Sexual and Reproductive Health and Rights. Policy and Implementation in the Belgian Development Cooperation

Transcription

1 Sexual and Reproductive Health and Rights Policy and Implementation in the Belgian Development Cooperation October 2013

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3 TABLE OF CONTENTS Overall Study Summary... 5 MODULE Background... 6 Study objectives... 6 Methods... 6 Results... 6 Conclusions... 7 Recommendations... 7 Summary I. Introduction I.1 Background I.2 Rationale II. Study Objectives III. Methods III.1. Structure of the questionnaire III.2. Target population III.3. Data Analysis III.4. Ethical Issues IV. Results IV.1. Respondents profile IV.2. Relevance of SRHR in projects or programmes IV.3. Awareness of the policy note IV.4. Knowledge on the policy note IV.5. Use of the policy note in professional activities IV.6. Commitment to use the policy note in near future IV.7. Subjective feedback V. Discussion VI. Conclusions and recommendations VII. References VIII. Annexes Annex 1. Terms of Reference submitted by DGD to ITM under the framework agreement Annex 2. Survey questions Annex 3. Sample request for completing the survey

4 MODULE Summary I. Introduction I.1. Context I.2. Study rationale I.3. Summary of the first module II. Objectives III. Method III.1. Choice of countries III.2. Data collection III.2.1. Literature review III.2.2. Belgian cooperation expenditure in conjunction with sexual and reproductive health and rights III.2.3. Interviews III.3. Data analysis III.3.1. Analysis of cooperation expenditure in III.3.2. Case studies and country study (interviews, project visits and literature review) III.4. Ethical considerations IV. Results IV.1. The results in context IV.2. Analysis of cooperation expenditure in IV.3. Case studies IV.4. Country study (Uganda) V. Discussion V.1. The role of sexual and reproductive health and rights in Belgian cooperation on the ground V.2. Alignment with national policies and priorities in health V.3. Harmonisation with other international partners V.4. Contribution towards MDGs V.5. Opportunities VI. Conclusion VII. Recommendations VII. Annexes Annex 1. Terms of Reference submitted by DGD to ITM under the framework agreement Annex 2. Country selection procedure Annex 3. List of organisations encountered Annex 4. Interview guide Annex 5. Documents consulted Annexe 6. Analysis grid Annex 7. DGD expenditure in 2011 in the Humanitarian aid sector Annex 8. SRHR services offered in the Kirundo district Annex 9. Balance between the Belgian policy note, the HSSP III and the PEAP

5 Overall study summary 5

6 Background Early in 2012, the Belgian Directorate- General for Development Cooperation (DGD) requested the Institute of Tropical Medicine to provide a qualitative description of the contribution made by Belgian development aid towards improving sexual and reproductive health in the supported programmes. The motivation for this request was threefold: 1) it had been five years since the publication of the policy note on sexual and reproductive health and rights (SRHR); 2) the overall insufficient progress towards the SRHR- related millennium development goals; and 3) the change in aid modalities following the Paris Declaration. Study objectives In order to respond to this request, a study with two different modules was agreed upon. The first module aimed to determine the awareness and use of the SRHR policy note by key actors of the Belgian cooperation, while the second module provided a review of sexual and reproductive health interventions in three different types of development aid programmes as well as one in- depth country study. This overall summary provides a short outline of the main findings of both study modules. For each module, a separate full report is available, discussing in detail the methodology, the observed results and recommendations. Methods For the first module, a structured questionnaire was sent to key actors of the Belgian development cooperation, based both in Brussels and in the partner countries. The questionnaire asked about the respondent s awareness, knowledge and use of the policy note, and allowed for some subjective feedback as well. The second module consisted of three case studies related to different types of aid programmes: the first case study focused on a project for which SRHR was part of the key objectives, while the second case study targeted a primary health care project. Both were carried out in Burundi. The third case study focused on health sector budget support, and took place in Uganda, where the overall country study was also done. The case and country studies were mainly based on the review of relevant documents and a series of interviews, using an assessment tool that had been prepared in advance. Results The results are described in detail in the respective reports of each study module, but the highlights are as follows: The SRHR policy note, even if considered useful, is insufficiently known and insufficiently used by the Belgian actors in development cooperation, independent from whether or not they are working in the health sector, and independent from the type of organisation they are working for. The multi- sectoral relevance of SRHR, its applicability also outside of health or rights- based contexts, is insufficiently recognised. The same is true for SRHR as a cross- cutting issue, to be integrated in all types of programmes. From an operational perspective, the contribution of the Belgian development cooperation towards improving SRHR differs according to the types of programme supported. Specific SRHR projects allow covering very specific SRHR needs, while SRHR components were seen to be well- integrated in the primary health care case study. However, in a context of sector 6

