JOINING FORCES
for sexual and reproductive health and rights
CONTENTS
INTRODUCTION
04
06
EDUCATING AND INFORMING
IN FOCUS
12
INVOLVING YOUNG PEOPLE TO BUILD CHANGE 02 MAGAZINE TITLE
16
SRH SERVICES, IMPROVING ACCESS AND QUALITY
ALLIES FOR CHANGE
EDUCATION
SERVICES
QUOTES
22
WHY ALLIANCES WORK...
IN FOCUS
GENDER AND SEXUAL RIGHTS
24
ENABLING ENVIRONMENT
28
THE ENABLING ENVIRONMENT
INFOGRAPHIC
34
RESULTS
THE THEORY OF CHANGE
36
BRINGING IT ALL TOGETHER
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ALLIES FOR CHANGE
Sexual and reproductive health and rights: the phrase ph may not appear succinct, but eve every word counts. It means that SRHR, its handy abbreviation, stands for bo both sexual health and reproductive hea health. More controversially, it includes both bot reproductive rights and sexual rights. Unfortunately many of these rights remain contenti contentious: your right to control body, choose your own partyour own bod access the education and serner, and acce vices you need for a fulfilling, happy and healthy sexua sexual life, regardless of your gender, age, m marital status, race, religion orientation. or sexual orien When you can exercise some or all of those rights, y you can achieve a greater degree of self-determinad ttion. At the other extreme, people who are denied p tthose rights have to live with unequal gender roles w and expectations, and the a persecution of sexual mip norities, members of the no
Lesbian Gay Bi-sexual Transgender Queer Intersex (LGBTQI) communities. At its very worst, the denial of SRHR rights is manifested in higher levels of STIs and HIV, maternal mortality, child and forced marriage, and sexual and gender-based violence. Pursuing a rights-based approach to sexual and reproductive health is a powerful, lifechanging strategy for all of us individually. And speaking for society as a whole the approach is also vital in working on gender equality and combatting poverty. This publication looks into the work of two alliances of NGOs: the Sexual and Reproductive Health and Rights Alliance, and the Youth Empowerment Alliance. They like to share their collaborative way of working with a broader audience, be it fellow NGOs, grant makers, or simply interested readers. They run two distinct but closely allied projects, funded by the Dutch Ministry of Foreign Aairs, that share a common purpose: to enable people to achieve the fulfilling, happy and healthy sexual and reproductive lives that are their human right.
The five members of the SRHR Alliance and their partner organisations in Africa and Asia started the UFBR - Unite for Body Rights Programme - in 2011; in 2013 two more NGOs and their partners joined with them to form the Youth Empowerment Alliance and developed ASK – the Access, Services and Knowledge Programme – with a focus on young people, aged 10 to 24. Both programmes run until 2016. Depending on funding opportunities UFBR and ASK may continue beyond then. Because both alliances share so many objectives and adhere to a common theory – that sustainable change in people’s lives can be achieved by simultaneously improving their education, services and the environment they live in – we will refer to them and to their corresponding country alliances simply as ‘the Alliance’.
THE COUNTRIES There are eleven countries across Asia (Bangladesh, India, Indonesia, Pakistan) and Africa (Ethiopia, Ghana, Kenya, Malawi, Senegal, Tanzania, Uganda) in the programmes in total – looking at them on a map they might seem distant and disparate. But across all the Alli-
ance countries there are common causes and familiar challenges that lead to communication of ideas and exchanges of approaches. In each country a national country alliance has been formed, based on partner organisations of the European NGOs. The national programmes all have a distinctive, custom-made approach, but they still benefit from the experiences of the other countries. The articles that follow examine some of the Alliance’s challenges and successes: like its work for the acceptance of comprehensive sexuality education and the provision of accurate, consistent information; the opening up of SRHR services to young people; and the engagement of communities and their leaders at all levels to deliver a supportive, enabling environment. Taken together they demonstrate that many strategic interventions – some smaller, some larger – can add up to a greater result: real change. Change in some of the most sensitive and deeply rooted attitudes and practices; change that can deliver greater sexual and reproductive health and rights for people who are still denied them.
THE ALLIANCE The SRHR Alliance (UFBR): Rutgers, Amref Flying Doctors, CHOICE for Youth and Sexuality, dance4life, and Simavi The Youth Empowerment Alliance (ASK): The SRHR Alliance members with STOP AIDS NOW! and the International Planned Parenthood Federation (IPPF), with Child Helpline International as a technical partner The Country Alliances in UFBR and ASK: UBR Bangladesh Alliance, SRHR and Youth Empowerment Alliances Ethiopia, Ghana SRHR Alliance, SRHR Alliance India, Aliansi Satu Visi (Indonesia), SRHR Alliance Kenya, Malawi SRHR Alliance, SRHR and Youth Empowerment Alliances Pakistan, Youth Empowerment Alliance Senegal, Pamoja Tunaweza Alliance (Tanzania) and SRHR Alliance Uganda
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EDUCATION
ETHIOPIA 57% of young Ethiopian women (age 15-24) do not know where to obtain a condom.1
PAKISTAN
BANGLADESH
UGANDA
SENEGAL
INDIA
GHANA KENYA MALAWI TANZANIA
INDONESIA Only 30% of young women and 19% of young men in Indonesia received instructions in school about birth control methods.3
24% of women (age 15-49) in Tanzania do not know that the risk of HIV is reduced by condom use.2 06 EDUCATING AND INFORMING
EDUCATING AND INFORMING COMPREHENSIVE SEXUALITY EDUCATION Comprehensive Sexuality Education (CSE) is an age-appropriate, culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgemental information. Sexuality education provides opportunities unities to unication explore one’s own values and attitudes and to build decision-making, communication and risk reduction skills.
‘When you don’t have access to information about your body and your feelings, and you can’t get answers to your questions or concerns, it can be hard to achieve what we all have a right to pursue: a healthy and fulfilling sexual life,’ says Jael van der Heijden, Director of Programmes at dance4life. ‘We find that knowledge and understanding about sexual and reproductive health and rights are often frighteningly limited: it is reflected in the numbers of unwanted pregnancies among
adolescents and young people in n our programme countries and our own surveys of their capacity to make safe and informed decisions.’ Young people don’t automatically lly understand how their bodies and nd emotions change as they grow up; p; they need some guidance. Too offten their friends and families are re unreliable or reluctant sources for or this kind of information and advice. e.
