V.

National Reproductive Health Strategy

Learning Objectives
At the end of the chapter, the student is expected to:
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Identify the National RH Strategy that addresses a set of critical issues Know the National RH Strategy guiding tool in your future activities

Reproductive Health Strategy

Access to reproductive health continues to be urgent in Ethiopia with the female population which accounts for half of the population, the high fertility profile of the Ethiopian woman, the prevailing high-risk characteristics among teen-age women, and the limited RH services.

The National Reproductive Health Strategy is developed by identifying RH needs and priorities reflecting the nations commitment to achieving the Millennium Development Goals. The Goal of the strategy is to build on the momentum occasioned by the Millennium Development Goals to garner the multisectoral support needed to meet the reproductive and sexual health needs of our culturally diverse population - one characterized by its youthfulness, geographic dispersion, conjugality, and persisting gender inequalities.

The National RH strategy addresses three priorities: The first is the nations commitment to achieving the Millennium Development Goals (MDGs), a framework for measuring progress towards sustainable development and eliminating poverty. Of the eight goals, three improving maternal health, promoting gender equality, and combating HIV/AIDS stand at the core of the strategy. The second priority is the need to respond to the socioeconomic and demographic realities of Ethiopia today. Although inclusion remains a hallmark of the RH concept, the reality is that nearly 80 percent of Ethiopians live in rural areas; 60% are under the age of 20; nearly all are married by the age of 18; and few will ever reach their 56th birthday. The contents of this strategy, therefore, do not seek to exhaust the full range of activities theoretically subsumed
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under the rubric of reproductive and sexual health. It is, instead, a road map one with a clear view of the journeys end; and one that reflects the cultural, socio-demographic, and political terrain that defines Ethiopia today.

The third priority is to build on the notable advances realized in the health sector over the past decade such as contraceptive prevalence, total fertility, maternal mortality, nutritional status, and immunization

REPRODUCTIVE HEALTH ENVIRONMENT RH is a comprehensive concept that implies a broad range of health and non-health related interventions. The larger social and institutional contexts that influence RH in Ethiopia, and it highlights the ways in which those conditions affect the RH status of women and men in the country includes poverty, Education, Legal Environment, Status of Women and the Health care system of a country which are discussed each in chapter one under the section Factors affecting RH.

STRATEGIES TO ADDRESS KEY REPRODUCTIVE HEALTH OUTCOMES

This section forms the core of the National RH Strategy. Outlining the strategic approach for improving RH in Ethiopia, it develops goals, strategies, targets, and key actions for each of the individual elements of RH addressed in this Strategy. 1. THE SOCIAL AND INSTITUTIONAL PARAMETERS OF WOMENS H EALTH Womens health is directly affected by the social and institutional context in which they live. Issues such as their low socioeconomic status, HTPs, especially FGC, early marriage, and low female literacy, all have a direct negative impact on womens health.

Strategies
Strengthen the legal frameworks that protect and advance womens reproductive health rights. To ensure the full application of existing laws, and the development of further protection, this strategy encompasses efforts to institutionalize womens rights at the local level, integrate them

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into regional-level planning activities, and to develop synergistic opportunities with womens groups to ensure that courts and police enforce such protections.

Targets: By 2006, ensure that all regions have the technical support needed to establish regional task forces on RH/FP. By 2010, ensure that all new law enforcement recruits are trained in the protection of womens rights, especially those pertaining to FGC, gender-based violence, and early marriage. By 2015, ensure the existence of functional and operational working groups on womens issues in all woredas. Prioritize the attainment of two indicators recognized to have the greatest impact on the reproductive health and well-being of women: age of marriage and educational attainment.

Targets: By 2015, ensure the legal enforcement of the median age of the first marriage to be 18 years. By 2015, increase the female literacy rate from 18.5 percent (2000) to 40 percent. But the figure is 41.6 % in 2005 EDHS. By 2015, increase the female gross secondary school enrollment ratio from 16 percent (2000) to 40 percent. But the figure is 28 % in UNICEF 2009 report.

Reduce the acceptability of all forms of FGC. An important step in eradicating FGC is limiting the social incentives perpetuating the practice. Focusing efforts, at the community level, this strategy works to alter social norms by providing information and testing the feasibly of alternatives to FGC, including alternate rights of passage and new income generating opportunities for FGC practitioners. Sharing lessons learned and best practices are also necessary.

Targets: By 2010, double awareness of the harmful consequences of FGC from 34 percent to 68 percent. But the national prevalence rate of FGM/C was 74% in 2005 EDHS.

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2. FERTILITY AND FAMILY PLANNING

High parity restricts womens educational and economic opportunities, thereby limiting their potential for empowerment broadly, as well as their ability to safeguard the health and economic well-being of the family and community at large.