7 budget support, there is a real risk that SRHR will be dwarfed by the many other priorities that need to be considered in the health sector political dialogue. On country level, the study illustrates that other international actors may be very active on SRHR related issues, including donors, non- governmental organisations and UN agencies. The strategic fields identified in the Belgian policy note seem largely to be in line with the strategies pursued by those national and international actors. However, in the absence of a conscious choice to give particular attention to SRHR issues, Belgium does not really gain visibility in this area. Conclusions This study provides a rather comprehensive view on the contribution made by the Belgian development cooperation towards improving sexual and reproductive health in the supported programmes. The two complementary study modules illustrate that there is room for the SRHR policy note to take a more prominent role in the process of defining and implementing development cooperation programmes. The study also confirms the challenge for a donor such as Belgium to keep SRHR as an active priority when aid is based on budget or health system support. Recommendations The key recommendations from both study modules are as follows: Ensure proactive and sustained efforts to raise awareness of the policy note s existence and its main areas of cooperation and strategic fields, and to make the policy note easily and widely available to all actors of the Belgian development cooperation; Promote and facilitate the use of the policy note in the health and rights sectors, but also in other sectors of the development cooperation; Continue to encourage a primary health care approach where as much as possible all aspects of SRHR are integrated in the health services; Continue to finance projects that cover very specific needs of SRHR, which may not be covered by the primary health care services; In partner countries where the health sector is a priority sector, ensure the presence of an attaché who is specifically responsible for that health sector; In case budget support is provided, use all opportunities to actively participate and contribute to the political dialogue, whether it be through participation in technical workinggroups or through other (multilateral) actors financed by Belgium. 7

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9 Module 1 Survey of SRHR policies and use of the Belgian SRHR policy note Final Report, October

10 This research project was carried out under the framework agreement between the Institute of Tropical Medicine (ITM) and the Belgian Development Cooperation (DGD). The principal investigators were Evelyn Depoortere and Dominique Dubourg. The project was supervised by the ITM steering committee: Vincent De Brouwere, Thérèse Delvaux, Rachel Hammonds and Dirk Van der Roost. Acknowledgements: We would like to thank all members of the Be- cause Health working group on sexual and reproductive health and rights for the initiative for this study, and for their constructive feedback and support during the whole process of carrying out this project. We also want to thank Ignace Ronse at DGD for his input at the different stages of the project, and for facilitating communication with the Belgian actors in development cooperation. 10

11 Summary It is almost a certainty that the fifth millennium development goal (MDG), i.e. improving maternal health, and specifically MDG 5B, i.e. achieve, by 2015, universal access to reproductive health, will not be reached. Belgium has identified sexual and reproductive health and rights (SRHR) as one of its priorities in development cooperation. For this reason, a web- based survey was carried out between May and July 2012 to determine the awareness and use of the Belgian SRHR policy note by key Belgian cooperation actors. Out of the 278 target respondents who received the request to complete the questionnaire, 90 responses were received, i.e. a response rate of 32.4%. Almost one third of the respondents were not aware of the existence of the SRHR policy note, and two thirds mentioned that they had never used the policy note since its publication in At the same time, almost half of the respondents considered the policy note an important tool for their current professional activities and almost two thirds anticipated that they would use the policy note in the coming year. This survey highlighted the need to make the SRHR policy note more easily and widely available, to actively draw attention to the existence of the policy note among all cooperation actors and to provide operational examples of how the SRHR policy can be implemented in the daily professional activities of the development cooperation, whether these are in the health sector, the rights sector, or any of the other sectors in which Belgian actors operate. 11

