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On October 4th and 5th, 2012, the International Consortium for Emergency Contraception (ICEC), which is hosted by FCI, and the American Society for Emergency Contraception (ASEC) held the annual EC Jamboree in New York City. The EC Jamboree brought together more than 100 advocates, researchers, pharmaceutical representatives, and other leaders in the field to discuss expanding efforts to ensure access to emergency contraception (EC) nationally and globally. EC is a crucial contraceptive tool for women, as it is the only available means to prevent a pregnancy after unprotected intercourse. It offers women an important second chance to prevent pregnancy when a regular method fails, no method was used, or sex was forced. Emergency contraceptive options include several kinds of EC pills (ECPs) as well as insertion of an intrauterine device (IUD). You can learn more about methods of emergency contraception here.
At the meeting, honors were presented to three “EC Champions.” ICEC and ASEC staff were delighted to present the Felicia Stewart Lifetime Achievement Award to Dr. James Trussell of Princeton University. This award, which honors the leadership of the late Felicia Stewart, is presented to “an outstanding leader who, through a substantial and prolonged body of work, has changed the face of, access to, and understanding of EC through programs, policy advocacy and/or research.” The Steering Committees of both organizations agreed that Dr. Trussell, a pioneer in the EC world, embodies the spirit of this award. He has published extensively on EC, developed the website www.not-2-late.com, and personally responds to consumer questions about EC that are received through the website. He also created the contraceptive effectiveness chart that is mandated to appear on all birth control labeling in the US.
The Charlotte Ellertson Award, established in honor of the late Charlotte Ellertson and supported by Ibis Reproductive Health, which she founded, was presented to the Venezuela Ministry of Health and the British Pregnancy Advisory Service. This award specifically recognizes innovation and goes to an individual or organization that has made a “bold EC move.” The Ministry of Health of Venezuela registered EC as an over-the-counter, non-prescription product with no age restrictions, making Venezuela the only country in the Western Hemisphere to have such unimpeded access to EC. The British Pregnancy Advisory Service spearheaded a nurse-led advance EC provision service over the Christmas holidays and during the London Olympics. The manager of this service, Karen Beechey, and the nurse who ran the program, Tracey Forsyth, attended the EC Jamboree to present on their program and accept the award.
ICEC and ASEC are grateful to all three of these leaders for their impressive work to expand women’s access to EC.
You can learn more about emergency contraception and ICEC’s work to expand access to EC on the ICEC website, and you can join the International Consortium for Emergency Conception by submitting this form.
Keep up with the latest news on EC by following ICEC on Facebook.
Last week, I joined over 8,000 obstetricians/gynecologists, midwives, public health practitioners, and women’s health advocates, as they gathered for the 20th World Congress of Gynecology and Obstetrics on the outskirts of Rome, Italy. Convened by the International Federation of Gynecology and Obstetrics (FIGO), the meeting focused on the vital role health professionals and health professional organizations can play in advancing women’s health and well-being, especially during pregnancy and childbirth.
At a press conference on the first day of the conference, Professor Gamal Serour, outgoing President of FIGO, noted that “Professional organizations can do a tremendous amount… from influencing policy decision-making to raising awareness of issues and their solutions, to setting standards, to educating and training healthcare professionals and providers.”
The FIGO World Congress included the global premier of a short film, “Why Did Mrs X Die, Retold.” Originally released in 1987 by the World Health Organization at the first global safe motherhood conference, “Mrs. X” told the story of a woman’s journey through pregnancy and childbirth, and the many cultural, social, and economic factors which contributed to her death. “Why Did Mrs. X Die, Retold” updates the story and shows that many of the factors which contributed to maternal mortality 25 years ago are unfortunately still causing maternal deaths today. The updated animated short film is compelling and worth watching, it can be viewed here.
Also during the World Congress, the World Health Organization (WHO) and FIGO launched updated, evidence-based guidelines and clinical recommendations for the prevention and management of postpartum hemorrhage (PPH), the major cause of maternal deaths worldwide. The new WHO guidelines include the recommendation for lay health workers to administer misoprostol after childbirth for prevention of PPH. FIGO issued new clinical recommendations for dosing, route of administration, and contra-indications for misoprostol’s use in PPH prevention and treatment.
Throughout the conference, the importance of partnership, with other health professionals such as midwives, and across sectors, was underscored: “We can’t do it alone,” said Professor Sir Sabaratnam Arulkumaran, the incoming President of FIGO. He called for support from advocacy groups to intensify global efforts toward achievement of Millennium Development Goals 4 (reduce child mortality) and 5 (improve maternal health).
To learn about how FCI works with partners to help achieve MDGs 4 and 5, visit FCI’s home page.
This item, featuring an interview with FCI president Ann Starrs, is cross-posted from the website of the Partnership for Maternal, Newborn & Child Health.
8 OCTOBER 2012 | ROME – Countdown to 2015 partners hosted a side event at the end of the first day of FIGO 2012 [the World Congress of Gynecology & Obstetrics]: “Reproductive, Maternal and Newborn Health: Are Countries Making Progress?” Participants heard about the newest Countdown to 2015 data on 75 highest-burden countries and received information on why and how countries should work with Countdown to amass data and tools to promote evidence-based policy change.
In her presentation on the Countdown initiative and its value, Dr Joy Lawn, Director of Global Evidence and Policy with Save the Children’s Saving Newborn Lives program, used recent child mortality findings to demonstrate how presenting clear and meaningful data is helpful for hammering home the need to address remaining challenges urgently even if progress is being made.
Among children under five years old, data shows deaths from diarrhea have come down and malaria as well, meanwhile there has been very little progress on neonatal causes of death. If countries were to continue making progress at their current rates (the global annual rate of reduction for neonatal death is 1.8 percent), it would take the following regions quite a long time to meet their Millennium Development Goal targets: the Americas would achieve their target in 2040, Southeast Asia not until 2085 and Africa not until 2165.
“It is so important to present data in a way that is understandable and has an impact,” said Ann Starrs, President of Family Care International, one of the partner organizations behind the Countdown Initiative who also spoke at the event. “Graphs are great, but they can be confusing. It’s helpful when you can look at indicators and they tell you a story — this can lead very directly to policy and funding changes.”
Ms Starrs said it is crucial that health professionals are brought on board when advocating for change.
“If the medical community resists then it’s very, very hard to get a new policy adopted and implemented,” she said, which is why initiatives like Countdown are essential for helping RMNCH champions within government or civil society make the case for adopting or investing in proven solutions to reduce preventable deaths.
Maritza Segura is FCI’s national coordinator in Ecuador.
