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

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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

22 IV.5. Use of the policy note in professional activities Have you ever used the policy note in your regular professional activities since its publication in 2007? (n = 71) Since its publication, in which context have you mainly used the policy note? (several answers possible) (n = 61) Since its publication, in which policy related activity have you mainly used the policy note? (several answers possible) (n = 61) Please indicate which of the areas for cooperation as specified below are most frequently used in your work. With regards to the 6 strategic fields to be considered in the Belgian development cooperation activities, please indicate their frequency of use in your professional activities. Have you ever recommended the policy note as useful reading material to? (several answers possible) (n = 69) Would you consider the policy note as an important tool for your current professional activities? (n = 69) Would you consider the ICPD programme of action an important tool for your professional activities? (n = 69) Out of 71 respondents, 48 (67.6%) stated that they had never used the SRHR policy note since its publication in (Table 7) There was no statistical difference between users and non- users, for each of the subgroups analysed: expertise health/gender/rights/srhr versus other expertise (p = 0.12), working at policy level, implementation level or both (p = 0.12), governmental versus non- governmental organisation (p = 0.10), main sector of organisation being health, rights, both health and rights, or other sector (p = 0.60), being based in Belgium or in a partner country (p = 0.67). The most frequently reported reason for not using it was that SRHR was not part of the activities or core business of the organisation (21/48). Based on the free text responses, other reasons included a recent start at the Belgian cooperation, no awareness of it, never having received it, never having needed it, etc. Interestingly, one person reported that they had not used it because they were mainly involved in policy dialogue and health systems strengthening. Other interesting responses included not working so much on the Belgian policy in this field but rather on the partner country s policy, and that the organisation didn t generally use governmental policy notes in their programmes. Respondents working at policy level reported that they had used the policy note more frequently since its publication (52.6% - 10/19), whereas 30.4% (7/23) of those working at implementation level and 24.0% (6/25) working on both levels had ever used it. 22

23 Table 7. Use of Belgian SRHR policy note since its publication in 2007 by affiliation of respondents (n = 83), SRHR survey, May July Affiliation Ever used Never used Unknown n % n % n % N Governmental, in Belgium Governmental, in partner country Non- governmental, in Belgium Non- governmental, in partner country Unknown affiliation Total The majority (58.0%, 29/50) also claimed not to have used the policy note in the past year, while 9 persons (18.0%) stated that they had used it 2 to 3 times in the past year, 6 persons (12.0%) on a regular basis, and 6 persons (12.0%) only once. Three responses were excluded because of inconsistency with a previous question (i.e. having previously indicated that the note had not been used). Figure 3 illustrates that for those claiming to have used the SRHR policy note since its publication, the note mainly served as a reference document, in the preparation of an indicative collaboration programme, or in political dialogue. For this particular question, eight additional persons were excluded from the analysis because of inconsistency with a previous question. 38 persons who responded none of the above or other all previously reported that they had never used the policy note since its publication and are therefore not depicted below. 23

24 Figure 3. Context in which the SRHR policy note is mainly used (n = 44), SRHR survey, May July As reference document 22,7% Responding to parliamentary questions 6,8% Technical support to partners 13,6% Preparing ISP/PIC 20,5% Preparing funding proposal 18,2% Political dialogue 18,2% Out of the 36 persons who claimed to have used the policy note and for whom information was available on its use in policy activities, it served mainly in the policy formulation step (Figure 4). For this particular question, eight additional persons were excluded from the analysis because of inconsistency with a previous question. Of the total of 41 persons who responded none of the above or other, the 38 who previously stated that they had never used the policy note since its publication, were not included in the figure below. 24

25 Figure 4. Policy activity in which the SRHR policy note is mainly used (n = 36), SRHR survey, May July Other 8,3% Agenda setting 16,7% Policy formulation 33,3% Evaluation 16,7% Policy implementation 25,0% Tables 8 and 9 indicate which areas of cooperation (Table 8) and which strategic fields are reportedly most frequently used by the respondents in their work. It should be noted that all but two of the 49 respondents who previously stated that they had never used the policy note still claimed to use one or more of the areas or fields in their work, with varying frequency; the remaining two respondents did not respond at all to these two questions. Table 8. Areas of cooperation most frequently used (n = 69), SRHR survey, May July Area of cooperation Frequently Sometimes Rarely Not at all n % n % n % n % 1 Integration Violence Crises 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. Area 1 (integration of sexual and reproductive health into general health care) is the area of cooperation most frequently used in the respondents work, with 62.3% reporting to have 25

26 used it frequently or sometimes. For the strategic fields, the most frequently used are field 2 (promoting gender equality and the empowerment of women and girls) and field 6 (supporting awareness raising, information and education (Table 9). Table 9. Strategic fields most frequently used, SRHR survey, May July 2012 Strategic field Frequently Sometimes Rarely Not at all n % n % n % n % 1 Integration Gender Adolescents Health systems AIDS Awareness The six strategic fields are: 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. N More than half of the respondents (59.4% - 41/69) stated that they had never recommended the policy note to anyone, while 26.1% (18/69) had recommended it to a colleague, 14.5% (10/69) to a local partner, and 11.6% (8/69) to their staff; 3 persons responded other. 47.8% (33/69) of the respondents considered the SRHR policy note to be an important tool for their current professional activities. There was no statistical difference for this response 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. Reasons for considering the policy note an important tool included the importance of SRHR for overall human and capacity development, and the policy note providing a reference when discussing strategy and ensuring synergy within the Belgian development cooperation. 34.8% (24/69) did not know whether this was an important tool for them, while 17.4% (12/69) did not consider it an important tool, the main reason being that SRHR was not within the scope of their activities. When asked the same question regarding ICPD, 42.0% (29/69) considered the ICPD programme of action an important tool for their professional activities (mainly as a common international reference), 14.5% (10/69) did not, and 43.5% (30/69) didn t know. 26

27 IV.6. Commitment to use the policy note in near future How frequent do you estimate you will use the policy note in the coming year (n = 68) In which context are you likely to use the policy note the most (n = 66) When asked about the estimated frequency of use of the SRHR policy note in the coming year, 41.2% of the respondents (28/68) answered a few times, 35.3% (24/68) don t know, 14.7% (10/68) on a regular basis and 8.8% (6/68) not/never. Additional analysis showed that respondents based in a partner country were more likely to anticipate using the policy note in the coming year, than those based in Belgium (p = 0.004). The most frequent context in which it is anticipated that the policy will be used is illustrated in Figure 5. Six respondents who answered negatively to the previous question were excluded. Those responding other all indicated that they anticipate using the policy note in a combination of different contexts. Figure 5. Context in which most likely to use SRHR policy note (n = 62), SRHR survey, May July Other 6,5% Responding to parliamentary questions 3,2% Technical support to partners 14,5% As reference document 30,6% Preparing funding proposal 14,5% Preparing ISP/PIC 16,1% Political dialogue 14,5% Interestingly, out of the 23 respondents who stated at the start of the questionnaire that they were not aware of the existence of the SRHR policy note, five indicated that they anticipated using it in the coming year. 27

28 IV.7. Subjective feedback A fair proportion of respondents (41.2% - 28/68) felt that they would need to use the SRHR policy note more often, while 26.5% (18/68) said they felt they would use the policy note as often as required. Respondents felt they would use the policy note more (14.7% - 10/68) if SRHR were the focus of their activities and/or if the note were available or if they read the note. SRHR not being a focus of activity is also the reason given for feeling no need to use the policy note; this was the case for three respondents (4.4%). Five respondents (7.4%) confirmed that they did not consider the note useful in their professional activities. When asked for recommendations in the event of the policy note being revised, a range of suggestions was made. These are copied below as received, while the categorisation was added for convenience. Increase user- friendliness Make it easier to understand; Make it more simple; Make it more practical; It would be useful if practical tools could be developed to analyse documents on the SHR matters. Increase awareness Make the note available and raise awareness about the note among diplomatic personnel and other staff. A focal point should be appointed; Promote it so people know it exists and is still valid. Organise a 'lunch- meeting' for all of the DGD to present the new note. Make it obligatory for at least one person per service to attend such a presentation. Ask for feedback on the usefulness of the policy note 6-12 months after its completion, rather than 6 years; Organise a presentation on the complete note; To promote it and to facilitate awareness of it among other organisations. Increase synergies Take into account the work and experience of Belgian NGOs and their partner organisations; To create institutional contacts with high level Belgian institutions, rather than set up programmes and search for consultants later on; Make sure there is consultation of different internal and external actors in the process to make sure it becomes a useful document; The evolution at international level: post- MDG, family planning, aids and SRHR (prevention progress, high level event, new strategies), UN high level event on mother and child health; To pay attention on MDG evolution; To align with the context of developing countries; Politicians and DGD to combine the path of birth control with investing in education, employment and empowerment of girls and women. See 28

29 Content updates Put a stronger focus on adolescents' sexual & reproductive rights (sexual orientation, partner's choice... ) and health (more awareness raising, medical services better adapted for youth...); Clarify the human rights approach in relation to the public health approach; Target men in our partner countries to support SHSR; Update with lessons learnt. When given the opportunity to provide any other free comments with regards to the SRHR policy note in general, suggestions included: The policy note should be known, understood, assimilated and used by all involved in the bilateral cooperation; Keep it short and practical, or at least include a one page summary with the key strategic policy choices; The Andean countries are very conservative countries when it comes to sexual health and rights. More than ever it is important that women and men, especially young people, have easy access to information, contraception and good health care. As the bilateral funds are more and more directly assigned to the ministries of health, the Belgian bilateral development can no longer make a big difference in being more active on promoting sexual rights. This should be taken into account in the PIC development and Belgium should foresee funding to civil society groups who give access to sexual health information and services in the countries where Belgium is present; It is more important to have policy notes and strategies on SRHR in the partner country than in Brussels; Have a regular qualitative and participative appreciation of the progress on the note rather than exclusively using checklists like the one proposed by GRAPPA which doesn't generate any momentum. The SRH group of Because Health could play a role in keeping the momentum going. And finally some other comments picked up throughout the survey: Everything depends on the national health policy of our partner country. It's difficult to introduce these matters if the country does not take it into consideration. The overall importance of SRHR in our health programme is obvious. However, SRHR elements could also be incorporated into other programmes and projects that we are engaged in such as our Decent Work Programme and our Food Security Programmes. As these programmes are much bigger the overall importance of SRHR becomes relatively minor (our health program works with only 3 partner organisations in our region). Under non- health related programs we focus on gender, not on SRHR specifically. I do consider it an important tool and this questionnaire has alerted me to it. I will surely read it and see how we can use it in our work from now on. I hardly have here any health programmes in the local activities, and it was decided by others that this is mainly on tertiary health care for special problems. Only for specific financing through local NGOs, humanitarian health programmes, and one specific health programme is there systematically space for this topic. If Belgium really has expertise and wants to work broadly in this sector, then we have a contradiction where we want the partner countries to decide on our priority sectors. 29

30 V. Discussion This survey provides a first insight into the awareness and perceived usefulness of the Belgian SRHR policy note from the perspective of key actors in the Belgian development cooperation, both from the governmental and non- governmental side, from the policy and implementation side. Since SRHR is not considered to be a pure health issue, the rights perspective being equally important, it was a conscious decision not to target only health related professionals or organisations with this survey, but to also include those working in other sectors. Overall, a good representation was obtained from the different sectors in which the Belgian cooperation is active, as well as from the different categories of respondents. Almost one third of the respondents were not aware of the SRHR policy note s existence, and no statistically significant difference was found between people with expertise in health, rights or other sectors. Two thirds mentioned that they had never used the policy note since its publication in 2007, mainly because SRHR was not a focus of their activities or because they never received a copy or had the opportunity to read the note. Again, there was no statistical difference in having used the policy note, between respondents working in the health sector or for a governmental organisation. 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. However, the survey clearly indicates that it is not sufficient to make the policy note available on the DGD website Respondents actively call for the policy note to be made more practical and easy to use, as well as raising awareness of the existence of the policy note and its content, and to make the note more easily available. The survey results show that a much more proactive and continuous effort is needed to promote this key reference document, both at a policy level and an implementation level, in Brussels and in the partner countries, within the DGD and with partners, while at the same time illustrating how the note can be used in daily working practice. Using the opportunity of the annual diplomacy days, including the policy note as part of the package of obligatory reading before departure to a partner country, including references to the policy note in guidance documents for submitting funding proposals to the DGD, etc. could be some suggestions for achieving increased awareness of the note s existence and its content, emphasising also its relevance for all sectors of the development cooperation. By the same token, more awareness on the ICPD programme of action, an essential SRHR reference, is needed. In this context, it is worth noting that on 14 September 2012, the UN High Commissioner for Human Rights convened a high level event to launch the technical guidance on the application of a human rights- based approach to reduce preventable maternal morbidity and mortality (4). It is expected that this guidance will be adopted during the UN Human Rights Council Session later the same month. The guidance stems from the demand to respect a broad range of women s sexual and reproductive rights, as was set out in the ICPD Programme of Action. It aims to assist policymakers in improving women s health and rights by providing guidance on implementing policies and programmes to reduce maternal mortality and morbidity in accordance with human rights standards. The increased visibility of SRHR following the adoption of this guidance could be a timely opportunity to reiterate the importance and relevance of the Belgian SRHR policy note to the DGD development partners. 30

31 Some of the remarks in the survey emphasised indeed the perceived importance of a policy note in general, to ensure a common reference between actors, but others highlighted the apparent contradiction between a Belgian policy note on the one hand, and the principles of the Paris Declaration, promoting alignment with the partner country s priorities and respecting its ownership. This exposes the challenges faced by bilateral cooperation, which need to be openly addressed and discussed between the different actors involved. Another main finding of the survey is that SRHR is still widely considered as a very specific issue, with no or little perceived relevance to non- health or rights- related projects or programmes, or in case SRHR is not the focus of the activities or the organisation. This illustrates that great efforts are needed to raise awareness about SRHR in general, emphasising its broad scope, pointing out its importance as a multi- sectoral issue on one hand, applicable also outside of health or rights- based contexts, but also as a cross- cutting issue on the other hand, which should be integrated in all types of programmes. The inclusion of short case studies in the policy note, set in sectors other than health or rights, might be useful to this end. In addition, reinforcing the importance of the rights perspective would benefit this same purpose, as was illustrated by one respondent stating that, the rights approach is not so clear for me in relation to the public health approach. While it is unlikely that the admittedly strong link between SRHR and health specifically will ever be broken in people s perception, reinforcing the rights aspect may be one step in putting it more into perspective. Interestingly, some of the remarks indicated that gender issues on the other hand are seen as a transversal issue in a more obvious manner. Since gender equality is a specific strategic field of the SRHR policy, it may be sensible to strengthen synergies with the gender issue, which is also recognised as a separate theme within the Belgian development cooperation. Another important even if not completely unexpected finding of the survey is that any knowledge of, or familiarity with any of the areas of cooperation or strategic fields outlined in the policy note, actually seems independent from knowing the note itself; even those respondents claiming not to be aware of the policy note, or to have never used or read it, still had some level of familiarity or knowledge of the issues. In order to increase the added value of the policy note, the emphasis may need to be put more on the fact that it provides a common framework to all actors in the Belgian development cooperation, that it can be a guide in political dialogue, but also for non- governmental organisations when determining country or project strategies. Moreover, it is worth considering in how far knowledge of the note can contribute to exploiting existing awareness to ensure its principles are actually being applied and integrated in projects and programmes, independent of the context or focus. There are some limitations to this survey. In spite of keeping the survey open longer than foreseen, and actively pursuing potential respondents where possible, the response rate remained relatively low. It is likely that professionals or organisations working outside of the health sector did not feel concerned by this topic and therefore decided not to respond; anecdotal evidence confirms this assumption. Unfortunately the timing of the survey was not ideal. At DGD Brussels level, where case managers were not only targeted themselves, but were also asked to forward the request to complete the questionnaire, significant organisational reforms were being implemented, which affected the regular functioning of the services. At partner country level, the survey coincided with the period of attachés changing country posts, ending their commitment in one country while preparing to move to the next. Also the fact that the survey was only available in English, or that it was clearly stated that completing the questionnaire was on a voluntary basis, may have affected the response rate. Language may also have made full comprehension of all questions by some respondents more difficult, as illustrated by a certain degree of incoherence in some of the responses. As much as possible we have tried to exclude such incoherence from the analysis. 31

32 In spite of the relatively low response rate, we believe that the survey still gives a good indication of the awareness and use of the SRHR policy note by actors in the Belgian cooperation. Unfortunately, the data are not available to assess representativeness in terms of age and sex of the respondents compared to those receiving the request to complete the questionnaire. However, there was no statistical difference in the distribution of those working at governmental versus non- governmental level, which gives an indication of representativeness. The survey aimed to determine the awareness and the use of the SRHR policy note; it does not give any indication of the perceived importance of SRHR in projects or programmes supported by the Belgian development cooperation. The survey remains very descriptive and caution is needed before making any hastened conclusions. Complementary information on the actual presence of SRHR in projects and programmes supported by DGD will become available through module 2 of this research project, through the case and country studies (Annex 1). VI. Conclusions and recommendations This survey shows that, for SRHR to be considered systematically in health- or rights- related projects or programmes, or even as a cross- cutting issue in all sectors, serious efforts are still required. The Belgian SRHR policy note may be an appropriate tool at hand with the potential to facilitate obtaining this goal. Awareness- raising on the existence of the policy note, as well as on its content with the areas of cooperation and strategic fields, and making the note easily and widely available, are active requests by the respondents of this survey. This could be done in a systematic manner for the different actors, e.g. within DGD, for the attachés, for BTC technical assistants and for NGOs supported by the Belgian cooperation. Opportunities to do so will need to be identified and actively used. Even if the link with health or rights is quite obvious, more can be done to promote the policy note in both these sectors. For the other sectors, the value of the policy note needs to be shown. This could be done through practical examples or recognisable case studies; strengthening the rights perspective may be an effective approach for this purpose. But knowing about SRHR is not enough; SRHR should be actively considered in all projects and programmes, whether it is through activities in the health sector, or through a rights- based approach in other sectors. A more proactive approach and sustained efforts are needed. A short plan of action on how to do this would be a useful follow- up of this survey. 32