12 I. Introduction I.1 Background In March 2007, the Belgian Directorate- General for Development Cooperation (DGD) published the policy note Belgian development cooperation in the field of sexual and reproductive health and rights. (1) The policy note outlines six strategic fields for Belgian policy in this area: 1) promoting the integration of sexual and reproductive rights into national policies, 2) promoting gender equality and the empowerment of women and girls, 3) devoting more attention to adolescents and young people, 4) strengthening health systems, 5) promoting a global approach to AIDS and 6) supporting awareness raising, information and education. An important reference for the Belgian policy note was the 1994 International Conference on Population and Development (ICPD), which took place in Cairo, and where a programme of action was adopted.(2) During the Millennium Summit in September 2000, the United Nations General Assembly adopted the Millennium Declaration, from which the Millennium Development Goals (MDGs) were derived. Four of the eight MDGs are directly related to health and reproductive rights, i.e. MDG 3 promoting gender equality and empower women, MDG 4 reducing child mortality, MDG 5 improving maternal health, and MDG 6 combating HIV/AIDS, malaria and other diseases. The latest progress reports on the MDGs have shown that MDG 5 is the one area in which the most progress has yet to be made, and this is particularly true of MDG 5B achieving, by 2015, universal access to reproductive health which was added only in A third element is linked to the operational consequences of the 2005 Paris Declaration;(3) the principles of ownership, alignment or harmonisation encourage the provision of aid through general budget support, sector- wide approaches (SWAp) or health systems strengthening. These more generic types of support make it increasingly difficult for donor countries to measure the direct results or impact of the development aid provided, particularly in specific areas such as sexual and reproductive health. In 2009, a working group on sexual and reproductive health and rights (SRHR), with representatives of DGD and the Belgian Technical Cooperation (BTC), relevant civil society and academic partners, was established within the platform Be- cause Health to increase awareness of the Belgian SRHR policy note and its implementation. I.2 Rationale Five years after publication of the Belgian SRHR policy note, and considering the room for improvement in reaching the SRHR- related MDGs as well as the consequences of the Paris Declaration, the DGD considered it important to investigate how Belgium through its policy note on SRHR contributes to the specific needs of sexual and reproductive health in developing countries. Terms of Reference (ToR) for such a research project were developed and the Institute of Tropical Medicine (ITM) was asked to implement them under the framework agreement with the DGD. (Annex 1) The ToR were agreed by the SRHR working group. This report refers to the implementation of the first part of these ToR, i.e. module 1: Survey of SRHR policies and the use of the Belgian SRHR policy note. 1 MDG 5A aims to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. 12

13 II. Study Objectives The objective of the overall research project is to provide a qualitative analysis of the contribution that Belgian development aid makes towards improving sexual and reproductive health in the supported programmes. The specific objective of module 1 was to determine the degree of awareness and how widely used the SRHR policy note is by key Belgian cooperation actors. III. Methods A structured questionnaire was developed as part of the study protocol, which was approved by the ITM Institutional Review Board (IRB) on 8 May 2012; members of the SRHR working group had been given the opportunity to comment on the questionnaire, and comments had been integrated as much as possible in the final version submitted to the IRB. The questionnaire was entered into the publicly available survey tool SurveyMonkey, and tested before final validation. The final questionnaire, produced only in English, was made available to the target population through a web link. Requests to complete the survey, including a written reminder, were sent at different times to different groups between 16 May and 16 July 2012 using the official DGD mail system. In addition, for those instances where there was no indication that the request to complete the survey had been forwarded, a follow- up telephone call was made. For one such instance, the follow- up was not possible due to the attaché being in the middle of changing country post. III.1. Structure of the questionnaire The questionnaire was structured around five different parts (Annex 2): The relevance of SRHR in the programmes/projects in which the respondent is involved; The respondent s awareness of the policy note; The respondent s knowledge on the policy note; The use of the policy note in professional activities; An indication of the respondent s commitment to use the policy note in the near future; Subjective feedback. The questionnaire ended with asking some basic information on the respondents characteristics. 13