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ONE UGANDAN SCHOOL RECORDED 43 TEENAGE PREGNANCIES THE YEAR BEFORE OUR PROGRAMME STARTED; NOW THERE ARE AS FEW AS TWO OR THREE. When deprived of knowledge about puberty, reproduction, safe sex, sexual pleasure and emotional needs, young people are more vulnerable to coercion or to making ill-informed choices. This can lead to low self-esteem or psychological harm, sexual and gender-based violence, unwanted pregnancy and infections like HIV. To remedy this the Alliance promotes SRHR education and information sharing in different ways. These range from timetabled comprehensive sexuality education in schools, through sexuality education sessions for young people in informal settings, to the use of appropriate communication tools to give them direct access to SRHR and HIV information. 08 EDUCATING AND INFORMING
SCHOOLS The Alliance develops the SRHR content of new and existing school curriculums and quality teaching and learning materials, so schools can deliver truly comprehensive sexuality education. “I have learned to appreciate the enormous potency of CSE”, says Jos Dusseljee, Manager International Programmes at Rutgers. “It is an empowerment mechanism, that assists young people in making responsible decisions that preserve their health and safety, particularly if education and information is provided in a gender transformative manner, with respect for sexual diversity. I get from the discussions
I attended that CSE promotes individual and community wellbeing with less gender based violence and reduced risks of STIs and HIV/ AIDS. When recently visiting communities in Uganda I was told of the challenges posed by unwanted pregnancies in particularly adolescents, which have strong socio-economic implications for individuals and communities. CSE in combination with youth friendly services has strong potency in reducing such untimely and unwanted pregnancies.” Alliance programmes like The World Starts with Me and It’s All One Curriculum are adapted for each country, or used in adaptation processes of existing curricula, to ensure they work in that context. The Alliance con-
tinuously improves programmes, advocates for the required funding, and lobbies for local and national commitment in the form of policies and guidelines. Teachers are trained to become CSE specialists and to be able to train others. School programmes are most successful when the whole community is involved in the introduction of the curriculum - not only students and teachers, but also other community members like support staff, nurses and parents. That way, communities take ownership of SRHR education. Involving everyone, but especially parents, enables the possibility to address sensitive topics, like delivery of sexuality education to 10-to-14 age group.
PEER EDUCATION Comprehensive sexuality education can be enhanced by the inclusion of young peer educators. People are simply more comfortable discussing sex and sexuality with people who are closer to their age or situation. In the alliance programs, pupils can volunteer for training so that they can help lead discussions and become the go-to sources of advice and guidance. Young peer educators are integral to the Alliance’s outreach work, taking SRHR information into communities to reach street children and others who cannot access CSE in the classroom, like those who cannot afford or access school, or those who had to drop out of school and migrants. In Indonesia peer educators have used special interests to meet young people out-of-school, including parkour enthusiasts, young people working in a reptile park and theatre groups. They reach young people where they are and provide the kind of detailed information on SRH they need. Another way of providing sexuality education through peer educators is with the Heart Connection Tour. Peer educators enter schools and deliver CSE to groups of young people with the energy of their unique dance drill. Each programme is tailored to the needs of local young
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people who are then inspired to engage on SRHR subjects through music and dance, removing the barriers to the discussion of personal, intimate issues. Once their confidence and curiosity is established, the young people are ready for the next stage: regular interactive sessions of CSE led by the peer educators.
APPROPRIATE TECHNOLOGY One of the strategies of the ASK programme is to expand young people’s direct access to SRHR information, access that doesn’t depend on teachers, parents, peer educators or other intermediaries. ‘E&M health’ recognises that young people are happy to use digital media and devices (‘E&M’ = electronic and mobile) to communicate, socialise and search for information. The Alliance worked with young people on their needs and the appropriateness of existing digital platforms to carry SRHR messages and information. Where necessary, new tools and content for the platforms were developed. Using mobile technology and social media has great advantages: it is popular and adaptable – the Alliance can easily assess its use and invite feedback to raise information standards across various platforms. Best of all is the enormous reach of the technology. In Pakistan the Alliance could reach 50,000 young people with its work each year. But its new website YouASK.pk, providing comprehensive SRHR information for young people and their parents, is unique in the country and will reach as many as one million young people in 2015, a significant scaling up of access. The pace of change in communication that is being driven by technological development is extraordinary; we need to stay abreast of the digital revolution so it continues to enhance sexual and reproductive health and rights education. However, we also need to use media that is most appropriate to the context.
10 EDUCATING AND INFORMING
In Ghana, for example, where far from every young person has a mobile phone or access to internet, the Alliance employs more traditional technology. Curious Minds uses radio to engage young people on SRHR. Its regular show not only provides information; by showcasing the work of sexual health experts it generates demand for services. Listeners even volunteer to train to be on-air peer educators. A successful innovation is the use of the radio show as a way to consult on Ghana’s youth policy, engaging young people in shaping the recent Plan of Action for the National Youth Strategy. “It’s simple, really – knowledge is power!” concludes Jael. “It isn’t everything, but it is at the start of everything – take education and information out of our programme and the rest could become almost useless, or at least unsustainable. When I see the changes in our young people, how they light up during our sessions, I know that together we have started something good and exciting.”
