REALISING RIGHTS: IMPROVING SEXUAL AND REPRODUCTIVE HEALTH FOR POOR AND VULNERABLE POPULATIONS

RESEARCH PROGRAMME CONSORTIUM

End of inception phase report for DfID

1st September 2005 - 28th February 2006

Consortium partners:

African Population and Health Research Center, P O Box 10787, Nairobi, Kenya

BRAC, 75 Mohakhali, Dhaka 1212, Bangladesh

EngenderHealth, 440 Ninth Avenue, 13th Floor, New York, NY 10001, USA

INDEPTH Network, P O Box KD 213, Kanda, Accra, Ghana

London School of Hygiene and Tropical Medicine, 49-51, Bedford Square, London WC1B 3DP

Institute of Development Studies, University of Sussex, Brighton, BN1 9RE (lead institution)

Director

Dr Hilary Standing, IDS

Project Co-ordinator

Jas Vaghadia

1. Introduction

The Realising Rights Consortium is a new partnership concerned with the more neglected or less policy visible areas of Sexual and Reproductive Health (SRH) such as abortion, cancers, fistula, STIs and RTIs and SRH related violence against women, and on demographic change and contraceptive use and access. The focus is low income countries in sub-Saharan Africa and South Asia. The consortium brings together organisations with strong competence in research, policy influence and service delivery. It is highly multi-disciplinary. The long term of aim of the RPC is to strengthen SRH and rights research particularly at national and local level and communicate it to those who can influence policies, programmes and behaviour. The RPC has three themes:

  • Improving the evidence base on the high levels of SRH morbidity and mortality and unmet needs
  • Finding innovative ways to improve access to existing and new low cost SRH technologies and services by poor women and men
  • Operationalising rights - improving knowledge of the constraints to the translation of SRH rights into reality, and building national capacity to put sexual and reproductive health and rights onto the policy agenda

This report describes progress over the last six months in a) meeting our inception phase targets, and b) developing a strategic vision for the work of the RPC.

2. Inception phase outputs and accomplishments

The inception phase had three major aims. The first was to create the internal structures and processes for partnership and communication within the RPC. The second was to carry out further consultations with key stakeholders – both internal and external – on capacity strengthening needs, research priorities and communications strategies. The third was to undertake selected research activities which would produce early outputs and feed into the longer term development of the three research themes. These activities have mainly built upon work that partners were already engaged in.

2.1 Consortium development

A half time project co-ordinator, Jas Vaghadia, was appointed in September 05. She has focused her efforts on developing internal processes for financial management and budget and time/milestone tracking and getting to know partners. She has also begun setting up databases of contacts and resources. The logo and website were designed and launched in January 2006. The website has a restricted password page for partners to use. There are no plans at present to develop a more complex internal communications structure, given the modest size of the consortium, but to encourage the informal modes of communication (e.g. through Skype) which are already developing. The Director visited partners in Nairobi, Dhaka, New York and London.

The Consortium Advisory group has been set up. It consists of half internal and half external members. We are still looking for someone with expertise in rights based approaches, preferably from the Africa region. Table 1 (see Annex) shows the current membership.

The first Annual Planning Meeting was held in December 2005 and attended by all partners. The first Consortium Advisory Group Meeting was held at the same time to enable partners and members to meet. Minutes of both of these are available on request.

2.2 Internal and external consultations

Capacity strengthening needs assessments were carried out by partners for presentation at the Planning Meeting. These involved assessments both of needs and of what partners can offer. EngenderHealth also carried out a survey of needs expressed by staff in their regional and country offices. Following this, a framework for consortium capacity strengthening has been drawn up (see section 3.3)

Three partners organised country or regional stakeholder consultation workshops which have provided valuable feedback on research and communications priorities. Participants (30-50 in each) were drawn from government, agencies, civil society, professional groups and research organisations. The first was organised by the INDEPTH Network in Accra. Key messages from this workshop were:

  • The need to reconcile inconsistencies in adolescent reproductive health policy in Ghana to facilitate effective implementation of the policy.
  • The need for much greater recognition of and attention to sexual reproductive health and the rights of individuals to information and services for the attainment of the health related MDGs.
  • The need to tackle ignorance of both the general population and health professionals on policies to related sexual reproductive health and rights.
  • The need to create an enabling environment and to get the different stakeholders working together to put the importance of sexual and reproductive health and rights high on their agenda.