14 III.2. Target population A request to complete the survey online using the web link was sent to the following key Belgian cooperation actors: Development cooperation attachés based in the partner countries; DGD case managers for bilateral cooperation; DGD case managers for indirect cooperation with NGOs; DGD thematic reference persons for health; Representatives/technical assistants of the Belgian Technical Cooperation (BTC) present in the partner countries; BTC case managers; BTC health team; Country- based coordinators of the NGOs supported by DGD; Brussels level reference persons for the NGOs supported by DGD. DGD staff (which includes the development cooperation attachés) received the request to complete the survey through the official internal mail system (Annex 3). Attachés based in the partner countries were asked through the same system to forward the request to the NGOs supported by the DGD in that country; an example message was provided to facilitate this task. Similarly, DGD case managers for indirect cooperation were asked to forward the request to the NGO reference persons at Brussels level, also using an example message. The request was made to copy in the principal investigator when forwarding messages to ensure a response rate could be calculated. BTC staff received the request through a regular . Attachés, DGD and BTC staff were addressed in their personal professional capacity; NGO reference persons were asked if the survey could be completed by the most suitable colleague on behalf of the organisation. III.3. Data Analysis Data were extracted from the SurveyMonkey tool into Microsoft Excel, the software in which the descriptive analysis was carried out. The automatic results provided by the SurveyMonkey tool were also used. Further analysis was carried out using SPSS version The answers were checked for coherence and incoherent responses were partly or completely discarded, as relevant. A descriptive analysis was carried out, providing frequencies of answers, overall or per relevant grouping. Comparisons between different subgroups (i.e. area of expertise, working on policy or implementation level, on governmental or non- governmental level, based in Belgium or in a partner country, sector of organisation) were provided for the main outcomes of the questionnaire (i.e. awareness of the note, previous use of the note, considering the note an important tool, anticipated use of the note) using the chi- square test. Statistically significant results are presented with the corresponding p- value. 14

15 III.4. Ethical Issues It was clearly mentioned in all communications that completing the survey was on a voluntary basis and remained anonymous. Any information that would allow the investigators to trace back the initial respondent is not (and will not be) used in any of the reporting or communication on the results of the survey. Funding of this study was ensured through the framework agreement between DGD and ITM. The ITM IRB approval s reference is IV. Results A total of 278 target respondents received the request to complete the survey, including the attachés in 18 partner countries and four multilateral representations, 41 DGD case managers including the health team, 42 BTC staff (in partner countries and in Brussels), 146 NGOs in partner countries and 27 NGO representatives at Brussels level. Therefore, out of the 278 target respondents, 105 (37.8%) were considered to be working on governmental level, and 173 (62.2%) on non- governmental level. The overall response rate was 32.4%. Between 16 May and 24 July 2012, 90 responses were received, of which 84 were through the on- line system. For the six remaining respondents, a completed printed version of only the first page of the 12- page survey, corresponding to questions to (Annex 2) was received; these were excluded from any further analysis. One additional respondent was excluded because answers were not consistent throughout the whole questionnaire. One partner country forwarded the survey request to the NGOs with the SRHR policy note in attachment, but answers from this country were kept for the final analysis. Therefore, the results outlined below are based on a total of 83 respondents. Considering the changing denominators per question, the number of responses (n) received for each question was added to the questionnaire in annex 2. When looking at the specific response rate of those working for governmental versus non- governmental organisations, information is available for 67 respondents, with a response rate of 27.6% (29/105) for those working on government level, and 22.0% (38/173) for those working on non- governmental level. IV.1. Respondents profile More than half of the 68 respondents for whom this information is available (58.8%) were male, and the biggest proportion of the respondents (36.8%) belonged to the years age group. A detailed distribution is shown in table 1. Figure 1 illustrates the professional expertise or profile of the respondents, the main being general/administrative and health. 15

