Context of FP in Rwanda by decree


    1. Context and BACKGROUND

In Rwanda and other African countries, one major factor contributing to the
development challenge is the continued rapid growth of the population. The number
of people in need of health, education, economic, and other services is large and
increasing, which, in turn, means that the amount of resources, personnel, and
infrastructure required to meet the Millennium Development Goals (MDGs) is also
increasing. In light of this fact, development efforts in support of the MDGs should
focus on the importance and benefits of slowing population growth.

With the highest population density in Africa (321 inhabitants per square kilometer),
a very young population (67% of Rwandans are under the age of 20) and a fertility
rate of 6.1, Rwanda urgently needs to develop Family Planning interventions that
address the real obstacles preventing women from accessing and/or using services.

Regarding FP in particular, CARE believes that the low contraceptive rate of 10% is
not only due to geographic accessibility problems but also to socio-cultural factors
and unequal power relations between men and women. CARE seeks to better
understand the social-cultural factors that hinder access of women to FP services
with the ultimate objective to develop a community based reproductive health
initiative, focusing on family planning. CARE received support from the Reproductive
Health Unit through the Knowledge Sharing Fund. The learning initiative will be
implemented among and with participants of CARE’s existing programme, such as
Voluntary Savings and Loan groups, People Living with HIV&AIDS, adolescents and
other marginalized groups.

2. General information on FP in Rwanda

Rwandan women have on average about 6 children each, and the unmet need for
FP services is high (36 percent of married women of reproductive age want to space
or limit births but are not currently using any method of family planning).

If access to family planning services was increased, this unmet need could be met,
therefore slowing population growth and reducing the costs of meeting the MDGs.

A multi-country study titled ―Achieving the Millennium Development Goals: The
Contribution of Family Planning,‖ (USAID) looks at how one strategy—meeting the
need for family planning—can reduce population growth and make achievement of
MDGs more affordable in Rwanda, in addition to directly contributing to the goals of

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reducing child mortality and improving maternal health. According to that study,
reducing the unmet need for FP services can help Rwanda significantly reduce the
costs of meeting the five selected MDGs, including:

• Achieve universal primary education

• Reduce child mortality

• Improve maternal health

• Ensure environmental sustainability

• Combat HIV/AIDS, malaria, and other diseases

Therefore, Family Planning (FP) is among national priorities of the country.
According to the draft of National Family Planning Policy and its five - year
strategies (2006-2010), “the broad objective is to ensure healthy citizens who are
able to work both for themselves and for their nation’s development.” Ministry of
Health, (2006).

The same document reveals that specific objectives are related to giving birth to a
number of children that is within the capacity of each household to support, in such
a way that every family and the entire population as a whole will be more productive
and then be able to contribute to the sustainable development of our country.

The major elements forming this draft policy are seven, stated as follows:

    Focus on advocacy;
    Mainstream Family Planning Programs in all health services and to increase
     access to full range of methods;
    Partnerships in administration structures;
    Community mobilization;
    Assure quality & formative supervision in public and private sectors;
    Sustainable (continuous) financing in family Planning;
    Evidence –based decision making
Some researches and studies have been done in FP and Reproductive health (RH)
in general in Rwanda. The main knowledge on FP is given by the Demographic and
Health Survey (DHS) report, the most recent one being DHS 2005.

According to the DHS 2005 (INSR and ORC Macro, 2006), “at the end of her
childbearing years a Rwandan woman has an average of 6.1 children”. The same
findings show that women in urban areas (4.9) have lower fertility than those in rural
areas (6.3).

Regarding FP, 95% of women and 98% of men aged of 15-49 years reported having
knowledge of at least one method of contraception. However, only 13% of all

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women have correct knowledge about the fertile period, and 72% have incorrect
knowledge or don’t know that there is a time during the menstrual cycle when a
woman is likely more to conceive.

In addition, the use of contraceptive method by Rwandan women is very weak: 17%
for any method and 10% for any modern method.

Women who were not using contraception and don’t plan to use it in the future gave
their reasons; important ones are summarized below:

            14.2% of women reported the fear for side effects;
            9.9% wanted to have as many children as possible.
            9.9% said it was forbidden by their religion;
            6.7% are themselves opposed to contraception;
            4.3% said it was forbidden by her husband/partner.
            3.8 % reported the fear of health concerns;
            2.3 % reported the lack of knowledge.
DHS 2005 findings show also that 59% of Rwandan women and 39% of men have
never heard any message on FP in magazine, journals, radio or television, which
means a big gap in communication. Radio is the most frequent source of FP
message (41% for women and 60.7% of men).