33 VII. References 1 Federal Public Service Foreign Affairs, Foreign Trade and Development Cooperation, Directorate- General for Development Cooperation. (2007) Belgian Development Cooperation in the Field of Sexual and Reproductive Health and Rights. Policy note. Available from: 2 United Nations Population Fund. (1995) International Conference on Population and Development ICPD Programme of action. Available from: 3 Organisation for Economic Co- operation and Development. (2005, 2008) The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Available from: 4 United Nations Human Rights Council. (2012) Technical guidance on the application of a human rights based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. General Assembly, Human Rights Council, A/HRC/21/22. Available from: HRC _en.pdf 33

34 VIII. Annexes 34

35 Annex 1. Terms of Reference submitted by DGD to ITM under the framework agreement I. 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. 2 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. 3 In 2009, a working group on sexual and reproductive health and rights (SRHR), with representation of DGD and the Belgian Technical Cooperation (BTC), relevant civil society and academic partners, was established within the platform Be- cause Health to strengthen awareness on the policy note and its implementation. During the Millennium Summit in September 2000, the United Nations General Assembly adopted the Millennium Declaration, from which the Millennium Development Goals (MDG) were derived. Four of the eight MDG are directly related to health and reproductive rights, i.e. MDG 3 promote gender equality and empower women, MDG 4 reduce child mortality, MDG 5 improve maternal health, and MDG 6 combat HIV/AIDS, malaria and other diseases. The latest progress reports on the MDGs have shown that MDG 5 is the one requiring the most progress still to be made, and this is particularly true of MDG 5B achieve, 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; 5 the principles of ownership, alignment or harmonisation encourage the provision of aid through general budget support, sector- wide approaches (SWAp) or health system 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. Five years after the publication of the SRHR policy note, and considering the room for improvement in reaching the SRHR- related MDG as well as the consequences of the Paris Declaration, it is considered important to investigate how Belgium through its policy note on SRHR contributes to the specific needs of sexual and reproductive health in developing countries. Therefore, the DGD requested the Institute for Tropical Medicine (ITM) to develop these terms of reference for such a research project, which will serve as the basis for the final study protocol. 2 Available from: 3 More information available from: 4 MDG 5A aims to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio 5 Available from: 35

36 II. Objectives The main objective of the research project is to provide a qualitative description of the contribution made by Belgian development aid towards improving sexual and reproductive health in the supported programmes. Specific objectives are: To determine the awareness and use of the SRHR policy note by key Belgian cooperation actors; To provide a review of sexual and reproductive health interventions in three different types of development aid programmes, and one in- depth country study. While the main focus of the research project is on health, it is important to note that the rights perspective will also be considered, in particular through the use of the strategic priorities outlined in the policy note, which will serve as a basis for the whole project. III. Study design The research project is composed of two modules in order to reach each of the specific objectives as outlined above. III.1. Module 1: Survey of SRHR policies and the use of the Belgian SRHR policy note A web- based questionnaire will be developed as part of the study protocol in order to describe the awareness and use of the SRHR policy note by key Belgian cooperation actors. The questionnaire will consist of three parts: 1) an overall description of the importance of sexual and reproductive health in programmes supported by the DGD, guided by the six strategic fields 6 and the three specific areas of cooperation 7 as outlined in the policy note, as well as in relation to the 1994 ICPD Programme of Action; 2) a series of (closed) questions with regard to the frequency of use of the policy note in different operational activities or tools, e.g. in the policy dialogue; 3) a number of open questions for more subjective feedback on the perceived added value of the policy note, including suggestions on how to overcome potential barriers and ensure optimal use of the policy note by the relevant stakeholders. A link to the web- based questionnaire will be sent to all key Belgian cooperation actors, including DGD collaborators with operational responsibilities, the DGD attachés in the partner countries, and the implementing partners such as BTC and the medical non- governmental organisations (NGO). A descriptive analysis of the collected data will allow the results of the questionnaire to be presented per respondent target group, per country, or per type of intervention (i.e. SRHR as a principal objective or rather integrated in overall health interventions). 6 Cf. page of the policy note: 2.1 Promoting the integration of sexual and reproductive rights into national policies, 2.2 Promoting gender equality and the empowerment of women and girls; 2.3 Devoting more attention to adolescents and young people; 2.4 Strengthening health systems; 2.5 Promoting a global approach to AIDS; 2.6 Supporting awareness-raising, information and education 7 Cf. page of the policy note: 3.1 Integration of sexual and reproductive health care into general health care; 3.2 The fight against sexual violence and harmful practices; 3.3 Care and rights during humanitarian crises, conflicts and peace-building. 36

37 III.2. Module 2: Case and country studies Module 2 consists of three case studies and one country study, which will complement the survey outlined in module Case studies Three case studies are planned in three different health programmes supported by the DGD, in order to describe 1) the extent to which sexual and reproductive health is considered in the programme, 2) the extent to which the programme contributes to MDG 3 to 6, and 3) the role played by the policy note in the process of defining and implementing the programme. The case studies aim to provide a qualitative perspective on the consideration of SRHR in the health programmes supported by Belgian cooperation, and do not aim to evaluate the interventions. The case studies will be carried out in two different countries. In the first country, the case study will focus on a project where health sector budget support is provided; in the second country, one case study will focus on a primary health care project, and another case study will focus on a project for which SRHR was defined as a key objective. The case studies will be carried out using a pre- defined assessment tool (as part of the study protocol), which will look at the complete cycle of developing the project, deciding on the details of the project, to its implementation in the field. The assessment tool will be prepared using the policy note as a basis, in particular the six strategic fields (point 2 in the policy note) and the three specific areas for cooperation (point 3), as well as some key principles outlined in point 4 on the implementation of the policy. Part of the case study can be conducted in Belgium, but for each of them, a field visit is considered necessary as well in order to get a better understanding of the field implementation. 2. Country study Finally, in one of the two countries where the case studies take place, the opportunity is used to carry out an in- depth country study in order to obtain a general overview of all sexual and reproductive health activities, directly or indirectly supported by the DGD, including through multilateral aid or in other sectors, e.g. education. The country study will aim to describe 1) the coherence of these activities with regards to the Belgian policy note, 2) the alignment with the national strategy on the issue and 3) the harmonisation with related interventions supported by other donors. Part of the country study can be done at Brussels level, e.g. systematic review of all projects and programmes with an identified or expected sexual and reproductive health component (including multilateral programmes), review of related progress reports, etc. In addition, a field visit will provide the opportunity to visit the concerned projects and programmes and directly observe the implementation of the sexual and reproductive health components and the coherence between them. In addition, a better understanding will be gained of the national health strategy (and the sexual and reproductive health component in it), and of the relevant programmes supported by other donors. An assessment tool to guide the country visit will be prepared beforehand as part of the study protocol, using the policy note as a basis. 3. Selection of the partner countries In preparation for the selection of the countries in which to carry out the case and country studies, a qualitative analysis will be done of ongoing programmes where the DGD provides health sector budget support, and of those where primary health care programmes are supported, in order to identify the presence of sexual and reproductive health components. The final selection of the countries to carry out the case and country studies will then be based on 37

38 the presence of a sexual and reproductive health component, that has been implemented for a sufficient period of time and is currently ongoing; the context, providing for a maximum learning opportunity; relevant indications obtained from the survey (module 1) results. In the event that several potential candidates are identified for the country study, the one where humanitarian aid is provided will be given priority; however, this is not a selection criterion in itself. III.3. Potential additional modules It is not excluded that additional modules will be proposed, considering the existence of other relevant projects, such as The EAGHA/Lancet initiative on health impact reporting In the light of increased levels of budget support, health impact reporting has been facing new challenges. The EAGHA/Lancet seminar on this topic (Feb 2012) might offer some opportunities to use the field of sexual and reproductive health as a practical example for related research. If this is the case, a separate note on suggested activities will be prepared. Translation of national policy into operations At ITM, a research project is foreseen for 2013 on how national health policies are being translated into practice (contact point is David Hercot). There is room for discussion to use sexual and reproductive health intervention as the focus in one of the Belgian partner countries where health sector budget support is provided. Such a project might provide some additional insight into the operational use or added value of the Belgian SRHR policy note in national health sector plan implementation. IV. Expected outputs The timeline for the expected outputs is provided below in point V. A first report will describe the results obtained from module 1, including the description of the DGD supported SRHR activities since the publication of the policy note, and the main findings of the survey. As and when relevant, the report will provide recommendations for improving the awareness and the use of the policy note by the key Belgian cooperation actors. A second report will combine the main findings of the case and country studies, as well as relevant recommendations for future priorities with regards to SRHR in Belgian development cooperation. Finally, an overall summary and key conclusions and recommendations for the complete study will be provided. Opportunities to discuss these further with the partners and key actors will also be explored. V. Timeline and resources The research project will be carried out under the framework agreement between the DGD and ITM, under which all related costs are covered. A preliminary timeline is suggested below: 38

39 Activity Timeline Resources Module 1 Mar Jul FTE Development of short protocol, including the questionnaire Mar Validation of questionnaire Web- based questionnaire Completion of questionnaire by key Belgian cooperation actors Data cleaning and analysis Final report module 1 Mar Mar Apr May Jun Jun- Jul 3 person- months Module 2 Sep 2012 Sep FTE Development of short protocol, including assessment tool for case and country studies Testing of assessment tools Case and country study HQ level Case and country study field level Data cleaning and analysis Final report module 2 Sep Dec 2012 Jan Feb 2013 Mar May Mar May June Jul Jul Sep 3 person- months 2 x 2 person- months 1 person- month Overall summary and conclusions Sep 2013 A peer- reviewed publication on the research project may be considered, but is not included in the timeline above. 39

40 VI. Coordination The research project will be carried out by and under the final responsibility of the ITM. Feedback on the progress of the research project will be given at the SRHR working group meetings, where preliminary results or challenges faced may be discussed; the working group may also provide feedback on the protocol, the questionnaire and the assessment tools which will be used. The final results will also be presented to the SRHR working group, before publication of the final reports. Finally, while the focus of the study is Belgian cooperation, from a Belgian perspective, communication with the involved partner countries will need to be ensured, before the start of the study, as well as with regard to the final results. 40

41 Annex 2. Survey questions 1. Relevance of SRHR 1.1. How do you consider the overall importance of SRHR in the programmes/projects you follow or are involved in (several answers possible) SRHR is not considered (n = 71) In any of them In some of them Other SRHR issues are considered but in a more latent manner (n = 67) In all In some Other SRHR plays an important role (n = 67) In any of them In some of them Other SRHR is the principal objective (n = 64) In any of them In some of them Other If difficult to say how you consider the overall importance of SRHR in your programmes/projects, please elaborate below Do you know whether SRHR is considered in the national health plan of the partner country you work with (n = 79) o Yes, I know: SRHR is considered o Yes, I know: SRHR is not considered o I m not sure / I don t know o I work with several countries (and get a chance to specify my answers per country on the next page) If you work with more than 1 partner country, please specify which countries Please specify in which of these countries SRHR is considered in the national health plan 2. Awareness on Belgian SRHR policy note 2.1. Are you aware the Belgian SRHR policy note exists (n = 76) o Yes / No 2.2. Have you ever read the SRHR policy note with due attention to its content (n = 53) o Yes / No 2.3. Do you know where to find a copy of the SRHR policy note (n = 53) o Yes / No 2.4. Are you aware about the ICPD programme of action (n = 75) o Yes / No 2.5. Have you ever read the ICPD programme of action (n = 75) o Yes, completely o Yes, but only partly o Yes, but only the summary o Yes, but only chapter 7: Reproductive rights and reproductive health o No, I have not read it 41

42 3. Knowledge on Belgian SRHR policy note Do you feel familiar with the area of cooperation Integration of sexual and reproductive health care into general health care (n = 74) o Yes I am familiar with this area of cooperation o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the area of cooperation the fight against sexual violence and harmful practices (n = 74) o Yes I am familiar with this area of cooperation o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the area of cooperation Sexual and reproductive health care and rights during humanitarian crises, conflicts and peace building (n = 74) o Yes I am familiar with this area of cooperation o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Promoting the integration of sexual and reproductive rights into national policies (n = 71) o Yes I am familiar with this strategic field o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Promoting gender equality and the empowerment of women and girls (n = 71) o Yes I am familiar with this strategic field o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Devoting more attention to adolescents and young people (n = 71) o Yes I am familiar with this strategic field o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Strengthening health systems (n = 71) o Yes I am familiar with this strategic field o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Promoting a global approach to AIDS (n = 71) o Yes I am familiar with this strategic field o I know about this o I don t know so much about this o I am not at all familiar with this Do you feel familiar with the strategic field Supporting awareness- raising, information and education (n = 71) 42

43 o o o o Yes I am familiar with this strategic field I know about this I don t know so much about this I am not at all familiar with this 4. Use of the Belgian SRHR policy note in professional activities 4.1. Have you ever used the policy note in your regular professional activities since its publication in 2007 (n = 71) o Yes / No o If not, please specify the main reason: o If yes, how frequently have you actively used/referred to the policy note in the past year (1 answer) Not Only once 2 to 3 times On a regular basis 4.2. Since its publication, in which context have you mainly used the policy note (several answers possible) (n = 61) o Preparing an indicative development cooperation programme (ISP/PIC) o Political dialogue o Preparing funding proposal o Technical support to partners o Responding to parliamentary questions o As a reference document in reports, publications, etc o None of the above o Other: please specify: 4.3. Since its publication, in which policy related activity have you mainly used the policy note (several answers possible) (n = 61) o Agenda setting o Policy formulation o Policy implementation o Evaluation o None of the above o Other: please specify: 4.4. Please indicate which of the areas for cooperation as specified below are most frequently used in your work Integration of sexual and reproductive health care into general health care (n = 69) o o o o Frequently Sometimes Rarely Not at all The fight against sexual violence and harmful practices (n = 69) o o o o Frequently Sometimes Rarely Not at all Sexual and reproductive health care and rights during humanitarian crises, conflicts and peace building (n = 69) 43

44 o Frequently o Sometimes o Rarely o Not at all 4.5. With regards to the 6 strategic fields to be considered in the Belgian development cooperation activities, please indicate their frequency of use in your professional activities Promoting the integration of sexual and reproductive rights into national policies (n = 67) o Frequently o Sometimes o Rarely o Not at all Promoting gender equality and the empowerment of women and girls (n = 68) o o o o Frequently Sometimes Rarely Not at all Devoting more attention to adolescents and young people (n = 68) o o o o Frequently Sometimes Rarely Not at all Strengthening health systems (n = 66) o o o o Frequently Sometimes Rarely Not at all Promoting a global approach to AIDS (n = 67) o o o o Frequently Sometimes Rarely Not at all Supporting awareness raising, information and education (n = 68) o o o o Frequently Sometimes Rarely Not at all 4.6. Have you ever recommended the policy note as useful reading material to (several answers possible) (n = 69) o colleague in my organisation o local partner o my staff o I have never recommended it to anyone o other: - please specify 4.7. Would you consider the policy note as an important tool for your current professional activities (n = 69) 44

45 o Yes / No o Please elaborate why (not): o I don t know 4.8. Would you consider the ICPD programme of action an important tool for your professional activities (n = 69) o Yes / No o Please elaborate why (not): o I don t know 5. Commitment to use the SRHR policy note in the near future 5.1. How frequent do you estimate you will use the policy note in the coming year (n = 68) o Not/never o A few times o On a regular basis o Don t know 5.2. In which context are you likely to use the policy note the most (n = 66) o Preparing an indicative development cooperation programme (ISP/PIC) o Political dialogue o Preparing funding proposal o Technical support to partners o Responding to parliamentary questions o As a reference document in reports, publications, etc o Other: please specify: 6. Subjective feedback 6.1. Do you feel (n = 68) o The SRHR policy note is not useful for you in your professional activities o You don t need to use the policy note because Free text o You should use the policy note more often o You would use the policy note more often if Free text o You use the SRHR policy note as often as required o Other: 6.2. If the policy note were to be revised, you would recommend to o Free text 6.3. If you have any other comment with regards to the policy note, please specify below: o Free text 7. Identification 7.1. Please specify your personal professional expertise/profile (n = 68) o General/administrative o Health o SRHR o Rights o Agriculture o Education o Gender o Other: 45

46 7.2. Do you consider yourself to be working on (1 answer) (n = 68) o Policy level o Implementation level o Both o None of the above 7.3. Are you a (n = 68) o Man o Woman 7.4. Please specify your age group (n = 68) o years o years o years o years o 60 years or more 7.5. What is the name of your organisation 7.6. Please categorise your organisation (n = 68) o o o Governmental Non- governmental Other please specify 7.7. What is (are) the main sector(s) your organisation works in (n = 38) o Health o Agriculture o Education o Environment o Migration o Infrastructure o Society building and conflict prevention o Gender o Aid for trade o Rights o Private sector o Other: 7.8. What is your function in the organisation 7.9. In which country are you currently based (n = 68) o Belgium o Partner country o One of the above, but I work on regional level If based in a partner country, please specify which country If based in Belgium or on regional level, please specify the countries in your portfolio For how long have you been based in this country Please feel free to provide any other comments you think may be useful with regards to SRHR policies and the Belgian SRHR policy note 46

47 Annex 3. Sample request for completing the survey In 2007 werd de beleidsnota "de Belgische ontwikkelingssamenwerking op het gebied van seksuele en reproductieve gezondheid en rechten" gepubliceerd. Gezien het belang van deze nota voor het bereiken van millenniumdoel 5 (de gezondheid van moeders verbeteren), zijn wij geïnteresseerd om te weten in hoeverre België, via de beleidsnota, bijdraagt tot de specifieke noden rond seksuele en reproductieve gezondheidszorg in ontwikkelingslanden. We hebben daarvoor de steun gevraagd van het Instituut voor Tropische Geneeskunde, die een korte vragenlijst ontwikkelde. U vindt de vragenlijst via deze link: Mogen wij u vragen deze vragenlijst in te vullen op basis van uw persoonlijke professionele kennis en ervaring, bij voorkeur voor woensdag 6 juni Niemand is verplicht om de vragenlijst in te vullen. De vragenlijst is anoniem. Het wordt geschat dat 15 minuten nodig zijn om de vragenlijst in te vullen. Vriendelijk dank voor uw gewaardeerde medewerking, 47