16 Table 1. Age group and sex of SRHR survey respondents (n = 68), May July Male Female Total n % n % n % years years years years years or more Total Figure 1: Personal professional expertise/profile of SRHR survey respondents (n = 68), May July Education 5,9% Gender 4,4% Other 10,3% General/admin 33,8% Agriculture 14,7% Rights 1,5% SRHR 1,5% Health 27,9% More than half of the respondents (55.9%, 38/68) worked for a non- governmental organisation, which is comparable to the distribution among the targeted respondents, where 62.2% worked at non- governmental level. The policy and implementation activities were more or less evenly distributed, i.e. 27.9% (19/68) reported to be working on policy level, 33.8% (23/68) at implementation level, and 36.8% (25/68) at both policy and implementation level; one person mentioned not to be working on any of these. Regarding the area of work, the 38 respondents for whom the information is available, reported that their organisation mainly worked in the health (21/38) and agriculture (15/38) sectors; multiple responses were possible for this question. (Figure 2) 16

17 Figure 2. Main sector(s) SRHR survey respondents organisation work in (n = 38), May July Health 55,3% Agriculture Rights Education Gender 39,5% 34,2% 34,2% 31,6% Society building and conflict prevention Environment Other Private sector Infrastructure 15,8% 15,8% 10,5% 10,5% 7,9% Aid for trade 2,6% 0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% Responses were received from respondents from 12 out of the 18 partner countries, nine in Africa, two in Latin America and one in the Middle East. More than half of the respondents (52.9%) reported that they were based in Belgium at the time of completing the survey, while 5 persons stated that they were working at regional level (Table 2). The great majority (69.7%, 46/66) reported that they had been based in the country for more than three years, while 6.1% (4/66) had been there for less than six months, 9.1% (6/66) between six months and one year, and 15.1% (10/66) between one and three years. Table 2. Country base of SRHR survey respondents (n = 68), May July Country base n % Belgium Benin Burundi Bolivia Mali Morocco Niger Palestine Peru Rwanda Senegal Tanzania Uganda

18 Regional level (Africa) Regional level (South America) Invalid or not further specified Total IV.2. Relevance of SRHR in projects or programmes How do you consider the overall importance of SRHR in the programmes/projects you follow or are involved in? Do you know whether SRHR is considered in the national health plan of the partner country you work with? (n = 79) Respondents were asked to what extent SRHR issues are considered in the projects or programmes they follow: 6.2% (4/64) stated that SRHR was the principal objective in all projects/programmes, and 17.9% (12/67) that SRHR plays an important role in all. As a reason for SRHR not being considered in projects or programmes, several respondents indicated that this issue was outside the scope of their organisation. When only considering the 21 respondents who indicated health as (one of) the main sector(s) of their organisation, three (14.3%) stated that SRHR was the principal objective in all of the projects/programmes, and 10 (47.6%) in some of them. In the same group, one stated that SRHR was not considered in any of the projects/programmes followed, while 16 (76.2%) stated that this was the case in some of them. When only considering the 13 respondents stating that rights was (one of) the main sector(s) of their organisation, SRHR was not considered in any of the projects/programmes in one instance and in some of them for the remaining 12. The majority of respondents (57.0%, 45/79) knew SRHR to be considered in the national health plan of the partner country they worked with, while 27.8% (22/79) stated they were not sure or didn t know and one respondent said to be sure that SRHR was not considered in the national health plan. For the 11 respondents working with several countries, no clear conclusion could be drawn. 18

