13
199 0
ia Ca am ri er bb ic ea a n &
la
ti
n
as
ri
ca
0
20 03 – 0 4
Despite the proliferation of global leaders proclaiming Source: Singh S, Darroch JE, Ashford LS and M Vlassof (2009) Adding It Up: The costs and benefits of investing in family planning and maternal and newborn health. New York: Guttmacher and UNFPA.
the Maputo Plan of Action offers an operational, realistic plan to guide African countries to achieve universal access to comprehensive sexual and reproductive health services The Maputo Plan of Action consolidates priorities and actions of African governments and civil society, it is built on a foundation of collaboration to achieve development goals. The Maputo Plan of Action was agreed by Ministers of Health at the Special Session of the African Union Conference (Maputo, September 2006), and put into force by the African Union in January 2007. It is the outcome of a consultative and participatory process, stemming from sub-
15 18
25
14
16
20
33 15
29 20
10
16
15
13
5
0
1995 2003
National and district-level governments should increase financing for sexual and reproductive health services and programmes
Lack of funding and political priority for sexual and reproductive health within national governments.
1995 2003
1995 2003
SAFE
Vertical funding and programmes hamper the integration of sexual and reproductive health programmes. Opportunities to provide efficient, integrated services are untapped.
Integrate sexual and reproductive health services together with sexually transmitted infections, HIV and AIDS services and programmes
The Maputo Plan of Action consolidates priorities and actions of African governments and civil society, it is built on a foundation of collaboration to achieve development goals
Although the Maputo Plan of Action has been implemented in policy and strategy, most African countries have failed to re-allocate the resources or mobilize additional funds that are necessary to implement their Maternal and Newborn Health Road Map. This is a major problem. Fewer than 10 per cent of countries have mobilized at least 50 per cent of the resources required to implement the Maputo Plan of Action. Much more commitment and priority is needed within the national government for sustained improvements. Where governments have increased their investments in sexual and reproductive health, people are seeing a marked change in their access to services, supplies and programmes; their health and well-being are improving.
Implementing the Maputo Plan of Action will help countries build and reinforce a strong foundation to ensure effective reproductive and maternal health programmes in the future. It is a major step towards the attainment of the MDGs.
UNSAFE
Source: Singh S, Wulf D, Hussain R, Bankole A and G Sedgh (2009) Abortion Worldwide: A Decade of Uneven Progress. New York: Guttmacher Institute.
How well has the Maputo Plan of Action been implemented? Some governments have made the Maputo Plan of Action a key part of their health strategy. At least 83 per cent of countries8 have formulated or revised national policies, strategies, plans, programmes and/or project documents
Foster the involvement and participation of the community, of the whole family, and of men in sexual and reproductive health and rights interventions
Invest in programmes that are specifically designed to increase choices for girls and women so they can exercise their rights and participate fully in society
to align their health sector with the Maputo Plan of Action since it was adopted, and more than 30 African countries have developed Maternal and Newborn Health Road Maps.9 These Road Maps are key outputs of the Maputo Plan of Action and a core element of any national reproductive health plan – thus essential to the national health plan as a whole.
The Maputo Plan of Action recommends a broad range of interventions that are rights-based and cross-cutting: they are designed to improve opportunities and quality of life for the poorest and most vulnerable women, men and young people. It recognizes that safe motherhood services are most effective when integrated into a continuum of care that is provided to women and children at critical points throughout their life.7
Involve community and religious leaders, educators and health providers, and the whole family, especially men, in sexual and reproductive health and rights interventions
Gender inequality impairs the ability of women to access reproductive health services and use contraception, thus contributing to unplanned pregnancies, to unsafe abortions, and to reproductive ill health and mortality. Gender inequality is also closely associated with gender-based violence.
regional stakeholder meetings (2003-06) that included the African Union Commission, UNFPA Africa Division, several African governments, and the IPPF Africa Regional Office and its Member Associations. It was also inspired by the International Conference on Population and Development (ICPD) Programme of Action (1994) and the Abuja Declaration (2001).
ca
10
21
29
ri
20
29
de co v e un lo tr ped ie s
30
30
33
ss
40
29
ld
47
34
le
53
52
35
What is the Maputo Plan of Action? Based on Africa’s Continental Policy Framework on Sexual and Reproductive Health and Rights, the Maputo Plan of Action offers an operational, realistic plan to guide African countries to achieve universal access to comprehensive sexual and reproductive health services. The Maputo Plan of Action highlights proven and effective interventions, any and all of which can be incorporated into existing health plans. It includes clear goals, outcomes, output and target indicators, as well as suggested timelines and budgets for different interventions.
