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

2. Presentation Outline 1.Study methods 2.Preliminary results South Sudan DRC Burkina Faso 3. Summary 2

3. Study Objectives 1.To assess the availability, quality and utilization of RH services 2.To propose how to adapt service delivery and IEC programs according to barriers and perceptions 3.To highlight differences between policies and practice, evidence-based decisions vs beliefs/myths/perceptions- based decisions. 4.To propose how to improve quality and utilization of services 5.To systematically assess the availability and use of facility-based RH services 3

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

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

6. Data collection 6 S. SudanDRCBurkina Faso DatesJuly-Aug. 2013Oct. 2013Nov. 2013 LocationMaban CountyMasisi HZSahel Region Population91,754385,13445,000 No. Facilities - Service availability 151128 No. Facilities - In-Depth386 No. Provider surveys180 (?)11 No. FGDs9129 No. Key informant interviews 222015

7. PRELIMINARY RESULTS: SOUTH SUDAN 7

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

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

10. Facilities assessed, n=15 10 PHCUs: Dispensaries, short acting FP methods PHCCs: BEmOC, delivery, all short and long acting FP methods Govt.- Supported INGO- supported & camp-based Local FBO- supported Total PHCUs 0909 PHCCs 1416 Total 113115

11. Family Planning 11

12. Abortion 12

13. EmOC 13

14. HIV & STIs 14

15. Care for Survivors of Sexual Assault: 15

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

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

18. PRELIMINARY RESULTS: DEMOCRATIC REPUBLIC OF CONGO 18

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

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

21. Facilities assessed, n=19 21 Health Centers: ANC, post-natal care, BEmOC, delivery, All short and long acting FP methods, testing and treatment of chronic diseases (including HIV) Hospital: Referral, surgery, CEmOC, all short-acting long- acting and permanent FP methods Govt.- Supported (only) INGO- supported* Total Health Centers 31518 Hospital 011 Total 31619 *1 or more RH service

22. Family Planning 22

23. Abortion 23

24. Basic EmOC 24

25. HIV & STIs 25

26. Care for Survivors of Sexual Assault 26

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

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

29. PRELIMINARY RESULTS: BURKINA FASO 29

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

31. Facilities assessed, n=28 Govt.- Supported INGO- Supported FBO- Supported Total Hospitals3*--3 Refugee Camp Facilities -4-4 Health Centers20-121 Total234128 31 Hospitals: Referrals, CEmOC, all FP methods, HIV services, care for sexual assault survivors Health centers and refugee camp facilities: Delivery, short and long- acting FP methods, HIV services, care for sexual assault survivors *2 hospitals receive NGO support for FP

32. Family Planning 32

33. Abortion 33

34. Basic EmOC 34

35. HIV & STIs 35

36. Care for Survivors of Sexual Assault: 36

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

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

39. OVERALL SUMMARY 39

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

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