The Beginnings of a
Sexual and Reproductive Health Sub-Strategy
BURUNDI, June 2009
Introduction:
This is a record of CARE Burundi’s early discussions and decisions on the subject of sexual and reproductive health (SRH). This document, as its title implies, presents the beginnings of the CO’s SRH Sub-Strategy. You will continue to develop this sub-strategy, informally and formally, in the months to come.
In these pages, you will find a brief account of how the CO arrived at the decision to examine SRH and its relevance to poverty in Burundi – notably, its relevance to OVERPOPULATION as an underlying cause of poverty and vulnerability (UCPVCV).
Next, you will see the draft SRH sub-strategy itself, developed in a short workshop held in Ngozi in June, 2009. Included are the topics we discussed, the ideas we generated, and some early decisions we made to guide the COs’ thinking and next discussions about SRH.
This document concludes with an outline of the decisions that CARE Burundi still must take to finalize the SRH sub-strategy during the next P-Bouge event in September 2009. You will also find ideas for activities and research that you can undertake in the meantime to prepare for incorporating SRH into the CO’s larger program discussions, and perhaps beyond.
Annexes to this document offer: a summary review of data, observations and opinions on the current status of overpopulation and SRH in Burundi today, drawn from secondary sources and from informal conversations with voisines, voisins, CARE and partner staff. A more full transcript of these very rich conversations follows, in Annex B, and we encourage all staff to read these pages.
This document is deliberately informal in nature. It recounts the opening exchanges in what will be an ongoing dialogue within CARE, and between the CO and others in Burundi. We want you to grasp the discussion so far, and to join us as we continue to examine this fascinating topic. SRH touches upon virtually every aspect of human lives and relationships, and the ideas, traditions and culture that shape them. And, as we discovered in the Ngozi workshop, SRH is linked not only to overpopulation, but to all five of the UCPVs that the CO has identified as relevant in Burundi.
Background
La démographie galopante au Burundi aura un impact négatif sur notre travail, notamment l’accès aux services de qualité par tous: compte tenu de l’ampleur de la surpopulation, il faut chercher les opportunités pour continuer à initier des actions de santé de la reproduction, on devra aussi mener une étude dans le projet existant (Umwizero) pour mieux comprendre les causes profondes et développer des stratégies d’une initiative plus consistante en santé sexuelle et reproductive.
Voyage Stratégique 2007-2011: Révision d’avril 2009
Sous-chapitre: implications du changement du context
CARE Burundi’s ‘Strategic Voyage,’ and CARE’s global shift to the program approach, led the CO to identify five UCPVs in Burundi, and two impact groups on whom our programs seek to have a positive impact:
Impact Group 1: Les femmes pauvres et vulnérables aux violences basées sur le genre issues du milieu rural, âgées de 18 à 45 ans des ménages ayant moins de 0,5 Ha de terre, sans accès ni contrôle à d’autres sources de revenus et ne participant pas de façon effective dans les structures de prise de décision / Impact Group 2: Les orphelins et enfants vulnérables âgés de 6 à 17 ans du milieu rural vivant dans des ménages économiquement vulnérablesUCPV 1:
Poor Governance / UCPV 2:
Conflict / UCPV 3: Patriarchal Structures and Gender Norms / UCPV4:
Overpopulation / UCPV 5:
Child Rights Abuses
In June 2009, the CO undertook an initial inquiry into overpopulation as a UCPV, including informal conversations with stakeholders on the topics of overpopulation and SRH. We held a short workshop to begin to develop a sub-strategy for SRH that will lead us to address not only overpopulation, but health, empowerment and rights fulfilment.
CARE Burundi’s Draft SRH Sub-Strategy
This section recounts the major inputs, discussions, decisions and outputs of the mini-workshop in Ngozi on June 17 and 18, 2009.
Overview of Selected Statistics, Burundi
To make sure that all participants began with the same perception of Burundi’s current demographic and SRH situation, we asked them to read aloud the series of data points reproduced in the box below. A more detailed account of demography and SRH status is found in Annex A.
Of note, we decided not to present the findings of our informal conversations with neighbors and other stakeholders in the days prior to the workshop (Annex B). We did not want participants to feel limited to the topics and themes contained therein.
