UBR Strategy for Bangladesh

In early 2012 UBR held three strategic meetings, where Programme Managers and Upazila Managers identified strategies for strengthening sexual and reproductive health and rights (SRHR) services, SRHR education, and building an enabling environment (through advocacy).  This document sets out the strategic planning till 2015.  It will form the basis for the annual planning meetings in September to establish the 12upazilas’ implementation plans, the 5 organizational support plans and the UBR secretariat plan, all to be approved by the steering committee.

Pillar 1: An ambitious but realistic youth-friendly strategy for strengthening SRHR services

The SRHR service centre in each of the 12 upazilas will form the physical home for the UBR programme.  In ten upazilas this is a general clinic or family planning clinic, and in Two it is hospital (Kaptai and Durgapur) . Each of these SRHR centers will focus on improving the usage and quality of four types of SRHR services:

Focus 1: Youth counseling services about sexual and reproductive health and rights;

Focus 2: Services to give people access to the full range of contraceptive choices;

Focus 3: Health promotion services focused on menstrual hygiene and prevention of gender based violence;

Focus 4: Improving the quality of antenatal and postnatal care (ANC & PNC) and menstrual regulation (MR) services [1] (and RTI/STI)

 Strategic choices on training for health providers

We shall discuss and plan our trainings for health providers each September during the annual planning sessions.  If one of the five partners has the experience needed, they will take the lead on the training.  If that is not possible, we shall bring in other trainers.  We will share and study existing service protocols in order to make informed decisions about the most do-able protocols for different settings (hospital, clinic, mobile clinic and community).  It is important that our training materials are unified, and that the trainers and facilitators have good skills. 

Our first training task is to orient all the health service providers in the 12 SRHR centers under the Unite for Body Rights programme.  We shall make a training module for this, and the Programme Managers and Upazila Managers will be the facilitators.  The participants will talk about youth-friendly services and issues such as contraceptive choices for unmarried people.  They will also learn about the UBR programme, and hopefully begin to develop ownership of it.  Staff members who are already trained in SRHR issues will still benefit from finding out about UBR. 

Aiming to ensure quality of services

The five UBR partners have different strengths and weaknesses.  In order to ensure quality of service, all five should:

  • Agree a protocol for the minimum standard in each setting, and follow it;
  • Orient towards improving patient and client satisfaction
  • Train staff, and provide refresher training;
  • Monitor staff performance  properly;
  • Maintain equipment and re-agents correctly.

Focus 1: Youth counseling services

We know that some young people are reluctant to use our services.  They may be put off by the term ‘family planning’, see a clinic as a place to go when you are sick, or feel stigma attached to seeking SRHR services.  There are things we can do to help make our services more attractive and acceptable to them.  We need to be motivated to provide:

 Confidentiality and privacy;

 Locations and opening times to suit young people;

 Staff who are youth-friendly and respectful;

 A brand which young people are comfortable with;

 Accessible information;

 Consistent standards of service;

 Support to problem-solve and make good choices;

 Affordable access to all commodities.

The 28 Youth Counselors in the UBR programme have had different degrees of training and some are not yet trained.  We plan that they should all attend a 5 day basic course at PSTC and receive 5 days’ training in Bangladesh from an expert from the SRHR alliance in the Netherlands.  They should also benefit from refresher trainings or inter-vision meetings twice a year. 

 In 2013 we would like to plan the introduction of a telephone counseling service. 

 Focus 2: Services for contraceptive choices

Five Upozilla of FPAB and one Upozilla of PSTC (Gazipur) are officially registered with the government’s Family Planning Directorate.  The directorate supplies them with contraceptives, and they offer the same range of contraceptives as government clinics.  Other Upozilla  will apply for the same registration as soon as possible. 

 

Table 1: Current availability of contraceptives

Contraceptive

Government

UBR

Market

Comments

Short-term non-permanent methods

Pill

ü

ü

ü

Many people prefer to buy on the market, but miss out on counseling regarding their use and wider aspects of SRHR.