Goal: To reduce unwanted pregnancies and enable individuals to achieve their desired family
size.

Strategies
Create acceptance and demand for FP, with special emphasis on populations rendered vulnerable by geographic dispersion, gender, and wealth.

Targets: Increase family planning service (CPR) from 32% (2010) to 65% (2015). But according to 2011 EDHS it is 29 %. Increase couples approval of FP to 75 percent by 2015. Ensure awareness by 80 percent of the adult population of the link between infertility on the one hand, and STIs or post-abortion complications on the other. Increase access and utilization of quality FP services, particularly for married and unmarried young people and those who have reached desired family size. This strategy encompasses a system-wide approach to service provision; one that enhances and maximizes referral systems; that segments contraceptive users by such factors as willingness to pay; and that maximizes the involvement of the public, private and NGO sectors. The strategy also entails the formulation and systematic implementation of an efficient logistics management system at both regional and central levels.

Targets: Increase demand satisfied to 80 percent. By 2007, ensure that adequate supplies of contraceptives are available in-country to meet the current demand for public sector FP services

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By 2007, reduce to 10 percent the number of public sector health facilities experiencing contraceptive stock outs within a 12 month period. By 2015, at least three FP methods are available to all households.

Delegate to the lowest service delivery level possible, the provision of all FP methods, especially long-term and permanent methods, without compromising safety or quality of care.

Targets: By 2008, include long-term FP service provision in the job-description of mid-level health workers. In 2010, conduct a mid-term comprehensive review of existing legislation and policies to identify service delivery barriers, appropriate mechanisms for enforcement, and potential areas for revision. It is already HSDP IV performed.

3. MATERNAL AND NEWBORN HEALTH

Ethiopias rates of maternal and newborn morbidity and mortality are among the highest in the world. The major causes of maternal death are obstructed/prolonged labor (13%), ruptured uterus (12%), severe pre-eclampsia/ eclampsia (11%) and malaria (9%). Moreover, 6% of all maternal deaths were attributable to complications from abortion. Shortage of skilled midwives, weak referral system at health centre levels, lack of inadequate availability of BEmONC and CEmONC equipment, and under financing of the service were identified as major supply side constraints that hindered progress. More than 90% of child deaths are due to pneumonia, diarrhea, malaria, neonatal problems, malnutrition and HIV/AIDS, and often to a combination of these conditions.

Goal: To reduce maternal and neonatal mortality in Ethiopia. Strategies

Empower women, men, families, and communities to recognize pregnancy-related risks, and to take responsibility for developing and implementing appropriate responses to them. Increased knowledge and awareness is essential for reducing delays in seeking health care and in reaching a health facility. Communities and individuals must be empowered not
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only to recognize pregnancy-related risks, but they must also have the capacity to react quickly and effectively once such problems arise.

Targets: By 2009, ensure the presence of one functioning health committee in every Kebele, with procedures for supporting pregnant women in emergency situations. By 2010, ensure that 80 percent of all households/families recognize at least three danger signs associated with pregnancy-related complications in areas where HEP is fully implemented. Ensure access to a core package of maternal and neonatal health services, especially in rural areas where health facilities are limited. To meet the maternal health needs of Ethiopias rural population, primary emphasis must be placed on delivering basic communitybased maternal and neonatal services, most notably through HEWs and mid-level service providers. Community- based health care workers must be able to refer complications to appropriate facilities; and hospitals must be adequately equipped and staffed to provide EmOC services.

Targets: Increase Delivery Service attended by skilled birth attendants from 18% (2010) to 60% (2015). But according to 2011 EDHS it is 10 %. Increase national antenatal care coverage levels to 70 percent. It is also 34 % according to 2011 EDHS. Equip one health post per 5,000 populations to provide essential obstetric and newborn care. Equip one health center per 25,000 populations to provide basic EmOC and newborn care. Equip one rural/district hospital (250,000 population coverage) to provide comprehensive EmOC.
Decrease maternal mortality ratio from 590 per 100,000 live births (2010) to 267/100,000 (2015)

Decrease the proportion of abortion-related deaths from 32 percent of all maternal deaths to 10 percent by 2015. Reduce neonatal mortality from 39/1000 LB (2010) to 15 deaths per 1,000 live births by the year (2015). It is 37/100LB according to 2011 EDHS.

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 Create an environment supportive to safe motherhood and newborn health.

Targets: By 2006, begin implementation of the Reduce advocacy model (MOH 2003) and the African Union Road Map to Accelerate the Reduction of Maternal and Newborn Mortality in Africa. Establish multisectoral committees within each region to build on the strengths, capacities, and resources of various institutions to create the framework within which safe motherhood and newborn health can be promoted.

