5.3. Challenges and Gaps

In Guinea, the Roadmap on Sexual Education aims to better integrate sexual education within the curriculum to strengthen the capacity of agencies promoting sexual education and the development of services targeting adolescents, and to improve knowledge among communities on sexual health.1300 In Benin, the National Strategy for the Safety of Reproductive Health Products 2011–2016 aims to strengthen and sustain the supply of reproductive health products.1301 In Cabo Verde, special facilities have been established in some health centres to ensure easy access, privacy and confidentiality within SRH services for adolescents.1302 Decree-law No. 47/2017 establishes social and educational support measures for girls attending school during pregnancy, after delivery and while breastfeeding. These measures apply to primary, secondary and higher education and professional training.1303

West African countries also implemented specific national HIV prevention strategies and programmes during the Decade. In Liberia, the 2015–2020 National HIV and AIDS Strategic Plan made provisions for pre-natal care and eliminating mother-to-child transmission of HIV.1304 In Mali, the 2014–2013 Health and Social Development Plan aimed to reduce maternal, neonatal, infant and child morbidity and mortality, and mortality related to sexually transmitted diseases.1305 The 2014 National Plan of Action of Nigeria addresses the intersections between GBV and HIV/AIDS. It aims to reduce the incidence of HIV by addressing GBV using a multi-sectoral approach, including with stakeholders at the national, state and local level.1306

In Ghana, the National HIV and AIDS and Sexually Transmitted Infection Policy recommends that elimination of mother-to-child transmission programmes be available to all pregnant women living with HIV. Such programmes encompass HIV testing as part of routine pre-natal services, psychosocial support, follow-up services and nutritional support for malnourished mothers. The Policy makes a special effort to target men with information on family planning and reproductive health.1307 In Gambia, the National Policy Guidelines on HIV and AIDS aim to ensure a sustained programme of information and education in the population, with a special focus on youth and women. It seeks to prevent new infections and empower women and girls educationally, socially and economically to enhance their self-esteem and equality in gender relationships. The Guidelines also call for a review of HIV and AIDS programmes to ensure they address gender perspectives. They also cover special programmes that provide women with economic opportunities, as well as counselling and support for victims of sexual violence. Furthermore, to prevent mother-to-child transmission of HIV, the Guidelines recommend that counselling and testing services be available and offered before birth in family planning clinics and all pregnant women be sensitised and encouraged to access counselling and testing.1308

Gambia Guinea Niger Benin Guinea-Bissau Nigeria Mali

Figure 20 West Africa: Contraceptive prevalence, any methods (% of women ages 15-49)

9.0% 10.9% 11.0% 15.5% 16.0% 16.6% 17.2% Togo 19.9%

Sierra Leone 22.5%

Côte d'Ivoire 23.3% Senegal 27.8% Ghana 30.8% Liberia 31.2%

Burkina Faso 31.7%

No data available for Cabo Verde. Source: The World Bank, World Development Indicators.

The first gap observed concerns constitutional provisions on health, specifically provisions related to SRH. Two countries (Ghana and Guinea-Bissau) do not have constitutional provisions on health. In Ghana’s case, the Constitution includes the right to health in connection to employment but does not extend this right to all citizens. No country in West Africa includes constitutional provisions specifically on SRH and family planning, according to the sources reviewed. While the 2020 draft Constitution of Gambia includes language that guarantees the right to reproductive health care, the country had not adopted this at the time of writing.

The second gap concerns the right to abortion. Many countries in West Africa restrict access to safe abortion and the right to abortion. Moreover, in most West African countries, the laws on abortion are not in line with the Maputo Protocol; rather, provisions

on abortion are found in penal or criminal codes. In two countries (Guinea-Bissau and Senegal), access to abortion is prohibited altogether. The majority of West African countries do not allow for abortion in cases of sexual assault, rape or incest. This lack of legal protection for young girls and women puts them at considerable risk. Abortion is considered a criminal act, rather than a human right; women who seek an illegal abortion may not only risk their lives but also face criminal charges. For example, in Senegal in 2017, 38% of incarcerated women were in jail for pregnancy-related crimes, including abortions, miscarriages and infanticide.1309

Weak legislation on SRH, maternal health and HIV/AIDS represents a third gap observed. Concerning the right to decide and control the family’s size, while Gambia guarantees this as one component of women’s right to health, under Section 31 of the Women’s Act, the right must nevertheless be exercised in consultation with the husband.1310 Concerning HIV/ AIDS, legislation in some West African countries fails to adequately protect women and other vulnerable groups, which contributes to increased stigmatisation and discrimination against people living with HIV. For example, in Ghana, the AIDS Commission Act 938 does not consider gender in formulating policies and strategies and determining programme priorities. In Gambia, the 2014 Amendment to the Criminal Code, which criminalises homosexuality, considers living with HIV/AIDS an aggravating factor in the offence of homosexuality.1311

Revising legislation on or adopting legislation on abortion faces challenges in many countries. For example, while Sierra Leone’s Parliament passed the Safe Abortion Act in 2015, according to sources consulted the president has repeatedly refused to sign this into law.

While West African governments have been active in establishing programmes and strategies to ensure women’s access to SRH, maternal health and HIV/AIDS services, from the data surveyed health care spending appears to be low. A particular challenge in assessing government spending on health relates to the lack of data and insufficient reporting. Given inadequate spending on SRH, maternal health and HIV/AIDS in many countries, it is often the case that NGOs do the work directly. For example, in 2011, it was estimated that NGOs provided 80% of Liberia’s health services.1312 In Mali, it is reported that NGOs complete most of the work done concerning HIV/AIDS.1313

Another challenge observed concerns awareness of legal rights and health services and care offered under national programmes and policies. For example, in Burkina Faso, many women do not know about the 2005 Reproductive Health Act. Many women who would benefit from its provisions regarding authorised abortion (e.g. when pregnancy is a result of rape or incest) risk their lives by resorting to backstreet abortions because they do not know their rights.1314 Moreover, in many countries, educational programmes, and the inclusion of SRH, maternal health and HIV/AIDS in the curriculum, are often insufficient or altogether lacking for adolescents. While the Ghanaian government has integrated a range of topics related to SRH into the primary, junior high and senior high school curricula, there is a strong focus on the benefits of abstinence.1315