ECP (72 hours pill)

ü

ü

ü

Male condom

ü

ü

ü

Female condom

û

û

û

Long-term non-permanent methods

Injectable

ü

ü

ü

Problem of irregular supply from government.  The local UBR steering committee has decided to hold a reserve stock for these methods, to reduce stock-outs in UBR clinics.

IUD

ü

ü

û

Implant

ü

ü

û

Patch

û

û

û

Long-term permanent methods

Tubectomy

ü

ü

û

The government refers people to our SRHR centres for these services and reimburses the organisations. 

Vasectomy

ü

ü

û

 The UBR SHRH centres aim to serve everyone who needs access to contraception.  However, unmarried people are under-served.  Within Bangladesh these is a strong social norm that sex only takes place within marriage.  Unmarried people are discouraged from accessing contraceptives in various ways.  For example, government clinics and most outreach workers only distribute contraceptives to married people, and in private and NGO clinics staff may show negative attitudes towards unmarried people seeking contraceptives.  Unmarried people may also have a sense that they are not entitled to contraceptive assistance. 

Our strategies for improving services for contraceptive choices are summarized here:

 Train staff

  • Improve 300 UBR community workers’ skills to provide information and advice about contraceptives, and to beyouth-friendly[2].
  • Challenge UBR service providers’ hearts and minds; they need to be convinced about the right of unmarried people to have access to contraceptives.  They also need to respect confidentiality, and not to ask about or judge someone by their marriage status.
  • Train UBR counselors on pre-marital counseling for young couples.

Widen distribution of contraceptives

  • Get UBR health promoters to distribute contraceptives to unmarried people;
  • Make them available in the youth corner of UBR clinics;
  • Train and equip traditional birth attendants to distribute contraceptives;
  • Enable village doctors to become distributors;
  • Use youth clubs as depots, where stocks of contraceptives are held;
  • Make agreements with small stores selling sweets and soap to offer free contraceptives;
  • Advertise availability of contraceptives.

Test new initiatives to serve unmarried people

We will try different methods to reach unmarried people who are sexually active, such as:

  • Target young couples with information and counseling about contraceptives and sexual health;
  • Run group sessions for couples who plan to marry, and allow them to get  contraceptives Train peer educators/youth trainers as distributors, as young people may find them more approachable;
  • Change UBR clinic registration methods so that clients are not asked their marital status.

Collaborate & advocate

·         Research which other NGOs could be useful allies, and collaborates with them.

  • Have dialogue with religious leaders, government officials and local leaders about the consequences of unsafe sex and the absence of any link between knowledge of contraception and sexual debut;
  • Advocate locally and nationally to change the policy that only married people can get contraceptives from government clinics;

 

 Focus 3: Health promotion

 Our health promotion aims to keep people healthy by enabling them to prevent problems related to sexual and reproductive health.  It is not the same as counseling, which is typically a one-to-one method of supporting someone to solve a problem which they already have.  It is also different from comprehensive sexuality education (CSE), as that involves planned education sessions with the same group of young people, going through seven elements (see Pillar 2). 

Health promotion is currently integrated within ANC, PNC and post-abortion care, and may also be undertaken through, for example, door-to-door visits, courtyard meetings, and meetings with peer groups such as young men, pregnant women, or parents.  Within the UBR, health promotion is carried out by different types of workers, depending on the partner and the setting[3]

From the baseline we learned that health promotion on the following topics will be useful to young people to keep themselves healthy: what are normal body changes; practicing safe, pleasurable sex including masturbation; how to prevent RTIs; coping with peer pressure and suicidal feelings; learning to relate normally to the opposite sex; correct information about menstruation; and information about equal relationships, child abuse and child rights. 

 The first topic we shall focus on is menstrual hygiene.  We want to challenge the cultural beliefs which lead men and women to treat menstrual blood as highly as polluting, and to treat females who are menstruating as being so dirty that they must be excluded from many activities.  By sharing factual information and sourcing and promoting the use of affordable sanitary pads we hope to erode the shame attached to menstruation and so improve the well-being of girls and women.

