrastructure. It additionally led to a brain drain, with many of the country's trained medical professionals leaving the country. Since recovering from the genocide, Rwanda's national government has made improving the health status of the country on of its highest priorities. This prioritization has largely been found in MCH areas like maternal health, immunizations, and family planning. Due to the government's ability to mobilize and implement new programs efficiently, the health gains have been dramatic. There is still much improvement to be made, however, as Rwanda currently ranks 166th out of 187 countries in the Human Development Index. Rationale Prioritizing future innovations to continue improving the health and economy of the country means understanding what has worked up to this point as well as identifying potential future barriers. In addition, lessons learned in developing the Rwandan health system may prove useful in informing other countries struggling to raise their health indicators to meet the Millennium Development Goals. Before discussing MCH-specific programs and changes, there were a number of important changes to the overall Rwandan health system that are important discuss in order to provide the proper context. Afterwards, programs implemented in the last 10 years in family planning, antenatal care, postnatal care, immunization, nutrition, and gender-based violence will be discussed. Discussion In order to ensure financial access to healthcare for almost all Rwandans, the country instituted a system of community-based health insurance plans, known as mutuelle de santé throughout the country. While the system is not necessarily a pure form of community-based health insurance, due to 16 EARHN_Newsletter

19 Progress on Family Planning the fact that each mutuelle is subsidized by the central government in order to ensure sustainability, it provides low-cost insurance to Rwandans around the country. Each member pays 1,000 Rwandan francs to their autonomous, member-run mutuelle for coverage, and pays 10% of the costs incurred for each incident of illness. The primary point-of-entry for clinical treatment is at the health centers for a basic package of health services, but for more specialized care, Rwandans are referred to district hospitals. The system of mutuelle allows medical care to be affordable for all at a small price and spreads the risk of catastrophic illness or injury among a large enough pool to minimize risk. The funding from the central government further protects against unforeseen catastrophy bankrupting the mutuelle. Another important recent development for the Rwandan health system was the strategic decision by the Ministry of Health (MINISANTE) to decentralize health systems operations to the district level. Each district is charged with planning, managing, coordinating, and evaluating the day-to-day health services operations within the district, while the central level is charged with strategic planning, monitoring & evaluation, and management of nationallevel facilities. This structure lets the separate districts tailor programs to meet the needs of their constituencies and also allows national priority programs to be rolled out in phases. A third important system-wide change that was made was the introduction of community health workers (CHWs) as a critical part of the health care system. Each village, around people) nominate one woman and one man to receive training and serve as CHWs in their area. As a result of making this an elected office, a CHW post is considered a spot of honor for those elected. CHWs help provide basic health services to Rwandans who may not often utilize health services otherwise. Family Planning (FP) The Contraceptive Prevalence Rate (CPR) for modern methods increased from 4% in the 2000 DHS to 45% in the 2010 report. CPR for all methods increased from 13% to 51% in the same time frame. At the same time, the total fertility rate decreased from an average of 5.8 children per women to 4.6. At the same time, women's attitudes about how many children they want are changing, with the women's reported ideal family size decreasing from 5 to 3. Total Fertility Rate for women age for the 3-year period before the survey(dhs) Family planning is one of the most successful areas of improvement for Rwanda's health system over the last decade. One of the many reasons for the rapid expansion of contraceptive use is that there were such low rates of usage at the start of the decade. Low availability of supplies and the lack of qualified staff to prescribe or administer FP were contributing factors to the low rates during the 2000 DHS. Since 2000, FP was made one of the highest national priorities by the Rwandan government. Due to the fact that Rwanda is already densely populated and their rapid fertility rate, there were concerns that neglecting to stem the population growth rate would have adverse effects on attempts to develop the economy. The commitment from leadership was critical to making modern contraceptive methods widely available throughout the country. Other important interventions during the early part of the decade included mass media campaigns to raise awareness about the benefits and availability of FP, integration of FP messages and education in men's groups, and integration of FP into Safe Motherhood and Child Health services. More recently, policy makers have realized that in order to continue increasing CPR around the country, innovative approaches will need to be implemented. Further integration of FP services is underway throughout the country. One large area of focus for integration has been between HIV and FP services in both ways. When a client comes in for an HIV test or antiretroviral therapy, they are screened for EARHN_Newsletter 17