Le Statut SSR Actuelle au Burundi: quelques données
▪La population burundaise: 8,508,000
▪Taux de croissance annuelle: 3,6%
▪% de la population agé <25 ans: 66
▪Taux de prévalence contraceptive (méthodes modernes): <10%
▪% actuel de la population qui peut s’approvisioner de 2.100 calories/jour (minimum pour une vie active): 33
▪Fertilité moyenne: 6,8 enfants/femme
▪Mortalité infanto-juvénile (0-59 mois): 180 / 1.000 nés vivants
▪Rang mondial (mortalité i-j): 10 sur 189
▪Mortalité maternelle: 800 / 100.000 nés vivants
▪Une femme burundaise sur 16 va (statistiquement) mourir des causes maternelles
▪Une femme suédoise sur 17,400 en mourira
▪% d’enfants malnutris (sous-poids modéré et sévère): ≥39
▪Produit national brut/personne 1990: $214
▪PNB/p 2002: $110
▪PNB/p 2005: $83
Sources:??
What is Sexual and Reproductive Health?
Next, we presented this (slightly abbreviated) definition of SRH from the World Health Organization:
La santé sexuelle et reproductive est…un état compréhensif de bien être physique, mental et social, en relation à la sexualite et les processus et apareils de la reproduction; elle ne consiste qu’en l’absence de maladie, dysfonction ou infirmité. La SSR recouvre une approche positive et respectueuse à la sexualite et aux relations sexuelles; et la possibilité d’avoir les relations sans coercion, discrimination et violence.
We then reviewed the Nine Pillars of SRH Services, as they appear in the Ministry of Health’s Policies, Norms and Standards for SRH:
Consultation pré-natale * Dépistage IST/VIH/SIDA * Accouchement en milieu * consultation post-natale * planning familial * vaccinations * dépistage cancer des organes reproductives, homme et femme * prise en charge couples inféconds * prevention et prise en charge violence basée sur genre.
And we asked ourselves these three questions:
- Does everyone in Burundi have access to the SRH services listed above?
- Does everyone in Burundi have knowledge of them?
- Does everyone who has knowledge and access make use of the services?
The answers to all three questions were, of course, NO. And this led us to discuss a fourth question: in addition to lack of services and lack of information, what factors prevent people from enjoying good SRH, as defined above?
Social Determinants of Health
According to the World Health Organization,
…les causes les plus puissantes de la mauvaise santé sont les conditions sociales dans lesquelles les gens vivent et travaillent. On les appele les déterminants sociaux de santé. L’évidence nous montre que la majorité du fardeau global de morbidité, et la grande partie des inéquités sanitaires, sont provoquées par les déterminants sociaux.[1]
Workshop participants split into three groups, and brainstormed some social determinants of SRH in Burundi:
Initial Ideas: Social Determinants of SRH in BurundiSmall Group / Small Group / Small Group
▪Domestic violence (sexual, physical, psychological, polygamy) and the culture of silence surrounding it.
▪Woman’s status: she is considered inferior to man, cannot decide how many children she will bear, has no inheritance rights.
▪Religious beliefs: For example, the bible says to be numerous like grains of sand, church is against modern contraception.
▪Lack of formal and informal education; lack of sex education for youth, in school or at home.
▪Traditional practices and mentalities: children are wealth; culture of silence; recourse to traditional practices (medicine?) / ▪Relations/hierarchy between men, women and children. Women’s position within household and extended family (no decision-making power over own bodies). Children are never consulted but suffer all the consequences.
▪Sex/sexuality education: adults don’t know their own physiology, results in unwanted pregnancies, STI/HIV. Children risk illness, orphanhood, etc.
▪Economic conditions: women have poor economic access to health services; are malnourished; get married as a survival mechanism.
▪Family status in the jurdicial realm: Women have no inheritance and succession rights, children born out of wedlock are ‘illegal’ humans.
▪Social, religious and traditional beliefs / ▪Religious beliefs (various faiths are against contraceptives, family planning; for polygymy.
▪Cultural practices: polgymy, early marriage, conjugal violence, supremacy of the male sex, “gutera intobo” (a man can demand sexual access to daughter-in-law)
▪Negative consequences of the war/conflict include overcrowding, poverty, notion of rebuilding families.
▪Government policy unclear, easy to misinterpret: free health and education may appear to encourage more children.
▪Rumors about the consequences of using FP; lack of access to accurate information.
The most salient points of our discussion around these social determinants of SRH were:
▪That cultural/social notions of masculinity and femininity – what a man or a woman is ‘supposed to be’ – underlie many of the determinants listed above;
▪That these notions are reproduced in social interfaces (for example, groups of young men talk about women in a way that emphasizes male ‘dominance’); and, as in every culture in the world, the pressure to conform is strong, and the individual’s ability to imagine options outside these norms is limited.
