Actors, policies, programs andactivities of family planning in Sudan By: Dr. Dina Sami Khalifa Dr. Hani Mohamed Ibrahim Geneva Foundation for Medical Education and Research GFMER Sudan 2012 Forum No: ( 3 )
Name of presenterName Position InstitutionWaleed Amin Head, Community Health Nursing UMSTAmal Khalil Coordinator, RCRU UMST Name of contributorsName Position Institution Dina Sami Khalifa Epidemiologist Ahfad University for Women (AUW) Hani Mohammed Medical Director Um Bakhita MaternityIbrahim Research Assistant –RCRU Hospital .
Objective of presentation• Introduction• FP objectives in Sudan• Policies of FP in Sudan• Actors & Stakeholders of FP in Sudan• FP programs & activities in Sudan• Recommendations & Conclusion
IntroductionFP implies the ability of individuals andcouples to anticipate and attain theirdesired number of children by spacingand timing their births. It is achievedthrough the use of contraceptivemethods and the treatment ofinvoluntary infertility.FP guards individual health, rights, andimproves the quality of life of couplesand their children.
Elements of FP Services Suggested by International Organizations¹:• Range/choice of methods• Delayed childbirth for adolescents• Male responsibility• Attention to unmet need/increasing demand• Safety/side effects research• Sterilization reversal• Implant removal• Quality services ¹ Hardee K, Yount K. From Rhetoric to Reality: Delivering Reproductive Health Promises through Integrated Services. FHI 360. 2012 (Working paper: http://www.fhi360.org/en/RH/Pubs/wsp/wrkngpapers/rhetreal.htm)
Population Demography¹ • TFR in Sudan = 5.5 (2008 census ) (vs. 6.6 in 1993) • Crude Death Rate (SHHS 2010) = 9.6 % ( vs. 26% in1956) • Pop Growth rate 2008 (before separation of South) = 2.6 (2.88 in 1956) • U 5 Mortality rate = 78/1000 (vs. 233/1000 in 1956) • U 15 years of age= 45% • MMR in Sudan ( SHHS 2010) = 216/100000 (vs. 554/100000 in 1989 SHHS) • Life expectancy at birth (2010)= 61.6 (vs. 38.2 in1956) • No legal access to abortion services in Sudan¹ Statistics from “Sudan population policy 2010 “ Document
In Sudan context, FP should be addressed as:1. Primarily: To improve Maternal Health by providing Child Spacing: The most recent survey estimated maternal mortality rate (216/100.000 LB) at national level (225/100,000 rural and 194/100,000 urban. ((SHHS 2010)2. Secondarily; To control population growth;Low SES, increasing poverty, economic instability, low resources for developing human capita.
Sudan Population Policy (SPP) targets for 2031 ¹: • Decrease TFR: (NO TARGET FOR TFR mentioned in SPP) • Decrease population growth: (NO TARGET mentioned in SPP) • Increase FP use to 39% (currently 7%) • Decrease crude death rate to 8% • Decrease under 15 years of age to 37% • Decrease MMR to 73/100000 LB Importance of FP as a strategy in improving maternal health or stabilizing pop growth is not clearly demarcated in Sudan Population Policy.¹ Sudan Population Policy. 2010 Document (Draft)
Family Planning in the “25 years Strategic Plan for Health Sector” 2003-2027¹ • Family planning is mentioned as one of the strategies to reach the goal (Goal 3) of “ Reducing Maternal & Child Mortality” through increasing contraceptives prevalence rate among married couple. FP is NOT stated as an OBJECTIVE. • A policy priority mentioned in the plan is “Goods with public health importance will be the responsibility of the government; this would include environmental health services, prevention of diseases, health promotion and quality assurance.” access to FP through government sector constitutes > 70 %¹ Sudan 25 year Strategic Plan for Health Sector 2003- 2027. doc.
Family Planning in National RH Policy¹ FP is mentioned in a separate statement in the RH policy: “At primary health care level, the health visitors and medical assistants will provide family planning information and services for child spacing and welfare of women. In remote villages and nomadic settings, village midwives and community health workers will act as change agent and in addition to providing condoms refer clients to the health facilities.”¹ Sudan RH Policy Document
The policy also requires these services are “kept confidential, and information about the services provided is divulged after an informed consent of the client. Further, such services, particularly regarding reproductive choices and birth control methods, following the principle of voluntarism, are administered after an informed consent of the client, and will be provided free of charge.”
Actors and Stakeholders Family planning services were introduced in the country in the 1960s with. 1. The “ Sudan Family Planning Association” SFPA: An NGO that is pioneer in FP in Sudan till this day. UNFPA is a key partner. Objectives ¹: • Advocacy and Information, Education and Communication (IEC) to religious and political leaders and the population. • Improving the status of women as an indirect contribution to successful family planning programs. • Providing FP services through its 93 clinics and government structures, and non-clinical services through a community based distribution (CBD) project.¹ www.ippf.org/en/Where/Country....