On October 18 and 19, 2012, in Quito, Ecuador, in partnership with the Spanish NGO Interarts, FCI is organizing a national advocacy event — Our Life, Our Rights: HIV Prevention for the Good Life — to strengthen political commitment and support for implementation of specific HIV prevention and treatment strategies for indigenous peoples and communities. We have seen firsthand that access to accurate information is critically important for preventing the spread of HIV among indigenous populations, and especially among young people in indigenous communities. To be effective in helping young people embark on safe and healthy adult lives, this information must be provided in way that is culturally appropriate and relevant to their cultural context.
Much of FCI’s work in Ecuador in recent years has focused on preventing HIV among young people and women in indigenous communities. In the villages of the Amazon jungle, young people’s access to information about their reproductive health, including HIV and AIDS, is limited. Even though these communities are seeing more and more cases of HIV each year, national surveillance systems — which don’t record ethnicity — don’t reflect the magnitude of the problem among the indigenous population.
FCI and Interarts are working with indigenous organizations in Ecuador to train young indigenous people on HIV prevention. The training uses a participatory, youth-centered methodology, adapted to the local culture, to provide information on a range of critically important topics, including how HIV is transmitted, means of prevention, and correct use of a condom. Participants also learn about the importance of solidarity, about non-discrimination, and about their sexual and reproductive rights.
To date, FCI has trained more than 5,000 young people in five Ecuadorian provinces. In 2011, at the request of the Ministry of Public Health, we implemented a pilot project on sexuality and vulnerability to HIV among the indigenous Shuar and Achuar peoples; we also proposed the development and implementation of a national strategy to respond to HIV and AIDS among the country’s indigenous populations. The October event in Quito will help to build support for this strategy.
This initiative is implemented with support from Interarts Foundation, through a grant from the Spanish Agency for International Development Cooperation (AECID).
You can directly support FCI’s work educating young people in Ecuador’s indigenous communities! Visit catapult.org to learn how.
La prevención del VIH en jóvenes y mujeres indígenas del Ecuador
Maritza Segura es la coordinadora nacional de FCI en Ecuador.
El 18 y 19 de octubre de 2012, a Quito, Ecuador, FCI y la ONG española Interarts están organizando un evento de incidencia nacional — Nuestra Vida , Nuestros Derechos: Prevenir el VIH para el buen vivir — para fortalecer los compromisos políticos en respuesta al VIH, asegurando estrategias específicas para pueblos y nacionalidades indígenas.
FCI ha visto de primera mano la importancia del acceso a información verídica y completa en la prevención de la propagación de la epidemia del VIH en poblaciones indígenas, especialmente jóvenes, y la pertinencia de material culturalmente adecuado para fortalecer la construcción de un proyecto de vida saludable, en un contexto cultural diverso.
En los últimos años, FCI ha centrado sus esfuerzos en la prevención del VIH en jóvenes y mujeres indígenas del Ecuador. A menudo, en lugares remotos del país, adolescentes y jóvenes tienen acceso limitado a información y educación sobre salud reproductiva, incluido el VIH/SIDA. Trágicamente, aunque cada año se identifican más y más casos de VIH en estas mismas poblaciones, los sistemas nacionales de vigilancia no permiten un registro por pertenencia étnica por lo tanto las estadísticas no reflejan la magnitud de este problema. Como parte de un proyecto con Interarts, FCI trabaja con organizaciones indígenas de Ecuador para capacitar a jóvenes indígenas en la prevención del VIH utilizando una metodología participativa centrada en la juventud: El recorrido participativo para la prevención del VIH, que incluye los temas de formas de transmisión, el camino de la protección, el uso correcto del condón, solidaridad, no discriminación y derechos. Hasta la fecha, FCI ha capacitado a más de 5.000 jóvenes en cinco provincias. En 2011, y a solicitud del Ministerio de Salud Pública, FCI desarrolló un estudio en una provincia piloto sobre la sexualidad y la vulnerabilidad al VIH en población Shuar y Achuar y realizó una propuesta de estrategia para dar respuesta al problema del VIH/SIDA entre las poblaciones indígenas.
Esta iniciativa es posible en coordinación con la fundación Interarts, y a través de fondos de la Agencia Española de Cooperación Internacional para el Desarrollo (AECID).
Family Care International was proud to partner with Merck for Mothers and Women Deliver to host a stimulating and provocative discussion on The Role of Private Providers in Expanding Access to Affordable, Quality Maternal Healthcare. At this side event to the 2012 UN General Assembly, held in New York on September 25, 2012, a distinguished panel of speakers highlighted the crucial role that private providers play in ensuring access to quality maternal health care, especially for the most marginalized populations, and the important contribution they can make in accelerating progress towards achieving Millennium Development Goal (MDG) 5, which aims to reduce maternal mortality by 75% and achieve universal access to reproductive health.
“There is a consensus in most parts of the world that it is the responsibility of governments to ensure that all people have access to basic preventative and curative health care. But that doesn’t mean that governments have to provide those services themselves. Partnership is the key.”
— Ann Starrs, FCI
While there has been notable progress in reducing maternal mortality globally over the past decade, only 10 countries are currently on track to reach the 75% reduction target, and more than a quarter-million women continue to die each year from complications of pregnancy and childbirth. Approximately 99% of maternal deaths occur in the developing world, most of them in sub-Saharan Africa and South Asia, and almost all of these deaths could be prevented with better access to skilled care before, during, and after childbirth. In many countries, the private health sector — including independent physicians, nurses, and midwives; traditional practitioners; private clinics and hospitals; pharmacies, health shops, and drug outlets; and health insurers — plays a central role in helping governments accelerate efforts to reach women with essential, lifesaving care. Non-health businesses, including transportation operators, mobile service providers, and financial institutions, also play an important role in facilitating health care.
Speakers at the event, moderated by Diane Brady of Bloomberg Businessweek, included Nigerian Minister of Finance Ngozi Okonjo-Iweala; Dr. Flavia Bustreo, Assistant Director-General of the World Health Organization; Sweta Mangal, co-founder and CEO of Ziqitza Health Care Limited, a private ambulance service in India; and Karl Hofmann, CEO of Population Services International (PSI), an NGO that focuses on “social marketing” of family planning and other essential health supplies and services.
Jill Sheffield, president of Women Deliver, provided the context for the discussion and introduced Geralyn Ritter, Merck’s Senior Vice President of Public Policy and Corporate Responsibility, who noted the vital, but often overlooked, role that private healthcare providers and health businesses play in delivering health care in local communities. Roughly half of Africans and up to 80% of South Asians now receive care from the private sector, she said; independent midwives, private clinics, and local pharmacies are trusted by the communities they serve, and are key partners in government efforts to improve maternal health. The Merck for Mothers initiative, a 10-year, $500 million initiative to reduce maternal deaths, is working with private providers and health businesses at the local level to ensure that the care they provide is accessible, affordable, and of high quality.