▪None of the social determinants listed above is fixed. All are open tochange. Even now, local churches are beginning to discuss the problem of overpopulation (one participant heard a debate on the radio the previous night). People’s interpretations of religious texts can change. And it is possible to change how women and men communicate with one another, about sex and other topics.
SRH Visions for CARE Burundi’s Impact Groups
Next, participants split into two groups according to the Impact Group that interested them most. They imagined themselves 16 years into the future. How would members of the Impact Group be different from today? More specifically, the groups were asked to use their knowledge, good judgment, imagination, hopes and dreams to describe a future ideal. They considered these elements:
When: 2025
Who: CARE and its partners,
What: The change we want to contribute to
Future attributes of the Impact Group: Their knowledge Their access to services Their health Their wishes and plans Their ability to take action and make decisions The support they have from their family, social circle, community, government.
VISION SSR pour Femmes Vulnérables
/ VISION SSR pour JeunesD’ici 2025, CARE et ses partenaries veulent contribuer à avoir une femme burundaise qui: est bien informée sur la santé sexuelle et reproductive et ses droits; fait des choix éclairés et décide sur sa santé sexuelle et reproductive; a un accès durable aux services de qualité dans un environnement favorable à son épanouissement et son empowerment. / D’ici 2025, nous les jeunes vivons dans un environnement où les droits sexuels spécifiques aux jeunes sont assurés avec équité, avec la compréhension et l’appui de la société accompagnés d’une capacité de prendre des décisions responsables…avec amour et passion! Nous sommes l’avenir!
(NB: Equité = tous les jeunes, malgré statut scolaire. Compréhension = environnement familial aussi bien que social.)
SRH Hypotheses: What Change Will Carry Us toward These Visions?
A hypothesis demands that we step back from our visions and begin to imagine what needs to happen before the vision can become reality. We brought together elements of CARE’s Empowerment Triangle and its Theory of Change to ask this question:
“What conditions must be met if we are to achieve these visions?”
Participants debated and developed necessary conditions at three levels: individuals (agency), relations and structures. Their results are presented on the following pages.
What Key Actions Lead to the Hypothesized Conditions?
At this stage of the Ngozi workshop, we originally intended to ask participants to identify specific actions that CARE Burundi could take at each corner of the Empowerment Triangle (individuals, relations, structures) and the internal modifications that would allow CARE to undertake those actions. However, this would have omitted a discussion of the actions that other stakeholders must take if the visions are to become reality.
Therefore, we asked participants simply to identify three key actions per corner. They could certainly discuss which actors must be involved (including but not limited to CARE), but the focus was on action rather than actor.
On the two pages that follow, you will find the Hypotheses and Key Actions for each of CARE Burundi’s Impact Groups:
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YOUTHConditions (Hypothesis)
Individuels / X / Relations / X / Structures / = / SSR Vision
▪Connaissances correctes et suffisantes sur la SSR
▪Sensibilité aux risques liés à leur situation socio-sanitaire
▪Capacité à prendre les décisions responsables en matière de SSR / ▪Communication et compréhension entre partenaires sexuels, parents, leaders (commu-nautaires, religieux) professionals de santé etc.
▪participaton accrue des jeunes dans les associations qui n’occupent que des problèmes leur concernant / ▪Politiques favorables à la SSR des jeunes et adolescents (gouvernement et autres intervenants dans le dév’t.)
▪Réseaux et structures capables à repondre aux besoins des jeunes (publique, privé…)
▪Les norms sociales favorables aux droits des jeunes en matière de SSR / D’ici 2025, nous les jeunes vivons dans un environnement les droits sexuels spécifiques aux jeunes sont assurés avec équité avec la compréhension et l’appui de la société accompagné d’une capacité de prendre des décisions responsables…avec amour et passion! Nous sommes l’avenir
Key Actions
▪Adapter et appliquer l’Analyse Sociale-Action (SAA)[2]
▪Formation, sensibilistaion, mobilisation (comprend compétences à la vie) / ▪SAA
▪Créer et multiplier et redynamiser les espaces pour les jeunes (les centres des jeunes qui existent, aussi ‘l’espace’ pour le dialogue
▪Initier des AGR pour les jeunes vulnerables / ▪SAA
▪Plaidoyer sur les droits des jeunes en matière SSR (pas nécéssairement dans le sens legal et formel; plutot, créer une masse critique des intervenants intérésés)
▪Renforcer les mécanismes de coordination entre différents intervenants en matière SSR
▪Disponibiliser des services, renforcer les autres structures existants; services ‘ami aux jeunes.’