48 48

49 Module 2 Case and country studies on sexual and reproductive health and rights in different types of Belgian development aid programmes Final Report, September

50 This research project has been produced as part of the framework agreement between the Institute of Tropical Medicine (ITM) and the Belgian Development Cooperation (DGD). The principal researchers were Dominique Dubourg and Evelyn Depoortere. The project was supervised by the ITM s steering committee consisting of: Vincent De Brouwere, Thérèse Delvaux, Rachel Hammonds and Lut Joris; Lut Joris also contributed to the Burundi visit. Acknowledgements We would like to thank all of the members of the Be- cause Health working group on sexual and reproductive health and rights for having initiated this study as well as for their constructive comments and support throughout the duration of the project. We would also like to thank Patrick Simons and Gaëtane Scavée from the DGD for having facilitated contact with key figures in Belgian development cooperation, Ludo Rochette and Guy Boreux for organising the visits to Uganda and Burundi, in addition to anyone who gave up their time to take part in interviews. 50

51 LIST OF ABBREVIATIONS ACP AMV ARV BEmONC CEmONC CPSD DGD DPT EmONC FP HDP HPAC HSSP HSSIP ICB IDCP ITM MDG NDP NGO NHDP NRHP OECD/DAC PEAP PMTCT PNC PNFP PONC RH SFGPR SRHR STI TFD TFP TWG UBOS UMHCP UNFPA VCT VLIR WHO Africa, Caribbean and Pacific Anti- measles vaccine Antiretroviral Basic emergency obstetric and neonatal care Comprehensive emergency obstetric and neonatal care Health sector development partner coordination group Directorate general for development cooperation and humanitarian aid Diphtheria/pertussis/tetanus Emergency obstetric and neonatal care Family planning Health development partners Health policy advisory committee Health sector strategic plan Health sector strategic & investment plan Institutional capacity building Indicative development cooperation plan Institute of tropical medicine Millennium development goals National development plan Non- governmental organisation National health development plan National reproductive health programme Organisation for economic cooperation and development/development assistance committee Poverty eradication action plan Prevention of mother- to- child transmission Prenatal consultation Private Not for Profit Postnatal consultation Reproductive health Strategic framework for growth and poverty reduction Sexual and reproductive health and rights Sexually transmitted infection Technical and financial dossier Technical and financial partners Technical working group Uganda bureau of statistics Uganda minimum health care package United nations population fund Voluntary counselling and testing Vlaamse interuniversitaire raad World Health Organisation 51

52 Summary The second module of the study on Belgium s contribution to improving sexual and reproductive health in the programmes supported was based on case studies looking at three types of cooperation programmes as well as a more detailed country study. In Burundi, the focus of the first two case studies was on a reproductive health project (treatment of fistulas) and a primary healthcare project. In Uganda, a third case study looked at a programme of budget support, in addition to the country study. Each of the studies was based on a series of interviews with the key actors and main partners in the Belgian Cooperation in an attempt to respond to the following questions: 1. To what extent are sexual and reproductive health and rights taken into consideration in the programmes financed by Belgium? 2. To what extent do the programmes financed by Belgium contribute towards Millennium Development Goals (MDG) 3 to 6? 3. What role does the policy note play in the process of designing programmes to be funded and in their implementation? This second study module concludes that Belgium s contribution to the needs surrounding sexual and reproductive health and rights of a population differs according to the type of intervention. The primary healthcare project in Burundi, which incorporates the various axes of reproductive health into the local healthcare system, is an excellent example of how to contribute successfully towards these needs. In the budget support programme, however, the impact of this contribution is more difficult to demonstrate. Special effort is required to ensure that full use is made of all of the opportunities to advance the Belgian priorities based on the national policies, as well as to encourage the other actors and partners to implement the strategies that have been defined by the partner country. Enhanced knowledge of the policy note by Belgian actors in development cooperation would facilitate this commitment to advancing SRHR as a priority. 52

53 I. Introduction I.1. Context In March 2007, Belgium s Directorate General for Development Cooperation and Humanitarian Aid (DGD) published a policy note entitled Belgian development cooperation in the field of sexual and reproductive health and rights which describes Belgium s policy in this area. The note sets out 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 and 6) Supporting awareness- raising, information and education. The note also identifies three specific areas of cooperation: 1) Integration of sexual and reproductive healthcare into general healthcare, 2) The fight against sexual violence and harmful practices and 3) sexual and reproductive healthcare and rights during humanitarian crises, conflicts and peace- building 8. I.2. Study rationale Five years after the publication of the policy note on sexual and reproductive health and rights, the DGD deemed it important to study how, through this note, Belgium was contributing towards populations needs in the area of sexual and reproductive health and rights in the countries it supports. To that end, terms of reference for a research project were developed by the Institute of Tropical Medicine (ITM) which was also asked to produce a body of research as part of the framework agreement between the DGD and the ITM (Annex 1). These terms of reference have been approved by the Sexual and Reproductive Health and Rights working group of Be- Cause Health. This report concerns the second part of the terms of reference (module 2: Case studies and country study). I.3. Summary of the first module The first module of this study, which was carried out between May and July 2012, and the report of which has been available since October 2012, revealed that there was little knowledge of the policy note and that it was not being used by development actors (DGD, Belgian technical cooperation, and NGOs) 9. Approximately one third of respondents were unaware of its existence and two thirds said that since its publication in 2007 they had never used it. The study showed, however, that almost half of the respondents considered the policy note to be an important tool within the context of their professional activities and that almost two thirds of the people consulted were considering using it as part of their work in the near future. This first part of the study highlighted the need to make the policy note more accessible, to promote the use of the policy note among people engaged in cooperation activities and to provide practical examples of the way in which it could be used on a daily basis within the context of cooperation activities, by professionals from the healthcare sector as well as from other sectors of cooperation. 8 Federal Public Service for Foreign Affairs, Foreign Trade and Development Cooperation "Belgian Development Cooperation in the Field of Sexual and Reproductive Health and Rights" 9 The objective of the first module was to determine the extent to which the policy note is familiar to and used by Belgian cooperation agents. 53

54 II. Objectives The overall study objective was to provide a quantitative analysis of Belgium s contribution towards improving sexual and reproductive health in the programmes it supports. The specific objective of module 2 was to review interventions in the field of sexual and reproductive health in three types of cooperation programmes (case studies) and one in- depth country study. The research questions for the case studies were as follows: 1. To what extent are sexual and reproductive health and rights taken into consideration in the programmes financed by Belgium? 2. To what extent do the programmes financed by Belgium contribute to the Millennium Development Goals (MDGs) 3 to 6? What role does the policy note play in the process of designing programmes to be funded and in their implementation? For the country study, the aim was to also find out if: 1. The activities carried out in the field of sexual and reproductive health and rights are consistent with the Belgian policy note, whether they are directly or indirectly financed by the DGD including via multilateral cooperation and aid in other sectors; 2. These activities are in line with national strategies; 3. These activities are in keeping with interventions supported by other donors. III. Method As indicated in the terms of reference, the study essentially focused on aid in the field of healthcare, via financing of projects in Burundi and via sector- specific budget support in Uganda. III.1. Choice of countries In order to select the countries where to carry out the case studies and the country study, we used the database from the website of the Federal public service for foreign affairs, foreign trade and development cooperation (ODA online). Based on criteria developed in the terms of reference, we drew up a shortlist of possible countries. The final decision was made together with the DGD. With health remaining a priority sector for the next few years and the priority being granted to low- income countries where Belgium has a strategic role to play, preference was given to Burundi for two case studies and to Uganda for one case study and the country study. The detailed selection method for the selection of the study countries can be found in Annex MDG 3: promote gender equality and empower women, MDG 4: reduce child mortality, MDG 5: improve maternal health, MDG 6: combat HIV/AIDS, malaria and other diseases. 54

55 III.2. Data collection III.2.1. Literature review We collected all available documents relating to the interventions that formed the subject of the research, from the DGD, project stakeholders and ministries for health in the countries visited (list of documents in Annex 5). III.2.2. Belgian cooperation expenditure in conjunction with sexual and reproductive health and rights Information relating to expenditure per sector and sub- sector of cooperation in 2011 (last year for which data was available on the website at the time of the research) 11 was extracted using ODA s online search engine on 17 July Only the sectors and sub- sectors taking up financing that are already or potentially in line with the strategic or specific areas of cooperation as defined in the policy note were selected for analysis. The sectors were Health and its various sub- sectors, the Population, health, fertility sector and its sub- sectors, Government and civil society (sub- sectors: human rights and organisations and institutions for women s equality) and the Social infrastructure sector (sub- sector: mitigating the social impact of HIV/AIDS). In order to take into consideration the third specific domain of cooperation (sexual and reproductive healthcare and rights during humanitarian crises, conflicts and peace- building) we also looked at financing in the humanitarian aid sector. Sexual and reproductive health and rights are not among the sub- sector headings so an attempt was made to identify from among the different areas of intervention those that could potentially have components linked to sexual and reproductive health and rights by using a series of key words 12 taken from the policy note (chapter on the three areas of cooperation and the six strategic fields). III.2.3. Interviews Interviews were carried out in Belgium and in the two countries visited. For the case studies, we held meetings in Brussels and in the countries with key people from the DGD, the Belgian technical cooperation and NGOs receiving financing from Belgium. In both of the countries, we conducted interviews with representatives from the Ministry of Health at national level. In Burundi, we met healthcare providers and representatives from the Ministry of Health in the districts where the selected projects were being implemented. In Burundi we also met a number of representatives from other donors and some United Nations agencies. For the case study and the country study in Uganda we met, in Brussels and in the country, key people from the DGD, the Belgian technical cooperation, representatives from the Ministry of Health, the Ministry of Finance, the Ministry of Gender, representatives of partners (members of the Health Development Partners Group), national and international organisations and NGOs. The list of organisations we met can be found in Annex 3 and the guide used when conducting the interviews can be found in Annex The ODA online search engine refers to upper sectors and sectors, which are named here sector (for the upper sectors) and sub-sector (for the sectors). 12 Right, sexual, reproductive, reproduction, sex, empowerment, woman, girl, health, AIDS, HIV, adolescent, youth, child. 55

56 III.3. Data analysis Data analysis was essentially descriptive, aiming to assess the level of integration of sexual and reproductive health and rights in the programmes and projects financed by the DGD, to evaluate the role played by the policy note in promoting this integration and the impact of these programmes/projects on Millennium Development Goals 3 to 6, and to check the consistency of these programmes/projects with national strategies and interventions supported by other donors. III.3.1. Analysis of cooperation expenditure in 2011 We used the amount of spending on the programmes/projects with sexual and reproductive health and rights (SRHR) components in an attempt to estimate the role of reproductive health in the Belgian development cooperation. III.3.2. Case studies and country study (interviews, project visits and literature review) We used an analysis grid that allowed us to respond to the six research questions (Annex 6). For each question the grid covers the elements to explore, the method to use in order to obtain the information and possibly also the selected indicators, as well as the information sources. From the documents collected, we were planning to search for a series of key words taken from the six strategic fields and the three specific areas of cooperation contained within the policy note and for each key word determine the type of document 13 and in which part of the document 14 they might appear. The intention was to carry out this analysis with the help of the NVIVO software. Unfortunately it was not possible to use this research method because, on the one hand, some documents were only available in scanned- in portable document format (PDF) which made it impossible to search automatically for words and, on the other hand, because after having looked at several key documents, it was quickly noted that the key words that had been chosen came up only very rarely in the documents. We therefore opted for a more traditional (manual) analysis of the documents to try to extract possible references to the policy note. The interviews were transcribed so that they could be analysed using the citations indexing tool in Word The coding of these citations was carried out on the basis of research questions: content of programmes/projects, use of the policy note when designing projects, alignment with national policies or national priorities, harmonisation with other donors, consistency between the activities financed by Belgium and national strategies. III.4. Ethical considerations The study protocol has been approved by the Institutional Review Board at the Institute of Tropical Medicine (reference number 865/13 of 07/03/2013). During the interviews, all steps were taken to preserve the anonymity of everyone involved, and the same applies to this report so that it is impossible to reveal people s identities. 13 Strategic/programme document; evaluation document/baseline; project document; working document, report and publication, follow-up and evaluation document? 14 Introduction/context; strategies; actions/activities; logic framework; budget; indicators 56

57 IV. Results IV.1. The results in context Belgium s development cooperation occurs via various channels: governmental cooperation (within the framework of a cooperation programme between two countries), non- governmental cooperation via non- governmental bodies, multilateral cooperation through international bodies such as agencies of the United Nations, delegated cooperation (based on a convention with another public multilateral or bilateral donor), and humanitarian aid. Within its governmental cooperation, each country defines the priority sectors such as health, education, agriculture or basic infrastructure. IV.1.1. Burundi In 2008, Burundi had a population of 8.05 million inhabitants 15 and due to strong demographic growth (2,4% per year), the population could reach 12 million in 2025 and 16 million in Health status indicators of the population are still very worrying and life expectancy at birth remains relatively low (49 years for men and 52 years for women in 2008) Third general census of the population and housing, from Republic of Burundi (2011). Ministry of Planning and Communal Development. Government declaration on national demographic policy. 57

58 Table 1. Selection of reproductive health indicators, Burundi, 2012 Indicator Maternal mortality rate (/100,000 live births) Recent data Previous data Year Value Source Year Value Source EDSB WHO* % births attended by skilled health professionals % EDSB % EDSB 1987 Overall fertility rate (children per woman) Modern contraceptive method prevalence rate (women aged in unions) Unmet family planning needs (women aged in unions) EDSB EDSB % EDSB % EDSB % EDSB HIV prevalence % ESP/VIH** % ESP/VIH** Source: Measure DHS, demographic and health survey, Burundi, 1987 (EDSB 1967) and 2010 (EDSB 2010) * WHO (2012), Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. ** National survey on seroprevalence 2007 and 2002 (ESP/VIH) The budget allocated to health increased from 5.6% to 7.7% of the national budget from 2006 to According to the 2007 National Health Accounts, the total expenditure on health was 156 million USD (18 USD per inhabitant). The sources of financing are divided between the State (17.1%), external resources (40.0%), households (37.7%) and the private sector (5.2%). Healthcare services are divided between public structures, accredited structures (confessional) and the private sector. Table 2. Breakdown of health structures per type and sector in 2010 Sector / type Health centres (n = 735) Hospitals (n = 63) Public 58% 65% Confessional 14% 13% Private 28% 22% Source: Ministry of Public Health and AIDS control. National health development plan The Belgian development cooperation has been actively working in Burundi since In 2010, Belgium was the 2 nd largest bilateral donor (after France) and 5 th donor after the World Bank, the African Development Bank and the European Commission. Belgium s public aid budget for development cooperation in Burundi for is 150 million euros which represents approximately 24.5% of aid provided by the different technical and financial partners (TFP). 58

59 The key document in development for Burundi is the Poverty reduction and growth strategy framework (PRGSF II). This document, in chapter 4 (Improving the access rate and the quality of basic social services and strengthening social protection) highlights the need to control population growth by managing fertility. Actions to reduce fertility therefore involve both direct interventions in the area of fertility and actions to reduce mortality. From that perspective, a number of specific objectives have been defined: (i) increasing the average age of mothers at the birth of their first child from 23.5 in 2011 to 25 in 2015, (ii) increasing the prevalence of contraception from 19% in 2011 to 28% in 2015,..., (v) giving indirect incentives to couples to reduce the size of their families and (vi) increasing family planning awareness among the population, opinion leaders and religious leaders. One of the objectives (objective 2) of the National Health Development Plan (NHDP), is to contribute towards reducing maternal and neonatal mortality by The National Reproductive Health Programme (NRHP) has in turn developed strategic axes on the main subjects surrounding reproductive health: family planning, maternal and neonatal health, sexually transmitted infections (STIs) including HIV/AIDS, prevention and control of sexual and gender- based violence and sexual and reproductive health of adolescents. Each one of the documents contains ad hoc indicators to monitor these strategies in conjunction with reproductive health 17. Health governance In December 2012, the Burundian Government and a number of partners 18 signed a memorandum of understanding (Compact) which had the overall objective of strengthening the partnership between the Government and TFPs and improving the mobilisation and use of the resources needed to implement the NHDP through a harmonised framework between the Government and its TFPs in keeping with the PRGSF II and the national aid policy with a view to accelerating attainment of the MDGs. 19 The Health sector development partner coordination group (CPSD) is the group responsible for monitoring the Compact. For four consecutive years, Belgium has headed the CPSD. The CPSD set up thematic groups: Medicines, Financing, Monitoring/Assessment, Human resources and Health districts. Belgium actively participates in the group on Health districts and in the group on Human resources. Public aid for development Belgium supports Burundi through governmental cooperation, non- governmental cooperation and multilateral cooperation. In its governmental cooperation, Belgium has defined three priority sectors for Burundi: health, education, agriculture as well as a cross- cutting subject, governance. It also assists via a scholarship programme (health is also a priority sector there), an expert support programme and microprojects. Belgium also operates through the channels of delegated cooperation (in particular via financing for 17 Maternal mortality rate, proportion of births attended by skilled health professionals, prevalence of contraceptives, prevalence of HIV/AIDS, etc. 18 Ministry of Health, Ministry of Finance, Belgian Cooperation, World Bank, European Union, WHO, UNFPA, WFP, UNICEF, Malaria Control Association, Burundi network of people living with HIV, Burundian Alliance Against AIDS. 19 Republic of Burundi. Ministry of Public Health and AIDS Control final version Compact Burundi;