The DHS (2005) findings have also shown a breach on providers’ side in their ability
to approach the potential clients, namely non users. Indeed, in the 12 months
preceding the survey, 90.5% of nonusers of FP had not discussed FP with a field
worker or at health facility. Opportunities to provide information on FP are missed at
health facility site: 18.6% of FP nonusers women have visited health centers but did
not get any information on contraception.

There are still taboos regarding discussions on FP between spouses. 29.7% of
Rwandan women have not discussed contraception with their husbands during 12
months preceding the survey. This is a serious issue and understanding why could
help the increase of contraceptive prevalence.

The survey revealed the power of the man in decision-making regarding
contraception. In fact, among 11% of all couples who have diverged opinion on
contraception, in 10% of couples, women approve but their husbands don’t, and the
reverse is true in only 1 percent of couples. 59% of couples have the same opinion
and both partners approve contraception.

Despite all efforts by the government, UN agencies, civil society and NGOs, in
Rwanda, unmet need for FP is high: 38% of women have expressed need for FP,
among them 25% to space births and 13% to limit them but they remain unserved.

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3. Literature review:

In Rwanda, apart from DHS reports which remain the most reliable national source
of information, not many studies have been conducted on FP. Among the few
documents done on FP, we can cite the following:

    -   ―An in-country qualitative assessment of family planning in Rwanda‖,
        conducted in 2002 by The Ministry of Health, Advance Africa, the DELIVER
        Project and PRIME II and supported by USAID/Rwanda;

    -   ―A study on the integration of FP in PMTCT services in the hospitals of
        Byumba and Kigoma‖, conducted in 2004 by the Ministry of Health in
        collaboration with Intrahealth /PRIME II, with USAID support;

    -   ―The Family Planning needs in former Provinces of Butare and Byumba‖
        conducted by GTZ and Health units of the two Provinces (2004),

    -   ―The Impact study of the introduction of the Standard Days Method (SDM) in
        Rwanda‖ conducted by the Ministry of Health in collaboration with The
        Institute for Reproductive Health of Georgetown University and Awareness
        Project (2007);

The in-country qualitative assessment of family planning in Rwanda (The Ministry of
Health, Advance Africa, the DELIVER Project and PRIME II, 2002) aimed to
respond to three major issues:

          Identification of barriers and opportunities for improving access of quality family
           planning services at service delivery points
          Assessing the impact of the genocide on sexual and reproductive behavior and
           Contraceptive use
          Determine Community perspectives on religious and socio-cultural barriers
           which impact contraceptive use.

In trying to know why Rwandan women don’t use FP services, the assessment
found out various reasons, which are summarized below:

    a) Lack of decision-making power of women in the household: men, women
       and adolescents considered men to be the primary decision makers related to
       sexual and reproductive health decisions for both men and women. This was
       identified as a major obstacle for women who were concerned about the
       consequences of making independent decisions regarding the use of family
       planning services.
    b) Socio-cultural and religious influences: There was a consensus in the
       community that religion has a major influence on people’s capacity to use

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        family planning services. The Catholics reinforce traditional Rwandan
        concepts of ―children are gifts from God‖ and further entrenches culturally held
        beliefs against use of modern contraceptives. However, the Anglican Church
        emphasizes family welfare and has promoted family planning since the 1980s.
        The Moslems also encourage child spacing and are not against family
        planning services.
    c) Informal relationship with multiple partners: Although polygamy is not
       extensive, the assessment found that informal relationships and multiple sex
       partners are becoming increasingly common as a result of the genocide.
    d) Insufficient access to health services in general: due partly to the physical
       terrain and lack of transport for women to travel to health centers for
       ―preventive‖ non-emergency services.
    e) Insufficient information and counseling on family planning: Men and
       women consider that there is a lack of information on family planning. IEC
       messages were non-existent in the health centers visited either as a guide to
       health care providers or to the clients who came for other services. Radio
       programs rarely address family planning, whereas HIV/AIDS awareness
       campaigns are organized throughout the country.
    f) Fear of side effects as a result of use of modern FP methods: In all six
       districts, there were repeated and consistent complaints among men, women,
       adolescents, and community leaders regarding potential side effects from the
       use of contraceptives.
    g) Rumors associated with Family planning: Discussions in the districts
       indicated that there were strong rumors regarding family planning. Family
       planning use is associated with causing sterility, cancer, and miscarriage.
       Some even said that condoms are not safe because Europeans inject HIV
       into condoms and sell condoms for commercial purposes.
    h) Perception of family planning as “limitation of births” only:    Family
       planning has become synonymous with the limitation of births rather than an
       intervention to improve the health of both mothers and children. This most
       probably results from the former ONAPO (Office of National Population) policy
       prior to 1994, which operated purely from demographic targets.
    i) Difficulty in using natural family planning methods: While natural family
       planning methods are culturally accepted, the majority of respondents felt that
       without strong discipline, self control by men, it is difficult to be effective. The
       services for helping women with natural family planning services are not
       currently available. Alcohol was also mentioned as another problem. For
       women who are illiterate counting from calendars was mentioned as one of
       the obstacles for effective use.