▪Promourvoir la bonne gouvernance, assurer equité d’acèss aux services pour jeunes, femmes, tout le monde
▪Mettre en place un système pour assurer la qualité des services SSR à tous les niveaux
Text in italics indicates Key Actions that were identified for both impact groups.
FEMMES VULNERABLESConditions (Hypothesis)
Individuels / X / Relations / X / Structures / = / SSR Vision
▪Si le pouvoir économique de la femme est assuré
▪Si le niveau de participation à la prise de décision au niveau du ménage et communautaire est garanti
▪Si les femmes ont des connaissances et capacités accrues en matière de SSR / ▪S’il y a des associations féminines qui promeuvent la SSR
▪Si l’éducation à la SSR est orientée à la fois aux hommes et aux femmes
▪S’il y a des réseaux d’hommes engagés dans le changement de comportement en matière de SSR / droits des femmes (ex: abatangamuco) / ▪Si la politique nationale de la SSR est claire, compréhensive, opérationnelle et soutenue par les structures de l’état
▪S’il y a coordination au niveau des différents mobilisateurs de la communauté (leaders religieux, les masses médias, les leaders politiques…) pour donner un même message sur la SSR
▪Si le gouvernement passe des lois favorables à la défense des droits de la femme (code des personnes et de la famille, code pénal, loi sur la succéssion) et applications
▪Si les normes sociales evoluent et soutiennent l’épanouissement de la femme. / D’ici 2025, CARE et ses partenaries veulent contribuer à avoir une femme burundaise qui: est bien informée sur la santé sexuelle et reproductive et ses droits; fait des choix éclairés et décide sur sa santé sexuelle et reproductive; a un accès durable aux services de qualité dans un environnement favorable à son épanouissement et son empowerment.
Key Actions
▪Renforcement des capacités individuelles et collectives des femmes et des hommes en matière de SSR
▪Développer des opportunités économiques profitables aux femmes / ▪Promouvoir l’émergences des associations réseaux et mouvements sociaux qui prônent la SSR
▪Développer, tester des approaches d’implication des hommes dans la SSR / ▪Plaidoyer en faveur des lois favorables a l’épanouissement de la femme.
▪Mise en place d’un cadre de coordination des acteurs en matière de la SSR
▪Promovoir la bonne gouvernance, assurer equité d’accèss aux services pour jeunes, femmes, tout le monde
▪Mettre en place un système pour assurer la qualité des services SSR à tous les niveaux
Text in italics indicates Key Actions that were identified for both impact groups.
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Closing Comments from the Workshop
▪We began the workshop thinking that we would isolate OVERPOPULATION from the CO’s four other UCPVs. Upon examination, however, it is clear that all five of the CO’s UCPVs have links to overpopulation and SRH.
▪The hypotheses and key actions we identified should lead to improved SRH and lower population growth rates, but they will also result in empowerment.
▪The key actions are very broad – in fact, Yawo joked that taking these actions would empower everyone, and CARE’s P-Bouge would be complete. In reality, this workshop has helped solidify CARE’s foundational understanding of SRH as a socio-cultural (as well as physical) phenomenon, and the CO must now proceed to identify concrete actions.
▪CARE Burundi will take up the topic of SRH again in September 2009 at our next P-Bouge event. At that time, we will be able to complete the remaining sections (below) of our SRH sub-strategy document.
▪In the meantime, CARE staff can move forward in our research, thinking, discussions and even activities on the topic of overpopulation and SRH – particularly, social determinants of health. See the green boxes below for some ideas.
CARE Burundi’s Next Steps
In September 2009, the CO will hold its next P-Bouge event. At that time, staff will discuss and decide the remaining elements of the SRH sub-strategy. These elements are OUTLINED below, to help guide your discussions.
Your task will be to view your SRH decisions – notably, your visions, hypotheses and the broad key actions defined above – within the larger CARE Burundi programs. Recall the SRH workshop conclusion that SRH is both a cause and result of poverty, and the discovery that it has links (roots and branches, as it were) not only in overpopulation but in all five of the UCPVs that CARE Burundi has identified. Seek common points – in external actions, internal modifications, measurements – where CARE and partners can use empowerment strategies to promote not only SRH but change in patriarchal/gender norms, governance, child rights and conflict.
In the green boxes below, I have added some of my own ideas for activities that the CO might pursue even before the September P-Bouge event. Some require only an investment of time (a rare commodity, I know); others may require modest financial and logistics input.