Dr. Bustreo, who heads WHO’s programs for Family, Women’s and Children’s Health, described WHO’s work, in partnership with governments and the private sector, to identify and promote innovative solutions to the maternal health challenges faced by countries, health providers, and women. She also highlighted the high cost of maternal health services as a critical barrier that limits women’s access to the services they need, and discussed approaches that countries are using to address it.
The Honorable Dr. Okonjo-Iweala, who has served as Nigeria’s Minister of Finance and as its Foreign Minister, and is a former Managing Director of The World Bank, focused on empowering women and girls: “Women are the next emerging market and are a force to reckon with. If we invest in women, we can move the world.” In Nigeria, she noted, 43% of health care facilities are private, so the government understands the importance of engaging private providers and ensuring that they are appropriately regulated. Scaling up midwifery services is a key to ensuring increased coverage in rural areas, she said, and Nigeria’s conditional cash transfer scheme, which provides women with financial incentives for attending a certain number of antenatal visits, is a key policy for expanding access to care. Dr. Okonjo-Iweala reported that, in the areas where these cash transfers have been offered, there has been a 16% decline in maternal deaths.
Karl Hofmann discussed social franchising, a “cousin of social marketing,” as a channel for ensuring that quality services and technologies reach women and their families. Social franchising efforts work to build recognition for providers who serve poor and vulnerable women: a key element of their “brand” is ensuring that all franchisees meet improved service standards and provide good quality care. PSI has, to date, provided support for franchising 10,000 providers in 24 countries; these providers reach 10 million people with essential health care services each year.
Sweta Mangal shared Ziqitza Health Care’s experience operating more than 860 advanced and basic life support ambulances across India, filling a gap in government services and increasing access to quality, lifesaving care for poor patients. One-third of Ziqitza’s patients are pregnant women needing transport to health facilities that offer skilled delivery care. In addition, she said, more than 5,000 babies have been born in Ziqitza’s ambulances, since government hospitals are often too overcrowded to immediately accommodate all of the pregnant women who arrive by ambulance.
A lively discussion followed these presentations, focusing on how to ensure that private providers and health businesses comply with government regulations and protocols, meet quality standards, and provide services that are affordable and accessible for users from all income levels.
At the meeting’s conclusion, Family Care International’s president Ann Starrs referenced recent remarks by Dr. Margaret Chan, Director General of WHO, that universal health coverage is an idea whose time has come. “There is a consensus in most parts of the world that it is the responsibility of governments to ensure that all people have access to basic preventative and curative health care,” she noted. “But that doesn’t mean that governments have to provide those services themselves.” The private sector offers clear advantages, she said, in terms of pioneering innovative approaches, their connection to the community, efficiency and cost-effectiveness, and sustainability. Enabling the private sector to maximize its potential contributions requires governments to provide a normative and regulatory framework to ensure that quality standards are met; financing mechanisms to make services affordable; training and support of private sector providers; and sharing learning, experiences, and evidence. “Partnership,” she said, “is the key.”
Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou.
In the West African country of Burkina Faso, FCI — with support from the UN Population Fund (UNFPA) and the Luxembourg Agency for Development Cooperation — is addressing the suffering of women who live with obstetric fistula, a devastating injury to the birth canal caused by obstructed and prolonged labor. If left untreated, fistula’s damage is permanent. It makes it impractical or impossible to have more children, causes leaking of urine or feces, and leads to a lifetime of pain, stigma, and social ostracism. Working with communities and grassroots organizations in the remote Sahel region, on the edge of the Sahara Desert, FCI’s program seeks to prevent obstetric fistula by improving women’s access to emergency obstetric care. We also provide surgical treatment for women living with fistula (see part 1 of this series to learn more), and support the reintegration of fistula survivors into their communities.
In the poor, semi-nomadic villages of the Sahel, women with obstetric fistula are often treated as if it is their own fault, and not the result of inadequate access to maternal health services. It is widely believed that fistula is a punishment for adultery or other moral transgressions, or that it is a sign that the woman is cursed. A woman living with fistula cannot hide it, because her chronic incontinence brings with it a constant odor. These women are often thought unworthy of living with their families, associating with friends, or participating in the life of the community. Many are rejected by husbands and in-laws, and forced to live in the shadows, with a triad of suffering: physical, psychological, and economic.
Successful surgery can heal fistula’s physical effects, but its psychosocial and economic impacts often last far longer. FCI works with our community-based partner organizations to meet this challenge by helping women, after their fistula has been repaired, to emerge from the shadows and rejoin their families and communities. In these villages, establishing a means of earning an income is a crucial way for a woman to regain her confidence, demonstrate her value to the family, and achieve status in the community.
Mariama Boubacar Diallo is one of these women. Mariama lives in the village of Kriollo Ourarsaba, 25 kilometers (16 miles) from Dori, the region’s capital. In 2009, already a 27-year old mother of two, she developed a fistula while giving birth to her third child (who survived, unusual in fistula cases). Mariama’s husband did not reject her, but her in-laws were less kind. “His parents did not want me anymore — every day there was strife… and they openly abused me in spite of my husband,” she said. Fortunately, one of FCI’s partners found her and arranged for her surgery at the hospital in Dori only a few months later. “Today,” Mariama says, “thank God, I no longer suffer. I’m healthy; I am healed.”
The healing that Mariama needed was not only physical; her position in the family and community also needed repair. So in the months after her surgery, she received training in modern methods of livestock farming. Raising cattle and sheep is the primary economic activity in many parts of the Sahel, and at the end of 2010 Mariama received a grant of 100,000 CFA francs (about $200 to purchase a ram and a ewe, along with some feed, and thereby establish her own breeding business.
Mariama now owns four head of cattle, making her one of the village’s most prosperous and successful citizens, and she generously shares her new agricultural knowledge with her neighbors. She is fully included in baptisms, weddings, and other social events of the village — something that was inconceivable only a year ago, and has fully reunited with her in-laws. “Today,” she says, “thanks to this program, my in-law family has truly accepted me.”
Mariam Sawadogo suffered for much longer: now 35 years old, she was still in her teens when her second pregnancy resulted in obstructed labor, stillbirth, and obstetric fistula. After 16 years of humiliation and isolation, the FCI program arranged for her repair surgery at the Dori hospital. Now a widow, she too was trained in farming techniques and small business management skills. With her small reintegration grant, Mariam has developed two small but successful businesses. Like Mariama Boubacar Diallo, Mariam used her grant to buy two ewes; after fattening them for a year, she sold them for a profit, using the proceeds to purchase two more young sheep and to begin making and selling beignets (donuts) in the village market.