35
or
50
Abortion rates declined between 1995 and 2003, but the reductions were mostly in safe abortions
w
56
af
While access to HIV services is improving, when the data is disaggregated clear gender disparities emerge: African women account for an ever increasing proportion of people living with HIV and HIV infection is highest among young women.6 Africa’s young people face immense barriers to services and supplies, which translates to a lack of choice, the denial of rights, and yet another generation plagued by ill health and premature mortality. 5
62
de v co el un op tr ing ie s
in the space of a 15-year-old’s entire life – from 1990 to 2005 – maternal mortality in sub-Saharan Africa declined hardly at all
65
60
Percentage of women aged 15–49 using modern methods
Progress in sexual and reproductive health in Africa has been slow and stunted, and girls and women bear the brunt of the burden. More women in this region die from pregnancy and childbirth than in any other part of the world, and in the space of a 15-year-old’s entire life – from 1990 to 2005 – maternal mortality in sub-Saharan Africa declined hardly at all.1 In contrast, maternal mortality in northern Africa dropped by more than a third over the same period.2 Maternal mortality is the leading cause of death of girls and young women aged 10–24.3 With the greatest unmet need for contraception, Africa also has an unparalleled record of unintended pregnancies and the highest rate of unsafe abortion – a major cause of maternal mortality.4
70
Ensure that all young people have access to comprehensive sexuality education and youth-friendly sexual and reproductive health services
Abortions per 1,000 women, aged 15–44
Sexual and reproductive health in Africa
priority and support for maternal health, we have yet to see substantial improvements in Africa. But it is possible! By substantially increasing funding and implementing policies that support women’s health and enrich their lives, Africa can advance towards the Millennium Development Goals (MDGs), including MDG 5 on maternal health, and other internationally agreed goals.
Devise and implement national maternal and infant health roadmaps to ensure the delivery of high quality safe motherhood, newborn and child health services
Young people’s – and particularly young girls’ – sexual and reproductive rights are violated by cultural norms and traditional customs that perpetuate discrimination.
Health systems and other public institutions do not provide the services and programmes required to meet the needs of Africa’s young people.
Learn about and respond to the particular sexual and reproductive health needs of adolescents and youth
Use of modern family planning methods has risen throughout the developing world, but is still very low in Africa
Carry out operational research to support evidence-based action and effective monitoring and evaluation
Severe shortage of skilled maternal and reproductive health professionals, including personnel who are trained to deliver safe abortion care. Health systems face challenges recruiting, training, motivating and retaining staff.
Recruit and train medical professionals, such as mid-level providers, to provide a wide range of reproductive health services, including safe abortion care
Sexual and reproductive health in Africa represents one of the most tragic public health records in modern history. Complications from pregnancy and childbirth, unsafe abortion, the HIV epidemic, other sexually transmitted infections and reproductive cancers pose incredible threats to the lives and well-being of women, men and young people.
Promote African and south-to-south cooperation for the achievement of the Millennium Development Goals (MDGs) and the ICPD goals
Supply chains are failing to ensure contraceptive security. Up to 40 per cent of maternal mortality could be prevented with modern contraceptives.
Strengthen sexual and reproductive health commodity security
Act now to improve Africa’s sexual and reproductive health
Moved to action, African leaders agreed the Maputo Plan of Action – a practical plan to deliver essential services and support. What has Maputo achieved so far?