“TO HAVE ACCESS TO CSE MAKES ME FEEL FORTUNATE. IT HAS CHANGED MY LIFE, KNOWING HOW TO DECIDE TO HAVE OR NOT HAVE A BOYFRIEND, TO HAVE SEX OR NOT, AND TO DO IT SAFELY. FRIENDS COME TO ME FOR ADVICE. I REALLY ENJOY SHARING MY INSIGHTS WITH MY PEERS.” PEER EDUCATOR, GHANA
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IN FOCUS
INVOLVING YOUNG PEOPLE TO BUILD CHANGE
12 MAGAZINE TITLE
YOUNG PEOPLE ‘AT THE CENTRE OF THE ALLIANCE’ “The Alliance is determined to have young people at the centre,” says Elsemieke de Jong, Executive Director at CHOICE for Youth and Sexuality, “and where possible for them to be the leaders of our work. Young people need to be listened to, because their participation is one of their human rights. Only if they become a central part of the planning and the decision making on sexual and reproductive health programmes will those services and interventions match their needs. It’s so important, but for many it’s new and challenging. What is needed is meaningful youth participation.” A typical example is ASBEF, one of the ASK partners in Senegal, which has its own Youth Action Movement. ASBEF ensures at least 25% of its board members are under 25 years old and the members of its Youth Action Movement are the driving force behind the local ASK programme, involved in its steering and technical committees, identifying partners, and implementing and evaluating project activity. Young board members give insight into the needs of their peer group and help determine the organisation’s strategies for reaching young people.
This is the essence of meaningful youth participation (MYP): young people are structurally involved in all layers of decision-making and in the research, design, planning, implementation and evaluation of programmes. In order to take on these roles, it is essential to give those young people the training and support they need. In the Alliance young people help run and direct projects through its national steering committees, and partners like ASBEF have young people on their boards. But because working with young people as equal partners challenges the status quo it inevitably meets with some resistance.
CHANGE IS NOT GOING TO HAPPEN OVERNIGHT, BUT ALREADY YOUNG PEOPLE HAVE A FEELING OF OWNERSHIP AND GREATER ACCEPTANCE OF SERVICES.
In Pakistan, for example, youth participation runs into serious cultural barriers, namely the powerful social norms around age and gender. Often young people are not listened to, and they are not supposed to talk about contraceptives and relationships. “Change is clearly not going to happen overnight,” says Qadeer Baig, Pakistan’s National Programme Coordinator. “But the strong participation of young people in our project’s activities has created a feeling of ownership of the project in the communities, and this is leading to a greater acceptance that services should be offered to young people.” It is a learning curve for the young people too. Thanks to her training, Kalkidan, a young researcher from Ethiopia has understood that it is important for the Alliance to work on meaningful youth participation and that they practice it: “Before my training I believed that I was already participating meaningfully in my organisation; now I understand there was a gap – those activities were not enough to be categorised as truly MYP. But now, thanks to these two weeks of training, I have learned how to work in a team, how to plan and how to execute those plans. Now my participation can be meaningful for me and the Alliance!”
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Also in advocacy for sexual and reproductive health and rights the voice of young people can be very powerful. On the international stage, the 2012 Commission on Population and Development (CPD) focused on youth and adolescence: the Alliance supported a strong representation of young people within and outside national delegations. They helped to ensure the CPD acknowledged certain adolescent sexual and reproductive rights for the first time.
CHANGE THAT BUILDS, CHANGE THAT LASTS
Once barriers for MYP begin to crumble and young people and adults know how to work with it and practice it, the benefits are huge. In Indonesia, young people helped deliver Alliance training in response to a lack of youth friendly services (YFS), sharing their needs with service providers and advocating for the adoption of YFS guidelines. Three years later they can point to their success: now there
14 INVOLVING YOUNG PEOPLE TO BUILD CHANGE
are eleven service providers in Jakarta and Lampung offering YFS, based on the model developed by the Alliance. And for the future, the Ministry of Health has adopted YFS and comprehensive sexuality education as part of their strategic planning for the next four years, supported by Aliansi Remaja Independen, a youth-led organisation in the Alliance partnership.
By prioritising youth participation, the Alliance has certainly enhanced its programmes strengthening their peer education, improving uptake of youth-friendly services and building a strong, young advocacy force to improve the enabling environment. An increasing number of youth-led organisations are active Alliance partners: they are able to develop their SRHR capacity, work as equal partners with ‘adult’ agencies, and form strong links with other youth-led organisations. By encouraging adult organisations to embrace MYP, facilitating youth-adult partnerships, and recognising and using the capacity of youth-led organisations, the Alliance has laid the foundations for the kind of structural change that can last.
A MODEL FOR CHANGE The Alliance has identified the essential elements of the process to achieve meaningful youth participation, shown in this graphic chart. Delivering MYP can be challenging in any environment; even when it starts to take hold, parts of the process have to be repeated. But by ensuring all the aspects of the essential elements are covered, important steps towards sustainable and meange are made. ingful change
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SERVICES
UGANDA Only half of the people living with HIV in Uganda receive antiretroviral treatment.4
ETHIOPIA PAKISTAN 20% of women in Pakistan have an unmet need for family planning.5
BANGLADESH
SENEGAL
INDIA
GHANA Unsafe abortions account for 11% of the maternal deaths in Ghana.6
KENYA MALAWI In Malawi an estimated 510 women die from pregnancy or delivery-related causes per 100,000 live births.7
TANZANIA 16 SRH SERVICES
INDONESIA
SRH SERVICES, IMPROVING ACCESS AND QUALITY WHAT ARE SRH SERVICES • Provide contraception • Legal and safe abortion and post-abortion care • STI testing and treatment • Counselling • Maternal health care including ante and post-natal care
• Voluntary HIV counselling and testing • HIV treatment and PMTCT • Preventing and responding to sexual and gender-based violence, including rape
“Our work has been focussing on the sexual rights of young people; to enable them to make their choices and decisions on their sexuality and sexual relationships, how to have pleasurable sex and how keep safe. This needs be reflected in everything we do in the programme, in our services and our tools” says Doortje Braeken, IPPFs Senior Adviser on Adolescents and Young People.
That is why the Alliance and its partners work with service vice providers to raise the qualality of sexual and reproducctive health services, widen n their accessibility, and en-sure they meet the needs s of young people and wom-en. Improving these serrvices – and access to them m – remains a big challenge..