19 IV.3. Awareness of the policy note Are you aware the Belgian SRHR policy note exists? (n = 76) Have you ever read the SRHR policy note with due attention to its content? (n = 53) Do you know where to find a copy of the SRHR policy note? (n = 53) Are you aware about the ICPD programme of action? (n = 75) Have you ever read the ICPD programme of action? (n = 75) Out of 76 respondents for whom the information is available, 23 (30.3%) stated that they were not aware that the Belgian SRHR policy note existed. There was no statistical difference on the awareness on the policy note between the different subgroups, i.e. area of expertise, working at policy or implementation level, at governmental or non- governmental level, based in Belgium or in a partner country, sector of organisation. Table 4 provides some more details by affiliation of the respondents, i.e. working for a governmental versus a non- governmental organisation, and based in Belgium or in a partner country. Table 4. Awareness of the existence of Belgian SRHR policy note by affiliation of respondents (n = 83), SRHR survey, May July Affiliation Aware of existence Not aware of existence Unknown Total n % n % n % Governmental, in Belgium Governmental, in partner country Non- governmental, in Belgium Non- governmental, in partner country Unknown affiliation Total

20 Awareness of the note s existence was highest among respondents working both at policy and implementation level (80.0% - 20/25), followed by those working at policy level (73.4% - 14/19) and then by those working at implementation level (65.2% - 15/23). Of the 53 respondents who were aware of the policy note s existence, 26 (49.1%) stated that they had never read the SRHR policy note with due attention, 26.4% (14/53) did not know where to find a copy of the note. As for the International Conference on Population and Development (ICPD) programme of action, 61.3% (46/75) stated that they were not aware of it. Of those who were aware of it, eight (27.6%) claimed not to have read it, while the remaining respondents said that they had read it partially (37.9%), its summary (20.7%), completely (10.3%), or only the chapter on reproductive rights and health (3.4%). IV.4. Knowledge on the policy note Do you feel familiar with the area of cooperation? Do you feel familiar with the strategic field? In order to understand the extent to which the Belgian SRHR policy note is actually known about by key actors in the Belgian cooperation for development, respondents were asked to indicate their level of familiarity with each of the three areas of cooperation and the six strategic fields outlined in the SRHR policy note (Tables 5 and 6). It is relevant to note that persons who had answered the previous question by saying that they were not aware of the policy note, indicated certain levels of familiarity with the areas of cooperation and/or strategic fields, and their responses are also included in the results below. As a reminder, the three areas of cooperation are: 1) integration of sexual and reproductive health into general health care; 2) the fight against sexual violence and harmful practices; 3) sexual and reproductive health care and rights during humanitarian crises, conflicts and peace building. Table 5. Level of familiarity with three areas of cooperation identified in the Belgian SRHR policy note (n = 74), SRHR survey, May July Area of cooperation Familiar Know about it Don t know much Not at all familiar n % n % n % n % 1 Integration Violence Crises Area 1 (integration of SRH in general health care) and area 2 (fight against sexual violence and harmful practices) were known to more than half of the respondents, 70.2% and 77.0% respectively. 20

21 Table 6 illustrates the knowledge of the six strategic fields: 1) promoting the integration of sexual and reproductive rights into national policies; 2) promoting gender equality and the empowerment of women and girls; 3) devoting more attention to adolescents and young people; 4) strengthening health systems; 5) promoting a global approach to AIDS; 6) supporting awareness raising information and education. Table 6. Level of familiarity with six strategic fields identified in the Belgian SRHR policy note (n = 71), SRHR survey, May July Strategic field Familiar Know about it Don t know much Not familiar n % n % n % n % 1 Integration Gender Adolescents Health systems AIDS Awareness The majority of respondents (between 64.7% and 88.7%) said they knew or were familiar with the strategic fields described in the policy note. Field 2 (promoting gender equality and empowerment of women and girls) came out as the most familiar field. 21