20 1 World Health Organization Trends in Maternal Mortality Population Reference Bureau Family Planning Saves Lives 4th edition. 3 Ethiopian Central Statistics Agency Ethiopia Demographic and Health Survey et/docs/edhs%202011%20preliminary%20report%20 Sep%2016% pdf. 4 Federal Ministry of Health Health Sector Development Program III Federal Ministry of Health National Reproductive Health Strategy Personal Communication by the Federal Ministry of Health. June 24, USAID Health Policy Initiative, Task Order Achieving the MDGs: The Contribution of Family Planning, Ethiopia. pdf. 8 Futures Group. Unpublished. Population Family Planning and Long-Term Development Goals: Predicting an Unpredictable Future. 9 USAID Health Policy Initiative, Task Order The Cost of Family Planning in Ethiopia. Ethiopia_Brief_FINAL_7_12_10_acc.pdf. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA- A , beginning September 30, It is implemented by Futures Group, in collaboration with the Centre for Development and Population Activities (CEDPA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Photo credit: Makis Partners in Population and Development Africa Regional Office (PPD ARO) Progress on Family Planning unmet contraceptive need. Wherever possible, the health worker will discuss family planning options and prescribe whatever method is most appropriate for the client. If the health worker is unable to adequately counsel or prescribe for the client, they are referred to the appropriate facility. Another area of recent innovation is the use of CHWs to counsel and administer contraceptive options. A handful of districts have already trained a portion of their CHWs to speak to their clients about traditional and modern FP methods. As a part of this training, they are taught how to administer injectables. While the first dose of injectables or round of birth control pills must still be administered via one of the district health centers, CHWs who are approved after training can administer the later rounds. This program will continue to be phased into other districts in the country in order to further increase the percent of the population with easy access to modern contraceptive options. Ethiopia FP Policy brief Photo credit: Dietmar Temps Photo credit: Dietmar Temps FAMILY PLANNING IN Ethiopia FAMILY PLANNING IN Ethiopia Contraceptive use has doubled in the last five years, but an Ethiopian woman still bears an average of five children and 25 percent of married women want to space or limit their births but are not currently using contraception. Priority Actions The Government of Ethiopia should increase investment in family planning to foster immediate health benefits. 9 Increased access to family planning in Ethiopia would vastly improve the health and lives of millions of women, children, and families. To make this possible, parliamentarians should Continue making family planning a multisectoral issue by securing family planning commitments from all relevant sectors and at all leadership levels; Make more domestic funding available for family planning; Focus more efforts on adolescent girls by expanding youth-friendly services; Scale up the delivery of services to hard-to-reach groups; and Monitor the availability of contraceptives by using innovative approaches. Resources Ethiopia has made progress Ethiopia has made commendable efforts toward fulfulling its national socio-economic development goals and is one of the few countries that has made significant progress toward achieving the MDGs, particularly those related to health. Through a 20-year Health Sector Development Program (HSDP), currently in Phase IV, the government has made family health a priority, particularly maternal, neonatal, and child health. Further, the Federal Ministry of Health (FMOH) has identified family planning as a key intervention in achieving the HSDP targets and MDGs, as well as broader socio-economic growth. 4 Over the last 15 years, the FMOH has made unreserved efforts to expand access to family planning information and a range of family planning method options. In addition to the usual static facility-based service, the ministry has substantially increased access to family planning services through its Health Extension Program, which has deployed more than 34,000 rural health extension workers (HEWs) capable of providing family planning information and short-term family planning methods (e.g., condoms, oral pills, and injectables). Over the last five years, the FMOH has been giving increased attention to expanding the family planning method mix, especially the expansion of services for long acting methods (non-permanent and permanent methods). To this end, the ministry has revised the national family planning guide and introduced task shifting. In 2009, an initiative began to scale up family planning implants, and as a result, HEWs are currently providing an implant called Implanon at the community level. In 2010, the scale-up of intrauterine family planning devices was initiated in more than 100 districts and will be extended throughout the country. And beginning in the next Ethiopian fiscal year, the FMOH plans to scale up permanent family planning services at hospitals and selected health centers. 5 As a result of these efforts, Ethiopia has made tremendous progress in doubling the contraceptive prevalence rate (CPR) over the last five years (from 15% in 2005 to 29% in 2011). However, the CPR is highly dependent on short-term family planning methods (e.g., nearly 21% for injectables), and unmet need for family planning is still high for spacing births (16%) and limiting (9%). Recognizing this situation, the FMOH, under HSDP IV, has set a target CPR of 66 percent by To achieve this goal, the FMOH has considered the important role of long acting non-permanent and permanent methods and aims to provide 20 percent of all family planning clients with these long-acting methods. Despite these significant efforts and achievements, however, higher authorities-such as parliamentarians, community leaders, associations, government and nongovernment officials, and other policy makers-need to foster a stronger enabling environment for family planning by raising awareness and delivering compelling public statements at all levels (national, district, and local). In addition, the government and donors need to increase funding for family planning to make achieving the set targets possible. 5 Family Planning Improves Maternal Health FAMILY PLANNING IN Ethiopia August 2012 Family planning plays an essential role in improving maternal health, which is one of the eight Millennium lows parents to devote more time to each child in the early dren. In addition to the health benefits, spacing births al- Development Goals (MDGs) world leaders have pledged years, easing pressures on the family s finances and giving to achieve by Family planning is a low-cost yet effective way to lower maternal mortality by reducing the An Ethiopian woman bears an average of five children in parents more time for income generating activities 2. number of high-risk births. Pregnancies that are too early, her lifetime. As of 2011, 29 percent of married too close, too many, or too late pose adverse health consequences for the mother, child, and family. In Ethiopia, the Ethiopian women of childbearing age (15 49) use any probability of an adult woman dying from a maternal cause method of family planning; 3 this is a dramatic increase from during her reproductive lifespan is about one in When 2005-when only 15 percent of married women of childbearing age were using any form of contraception. However, 25 a woman dies in pregnancy or childbirth, this affects not only the well-being of the family but also the social and economic development of the community and nation. Further, percent of married women do not want any more children or want to wait for two or more years before having another child but are not currently using any form of contra- the surviving newborns often suffer from poor health and are at a greater risk of dying before reaching age 5. ception. Family planning efforts need to expand to address this unmet need for family planning-particularly among Waiting at least two years from the previous birth to attempt another pregnancy reduces the risk of illness and need (33%). young women ages who have the highest unmet death for mothers, as well as newborns, infants, and chil- Increased family planning use could save 13,000 mothers and more than 1 million children Increased contraceptive financing is needed In the past few years, Ethiopia has made considerable progress toward achieving contraceptive security-the ability of five-year health strategies. 6 evident in their respective policy documents, such as their every woman and man to access contraceptives. An important element in achieving this goal is allocating adequate centrated on short-term methods, such as pills, injectables, While funding has been rising, family planning use is con- funding to contraceptive procurement. Historically, almost and condoms. Increased allocations for the procurement of all contraceptives have been donated to Ethiopia by the long-acting methods (permanent and non-permanent) are U.S. Agency for International Development, United Nations needed, as well as for family planning services and education more broadly. Population Fund, and UK Department for International Development. However, in 2007, the federal government earmarked a budget line item for contraceptive procurement for the first time. Family planning is a smart investment In fiscal year , the government spent US$910,000 Investing in family planning improves maternal and child of its own internally generated funds and used US$12 million from basket funds to purchase contraceptives, repre- health and also has benefits for Ethiopia across several sectors. For example, fulfilling unmet need for family planning senting 59 percent of total spending for public sector contraceptives that year. would generate significant cost savings in meeting five of the MDGs-achieve universal primary education; reduce child mortality;improve maternal health; ensure environmental In 2009, total government spending increased to 68 percent, with US$20 million from basket funds. In 2010, the eases. The savings would be more than two times greater sustainability and combat HIV/AIDS, malaria, and other dis- MDG Pool Fund, a funding arrangement in addition to the than the increased costs of family planning. 7 basket funding arrangement, began to finance contraceptives. For , US$5 million were allocated from Satisfying unmet need for family planning by 2015 would the MDG pool fund, US$9 million from basket funds, and meet the desires of women and men for their families and about US$919,000 from internally generated funds. Similarly, recognizing the importance of contraceptive security, save the lives of nearly 13,000 mothers and more than 1 million children. In addition, meeting unmet need would Ethiopia s four major regions-oromia; the Southern Nations, generate $23 million in savings in the education sector and Nationalities and Peoples (SNNP); Amhara; and Tigray-have $26 million in the water and sanitation sector. 8 all committed their own funds to support contraceptive security. The amounts range from approximately US$30,000 help Ethiopia fulfill its national vision of reducing poverty and Addressing the high unmet need for family planning will to US$400,000. The commitment of these regions is also becoming a middle-income country. Photo credit: Dietmar Temps Percent of women age using FP modern methods (RDHS) The most prevalent method used in the region continues to be injectable, making up 26% of the 2010 method mix. The only long-term FP method that contributes to more than 1% of the method mix are implants, at 6%. Despite recent initiatives to encourage tubal ligation and vasectomies, those procedures still only make up around 1% of the method mix total, though evidence shows that uptake of those methods is increasing. It is hoped that the next DHS shows an increase of the contribution of long-term and permanent methods to the overall method mix. 18 EARHN_Newsletter

21 Advocacy Advocacy on RH/FP Ethiopia on truck to achieving MDGs Mr. Alula Sebhatu Senior Expert of Reproductive Health Chief Public Health Professional MoFED Today, with the population size of 84 million, Ethiopia is the second populous country in Africa, next to Nigeria. The population growth rate is 2.6% per annum, among the highest in sub-saharan Africa. (CSA, 2012) Furthermore, the urban population is growing at around 3.9 percent per year, the rural population is also growing at around 2.1 percent and the pyramidal age structure of the population has remained predominately young with 45% under the age of 15 years, the population in the age group of over 65 years accounts for only 3.1% of the total. (CSA, 2012) Population as cross cutting issue in growth and transformation plan The population Policy, by its nature, is multi sectoral and its translation into action also requires a coordinated effort, including integrating population variables into all sectoral development programs at all levels. In this regard, The Ethiopian government has given emphasis to population and development linkages, also considered population as one of the major development challenges to poverty reduction which is really revealing of government commitment to the demographic factors. To this end, population was considered as one of eight pillar strategies in the government s former plan for Accelerated and Sustainable Development to End Poverty (PASDEP) and then The second development plan, Growth Transformation Plan (GTP) made for the period of (2010/ /15) has also proposed to incorporate the population pillar into the women and youth empowerment pillar and as cross cutting strategic direction. The 1993 policy, (National Population Policy) High fertility is a major contributor to poverty. Unregulated fertility is associated with high maternal, neonatal and child mortality due to teenage pregnancy, short birth interval, underweight babies etc. High prevalence of infectious diseases and nutritional deficiencies further complicate these conditions. In order to mitigate the adverse effects of high population growth, the Government of Ethiopia formulated and embarked on implementation of National Population Policy. The National Population Policy is an overarching policy document that gives strong emphasis to the well being population through time. The government of Ethiopia has adopted an explicit population policy in April 1993, recognizing the links and inter- EARHN_Newsletter 19