Focus 4: Improving the quality of services

Accessible services are not only physically within reach, but financially too.  The high cost of emergency obstetric interventions may be a key reason why women who need specialized care often fail to get it.  Therefore it is important to document these costs in each Upazilla (see advocacy pillar).

All 12 SRHR centers in our UBR programme offer ANC, and all but Kaptai hospital provide MR services.  Kaptai is the only upazila where the UBR centre has an organized EOC system.  In all other upazilas the UBR health providers must know where to refer to for delivery care and EOC for high risk pregnancies and deliveries.  There is an assumption that at least 15% of all births are expected to be ‘complicated’, though some studies find the figure is around one quarter [4].  Poor, uneducated, and rural women have more complications than their educated, wealthy, and urban counterparts. 

Rural disadvantage regarding service provision can be seen within the UBR.  In four of the five rural upazilas (Modhanagar, Durgapur, Kawkhali and Rajostoli) access to adequate care during pregnancy and childbirth is generally lacking and there are hardly any private practitioners or government facilities offering quality delivery services. 

Our strategy in these four upazilas is to strengthen community-based health care.  We will improve the ANC offered by community health workers and traditional birth attendants, including building their skills to screen high-risk pregnant women for referral for medical care, and developing an alarm and transport system to serve as a link between community and referral care. 

In the urban upazilas, the UBR programme will motivate pregnant women to use existing delivery and obstetric services, of the private sector or the government sector, as these are of adequate quality. 

Overall our aim to provide a minimum level of care for all and a higher level of care only for those who need it, as established by medical indications.  In some instances, for example caesarean sections, poor women may not get treatment they need, while richer women may undergo treatment without any medical indication.  Both groups can benefit from health promotion information and support to their decision-making. 

 With regard to improving MR care, RHSTEP has a good training center on this.  Within UBR, 34 health providers are implementing MR (2 at RHSTEP, 7 at DSK, 16 in FPAB, and 9 with PSTC).  They will all undertake 21 days technical training with RHSTEP, paid for by UBR.  RHSTEP will also introduce the MR protocol to all the UBR SRHR centers.

When evaluating the quality of care in each upazila, we will focus on small-scale facility based efforts that incorporate mechanisms for improvements, rather than attempt to measure outcomes at upazila level, across facilities. 

In our baseline study we established the existing structures such as facilities, equipment, staff numbers and their level of training.  Our next step is to assess the processes involved in ANC and MR Service delivery, guided by the question ‘what procedure guarantees quality to the client?’ Examples of process data include the proportion of women with eclamptic seizures who have received magnesium sulphate, and the proportion of women with severe morbidity for which an observation chart has been maintained according to protocol.  We prefer process data as a measure of quality rather than outcome data because a poor outcome does not occur every time there is an error in the provision of care, and outcomes are not always under the control of the health care providers.  Our third step will take place during the mid-term evaluation, assessing outcome indicators such as the result for the client and client satisfaction.         

Pillar 2: Strengthening SRHR education

Child abuse, including sexual abuse, is common in Bangladesh.  In addition to influencing the wider community (see Pillar 3) it is important to teach children and adolescents their right to have control over, and to protect, their bodies and to respect others equally.  This is the purpose of CSE (see Box 1 below).

The bodies of girls and women are heavily regulated by cultural norms which limit their movements, what they wear, and what activities they may participate in.  These restrictions are worse when they are menstruating due to taboos and inadequate materials to contain menstrual blood.  Some experience physical violence (so-called “eve-teasing”), sexual harassment and rape, and early or forced marriage.  While others act on their bodies, there are strong limits on their own sexual expression. 

Some males are pressured to engage in practices which may not be in their best interests, such as taking drugs to increase their muscle size or penis size, or undergoing sexual initiation with a commercial sex worker.  And while they gain power over females from inequitable gender relationships, there are also negative consequences for them. 