The second was organised by APHRC in Nairobi and drew participation from the wider region. Key issues raised included:

  • Start from local understandings to bridge the gaps between language and meanings in discussions about SRH, including gaps between international and local terminologies, and between service providers and users.
  • Look beyond individuals to collective rights and responsibilities and work to expand or strengthen the rights claims that are socially validated.
  • Work with issues that concern people at the grassroots, such as sexual abuse of children, and the relationship between different forms of sexual behaviour and sexual health
  • Pay attention to non-formal providers, public-private partnerships and social marketing and how to ensure quality within the huge heterogeneity of providers.
  • Work with men on all SRH issues and at all levels, from the individual to the national policy level, providing men with information, understanding and addressing male sexual behaviour, motivations for violence and male demand for services
  • Work with change agents throughout the research process and communicate research effectively in order to achieve change and communicate in an accessible way

The third was organised by BRAC and the School of Public Health, BRAC University in Dhaka. Key SRH issues raised included:

  • Lack of implementation of SRH policy in terms of actual service delivery
  • Lack of research on the private sector’s involvement in SRH
  • The high level of gender based violence
  • Difficulties of talking about rights in a non-enabling environment and being realistic in terms of finding ways of working within the cultural and religious context.
  • The active involvement of the media and how they are using SRH issues to address censorship in Bangladesh was also raised.

Two key outcomes of these workshops were, first, the participants in each have agreed to become regional/national reference groups for the RPC. They will be kept in touch with the programme and brought back together on an annual basis to review and comment on progress. Second, journalists from the national media were present at all workshops and reports appeared in the national press. It is intended to capitalise on these links in developing the RPC communications work.

2.3 Communications strategy

With support from IDS based communications staff and dedicated staff in several partner institutions, the communications strategy is now set up. Main elements are a decentralised approach which recognises and builds on the existing communications capacity in partner organisations; flexibility to shift the focus when necessary to reflect changing audiences and enable new opportunities to be exploited; and selectivity – we will focus on 2-3 key areas at a time. What has emerged from the inception phase, building on both external events and internal capacity, is an initial focus on working with media and working with parliamentarians.

2.4 Research development

Completed inception phase research and related activities consist of analyses of existing primary and secondary data for publication and/or to feed into development of further research proposals; proposal development, and research related outputs such as workshops and development of policy products. Table 2 (see Annex) brings together a summary of all research related activities. Capacity building events are reported on under section 3.3. A number of inception phase studies have produced findings which will inform the development of RPC subthemes on neglected SRH conditions and contraception, on universal access to SRH services and on sexual and reproductive rights. Some selected findings are highlighted here.

Measurement and mapping

A meta-review of ‘reproductive tract infections and sexually transmitted infections of women in Bangladesh’ compiled findings from 6 qualitative studies and 12 quantitative cross-sectional studies on sex workers, rural women and health providers. The qualitative studies found that women did not view RTIs (white discharge) as purely a biomedical problem, but blamed it on the larger stresses in their lives, social economic and financial. Accordingly, treatment was sought from healers, homeopaths and allopathic doctors. However, many of the women perceived no clear difference in symptoms and consequences between RTIs and STIs. Some of the prevalence studies found high STIs among sex workers in brothels and among women living near truck stands as compared to rural women and urban slum women. A study on diagnosis of STIs found that the speculum-based algorithm might be a cheap and effective diagnostic and management tool. Diagnosis and management of cervical STIs is highly compromised due to lack of diagnostic tools and by the low specificity or absence of clinical signs.

Initial analysis of experiences and outcomes of fistula among women in northern Nigeria focused on husbands’ support It was found that only 42% women continue to live with the husband after fistula; 1/3 women have already been divorced/formally separated; only 26% expect to live with the husband after discharge from hospital and a similar proportion expect to rely on him for future support. However, women in love marriages rather than arranged marriages, fare significantly better on some indicators of spousal support. Literate husbands are significantly less likely than illiterate husbands to divorce their wives.

A review of menstrual problems of women in Bangladesh found that menstrual flow and other perceived problems were a major health concern of young women in particular and frequently associated with contraceptive use and sometimes with infertility. Because of taboos and the lack of any public health awareness, it is very difficult for women and men to access open and accurate information.