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“The Alliance’s starting point is to think about the reality and needs of young people. Sometimes needs are easily met – a condom, a good referral – but often it requires better understanding of the reality,” says Yvette Fleming, Manager of Programmes at STOP AIDS NOW!. “Providing non-judgmental and integrated SRHR and HIV services for young people requires a high degree of professionalism from the nurse or doctor. And to address issues, like stigma and discrimination, genderbased violence and sexual orientation, requires context specific and evidence informed strategies”
INNOVATION IN HEALTH CARE MANAGEMENT To make sure the services are available, accessible, and meet the needs of the clients, besides the more traditional strategies like outreach and capacity building, the Alliance piloted and introduced innovative approaches. For example, in India the Alliance used a mobile phone application for health workers, Mobile for Mothers, to improve home visits to pregnant women. Community health workers can ask questions, find information and seek advice in real time and store essential health data in an online database. This 18 SRH SERVICES
soon resulted in better services: workers gave more effective advice and clients followed it; related health problems were identified, referred and treated. births. Preliminary research showed that using the app increased use of antenatal care and substantially reduced the percentage of home deliveries. The Alliance found another way to drive up standards: ask users what they think about the quality of the SRH services they receive. In North Shewa, Ethiopia, Alliance partner Amref Health Africa introduced a card system in six health centres: clients are encouraged to leave a green, yellow or red card in a box after their visit, indicating how satisfied they are with the services they received. The majority of clients make use of the cards.
WITHIN FOUR MONTHS SATISFACTION LEVELS HAD LEAPT FROM UNDER ONE IN FIVE SERVICE USERS SATISFIED, TO OVER TWO-THIRDS
Follow-up client interviews uncovered the main reasons for dissatisfaction: stock outs of drugs, referral to other facilities, lack of counselling and long waiting times. As soon as these were addressed, satisfaction levels rose. In 2014 one health centre’s results jumped from 18% green cards in July to 67% in mid-October. Simple tools can have sophisticated results. Similarly, complex problems can have simple solutions. Stock outs, for example, have an enormous impact: they interrupt care and treatment, and damage service users’ confidence. In Uganda, Alliance partners the Family Life Education Program (FLEP) and Mama’s Club were previously unaware that contraceptives were available free via the Uganda Health Marketing Group. As a FLEP staff member puts it: “With no regular family planning supplies our service to young people was arbitrary. Now we have free and reliable supplies we fulfill considerable demand for all forms of contraception. HIV testing and counselling has increased as have the numbers of people living with HIV benefitting from comprehensive services.”
ADDRESSING STIGMA Services for those affected by a taboo issue, like someone who experienced sexual and gender-based violence (SGBV), men having sex with men (MSM) or young people living with HIV are often fragmented or service providers do not possess the right skills to talk to these clients. Approaching the client in a confidential and non-judgemental attitude is crucial for them to address their needs. To make services user-friendly and effective requires a high-level of cooperation between agencies. The Alliance has helped achieve sensitisation on taboo issues within the communities, the overall public and the services providers and through acceptance strengthened the foundations for better referral and response.
TAKING THE SERVICE INTO THE COMMUNITY Sometimes the only way to improve access is to change the way a service is offered or promoted. Often the Alliance does this by improving referrals between different providers, delivering services in more accessible settings or even taking them into communities. The Alliance learned that
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bringing the services to the community is an effective way to reach young people, as they come in much larger numbers to outreach clinics than to fixed clinics. This could be because this is more convenient (closer to home or school), offers greater confidentiality or is cheaper, or it could be that the combination with sport, theatre or music activities makes the outreach services more attractive for young people. But in some cases, such in Indonesia, outreach services are the only place where young people can access SRH services at all, as restrictive laws and cultural norms make it almost impossible for unmarried young people to get these services at government health clinics. In Hawassa, Ethiopia, there are large numbers of young migrants looking for jobs, sexually active young people who do not access mainstream SRH services. Family Guidance Association of Ethiopia (FGAE) set up regular education and HIV testing days at several of the employment agencies or ‘broker houses’ where young people go to find work. They now have access to SRH information, condoms, VCT and referral to the other services they were previously unaware of, including sexual health, income generation and legal advice. Access to services is supported through collaboration of the Alliance with technical partner Child Helpline International. In 7 countries, helplines provide information, counselling and referral to alliance partners and their board networks of service providers. Toll-free numbers provide young people a private, unanimous and inexpensive way to seek 20 SRH SERVICES
help. Collaboration with the alliance partners, have strengthened the SRHR knowledge of the helpline staff and strengthened their capacity, to deal with intimate, sensitive topics.
YOUTH-FRIENDLY SERVICES SRH services have been traditionally designed and run with adults in mind, the use of family in family planning is an obvious example. Therefore many services do not sufficiently address the needs and rights of young people. To provide services that are ‘youth friendly’ the Alliance trains local partners and service providers, encourages outreach and even makes physical changes to the facilities: ‘youth-friendly corners’ in or close to SRH services. These corners have specialist staff and even recreational facilities, which encourages young people to take up services. Too often it is service providers themselves who are the barriers to youth access. “Prior to my training, I thought adolescents were too young to be educated on SRHR issues,” admits Alice, a community health nurse in Ghana. “I thought that SRHR services like condoms, contraceptives and family planning were for adults only. Young people who visited my facility always left disappointed as I refused them these services.” A workshop on Youth Friendly Services for Alliance partner Hope For Future Generations in Ghana, changed all that: “I now realise young people need this information and services to stay healthy. Besides, it is their right.
Now I see them as people with specific SRHR needs and so I make adequate time to listen to them more patiently. I am so happy to see many young people taking up SRHR services in this facility.” Doortje Braeken concludes: “We must look at services from the point of view of the service user. When they can locate the services they need or they are successfully referred, when they are satisfied and they will use them again, when their confidentiality and their rights are respected, when they feel empowered after accessing our services, then their chances of a happy healthy sexual life has improved. This will also have an impact on their confidence in general. Sex positive, high quality and nonjudgmental access for all - that is an Alliance success!”
“I USED TO REFUSE YOUNG PEOPLE THESE SERVICES – NOW I AM SO HAPPY TO SEE MANY YOUTH TAKING UP SRHR SERVICES HERE.”