Reposition family planning as an essential part of the health Millennium Development Goals (MDGs) and of national health and poverty reduction strategies
af
Maputo plan of action
Scale up services in neglected areas to improve service delivery equity (for example, in rural areas and among the urban poor)
To ensure that civil society fulfills its responsibilities in implementing the Maputo Plan of Action, in January 2007 IPPF Africa Region mobilized African civil society, including media outlets. Dialogues and negotiations resulted in national action plans for civil society organizations and media. This work was done in collaboration with the Regional Economic Communities, including the Southern Africa Development Community, the Economic Community of West African States, the West African Health Organization and the Economic Commission for Africa.
Fewer than 10 per cent of countries have mobilized at least 50 per cent of the resources required to implement the Maputo Plan of Action
Progress towards MDG 5, TO IMPROVE MATERNAL HEALTH Targets
Sub-Saharan Africa 1990
2005–08
% change
Northern Africa 1990
2005–08
Developing regions
% change
1990
2005–08
480
450
47
61
7
5
54
74
% change
MDG 5a Reduce the maternal mortality ratio by 75 per cent by 2015 Maternal mortality ratio per 100,000 live births
920
900
Deliveries attended by skilled health personnel (%)
42
47
2 5
250
160
45
79
36 34
6 14
MDG 5b Achieve universal access to reproductive health by 2015 Adolescent women (aged 15-19) who have begun childbearing (%)
12
13
Antenatal care coverage, at least one visit (%)
68
75
Unmet need for family planning (%)
26
28
-1 7 2
43
31
47
70
16
10
12 23 6
Unavailable
2 20
2210
Sources: United Nations (2009) Millennium Development Goals Report 2009. UN: New York. Sedgh G, Hussain R, Bankole A and S. Singh. (2007) Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Guttmacher Institute. Data is based on 29 countries in sub-Saharan Africa. Occasional Report No. 37, Singh S, Darroch JE, Ashford LS and M Vlassof (2009) Adding It Up: The costs and benefits of investing in family planning and maternal and newborn health. New York: Guttmacher and UNFPA.
Ghana
Senegal
Tanzania
“Poor and young women are the ones who are at greatest risk for unintended pregnancies and who end up having the unsafe services and suffering the consequences.”
“Despite positive results achieved through our common efforts, much remains to be done. Now, we, as Africans, must go beyond those conceptual advances and fully invest our efforts in priority projects that we have identified.”
“Having a budget line for SRH for this country is a very positive thing for us. However, while there is a budget line for contraceptives, the funds are rarely available when needed.”
David Kansuk, tribal chief in Nalerigu and medical assistant with the Planned Parenthood Association of Ghana
Paul Badji, Permanent Representative of Senegal to the United Nations
Uzazi na Malezi Bora (UMATI), IPPF Member Association
Ghana has demonstrated strong commitment to sexual and reproductive health in recent years. By increasing women’s access to services and choices, Ghana has substantially reduced maternal mortality, and the country has adopted strong policy frameworks for reproductive health.
Senegal faces a host of cultural and geographical barriers when it comes to sexual and reproductive health. A strongly Islamic and socially conservative society, people are reluctant and sometimes opposed to contraception, and thus contraceptive prevalence remains low.
While contraceptive prevalence is increasing and antenatal coverage is high, Tanzania is considered one of the highest risk countries for women’s sexual and reproductive health (SRH).
An inadequate health care work force, both in overall numbers and in the number of staff who are appropriately trained to deliver high quality reproductive health services, is a daunting challenge. With greater investment and by focusing on the effective implementation of existing policies, Ghana will be able to achieve its health-related and other development goals.
The Government of Senegal is working hard to turn the situation around, however, by tackling gender inequality, outlawing female genital mutilation and addressing inequities between rural and urban areas. Senegal’s decentralized health system should allow greater flexibility to tailor services and programmes to the local people, but the system is weak in many areas, partly due to limited human resources and infrastructure. Ongoing monitoring and evaluation is needed to ensure that sexual and reproductive health services are not neglected.
progress towards mdg 5
per cent change
Maternal mortality ratio (maternal deaths per 100,000 live births) 540 0
100
200
300
400
600
500
700
59 0
10
20
30
40
50
17 0
30
20
10
40
13 0
10
5
15
20
Antenatal care coverage, at least one visit, % 95 0
10
20
30
40
50
60
70
90
80
35 0
5
20
15
10
25
35
30
Problems in practice
Delivering on Maputo
Roadmap for Repositioning Family Planning (20062010) positions access to contraception as central to the achievement of the MDGs.