60 the programme in support of gender and human rights UN Women). Three cross- cutting subjects, equality between men and women, sustainable use of the environment and child rights receive special attention. The overall budget for the Indicative Development Cooperation Programme (IDCP) is 150 million euros with an additional possible contribution of 50 million euros contingent upon progress made in the field of good governance. The health programme is monitored in Bujumbura at DGD level by a cooperation attaché and a health expert, and at Belgian technical cooperation (BTC) level by two technical assistants. Belgium supports the health sector through an integrated programme of institutional support and healthcare staff capacity strengthening with a budget of 25 million euros. This programme has three components: 1) support for governance in health at central level, 2) support for governance in health at peripheral level (Kirundo Province in particular) and 3) support for the human resources department in health with special attention paid to paramedics skills. In the IDCP, the headings gender and HIV/AIDS are also found in sectors other than health such as the street paving project or the agriculture project. 20 As stipulated by the terms of reference, we visited two project implementation sites in Burundi. The first site was Gitega where a project focusing on reproductive health is being implemented. This project treats vesico- vaginal fistulas and is coordinated by Handicap international. The second project visited focuses on primary healthcare. This is a project run by the Belgian Technical Cooperation in the Kirundo province as part of the second component in the support programme for the health sector defined in the last IDCP. Project centred on reproductive health (Gitega) The project Women of the backyard or the history of fistula in Burundi is coordinated by Handicap International and managed in partnership with the Burundian association SHUJAA LINK and with the NGOs Doctors Without Borders- Belgium and Gynaecology Without Borders. This project is 80% financed by the DGD and has the specific objective of improving the quality of life of women living with a fistula in the Ruyigi region. The expected results are improved access to operations for women with a fistula, quality of care for women suffering from fistulas and family and social integration for women who have undergone surgery for fistulas. Project centred on primary healthcare (Kirundo) The Kirundo province is the site where the Institutional support programme to the public health sector in Burundi - Section on support for health governance at the peripheral level (Kirundo province) is being implemented. It should be specified that if the BTC is involved in the Kirundo province, it is because this province was selected by the national partner due to the fact that it was not being supported by any other international partner and that it is one of the country s poorest provinces. The Kirundo project is based on supporting management structures in the health districts (provincial and district management team), offering high quality health care (technical quality and human resources management), and the demand for healthcare (access to care and financing mechanisms). 20 In the document Agricultural development support programme in the Kirundo province, a highly relevant gender analysis reveals the lack of harmony between women s involvement in food crops and their quasi absence from producer organisations and provincial departments of agriculture. 60

61 The technical and financial dossier produced by the BTC does not mention in detail all of the aspects surrounding sexual and reproductive health and rights encompassed within this project. With this support aiming to implement national health policy and reinforce the package of care on offer at district level, however, we may consider that the activities being carried out are, as a matter of principle, in line with the NHDP and the NRHP. The NRHP from 2007 contains 8 essential components which form the basic elements of a reproductive health programme as defined by the Cairo Programme of Action: 1. Safe motherhood and neonatal and child health; 2. Family planning; 3. Prevention and management of STIs and HIV/AIDS; 4. Prevention and care for people having suffered from sexual violence; 5. Prevention and management of complications arising from abortion; 6. Prevention and management of infertility and sexual dysfunction; 7. Promotion of the reproductive health of young people and adolescents; 8. Promotion of women s health pre- and post- menopause and early detection and adequate care for cancers of the cervix, breast and other gynaecological cancers. IV.1.2. Uganda According to the forecasts of the Uganda Bureau of Statistics (UBOS), in 2012 Uganda had a population of 34.1 million inhabitants and a life expectancy at birth of 46.1 years for men and 47.5 years for women. Some key indicators in the area of reproductive health can be found in Table 3. 61

62 Table 3. Key reproductive health indicators Indicator Maternal mortality rate (per 100,000 live births) Recent data Previous data Year Value Source Year Value Source WHO* WHO* % births attended by skilled health professionals % UBOS % UBOS Overall fertility rate (children per woman) Modern contraceptive method prevalence rate (women aged in union) Unmet family planning needs (women aged in union) HIV prevalence UBOS DHS % DHS % DHS % DHS % DHS % UAIS** % UHSBS** Source : UBOS, Uganda bureau of statistics. Statistical abstract 2012 and 2007, Demographic and Health Survey, DHS 2000/01 and * WHO (2012), Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. ** 2011 Uganda AIDS Indicator Survey and Uganda HIV/AIDS Sero- Behavioural Survey (UHSBS) In 2012 the total expenditure on health was estimated at 1,500 million USD (i.e. 45 USD per inhabitant), with half of this expenditure coming from households, 300 million from State revenues and 450 million from external partners and donors 21. The distribution of healthcare provision between public and private services is shown in table 4. Table 4. Distribution of healthcare services between public and private services Sector / Type Health centres Hospitals Public 54% 46% Private not for profit 17% 43% Private for profit 29% 11% Source : Uganda Statistical Abstract The national development plan (Ugandan National Development Plan 2010/11 to 2014/15) has the main objective of seeking to improve access to reproductive healthcare services in health centres III and IV 22 and especially to maternal health services (paragraph 614). A special chapter is dedicated to HIV/AIDS. In the chapter Population, the problems associated with high fertility and maternal 21 Data presented by DFID during our visit at an HDP meeting. 22 Health centres III are sub-county level; consultations are held there and there is a maternity section and a laboratory. Health centres IV are at county level and may be considered a small hospital. 62

63 mortality are clearly identified and strategies are put forward for responding to these. Among other aspects, these strategies concern the accessibility and availability of high quality services and a reduction in unmet family planning needs. A mid- term review of this national development plan was underway during the field visit and Belgium was taking part in this review as part of the working group on assessing the progress made with regard to gender problems. The national health plan (Ugandan health sector strategic and investment plan (HSSIP) 2010/ /15) sets out the strategic framework for achieving the objectives set in the area of health. These objectives include reducing maternal mortality and morbidity. Activities, specific objectives and indicators relating to this strategy can all be found in the document. Health governance The HSSIP, supported by the Compact 23, describes how development cooperation is structured between the Ugandan government and its partners. Working groups (technical working groups, TWG) were created to support the plan s implementation. The development partners and representatives from civil society as well as the not for profit private sector take part in working groups and are members of the Health policy advisory committee (HPAC) 24. There are 14 working groups 25 and one of these is particularly concerned with maternal and child health, whereas the working group on communicable diseases oversees HIV/AIDS. Belgium, through a technical assistant, participates in two working groups, one on Sector budget support and the other on Public private partnerships in health. In addition to attending these working groups and the HPAC, the development partners also meet together once a month. Public development aid Through the Ministry of Finance, Belgium provides budget support to the Ministry of Health for improving districts capacity to strengthen decentralisation and put in place effective primary healthcare. In theory, the funds from Belgium that contribute to the overall budget of the Ministry of Finance should feed into the conditional budget (paid quarterly to the districts on the basis of their action plan) for primary healthcare in the districts. The Ugandan government is committed to allocating the funds from this budget support to the priority sectors in the Poverty eradication action plan (PEAP) but is free to decide which of these sectors should receive the funds first. In reality, it seems to be difficult and at times even impossible to ensure that the funds from Belgium do arrive at district level, or even that it is really paid into the Ministry of Health s account. This is evidenced by 23 The Compacts are national agreements that aim to define the respective roles assigned to the government, the development partners and partners in charge of implementation in order to improve healthcare systems and achieve the best possible results in healthcare. They are signed within the framework of the International Health Partnership (IHP+). 24 The Health Policy Advisory Committee (HPAC) is a forum that allows the government, development partners and other stakeholders to discuss health policy and provide expert advice on implementing the Health sector strategic and investment plan (HSSIP). The HPAC is a mechanism for coordination between donors/partners which operates via working groups (TWG). It enables information and experiences to be shared and offers an opportunity to resolve disagreements or conflicts that arise between stakeholders in the health sector. The HPAC approves the working plan, the budget and other health sector spending. 25 The 14 TWG : Sector Budget Support; Nutrition; Human Resources for Health; Maternal and Child Health; Environmental health & Health Promotion & Health Education; e-health; Public Private Partnerships for Health; Hospitals and Lower Level Health Facilities; Health Infrastructures; Policy, Legal and Regulatory; Medicines Procurement and Management; Communicable Diseases Control; Non-Communicable Diseases Control; Supervision, Monitoring, Evaluation and Research. 63

64 the recent corruption scandal which has meant that in March 2013 the three partners providing budget support to Uganda (Belgium, UK and Sweden) made the decision to terminate their financing through budget support. Belgium s development cooperation in Uganda began in Until September 2012, there was a dedicated attaché at the embassy in charge of monitoring developments in the health sector, but since then there is no longer an attaché position and the health sector is now followed by the attaché for development cooperation who also has many other roles assigned to him. At IDCP implementation level, the Belgian technical cooperation has a technical assistant who acts as the advisor for the health sector and who actively participates in two working groups, one on budget support and the other on public- private partnerships in health. The second technical assistant is in charge of capacity- building in the health sector. This initiative, which is co- financed by the Swedish development cooperation, is a continuation of the previous IDCP ( ). The aim of that IDCP ( ) was to contribute towards implementing the Ugandan poverty eradication action plan (2004/ /09) and its successor, the National development plan (NDP 2009/ /14) and achieving the Millennium development goals. Nowhere does the IDCP make any specific reference to sexual and reproductive health and rights. Aside from budget support, the IDCP had a programme for strengthening institutional capacities in planning, leadership and central level management (Ministry of Health) and at decentralised level in the two pilot regions, Fort Portal (Rwenzori region) and Arua. The technical and financial document for Institutional capacity building in planning, leadership and management in the Ugandan health sector project describes the results expected in the field of health. These are linked to developing institutional, organisational and managerial capacities at various levels of the health pyramid (ministry, region, district, sub- district). The new IDCP (Indicative Development Cooperation Programme FY2012/13 FY2015/16) continues to focus its aid on the same sectors, health and education, and has a budget of 64 million euros. For the health sector, the IDCP allocates sector specific budget support of 12 million euros and programme/project financing of a total of 8 million euros. In addition to sector budget support, the IDCP allocates financing for a programme/project that aims to provide institutional support to the private not for profit sector (PNFP) to increase healthcare provision. 64

65 IV.2. Analysis of cooperation expenditure in 2011 The first significant information comes from analysing the spending in 2011 per sector and sub- sector of development cooperation. Firstly, it becomes apparent that there is no specific name for sexual and reproductive health and rights although this exists at OECD/DAC 26 level, which inspired Belgium to codify its sectors of development cooperation with two specific codes that relate to this subject area (13020: Reproductive health care, and 13081: Personnel development for population and reproductive health). One of the largest sectors financed is that of health policy and administrative management. The two other largest sub- sectors are basic healthcare and services (4 th strategic field of the policy note) and the fight against STIs and HIV/AIDS (5 th strategic field in the policy note). There is a specific sub- sector for family planning but there was no spending in this sector in Table 5. DGD spending in 2011 for sectors of cooperation relating to sexual and reproductive health and rights Sectors and sub- sectors of cooperation Spending 2011 % of total spending Health Health policy and administrative management 53,714, % Health Medical education and training 4,236, % Health Medical research 5,500, % Health Medical services 6,666, % Health Basic health Basic healthcare and services 28,210, % Health - Basic health - Infrastructure for basic health 1,570, % Health - Basic health Basic nutrition 5,905, % Health - Basic health Combating infectious diseases 3,211, % Health - Basic health Health education 1,767, % Health - Basic health Combating malaria 52, % Health - Basic health Combating tuberculosis 9,755, % Health - Basic health Healthcare personnel training 4,824, % Population, Health and Fertility Family planning 0 0.0% Population, Health and Fertility - Policy/programmes and administrative management 9,228, % Population, Health and Fertility Fertility care 1,260, % Population, Health and Fertility Combating STIs and HIV/AIDS 17,194, % Population, Health and Fertility Training for personnel in population, health, fertility 19, % Government and civil society Human rights 5,785, % Government and civil society - Organisations and institutions working for women s equality 6,584, % Social infrastructure Mitigating the impact of HIV/AIDS 112, % Total 165,599, % One other major sector in the policy note refers to sexual and reproductive healthcare and rights during humanitarian crises, conflicts and peace- building. From a total of 282 interventions, List of codes viewed at 65

66 (presented in Annex 7) contain elements of reproductive health. These 15 interventions represent only 0.04 % of the total spending in the humanitarian aid sector. This, however, does not mean that reproductive health is missing from the majority of interventions financed within the framework of humanitarian aid but it may serve as an indication of the importance that has been attached to it. Table 6. DGD spending in 2011 for the humanitarian aid sector of cooperation Sectors and sub- sectors of cooperation Spending 2011 % of total spending Humanitarian aid Emergency aid Material relief assistance and emergency services (non- food) 42,331, % Humanitarian aid - Emergency aid Food aid 61,594, % Humanitarian aid - Emergency aid - Coordination of support and protection relief and services 10,408, % Humanitarian aid Aid for reconstruction and rehabilitation 24,380, % Humanitarian aid Disaster prevention and preparedness 5,873, % Total 144,588, % IV.3. Case studies We carried out three case studies, the first two in Burundi, one in a project focusing on reproductive health ( Women of the backyard or the history of fistula in Burundi ) and the second in a project focusing on primary healthcare ( Institutional support programme to the public health sector in Burundi. Section on support for health governance at the peripheral level (Kirundo province) ). The third case study was carried out in Uganda where Belgium is actively working in the area of health by providing sector- specific budget support. The results are structured by referring to three research questions which were designed for these case studies, and present the analysis of the literature review and interviews as well as the information gained from site visits to the projects in question. IV.3.1. To what extent have sexual and reproductive health and rights been taken into consideration in the programme? Which SRHR components are found in the reference documents and which ones are actually being provided? Due to its highly targeted nature, the SRHR project (fistula) does not refer to all six strategic fields contained within the policy note. At the heart of the project is of course the surgical treatment of fistulas, but other components that are just as important as the surgical aspect are also taken into consideration: conservative treatment through urinary catheterisation for fresh fistulas, detection of cases within the community (passive screening, active screening, continued screening via health centres, green line and information via the media and community leaders) and free referrals to a hospital receiving patients, rehabilitation (physiotherapy), psychological support and the psycho- social and economic reintegration of cured or non- cured women, prevention of relapses through family planning as well as primary prevention by raising awareness of the institutionalisation of childbirth. The positive effects of this type of project can already be detected in several strategic or specific fields of cooperation. An example is the greater awareness of the problem of access for 66

67 adolescent victims of early pregnancies to obstetric services or even a possible change of attitude towards family planning which, in the case of immediate and medium- term post- operation follow- up, constitutes a medical necessity which over the long term could result in the subject becoming less taboo. The intervention focusing on primary healthcare being carried out in Kirundo essentially corresponds to the fourth strategic field of the Belgian policy note (Reinforcing healthcare systems) and to the first area of cooperation (Incorporation of sexual and reproductive healthcare into general healthcare). From the field visit and interviews with staff from the BTC, the district management team, the Kirundo hospital and health centres, it appears that the reproductive healthcare services available in the Kirundo district are reasonably comprehensive (Annex 8) and that the various components of reproductive health are taken into consideration but with varying degrees of success, reflecting the local situation. It is particularly challenging for topics such as access for adolescents to reproductive health services or fertility treatment, to be taken actively into account. Access for adolescents is difficult because of cultural barriers, access to health and services provided for gender- based violence is difficult in a context where women still do not enjoy enough rights and decision- making power, whereas access to post- abortion care is problematic due to the current legislation and stigma surrounding the subject. In summary, in the primary healthcare project in Kirundo, incorporating sexual and reproductive healthcare into general healthcare (specific area of cooperation) is a reality. At least three of the six strategic fields are taken into consideration: reinforcing healthcare systems, promoting a global approach to AIDS and supporting awareness- raising, information and education. In the context of the project, it is not as easy to act upon two of the other fields which are promoting gender equality and the empowerment of women and girls, and devoting greater attention to adolescents and young people. At the moment it seems that very little specific attention is paid to adolescents and sexual and reproductive rights but the district management team intends to launch a pilot project in a health centre to label certain health centres friends of young people centres, which is part of the NRHP strategy, but the project is still awaiting financing. The final strategic field, promoting the integration of sexual and reproductive rights into national policies, is not a matter of current concern for this project being implemented at peripheral level. In the documents relating to budget support (IDCP and the technical and financial dossier (TFD)) in Uganda, no particular reference is made to sexual and reproductive health and rights when not referring to the recommendations made following the mid- term review of the second Health Sector Strategic Plan (HSSP II). In the same way as the previous one, the new IDCP clearly mentions the fact that budget support funds will be primarily aimed at reinforcing primary healthcare services in the districts. We may therefore consider that, indirectly, the Belgian intervention supports the implementation of the minimum care package (UHMCP, Uganda health minimum care package) 67

68 contained within the HSSP III at peripheral level 27 and especially under the headings maternal and child health and prevention and control of communicable diseases 28. IV.3.2. To what extent does the programme contribute towards MDGs 3 to 6? The SRHR (fistula) project may not have the ambition of directly contributing towards MDGs 3 to 6, but it certainly contributes towards reducing the mortality rate of children born to women who have suffered from fistulas, and through reducing morbidity and improving maternal health in general. It should also be emphasised that the project contains a chapter on the socio- economic reintegration of women who have been affected by fistulas (successfully operated or otherwise) which is an important factor in promoting their autonomy. Table 7. MDG indicators, fistula project Elements Indicators Observations Proportion and posts occupied by the female Expatriate staff consists exclusively of staff on the project women MDG 3: Promote gender Proportion and posts occupied by female staff 80% women but no positions of equality and empower members in health services responsibility. The hospital director is a man women Proportion of female patients who use health Not relevant services (per service) Children of mothers affected by fistulas and Availability and use of health services for referred to the district hospital in the event MDG 4: Reduce child children of a problem mortality Availability and use of emergency obstetric Available at the district hospital services (including newborn resuscitation) Specific budget heading for EmOCs, FP in the key RH documents Not relevant MDG 5: Improve maternal health MDG 6: Combat HIV/AIDS, malaria and other diseases Availability and use of basic and comprehensive emergency obstetric services Availability and use of FP services (including availability of different contraceptive methods) Availability and use of counselling services, prevention (including PMTCT), care services (specific services for adolescents) Not relevant but available at the district hospital Available methods: pills, implants, Depo- Provera injections, condoms. Strongly recommended to all post- operative women Only counselling, care services are available at the district hospital The primary healthcare project (Kirundo) supports in a comprehensive way the implementation of the NHDP and the NRHP in Kirundo province. 27 The minimum package defines four action areas: 1) Promoting health, preventing diseases and communitybased health initiatives, 2) Maternal and child health, 3) Preventing and controlling communicable diseases and 4) Preventing and controlling non-communicable diseases. 28 The chapter on maternal and child health takes into consideration the problems of using prenatal care, accessing basic and comprehensive emergency obstetric care, use of post-natal care, neonatal mortality, high fertility as a cause of maternal mortality and morbidity, first sexual relations taking place at an early age with unwanted or unplanned pregnancies as a result, abortions and labour complications, mortality of infants and children under the age of five. The chapter on preventing and controlling communicable diseases highlights, among other aspects, the problems associated with HIV/AIDS: information and education, community mobilisation campaign, access to counselling/screening services, preventing mother-child transmission, access to ARVs, condom distribution. The priorities of the action plan on reproductive health (combating maternal mortality and reducing the unmet family planning needs), child health, education and promotion of health, controlling and preventing HIV/AIDS, malaria and tuberculosis and strengthening the healthcare system. 68