These two small businesses have enabled Mariamto emerge from extreme poverty — she now has both assets (her livestock) and a steady income, and can pay her child’s tuition at the village school. She also is able to buy jewelry, an important marker of social status for women of her generation in her community. At her market stall, Mariam, no longer a social pariah, chats and gossips with the many customers who come to buy her delicious cakes. In line with tradition — and a clear sign of her successful reconciliation with her in-laws — she now lives in the household of her late husband’s younger brother.
Mariama and Mariam are just two of the hundreds of women whose lives have been transformed through a simple surgery and a $200 grant.
La seconde vie des survivantes de la fistule obstétricale (suite): histoire de succès au Burkina Faso
Alain Kaboré est chargé de programme à FCI-Burkina Faso, basé dans notre bureau à Ouagadougou.
Au Burkina Faso, pays de l’Afrique de l’Ouest, FCI – financé par le Fonds des Nations Unies pour la Population (UNFPA) grâce à des fonds du Grand-Duché du Luxembourg – est en train de répondre aux souffrances des femmes qui vivent avec une fistule obstétricale, une blessure à la filière génitale causée par un accouchement obstrué et prolongé. Sans traitement, la fistule provoque l’incontinence et l’odeur, et rend difficile voire impossible d’avoir encore des enfants, ce qui résulte en une vie de douleur, de stigmatisation, d’ostracisme social pour les femmes victimes. En collaboration avec les communautés et les organisations locales du Sahel, un projet de FCI vise à prévenir les fistules obstétricales (en améliorant l’accès aux soins obstétricaux d’urgence), fournir un traitement chirurgical aux femmes vivant avec une fistule (voir la partie 1 de cette série), et soutenir la réintégration des survivantes de la fistule au sein de leurs communautés.
Dans les villages pauvres et semi-nomades du Sahel, les femmes souffrant de fistule obstétricale sont traitées comme si elles étaient responsables, alors qu’en réalité l’accès inadéquat aux services de santé maternelle est responsable.
Beaucoup croient que la fistule est une punition de l’adultère, d’autres transgressions morales, ou est un signe que la femme est maudite. Les femmes qui vivent avec une fistule ne peuvent pas le cacher : leur incontinence chronique apporte une odeur constante d’urine et/ou d’excréments, et elles sont souvent perçues comme n’étant pas dignes de vivre avec leurs familles, de voir leurs ami(e)s, ou de participer à la vie de leur communauté. De nombreuses femmes sont rejetées par leurs époux et leurs beaux-parents et forcées de vivre dans l’ombre, et à subir une souffrance physique, psychosociale et économique.
Une chirurgie réussie peut guérir les effets physiques de la fistule, mais ses impacts psychologiques et économiques peuvent durer plus longtemps. En collaboration avec nos partenaires locaux, FCI répond à ce défi en aidant les femmes, après la réparation de la fistule, à sortir de l’ombre et à rejoindre leurs familles et communauté. Dans ces villages, avoir une activité génératrice de revenus (AGR) est un moyen crucial par lequel une femme peut reprendre confiance en elle, démontrer sa valeur à la famille, et obtenir un statut au sein de la communauté.
Mariama Boubacar Diallo est une de ces femmes. Mariama vit dans le village de Kriollo Ourarsaba à 25 km de Dori, chef-lieu de la région du Sahel. En 2009, déjà mère de deux enfants à 27 ans, elle a développé une fistule pendant l’accouchement de son troisième enfant (qui a survécu, événement rare dans le cas des fistules). Bien que son époux ne l’ait pas rejetée, ses beaux-parents étaient moins compréhensifs : « … mes beaux-parents ne voulaient plus de moi, chaque jour avait ses épisodes de querelles, on me lançait des proverbes et des injures ouvertes et tout cela au mépris de mon époux ». Heureusement, un des partenaires de FCI l’a trouvée et a pris toutes les dispositions nécessaires pour qu’elle puisse être opérée à l’hôpital de Dori quelques mois plus tard. « Aujourd’hui » dit-elle, « Dieu merci je ne souffre de rien ; je suis bien portante, je suis guérie, même en me voyant vous savez que je suis en bonne santé ». Une fois le mal physique guéri, Mariama avait également besoin d’aide pour retrouver sa position au sein de sa famille et sa communauté. Dans les mois qui ont suivis l’opération chirurgicale, Mariama a reçu une formation sur les techniques modernes d’élevage (l’élevage des bovins et des moutons est la principale activité économique dans de nombreuses parties du Sahel), et à la fin de l’année 2010, elle a reçu 100 000 francs CFA (environ 200 dollars). Les fonds lui ont permis d’acheter un bélier, une brebis, et de la nourriture pour établir sa propre entreprise de l’élevage.
Aujourd’hui, Mariama est propriétaire d’un élevage de quatre bêtes, ce qui fait d’elle une des personnes les plus prospères du village. Elle partage son nouveau savoir-faire agricole avec ses voisins et elle participe pleinement aux baptêmes, mariages, et autres évènements sociaux du village – quelque chose d’inconcevable il y a un an. Elle est aussi pleinement réunifiée avec sa belle-famille : « Aujourd’hui, je peux dire que c’est grâce aux AGR que ma belle-famille m’a acceptée réellement. » Après l’avoir exclue dans le passé, maintenant ils viennent vers elle pour des conseils et de l’aide.
Mariam Sawadogo a souffert pendant bien plus longtemps : aujourd’hui âgée de 35 ans, elle était adolescente quand sa deuxième grossesse a abouti à une fistule obstétricale. Après 16 ans d’humiliation et d’isolation, le projet de FCI a facilité sa chirurgie à l’hôpital de Dori. Maintenant veuve, elle aussi a bénéficié d’une formation en techniques d’élevage et en gestion de petit commerce. Avec sa subvention de 100 000 francs CFA, Mariam a commencé deux petites entreprises pleines de succès. Comme Mariama Diallo, Mariam s’est acheté deux brebis et un an plus tard, elle les a revendues à profit pour acheter deux jeunes moutons. Les bénéfices engendrés lui ont également permis de démarrer un petit commerce de vente de beignets sur le marché du village.