In April 2008, the Government of Ghana declared maternal mortality a national disaster.
Family planning is excluded from the National Health Insurance Scheme, partly due to the misconception that family planning is free in public sector clinics.13
The Government introduced free maternal health care (July 2008). Now all pregnant women can obtain free services for delivery, antenatal and post-natal care, and emergency obstetric care. Eighteen days after the programme began, 50,924 women had registered to access the free services.
40
10
20
40
10
5
15
20
Antenatal care coverage, at least one visit, % 87 0
10
20
30
40
50
60
70
90
80
40
32 0
5
20
15
10
25
35
30
Health Sector Programme of Work (2007-2011) highlights the critical importance of family planning and contraceptive security
Positive policies
Contraceptive Security Strategy (2004-2010)
Lack of choice when it comes to contraceptive method through public outlets. This results in nonuse and unmet need. In 2009, the Government spent US$800,000 on contraceptives, based on recommendations by the Interagency Coordination Committee for Contraceptive Security. The Government committed funds when it understood that family planning is critical to the MDGs and other highpriority development goals.
In December 2009, the Ghana National Drugs Programme included eight new contraceptives on the National Essential Medicines List. Public health facilities must now procure these contraceptive methods in order to offer more contraceptive choices to clients. For the first time, Ghana Health Service facilities in northern and western regions are procuring contraceptives.
National Strategy on Adolescents and Young People’s Health (2007)
Roadmap to accelerate the reduction of maternal and infant mortality and morbidity (2006-2015)
Public health service outlets often have contraceptive stock-outs because of limited funding and cumbersome financial processes. Vulnerable groups, including sex workers, face substantial barriers in accessing family planning services and supplies.
Delivering on Maputo
The Government increased the budget for contraceptives from 46 million CFA francs (US$93,671) in 2006 to 100 million CFA francs (US$203,633) in 2007.16 National Programme on Family Planning has made efforts to deliver SRH services to certain vulnerable groups, including sex workers.
1 OECD (2009) Issue focus 9: Gender. 3 Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, Vos T, Ferguson J and CD Mathers (2009) Global patterns of mortality in young
7 UNICEF (2009) State of the World’s Children Report on Maternal and Newborn Health.
11 Ghana Statistical Service, Ghana Health Service, and ICF Macro (1994) Ghana Demographic Health Survey 1993. Calverton, Maryland, USA:
8 This report reviewed data from 30 of 45 African countries.
GSS, GHS, and ICF Macro. Maternal mortality indicator only: UNFPA and
9 African Population and Health Research Centre (2009) Status Report on
Population Reference Bureau (2005) Country Profiles for Population and
the Implementation of the Maputo Plan of Action: Opportunities and
Reproductive Health: Policy Developments and Indicators 2005. New York:
September 12, 2009.
Challenges for CSO Action in Promoting Sexual and Reproductive Health
UNFPA and PRB.
costs and benefits of investing in family planning and maternal and
60
50
13
10
20
30
40
50
6
29 23 10
5
15
20
30
25
Antenatal care coverage, at least one visit, %
5
92
1991/92 l atest data
97 10
20
30
40
50
60
70
90
80
100
Unmet need for family planning (%)
40
6
28
1991/92 l atest data
22 0
Positive policies
National Observatory of Women’s Rights, an initiative to strengthen the legal environment for women’s empowerment Equality and Equity of Gender National Strategy (2005-2015)
Young people lack access to information, education and vocational training that will allow them to develop careers and livelihoods, as well as comprehensive sexual and reproductive health services, including sexuality education.
Gender-based violence, including harmful traditional practices such as female genital mutilation, is common, especially in rural areas.