22 Advocacy relationships between population, resources, the environment and development. The goal of the 1993 NPP was to the harmonize the rate of population growth with that of economy, to coordinate and influence other strategies and programs that ensure sustainable development of the people and to promote gender equality and the empowerment of women; its demographic objectives include reducing total fertility rate from 7.7 children per women to 4; achieving a corresponding increase in modern contraceptive prevalence (CPR) from less than 5 to 44% of married women of reproductive age; and reducing infant, child, and maternal Mortality. Country at high momentum of MDGs As recently as 2015, reaching targets set both in the policy and MDGs seemed a nearing possibility. Fertility, which is the major responsible factor for high population growth in Ethiopia, is showing decreasing trend but at lower rate compared with Mortality. both infant and under five mortality rates decreased significantly, and maternal Mortality decreased, but not in a statistically significant way. Nation wise, The EDHS (2011) key findings on contraceptive services are: knowledge of contraception is nearly universal; nearly thirty percent of currently married women are using any method of contraception, mostly modern methods (27 percent); Contraceptive prevalence varied enormously, from 52.5 percent among women in urban areas to 23.4 percent in rural areas. injectables are the most popular modern method used by 21 percent of currently married women; use of modern methods among currently married women has increased from 6 percent in 2000 to 27 percent in the 2011 (EDHS) due to increase in the use of injectables, from 3 percent in 2000 to 21 percent in Infant and under-five mortality rates recorded in these surveys point to a continuous fall in mortality trend. Infant mortality declined from 97 deaths per 1000 thousand live births in 2000 to 59 in 2011, while under-five mortality declined from 166 deaths per 1000 live births in 2000 to 88 in Neonatal mortality rate decreased from 49 deaths per 1000 live births in 2000 to 39 deaths per 1000 live births in 2005 and it seems to stabilize at 37 deaths per 1000 in 2011 as reported in the EDHS. A falling birth rate increases likelihood of a demographic dividend The demographic dividend occurs when a falling birth rate changes the age distribution, so that fewer investments are needed to meet the needs of the youngest age groups and resources are released for investment in economic development and family welfare. Ethiopia has a greater likelihood of capturing a demographic bonus or dividend under the lower population growth scenario. If women have fewer children, the altered age structure of the population produces a more favorable ratio of adults in their economically productive years to dependent children and the elderly. With fewer children requiring education and health services, the government has greater discretion to invest resources in other critical areas. Greater investment and increased savings create a one-time, age structure-related economic growth spurt that is either captured or forever lost. In sum, there have been promising trends, reliable and well-documented, in the major determinants of fertility decline. The combined effects of a rising age at marriage, rapid increase in use of contraception, decreasing desired number of children among younger couples, and dramatic increase in the education of girls will reduce family size and slow the rate of population growth. Ethiopia is on the right track to capitalize on these favorable trends and has already laid the necessary groundwork to capture the demographic dividend through effective policy implementation. 20 EARHN_Newsletter

23 Advocacy Policy recommendations There needs to be increased commitment of in overcoming the constraints in policy implementation and to reaching the 2015 goals. Appropriate institutional mechanisms are to be established (e.g., National Population Council with the necessary legal framework). There is also a need to make concerted efforts to execute the National Population of Action that was developed and a system for monitoring and evaluation of progress in the implementation of the policy needs to be in place. There must be an enhanced stakeholder s capacity to integrate population variables in to development planning. EARHN_Newsletter 21

24 Advocacy Kenya s Parliament Adopts Population Policy for National Development Ms. Lucy Kimondo Senior Population Programme Officer for Advocacy & Communication National Council for Population and Development, Kenya 10 th Members of Parliament inkenya adopted the Population Policy for National Development (PPND) in October During the past three years, the PPND was developed through an extensive consultative process that involved the participation of various stakeholders from the public and private sectors at the national and county levels. This public engagement was led by the National Council for Population and Development (NCPD), and included a national leaders conference, forums among Members of Parliament (MPs), meetings with district and regional leaders, and ongoing nationwide mobilization and advocacy. The National Leaders Conference on Population and Development was organized by NCPD and held in November More than 1,000 national leaders from the government and the private sector gathered in Nairobi for three days to reprioritize family planning as a central component of Kenya s population agenda and development goals. The conference resolutions, report, and call to action recognized the consequences of rapid population growth on Kenya s development goals, and proposed multi-sectoral approaches to address these concerns with a focus on family planning. NCPD moved forward with its mandate to draft the PPND based on the conference resolutions and call to action. In July 2011, approximately 185 stakeholders, half of whom were MPs and development partners, discussed the draft PPND, and how to incorporate the resolutions from the National Leaders Conference. At the end of the retreat, the MPs resolved to support the adoption of the PPND, to endorse the final report and resolutions of the National Leaders Conference, to ensure increased allocation of resources for population program managementand to advocate for population issues at all levels. As a follow-up to the parliamentary retreat in Mombasa, the Parliamentarian Breakfast Meeting on the Draft Population Policy on National Development was organized by NCPD in June Over 50 attendees, Successful implementation of the Population Policy will result in a well-managed population with high quality of life thereby contributing to the attainment of Vision 2030 goals. 22 EARHN_Newsletter

25 Advocacy including MPs, government officials, donors, development partners, and journalists, gathered in Nairobi to discuss the draft PPND. The meeting helped advance the policy to the Speaker of the National Assembly for review before it was approved by parliament. Guests going through the Population Policy after it were launched by Hon. Wycliffe Oparanyah at Kenyatta Conference Centre Nairobi on 30 th October Additionally over the years, NCPD and partners produced a variety of advocacy materials, including multimedia presentations and advocacy publications, that portrayed the impact of rapid population growth on a range of crosscutting development issues. These materials were disseminated at the national and county levels, and helped raise awareness among a broader range of stakeholders about population growth and crosscutting issues, and why the PPND is essential for Kenya s development. The goal of the PPND is to attain high quality of life for the people of Kenya by managing population growth to a level that can be sustained with available resources. The principal objective of the policy is to provide a framework that will guide national population programs and activities until The policy is aligned with Kenya s international and national population and development agenda, including the 2010 Kenya constitution and the goals of Vision It includes key policy measures that address critical population management issues, such as unmet need for family planning, high fertility and rapid population growth, a youthful age structure, poverty reduction, gender equality, environmental sustainability, and more. The PPND also addresses how to engage and serve marginalized populations with special needs, such as young people and people living with disabilities. The PPND emphasizes the need for human and technical, financial and capital resources to ensure the policy strategies are achieved within the policy timeframe. Successful implementation of the PPND will result in a well-managed population with high quality of life thereby contributing to the attainment of Vision 2030 goals. Other expected results include: Reduced fertility and mortality rates A substantial increase in resources available for national development Enhanced youth skill development and utilization Environmental sustainability These achievements will also free funds for investment in other development programs and projects for accelerated socio-economic development. EARHN_Newsletter 23