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WHY ALLIANCES WORK… “It is only by joining hands towards a common cause that we can be hopeful of achieving results in promoting SRHR, as strength of one organization becomes the strength of all and possible weaknesses are addressed by joint strength of collaboration.” QADEER BAIG, NATIONAL PROGRAMME COORDINATOR PAKISTAN
“An advocacy message is much stronger when it comes from a group of stakeholders instead of individual organisations; working as an alliance has thus strengthened our advocacy.” NIENKE BLAUW, PUBLIC AFFAIRS OFFICER SRHR SIMAVI, MEMBER OF THE ADVOCACY WORKING GROUP OF THE ALLIANCE
“It is amazing how the Alliance has grown in capacity. When we started in 2011 with UFBR, some organisations possessed only basic knowledge on SRHR aspects. Partners have been able to build capacity through interaction and learning from each other. The Theory of Change played a big role in this. By now, each partner can confidentially implement an SRHR programme.” TALIMBA BANDAWE, NATIONAL PROGRAMME COORDINATOR MALAWI
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“The alliance partners used to see each other as competitors for funding, but now realise that they are complementing each other’s efforts and are seeking the same objective. Working together, they can have more impact.” KENNETH DANUO, NATIONAL PROGRAMME COORDINATOR GHANA
“In Uganda I spoke to staff members of smaller NGOs who told me they were inspired by the wealth of knowledge and variety in approaches used by the alliance. For me it became very clear what working in an alliance can mean for the organisations involved. They do not just implement a programme together: they align their work, learn from each other and grow stronger together.” LAMBERT GRIJNS, AMBASSADOR FOR SRHR & HIV/AIDS OF THE NETHERLANDS MINISTRY OF FOREIGN AFFAIRS
“The SRHR context is complex and sensitive. By combining our strengths as individual NGOs we have been able to reach further and to offer more to young people for whom high quality SRHR is still lacking. The co-operation has forced us to be self-critical and transparent about our own organisations. A rich process in which we have come to know each other really well, and experienced with trial and error the opportunities and the limits of collaboration.” MARIJKE PRIESTER, MANAGER SRHR AND YOUTH EMPOWERMENT ALLIANCE
“All alliance partners feel that there is definitely an added value of bringing different expertise together and complementing each other. The benefits of working as a team are large, you can really see the impact.” SERAFINA MKUWA, NATIONAL PROGRAMME COORDINATOR TANZANIA
“An old African proverb says: ‘If you want to go fast, go alone. If you want to go far, go together.’ Rutgers has been cooperating more closely than ever with like-minded organisations in the past few years. And as the proverb goes, we have noticed that things sometimes proceed a little slower than they might if we were to work alone. The ultimate benefits however, are far greater.” DIANDA VELDMAN, EXECUTIVE DIRECTOR RUTGERS (LEAD ORGANISATION)
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IN FOCUS
GENDER AND SEXUAL RIGHTS
24 MAGAZINE TITLE
RAISING AWARENESS ON EQUALITY AND RIGHTS “At first I saw girls as human beings of a lower level. In my community, women cannot be outside the house without guidance and their role is to cook and do the household work.” Ammar Khan, a youth organiser at Unite for Body Rights in Bangladesh, admitted last year how his upbringing and his environment had framed his negative attitudes to women as a young man, attitudes that weren’t challenged until he started working with UFBR. “I think of gender equality as a continuum,” explains Aika van der Kleij, SRHR Programme Manager at Simavi, “Globally, great progress has been made in areas like access to primary education, but the change to a society’s expectations of women is slow. In places where attitudes like Ammar’s are still commonplace, the more sensitive side of gender rights is easily overlooked: it’s not just about cooking and cleaning. If a society defines girls and women as ‘of a lower level’ their gender is innately unequal and their sexual and reproductive rights are ignored. We have to challenge that premise.”
“I SAW GIRLS AS HUMAN BEINGS OF A LOWER LEVEL” In that continuum, the Alliance addresses the gender stereotyping common in school children’s families with The World Starts with Me curriculum – arguing that brothers should help with chores and sisters should have time for school and homework. Boys and girls learn that they have an equal claim on sexual rights, on all human rights; in that context, the same curriculum covers sexual consent, coercion and rape, and coming of age rituals like FGM.
SENSITISATION – THE START OF CAPACITY BUILDING Outside the classroom, the same human rights message forms the basis of the kind of training given to youth workers like Ammar and the sensitisation of health care workers to the needs of young people and women. The Alliance also designs specific interventions to help its partner organisations to embrace gender equality and sexual rights.
This often starts with discussions, reflections and exercises which help deepen understanding of what sexual rights are and what needs to be done in order to respect, protect and fulfill women’s and young people’s rights. Partner organisations and service providers discuss how this may conflict with their personal values and upbringing, and how to deal with that in their professional life. The impact of these sessions can be significant, which is illustrated by the moving reflection of a service provider trained in Ghana on youth-friendly services: “Last Friday I saw a young girl who came to me for a pregnancy test. It was positive. I could tell that what she wanted was an abortion, but I told her we don’t provide those services at our clinic. I told her to call me anytime during her pregnancy for support. Now, after this workshop, I feel I have given her a bad service.” Partners in Kenya have begun the long process of learning and planning on sexual and gender-based violence (SGBV). Once staff were sensitised to the issues of gender and SGBV, a South African NGO helped them to
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consider how to promote gender equality and involve boys and men in addressing SGBV. “When they’re sensitised to gender issues our partners want to embed equality in their own policy and practice,” Aika van der Kleij points out. “They monitor the gender balance in their teams and programme activities and take measures to improve this. They challenge conservative and restrictive attitudes through staff training. These organisations are more likely to be committed to work on gender in their communities.”
“IF YOU CONTINUOUSLY VIOLATE A GIRL, THE POWER OF HER LIFE WILL GRADUALLY DISAPPEAR.”