69 As far as MDG 3 is concerned, the NHDP mentions gender aspects in the chapter that describes the context (gender in access to education, economic life, violence, access to positions of leadership) but does not offer any specific indicators on the progress made in this domain. The gender problem which is also a cross- cutting topic in the IDCP is not explicitly mentioned in the technical and financial dossier of the Kirundo project. Table 8. Selected gender indicators, Kirundo Project Elements Indicators Observations MDG 3: Promote gender equality and empower women Proportion and posts occupied by the female staff on the project Proportion and posts occupied by female staff members in health services Proportion of female patients who use health services (per service) 1 TA senior man, 1 TA junior woman Majority of health centre bosses are men All of the doctors at the hospital are men The majority of nursing staff at the hospital are women Women can be found in almost all health centres (maternity, family planning service) Male/female ratio in curative care (+ de 15 years) = 0.65* *Source: data taken from the national health information system for the Kirundo district With data on the gender breakdown of the staff being unavailable, we based our assessment on interviews carried out with people we met in Kirundo and the visit to the district hospital and two health centres. In the health centres and the hospital many members of the nursing staff were female (or even in majority at the hospital), but they were rarely in the highest- ranking positions (chief of the centre or head of service). During visits to the health centre it was noted that the patients awaiting consultations were all women and children of a young age (only one man was present at the time of the visit). This overrepresentation of women in consultations is corroborated by the figures from the health information system which show that the majority of patients who visit health centres in Kirundo district are women (the male/female ratio for curative care for those over the age of 15 is 0.65). The fact that care for pregnant women and children of a young age is free of charge could be at the root of a problem of men s access to primary care. Table 9. Indicators for MDG 4, Kirundo project Elements Indicators Observations MDG 4: Reduce child mortality Availability and use of healthcare services for children Vaccination, surveillance of children under the age of 5, nutrition rehabilitation Vaccination coverage: VAR: 91%, DPT3: 96%* Usage rate of curative consultation (< 5 years) 3.75 new contacts/year/inhabitant* Usage rate of preventive consultation* Children 0-11 months: 1.3 new contacts/year /inhabitant Children months: 0.11 new contacts /year/inhabitant 69

70 Availability and use of emergency obstetric services (including newborn resuscitation) Reference to the analysis of the main causes of infant and juvenile mortality/morbidity in the action plan *Source: data from the national health information system for the Kirundo district Basic urgent obstetric and neonatal care, including newborn resuscitation in health centres and in hospital Coverage CPN1: 90 %* % institutional births: 51%* Coverage CPON2 (<42d): 37%* Roadmap to Accelerate the Reduction of Maternal and Neonatal Mortality in Burundi Strategic plan of the health sector s response to HIV/AIDS and STIs in Burundi for the period Data on the causes of morbidity per age cohort are available in the health information system. The activities in conjunction with MDG 4 are part of the minimum package of activities in all health centres; with the Belgian project supporting all of the district s health- related activities, it contributes directly towards achieving MDG 4. Table 10. Indicators for MDG 5, Kirundo project Elements Indicators Observations MDG 5: Improve maternal health Specific budget heading for EmOC, FP in the key documents on RH Availability and use of basic and comprehensive emergency obstetric services Availability and use of FP services (including availability of different contraceptive methods) Budget headings for EmOC in the TFD Estimate of financing needs for EmOCs and FP in the NHDP Childbirth by vaginal delivery, parental administration of antibiotics, parental administration of uterotonic (but not ocytocin), parental administration of anti- epileptics (but not magnesium sulphate, medication not included on the national list), manual extraction of the placenta. Hospital: abdominal delivery (caesarean), instrumental delivery (suction cup but not forceps), blood transfusion (but no on- site blood bank) % institutional deliveries: 51% (17% in 2004) Coverage CPON2 (<42d): 37%* FP available at all health centres (three types of pill including progestin- only for post- partum FP), implant, injection, IUD, condom (male and female) and morning after pill. Surgical sterilisation for men and women in hospital) 38% of women of childbearing age use a modern contraceptive method* Reference to the analysis of the main causes of maternal mortality and morbidity in the action plans Roadmap to Accelerate the Reduction of Maternal and Neonatal Mortality in Burundi *Source: data from the national health information system for the Kirundo district Belgium s intervention mainly focuses on access to surgery within the district (in which obstetric surgery plays a very important role) and promotion of family planning, which is the subject of an action research project involving women who use contraceptives, to promote family planning. The Belgian technical cooperation also takes part in the project run by the Burundi Association for Family Welfare which aims to promote surgical sterilisation for men (vasectomy). 70

71 Table 11. Indicators for MDG 6, Kirundo project Elements Indicators Observations MDG 6: Combat HIV/AIDS, malaria and other diseases Availability and use of counselling services, prevention (including the PMTCT), care services (specific services for adolescents) 36 VCT centres / 47 healthcare structures (4 urban, 32 rural)* 33 PMTCT sites (4 urban, 29 rural)* 4 ARV sites (3 urban, 1 rural)* No specific services for adolescents *Source: National Council for Combating AIDS. Permanent executive secretariat of the NACC. Progress review of the national action plan for combating AIDS 2011 Screening/counselling/treatment services are available in a relatively decentralised way. There are three treatment centres at Kirundo, one with an active file of approximately 2000 patients of whom almost 800 are receiving ARV treatment. In 2012, 26,682 AIDS screening tests were carried out in the health centres, of which 395 came back positive (1.5% of tests were positive) but only 14,000 condoms were distributed to a population of over 200,000 inhabitants. In Uganda, the intervention focuses on supporting the district by reinforcing primary health services in accordance with the districts health plans. As the IDCP has the overall objective of contributing towards implementation of the NDP and the HSSIP, it could be considered that the Belgian cooperation, via budget support, contributes towards the objectives set out in both of these documents. Gender is taken into account (cross- cutting subject in the HSSIP with a particular focus on gender- based violence and a subject widely mentioned in the NDP, particularly in the fields of education, economy, violence, as a determining factor in access to healthcare and levels of representation in decision- making bodies...). In the IDCP and in the IDCP , gender equality and women s empowerment are cross- cutting subjects. We may therefore consider that, through its intervention in Uganda via budget support, Belgium contributes towards MDGs 3 to 6 since actions related to these areas can be found in the NDP and the HSSIP. The data presented here are taken from statistical reports from the Ministry of Health (Annual health sector performance report for 2011/12). Table 12. Indicators for MDGs 3 to 6, Uganda Elements Indicators 2011/12 MDG 3: Promote gender equality and empower women Proportion and posts occupied by the female staff on the project Not relevant (no project visit) Proportion and posts occupied by female staff members in health services Proportion of female patients who use health services (per service) Data unavailable Data unavailable MDG 4: Reduce child mortality Availability and use of health services for children Availability and use of emergency obstetric services (including Vaccination coverage (Polio3): 95% Proportion of BEmONC and CEmONC structures (national level) CEmONC 60% (of hospitals) 71

72 MDG 5: Improve maternal health MDG 6: Combat HIV/AIDS, malaria and other diseases newborn resuscitation) Reference to the analysis of the main causes of infant and juvenile mortality/morbidity in the action plan Specific budget heading for the EmONCs, FP in the key RH documents Availability and use of basic and comprehensive emergency obstetric services Availability and use of FP services (including availability of different methods of contraception) Reference to the analysis of the main causes of maternal mortality and morbidity in the action plans Availability and use of counselling services, prevention (including PMTCT), care services (specific services for adolescents) BEmONC 17 % of 1177 HC III Strategic plan maternal, perinatal and child death review. 2009/ /15 Reproductive Health Division. Ministry of Health Reproductive health commodity security strategic plan 2009/ /14 % of institutional births: 58% Contraceptive prevalence (national) 30% % of structures offering FP: 81% (but not necessarily always modern methods) Strategic plan maternal, perinatal and child death review. 2009/ /15 Reproductive Health Division. Ministry of Health Availability of HIV/AIDS services (proportion of the 4,980 healthcare structures offering services): counselling and screening (86%), PMTCT (84%), ARV treatment (75%) Source: Annual Health Sector Performance report 2011/12 IV.3.3. The role played by the policy note in the process of determining and implementing programmes For the SRHR (fistula) project, as the proponents of the project were unfamiliar with the policy note, it was not possible to take it into consideration when drafting the project. According to the interviews, the policy note would not have been used by the DGD either when it came to examining the project and judging whether or not it was relevant and acceptable. We learned, nevertheless, that a guide Criteria for the relevance of an NGO s health projects/programmes with regard to the Belgian cooperation s policy notes on health is available for assessing the content of a project and whether or not it is in line with Belgian policy on health (the three policy notes) within the framework of non- governmental cooperation. For the primary healthcare project (Kirundo), there is knowledge of the policy note among Belgian actors but very little on the ground. It is clear, however, that this note is kept in mind, either actively or passively, when compiling the technical and financial dossier. The Kirundo project is essentially a project aimed at reinforcing health systems (4 th strategic field of the policy note), which aims to integrate sexual and reproductive health into general health (1 st area of cooperation). The technical and financial dossier mentions the subject of gender as a cross- cutting topic and proposes a number of activities aimed at reinforcing the fight against HIV/AIDS such as community interface organisation and organising healthcare services with integrated care and streamlining of patient care (5 th strategic field: Promoting a global approach to AIDS). In Burundi, the National reproductive health programme (NRHP) is in line with the Belgian policy note, in theory therefore there are no sources of potential conflicts between the Belgian vision and the Burundian vision in this area. Belgium is also the leader of the technical and financial partners for 72

73 health (Partner consultation framework for health and development) and to this end plays a role that is important and has been recognised by the different partners involved in bringing all of the actors together around a common aim, harmonising, aligning and developing synergy of actions under the leadership of the government. Naturally there are weak points and some subjects which are almost completely missing from the proposed programmes and strategies. There are also several subjects which are almost systematically points of contention in the countries of the South. Access for adolescents to healthcare is difficult everywhere and this is a concern both for the Burundian government through the Ministry of Health as well as for all international partners. Abortion in a country where medical abortions are still limited is a difficult subject to address but access to post- abortion care is one of the government s priorities. Homosexuality is a difficult subject to tackle for national as well as international partners, and the Belgian policy note is noticeably very discreet on the subject; the only very explicit mention of this subject in the document is in the chapter explaining the principles of cooperation. Respect for sexual and reproductive rights combats discrimination against vulnerable groups and people with a different sexual orientation. In Uganda, since 2012 there has no longer been an attaché for the health sector at the embassy which makes it difficult to say to what extent the policy note has been used during the drafting of the IDCP, but from interviews it has emerged that the policy note is kept in mind for everything pertaining to interventions in the area of health and is used by the BTC during the formulation stage. It may, however, be considered for the subsequent stages of implementing the IDCP since it emerged that it is partially thanks to this study that knowledge of the document s existence came to light. IV.4. Country study (Uganda) IV.4.1. Consistency of activities with regard to the policy note Within its governmental cooperation in the health sector, Belgium does not have any interventions in Uganda that are directly linked to reproductive health. Aside from the budget support analysed previously, the primary intervention in the area of health i.e. reinforcing the institutional capacities of the Ministry of Health, aims to assist the implementation of the HSSIP and the NDP. We may therefore consider that Belgium supports the activities proposed by these documents, especially the minimum healthcare package (UMHCP, Uganda minimum health care package). In order to assess this consistency, we used the sector- specific analysis grid in the formulation dossiers from Belgium s governmental cooperation. The detailed analysis can be found in Annex 9. Generally speaking, the HSSP III takes into consideration various elements from the Belgian policy note. The elements with less importance attached to them are geographical and financial access to health services. Geographical access is mentioned in the part concerning partnerships with private not for profit (PNFP) structures. Financial access is not taken into consideration but it is true that in Uganda, this problem is in theory already taken into account since primary healthcare is free of charge. Gender- based violence is covered in the HSSP, but nowhere does it mention harmful practices such as female genital mutilation. This form of violence, however, is rare in Uganda where the prevalence of this type of mutilation is 1.4%. 73

74 In Uganda, the new IDCP also contains a large chapter on financing of the PNFPs 29. There is a common fund that would finance the PNFPs according to the subsidy disbursement mechanisms based on performance criteria mutually agreed upon by the PNFPs and the Health development partners (HDP). The importance of PNFPs in healthcare provision, both at district hospital level as well as in health centres, is a major factor in this decision. The identification proposal for institutional support to the PNFP health sub- sector in Uganda makes very little reference to the potential impact of such a strategy on reproductive health. The four organisations explicitly mentioned in this document are all confessional (Uganda catholic medical bureau, Uganda muslim medical bureau, Uganda orthodox medical bureau, Uganda protestant medical bureau) and were selected because they would offer comprehensive healthcare services that would conform with the minimum healthcare package determined by the Ugandan government and are said to comply with the requirements of the IDCP in attaining MDGs 4, 5 and The interviews held during the visit confirmed that in the field of family planning some PNFP partners could hold values that could potentially conflict with the Belgian policy note by refusing to offer modern methods of contraception. Belgium also works actively in the sector of education. The interventions are essentially focused on programmes relating to Business technical vocational education training and do not contain a chapter on education in the area of health. The policy note would not be used during the identification stage but rather during the formulation stage carried out by the BTC. There are no activities underway on reproductive health, not even in health within the framework of delegated cooperation. The activities focus mainly on climate change. In non- governmental cooperation, Belgium mainly finances NGOs working in the domain of agriculture and rural development. Belgium has financed in the recent past or still continues to finance a number of NGOs working in the field of health. Memisa, for example, has rehabilitated health infrastructure in the North; the Belgian Red Cross is involved in a programme that supports children who have been left orphaned by AIDS, and which has a reproductive health component (screening and counselling, violence); the NGO Enfance Tiers- Monde has two projects that involve reproductive health, the first in Jinja is aimed at improving living conditions for people living in slums and has a number of objectives including preventing HIV/AIDS, improving the status of women and the education of young girls. The second project works with street children and vulnerable adolescents in Kampala; this project has an access to healthcare component. The scholarship programme has also financed or continues to finance research in the domain of health, for example, with Antwerp s Institute of Tropical Medicine, via institutional collaboration with the Public health institute of Makerere university (research into health systems and health policy in order to consolidate the implementation of national health policy) or through a research project on how to prevent AIDS among young people; also with the Vlaamse Interuniversitaire Raad (VLIR) through a research project studying infectious diseases and establishing a reference centre for treating congenital facial pathologies and tumours of the jaw. This programme would also support capacity- building upon analysis according to gender, planning and budgeting by taking into account the gender dimension million euros i.e. 12.5% of the total budget of 64 million. 30 Second draft Identification Proposal (IP). Identification proposal for institutional support to the Private Non for Profit (PNFP) health sub-sector in Uganda; Kampala, 21 December

75 Concerning multilateral cooperation via international bodies, Belgium finances in particular the UNFPA and the WHO. The IDCP also proposes interventions in association with cross- cutting subjects, such as gender, children s rights and HIV/AIDS and offers to finance interventions in line with national strategies, such as support for updating the national HIV/AIDS policy (National HIV/AIDS Policy 2011) particularly through the study and consultancy fund and in line with national strategies. With regard to children s rights, Belgium will support civil society organisations actively working in this domain as well as Avocats Sans Frontières Belgique (Lawyers Without Borders Belgium). IV.4.2. Alignment with national strategies In Uganda there is a document that dates back to 2004 which defines the overall strategy for reproductive health for the period There are also two more recent key documents on the subject, the Reproductive health commodity security strategic plan 2009/ /14 for Uganda and the Road map for reducing maternal mortality. 32 Since the design of the IDCPs, everything has been put in place to ensure that the interventions financed by Belgium within the framework of governmental cooperation are in line with the country s general health policies (HSSIP) and development policies (PEAP, NDP). In the IDCP, however, there is no reference to specific policy documents on reproductive health. In the technical and financial dossiers compiled by the BTC there is an in- dept analysis of the country s priorities in the area of health but the reference documents used in these dossiers are the major national policies or strategies and have no reference to specific policies or strategies on reproductive health either. IV.4.3. Harmonisation with interventions from other donors In the same way that alignment of national policies and strategies is a point that is systematically analysed in the IDCP and TFD documents, harmonisation with partners is a point that is seriously taken into consideration from the drafting of the IDCP and in even greater detail in the TFDs. Knowledge of activities carried out by partners has a broader aim than mere harmonisation; one of the main objectives is to ensure synergy between the technical and financial partners as well as alignment with national policies. This harmonisation effort, translated especially by the steady presence of Belgium at HDP meetings, is recognised by the other partners who are members of these consultation bodies. In Uganda, Belgium does not have any specific activities linked to reproductive health and does not take part in working groups held on this topic but keeps up to date with what the other partners are doing in this area. This view can be seen as a sign of the confidence entrusted in the other donors to implement activities in the field of reproductive health but may also be interpreted as a lack of attention and commitment with regard to topics that are sometimes difficult to tackle. 31 Ministry of Health 2004 Strategy to Improve Reproductive Health in Uganda " " 32 Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda (2008) 75