26 Advocacy Ten years down the road; Accomplishments of the Rwandan Parliamentarians Network on Population and Development Mr. Jean Marie Mbonyintwali Rwanda Parliament The Rwandan Parliamentarians Network on Population and Development (RPRPD) was created in January In preparation for the celebration of its 10th anniversary, RPRPD welcomes the fact that its family planning advocacy efforts have yielded results as the number of Rwandan couples using family planning methods is increasing rapidly. The primary objective of the Network was to work towards implementation the recommendations of the Program of Action of the United Nations International Conference on Population and Development (ICPD) held in Cairo, Egypt in September 1994 which was mainly focused on the impact of rapid population growth on economic development and welfare of the world s population. This objective will be achieved not only by taking into account the number of the population but also taking into account the universal access to reproductive health services for all those who need it. As Rwanda rebuilt itself after the 1994 genocide, authorities and the population in general were of the view that the imbalance between population growth and economic growth represents a hindrance to sustainable development. 24 EARHN_Newsletter

27 Advocacy As elected representatives, Members of Parliament committed themselves to taking the lead in raising awareness of the issue by creating RPRPD. With nearly 10 years of its existence, RPRPD currently accounts 80 members including Deputies and Senators whose aim is to ensure the legal framework of population, family planning and reproductive health issues. Over the past 10 years, Rwanda has made tremendous progress towards promoting universal access to reproductive health services for all through good governance and political will. Since 2003 Rwanda has particularly put in place: Various policies: Population Policy (2003), Reproductive Health Policy (2003); Resources Assessment for Population Impact on Development (2005 RAPID Model); Family Planning Policy and its Implementation Strategies (2006); In 2007, the Government declared family planning a national development priority; In 2010, family planning-oriented reproductive health services were decentralized to the lowest level of villages through Community Health Workers (CHWs) in each village of the country. All these achievements would not have been possible without collaborative efforts of RPRPD and other various institutions including line ministries, public institutions, NGOs and development partners. The number of people having access to family planning programs has increased from 4% in 2000 to 10% in 2005 and to 27% and 45% in 2007 and 2010 respectively. The average number of births per Rwandan woman decreased from 6.1 in 2005 to 5.5 in 2007 and to 4.6 in This is a clear indication that Rwanda will achieve its vision especially because one of the major impediments to development is the rapid population growth which far exceeds economic growth. Universal access to reproductive health services for all is the foundation for other fundamental rights including access to sufficient food, which is possible only for small size families. At the same time this provides the opportunity to invest more in education, have access to health care, get clothing and proper housing and have time to go about other business especially for women because they get time to carry out their household activities and hence contribute to self-development and national development. The survey also showed that focusing efforts on family planning programs is the best way to scale up public health and achieve sustainable development. As shown in the 7 year Government Program ( ), Rwanda s objective is to ensure that 90% of the married couples use modern contraceptive methods and that the GDP per capita increases from USD 560 to 1050 in The role of Parliamentarians in making this a reality is very crucial and RPRPD will continue to advocate for the universal access to reproductive health services in this new coming decade! Through Parliamentary triple role of Representation, legislation and adopting the national budget, RPRPD will continue to ensure that Family Planning is a basic right for all Rwandans to be able to properly manage one s family Size and advocate for the scaling up of Family Planning as a collective responsibility. EARHN_Newsletter 25

28 Advocacy Rwanda s Hon. Dr. Ntawukiliryayo honoured for pivotal role reducing maternal mortality Mr. Jean Marie Mbonyintwali Rwanda Parliament On December 6, 2012, the President of the Senate, Dr. Ntawukuliryayo Jean Damascène received UNFPA Population Award in recognition of his outstanding commitment to population issues. Why awarding Dr. JD Ntawukuliryayo? H.E Dr. Jean Damascene Ntawukuliryayo deserves the Population award because of the critical role he played to improve the wellbeing of Rwandan population especially in the area of reproductive health and right. He served as the President of the Rwandan Parliamentarians Network on Population and Development (RPRPD) which is a network that gathers parliamentarians with a prime objective to advocate on population issues. As a President of this Network, Dr. Ntawukuliryayo has organized several outreach activities where he strongly advocated and sensitized people on family planning, HIV/AIDs, women empowerment, gender equality and human rights. Among the sensitized people he reached out to religious leaders, students and youth representatives. He played a leadership role by bringing other parliamentarians on board to advocate and sensitize Rwandans especially youngsters to live a better life free of HIV/AIDS, where family planning prevails and where reproductive health, gender equality and women dignity are observed. When he was the Minister of Health (2004 to 2008), Dr. Ntawukuliryayo played a big role in Maternal Health, especially in positioning Family Planning as a strategy to reduce maternal mortality. He has been outspoken against religious leaders opposition to family planning and to condom use for HIV prevention, but he acknowledges the difficultly in having them change their stance: For me, we can t change our Bishops. We need to change our people to understand. We have to empower people to understand the importance of family planning policy. (Ntawukuliryayo, March 27, 2008). As a key partner of UNFPA, Dr. Ntawukuliryayo supported without limit among many initiatives the 7 billion people campaign. The campaign was organized with the aim of sensitizing Rwandan people on the importance of Family planning. He addressed UNFPA leaders in the Africa regional consultative meeting that took place early this year where Rwanda was commended for its inspirational leadership that allows achievement of impact. These reasons are just a few among many related to his Population Award. The award was handed out to Hon. Dr. Ntawukuliryayo by the UN Resident Coordinator during the ceremony on release of State of World Population 2012 Report which was held at Umubano Hotel on December 6, The ceremony was attended by other 26 EARHN_Newsletter