Ces deux entreprises ont permis à Mariam d’échapper à la pauvreté extrême –elle possède actuellement un patrimoine (ses animaux) et un revenu stable qui lui permet de payer les frais de scolarité de son enfant qui fréquente l’école du village. Ses revenus lui permettent également de s’offrir des bijoux, un signe important du statut social pour les femmes de sa génération dans sa communauté. Devant son étal au marché, Mariam, qui n’est plus un paria social, bavarde avec ses nombreux clients qui défilent autour de son étal à la recherche de ses succulents beignets. Selon la tradition –et un signe clair de sa réconciliation réussie avec sa belle-famille – elle vit dans la famille du jeune frère de son défunt époux.
Mariama et Mariam ne sont que deux des centaines de femmes dont la vie a été transformée par une chirurgie simple et une subvention de 200 dollars.
In Kenya, FCI and our project partners, the International Center for Research on Women (ICRW) and the Kenya Medical Research Institute/Centers for Disease Control (KEMRI/CDC-Kisumu), are conducting focus group discussions to explore the impact on the family of a woman’s death in pregnancy or childbirth. These discussion are part of a three-year research project that seeks to provide the first full accounting of the costs of a maternal death for families and communities: the direct monetary cost, the indirect costs in terms of lost productivity and income, and the “social costs” in terms of changes in household structure and responsibilities. This information will provide critical support for advocacy — in Kenya, in other developing countries, and at the global level — for improvements in the availability, quality, and utilization of maternal health services.
The blog post below, cross-posted from Perspectives: The ICRW Blog, is by Radha Rajan. Radha is an ICRW consultant with expertise in qualitative research and program evaluation, and a participant in these focus group discussions.
Ours is the only vehicle in sight on the bumpy dirt road to the village of Nyamula in Western Kenya. Compounds with semi-permanent houses set far apart from each other dot the landscape, and acres of farmland fill the spaces in between. I’ve come to this remote community to meet a few families who are reeling from an unexpected loss.
It’s quiet as we drive into one family’s compound situated miles away from any town center; the only sound is the bleating of a small goat as our jeep pulls to a stop. Before we leave the vehicle I ask my colleague from the Kenya Medical Research Institute (KEMRI) if a woman wanted to give birth in a hospital or at a clinic, how would she get there?
“After she goes into labor, someone may give the woman a ride on the back of their bicycle,” my colleague tells me. “If it is night, there is cell service and the family knows someone, maybe she can get a ride on a motorcycle. But that is often too difficult. Many women give birth at home.”
I picture a woman in labor faced with the options of riding a bike to the health clinic or delivering at home without the benefit of skilled medical care, and I start to understand the importance of advocating for increased funding to support maternal health. In women of reproductive age, maternal ill health is one of the leading single causes of death and disability. Each year about 358,000 women worldwide die from pregnancy-related causes, and most who die in childbirth suffer one of five preventable or treatable complications, such as severe bleeding. Recent reviews show that while the annual global number of maternal deaths declined by about one-third between 1990 and 2008, a large number of African countries, including Kenya, have made little or no progress in lowering maternal mortality rates over the past two decades.
Here at ICRW, we believe those figures can be reversed, and we’re working to illustrate, through research, the need for more investments to prevent maternal deaths. With the KEMRI/CDC Research and Public Health Collaboration and Family Care International (FCI) our latest research on maternal mortality aims to demonstrate the social, emotional, financial and practical burdens rural Kenyan families experience when a young woman dies during childbirth or pregnancy. Estimating how this combination of burdens – as opposed to just one – affects families and communities makes this study particularly unique. Ultimately, we hope our findings on the costs of maternal mortality will compel policymakers to take action so families can avoid another mother’s preventable death.
In Kenya, we are meeting poor rural families affected by maternal death to better understand their experience. We are collecting data on the financial toll they incur when they have to pay for emergency treatment and funeral services. And we’re learning how families already struggling to make ends meet are sent further into a cycle of poverty when they lose a productive member of their household.
While I was in Nyamula, we visited a house where a woman died, leaving behind one child. The mother of the deceased used to take small jobs outside the home to earn income that helped offset household expenses. Now that her daughter is dead, she must look after her grandchild and cannot work outside the home. As a result there is less money to pay for daily expenses and less flexibility to earn the money the family needs.
The emotional strain of a maternal death also weighs on surviving family members. The same mother told us that since her daughter died she has relied on her school-age children for help with household chores. The children resent having less time to study. Furthermore, the mother also said that she is frustrated because she has to rush through cooking meals so that she can care for her baby granddaughter. She said she feels like she wouldn’t be going through all of this if her daughter were still alive.
Tragically, that mother’s experience is all too common in rural Kenya and poor communities worldwide. But this is more than just about just one mother or one family: ICRW’s study and other efforts striving to curb the rate of maternal mortality can contribute to alleviating ill health, poor education opportunities and poverty worldwide. For instance, studies show that a mother’s health has profound implications for the long term well-being of children – particularly girls – through its effect on their education, growth, and care.
There are solutions for Kenyan families and others around the globe. Maternal deaths can be avoided by anchoring health facilities in locations accessible to the poorest, more remote households. That way, women can easily take advantage of pre-natal, post-natal and other care. We also have to change social norms so that women – young women especially – are allowed by other household members to access this important care. And we need the political will – from health and finance ministries to donor organizations – to invest in these solutions.
There is ample evidence illustrating that the health of a woman and her newborn baby are intimately connected. We know that:
- most maternal and newborn deaths are caused by the mother’s poor health before or during pregnancy or due to inadequate care in the critical hours, days, and weeks after birth
- when a woman dies in childbirth, her newborn baby is less likely to survive
Recent research conducted by Dr. Zulfiqar Bhutta and colleagues at the Aga Khan University in Karachi, Pakistan confirms what we already know, and goes one step further: it identifies which maternal and newborn health interventions benefit both mother and newborn. These include:
- Family planning/birth spacing: Family planning, including counseling on and provision of contraceptive methods, prevents unwanted pregnancies and unsafe abortion, and increases spacing between births. Adequate birth spacing (between 18-23 months) reduces the risk of maternal and newborn-related deaths.
- High-quality antenatal care: Antenatal care provides a critical window to address a range of health care needs, such as treating HIV and sexually transmitted diseases (STDs), and providing counseling and educational support. Well-designed, good quality ANC reduces the risk of preterm birth, perinatal mortality, and low-birth-weight infants
- Detection and management of maternal diabetes: Treating maternal diabetes (through dietary advice, glucose monitoring, and insulin) reduces maternal and perinatal morbidity, specifically antenatal high blood pressure and neonatal convulsions.
- Exclusive breastfeeding during the first six months of life: The benefits of breastfeeding for the mother are both short- and long-term. In the short term, she is likely to recover more rapidly from the birthing process. It also has a significant impact on reducing the risk of breast cancer. For the newborn, exclusive breastfeeding for the first six months of life is recommended for optimal growth, development, and health.