76 V. Discussion As the first module of this study has already demonstrated, the Belgian policy note on sexual and reproductive health and rights is only known to a minority of Belgian actors in the countries visited, be they from the DGD, the BTC or Belgian NGOs financed by Belgium. Some have heard mention of it (often thanks to the questionnaire sent as part of the first qualitative module of the research project), but very often they have not read and do not use it in their work. Several expressed the view that merely sending the policy note was not enough and that it would be useful to organise occasions when the policy note could be presented and discussed, possibly during training seminars. This suggestion had already appeared among the comments received during the first part of the study (module 1). Others thought that there were too many policy documents and it was difficult or even impossible to find out about them all, let alone use them. On the Development cooperation s website there are 30 policy documents of which 17 are policy/strategic notes and run to a total of 512 pages. There are, for example, 7 policy notes for the priority sectors in Uganda and Burundi (health, education, agriculture). When, as is the case in Uganda, there is no specific attaché for the health sector, it is easy to imagine the difficulty that one person would have to stay correctly informed about the content of these different policy notes. At Brussels level, however, the policy note seems to be known but it only seems to be truly taken into consideration by the BTC. This is no doubt linked to the fact that in the BTC- Brussels there is a gender focal point and an HIV/AIDS focal point; the latter is one of the persons involved in drafting the SRHR policy note. At DGD level, a relatively recent document is used when reviewing project documents; the guide dates back to April 2010 (Criteria for the relevance of an NGO s health projects/programmes with regard to the Belgian cooperation s policy notes on health) makes reference to three policy notes on health: The right to health and healthcare ; Combating HIV/AIDS ; Sexual and reproductive health and rights and encompasses the recommendations contained within these three policy notes. This highly useful document is known in Brussels but it was not possible to confirm that it is systematically used when reviewing health project/programme documents. None of the people we encountered in the countries alluded to this guide. V.1. The role of sexual and reproductive health and rights in Belgian cooperation on the ground Sexual and reproductive health and rights are clearly taken into consideration in both of the two projects visited in Burundi, on the one hand in the project implemented by the BTC and which is based on reinforcing the health system at district level, and on the other hand in the fistula project coordinated by a Belgian NGO. The latter project, although it was not analysed by the Belgian representation in Burundi during the design stage, nevertheless was supported and followed by the embassy attaché and was perceived by all involved to be in perfect harmony with the IDCP and Belgium s priorities. The fistula project implemented in the district of Gitega is a project that targets a specific domain of reproductive health and therefore is not intended to take into account all of the strategic fields defined by the policy note. Whilst the policy note does not seem to have been used during the formulation stage, the project, either directly or indirectly, takes a rather broad view of maternal health and it is positive to note that it contains elements that are linked to the six strategic fields of the policy note. 76

77 In the primary healthcare project in Burundi, sexual and reproductive health and rights form an integral part of the package of activities that has to be implemented in a health district. Topics that are difficult to address in many different contexts, such as access for adolescents to reproductive healthcare or post- abortion care, for example, form part of the activities underway in the district. This shows that through interventions based on primary healthcare at peripheral level, Belgium is able to make a significant contribution towards meeting the needs of people in reproductive health. The situation in Uganda is different; it is clear that little attention is paid to sexual and reproductive health and rights in the activities supported by Belgium, whether they are financed directly or indirectly. In the sector- specific budget support, which is the first choice of intervention in the health sector, reproductive health does not emerge as a particular point of attention. By choosing to operate through the means of budget support, Belgium is not truly recognised by the partners as an active player in this domain. But it could be, as budget support offers the opportunity, via political dialogue, to influence national policies. Belgium could, for example, use the opportunity of HPAC meetings to inform national partners as well as other donors who are members of this important consultation body, about its policy on sexual and reproductive health and rights. The IDCP for Uganda also mentions support for PNFPs as the second intervention and, as stated above, there is a direct conflict with the Belgian policy note if these PNFPs are not capable of offering modern family planning services. Nevertheless, one option could be actively seeking means of filling the gap that could be left by PNFPs in family planning provision. This illustrates the importance of thoroughly analysing proposals, based on relevant policy notes, in order to avoid conflicts between the Belgian strategy and that of the partners or of institutions supported by the development cooperation. V.2. Alignment with national policies and priorities in health The Belgian development cooperation policy seems to be very much in line with the policy of the Ugandan and Burundian governments. In both countries, objectives for sexual and reproductive health and rights can be found in policy documents and national strategies. However, better knowledge of the policy note by Belgian actors would allow encouraging governments and different partners who wish to effectively implement strategies that are in line with Belgian policy. In the opinion of the development cooperation partners, NGOs and officials from the Ministry of Health at all levels (this is the opinion of 8/9 people questioned on the subject), the current priority in Burundi is managing demographic growth through promoting family planning services 33. This priority does not seem to be shared by all Belgian actors. By way of illustration, in the TFD of 2009 on the Institutional support programme to the public health sector. Burundi, demographic growth and family planning are only mentioned in the situation analysis or in the chapter on cross- cutting subjects (gender and HIV/AIDS) Demographic growth already represented a major challenge in the CPLS from The first NRHP from 2007 on the other hand designated family planning as a second strategic axis. 34 No mention of the problem of demographic growth and family planning needs is made either in the document Programme to support local NGOS strategic note Burundi Direct financing of local non governmental organisations or in the Programme to support civil society. Strategic note Burundi Direct financing of local civil society organisations. These two documents, however, highlight the need for sustainable economic growth. 77

78 In Uganda, several of the people interviewed (6/14) mentioned human resources in health as being one of the major focal points for the Ministry of Health 35. In the specific domain of reproductive health, according to 15/20 of the people questioned, maternal health and especially the fight against maternal mortality seems to be the country s biggest challenge. Belgium does not intervene directly in the activities aimed at reducing maternal mortality in Uganda. We could imagine, but without any real certainty, that through sector- specific budget support aimed at reinforcing the decentralisation process for implementing primary healthcare 36, through institutional support for PNFPs 37 and reinforcing institutional capacities 38, Belgium may play a role more generally with regard to the priority that human resources represent. V.3. Harmonisation with other international partners In both countries, Belgium participates very actively in the consultation bodies between partners that have been put in place, the HDP in Uganda and the CPSD in Burundi. Participation in this type of meeting and sharing the knowledge of other partners should also ensure that certain topics that are not taken into consideration by Belgium receive attention from other donors. If a decision is made not to become actively involved in certain areas (for example politically or culturally sensitive subjects such as gender- based violence, discrimination against vulnerable groups and people with a different sexual orientation, adolescent health, abortion or family planning), it does not alter the need to continue to advance Belgium s priorities and support the donors who share them in the context of these consultation bodies or on other occasions. V.4. Contribution towards MDGs It is difficult to quantify the contribution made by Belgian interventions towards the MDGs even if all interventions could potentially have a positive impact on goals 3 to 6. It is difficult to demonstrate this contribution when intervening via budget support. For MDG 5, however, it is quite clear in the SRHR project and the primary healthcare project. The latter clearly demonstrates that through project work it is possible to make an active contribution towards meeting people s needs in health and reproductive health and it may perhaps be appropriate to draw inspiration from this integrated approach for example when examining financing requests by NGOs. V.5. Opportunities In both countries, Belgium participates very actively in the activities of the consultation bodies between partners (the Health Sector Development Partner Coordination Group, CPSD in Burundi, which Belgium is leading, and the HDP in Uganda). Belgium is also a member of several working groups called thematic groups in Burundi and the Technical working groups in Uganda. For four consecutive years, Belgium has been the lead partner among the health partners in Burundi and, via the BTC, has been an active member of the thematic groups Health districts and Human resources. In Uganda, Belgium takes part in the TWG Sector budget support and Public private partnerships in health. 35 The problem is the number of them and how they are divided as well as their management, qualification and qualities. 36 District capacity to strengthen decentralisation and implement effective PHC activities 37 Institutional support to the PNFP sector to increase service delivery 38 Institutional Capacity Building (ICB) 78

79 These groups are privileged settings where Belgium can advance its priorities based on national policies and encourage the countries and technical and financial partners to truly implement the strategies put forward in the national strategic documents. Whilst in Burundi the reference document on reproductive health (NRHP) is very comprehensive and the activities it describes seem to have been actually put in place on the ground, this is not the case in Uganda where there are several documents that set out policies and strategies but which fall short when it comes to implementing them at operational level, Uganda is really good at creating policies but implementing them is quite a challenge. If Belgium is to play a role in Uganda in implementing sexual and reproductive health and rights policies, it seems appropriate to play an active role in the technical group on maternal and child health. VI. Conclusion This study has demonstrated that SRHR is not always a component of the interventions supported by Belgium and that the significance attributed to them depends on the national situation and the channels of development cooperation. Belgium s contribution towards meeting the needs of people in sexual and reproductive health and rights differs according to the type of intervention. In Burundi, the project based on primary healthcare is a prime example of successfully contributing towards improving reproductive health in an integrated approach within a local health system. Although from a public health point of view we could wish for or foster this type of intervention based on a systemic approach, more specialised projects will remain useful or even necessary when tackling specific health- related matters which, in the case of vesico- vaginal fistulas for example, require specialist services. When intervening via budgetary aid, as in Uganda, it is not as easy to target specific topics such as SRHR. In order to defend Belgium s priorities in this domain it must be assured that reproductive health is a component in the strategies and policies supported but also be verified that these strategies are being properly implemented. If this is not the case, through political dialogue it may be possible to promote the integration of SRHR in the national strategic plans and/or facilitate their implementation at operational level by the Ministry of Health or by other partners. The role that the policy note plays when drafting the financed programmes and in their implementation remains limited. However, when the interventions that have components in the area of sexual and reproductive health and rights are financed, generally speaking they are consistent with the policy note, in line with national policies and in relative harmony with the interventions of other donors. Nevertheless we must remain vigilant and must not hesitate to refer to the policy note in order to avoid, as was the case in Uganda, responding to requests that could potentially conflict with Belgian strategies. VII. Recommendations In order to improve the contribution made by Belgium in the area of SRHR, a discussion must be launched on the way in which SRHR should be incorporated into the interventions financed by Belgium. This discussion must result in practical recommendations on the way in which SRHR can be 79

80 kept on the agenda regardless of the channels used and in a way that is adapted to development cooperation modalities. To feed into the debate, the following recommendations could be taken into consideration: 1. In each country where health is a priority, it would be useful to guarantee the presence of an attaché who is specifically in charge of the sector, to ensure optimal follow- up and that particular attention is paid to the priorities defined by the development cooperation; 2. An approach based on primary healthcare, incorporating where possible the various strategies identified in the SRHR policy note, must continue to be the reference for any support for the health sector, whether this support is provided via governmental or non- governmental cooperation; 3. As an integrated approach, in a context of limited resources, cannot hope to cover all of the SRHR needs, it is still recommended that the Belgian development cooperation continues to finance projects that cover the very specific needs in the area of SRHR, such as the fistula project in Burundi; 4. In the countries where Belgian cooperation is provided via budget support, special efforts are needed so that the Belgian actors benefit from their involvement in various fora bringing together government, development partners and other actors in order to follow and even exert influence over the progress associated with development cooperation priorities such as SRHR. Participation in the technical group on maternal health may be a very effective means of achieving this aim. Other actors, such as multilateral actors in the area of SRHR and particularly those receiving financing from Belgium, could be encouraged to play an active role in political dialogue, especially by participating in the relevant technical groups; 5. So that Belgium is able to play a role in the political dialogue or through interacting with partners and donors, enhanced knowledge of the SRHR policy note and therefore what is at stake in this domain, is essential. When analysing the proposals made by the national authorities as well as international partners or even NGOs, it would be useful to refer systematically to the policy note, on the one hand to ensure that reproductive health is fully taken into account and on the other hand to avoid any conflict between the Belgian strategy and the strategies of partners or institutions requiring support from Belgium. 80

81 VII. Annexes 81

82 Annex 1. Terms of Reference submitted by DGD to ITM under the framework agreement 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. 39 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. 40 In 2009, a working group on sexual and reproductive health and rights (SRHR), with representation of DGD and the Belgian Technical Cooperation (BTC), relevant civil society and academic partners, was established within the platform Be- cause Health to strengthen awareness on the policy note and its implementation. During the Millennium Summit in September 2000, the United Nations General Assembly adopted the Millennium Declaration, from which the Millennium Development Goals (MDG) were derived. Four of the eight MDG are directly related to health and reproductive rights, i.e. MDG 3 promote gender equality and empower women, MDG 4 reduce child mortality, MDG 5 improve maternal health, and MDG 6 combat HIV/AIDS, malaria and other diseases. The latest progress reports on the MDGs have shown that MDG 5 is the one requiring the most progress still to be made, and this is particularly true of MDG 5B achieve, 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; 42 the principles of ownership, alignment or harmonisation encourage the provision of aid through general budget support, sector- wide approaches (SWAp) or health system 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. Five years after the publication of the SRHR policy note, and considering the room for improvement in reaching the SRHR related MDG as well as the consequences of the Paris Declaration, it is considered important to investigate how Belgium through its policy note on SRHR contributes to the specific needs of sexual and reproductive health in developing countries. Therefore, DGD requested the Institute for Tropical Medicine (ITM) to develop these terms of reference for such a research project, which will serve as the basis for the final study protocol. 39 Available from : 40 More information available from: 41 MDG 5A aims to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio 42 Available from : 82

83 Objectives The main objective of the research project is to provide a qualitative description of the contribution of Belgian development aid to the improvement of sexual and reproductive health in the supported programmes. Specific objectives are: To determine the awareness and use of the SRHR policy note by key Belgian cooperation actors; To provide a review of sexual and reproductive health interventions in three different types of development aid programmes, and one in- depth country study. While the main focus of the research project is on health, it is important to note that the rights perspective will also be considered, in particular through the use of the strategic priorities outlined in the policy note, which will serve as a basis for the whole project. Study design The research project is composed of two modules in order to reach each of the specific objectives as outlined above. 1. Module 1: Survey of SRHR policies and the use of the Belgian SRHR policy note A web- based questionnaire will be developed as part of the study protocol in order to describe the awareness and use of the SRHR policy note by key Belgian cooperation actors. The questionnaire will consist of three parts: 4) an overall description of the importance of sexual and reproductive health in programmes supported by DGD, guided by the six strategic fields 43 and the three specific areas of cooperation 44 as outlined in the policy note, as well as in relation to the 1994 ICPD Programme of Action; 5) a series of (closed) questions with regards to the frequency of use of the policy note in different operational activities or tools, e.g. in the policy dialogue; 6) a number of open questions for a more subjective feedback on the perceived added value of the policy note, including suggestions on how to overcome potential barriers and ensure an optimal use of the policy note by the relevant stakeholders. A link to the web- based questionnaire will be sent to all key Belgian cooperation actors, including DGD collaborators with operational responsibilities, the DGD attachés in the partner countries, and the implementing partners such as BTC and the medical non- governmental organisations (NGO). 43 Cf. page of the policy note: 2.1 Promoting the integration of sexual and reproductive rights into national policies, 2.2 Promoting gender equality and the empowerment of women and girls; 2.3 Devoting more attention to adolescents and young people; 2.4 Strengthening health systems; 2.5 Promoting a global approach to AIDS; 2.6 Supporting awareness-raising, information and education 44 Cf. page of the policy note: 3.1 Integration of sexual and reproductive health care into general health care; 3.2 The fight against sexual violence and harmful practices; 3.3 Care and rights during humanitarian crises, conflicts and peacebuilding. 83

84 A descriptive analysis of the collected data will allow the results of the questionnaire to be presented per respondent target group, per country, or per type of intervention (i.e. SRHR as a principal objective or rather integrated in overall health interventions). 2. Module 2: Case and country studies Module 2 consists of three case studies and one country study, which will complement the survey outlined in module Case studies Three case studies are planned in three different health programmes supported by DGD, in order to describe 1) the extent to which sexual and reproductive health is considered in the programme, 2) the extent to which the programme contributes to MDG 3 to 6, and 3) the role played by the policy note in the process of defining and implementing the programme. The case studies aim to provide a qualitative perspective on the consideration of SRHR in the health programmes supported by Belgian cooperation, and do not aim to evaluate the interventions. The case studies will be carried out in two different countries. In the first country, the case study will focus on a project where health sector budget support is provided; in the second country, one case study will focus on a primary health care project, and another case study will focus on a project for which SRHR was defined as a key objective. The case studies will be carried out using a pre- defined assessment tool (as part of the study protocol), which will look at the complete cycle of developing the project, deciding on the details of the project, to its implementation in the field. The assessment tool will be prepared using the policy note as a basis, in particular the six strategic fields (point 2 in the policy note) and the three specific areas for cooperation (point 3), as well as some key principles outlined in point 4 on the implementation of the policy. Part of the case study can be conducted in Belgium, but for each of them, a field visit is considered necessary as well in order to get a better understanding of the field implementation Country study Finally, in one of the two countries where the case studies take place, the opportunity is used to carry out an in- depth country study in order to obtain a general overview of all sexual and reproductive health activities, directly or indirectly supported by DGD, including through multilateral aid or in other sectors, e.g. education. The country study will aim to describe 1) the coherence of these activities with regards to the Belgian policy note, 2) the alignment with the national strategy on the issue and 3) the harmonisation with related interventions supported by other donors. Part of the country study can be done at Brussels level, e.g. systematic review of all projects and programmes with an identified or expected sexual and reproductive health component (including multilateral programmes), review of related progress reports, etc. In addition, a field visit will provide the opportunity to visit the concerned projects and programmes and directly observe the implementation of the sexual and reproductive health components and the coherence between them. In addition, a better understanding will be gained of the national health strategy (and the sexual and reproductive health component in it), and of the relevant programmes supported by other donors. An assessment tool to guide the country visit will be prepared beforehand as part of the study protocol, using the policy note as a basis. 84