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    j) Specific problems associated with widows, separated and divorced
       women who face significant obstacles in accessing family planning services
       mainly because of lack of confidentiality at the health center.
    k) Lack of access, awareness, and support of adolescent reproductive
       health services:
    l) Early marriages were said to be a problem in some districts as the use of
       health services among this group is low, which places them and their children
       at greater risk of disability and death.
    m) Impact of the genocide: The genocide has had a significant impact on both
       fertility and contraceptive use. The significant number of households headed
       by widows, single women, orphans and wives of prisoners have changed
       household organization and gender relations. As a result, sexual relations
       among men and women outside of marriage have increased for various
       reasons. Men have a greater tendency to have multiple partners and co
       spouses women ―compete‖ in such relationships by having more children.
    n) Factors associated with poverty which impact contraceptive use:
       communities link high fertility and low contraceptive use with poverty. Low
       fertility was associated with ―better standards of living‖, ―less kwashiorkor‖
       better health and ―harmony‖.
The study on the integration of FP in PMTCT services in the hospitals of Byumba
and Kigoma (Ministry of Health, Intrahealth /PRIME II, 2004), had the goal of
analyzing the situation and contribute to the development of an approach for
evaluation and if possible, reinforcing and improving the integration of FP services in
PMTCT activities.

The assessment evaluated reasons of low attendance by women of FP. The
findings revealed the importance of rumors and exaggerated fear around side
effects of modern FP methods. Among those persistent rumors, it was said that
modern FP methods lead to women sterility, non stop menstruations, congenital
deformations, headaches, too much weight; many people thought also that condom
could migrate into the uterus.

According to the assessment conducted in former Butare and Byumba Provinces by
GTZ (2004), essential needs in reinforcing FP services were among others ―means
to sensitize the population from the grassroots‖. This assessment report revealed
also that ignorance of the population and the influences of religion were key causes
in women’s unwillingness to FP.

The results of the Impact study of the introduction of the Standard Days Method (the
Ministry of Health in collaboration with The Institute for Reproductive Health of
Georgetown University and Awareness Project, 2007) revealed that contraceptive

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prevalence increases with community mobilization done by health centers. But,
providers mentioned traditional mentality that children are gift from God, rumors on
exaggerated side effects, and resistance to change as key obstacles to the increase
in contraceptive prevalence rate.

Many of those studies, researches and assessments quoted above confirm the
socio cultural barriers preventing women from accessing FP services. In brief, socio
cultural barriers stated in cited documents can be summarized as follows:
            Lack of decision-making power of women in the household
            religious influences on people’s capacity to use family planning services
            informal sex relationships and multiple sex partners
            strong rumors regarding family planning
            Specific problems associated with widows, separated and divorced women
            Early marriages
            Impact of the genocide:
            rumors on exaggerated side effects, and
            resistance to change;

In addition, this literature shows two main issues:

            On the one hand, there is recognition that socio-cultural barriers and
             men/women power relations are part of the access problem. At the same time,
             there is a lack of an in depth and profound knowledge of these two aspects,
             including religion. The objective of this research will therefore be to explore
             these two aspects in more depth.
            On the other hand, the review also leads to the conclusion that FP programs
             must engage and involve men and Church leaders more actively and
             strategically. This research will explore how to engage men and church leaders
             in FP programs.

4. Information on the existing use of theater in Family Planning / reproductive
health programs in Rwanda and elsewhere

CARE has got extensive experience in other countries in Social Analysis and Action
(SAA) and would like to test that during this research.