This research is a critical step in better understanding just how deeply interconnected are the health of a woman and that of her newborn baby. It also underscores how vital it is to interconnect health care for women and their newborns — to promote greater efficiency, reduce costs, limit duplication of resources, and achieve greater impact.
As part of efforts to promote investment in and implementation of health interventions that can save the lives of both women and their newborn babies, FCI developed two publications summarizing the findings from this research and its impact on advocacy, policy, research, and programming:
- A pocket card for non-technical audiences including policy makers, health officials, and civil society groups.
- An Executive Summary for program managers and implementers working in low-resource settings.
With only three years remaining until the 2015 deadline for achievement of the Millennium Development Goals (MDGs), this year will be a critical moment for efforts to improve global health. Because the health-related MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) — are furthest off-track, advocates, researchers, programmers, and policy makers must work together to develop, support, and implement effective, integrated policies and programs.
TEDxChange, a partnership of TED and the Gates Foundation, was created to spark global conversations about social issues. An event in Berlin this Thursday TEDxChange: The Big Picture, will challenge traditional thinking around a critical global issue — contraception.
Speaking at the event, which will be webcast live, Melinda Gates will kick off a long-term initiative to change the global conversation around family planning, leading up to a major global summit on family planning in London this July. FCI is a partner in the global coalition supporting this campaign.
TEDxChange: The Big Picture
Thursday, April 5 at 12:30p EST
Webcast live in 7 languages | http://tedxchange.org
- Chris Anderson, curator of the TED conference
- Jeff Chapin, designer and engineer for IDEO
- Melinda Gates, co-chair of the world’s largest private philanthropy
- Sven Giegold, German EP Member and environmental advocate
- Baaba Maal, Song writer and artist
- Theo Sowa, Head of African Women’s Development Fund
This will be a truly global event, bringing together an online audience of thousands, as well as 190 local simulcast events in 60 countries.
Connect with the TEDxChange network on Facebook at http://facebook.com/tedxchange and on Twitter by following at http://twitter.com/tedxchange. Join the Twitter conversation on the hashtag #TEDxChange.
Basic medicines, contraceptives, and other health commodities can save millions of lives, but only if people can access them.
A thousand women die needlessly every day from preventable or treatable complications of pregnancy and childbirth. Every year more than 7.6 million children die before reaching their fifth birthday, from preventable and treatable conditions like diarrhea and pneumonia: a child who lives in a poor country is about 18 times more likely to die than one who lives in a wealthier country. And the family planning needs of 215 million women who want to prevent or delay pregnancy remain unmet — meeting this need would prevent 53 million unintended pregnancies and 100,000 maternal deaths every year. Too often, affordable, effective medicines and health supplies do not reach the women and children who need them most.
To address these gaps, UNICEF and UNFPA today launched the Commission on Life-saving Commodities for Women and Children, with a mandate to improve access to essential but overlooked health supplies. President Goodluck Jonathan of Nigeria and Prime Minister Jens Stoltenberg of Norway will serve as founding co-chairs of the Commission, with UNICEF Executive
Director Anthony Lake and UNFPA Executive Director Dr. Babatunde Osotimehin serving as its vice-chairs. The launch announcement said that the Commission will “focus on high-impact health supplies that can reduce the main causes of child and maternal deaths, as well as innovations that can be scaled up, including mechanisms for price reduction and supplies stability.”
Much of FCI’s work focuses on “building the evidence base” on reproductive, maternal, and newborn health, in order to expand access to lifesaving medicines, commodities, and services. Included on the initial list of 12 essential, overlooked medicines and health supplies identified for consideration by the Commission are two medicines that have been focuses of FCI’s advocacy work:
- Misoprostol for post-partum hemorrhage (PPH): The Commission aims to ensure that all women, at the time of delivery, have access to medicines that cause the uterus to contract — or uterotonics — in order to prevent or treat the post-partum bleeding that is the leading cause of maternal death in the developed world. The most commonly-used uterotonics are oxytocin and misoprostol, both of which are on the Commission list. In collaboration with Gynuity Health Projects, FCI has been working on a multi-year project that aims to increase understanding, use, and acceptance of misoprostol for PPH in low-resource settings. Research has shown that misoprostol is safe and effective for preventing and treating PPH, and is particularly useful in settings without refrigeration, electricity, IV therapy, and skilled health providers. Unlike oxytocin, misoprostol can be delivered in tablet form, and is temperature stable, so it does not have to be refrigerated or delivered intravenously.
- Emergency contraception (EC): EC is one of a suite of three particularly overlooked family planning commodities, also including female condoms and contraceptive implants, identified for Commission discussion. FCI serves as host organization for the International Consortium for Emergency Contraception (ICEC), an alliance of non-governmental organizations working to expand access to emergency contraception (EC), with a focus on developing countries. FCI and our colleagues in ICEC and in the broader reproductive health community worked together during the preparatory work prior to the Commission’s launch to ensure that it re-affirms the critical role of family planning in averting maternal and newborn deaths and the importance of ensuring access to EC and other contraceptive methods that are neglected, underutilized, and orphaned.
FCI welcomes the launch of the Commission, and looks forward to working closely with it and with our advocacy and program partners to ensure its effectiveness in improving access to misoprostol, emergency contraception, and other essential health supplies.
For the past five years, FCI has been a key partner in Countdown to 2015, a global coalition of academics, governments, international agencies, health-care professional associations, donors, and NGOs that uses country-specific data to stimulate and support country progress towards achieving the health-related MDGs. FCI shares (with the secretariat of the Partnership for Maternal, Newborn & Child Health—PMNCH) overall responsibility for Countdown’s advocacy and communications, working with partners to ensure that Countdown’s data, analysis, and key messages are seen and used by policy makers to effect real change.
This week, Countdown released a new publication, Accountability for Maternal, Newborn & Child Survival: An update on progress in priority countries, which contains updated profiles on high-burden priority countries that account for over 95% of the world’s maternal and child deaths. The report will be launched at the 126th Assembly of the Inter-Parliamentary Union, which takes place in Kampala, Uganda next week. These profiles highlight how well each country is doing in increasing coverage of high-impact interventions — key elements of the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — that can save the lives of millions of women and children. The charts and graphs in each country profile provide an easy-to-read, attractive, and succinct portrait of whether these high-burden countries are making progress (or not) in increasing women’s and children’s access to essential services like antenatal care, skilled attendance during childbirth, immunization, and prevention of mother-to-child transmission of HIV.