85 2.3. Selection of the partner countries In preparation of the selection of the countries to carry out the case and country studies, a qualitative analysis will be done of ongoing programmes where DGD provides health sector budget support, and of those where primary health care programmes are supported, in order to identify the presence of sexual and reproductive health components. The final selection of the countries to carry out the case and country studies will then be based on the presence of a sexual and reproductive health component, that has been implemented for a sufficient period of time and is currently ongoing; the context, providing for a maximum learning opportunity; relevant indications obtained from the survey (module 1) results. In the event that several potential candidates are identified for the country study, the one where humanitarian aid is provided will be given priority; however, this is not a selection criterion in itself. 3. Potential additional modules It is not excluded that additional modules will be proposed, considering the existence of other relevant projects, such as The EAGHA/Lancet initiative on health impact reporting In the light of increased levels of budget support, health impact reporting has been facing new challenges. The EAGHA/Lancet seminar on this topic (Feb 2012) might offer some opportunities to use the field of sexual and reproductive health as a practical example for related research. If this is the case, a separate note on suggested activities will be prepared. Translation of national policy into operations At ITM, a research project is foreseen for 2013 on how national health policies are being translated into practice (contact point is David Hercot). There is room for discussion to use a sexual and reproductive health intervention as the focus in one of the Belgian partner countries where health sector budget support is provided. Such a project might provide some additional insight into the operational use or added value of the Belgian SRHR policy note in national health sector plan implementation. Expected outputs The timeline for the expected outputs is provided below in point V. A first report will describe the obtained results of module 1, including the description of the DGD supported SRHR activities since the publication of the policy note, and the main findings of the survey. As relevant, the report will provide recommendations for improving the awareness and the use of the policy note by the key Belgian cooperation actors. A second report will combine the main findings of the case and country studies, as well as relevant recommendations for future priorities with regards to SRHR in Belgian development cooperation. Finally, an overall summary and key conclusions and recommendations for the complete study will be provided. Opportunities to further discuss these with the partners and key actors will also be explored. 85

86 Timeline and resources The research project will be carried out under the framework agreement between DGD and ITM, under which all related costs are covered. A preliminary timeline is suggested below: Activity Timeline Resources Module 1 Mar Jul FTE Development of short protocol, including the questionnaire Mar Validation of questionnaire Web- based questionnaire Completion of questionnaire by key Belgian cooperation actors Data cleaning and analysis Final report module 1 Mar Mar Apr May Jun Jun- Jul 3 person- months Module 2 Sep 2012 Sep FTE Development of short protocol, including assessment tool for case and country studies Testing of assessment tools Case and country study HQ level Case and country study field level Data cleaning and analysis Final report module 2 Sep Dec 2012 Jan Feb 2013 Mar May Mar May June Jul Jul Sep 3 person- months 2 x 2 person- months 1 person- month Overall summary and conclusions Sep 2013 A peer- reviewed publication on the research project may be considered, but is not included in the timeline above. 86

87 Coordination The research project will be carried out by, and under the final responsibility of the ITM. Feedback on the progress of the research project will be given at the SRHR working group meetings, where preliminary results or challenges faced may be discussed; the working group may also provide feedback on the protocol, the questionnaire and the assessment tools which will be used. The final results will also be presented to the SRHR working group, before publication of the final reports. Finally, while the focus of the study is Belgian cooperation, from a Belgian perspective, communication with the involved partner countries will need to be ensured, before the start of the study, as well as with regards to the final results. 87

88 Annex 2. Country selection procedure Selection criteria The terms of reference specify that two countries must be selected for the three case studies, and that the country study must be carried out in one of the two countries where the case studies are to be carried out. Selection criteria for the case studies A country that receives budget support from the DGD; A country where the following are being carried out: 1) a project or programme focusing on primary healthcare, and 2) a project or programme focusing on sexual and reproductive health and rights. Selection criteria for the country study One of the countries selected for one of the case studies. Other selection criteria The projects or programmes must be on- going and implemented over a sufficient duration; The context must provide as many opportunities as possible for acquiring knowledge; One of the projects or programmes must be implemented by a Belgian national agency and the other by a non- governmental agency. This last criterion was added at the request of the working group on sexual and reproductive health and rights (S&RHR) from Be- cause Health; If several countries are potential candidates, the country receiving humanitarian aid will be selected. In order to select countries where it is possible to carry out case studies, operational criteria have been applied systematically and in the order presented in a summarised way hereinafter. The database used is that provided by the website of the FPS Foreign Affairs, External Trade and Development Cooperation (ODA Online): Application of the selection criteria Stage 1. The project selection criteria in the ODA database are, regardless of the continents, countries or actors: 1) projects in the Health sector (454), 2) projects in the Population, Health and Fertility sector (95) and 3) projects in the Humanitarian aid sector (151) with the exception of food aid and Relief coordination, protection and support services. In total, 700 projects were selected in the first stage. The subsequent stages and selection criteria are summarised in the diagram at the end of this annex. Stage 2. Applying systematic criteria allowed the list of projects/countries that were likely to be selected to be limited to 91. Stage 3. Among these 91 projects, 23 are being implemented in the Democratic Republic of the Congo. Given the difficult context in terms of security, opportunities and speed of travelling within the country and the complexity arising from the sheer number of actors making the country study extremely complex, it was decided to rule out the DRC if other countries met the criteria. 88

89 Stage 4. There were therefore 70 projects which passed to the review stage in order to verify whether or not they had a activities on primary healthcare and/or activities on reproductive health. This stage allowed 43 additional projects to be eliminated as they did not contain at least one of these components. Stage 5. At the end of the systematic selection process, there were 25 projects left being implemented in 12 countries (Algeria, Benin, Bolivia, Burundi, Cambodia, Ecuador, Laos, Madagascar, Mauritania, Rwanda, Senegal, Vietnam). At this point, we classified the countries according to eligibility criteria: 1) presence of a project focusing on primary healthcare, 2) presence of a project focusing on reproductive health 3) presence of a project implemented by a governmental player and 4) presence of a project implemented by a non- governmental player. In addition, the table displays the countries receiving budget support. Country Actor Budget support Primary healthcare (1) Reproductive health (2) BTC (3) NGO (4) BTC (3) NGO (4) Criteria met Algeria BTC Benin Bolivia Burundi Cambodia CDIBWA BTC BTC LouvDev BTC SOSVE MEMISA HIB BTC LouvDev Ecuador BTC Laos HIB Madagascar LouvDev Mauritania MEMISA Uganda 1 89

90 Peru 1 Rwanda CMI Senegal BTC Vietnam HIB CTB At the end of this selection process, there were several possibilities open to us depending on the choice made for the case study in a country benefiting from budget support. The countries receiving budget support are Uganda, Rwanda and Peru. Peru was not selected because of the language barrier and the fact that it is so far away which would mean a longer mission; Rwanda has a heavy political context and a population policy that already involves significant investment in some areas of reproductive health such as family planning; Therefore Uganda seemed to be the best choice. By selecting Uganda as the first country (country with budget support), we were obliged to choose a second country that met the two essential criteria contained within the table above (there are no projects in Uganda that respond to these two criteria): Presence of a project focusing on primary healthcare (criterion 1) and a project focusing on reproductive health (criterion 2); A project implemented by a governmental actor (criterion 3) and a project implemented by a non- governmental actor (criterion 4); The possibilities were as follows: Benin, Bolivia, Burundi, Cambodia and Vietnam. Bolivia: similarly to Peru (country with budget support), there was an issue of distance and language; Benin: the reproductive health project is limited to zone hospitals; Burundi: low- income country where Belgium plays a strategic role; Vietnam and Cambodia are medium- income countries. We contacted the DGD for an opinion regarding the final choice of country. Health remains a priority sector for the next few years and with priority being granted to low- income countries where Belgium has a strategic role to play, preference was granted to Burundi. Benin could also have been chosen if the project had not targeted zone hospitals. The countries selected for the research were therefore Burundi (two case studies) and Uganda (one case study and a country study). 90

91 Details of the selection process Stage projects (ODA online) projects - 61 projects No expenditure in 2011 Projects not implemented in a specific country UNIVERSAL/COUNTRY NOT SPECIFIED/Belgium CENTRAL AFRICAN REGION several countries or indeterminate EUROPEAN REGION (ODA) several countries or indeterminate SUB- SAHARAN AFRICAN REGION several countries or indeterminate CENTRAL AND NORTH AMERICAN REGION several countries or indeterminate SOUTH AMERICAN REGION several countries or indeterminate - 24 projects projects Medical research projects (clinical studies, laboratory research ) Sectorial budgetary aid/support Institutional support Joint Health Sector Support Improving partner management capacity/support for budgetary management University cooperation project, support for clinical or laboratory research Participation in funds (HCR, Unicef) Logistics and infrastructure rehabilitation (transport, construction, rehabilitation) - 46 projects Targeted programmes (Leishmaniasis, malnutrition, mental health, tuberculosis, tripanosomiasis, leprosy, dental health, specialist healthcare, disabilities, drugs and drug addiction, central purchasing of medicines, first aid training) - 9 projects - 4 projects Projects focusing on financing mechanisms (health insurance, mutuals) Project implemented by the Institute of Tropical Medicine (possible conflict of interests) 91 projects remaining 91

92 Stage 3 91 projects - 23 projects Projects in DRC 68 projects remaining Stage 4 68 projects - 43 projects Projects that have no chapter on primary healthcare and/or reproductive health AIDS projects focusing on disease treatment without a dimension aimed at promoting a global approach to AIDS (as explicitly recommended in the policy note) 25 projects remaining 92

93 Annex 3. List of organisations encountered In Burundi Agence japonaise de coopération internationale, JICA Embassy of the Kingdom of the Netherlands Coopération technique belge, CTB. Coopération suisse Deutsche Gesellschaft für Internationale Zusammenarbeit, GIZ Direction du développement et de la coopération (DDC) Direction générale Coopération au développement et Aide humanitaire (DGD) Handicap International, HI Médecins sans frontières, MSF Ministère burundais de la Santé Publique et de la Lutte contre le Sida Shujaa Link United Nations Population Fund, UNFPA United States Agency for International Development / President's Emergency Plan for AIDS Relief, USAID/PEPFAR In Uganda Belgian Technical Cooperation agency, BTC Cooperazione Italiana allo Sviluppo Department for International Development, DFID Directorate- General for Development, DGD Health Development partners, HDP Independent consultant in SRHR Italian cooperation Japan International Cooperation Agency, JICA Joint United Nations Programme on HIV/AIDS, UNAIDS Marie Stopes International Member of Parliament Ministry of Finance Ministry of Gender Ministry of Health Reproductive Health Uganda, RHU 93

94 Rode Kruis Vlaanderen, RKV Swedish International Development Cooperation, SIDA Uganda Catholic Medical Bureau, UCMB Uganda National Health Consumers' Organisation United Nations Children's Fund, UNICEF United Nations Population Fund, UNFPA United States Agency for International Development, USAID World Bank, WB World Health Organisation, WHO 94

95 Annex 4. Interview guide Interview guide: Country office Profile: DGD country representative, CTB country representative Director of operations, project or regional manager Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this country? Q. What are your main responsibilities? Which programme(s) / project(s) do you supervise? Themes What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Use of the policy note as a reference when preparing the project proposal / IDCP /policy dialogue Coherence between activities supported by DGD and the policy note Coherence between national plan / strategy and the Belgian policy note Coherence between other international partners plan/strategy and the Belgian policy note Final question Q. Do you use the policy note when you discuss requests for funding new programmes or projects? Q. Do you use the policy note in the policy dialogue with the national authorities? Probe: formulation phase of the projects Q. To which SRHR themes do you pay particular attention during these discussions? Q. Do you also use the policy note when discussing programmes or projects other than health? Give examples Q. Given that the policy note exists and it is supposed to guide the Belgian cooperation interventions, how do you stimulate DGD funded organisations (NGO/ BTC) to put it in practice? If so, give examples? If not, why? What are the barriers? Probe: lack of awareness (do not know the content of RH), NGO ideologies (different values), practical barriers (conflict with cultural value of beneficiaries or other context factors), etc. Q. What are the main congruence points between the Belgian policy note and the national reproductive health policy? Q. What are the main potential conflicts (RH themes, i.e. abortion) between the Belgian policy note and the national reproductive health policy? Q. Referring to the goals and objectives of the Belgian policy note, to what extent do you think these goals and objectives address the key issues of the national policy? Q. Is (or was) your organisation involved in designing the national policy? Probe: informed of, consulted, actively participating, steering; How is this happening in practice? Q. What, if any, other organisations are involved in the implementation of the national RH policy and / or RH programmes? Please identify organisations and explain why their participation would foster implementation? Q. Do you collaborate with these agencies? If so, how? Probe: formal alliance, informal contacts, joint programme Q. What are the main congruence points between the Belgian policy note and these international agencies' SRHR agenda? Q. What are the main potential conflicts (RH themes, i.e. abortion) between the Belgian policy note and these international agencies' SRHR agenda? Q. Have you seen changes in reproductive health policy / programme in line with the Belgian policy note? 95

96 Interview guide: Brussels office Profile: DGD case managers, CTB Health care expert, gender expert, concerned geographical advisors Director of operations, project or regional manager Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. What are your main responsibilities? Which programme(s) / project(s) do you supervise? Themes What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Use of the policy note as a reference when preparing the project proposal / IDCP /policy dialogue Coherence between activities supported by DGD and the policy note Coherence between national plan / strategy and the Belgian policy note (For Burundi & Uganda) Coherence between other international partners plan/strategy and the Belgian policy note Final question Q. Do you use the policy note when you discuss requests for funding for new programmes or projects? Q. To which SRHR themes do you pay particular attention during these discussions? Q. Do you also use the policy note when discussing programmes or projects other than health? Give examples Q. Given that the policy note exists and it is supposed to guide the Belgian cooperation interventions, how do you stimulate DGD funded organisations (NGO/ BTC) to put it in practice? If so, give examples? If not, why? What are the barriers? Probe: lack of awareness (do not know the content of RH), NGO ideologies (different values), practical barriers (conflict with cultural value of beneficiaries or other context factors), etc. Q. When preparing a new Development Cooperation Program how do you pay attention to the alignment to the national plan / strategy How is this happening in practice? Q. When preparing a new Development Cooperation Program, do you use the policy note as a reference document for all cooperation sectors (health, but also education, agriculture, etc.)? Q. Are you aware of difficulties when using the policy note in the country? Probe: controversial issues like abortion, adolescent Q. When preparing a new Development Cooperation Program do you pay attention to other international partners / donors priorities / action plan How is this happening in practice? Formal meeting with partners, partner policy documents Q. Have you seen changes in reproductive health policy / programme in line with the Belgian policy note? 96

97 Interview guide: Country office Profile: Project coordinator Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Setting in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this country? Q. What are the project s objectives? Themes What I would like to discuss now with you is the extent to which sexual and reproductive health is considered in the project Description of package of RH services actually provided (health care and other activities, like promotion, etc.) Female staff in the project Female staff in health services Themes Use the policy note as a reference when preparing the project proposal / IDCP / policy dialogue Coherence between activities supported by DGD and the policy note Final question Q. What is the situation here in the district / region / country regarding SHRH services? What are the SRHR services available in the structures supported by the project? Are they available at each level (health centre, hospital, etc.)? Q. What SRHR services are NOT available? Why are these services not available, what are the constraints? Q. What could be change to improve / expand the availability and use of reproductive health services in your project? Q. What is the proportion and position of female staff in the project? Q. What is the proportion and position of female staff in health services? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Q. What has influenced the selection of SRHR priorities when the project was being written? Probe: national priorities, local (district) priorities, your organisation priorities, DGD (funder) priorities? Q. Have you received DGD advice / instructions on which SRHR components should be included in the project? Q. How did you decide which SRHR components to prioritise in your projects/programmes? Probe: Policy Note, international commitments, national legislation, needs- assessment Q. Have you received DGD advice / instructions on what SHRH components should be implemented in priority? Q. In your view, does your organisation contribute in its activities to SHRH priorities of the Belgian cooperation? If yes, in what way? Give example Q. Given that the policy note exists and that it is supposed to guide the Belgian cooperation interventions, how does DGD stimulate your organisation to put these priorities in practice? Probe: clear guidelines for the project proposal, mandatory SRHR outputs indicators, etc. Q. Have you seen changes in reproductive health policy / programmes in line with the Belgian policy note? Compare with a reference list of standard SRHR services 97

98 Interview guide: Belgium office Profile: Project coordinator Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. What are the project s objectives? Themes What I would like to discuss now with you is the extent to which sexual and reproductive health is considered in the project SHRH components in projects Themes Use the policy note as a reference when preparing the project proposal / IDCP / policy dialogue Coherence between activities supported by the DGD and the policy note Final question Q. To which SRHR themes do you pay particular attention when writing a new project? Q. Are there SRHR components that you do not usually consider when writing a project? Why these components are not considered, what are the constraints? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Q. What influences the selection of SRHR priorities when writing the project? Probe: national priorities, local (district) priorities, your organisation priorities, DGD (funder) priorities? Q. Have you received DGD advice / instructions on what SHRH components should be included in the project? Q. In your view, does your organisation contribute in its activities to SHRH priorities of the Belgian cooperation? If yes, in what way? Give example Q. Given that the policy note exists and that it is supposed to guide the Belgian cooperation interventions, how does DGD stimulate your organisation to put his priorities in practice? Probe: clear guidelines for the project proposal, mandatory SRHR outputs indicators, etc. Q. Have you seen changes in reproductive health policy / programmes in line with the Belgian policy note? 98