Ministry of Health mainstreamed adolescent sexual and reproductive health into health service delivery and health programmes.
National Programme on Family Planning has implemented programmes to tackle genderbased violence.
The Ministry is establishing special facilities in every region where youth can obtain skills and training, use the internet and access sexual and reproductive health services.17
The Ministry of Family Affairs is working with village leaders to help them eradicate female genital mutilation.
and Rights in sub-Saharan Africa. Nairobi: APHRC. 10 Fifteen per cent of married women aged 15–49 in 53 developing countries
12 Ghana Statistical Service, Ghana Health Service, and ICF Macro (2009) Ghana Demographic and Health Survey 2008: Key Findings. Calverton,
13 Population Action International (2009) Reproductive Health Supplies in Six Countries. Washington: PAI. 14 MEASURE DHS (1994) Enquete Demographique et de Sante au Senegal 1992/93. Macro International. 15 MEASURE DHS (nd) STATCompiler>Quick view: view indicators: Senegal. Senegal 2005 Demographic Health Survey; MEASURE DHS (2005) Enquete Demographique et de Sante au Senegal 1992/93. Macro International. 16 African Population and Health Research Center (2009) Status Report on
17 Diop, N and AF Diagne (2007) Mainstreaming Adolescent Reproductive Health in Senegal. Population Council Frontiers in Reproductive Health Program. Population Council. <www.popcouncil.org/frontiers/projects/afr/ Senegal 18 Maternal mortality ratio: United Nations Statistics Division: Millennium Development Goal Indicators. URL: http://mdgs.un.org/unsd/mdg/Data. aspx. Accessed Oct 2006. 19 All other figures: Bureau of Statistics Planning Commission, Tanzania
surveyed have an unmet need for contraception, as do 7 per cent of
Maryland, USA: GSS, GHS, and ICF Macro. Maternal mortality indicator
the Implementation of the Maputo Plan of Action: Opportunities and
(1993) Tanzania Demographic and Health Survey 1991/92. Calverton,
5 UNAIDS (2009) 2008 Report on the global AIDS epidemic. Geneva: UNAIDS.
never-married women of that age in the 36 countries in which they were
only: UNFPA and Population Reference Bureau (2005) Country Profiles for
Challenges for CSO Action in Promoting Sexual and Reproductive Health
Maryland, US: Macro International Inc. National Bureau of Statistics (2009)
6 OECD (2009) Issue focus 9: Gender.
surveyed.
Population and Reproductive Health: Policy Developments and Indicators
and Rights in sub-Saharan Africa. Nairobi: IPPF ARO and APHRC.
[Tanzania] and Macro International Inc. Tanzania HIV/AIDS and Malaria
newborn health. New York: Guttmacher and UNFPA.
40
5
10
25
20
15
35
30
40
Reproductive Health Policy (2005–2010) highlights unmet need for family planning Essential Medicines List (2007) includes oral contraception National Package of Essential Reproductive and Child Health Interventions
Roadmap for Maternal, Newborn and Child Health (2007) includes calls for increased funding and availability of contraceptives. Second Health Sector Strategic Plan (2003–08) mentions need for continuous supply of contraceptives.
Problems in practice
Funding for reproductive health supplies is insufficient to provide contraception to all women who have expressed a desire for it.
The national logistics and distribution systems are poorly managed, with the result that health service delivery points frequently run out of reproductive health commodities, including contraception.
Delivering on Maputo
In 2009, the Government of Tanzania announced an increase from US$2.65 million to US$7.26 million for family planning for the fiscal year 2009/10.
Civil society networks at the district level are now acting as watchdog for logistical and distribution systems.
Reproductive and child health is one of five major components of the National Essential Health Package, includes comprehensive family planning services and reproductive health supplies, education and counselling
Within the Ministry of Health, the Reproductive and Child Health Section occupies a lower position in the bureaucratic hierarchy than offices devoted to other health issues.20
Who we are
people: a systemic analysis of population health data. The Lancet, vol 374, 4 Singh S, Darroch JE, Ashford LS and M Vlassof (2009) Adding It Up: The
30
20
0
References
2 Ibid.
-7
7
0
Penal law (1999) outlaws sexual, domestic and gender-based violence, including female genital mutilation
National Programme on Family Planning (1991) includes policies, protocols and guidelines to reposition family planning.