Box 1: The seven elements of comprehensive sexuality education (CSE):

1)    CSE is evidence-based.  It builds on curricular standards derived from global research, and integrates important findings about the links between gender dynamics and sexual health outcomes;

2)    CSE covers core issues of sexual and reproductive health, including health promotion, accurate information about all the psychosocial and health topics covering sexual health, HIV prevention, the right to abstain from sex, and family life education;

3)    CSE has core values of human rights and sexual rights, promoting principles of fairness, human dignity, equal treatment and opportunities for participation.  It sees human rights for all as the basis for achieving sexual and reproductive health and well-being;

4)    CSE emphasises the importance of gender equality and a more equitable social environment for achieving sexual and reproductive health and greater well-being for both boys and girls;

5)    CSE fosters thinking of shared pleasure and joint responsibility, enabling boys and girls to understand how their actions within intimate and other relationships affect their and others’ lives.  By attending to rights and responsibilities CSE provides transferable skills to social and civic studies;

6)    CSE encourages healthy, violence free relationships and civic engagement by building skills and championing the idea that each person matters and can make a positive difference in his or her world. 

7)    CSE is culturally appropriate, incorporating the sexual diversity and varied circumstances and realities of young people around the world.

Learning about strengthening SRHR education

We will run pilot projects in two upazilas: Chittagong (PSTC) and Mymesingh (FPAB).  In each case the Upazila Managers will be in charge, with cautious support from RutgersWPF’s CSE expert and respective organization.  Each upazila will run SRHR activities in two schools: one government facility, which will use CSE, and one madrasa, where a curriculum of life skills education will be used. At this moment we can only use life skills curriculum in Madrasas, which is less outspoken on sexuality education than CSE.

We have already assessed the needs of young people, teachers and parents as part of the baseline research.  Some aspects may be repeated, however, in order to create ownership and have a firm basis for monitoring and evaluation.  We will also need to establish the starting point for SRHR education in the pilot schools (what are they already doing?) and to respond as appropriate to government plans, supported by UNICEF, to introduce a new sexuality education curriculum. 

Each upazila will have an advisory group, comprising 4 students (2 girls and 2 boys), 3 technical experts including a journalist, a SRHR activist, a SRHR researcher and 3 teachers, Madrassah.  College and school and 3 government officials (Upazila chair, information officer, education officer). We hope that the advisory groups will support the Upazila Managers to influence local policies and to create a positive environment, as well as helping to develop ownership at upazila level. 

The participating schools willbe supported to develop and adopt a youth or SRHR school policy, aimed at making school a safe place for young people.  For example, that teachers are not abusing their pupils, that there are appropriate sanitary facilities for boys and girls, and that boys and girls relate respectfully to each other without violence or aggression.  Each school will need a system for reporting abuse of a minor to be used for feedback and discussion in the teacher’s team.

The teachers in the pilot schools and madrasas will be trained by the ten UBR ‘master trainers”, firstly only small-scale in the pilots. These ten individuals are from the five UBR organizations, and meet three times a year for training with the RutgersWPF CSE expert.  They will train teachers in the pilot schools to help students to understand how sexuality relates to well-being and health, to address the positive aspects of sexuality, including concepts of mutuality and respect, and to discuss the meaning of mutual consent in a meaningful way.  We know that some teachers will find it hard to discuss sexuality and to set aside their personal views.  This is partly why we are beginning with a pilot programme in two schools and two madrasas, so that we can learn from experience and adjust our approach before attempting to scale up. This scale up of teacher training will need a separate project proposal and funding request.

Health promotion among children of school age

In 2011 the Programme and Upazila Managers compiled and tested six modules used to train young peer educators.  They also adapted and translated the ‘blue book’, an information booklet for 15 to 23 year olds about sexual health.  These resources will be used to train 20 young peer educators (half of them female) in each upazila, who will then conduct health promotion among their fellow students and young people who are not in school.

Pillar 3: Creating an enabling environment

Recognizing the influence of the social and cultural context on individuals’ beliefs and behaviour, we will work to create an enabling environment in which each person can exercise their sexual and reproductive rights. 

Our plans for working with different actors in each of the 12 upazilas are as follows:

Community level:

  • Inform and involve community leaders and local elite groups;
  • Inform religious leaders and village doctors and ask them to collaborate with UBR;
  • Reach out to groups such as youth clubs, football clubs and school club;
  • Work with different groups to conduct health promotion about menstrual hygiene. 