29 Advocacy various Government Officials and Development Partners. Who is Dr. Jean- Damascene Ntawukuliryayo Dr. Jean Damascene Ntawukuliryayo is the President of the senate of Rwanda. He occupied various high positions in the Government of Rwanda: Before joining the Parliament, he served as the Minister of Health He also served as the Minister of infrastructure Minister of State in Charge of Higher Education and Scientific Research Vice Rector in Charge of Administration and Finance at the National University of Rwanda Senior Lecturer at the National University of Rwanda He is a Pharmacist by profession and holds a PhD in Pharmacy RPRPD wishes him continued success Budget support Budget Support (BS) is a challenge for Reproductive Health (RH) funding. This is especially so regarding developing/recipient countries in which sexual reproductive health (SRH) may not a priority. SRH may not be a priority in many countries for various reasons. Some of these reasons could simply be that the topic is sensitive or regarded as controversial or as simply foreign in origin. But the other reasons could be that the RH communities have not yet explained well enough the linkages between SRH, women's health, poverty eradication and development in general. Bringing these linkages well enough to be undertook at various levels including for policy makers, Members of Parliament, cultural institutions, Civil Society Organizations (CSOs) and communities themselves is a major task and in a way we have not yet gotten many examples of success in this regard. So the first premise for this debate must take into account that we should not just blame either government or civil society organizations or even donors that they have not done their job. The advocacy work required to change the mindset of all stakeholders, if we are to make a difference, is for all of us and must be continuous. For example, when governments are negotiating the Budget Support with donors, both governments and donors must be made aware that it is in the interest of everybody that CSOs must be invited to be on the table to play their role. In addition, governments must be made aware that subject matter specialists and experts must be on the table as well to ensure that the right priorities of the sector are the ones emphasized e.g. SRH to be included as a clear Budget Line in the Health Sector. Budget Support needs also to know that in some cases we need to have Sector Budget Support (SBS) as opposed to General Budget Support (GBS) where this would be more useful. It is also important that subject matter specialists/experts do not insist on separate or parallel mechanisms for integration of e.g. SRH in Budget Support, but rather should take advantage of existing mechanisms used by government, especially Ministry of Finance, when incorporating their concerns. This requires that they understand and have capacity to engage economists who normally are the ones spearheading most negotiations with donors. So they need to be well equipped with skills to do this. Similarly, in order for civil society organizations and other stakeholders to meaningfully engage government, they need to have the necessary capacity and skills. This often requires that donors should also play a role in capacitating these CSOs and other stakeholders which means funding them for this. If all this is done, then we may find that BS is not always putting funding for RH at a disadvantage. In fact since Budget Support leads to better national ownership, and then this would be an opportunity for various stakeholders to have their genuine imprint in the process. This could actually result in more resources for RH. Diana Nambatya Nsubuga Programme Officer, Partners in Population and Development Africa Regional Office (PPD ARO) EARHN_Newsletter 27

30 Services Responding to Sexual reproductive health services for young people in Rwanda Mr. Jean Marie Mbonyintwali Rwanda Parliament Student activists in Youth Reproductive Health explained to their counterparts the different methods of Family Planning. Youth Reproductive Health and rights has become a great concern among Rwandans. Data from Rwanda Demographic and Health Survey (RDHS 2010) estimated the number of adolescent pregnancies at 5%. In response to this challenge the Rwanda Ministry of Health in collaboration with its partners has developed the First Youth Sexual and Reproductive Health Policy and Strategies. As over 69 percent of the population is comprised of youth, the issue of their sexuality is very important, especially when Rwanda is preoccupied with curbing the population growth rate. Any program which is not youth centered is a white elephant program and in that situation country cannot achieve the Millennium Development Goals. Rwanda has recently done what no other country has done to date-increased its contraceptive prevalence (CPR) more than 10-fold in less than a decade. In the 2000 DHS, CPR was at the very poor rate of 4%, this rate has transited to 10% in 2005 then reached 45% in These changes are among of married women. The issue of adolescent teenage pregnancies cannot be ignored and, therefore, it is very important to target the problems that address sexuality needs among Rwanda s youth so that the country can be sure that the momentum will be going on. Integrating sexual reproductive health services for young people by creating youth friendly health services and developing national norms and standards that offer quality services appropriate to young people s needs, would increase reproductive health awareness among the youth. Although some development partners like UNFPA and PSI Rwanda collaborate with the Rwanda Biomedical Center (RBC) and districts to develop youth friendly health services, the way still very long. Youth Reproductive 28 EARHN_Newsletter

31 Services health has to be everyone concerns as President Paul Kagame said while addressing his keynote remark during the London Family Planning Summit held on July 11th, He said: [ ]families are planned in a waythat meets the needs of our people. Women, men and even adolescents should be involved in that. [ ] Family Planning and Reproductive Health is a responsibility that families and country cannot avoid or just delegate. The high political will is already there! Partners have to plan training people to receive and counsel young people. The youth reproductive health commodities should be available for them to make a choice without worrying about bumping into a relative who will probably pass the scenario on to their parents about a condom and birth control purchase. Once done, it will be a good breakthrough for the youth. The youth reproductive health programs to succeed have to include other youth-friendly services such as: employment promotion, income generating activities, sports, and culture and environment protection services so that young people should be the leverage of country sustainable development. The continued establishment of reproductive health services that are youth-friendly to reach as young people as possible, Rwanda with venture into a path that will see the creation of a generation that is informed about their reproductive health rights. This would, consequently, change their reproductive health views and curb the country high population growth. Rwanda is now the most densely populated sub-saharan country with the total population of more than 10.5 million people on the area of square kilometers with a population growth rate of 2.6%, the country come at the 33rd rank in the world population density with 416 inhab/km². The repressive consequences of population growth on the environment, the misuse of natural resources put not only the country in the alarm situation and the region as a whole. Therefor Regional partnership is needed to tackle the everlasting challenges of youth in regards of sexual reproductive health and rights. The triple tragedy of fistula The Scourge Destroying Women s Lives Ms. Grace Ikirimat O. Senior National Programme Officer, Policy and Planning Department - Population Secretariat, Uganda My recent visit to the anti-natal care-outpatient Clinic in Mulago National Referral Hospital was so revealing. I purposely wanted to know more about fistula and its management. Over 25 women (some where fistula patients) sat on a queue waiting to EARHN_Newsletter 29

32 Services see the gynecologist. I picked a conversation with Sarah Amongin; a 21-year-old fistula patient from Pallisa district. Amongin was here to seek treatment for a fistula injury she sustained in This was my first pregnancy, I labored for two days and when I was rushed to Mbale hospital I had a caesarean section/ birth, unfortunately the baby was already dead and they also removed my uterus which was completely ruptured, she emotionally told me with a haggard look in her eyes. I was told that I can never be able to bear children anymore. It was after they removed the catheter that I realized that I was leaking urine and feces. Sarah suffered a triple tragedy; she lost her baby, her dignity, and also her economic independence. She had to leave her job as a shop attendant since it was so inconveniencing to be around people. Sarah s husband could not bear the smell any-more; he abandoned her and married another wife. Though fistula has been eradicated in coun- 30 EARHN_Newsletter

33 Services In Uganda, the maternal mortality ratio is as high as 438 per 100,000 live births, and a woman has a one in 18 lifetime risk of dying from complications from childbirth tries where quality obstetric care is available, in Uganda it is an all-too-common result of the health risks of childbirth. Obstetric fistula is a condition that very few people know about. A fistula is an abnormal hole, after prolonged and obstructed labor, between a woman s birth canal and bladder and/or rectum that causes her to leak urine and/or faeces uncontrollably. Most fistulas are caused by childbirth lasting more than 24 hours. The pressure of the baby s head can injure the tissue in the birth canal creating a hole between the birth canal and the bladder or rectum. The hole in the birth canal causes continuous and uncontrollable leakage of urine, faeces or both. Fistula can also be caused by violent rape or other forms of sexual violence. The woman is left with chronic incontinence and, in most cases, a stillborn baby. The smell of leaking urine or feces or both is constant and humiliating, and survivors often face social seclusion and abandonment. Left untreated, fistula can lead to chronic medical problems, such as ulcers, kidney disease, and nerve damage in the legs thus disability. Worldwide, 3.5 million women are reported to be living with a fistula condition. In sub- Saharan Africa alone, between 30,000 and 130,000 of women giving birth develop fistula each year (UNFPA). In Uganda, the maternal mortality ratio is as high as 435 per 100,000 live births, and a woman has a one in 18 lifetime risk of dying from complications from childbirth. In comparison, this figure falls to one in 2,400 in Europe. The United Nations Population Fund (UNFPA) estimates that for each woman who dies in childbirth, more who survive are seriously impaired and disabled from childbirth-related complications, such as fistula, in less-developed countries. Statistics from the World Health Organisation also show that obstructed labour occurs in an estimated five percent of live births and accounts for 8 percent of maternal deaths worldwide. It is estimated that more than 2 million young women live with untreated fistula in sub-saharan Africa and Asia. It should be noted that the available statistics may be lower than the real numbers since the affected women tend to live in fear, stigmatization, silence and isolation. With access to skilled maternal care, such labour can be predicted, identified and treated. The persistence of fistula is an indication that health social systems are failing to meet the needs of women during pregnancy and delivery. There are several reasons why fistula remains a threat to so many women worldwide. The first is simply a lack of quality obstetric EARHN_Newsletter 31