26 GENDER AND SEXUAL RIGHTS
The Alliance also promotes training in an area of sexual rights that is highly sensitive for many of its partners: sexual diversity. Tolerance of the Lesbian Gay Bisexual Transgender Queer and Intersex (LGBTQI) community and same-sex relationships varies across the eleven countries, but same-sex acts are illegal in all of them except Indonesia. Not surprisingly, at the onset of the programme most Alliance partners had no or limited experience of working on sexual diversity and workers’ attitudes reflect society at large. The legal situation has not entirely suppressed those working for the
rights of the LGBTQI community, but it is harder for them to organise and be visible. Where it can, the Alliance works with local organisations of or for LGBTQI to help sensitise its SRHR partners. In Kenya and Tanzania, raising awareness through exposure to local LGBTQI groups has provided partners with new insights into their challenges, while Malawi has supported new LGBTQI networks.
ONE STEP AT A TIME The Alliance is sensitive to what can and cannot be done, when to push for action on gender and rights topics, and when to be satisfied with the early steps of sensitisation. In India, partners have been very effective on SGBV within their programme, including domestic violence, rape and child marriage. In Malawi, partners would like to see local by-laws abolished that punish survivors of rape by forcing them to marry their attackers; as these represent ingrained cultural practice, any effort to open debate in the community will need careful and sensitive planning. Alliance programmes have to operate within the law of their countries, but advocating for necessary legal reform is an important part of their work.
The Alliance acknowledges the historical and cultural rootedness of many expressions of gender inequality and sexual repression. But change is possible and happens, and so long as there is a strategy for maintaining and building on that progress, every step counts, every individual reached in the process becomes part of that success. Back in Bangladesh, Ammar reflected on how his attitudes to women were changed. “From childhood I got the idea that women are made for that purpose. But I learned that they are also human beings, and they deserve respect.” Ammar’s work has made him a strident supporter of gender equality: “If you continuously violate a girl, the power of her life will gradually disappear. Having female friends in our project, access to books on SRHR and the counseling sessions, all together made me gain this insight on same rights for males and females.”
JOINING FORCES 27
ENABLING ENVIRONMENT
ETHIOPIA PAKISTAN
BANGLADESH
UGANDA
43 to 51% of girls in Bangladesh marry between the age of 15 and 19.8
SENEGAL More than 50% of people in Senegal (age 18-49) think young people of 12-14 years of age should not be taught about the use of a condom.9
INDONESIA INDIA 47% of 20 to 24-year-old women in India were married before the legal age of 18.10
GHANA MALAWI KENYA TANZANIA Three of every ten Tanzanian females age 12 to 24 have been a victim of sexual violence.11 28 THE ENABLING ENVIRONMENT
Kenyan law states that abortion is illegal, except when the life of the woman is in danger.12
THE ENABLING ENVIRONMENT “It sounds like the most terrible jargon, doesn’t it?” admits Veerle Ver Loren van Themaat, Portfolio Manager at Amref Flying Doctors, when asked to explain what is meant by an ‘enabling environment’. “But when we talk sexual and reproductive health and rights, creating the right environment counts for everything.” She goes on to list what makes it possible for an individual, specifically a woman or young person, to achieve that health and secure those rights: adequate and accessible education and services; acceptance and respect of their rights by others – in the family and wider society; and a supportive legal framework that represents government commitment to these rights. “This is the enabling environment, which is beyond the individual but essential to be able to make safe and informed decisions on their SRHR and enjoy a healthy sexual life.”
Sadly this situation is rare. “There are still many places es in the world where that environment needs eeds to improve. To be honest, I’m not sure re the perfect environment exists anywhere. As agencies from the North, we certainly aren’t ren’t complacent about what still needs to be done at home. However, looking ng at the eleven country programmes es in general, they present some major or challenges in realising people’s right ght to sexual and reproductive health.” She cites discriminatory laws and policies, like age of consent ent rules for SRHR services vices like family planning, criminalisation ation of HIV transmission smission and restrictive tive abortion policies. es. And the belief that young people eople JOINING FORCES 29
should not be sexually active, which is still widespread in many of the Alliance countries, fuelling stigma and discrimination and hindering access to comprehensive information and services. If these social, cultural and legal barriers to people’s SRHR are not addressed, any work done on services and education can never be properly effective or sustainable. By building the capacity of local partners, by raising awareness and sensitising communities, gatekeepers and the general public, and by engaging in local, national and international advocacy, the Alliance helps to make the environment around young people more supportive and enabling.
STRENGTHEN CAPACITY ON THE GROUND The Alliance’s local partners are deeply embedded and respected in their communities and well aware of ‘how things work on the ground’. So they are well placed to address harmful norms and values and to advocate for a more supportive policy environment. However, being part of that society also means they are influenced by its social and cultural norms and their staff values can reflect this, potentially hindering access for young people and marginalised groups to a healthy and fulfilling sexual life. To address this, the Alliance organises sessions to clarify understanding of SRHR values with its local partners. These help build 30 THE ENABLING ENVIRONMENT
the skills and confidence they need to discuss sensitive issues (such as access to contraception, safe abortion and sexual diversity) with colleagues, other stakeholders and to reach out to the wider community.
“FGM INFLICTS A LOT OF PAIN. HENCE, PASTORS FROM LOITOKITOK AND MAGADI HAVE DECLARED THERE WILL BE NO FGM IN FAMILIES AND CHURCHES.” RELIGIOUS LEADER, KENYA
RAISE AWARENESS AND SENSITISE COMMUNITIES To create support for young people’s and women’s SRHR at community level, the Alliance sensitises and involves people across the community. It trains large groups of volunteers and peer educators who discuss SRHR topics with their peers and communicate SRHR messages within their communities. Social activities and events, such as theatre, sporting activities and celebrations on (inter)national days, combined with mass media campaigns (social media, radio and television) are effec-
tive in raising awareness, increasing acceptance and slowly changing beliefs. Although changing beliefs and practices takes time, the Alliance is determined to make it work. Female Genital Mutilation (FGM) is a serious violation of human rights linked to other harmful traditions, such as early marriage and forced marriage, with impacts like early pregnancy and high drop out rates in school for girls. In Kenya, it is a common practice among the Masaai, deeply rooted in their culture and society. So the Alliance mobilised all potential change agents to create alternatives to FGM: religious leaders, community elders, former circumcisers and traditional birth attendants, young people and their families, schools, and health workers. With the Masaai, Alliance partners have developed alternative rites of passage that everyone can endorse, creating the possibility of an enabling environment where girls and boys can claim their rights.
