Sexual and Reproductive Health and Rights Education and Services in Pakistan | Reproductive Health

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This case study covers the work of Aahung in Pakistan. Aahung is a Karachi-based NGO which aims to improve the sexual and reproductive health (SRH) of men, women, and adolescents across Pakistan. Aahung works towards enhancing the scope and improving the quality of services that uphold sexual health and rights, while advocating for an enabling environment where every individual
  OXFAM NOVIB CASE STUDY   SEXUAL AND REPRODUCTIVE HEALTH RIGHTS EDUCATION AND SERVICES IN PAKISTAN This case study covers the work of Aahung in Pakistan. Aahung is a Karachi-based NGO which aims to improve the Sexual and Reproductive Health (SRH) of men, women, and adolescents across Pakistan. Aahung works towards enhancing the scope and improving the quality of services that uphold sexual health and rights, while advocating for an enabling environment where every individual’s sexual health and rights are respected, protected, and fulfilled as an inalienable human right. This Case Study was a background briefing for Oxfam Novib’s 2013 Annual Review, prepared in partnership with Aahung, and describes the programme in Pakistan. Although it is not a formal evaluation it does consider lessons learned by both Oxfam Novib and its partner organisations. These Case Studies are shared in the form in which they were submitted, often written by partners whose first language is not English, and have not been edited since submission. We believe that the meaning is clear enough, and the authenticity of the reporting and the availability of Southern Voices on development makes their inclusion in the Oxfam iLibrary worthwhile for sharing with external readers. Programme Partner: Aahung  2  AIM OF THE PROJECT    Aahung’s aim is to create an enabling environment which provides quality sexual and reproductive health information and services so that people have comfort with their body, are practicing sexually healthy behaviours and are exercising their sexual rights. CONTEXT Larger country context Pakistan, a lower middle income country with an estimated population of 169 million1 is seen with great concern in the health and development sector not only due to its high population growth rate of 1.882 but also due to its soaring health and development indicators. The country’s population that is deemed to double in the next 37 years is understood to exert undue pressure on the already overburdened resources and implicates upon planning, resource allocation and accountability mechanisms in the health and development sectors. Ensuring availability, affordability and access to acceptable quality healthcare services will be a challenge for the health sector in the years to come. The recent demographic and health survey has shown an improving trend in indicators for literacy and living standards, yet more than 50% women and almost 33% men in the country have no formal education. Moreover, poverty and the widening gap between people in different wealth quintiles is on the rise and the worse affected population segments are rural residents and women, particularly of young age groups. Lack or inadequacy of education, health and social support services can lead to individual and collective frustration, despair and hopelessness that may manifest as disease or behavioural disorders including violence and criminal acts. Ensuring universal education and access to reproductive healthcare, promoting gender equality and reducing maternal and child mortalities are included as targets of various international agreements including Pakistan’s most recent commitment to achievement of Millennium Development Goals, but their socio-cultural determinants especially those related to sexual and reproductive rights are often ignored due to stigma associated with openly discussing and addressing such issues. Limited communication on sexuality and sexual and reproductive health needs throughout the course of life have given way to lack of information among healthcare consumers and providers that in turn prevents exchange of quality sexual and reproductive health and rights education as well as services. Direct environment Pakistan’s demographic profile depicts the features of a population with high fertility levels with 41% individuals being under 15 years of age and 55% being between 15-64 years old. This demographic profile is suggestive of a population momentum that will maintain the number of adolescents and young adults for the next two decades and highlights the need for health policies and programs to focus on addressing the needs of children and young adults. According to figures reported by the World Health Organization (WHO) in 2009, the life and health of children in developing countries is most commonly affected by infectious diseases while road traffic accidents, complications during pregnancy and child birth, suicide, violence, HIV/AIDS and tuberculosis have been found to be the major causes of mortality in adolescents3. However, the WHO report has ignored grave problems like child abuse particularly sexual abuse that remains under reported and often unrecognized in developing countries. Based on news reports, a Pakistani NGO named Sahil has estimated that every day 4 children are sexually abused in Pakistan4. The WHO report has highlighted that the underlying issues of adolescent mortality caused by suicide, violence, HIV/AIDS and complications during pregnancy and child birth pertain to sexual and reproductive health and rights issues that usually remain unattended due to social taboos and limited communication. Sexuality and life skills education, along with adolescent friendly healthcare services and parental or community support have been proposed as an option for ensuring the well being of adolescents and future generations. Adolescent health problems and their socio-cultural determinants remain fairly ignored in the Pakistani context. According to a study conducted by Marie   3 Stopes Society in selected districts of Pakistan5, the onset of menstruation was associated with anxiety in 47% girls as only 13% of them reported receiving information about puberty before the onset of menstruation. The study also revealed the cultural misconceptions that prompted early marriage and onset of pregnancies in young women while ignoring their sexual and reproductive health rights and needs. The dearth of communication and correct information on sexual health issues in Paki stan’s society predisposes many adolescents and young adults to physical disease and dysfunction while the emotional and mental challenges of this age also remain unaddressed. The induction of a national youth policy and inclusion of life skills based education in the national educational curriculum are noteworthy changes in the policy making arena that must be backed with comprehensive implementation plans. Unfortunately, a considerable part of the life skills curriculum is to be taught as extra-curricular activities that are often overlooked by teachers due to lack of time. In pockets where sexual health content is being prioritized, teachers are not equipped with the skills and comfort to deal with such