34 Services care. The vast majority of these women live in resource-poor countries like Uganda, and tragically, nearly all of these injuries could have been avoided if timely and competent obstetric care was available, accessible, and affordable. In Uganda, where about 2.6 percent of women of reproductive age have experienced obstetric fistula (every one in 40 women); with more women in rural areas reporting fistula as compared to those in urban areas (UBOS, 2006); this means about 200,000 women are living with the condition with about 1,900 new cases annually, yet less than 3 percent have sought care. Whereas an accumulated 4,337 fistula cases that have reported to a health facility are still waiting for repairs in Uganda, only 1,500 fistula patients get a surgery every year. It is worth noting that only 59 percent of women in Uganda give birth with assistance of a trained health worker, compared to over 99 percent of women in the U.S. who have a trained attendant present. Without maternal care, when emergencies develop, women suffer severe consequences. Adolescent girls are particularly at risk for obstetric fistula and face a risk of maternal death two to five times greater than that faced by women in their twenties. There is evidence that delaying pregnancy until after adolescence may reduce the risk of obstructed labour and obstetric fistula. Sixteen million adolescent girls give birth each year, with almost 95 percent of those births occurring in developing countries. Ahmed Obaid (former Executive Director, UNFPA) once remarked Obstetric fistula is a double sorrow because women lose their babies and also their dignity. These women live in shame, isolation and embarrassment that they are unable to control their bodily functions, they are constantly soiled, wet, and they smell. Their pain and humiliation may further be complicated by recurring infections, infertility, and damage to their vaginal tissue that makes sexual activity impossible and may lead to paralysis. These women are often rejected by their husbands and excluded by their families and communities and usually live in abject poverty. In addition to causing physical torment and social exclusion, fistula has a third devastating effect; economic disaster. Fistula victims are blamed by society for their condition, and, unable to earn a living, fall deeper into poverty and hopelessness. Many of these women are ignorant that the condition can be repaired, and their shame is compounded by the common misconception that fistula is caused by witchcraft. Marginalized and shunned by society, the voices of women with fistula are rarely heard and less reported. The victims live a life of depression, because they believe fistula is incurable. In a discussion with Honorable Sylvia Ssenabulya Nabidde - Woman Member of Parliament for Mityana (also Chairperson Network of African Women Ministers and Parliamentarians- Uganda Chapter and also Champion for Population and Development), she recognized that fistula is a silent predicament that develops because of either a delay in deciding to seek care caused by community or sociocultural factors, by being unaware of the need for care, or warning signs of problems; a delay in reaching a health-care facility, perhaps because of transport problems, distance or cost; and a delay in receiving adequate care at the facility. But also lack of or inadequate knowledge about facilities for fistula repair in this Uganda. Although surgical repair can cure most cases of obstetric fistula, poverty, social stigmatization, widespread misconceptions about the condition, and inadequate access to surgical facilities make treatment a nightmare for most of these women. As parliament, we are now advocating and engaging more for interventions to prevent and manage maternal morbidity. Prevention is critical to fistula elimination. Women who have the problem need surgical treatment then post-operative care, Honorable Sylvia Ssenabulya stressed. In Uganda, most of the hospitals are unable to repair fistulas because of a lack of surgeons trained in the specialized procedures required. Most fistula victims tend to go from one hospital to another without finding adequate care or even resort to using local traditional medicines and often end up losing hope and get re- 32 EARHN_Newsletter

35 Services signed to their fate. In a country with a population of nearly 34 million, only 20 Hospitals and about 40 doctors offer fistula treatment. Hon Sylvia Ssenabulya Nabidde stresses the need to adequately equip and staff designated fistula treatment hospitals with what is required to perform these operations. As government there is need to prioritize, focus and take on fistula prevention and treatment seriously. Most of the fistula operations conducted are mainly conducted in private hospitals such as Kitovu Hospital in Masaka district and those that are performed in government hospitals are mainly performed by visiting surgeons and this means that they are irregular and sometimes not affordable She says. The African Women Ministers and Parliamentarians Network in 2008 observed that cases of obstetric fistula were on the increase due to inadequate political and financial support. The then Chairperson of the network in Uganda, also former Woman Member of Parliament- Kayunga district, Honorable Sarah Nyombi, once expressed concern about fistula treatment that is only available during annual or biannual missions of visiting surgical teams. She also articulates that more needs to be done to upgrade health facilities, provide equipment and supplies and team-based training of medical personnel. The doctor population ratio of one to over 24,000 is unacceptably high (WHO). However, it is not only lack of quality obstetric care that leads to fistula. Other risk factors for fistula have socio-cultural roots. Ugandan communities are still dominated by cultures and norms (social and religious) that increase the risk of obstetric fistula. In Uganda, societies are patriarchal and women usually lack the social power to make choices for themselves about health care and pregnancy. The husband is the one who decides important family matters; even when it is about a woman s own health. Birthing decisions are often made by the husband or mother-in-law, who may support traditional practices. Socio-cultural beliefs and practices that glorify women who endure labour pains and deliver at home as strong, is a contributing factor. Therefore, EARHN_Newsletter 33