ADVOCATE FOR A SUPPORTIVE POLICY ENVIRONMENT Despite positive achievements in all programme countries, restrictive and discriminatory laws remain. The Alliance helps local partners to target advocacy at policy makers at local, national and international levels. They and their partners hold governments accountable for implementing existing policies and international agreements and promote more
“BEFORE WE WERE NOT EVEN ALLOWED TO COME TOGETHER AS YOUNG PEOPLE, LET ALONE DISCUSS SEXUALITY. NOW THE COMMUNITY LEADER SUPPORTS AND PROTECTS US IN OUR PEER EDUCATION ACTIVITIES.” PEER EDUCATOR, MALAWI
JOINING FORCES 31
TANZANIA In Tanzania the Alliance has contributed to an enabling environment for the right to education for pregnant and young mothers. Through evidencebased advocacy, the Alliance helped secure revisions of the Education and Training Policy, supporting re-entry of girls to school after pregnancy, an important achievement, because girls were often expelled from school when pregnant. The Alliance also helped to finalise national guidelines for district level implementation of this policy.
progressive thinking and language on SRHR in international resolutions, like the agreements from the Commission on Population Development (CPD) and the Sustainable Development Goals. Support for the SRHR agenda is not universal, so it is important that local partners develop the activist and proactive attitudes necessary to address sensitive issues at international and regional levels. Partners from India, Ghana, Uganda, Malawi, Kenya, Pakistan and Tanzania contribute to international position papers, pre-CPD meetings with their governments and meetings with country representatives at African Union and UN levels. More and more, the alliances in the countries are invited to technical working groups as SRHR experts by their responsible government agencies. This way, when conservative opponents of an inclusive SRHR agenda push back, the Alliance can give voice to those who are affected by poor sexual and reproductive health and rights. With skills and evidence, local partners can speak directly to their own governments.
“SUPPORT CAN AND DOES COME FROM ANYONE WHO UNDERSTANDS THE VALUE OF SRHR”
32 THE ENABLING ENVIRONMENT
The Alliance’s advocates have learned the hard way that advocacy is still important. During the CPD of 2015, the Alliance supported two impressive regional statements calling on governments to recognise the needs of young people
and commit to robust and comprehensive action; the participation of adolescents and young people and having their voices heard at the Commission was a success in itself. But the meeting proved that advocacy faces serious challenges: for the first time in its history, the CPD ended without agreeing a resolution. Over the years, however, there has been noticeable, positive change. A human rights approach is becoming the cornerstone for sustainable development. Many governments have spoken out in favour of sexual rights, inclusive societies and ending discrimination and violence based on sexual orientation and gender identity. Working in an alliance is vital to these results: its advocacy is based on expertise in the fields of health service provision, education, youth development and from community-based organisations and stakeholders. This ensures its efforts are evidence-based and that messages are developed with the support of the wider community. Furthermore, joint advocacy makes the individual organisations more confident and less vulnerable: communicating the same SRHR messages makes their case even more convincing. Building an enabling environment is a cornerstone of the Alliance’s approach,
a key component of its Theory of Change. In practical terms this means working at all levels, all of the time: “We have to take a holistic approach,” Veerle Ver Loren van Themaat concludes, “because support can and does come from anyone once they understand the value of sexual and reproductive health and rights. In our project work and through our advocacy efforts we must keep everyone in mind: whether it is including religious leaders in discussions about sex education, supporting parents in accepting that their children have their own sexual identities or advocating for more progressive laws. What we do to create an enabling environment really can bring about lasting social change.”
COLLABORATING WITH THE DUTCH GOVERNMENT Working together, not only within the Alliance, but with other important stakeholders in the field of SRHR, is a crucial approach to build an enabling environment. The Alliance members from the Netherlands are in regular contact with members of Parliament and the Ministry of Foreign Affairs to convince them of the importance to keep SRHR high on their agendas. This way the Alliance helps to keep SRHR as a focal point in the Dutch policy on development aid. And because Dutch policy on development aid reaches further than the Netherlands the country alliances work with the Dutch embassies to gain wider support for their work on SRHR.
JOINING FORCES 33
RESULTS
62,000 About 62,000 service providers have been trained in provision of youth friendly services, including 600 on safe abortion.
2,300 2,300 staff members of partner organisations were trained in meaningful youth participation in programme design, planning, implementation, M&E, research, and advocacy.
1,950
5,550 Already 1,950 advocacy meetings were conducted by our partners at local, district or national level in order to spur change.
34 MAGAZINE TITLE
Through 5,550 youth-led community activities, youth voiced their needs and rights to increase support for young people’s SRHR.
170,000 Almost 170,000 NGO/CBO staff received training on a wide range of topics, varying from SRHR and SGBV, CSE and HIV and AIDS, to project cycle management and advocacy.
27 young people, women and men were reached with SRHR education and information.
26,500,000 Through the alliance almost 26,500,000 services were (directly and indirectly) provided to young people, women and men.
Large scale campaigning has helped us reach over 55 million people with SRHR messages.
55
million JOINING FORCES 35
All these numbers are results up to 2015
6,875,000
million
young people have been reached by campaigns on adolescent SRHR and access to services.
EDUCATION
SERVICES
ENABLING ENVIRONMENT
“Bringin it all together!” That’s the Al“Bringing liance’s ‘secret weapon’ according to Marijke Priester, the Alliance Manager. “The rea reality of SRHR is complex. It is hard to separate separ programme activities into neat categori categories: they rely on each other for their suc success. An organisation cannot do it on its own. The Alliance knows this: we plan our interventions together to ensure we capitalise capi on this important synergy. This is h how we reach change”. The Th Theory of Change (ToC) is what the Allia Alliance calls its model for achieving last lasting and effective change. The explanation behind it is that all three explana components of the ToC - education and compon information, services, and an enabling informat environment - relate to and influence environ each other. Activities within each component, like improving the com q quality of schools’ sexuality curriculums or developing youthfriendly SRHR services, cannot be separate efforts, but need to b be connected to each other. The
result is a high quality, multi-faceted yet coherent approach that can reach a broad range of young people. This multi-component approach broadens the impact of the Alliance programmes. Reach is increased by linking outreach and referrals with information and education, as the Alliance improves both demand and access. Quality and effectiveness improve as messaging can be fine-tuned between the different sources if information, to make sure young people are provided with the same message, preventing potential confusion among young people. Lastly, as the approach ensures involvement of actors at all level, engagement and mutual accountability increase the likeliness for sustainable change. The story of Pamela, a 24-year-old woman from Northern Uganda, demonstrates just how important these three components - education, services and an enabling environment - and the connections between them are in people’s lives.