Problems in practice
800
Sources: for ‘1991-92’ data see reference 18; for ‘Latest data’ see reference 19.
Legislation on Reproductive Health (2005)
Contraceptives are not included in the distribution chain of Ghana Health Service. Those responsible for procuring drugs have low capacity for managing the supply of contraception.
National Plan for Health (2009-2018) gives reproductive health priority
20
1991/92 l atest data
-4
28
1992/93 l atest data
700
Adolescent women (aged 15–19) who have begun childbearing, %
100
Unmet need for family planning (%)
10
0
13
74
1992/93 l atest data
600
500
53
1991/92 l atest data
30
25
400
Contraceptive prevalence rate for married women 15–49, modern method
5
24
300
46 0
50
19
200
1991/92 l atest data
5
30
100
Deliveries attended by skilled health personnel
60
10
578 0
5
50
25
770
1991/92 l atest data
Sources: for’1992/93’ data see reference 14; for ‘Latest data’ see reference 15.
The Ghana constitution grants protection of maternal health, including special care to women before and after childbirth, granting paid leave to women during the period and child care facilities to enable mothers to realize their full potential.
Reproductive health and family planning are treated as special programmes and therefore not included in the primary care package.
30
per cent change
Maternal mortality ratio (maternal deaths per 100,000 live births)
800
5
0
Sources: for ‘1990-93’ data see reference 11; for ‘Latest data’ see reference 12.
Positive policies
20
1992/93 l atest data
3
38
199 0 – 93 l atest data
700
Adolescent women (aged 15–19) who have begun childbearing, %
100
Unmet need for family planning (%)
10
0
8
87
199 0 – 93 l atest data
600
500
52
1992/93 l atest data
30
25
400
Contraceptive prevalence rate for married women 15–49, modern method
9
22
199 0 – 93 l atest data
300
47
0
50
Adolescent women (aged 15–19) who have begun childbearing, %
200
1992/93 l atest data
7
10
199 0 – 93 l atest data
100
Deliveries attended by skilled health personnel
60
Contraceptive prevalence rate for married women 15–49, modern method
401 0
progress towards mdg 5
21
510
1992/93 l atest data
15
44
per cent change
Maternal mortality ratio (maternal deaths per 100,000 live births)
800
Deliveries attended by skilled health personnel 199 0 – 93 l atest data
progress towards mdg 5
27
740
199 0 – 93 l atest data
In order to address a rapidly growing, largely rural population and significant unmet need for contraception, Tanzania must commit domestic resources and urgently scale up sexual and reproductive health services. The country has traditionally relied on donors to fund and manage contraception, but in the new context of country ownership and with increased attention and priority given to strengthening health systems, Tanzania needs to develop capacity within its own health system to manage sexual and reproductive health concerns and deliver services effectively.
2005. New York: UNFPA and PRB.
Indicator Survey: Key Findings. Calverton, Maryland, USA: NBS and Macro International Inc. 20 PAI (2009) Reproductive Health Supplies in Six Countries. Washington, DC:
The International Planned Parenthood Federation (IPPF) is a global service provider and a leading advocate of sexual and reproductive health and rights for all. We are a worldwide movement of national organizations working with and for communities and individuals.
Published in May 2010 by the International Planned Parenthood Federation
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IPPF works towards a world where women, men and young people everywhere have control over their own bodies, and therefore their destinies. A world where they are free to choose parenthood or not; free to decide how many children they will have and when; free to pursue healthy sexual lives without fear of unwanted pregnancies and sexually transmitted infections, including HIV. A world where gender or sexuality are no longer a source of inequality or stigma. We will not retreat from doing everything we can to safeguard these important choices and rights for current and future generations.
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PAI. 1 Chloe Hall – Ethiopia 2005 2 Dale Cooper – Ghana 2006 3 Nguyen-Toan Tran – Senegal 2010
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