This publication is one of the significant contributions that Countdown is making to the global accountability agenda around the Global Strategy for Women’s and Children’s Health, an unprecedented plan to save the lives of 16 million women and children by 2015, which was launched by UN Secretary-General Ban Ki-moon in September 2010. The country profiles in this publication, customized to showcase the core indicators selected by the Commission on Information and Accountability for Women’s and Children’s Health, are adapted from the full, two-page Countdown country profile, which Countdown produces on a roughly two-year cycle. Full country profiles will be included in Countdown’s 2012 Report, which will be published in June 2012.
FCI is also working on a number of other Countdown initiatives, including the launch of a new Countdown website and the development of a toolkit to assist high-burden countries in developing their own country-level Countdown conferences and publications.
Please join FCI and our partners at a side event to this week’s meetings of the UN Commission on the Status of Women. 1,000 Days: Improving the Nutrition of Rural Women will focus on the crucial time between a woman’s pregnancy and her child’s 2nd birthday. These 1,000 days offer a unique window of opportunity to shape healthier and more prosperous futures. By investing in improving nutrition for mothers and children in this 1,000-day window, we can help ensure that a child can live a healthy and productive life, and we can also help families, communities and countries break out of the cycle of poverty.
Friday, March 2, 2012 10:30 a.m. – 12:00 noon
Salvation Army (Downstairs Conference Room)
221 E. 52nd Street (between 2nd and 3rd Avenues)
New York City
Free and open to the public.
RSVP at www.thp.org/csw56
Questions? Please contact Carolyn Ramsdell at 212-251-9130 or Carolyn.firstname.lastname@example.org
In many developing countries, national health systems don’t always effectively reach certain groups of people with the information and services they need to stay healthy. Too often, the health services that are available are designed without sufficient regard for the cultures, beliefs, and traditions of those they aim to reach, and the result is that essential information doesn’t get through to its intended audiences, and that urgently important health services don’t get utilized. Many members of particularly marginalized groups — which can include teenagers who have left school or their home villages to seek work in the city, or indigenous populations living in poor, underserved rural communities — don’t know what they need to know about their sexual and reproductive health, and are particularly vulnerable to HIV infection.
FCI works with our local partners to address this challenge by developing culturally-sensitive programs for reaching vulnerable groups with the information and services they need. Working with out-of-school young people in the port city of Mopti, on the Niger River in Mali, West Africa, and with women and young people in remote indigenous villages in Ecuador, we have partnered with Interarts, with support from the Spanish Agency for International Development Cooperation (AECID), to promote sexual and reproductive health and prevent HIV.
In mid-February, Fatimata Kané, FCI’s country director in Mali, and Maritza Segura, our national coordinator in Ecuador, together with representatives from our local partner organizations, presented this work at a conference in Barcelona, Spain. This meeting, entitled “Culture and Sexual and Reproductive Health—towards a new interconnection: A day to think, discuss and act,” was organized by Interarts as an opportunity for 50 NGOs, development agencies, migrant organizations, health workers, anthropologists, and educational professionals to share best practices and exchange ideas on the links between cultural rights, sexual and reproductive rights, and health. Meeting participants emphasized that integrated programs must focus on community needs, guarantee health rights, and respect local cultures and cultural rights. Understanding a community’s culture is essential to any health project’s success and sustainability, and is particularly important in efforts to modify behaviors that may have a negative impact on sexual and reproductive health, enabling programmers to identify bottlenecks and address issues in a participatory way.
For the Barcelona conference, the representatives from FCI-Mali and FCI-Ecuador were accompanied by youth leaders from FCI’s project partners: AEJT (the Association of Working Children and Youth) in Mopti, Mali, and Ecuarunari (the Kichwa Confederation of Ecuador). The team from Mali described their work with young people in Mopti’s ‘informal sector’ (domestic workers, market vendors, artisanal apprentices, etc.), and with the traditional leaders, employers, and parents who can influence them, to raise awareness about the consequences of negative and high-risk practices and to encourage cultural change for better sexual and reproductive health. (At first, taboos about discussions of sexuality made it difficult to involve religious leaders in the project; by sensitively integrating culture and religion into our approach, however, FCI was able to facilitate constructive dialogue by showing that religious texts do not actually support female genital mutilation and other negative practices.) The team from Ecuador discussed their work with indigenous women’s and youth groups to identify the traditions, beliefs, and cultural factors that lead to increased vulnerability to HIV, and to strengthen cultural values that can help prevent HIV and its attached stigma in indigenous communities.
Ann Starrs is FCI’s president. The remarks below were delivered by Ann at the United Nations Association of the USA’s Members’ Day, at the UN on February 10, 2012.
I’m going to start this talk with a story. It’s the story of a family in Afghanistan, several years ago. The wife was pregnant for the seventh time; she died of postpartum hemorrhage, the most common cause of maternal death in poor countries. Because her husband couldn’t cope with the responsibilities and cost of caring for a large family on his own, one of their daughters, aged 13, was married off, to a much older man. At the age of 15, she gave birth to twins. One of the infants died right after birth, and the young mother developed fistula, a horrifying complication in which a woman develops a hole between her urethra and vagina, and leaks urine for the rest of her life unless the hole is surgically repaired. Because of her smell, her husband sent her back to her father, with the weak and ailing surviving infant. They had to spend what was, for them, a significant amount of money trying to get care for the baby.
This is just one family’s story, but it is representative of millions more. Around the world, a woman dies from preventable causes related to pregnancy and childbirth a thousand times every day. A child dies, of similarly preventable causes, every 3 seconds. Add these stories up, and the annual death toll is staggering: 350,000 maternal deaths a year, each one leaving grieving parents, husbands, or children, and 7.6 million children dying before the age of 5. Forty percent of these children are lost in their first month of life, and again, nearly all of these deaths are preventable.
The tragedy of this Afghan family is representative in another way. It portrays, in a nutshell, the multiple reasons why the world must invest in women’s and children’s health. There is a clear moral imperative to prevent these needless deaths, but no less clearly there is an economic imperative. A healthy woman — who is able to decide on the number and spacing of her children, who can deliver them safely, who can see them through childhood in good health — is someone who can contribute to the economic productivity, and to the social and cultural stability, of her family, her community, her nation, and the world. A family destroyed by the loss of a mother or daughter, made desperate by the loss of a breadwinner, or burdened by the tragedy of a lost child, is far too often a family that finds itself trapped in an inescapable cycle of poverty.