sensitive topics. Moreover, lack of counselling, appropriate referral networks and youth-friendly services in school health programs and ignorance of adolescent health issues in general healthcare services compound the complexity of matters. Educational interventions are limited in their success as they ignore the uneducated and out of school adolescents and youth. More so, they miss out on creating an enabling environment in families and communities. The more specific reproductive health indicators like maternal mortality ratio (MMR= 276 maternal deaths per 100,000 live births) have shown an improving trend in the recent demographic and health survey, but pregnancy-related and maternal mortality was found to be the highest in mothers below 20 years and 40-44 year age group. The survey has also revealed that one-fifth of Pakistani women in the reproductive age bracket of 15-49 years die of pregnancy complications, childbirth and puerperium while 35% of them receive no prenatal care. Additionally, only 61% of those who do receive prenatal care get it from skilled health providers (doctor, nurse, midwife or lady health visitor). Sixty-five percent of women of reproductive age deliver at home of which only 32% births are assisted by skilled medical providers and 52% by traditional birth attendants. Of the women who did not deliver their last child in a health facility, only 32% reported usage of safe delivery kits. Health seeking behaviours and access of Pakistani women vary by place of residence, educational level, wealth quintile, age group of mothers and the number of pregnancies or children but in general women living in rural settings, having limited education, belonging to lower wealth quintiles, having more children or in 15-20 or 40-49 year age groups are more vulnerable.  Although teenage marriages have declined, 80% women of reproductive age have been found to be ever married by the age of 25-29 years. Once again the 15-19 year old married Pakistani women tend to be least informed about sexually transmitted infections (STIs), HIV/AIDS and have less than 24 month birth intervals. More than 95% women of reproductive age have knowledge of contraceptive methods but only 30% were found to be current users of any method of contraception. Forty-eight percent of modern contraceptive users rely on public sector institutions while 30% rely on private medical sector as the source of information and services. The main public sector institutions accessed by modern contraceptive users include government hospitals and reproductive health service centers (32% users) while Lady Health Workers are a good source for 8% clients, Lady Health Visitors for 3% clients and family welfare centers for 2% clients. Most users are being reached through healthcare providers and only 23% non-users were found to be reached by field workers. The availability of quality healthcare is one of the factors determining access and health seeking behaviours. In Pakistan, most healthcare providers often lack the necessary knowledge and skills required to treat sexual and reproductive health issues because these topics are not part of the health curricula. Furthermore, the fairly recent notions like client centered care and counselling are usually not incorporated into teaching practices thereby preventing the creation of an enabling environment for clients seeking healthcare. In addition, due to repressive social norms, clients often lack the necessary confidence and comfort in discussing sexual health issues openly while health care providers can exhibit judgmental attitudes regarding sexual practices which inevitably affects healthcare management. Evidence shows that there is great potential in the already existent public and private healthcare infrastructure and services that can be tapped for improving provision of sexual and reproductive health education and services, but without proper training, health care providers may also shy away from discussions concerning sexuality because they feel unable to  4 handle complex issues (e.g., sexual abuse, conflicts about sexual orientation, sexual dysfunction etc.) that can arise during such discussions. Similar to the adolescent population, healthcare of adults on sexual and reproductive health and rights issues remains incomplete without concomitant education and communication. Pakistan’s commitment to the Cairo Platform of Action (International Conference on Population and Development) in 1994 gave government and non-government organizations a framework with which to develop their sexual and reproductive health programs. The ICPD approach linked population and development in a holistic manner and helped introduce sexual health and rights concerns into the already existing dialogue on reproductive health. Sixteen years after ICPD, Pakistan continues to struggle with the ongoing reproductive health and population challenges present in the country. The NGOs and CBOs working in different areas of Pakistan have adopted the ICPD agenda and seem to be promising partners for reaching out to adult populations on sexual and reproductive health and rights education and services. Contrarily, the Pakistani Government has been resistant to openly acknowledging sexuality or sexual health as a relevant topic due to social, cultural and religious taboos, and continues to focus on population control programs. An obvious limitation of resources is also a problem as resources are more likely to be allocated towards addressing more pressing current needs. Furthermore, where resources are available, there is the threat of mismanagement compounded by the lack of accountability and transparency. In spite the challenges, efforts towards partnering with government institutions must not be abandoned keeping in mind issues of national ownership and sustainability. Main actors Young people and community adults Teachers Parents and Gatekeepers Healthcare Providers Policy Makers Clients of healthcare providers Students at medical education institutes Religious and community leaders METHODOLOGY  Activities, strategies, theory of change Thematic Areas Considering its organizational expertise and the critical needs and cultural acceptability concerns related to information, education and services of Sexual and Reproductive Health and Rights (SRHR) in Pakistan, Aahung works towards creating an enabling environment by focusing on institutionalization of SRHR education and services while constantly exploring new strategies for changing individual behaviours by direct communication campaigns. In this project cycle; Aahung focused on the following thematic areas: Sexual and Reproductive Health Management (SRHM) Sexual Rights (SR)  –  Education and Awareness  Adolescent Sexual and Reproductive Health (ASRH) Child Sexual Abuse (CSA) Strategy  Aahung’s core strength lies in usage of participatory methodology to promulgate gend er equality and to utilize the rights based approach as a cross cutting theme in all activities. Aahung builds the capacity of institutions and advocates for policy change in order to create an enabling environment and empower individuals to exercise their sexual rights. Aahung follows a cascading model in its
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