36 Services lack of empowerment and autonomy affects the time when health care is sought, because women need permission from their husbands, or their in-laws to go to a health facility, which delays emergency care. Female genital mutilation is one of the harmful traditional practices that increase the risk of fistula. In Uganda, the Sabiny and Pokot are the tribes that practice female genital mutilation although recently outlawed in Uganda. In its different forms, female genital mutilation results in impaired female genital tracts which ultimately endanger the health of the mother including fistula. Other risk factors for fistula are teenage pregnancy (seventy percent of teenagers in Uganda give birth by age 19); illiteracy; poverty; and living in a conflict or post -conflict zone. While about 90 percent of pregnant women make at least one prenatal visit, only 59 percent births are assisted by a skilled health worker in Uganda, Women still face multiple barriers in accessing adequate care during delivery, including life-saving caesarean sections. Fistula is recognised as a maternal health problem but inadequate skilled health workers as well as lack of equipment, medication, and other supplies is a constraint in providing treatment to fistula victims. With 25 percent of Ugandans living in poverty, many women cannot afford the costs of an emergency caesarean section. Even where fistula repair services are provided, a fistula repair is financially out of reach for many Ugandans: the surgery averages 150 U.S dollars, plus more for transport and upkeep since the repair is not a one-time treatment. The Ministry of Health identifies three delays in accessing maternal services: at home, to the health facility, and at the health facility. A research conducted by Engender Health on fistula victims reveals that two-thirds of the women faced multiple delays in reaching a facility with the necessary services to enable them to deliver safely. A famous African proverb says it all A woman in labour should not see the sun rise twice. In 2007, the UN General Assembly adopted a resolution supporting efforts to eradicate obstetric fistula. In the Sixty-fifth session on the Advancement of Women, the General Assembly resolution 63/158 highlighted that obstetric fistula is a devastating childbirth injury that leaves women incontinent and often isolated from their communities. It is a stark example of continued poor maternal and reproductive health services and an indication of high levels of maternal death and disability. This called for efforts at the international, regional and national levels, including by the United Nations system, to end obstetric fistula. It recommended that efforts to end obstetric fistula be intensified as part of support for the achievement of Millennium Development Goal 5, on improving maternal health, including the strengthening of health-care systems and increasing the levels and predictability of funding. Fistula in Uganda has come to light in recent years because of the efforts of partners in Reproductive Health especially the United Nations Population Fund, Population Secretariat and Ministry of Health, Engender Health and others working to raise awareness. Reducing maternal morbidity and mortality is a priority of the government, focused on addressing maternity-related care, antenatal and postpartum care, basic and emergency obstetric care, sexual and reproductive health needs of adolescents, and health information and education. Improving access to timely obstetric care is the most important first step that can be taken to prevent fistula from occurring. Therefore among these priorities are plans to: Increase skilled assistance during delivery, lower the fertility rate, provide adolescents with appropriate, accessible, and affordable health services; reduce maternal mortality; increase modern contraceptive use; and upgrade health centers. Education is another key step in the effort to end fistula. Scientific studies conducted on fistula show that socioeconomic characteristics of women such as maternal education, socioeconomic status, and place of residence have impact on the risk of fistula. The fact is that education directly improves an individual s 34 EARHN_Newsletter

37 Services knowledge and ability to process information, regarding healthy pregnancy behaviors. And yet the economic independence of a woman has an effect on her ability to make decision about her health. Many women and communities are not aware of the causes of fistula and that it is a curable medical condition. Over 70 percent of women can be cured with one operation and can resume an active and fulfilling life. Ms. Demita Nabyobo, the medical Coordinator at Reproductive-Health Uganda, stated More fistula information through intensive media campaigns should be provided to rural communities, including where treatment can be sought Promoting the Village Health Teams in Uganda is crucial since they are first health contact in communities. VHTs provide basic health information to households such as maternal care including ensuring women know about fistula prevention, identify fistula victims and guide them where to go for treatment. The VHT concept is innovative and simple yet communities are able to overcome barriers to healthcare access based solely on their motivation to improve the lives of their people. However, for the few fistula women who get the opportunity for a new life, it is just a drop in the ocean. As Uganda strives to reduce maternal morbidity and mortality by three quarters, prevention, treatment and rehabilitation of fistula victims should be top priority. Expressions from fistula victims, such as, I am not dead, but I am not living are so daunting. With more education and access to quality obstetric treatment, we can help fistula victims emerge from the shadows and live in dignity once more. We can stamp out this devastating yet completely preventable condition. EARHN_Newsletter 35

38 MDGs and other related topics Uganda s progress on MDG 5: A case of promoting Safe Motherhood in Uganda Ms. Luwaga Liliane Ministry of Health, Uganda Women account for more than half of the population of the Uganda. They play a vital role in the survival and development of our society. They have proved to be the very fabric that binds communities together everywhere. However, in spite of their invaluable contribution, women, at every stage of their lives, bear the highest burden of morbidity and mortality from the process of procreation and replenishing the population of this country. They also bear a burden due to their role as key primary producers of health and other socioeconomic, cultural and environmental pressures. The Millennium Development Goal 5 is to reduce maternal mortality ratio by three quarters between 1990 and To achieve this there should be at least 5.5% annual reduction rate. However the maternal mortality has not changed in this country for various factors during the period between 1990 and 2011 (see figure 1 below). According to the recent UDHS (2011) results, the maternal mortality in Uganda is 438 per live births. If the trend does not improve Uganda is not likely to achieve the MDG 5 target. The causes of maternal mortality range from direct to indirect. The direct causes include; excessive bleeding, obstructed labour; infection; high blood pressure, and unsafe abortion. All these are preventable if detected early and managed appropriately. The fertility rate is also high at 6.2 see figure 2 below. On average a Ugandan woman gives birth to 6.2 children as evidenced 36 EARHN_Newsletter

39 MDGs and other related topics in the Uganda Health and Demographic Survey of And only 30% of the population years use family planning. These as noted by His Excellency the President of Uganda these are too many children per woman. Fewer children would be better for the sake of her health and family welfare. The fertility rate is also high at 6.2 see figure 2 below. On average a Ugandan woman gives birth to 6.2 children as evidenced in the Uganda Health and Demographic Survey of And only 30% of Figure 1: Maternal death trend Figure 2: Fertility by Region The balance of over shs.43 billion will be financed through a supplementary budget after the Minister of Health together with Public Service submit to Ministry of Finance an implementation plan with costs for recruitment within one month of budget passing. Source: UDHS (2011) the population years use family planning. These as noted by His Excellency the President of Uganda these are too many children per woman. Fewer children would be better for the sake of her health and family welfare. EARHN_Newsletter 37

40 MDGs and other related topics CURRENT STATUS OF TARGETS FOR MDG 5a: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio The low health status of women resulting from a wide range of factors including gender inequality as well as socioeconomic, legal, political, environmental and other factors related to health systems. For this reason, women s health concerns cannot be addressed by the health sector alone. Addressing the concerns will require a comprehensive and multisectoral approach involving a broad range of key actors. Effective partnerships can contribute to addressing the problem of women s health. There are several ongoing initiatives being implemented designed to improve women and newborn health through partnerships with governments, bilateral and multilateral agencies, civil society and the private sector. Saving the Mothers giving life project being implemented in the district of Kyenjojo, Kamwenge, Kibaale and Kabarole is a typical example of such partnerships. This project has demonstrated that with additional resources better outcomes are ensured. The Village Health Teams initiative is also key in ensuring that mothers are registered, monitored and supported to adhere to the recommended practices that promote Safe Motherhood. The Government of Uganda has committed to recruit the recommended number of health workers as per the approved staffing norms at Health Centre III and IV across the country. This level of healthcare is the first point of maternal health services delivery nearer to the people and essential for the management of safe pregnancies. This will be achieved with a provision of additional shs 49.5billion (approx US $19.8 billion) to the sector. With this allocation, Government will recruit 19 health workers-all cadres at each Health Centre III and 49 at Health Centre IV in the financial year 2012/2013 with immediate budgetary provision of shs. 6.5 billion (Approx US $2.6 million). The balance of over shs.43 billion will be financed through a supplementary budget after the Minister of Health together with Public Service submit to Ministry of Finance an implementation plan with costs for recruitment within one month of budget passing. If this is fully met it will increase the health sector budget to about 8% of the national budget. In addition, the Government also is taking action to double the number of Medical Doctors at every Health In Centre IV and to increase their salary from shs 1.2 million (Approx US $480) to 2.5M (US $1,000) per month to improve recruitment and retention in rural, hard-to-serve areas across the country. Annually Uganda commemorates the Safe Motherhood day on 17th October. This provides an opportunity to reflect on the achievements made in addressing the health status of women and newborns in Uganda, consolidating the efforts, setting new targets and identifying solutions to address the prevailing problems and challenges. The theme for Safe Motherhood Day this year was Zero tolerance to maternal and newborn deaths: Play your part. The theme was adopted in recognition of the urgent need for collective and multisectoral actions for more coherent political and institutional support to improve maternal and child health. The Guest of Honor was the Rt Hon Deputy Speaker of Parliament of Uganda who made a commitment to ensure Zero Tolerance to maternal and newborn deaths. He urged intensification of partnership building to empower women to have control over their own health; to have proper education and lead more fulfilling lives; to be free from violence and its physical and mental health impacts; and to take part in decision-making about all issues that affect their health and that of their families. The Ministry of Health remains committed to supporting partnerships and to promote policies and actions to improve women s health throughout the country. 38 EARHN_Newsletter