4. HIV/AIDS
Ethiopia faces a mixed epidemic among sub-populations and geographic areas, with an estimated overall HIV prevalence rate of 1.8 in males and 2.8 in females, with a national point prevalence of 2.3 in 2009 (HAPCO, Single point estimate 2007). During the same year Adult HIV incidence was 0.28 with a total of 44,751 AIDS deaths. In fact, there is a challenge of describing the trend in incidence and prevalence of HIV due to varying methodologies applied in series of surveys. Till the year 2007/08 there were 262, 677 AIDS orphans in the country. There were around 1,030,000 people living with HIV/ADIS and of these 289,732 needed ART.

Goal: To reduce HIV infection and improve the quality of life of those living with the disease by
optimizing the synergies between RH and HIV/AIDS initiatives.

Strategies: Exploit opportunities within current RH and HIV/AIDS programs to access populations
whose needs would not otherwise be met under existing service delivery arrangements. Targets: By the end of 2007, implement a national Services Provision Assessment (SPA) to establish baselines for setting targets and measuring changes in the integration of facility-level RH and HIV/AIDS services By 2015, ensure that :
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All mothers attending antenatal care will receive PMTCT services. All STI clients are provided VCT service. All ART clients counseled and referred for FP services. All FP clinics providing VCT services. All workplace programs providing both HIV/AIDS and FP services.

Maximize opportunities to transfer knowledge and best practices across RH and HIV/AIDS fields. Targets: Between 2008 and 2015, ensure universal knowledge of post-exposure prophylaxis by all cadres of RH care providers. Between 2008 and 2015, ensure universal knowledge of infection prevention techniques for RH services by health care providers.

5. RH OF YOUNG PEOPLE
The limited access to targeted RH care and services for young people contributes to, and exacerbates, many of the RH problems outlined above. Over a quarter of all pregnant youth and adolescents feel that their pregnancies are mistimed, reflecting this populations limited access to FP as well as their vulnerability to broader social problems such as early marriage, nonconsensual sex, and sex work (CSA and ORC Macro, 2001).

These unwanted pregnancies entail significant risks for maternal health, including high rates of delivery-related complications and high abortion rates. Additionally, because of the risky, often unprotected and non-voluntary nature of their sexual activities, adolescents and youth are most likely to contract HIV and other STIs, so that the highest infection among young women between the ages of 15 to 24. rates in the country are currently seen

Goal: To enhance the reproductive health and well-being of the countrys diverse populations of
young people.

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Strategies
Segment the design and delivery of all youth RH-related interventions and policies by gender, age cohort, marital status, and rural/urban residence. The definition of young people employed by this strategy (10-19 years) masks significant differences in RH needs, and the kinds of interventions needed to address them. This is especially true in Ethiopia, where early marriage and childbirth, a predominantly rural population base; and strong gender-based proscriptions on behavior give rise to different sets of RH needs, and very different sets of constraints to addressing them.

Targets: By 2006, develop a National Adolescent and Youth RH Strategy. By 2007, develop regional implementation plans for the National Adolescent and Youth RH Strategy. Address the immediate and long-term RH needs of young people, with priority given to married women between the ages of 15-19 and their partners, and young people generally between the ages of 10-14.

Targets: Increase the median age of first intercourse for women in the age cohort 20-49, from 16.4 to 17 by 2010, and to 18 by 2015. By the year 2015, decrease by 20 percent, HIV prevalence among women in the age cohort 1524. Strengthen multisectoral partnerships to respond to young womens heightened vulnerability to sexual violence and non-consensual sex.

Targets: By 2007, establish multisectoral committee for the development and implementation of national protocols and standards on the treatment of victims of sexual violence, with provisions for the needs of young people. Simultaneously, establish multisectoral youth RH committees in every region.
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6. REPRODUCTIVE ORGAN CANCERS

A comprehensive approach to RH implies meeting the reproductive needs of women and men at all stages of their lives. One important need, often overshadowed by the more traditional aspects of RH, is the detection and treatment of reproductive organ cancers (ROCs) which tend to affect women (and men) later in life. This is also true in Ethiopia, where ROCs are a widespread, but rarely acknowledged problem.

Goal:
To reduce the risk of developing ROCs, provide early detection and treatment, and improve the quality of life of those suffering from them.

Strategy
Understand the magnitude of the problem and identify cost-effective interventions for ROC screening, diagnosis and treatment.

Targets:

By the end of 2006, conduct a national assessment to determine the frequency and type of ROCs prevailing in the country. Results to be used to design appropriate interventions and measure their impact.

By the end of 2006, launch appropriate cost-effective cervical and breast cancer prevention and treatment demonstration (pilot) projects/programs in five selected areas in the country By 2008, develop a national plan for implementing ROC prevention and control activities.

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