Analysis of data on the impact and outcomes for women who discontinue oral contraceptives produced the following findings: in 18 developing countries on average 30% of adopters of oral contraception ceased use within 12 months for reasons that implied dissatisfaction with the method. About 60% successfully switched to another method within 3 months, predominantly to injectables (16%) or traditional methods - withdrawal, periodic abstinence – (19%); 14% women became pregnant before adopting another method. A woman’s education was unrelated to discontinuation but strongly predictive of switching. The probability of switching is also strongly related to the overall quality of the family planning programme in each of the 18 countries. The main lesson appears to be that services should focus much more than hitherto on enabling women to successfully switch when they are dissatisfied with their initially selected method.

A study of geographical variation in the use of modern contraception within countries identified approval for family planning methods within the community, the religious composition, and socioeconomic development as important influences on the decision by a woman to use or not to use modern contraceptives. This study confirms findings from other studies that the influence of the community on decision to use modern contraception is important and that uptake can be increased by addressing socio-cultural barriers and by improving access.

DHS data on trends in sexual behaviour among young African women were also analysed. Condom use among single, sexually active African women is increasing at a rate of 14 percentage points per decade. Well over half of condom use is motivated mainly or partly by pregnancy prevention, thus underscoring the common ground between contraceptive use and HIV prevention. Analysis of nationally representative data on adolescents sexual behaviour from Burkina Faso, Ghana, Malawi, and Uganda showed that condom use among single adolescent males and females was less common among the poorest sub-groups. Wealth status was not a strong predictor of having had sex in three of the four countries although in Burkina Faso wealthier males and poor females initiate sexual activity earlier than their counterparts. The lesson from this study is that the association between poverty and risky sexual behaviour among adolescents is not straight-forward and that adolescents in different socioeconomic groups may have different motivations for initiating sexual activity at early ages.

Analysis of reproductive health data from the Navrongo Health Research Centre in northern Ghana demonstrated discrepancy in reported and actual contraceptive use due in part to spousal secrecy about the use of contraception. Clinical encounters showed that women preferred contraceptive methods that can be clandestinely used to prevent reprisals from their husbands. These findings suggest that for women to meet their reproductive preferences, mechanisms need to be established for offsetting the social costs of fertility regulation. For instance, there is need to work with traditional leaders and institutions, including male networks if women’s reproductive health rights are to be met in societies with deeply ingrained male dominance.

Access to services and technologies

A review of ‘Existing Reproductive and Sexual Health Interventions for Young People in South Asia’ found that there are around a hundred and fifty organizations operating programmes focused on adolescent sexual and reproductive health and rights with a wide range of interventions. The main barriers for effective implementation are religious and cultural factors hindering open discussion and communication on sexuality and reproductive health issues, poor gender sensitization and limited access to services and information, particularly for unmarried adolescents.

The government of Bangladesh has recently approved the introduction of emergency contraception pills into the wider national family planning program. A review of ‘Emergency contraception in Bangladesh’ found low levels of knowledge of the technology by both potential users and doctors. In the study sample, there were high levels of use of potentially harmful methods, including drugs from the pharmacy (52%), herbal medicine (58%), insertion of roots and other risky methods (56%) to terminate unwanted pregnancies. Most women would welcome the availability of emergency contraception pills (ECPs) and would be willing to pay Taka 10-15 for each packet of EC to prevent unwanted pregnancy from an episode of unprotected sex. Only 22% of the providers knew that oral contraceptive pills can be used as EC and few knew about the correct use for EC. These findings indicate the need for increased IEC effort.

Operationalising rights

The RPC has been collaborating with a Nairobi NGO, the Women’s Rights Awareness Programme (WRAP), to organise and analyse WRAP’s data on clients who have experienced gender based violence. WRAP works with clients to provide practical support, including medical care and had a great deal of case material but no systematic way of understanding the links between violence and SRH. A researcher funded by the RPC has worked with WRAP to set up an electronic database to enhance their capacity to provide services and referrals, monitor services and identify trends and improve their capacity to generate funding applications. Findings from the analysis of client data indicate that some women experience severe long term SRH complications from violence for which they cannot access timely treatment. Lessons from this will be shared with other organisations working in this field with a view to strengthening referral systems and joint research and advocacy. Research findings are informing planned work on sexual and reproductive health related violence in Kenya.

3. Consortium development plans

3.1 Inception phase challenges and lessons

The consortium has made a good start in terms of capitalising on existing capacity and opportunities to get quick outputs, particularly in secondary and primary data analysis and in proposal development. Funding has also enabled partners to write or complete papers and briefings and attend workshops. We face both external and internal challenges in developing the strategic direction of the consortium in the next 1-2 years in particular and these are noted here.