NGOs:

  • Organize a collaboration meeting with all the relevant NGOs in the upazila;
  • Explain what UBR can offer, such as training on SRHR and booklets
  • Identify complementary areas between our activities and theirs, especially in education, gender, water and sanitation, legal support and micro-credit;
  • Where mutually beneficial, set up joint activities or lend our support to their future events.

Local government:

  • Organize meetings to share the baseline survey results with UHFPO, DDFP, UFO etc.
  • Arrange joint activities or support government activities as appropriate, for example in the union health complex and community clinics.  Establish collaboration with FWV, FWA, HA and FPI.
  • Include government health staff in training sessions.  If we help them, they can help us achieve our objectives;
  • Work with the upazila Family Planning Department to convince them that unmarried people need information about contraception, which they don’t get from private pharmacies.  Use results from UBR and elsewhere to demonstrate that giving information to young people is useful, and does not lead to greater sexual activity.  Formally request that the government distributes contraceptives regardless of marital status. 
  • Once the government has issued the new SRH curriculum for schools, support the Upazila or City Corporation Education Officer to issue a circular to all schools and madrasas on its implementation.  Offer help, such as providing the blue book or other UBR materials for distribution to the students.  Advocate that the (national) examination committee and the District Educational Officer include SRH questions in their examination format.
  • Challenge the government to improve services and increase accountability.  Use our right to know how government resources are spent and, for example, publish results such as a citizen report card to hold the government accountable. 

Schools:

  • Convince school governing committees about the importance of teaching on menstrual hygiene, and help them to implement menstrual hygiene management;
  • Motivate the committees to get the Upazila/Pourashava Chairman to provide toilets, with access to separate clean toilets for girls and access to affordable hygienic pads. 
  • Choose one of the six models used in India or explore local alternatives for producing low cost sanitary pads and ensure access to low cost sanitary pads, affordable to poor girls and women.

Local media:

  • Organize a meeting for journalists to inform them about the programme with our own words, not to rely on rumours;
  • Build relationships with journalists to encourage them to make responsible and accurate reports.

We are aware, of course, that some actors may oppose the UBR programme.  One of the greatest barriers to implementing sex education is fear of opposition from community members.  In each group of stakeholders we need to nurture relationships with those who most believe in the values of Unite for Body Rights.  Specifically, we will train and support four types of advocates from those who are most convinced of the UBR approach:

School teachers and madrasa teachers: we will help them form evidence based arguments to persuade others that SRHR education helps rather than harms young people and their communities; 

Religious leaders: our rationale in asking religious leaders to become advocates of SRHR are that:

  • Young people want and need to hear more from their religious communities about sexuality; if they lack information from trusted adults, they turn to less-reliable sources that put them at risk of disease and unintended pregnancy;
  • Young religious people make sexual decisions in a religious framework if supported by caring adults;
  •  Religious leaders should speak up as scripture calls us to care for those in need and to serve others, and in Islam it is advised for all Muslims to know their body first of all then try to know the nature. 

Journalists: in addition to working with individual journalists as advocates, we will keep journalists updated, and might offer a prize to the best local journalist reporting on SHRH issues.

  •  [1]  A legal and safe form of abortion, used up to the tenth week of pregnancy. 
  • [2] These 300 from the 12 upazilas comprise 120 Basic Medical Workers (Kaptai), 150 Reproductive Health Providers (30 in each of Pabna, Paba, Noakhali, Mymesing, Bogra), and 30 community mobilizers and fieldworkers (Chittagong, Kawkali, Rajostoli, Nodhanagar, Durgapur and Gazipur).
  • [3] The UBR health promoters are (a) the paramedics in the clinics and mobile clinics, who do health promotion as part of ANC, PNC and MR and (b) the community workers: 4 RHSTEP field workers, 4 community mobilizers in both PSTC and DSK, 64 CHC Basic Medical Workers, 150 FPAB Reproductive Health Providers, and 240 young peer educators (10 F and 10 M in each Upazilla). 
  • [4] Vanneste et al (2000) found that 26.2% of women experienced a labour or delivery complication. 

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