2. The “Maternal and Child Health and Family Planning project”. MOH & University of Khartoum:• Established in 1980s• Focus: VMW training on various MCH issues as well as community outreach activities e.g. FP distribution• It is considered a success story.¹3. The “Sudan Fertility Control Association”:• Established in 1976.• Work with Sudan Family Planning Association to provide family planning services throughout the country.4. National Population Council:• Worked intermittently in Sudan for more then 20 years through the Middle East Capacity Awards (MEAwards) program.¹ El Tom AR, Farah AA, Lauro D, Fenn T. Community and individual acceptance: family planning services inthe Sudan. Ahfad J. 1987 Jun;4(1):12-30.
5. UN agencies contribution to FP: • UNFPA ¹: “Advocacy for integration of reproductive health commodity security, including HIV/AIDS commodities, in the national health commodity system” “Support to integrating management and prevention of sexually transmitted infections/HIV in reproductive health services outlets, including services for young people” “Support to enhancing capacities of reproductive health care providers” “Capacity building to implement minimum initial service package in humanitarian settings”¹ Sudan UNDAF document 2013-2016
“Support to integrating management and prevention of sexually transmitted infections/HIV in reproductive health services outlets, including services for young people” “Support to comprehensive condom programming” “Strengthening of the knowledge base on socio- cultural determinants to guide reproductive health interventions, including for HIV prevention”
• WHO¹: “Support MoH to scale up coverage of health services, including: increasing the number of PHC facilities delivering the integrated basic RH package- Inclusive of FP services” “Capacity development of health cadres to provide quality services”¹ Sudan UNDAF document 2013-2016
FP activities/interventions in Sudan and expected impact(Most of FP interventions/activities, no Evaluation Research is conducted) Mostly implemented: Capacity building of health personnel on FP (UNFPA,WHO, NP): MD, MA, HV VMWs. presumed effective if training is tailored , phased and based on needs assessment. Community awareness raising ,advocacy & education on FP presumed effective if barrier to FP uptake is low acceptability Community-based distribution (CBD) of FP: a component of community health outreach. Started 1996, still weak in Sudan. presumed effective if inaccessibility to FP is the problem Ensuring availability of FP commodities to all communities presumed effective if low supply/inequity in distribution of FP is the problem
Performance based approach to RH service delivery: Incentives to HCP to provide RH services and commodities presumed effective if accessibility to FP is the problem but will not guarantee effectiveness of FP (highly dependent on capacity and skills of HCP) Integration of FP services with RH services presumed effective if it meets clients needs, best utilizes a limited pool of resources and may improve the efficiency and effectiveness of services.
Barriers to FP programs implementationCountry level Barriers: Challenges to integration of FP service delivery:Integration can facilitate- - but does not guarantee - implementation of services, due to the complexity of RH service packages, the existence of established vertical programs, and weak administrative capacity. ¹¹ Hardee K, Yount K. From Rhetoric to Reality: Delivering Reproductive Health Promises through Integrated Services.FHI 360. 2012 (Working paper: http://www.fhi360.org/en/RH/Pubs/wsp/wrkngpapers/rhetreal.htm)
Challenges with expanded RH services: infrastructure and referral systems; medical support, supplies and logistics; updated & evidence based RH service delivery guidelines; integrated HIS; delegation of activities; competence of personnel; training for staff and supervisors; supervision; and evaluation of integrated programs.¹ Cost & Funding: the assumption that Sudan contributes two-thirds of the resources for RH, and donors contribute the remaining one-third is a challenge under current National Health Expenditure.¹¹ Hardee K, Yount K. From Rhetoric to Reality: Delivering Reproductive Health Promises through IntegratedServices. FHI 360. 2012 (Working paper: http://www.fhi360.org/en/RH/Pubs/wsp/wrkngpapers/rhetreal.htm)
Community level barriers: National research¹² has identified inequity in distribution/uptake of FP and highlighted barriers to effective FP uptake in the community: Misplaced religious believes. Misplaced believes about side effects of FP Significant role of husbands mainly husbands with lower educational level. Low educational level of women.¹ Ali et al. Use of family planning methods in Kassala, Eastern Sudan. BMC Research Notes 2011, 4:43² Saghayroun AA, Khalifa MA. Fertility and Islam in the Sudan. Sudan J Popul Stud. 1984 Jun;1(2):1-28.
Opportunities for effective FP in Sudan Positive political commitment. Positive donor collaboration. Increasing collaboration with Academia to undergo operation/evaluation research. Increasing range of stakeholders, such as policy- makers, womens advocacy groups, grass-roots organizers, service providers, and client representatives, academia among others.
Recommendations: • Addressing FP issues from a Maternal Health perspective not Population Growth Control to gain more religious, governmental and community support. • Targeting religious leaders so as to increase community awareness on importance of FP on the socio economic level and health of mother and child. • Targeting men as they constitute a large proportion of decision making on use of FP ( 34.1% of families the male is the sole decision maker on FP use) ¹ • Targeting women immediately postpartum via counselling and follow-up on FP issues. Prime target should be women with lower SES, high parity, low educational level.¹ Khalifa MA. Attitudes of urban Sudanese men toward family planning. Stud Fam Plann. 1988 Jul Aug;19(4):236-43.
• Massive and comprehensive FP promotion campaigns addressing FP types, effective use, side effects and health benefits. Campaigns involving multiple influential stakeholders so as tackle social determinants for the high FP unmet need in Sudan.• Strengthening policies to support CBD of FP• Establishing Operational/ Evaluation research to examine impact of the various FP interventions in the country to provide evidence for new policy & interventions.