This is a challenge that advocates, NGOs, and UN agencies have been working on tirelessly, for decades. My organization, Family Care International, has been working in partnership with governments, other NGOs, donors, academics, and others to raise attention and mobilize commitment — and funding — to address the multiple causes and prevent the horrifying consequences of maternal death. Much of our work is done through and with the Partnership for Maternal, Newborn, & Child Health (known as PMNCH), which has worked to great effect to focus the world’s attention on the powerful and crucial concept of the continuum of care.
The Global Strategy for Women’s and Children’s Health was launched by UN Secretary-General Ban Ki-moon at the General Assembly in September 2010. The Global Strategy was an expression of the Secretary-General’s recognition that the health MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) — were headed for failure, and that this dire circumstance presented the world with an urgent moral imperative. The Global Strategy, and the Every Woman Every Child effort that aims to generate commitments to the Global Strategy, represents the compelling moral power of the UN and its Secretary-General to mobilize the world into focused action. Its stated goal was to save 16 million lives between 2010 and 2015.
The Global Strategy has, so far, provided a much-needed jumpstart to international efforts to bring about real progress on women’s and children’s health. It has bought together key UN and other multilateral agencies (including WHO, UNICEF, UNFPA, UNAIDS, and the World Bank) around a coherent, comprehensive vision of what needs to be done to save lives. The Global Strategy set clear, measurable targets, and mechanisms have been established to keep track of whether targets are being met and to ensure accountability. It has mobilized a broad range of stakeholders — from civil society organizations to corporations, from all of the most important international donors to the governments of dozens of developing countries — to commit themselves to take specific, concrete, and significant actions. Many of these commitments have been pledges of money, which is desperately needed, but many have also been commitments in kind: pledges to build new midwifery schools, to achieve specific increases in national skilled childbirth attendance or immunization rates, to institute free emergency obstetric and child health care, or to increase access to and use of contraceptives.
This is a multi-year effort, and one whose goals are both ambitious and urgently necessary, and much more still needs to be done. In this time of limited and constrained resources, we must bring about greater efficiency and effectiveness in the ways that aid is allocated and programs are implemented, with a particular focus on the integration of services, so that women and families can meet their health care needs at a single health center offering high-quality, comprehensive services across the continuum of care. We must work in a targeted way, focusing our resources and efforts on key countries, where the burden is highest, and on key, proven interventions. We must ensure that governments, donors, and all other stakeholders are held to account for fulfillment of their commitments: the Global Strategy only becomes truly meaningful when its promises are kept, and advocates (including my organization) are working hard to make sure that they are. And we must have sustained, vocal, visible, high-level leadership — from the Secretary-General himself, from heads of state, and from celebrities; but also from dedicated and often unsung individuals in ministries of health, in civil society organizations like the United Nations Association, in hospitals and clinics, and in the villages and communities where so many women and children are still dying.
So what am I —an advocate from an NGO, and not a representative of the UN — doing here, in front of the United Nations Association, describing an initiative of the UN Secretary-General? I’m here because a great part of the power of this initiative is the way it focuses on the value of partnership to get things done. An engaged, empowered civil society — both here at the global level, and at the grass roots in every country with a high burden of maternal and child death — must play, and is playing, a central role in that partnership. The voice of civil society is key to making change happen, in every corner of the world.
In 2000, the world committed itself in the Millennium Declaration to bring about momentous change by the year 2015, to address the historic challenges of poverty, hunger, disease, inequality, and environmental degradation that deform or end so many lives in the developing world. Much progress has been made, but it is clear that the goals related to health will not be fulfilled. And MDG 5 is the furthest from success. As we begin to talk about an international framework for continued, and accelerated, progress beyond 2015, that framework must include special attention to the health, well-being, and education of children and women. The United Nations, under the leadership of Ban Ki-moon, has set a visionary, progressive agenda. It is our obligation to build on that legacy, to build a world where no woman and no child dies a preventable death, simply because they were born in the wrong place, because they are poor, because we pretend we can’t afford to save them. The Global Strategy has been an essential first step, and its urgent, essential work will continue until it is done.
Robinson Karuga is research coordinator at FCI-Kenya.
In Kenya, when someone in a poor, rural community needs health care, she goes to a health center — a facility in a nearby market town, offering a broad range of primary health services — or to a dispensary — a lower-level facility, typically staffed by a single nurse and providing only limited services. For most Kenyans, health centers and dispensaries are their only contact with the health system, and the only available source of primary care. For Kenya to make meaningful progress in reducing its high rates of maternal and child mortality, the services offered in these primary-level facilities must be strengthened, and more Kenyans must be persuaded to use them: more than half of Kenyan women still give birth without help from a skilled attendant, a statistic that has actually become worse over the past 20 years.
Unfortunately, primary-level facilities often have not had the money they need to support consistent, high-quality services — in Kenya’s centralized national health system, allocated funds rarely filtered down to facilities through inefficient district disbursement channels characterized by leakages and mismanagement. In recent years, this funding shortfall was made worse by the government’s reduction and ultimate abolition of official user fees for many essential health services: ironically, a policy designed to increase poor people’s access to services often resulted in poorer service quality, as the facilities’ lost revenue was not replaced.
Beginning in 2010, the Ministry of Health addressed this problem with a program of ‘Direct Facility Funding’ (DFF), by which funds are provided directly from the national government to cover facilities’ core expenses, so that they can provide high-quality services that are responsive to communities’ needs. This is a potentially powerful reform, but facilities face significant challenges in implementing it, including managers with insufficient budgeting and money management skills and a lack of transparency in how money is allocated and spent. There is also a lack of community awareness and monitoring of the DFF process, which minimizes community input on priorities for quality‐of‐care improvements.
This year, with support a from the Transparency and Accountability Program of the Results for Development Institute, FCI-Kenya will evaluate communities’ knowledge and understanding of the direct facility funding system and their level of satisfaction with health facilities’ quality of service and accountability. FCI will work in two counties (one rural and one urban), using “citizen report cards” to collect quantitative and qualitative data from health facility clients and from members of Health Facility Management Committees, community-based groups that are charged with managing funds at the facility level.
FCI will then work with government partners to develop an advocacy and community mobilization strategy to provide Health Facility Management Committee members with the knowledge and skills to manage funds effectively, and to ensure that community members have input into how funds are spent. Based on lessons learned from the project, the Ministry of Health — which enthusiastically supports this first-ever evaluation of the DFF reforms —plans to introduce the citizen report card throughout the country. It will serve as a continuous social accountability tool, creating a feedback loop between the national health financing structure and the community, and giving users of the health system a real voice in the services it provides. By empowering communities and building financial management capacity in the facilities themselves, this project offers a new and meaningful opportunity both to improve the quality of care and to increase demand for high-quality services.