41 MDGs and other related topics Population growth and climate change Ms. Grace Ikirimat O. Senior National Programme Officer, Policy and Planning Department - Population Secretariat, Uganda he development of a Climate Change Policy by Government of Uganda confirms the urgency and pressure to domesticate the Kyoto protocol and deliberately and systematically address and mitigate the effects of climate change that are taking a toll on the country s development efforts. However, tackling climate change requires new, innovative solutions and ambitious policies. It s important to note outright that dealing with climate change is not simply an issue of CO2 emission reduction but a comprehensive challenge involving political, economic, social, cultural and ecological concern and therefore the population concern fits right into the jigsaw puzzle. One key factor in addressing climate change is population: how many they are, how old they are, where they live and how they live, what are their demands, consumption levels among others. It is worth noting that population and climate change are interweaved, however, the population issue has remained a blind spot in discussions of how to mitigate climate change and slow down global warming by policy makers. Recent studies have linked population growth with emissions and the effect of climate change to the population. Uganda has one of the highest population growth rates in the world today (3.2 percent per annum) mainly caused by high fertility rates of about 6 children per woman of reproductive age. In comparison, over the period 1980 to 2010, the world population has increased by 30 percent, Sub Saharan Africa population by 66 percent, Eastern African population by 68 percent and Uganda population has increased by 89 percent. This kind of population growth is said to have made a substantial contribution to emissions growth globally of between 40 per cent and 60 percent (2009 State of World Population report). Much as the government of Uganda acknowledges that the rapid population growth rate as a result of persistent high fertility rate over the last 4 decades, it is a hindrance to achievement of development goals, and population also aggravates existing problems over access to water, land, food and other resources. Of course, EARHN_Newsletter 39

42 MDGs and other related topics it is principally much easier to talk about how areas of high population growth will be impacted by climate change, rather than how population growth itself is a cause of climate change and other environmental problems, as Attenborough argues. The increasing numbers of people on the planet and their actions are impacting our environment and causing climate change. It is projected that if the global population would remain 8 billion by the year 2050 instead of a little more than 9 billion according to mediumgrowth scenario, it might result in 1 billion to 2 billion fewer tons of carbon emissions (United Nations). Meanwhile, studies show that family planning programs are more efficient in helping cut emissions, as indicated by Thomas Wire from London School of Economics where every 7 dollars spent on family planning can reduce CO2 emissions by more than one tonne. It has been argued by researchers that a holistic approach that integrates policy on population and development, a strategy promoting sustainable development of population, resources and environment should serve as a model for integrating population programs into the framework of climate change adaptation. A broad thought that a larger population leads to greater emissions and the per capita carbon dioxide emissions average varies hugely from nation to nation holds but the general trend is that, as the population has grown, emissions have increased in proportion. The world population currently stands at around 7 billion, up from 1 billion in 1830, and the United Nations projects that 9 billion people will share the Earth and generate the associated emissions by So on the face of it, having fewer people is one reasonable approach to mitigating climate change. Reducing the population growth rate in a country like Uganda, for example, where the population size is predicted to triple by 2050 would not have a dramatic effect on emissions right now because the population momentum is already created, a strong reason why factoring population in climate strategies at the very start is critical. The population has increased from 5 million in 1969 to the current projected population of 34 million, thus evidence that those numbers are ecologically unsustainable. Reducing unintended births is argued as a 40 EARHN_Newsletter

43 MDGs and other related topics possible useful strategy when tackling climate change. In Uganda, 38 percent of pregnancies are unintended. Instead, ensuring adequate reproductive health services and contraception supplies to communities will enhance and promote having children by choice but not by chance. Increasing the awareness and demand for family planning services is also key in facilitating their acceptability and use. It is increasingly evident that in Uganda, many people are beginning to desire smaller families, therefore reducing unwanted or unintended fertility. The need is created but the question is ; are they able to fulfill their demands?. Of course reducing population growth helps, though it is not the one single magic bullet for climate change mitigation. The population of Uganda is estimated to grow to over 100 million by 2050 and will continue to grow for the next over 40 years. This is because the momentum is already built. Population policies could have an immediate effect if they are built into our thinking on climate change here and now. Uganda needs to start taking notice of population effects today. Population policy can have immediate impacts on lots of things, but effects on total population size aren't significant for generations. The population size visa vis consumption levels matter to emissions levels and also urbanization. Statistical analyses of historical data suggest that population growth has been one driver of emissions growth over the past several decades and that urbanization, aging, and changes in household size can also affect energy use and emissions. It is estimated that between 1990 and 2005, a total of 1,329,550 hectares (27 percent of original forest cover) was lost in Uganda, with some districts losing all of its forest cover. It is estimated that every year, Uganda loses 1.8 percent forest cover and this is largely attributed to increasing demand for agricultural land fuel wood by the rapidly growing population. The habitat loss has affected the ecosystems such as forests, wetlands, rangelands and catchments and has resulted into loss of biodiversity. The proportion of the population dependent on wood fuel in Uganda is over 90 percent, however, even if this dependence on fuel wood declined, the consumption is likely to increase to about 39.5 million tonnes by 2037 with a continued high fertility. The size of the population and its growth rates will always greatly impact on the environment and for this reason; population policy should be a critical feature in climate change adaptation strategies. Slowing population growth could provide per cent of emission reductions needed to avoid dangerous climate change. Rising consumption today far outstrips the rising population and this is a threat to the planet. It is time to include the population factor in the climate change debate that is more transparent if sustainability is to be achieved. Based on assumptions used by the United Nations Population Division, the urban population in Uganda is projected to increase nearly six fold by 2037 with high fertility continued, rising from 3.7 million in 2007 to 21.9 million in This implies that Uganda will require 4.3 million new urban housing units between 2007 and As empowering women, education of the girls beyond primary education is priority to lowering fertility and changing reproductive behaviours, it is critical that countries (Uganda) move to satisfying current unmet need for family planning among the 34.3 percent of married women who want to space or limit their births but are not using contraceptives or else, it will not be on track to achieve a fertility transition in a generation. Also essential is meeting the reproductive health needs and demands of young people is key. The bottom line is putting the population at the centre of addressing climate change will give direction and solutions to tackling climate change and achieve sustainable development on this earth. Everyone has a contribution to make! EARHN_Newsletter 41

44 SUPPORTED BY Federal Democratic Republic of Ethiopia Ministry of Health P.O. Box 1234, Addis Ababa, Ethiopia Statistics House, 9 Colville Street P.O. Box 2666, Kampala - Uganda Tel: , Fax: aro@ppdafrica.org