99 Interview guide: Country office Profile: Ministry of Health, central level & district level Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the MOH? Q. What is your professional background? Q. How long are you in this position? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Coherence between national plan / strategy and the Belgian policy note Final question Q. Is there a specific national SRHR policy? Q. What has been the basis for designing this policy? What are the main principles it is based on? Probe: international commitments, national legislation. Q. Were external partners (including donors) involved in designing the SRHR policy? If yes, what has been their contribution and how was it organised? Probe: formal meetings, consultation, working groups, etc. Q. Have Belgian actors (attaché, BTC) contributed to the development of the national SRHR policy? If yes, were there specific points of view, strategies, etc. that Belgian representatives wanted to be addressed by the national policy? Q. Are the following dimensions included in the national SRHR policy plan? Integration of sexual and reproductive rights into national policies Gender equality and empowerment of women and girls More attention to adolescents and young people Strengthening health systems Global approach to AIDS Supporting awareness- raising, information and education Q. In your opinion, did/does Belgium provide any added value with specific regard to the country's SRHR related policies and activities? 99

100 Interview guide: Country field Profile: Health services managers and providers Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this position in this health service? Themes What I would like to discuss now with you is the extent to which sexual and reproductive health is considered in the health service(s) Description of Q. What are the SRHR services available in this health facility (in district health package of RH facilities)? services actually Q. What SRHR services are NOT available? Why are these services not available, what provided are the constraints? Q. In your point of view, are these services available for everybody? Probe: adolescents, women with HIV, poor- poorest, remote population, etc.? Do you think barriers to access SRHR services exist? If yes, what are they? Availability of EmONC, basic and comprehensive services Female staff in health services Availability of infant and child health services Availability of FP services Combat HIV/Aids, malaria and other diseases Final question Q. Can you list the obstetric medical procedures that are performed in your service? Probe: assisted deliveries, neonate resuscitation, etc. See WHO signal functions. Q. What is the proportion and position of female staff in health services? Q. Can you list the services for infant and child that are available in your structure? Q. Can you list the contraception methods that are available in your service? Q. Can you list the available services targeting HIV/aids, malaria and tuberculosis? Probe: PMTCT, ARV, HIV counselling, bed nets, ITP, etc. Q. In your opinion, did/does Belgium provide any added value with specific regard to the SRHR activities in this health facility? Compare with a reference list of standard SRHR services 100

101 Interview guide: Country office Profile: Representative of international partners / agencies at national level Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this country? Q. What are the main organisation activities and priorities? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes and the harmonisation of Belgian policy with related interventions supported by other donors Coherence between other international partners plan / strategy and the Belgian policy note Final question Q. What are your organisation's priorities with regards to SRHR? Q. According to your personal view, what are the SRHR topics that are priority for this country? Could you tell me what are the national priorities? Do you know other stakeholders' (International agencies) priorities? Q. Is (was) your organisation involved in designing the national SRHR policy? Probe: informed of, consulted, actively participating, steering; How does this happen in practice? Q. Are you aware of conflicting priorities with regards to SRHR policy among national and international actors? Q. How do (did) you deal with these possible conflicts? Q. Is your organisation actively involved in implementing the national SRHR policy? Q. What, if any, are the other main organisations involved in the implementation of the national SRHR policy? Please identify organizations and explain how their participation fosters implementation of SRHR policies? Q. Currently, is there support among stakeholders or influential institutions from other sectors for implementing the national SRHR policy? Which stakeholders? Which institutions? Q. Do you collaborate with these institutions / agencies? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Does your organisation collaborate with the Belgian cooperation? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Do you know the Belgian cooperation's priorities with regards to SRHR? If yes, What are the main congruence points between your organisation priorities and the Belgian ones? Q. What are the main potential conflicts (RH themes, i.e. abortion) between your organisation priorities and the Belgian ones? Q. Have you seen changes in reproductive health policy / programmes since your arrival in this country? Q. In your opinion, did/does Belgium provide any added value with specific regard to this country's SRHR related policies and activities? 101

102 Interview guide: Country office Profile: Ministry of education, agriculture, etc. Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position ) Q. When did you join this ministry? Q. What is your professional background? Q. How long are you in this position? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes Coherence between national plan / strategy and the Belgian policy note Final question Q. Are there specific SHRH components addressed by the national policy / strategic plan of your ministry? Probe: empowerment, gender equality, youth sex education, education on prevention of unwanted pregnancies / sexual violence If yes, what components? Q. Are SRHR issues sometimes raised when discussing with the Ministry of Health, with other national partners, with international organisations or donors? Q. When discussing with representatives from the Belgian cooperation, do they sometimes refer to SRHR related issues? Probe. Any time, often, never. Project development, monitoring, reporting, financial audit, dissemination (visibility), etc. If yes, to which components? Probe: gender, women empowerment Q. In your view, what are the main points related to SRHR issues that seem difficult to consider in your programmes/ projects/ strategies? Why? Give example. Probe: youth / adolescent sex education. Q. In your opinion, did/does Belgium provide any added value with specific regard to this country's SRHR related policies and activities? 102

103 Interview guide: Country office Profile: NGO, international organisations, UN agencies active in SRHR, SHRH project coordinators Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position )? Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this country? Q. What are the main organisation activities and priorities? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes and the harmonisation of Belgian policy with related interventions supported by other donors Coherence between other international partners plan / strategy and the Belgian policy note Q. What are your organisation's priorities with regards to SRHR? Q. According to your personal view, what are the SRHR topics that are priority for this country? Do you know the national priorities? Do you know the other stakeholders (International agencies) priorities? Do you know the Belgian cooperation priorities? Q. What has influenced the selection of SRHR priorities when writing the project? Probe: national priorities, local priorities (district), other agencies priorities, your organisation priorities Q Is (was) your organisation involved in designing the national SRHR policy? Probe: informed of, consulted, actively participating, steering; How does this happen in practice? Final question Q. Is your organisation actively involved in implementing the national SRHR policy? Q. What, if any, are the main other organisations involved in the implementation of the national SRHR policy? Please identify organizations and explain how their participation fosters implementation of SRHR policies? Q. Currently, is there support among stakeholders or influential institutions from other sectors for implementing the national SRHR policy? Which stakeholders? Which institutions? Q. Do you collaborate with these institutions/agencies? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Does your organisation collaborate with the Belgian cooperation? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Do you know the Belgian cooperation's priorities with regards to SRHR? If yes, what are the main congruence points between your organisation priorities and the Belgian ones? Q. What were the main potential conflicts (RH themes, i.e. abortion) between your organisation priorities and the Belgian ones? Q. In your opinion, did/does Belgium provide any added value with specific regard to this country's SRHR related policies and activities? 103

104 Interview guide: Country office Profile: Women health and rights organisation Interview type : in- depth interview Remind respondent that the interview will remain confidential and its results anonymous, that no one will be able to trace back comments, and explain the opt out rules Element Actions / Questions Arrival Settling in Introduction Intro interview (objectives of the study) Written informed consent procedure Ask permission to audio- record the interview and to take notes Equipment check Check the audio conditions and if tape recorder is functioning General part Q. Could you please describe to me your responsibilities (as position )? Q. When did you join the organisation? Q. What is your professional background? Q. How long are you in this position? Q. How long are you in this country? Q. What are the main organisation activities and priorities? What I would like to discuss now with you is the contribution of Belgian development aid to the improvement of sexual and reproductive health and rights in the supported programmes and the harmonisation of Belgian policy with related interventions supported by other donors Coherence between other international partners plan / strategy and the Belgian policy note Final question Q. According to your personal view, what are the SRHR topics that are priority for this country? Do you know the national priorities in the field of SRHR? Do you know other stakeholders (International agencies) priorities in the field of SRHR? Do you know the Belgian cooperation priorities in the field of SRHR? Q Is (was) your organisation involved in designing the national SRHR policy? Probe: informed of, consulted, actively participating, steering; How does this happen in practice? Q. Currently, what are the main stakeholders or influential institutions from any sector influencing the orientation of the national SRHR strategy? Which stakeholders? Which institutions? Q. Do you collaborate with these agencies? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Does your organisation collaborate with the Belgian cooperation? If so, how? Probe: formal alliance, informal contacts, joint programmes Q. Do you know the Belgian cooperation's priorities with regards to SRHR? If yes, what are the main congruence points between your organisation priorities and the Belgian ones? Q. What are the main potential conflicts (RH themes, i.e. abortion) between your organisation's priorities and the Belgian ones? Q. Have you seen changes in reproductive health policy / programme since your arrival in this country? 104

105 Annex 5. Documents consulted Burundi République du Burundi Royaume de Belgique. Coopération Belgique- Burundi. Programme indicatif de coopération (PIC) Bujumbura Ambassade van België, Bujumbura. Burundi. Jaarverslag ontwikkelingssamenwerking Ambassade van België, Bujumbura. Burundi. Jaarverslag ontwikkelingssamenwerking Ambassade van België, Bujumbura. Burundi. Jaarverslag ontwikkelingssamenwerking Coopération belge au développement. Dossier technique et financier projet d appui à la province sanitaire de Kirundo Burundi Coopération belge au développement. Dossier technique et financier programme d'appui institutionnel au secteur de la santé publique Burundi Coopération belge au développement. Dossier technique et financier Appui institutionnel au Ministère de la santé publique au Burundi Coopération belge au développement. Dossier technique et financier Projet d appui au développement agricole de la province de Kirundo titre du projet, PADAP- Kirundo CTB. Agence belge de développement. Rapport annuel Juin Handicap international Belgique. La mobilisation communautaire au service de la lutte contre la fistule. Du 1er janvier 2013 au 31 décembre Handicap international Belgique. Les femmes de l arrière- cour ou l histoire de la fistule au Burundi. Burundi Ministère du Plan et du Développement Communal/Cellule Prospective, Programme des Nations Unies pour le Développement au Burundi. Vision Burundi Juin République du Burundi Royaume de Belgique. Coopération Belgique- Burundi. Programme indicatif de coopération (PIC) Bujumbura République du Burundi. Cadre Stratégique de Croissance et de Lutte contre la Pauvreté CSLP II République du Burundi. Cadre Stratégique de Croissance et de Lutte contre la Pauvreté. CSLP II République du Burundi. Conseil national de lutte contre le Sida. Ministère de la Santé Publique. Unité sectorielle de lutte contre le VIH/Sida. Plan stratégique de la réponse du secteur de la sante face au VIH/Sida et aux IST au Burundi pour la période Novembre République du Burundi. Conseil national de lutte contre le Sida. Secrétariat exécutif permanent du CNLS. Bilan des réalisations du Plan d action national de lutte contre le Sida

106 République du Burundi. Ministère de la sante publique et de la lutte contre le sida. Enquête ménages de base pour le suivi et l évaluation de l impact de l appui au système de remboursement du Paquet Minimum des Services de santé (PMS 2009). Rapport définitif République du Burundi. Ministère de la sante publique et de la lutte contre le sida. Compact Burundi Décembre République du Burundi. Ministère de la sante publique et de la lutte contre le sida. Plan national de développement sanitaire Janvier République du Burundi. Ministère de la santé publique et de la lutte contre le sida. Compact Burundi République du Burundi. Ministère de la sante publique et de la lutte contre le sida. Programme National de Santé de la Reproduction. Plan stratégique de santé de la reproduction révisé Février République du Burundi. Ministère de la Santé Publique Programme National de Santé de la Reproduction. Politique Nationale de la Santé de la Reproduction. Septembre République du Burundi. Ministère de la Santé Publique. Programme Nationale de Santé de la Reproduction Feuille de Route pour Accélérer la Réduction de la Mortalité Maternelle et Néonatale au Burundi République du Burundi. Ministère de la Santé Publique. Programme Nationale de Santé de la Reproduction. Feuille de Route pour Accélérer la Réduction de la Mortalité Maternelle et Néonatale au Burundi République du Burundi. Ministère de la sante publique. Rapport d évaluation du PNDS du Burundi République du Burundi. Ministère de la Santé Publique. Rapport d évaluation du PNDS du Burundi. Juin République du Burundi. Politique nationale de la santé Royaume de Belgique. Coopération au développement. Programme d appui à la société civile. Note stratégique Burundi Financement direct d organisations de la société civile locale. Royaume de Belgique. Coopération au développement. Programme d appui aux ONG locales. Note stratégique Burundi Financement direct d organisations non gouvernementales locales. Service Public Fédéral Affaires Etrangères, Commerce extérieur et Coopération au Développement. Federale Overheidsdienst Buitenlandse Zaken, Buitenlandse Handel en Ontwikkelingssamenwerking. Fiche Pays Landenfiche Burundi Service Public Fédéral Affaires étrangères, Commerce extérieur et Coopération au développement. Rapport annuel Mai

107 Uganda Ambassade Kampala Oeganda. Jaarverslag 2010 (1 juli juni 2010).Kampala Oeganda. Ambassade Kampala Oeganda. Jaarverslag 2011 (1 juli juni 2011).Kampala Oeganda. Ambassade Kampala Oeganda. Oeganda. Politiek en economisch jaarverslag Compact between Government of Uganda and Partners for implementation of health sector strategic and investment plan 2010/ /15. July Government of Uganda. Ministry of Health. Health Sector Strategic Plan III. 2010/ /15. Independent Consultancy Team. Identification proposal for institutional support to the Private Non for Profit (PNFP) health sub- sector in Uganda. Kampala, December International Health Partnership. Joint Assessment of Uganda s. Health Sector Strategic & Investment Plan (HSSIP). Final report. January Kingdom of Belgium Republic of Uganda Belgium Uganda Indicative Development Cooperation Program (IDCP) November Kingdom of Belgium Republic of Uganda Belgium. Sector Budget Support for the implementation of the Health Sector Strategic and Investment Plan (2010/ /15). November Kingdom of Belgium Republic of Uganda. Indicative Development Cooperation Program IDCP. FY2012/13 FY2015/16. Kingdom of Belgium Republic of Uganda. Technical & financial file. Institutional capacity building in planning, leadership and management in the Ugandan health sector project Uganda. Kingdom of Belgium Republic of Uganda. Uganda Indicative Development Cooperation Program (IDCP) November Ministry of Finance, Planning and Economic Development. Poverty Eradication Action Plan (2004/5-2007/8) Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health. April Uganda Health System Assessment Kampala, Uganda and Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc. The Republic of Uganda. Annual Health Sector Performance Report Financial Year 2010/2011. The Republic of Uganda. Annual Health Sector Performance Report Financial Year 2011/2012. The Republic of Uganda. Ministry of Health. Health Sector Strategic Plan II. 2005/ /2010. The Republic of Uganda. Ministry of Health. Health sector strategic and investment plan 2010/ /15. July The Republic of Uganda. Ministry of Health. Reproductive Health Commodity Security Strategic Plan 2009/ /14. December The Republic of Uganda. Ministry of Health. Reproductive Health Division. National Adolescent Health Policy for Uganda. October The Republic of Uganda. Ministry of Health. Statistical abstract

108 The Republic of Uganda. Ministry of Health. The Second National Health Policy. Promoting People s Health to Enhance Socio- economic Development. July The Republic of Uganda. National Development Plan 2010/ /15. Uganda APRM National Governing Council. APRM Country Review Report and Progress. July Uganda Bureau of Statistics statistical abstract. June Uganda Bureau of Statistics Statistical abstract. June Uganda Bureau of Statistics Statistical abstract. June Uganda statistics summary ( present). World Health Organization. Accessed on 3 July 2013, and available from: 108

109 Annexe 6. Analysis grid Reproductive health components in programme / project Elements Methodology Source Type of study SHRH components Document review DGD documents proposed in key (Indicative Development Project (NGOs) reference documents Cooperation Programme, project proposal, national health policy and action plan, etc.) documents MOH documents Projects case study Budget support case Country study Description of package of RH services actually provided Field visit Interview of project coordinators Interview of health services managers Visit of health structures Interviews Projects case study Country case study 109

110 MDG 3 6 indicators Elements Indicator Methodology / source Type of study MDG 3: Promote Proportion and position of Field visit Projects case study gender equality female staff in the project Interview of project coordinator and empower Proportion and position of Field visit Projects case study women female staff in health services Interview of project coordinator Interview of MOH at district level Document review: health information system Budget support study Country study MDG 4: Reduce child mortality MDG 5: Improve maternal health MDG 6: Combat HIV/Aids, malaria and other diseases Proportion of female patients attending services (by service: curative care, immunization) Are gender issues addressed in the political dialogue? Availability and use of infant and child health services Availability and use of EmONC including neonatal care (i.e. new- born resuscitation) Reference to analysis of main causes of infant and child mortality/morbidity in action plan Specific budget line for EmONC, FP, etc. in SRHR key document Availability and use of EmONC, basic and comprehensive services Availability and use of FP services (including availability of contraceptive methods (full package) Reference to analysis of main causes of maternal mortality / morbidity in action plan Availability and use of counselling services, prevention (including PMTCT), curative services (specific services for adolescents) Document review: health information system and facility annual reports Document review Interview of DGD representatives Interview of Women health and rights organisation(s) representative(s) Document review: health information system and facility annual reports (immunisation coverage, utilisation rates (IMCI services) Interview with health services managers and providers Document review: health information system and facility annual reports (proportion of institutional deliveries) Interview with health services managers and providers Document review Document review (project proposal and action plan) Document review: health information system and facility annual reports (% of institutional deliveries) ANC coverage and proportion of institutional deliveries (general and for adolescent) Interview with health services managers and providers Document review: health information system and facility annual reports (Number of FP clients (by age, availability of specific services for adolescents (i.e. at school) Interview with health services managers and providers Document review: health information system, facility annual reports Interview with health services managers and providers Projects case study Budget support study Budget support Country study Projects case study Budget support study Country study Projects case Budget support study Country study Budget support study Projects case study Budget support study Country study Projects case study Budget support study Country study Projects case study Budget support study Country study Budget support study Projects case study Budget support study Country study 110

111 The role played by the policy note in the process of defining and implementing the programme. Element Methodology Type of survey Use the policy note as a reference when preparing the project proposal / IDCP / policy dialogue Interview with DGD representatives, project coordinators Projects case study Budget support case study The coherence of activities with regards to the Belgian policy note, Coherence between activities supported by the DGD and the policy note Document review ( Interview with DGD representatives, project coordinators Country study The alignment with the national strategy on the issue Coherence between national plan / strategy and the Belgian policy note Document review Interview with DGD representatives, MOH representatives, other relevant ministries representatives Country study The harmonisation with related interventions supported by other donors. Coherence between other international partners plan / strategy and the Belgian policy note Document review Interview with DGD representatives, international partners representative Country study 111