BRINGING IT ALL TOGETHER “I liked school, but I did not receive any sexuality education. I did not know what contraceptives were or how to get them. When I was 15 my father died. He was the breadwinner of our family so there was no income after he died, and no money for my school fees. One day a boy from school came up to me and said he would pay my school fees in return for sex. Soon I was pregnant. At age 16 I gave birth to my daughter Maria. Her father did not keep his promise, I never saw him again. I had to drop out of school and start working to help provide for my family”. Without the knowledge of how you get pregnant and how to use contraceptives it is difficult for a young girl to protect herself. That’s why comprehensive sexuality education is crucial. However, education by itself is not enough. Young people need to be able to act on the information they receive. That’s why sexuality education needs to include information on how and where to obtain contraceptives. Even then, information alone can’t guarantee that young people will be able to act: if a service provider stigmatises their clients based on their age (or on their sexual orientation, marital or HIV status), they won’t feel comfortable enough to walk through the door and talk to that service provider.
Pamela, who was born with HIV, can confirm that: “It is hard to grow up with the stigma around my HIV status. People will rinse the cup I drink from so carefully – as if they will get infected by it! When I tried to obtain contraceptives everyone was very judgmental. They would say things like: ‘Why should that girl get contraceptives? She should not have sex or reproduce at all with her HIV status. She can only infect others while having sex and her children will get HIV and will be useless ... ’” An environment which is supportive and open to the needs of all young people, regardless of characteristics like gender, age, marital status, HIV status, gender identity and sexual orientation, would make is much easier for someone like Pamela to access services and decide for herself whether to be sexually active. This way she could act on her sexual and reproductive rights. Pamela’s story shows how important it is to work at linking the pillars in the Theory of Change. The real strength of the Alliance lies in the way we combine different activities and interventions that are devised by specialists who all appreciate the synergy of what we do. As a result, the person who accesses a service or attends a lesson or obtains a condom JOINING FORCES 37
as a result of one of the Alliance’s programmes stands a good chance of doing so in an environment that is also changing for the better. And whether they realise it or not, they become an agent for change themselves. Fortunately, Pamela’s story has included some opportunities to access support, regardless of her age or HIV status. It was through a referral from TASO, an AIDS support agency that provided her antiretroviral treatment, that Pamela joined Mama’s Club: “At Mama’s Club I knew I was not alone: I could share experiences and ask advice from other young mothers living with HIV. In this way I started to grow in self-esteem. Now I am less afraid of what other people might say about me. The stigma has not changed, but my way of dealing with it has; it does not stop me anymore from living a healthy life. I even have become a peer educator: I talk to the other young mothers about living with HIV, contraceptives and relationships. I have confidence and friends.”
THE THEORY OF CHANGE IN PRACTICE • Malawi Partner organisation FPAM trained teachers, parents, and community leaders on sexuality education and at the same time developed a strong community based service provision as a result of information shared. This made communities, particularly young people, aware of the services and how to access them at any time without being stigmatised. • Tanzania Village health workers collect information on SRHR in their villages, analyse it and share that analysis in village development meetings, demonstrating a link between gaps in health services and the need for an enabling environment. This helped village leaders to formulate by-laws with a council attorney. • Bangladesh Religious leaders are part of the CSE advisory groups. In one of the pilot areas this has led to the adoption of a more progressive Comprehensive Sexuality Education programme in the madrassa, the Islamic religious schools.
38 BRINGING IT ALL TOGETHER
© All rights reserved SRHR Alliance and Youth Empowerment Alliance, August 2015.
Suggested citation: Joining forces: for sexual and reproductive health and rights. SRHR Alliance / Youth Empowerment Alliance, Utrecht, August 2015. Text and editing: Julian Hussey, Margo Bakker, Woutine van Beek, Martin Stolk. Photo and graphs credits: All pictures by Alliance/J. van Loon, except page 24, 27, 29 (CHOICE/Marije Kuiper), 32 (Rutgers/Nancy Durell McKenna) and 36 (Amref Flying Doctors/Boniface Mwangi). Graphs page 15 and 38 by studio WvdV Design: Raffaele Teo, www.arteographik.com Print: Raddraaier, Amsterdam For more information visit www.srhralliance.org or contact office@rutgers.nl
Notes: 1)
https://www.guttmacher.org/pubs/FB-DD-Ethiopia.html
2)
http://www.guttmacher.org/pubs/demystifying-data.pdf
3)
http://dhsprogram.com/pubs/pdf/FR281/FR281.pdf
4)
http://aidsinfo.unaids.org/#
5)
http://apps.who.int/gho/data/node.country.country-PAK?lang=en
6)
https://www.guttmacher.org/pubs/FB-Abortion-in-Ghana.html
7)
https://www.guttmacher.org/pubs/FB-Malawi.html
8)
http://www.oneworld.nl/atlas/kindhuwelijken
9)
http://www.guttmacher.org/pubs/demystifying-data.pdf
10) https://www.guttmacher.org/pubs/FB-DD-India.html 11) http://www.unfoundation.org/what-we-do/campaigns-and-initiatives/universalaccess-project/briefing-cards-srhr.pdf 12) https://www.kenyaembassy.com/pdfs/The%20Constitution%20of%20Kenya.pdf and http://www.guttmacher.org/pubs/demystifying-data.pdf
This is a joint publication of the SRHR Alliance and the Youth Empowerment Alliance