RAISE Initiative, Columbia University Global Evaluation Steering Committee Workshop

1. Reproductive Health Services in South Sudan, DRC and Burkina Faso:Preliminary Results from the Service Availability and In-Depth Studies RAISE Initiative, Columbia University Global Evaluation Steering Committee Workshop February 12, 2014

2. Presentation Outline • Study methods • Preliminary results • South Sudan • DRC • Burkina Faso 3. Summary

3. Study Objectives • To assess the availability, quality and utilization of RH services • To propose how to adapt service delivery and IEC programs according to barriers and perceptions • To highlight differences between policies and practice, evidence-based decisions vs beliefs/myths/perceptions-based decisions. • To propose how to improve quality and utilization of services • To systematically assess the availability and use of facility-based RH services

4. In depth - Methods • Background desk review • Interviews with key informants • Focus group discussions with men, women and young people • Detailed facility assessments (small sample) • Assessment of provider knowledge and attitudes

5. Service availability - Methods • Facility assessment (shorter than in-depth) • All (or sub-sample of) facilities providing RH

6. Data collection

7. Preliminary results: South sudan

8. National Policies and Financing • RH integrated into government health policy • No functional public health sector financial management system • Services are free, in theory • Critical shortage of trained health providers • Low access to and utilization of RH services

9. Coordination and Emergency Preparedness • National RH Forum meets monthly, open to all active agencies in sector • RH integrated in health and protection clusters, but considered low priority • GBV is an active sub-cluster of the protection cluster • Maban County: • UNFPA coordinates MISP and provides (insufficient) RH kits • RH working group launched in May 2013

10. Facilities assessed, n=15 • PHCUs: Dispensaries, short acting FP methods • PHCCs: BEmOC, delivery, all short and long acting FP methods

11. Family Planning

12. Abortion

13. EmOC

14. HIV & STIs

15. Care for Survivors of Sexual Assault:

16. Key Beneficiary Perceptions of RH Issues • Women aware of benefits of birth spacing • Men think stopping a woman from having children is bad for women and the community • FP for unmarried women is unacceptable; husband consent required • In rare cases, a women can have her baby “removed” with herbs • General belief that delivering at health facility important • All knew HIV/AIDS – but have misconceptions about transmission • Domestic violence common, but rape (outside marriage) considered rare • Rape sometimes used as strategy to force a woman to marry

17. Key Beneficiary Perceptions of RH Services • No FP information or services available in camps • Women like delivering at camp health facilities – high quality, free and later receive food assistance • No treatment exists for HIV/AIDS • Don’t know of any GBV services

18. Preliminary Results: Democratic republic of congo

19. National Policies and Financing • RH services part of national health policy and minimum service package at health centers • Practical availability of RH services depends on support by INGOs • 4% of national budget goes to health - fee for service in place for all services (unless supported by NGO)

20. Coordination and Emergency Preparedness • RH Working Group • Meets monthly & coordinates with Health Cluster • Trained NGO staff in MISP implementation • Agencies have separate EP plans, usually include RH • UNHCR provides hygiene & PEP kits • WHO includes MISP supplies in pre-positioned kits

21. Facilities assessed, n=19 • Health Centers: ANC, post-natal care, BEmOC, delivery, All short and long acting FP methods, testing and treatment of chronic diseases (including HIV) • Hospital: Referral, surgery, CEmOC, all short-acting long-acting and permanent FP methods *1 or more RH service

22. Family Planning

23. Abortion

24. Basic EmOC

25. HIV & STIs

26. Care for Survivors of Sexual Assault

27. Key Beneficiary Perceptions of RH Issues • Aware of some modern methods, but FP associated with “prostitution” and should be kept secret • Children outside marriage common, but present many social challenges • Catholic influence is strong • Aware of importance of facility deliveries, but actual behavior influenced by many factors, decision-makers • Some unmarried women have never heard of HIV • Physical and sexual violence considered common

28. Key Beneficiary Perceptions of RH Services • FP services not considered available for adolescents • Access to FP difficult due to misconceptions and lack of information (by community and providers) • ANC services available and of high quality • Concerns about availability of staff, comfort and distance for facility delivery • Induced abortion considered unavailable, but believe demand exists for unmarried women • HIV services not believed to be widely available • Services for survivors of sexual assault not available in IDP camps but are in HCs and hospitals

29. Preliminary results: Burkina faso

30. National Policies, Financing and Emergency Coordination • RH integrated in national health policy, services for refugees expected to align • Refugees receive free care, but host population typically pays a small portion of cost of care • In practice, access difficult in Sahel Province but refugees have better access than host population • Emergency preparedness and response plan developed in 2012 • Weekly national coordination meetings held with relevant actors

31. Facilities assessed, n=28 *2 hospitals receive NGO support for FP • Hospitals: Referrals, CEmOC, all FP methods, HIV services, care for sexual assault survivors • Health centers and refugee camp facilities: Delivery, short and long-acting FP methods, HIV services, care for sexual assault survivors

32. Family Planning

33. Abortion

34. Basic EmOC

35. HIV & STIs

36. Care for Survivors of Sexual Assault:

37. Key Beneficiary Perceptions of RH Issues • Believe ANC visits and facility deliveries important for maternal & child health • Unmarried women most lacking in knowledge of RH issues, services • All had heard of HIV/AIDS • Most knew of other STIs, but some hold misconceptions • Domestic and physical violence common, sexual violence occurs but considered less common • Women collecting firewood and visiting latrines at night considered high risk

38. Key Beneficiary Perceptions of RH Services • Refugees have better access to RH services than host population • Most aware of free FP services at camp facilities, but have concerns about confidentiality • Camp ANC and delivery services high quality – better than “back home” • Most aware of HIV testing services, some thought treatment available at the hospital • Aware of reporting system for sexual violence, little discussion of services

39. OVERALL Summary

40. Summary results • FP:Some methods available at most facilities • Long-acting methods available in some facilities • Permanent methods unavailable • PAC is very limited • Comprehensive abortion carenon-existent • EmOC: Few facilities offer all BEmOC signal functions • GBV: Care for survivors of sexual assault available in about half of facilities

41. Summary results (continued) • HIV/STIs services are sporadic • Syndromic diagnosis and treatment of STIs mostly available • VCT, PMTCT and ART largely unavailable • RH often included in govt. health policies • RH working group active in 2 of 3 countries