Social analysis builds on and utilizes familiar participatory approaches, but with
variations that encourage the development facilitator to work with communities to
ask themselves the difficult, unspoken questions about their social realities, to
unlock patterns of communication that have the potential to not only achieve better
project results, but to see real changes in community members’ sense of pride,
strength and dignity.

In other words, exploring SAA requires to build on everything you know about
engaging communities in participatory dialogue, but to set aside some of the
boundaries and assumptions that have limited that dialogue in the past.

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Three concepts central to social analysis and action are:

          Seeing people as lead actors in their own development processes and not
           just active participants in exercises intended to address those needs;
          Breaking out of sectoral boxes that circumscribe our work and limit its
           impact; and
          Embracing CARE’s role as a catalyst and facilitator of change, rather than
           just a provider of development services.
Social analysis and action opens doors to new discussions with communities around
issues of health from a social lens. Social analysis often involves the use of
interactive theater. This is good in terms of program but does not apply easily with
small and rapid research context. However, if CARE Rwanda develops a
community-based Family Planning intervention, it plans to use social analysis
throughout the intervention. Therefore, the use of theater in this original research
has two objectives: 1. To test the feasibility of using theater as a tool to pass on
messages on FP and to collect sensitive information from participants 2. To start the
process of social analysis within CARE Rwanda’s FP intervention. It is in that
context that CARE has been looking for successful experiences using theater in the
region and particularly in Rwanda and in Reproductive Health programs. The
following relevant experiences were identified:

An interesting experience of interactive drama was conducted by CARE Burundi in
its Peace Building Project. The process used FGD to better understand how
communities dealt with the conflict. They discussed with various groups in the
community. Based on the analyzed findings, a local professional drama group
―TUBIYAGE‖ prepared and presented role plays in the community. In case of
sensitive issues, TUBIYAGE group develop a story telling. “In some cases, a story is
told from the beginning to the end; in other cases, the story is started and as the
conflict is beginning to boil, it is stopped and members of the audience are invited to
come play a role and change the scene so that the conflict is avoided”. In order to
succeed, all pieces have a mixture of characters reflecting the real situation, which
includes many actors.

There were discussions that took place after the performances to enable the
audience to share critical issues. Such an approach could be considered in CARE’s
future program but it requires using professional actors who have the capacity to
immediately translate information into play in an effective manner.

Other studies conducted on social interactions and influence have shown that
people’s sexual behaviors and fertility ideas are influenced by the attitudes and
behaviors of others in their social networks regarding contraceptive use. A study
conducted in Cameroon (Valente et al.1997) found that “respondents’ perception of

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other members’ use influenced their own contraceptive practice more than whether
any other members were, in fact, using contraceptives or not.‖

Another study conducted in Malawi (2004) using in-depth interviews, has shown that
“both men and women reported feeling more comfortable speaking with others of a
similar age group”. In addition, it was revealed that men’s acquisition of knowledge
about family planning practice was indirect, based mainly on their observations of
child spacing and size of the others’ family, whereas women’s was direct: they
discuss with colleagues and neighbors. This study yielded a lot of information of
social influence on SRP (sexuality and reproductive health) in the community.
Thereafter, drama groups were formed with the purpose of discussing and
disseminating reproductive health information in the community.

In Rwanda, there is a bi-weekly radio theater on community health issues. It is
prepared and played by URUNANA Development Communication (UDC), supported
by Health Unlimited (UK). It started in 1997 and is very popular and is broadcasted
on Tuesdays, Thursdays at 6:45 pm and Sundays morning at 7:30 am, through BBC
in Kinyarwanda and on National Radio, every Sunday at 6 pm. Sometimes, actors
participate and play in public community awareness campaigns.

According to the final evaluation report conducted on URUNANA phase II activities
(2006) “the overwhelming majority of project partners interviewed during this
evaluation at community, ministry and NGO level believe the program is of high
quality as well as relevant and appropriate to Rwandese culture and values”.

With a large number of mainly rural listeners, the URUNANA soap opera is highly
popular due its ability to balance entertainment and educational issues. Given
Rwanda’s high levels of illiteracy and poverty, the radio is the most widely used
among the media. URUNANA has reached a very large audience in the rural areas
where the intended primary beneficiaries live.

There was unanimity that URUNANA has contributed to awareness of health issues
among rural populations. Government officials were pleased that URUNANA had
assisted in their aim of changing Rwandan taboos preventing parents from
discussing sexual matters with their children.

URUNANA has brought changes in social attitudes and environment leading to
increased ability to discuss SRH related issues. URUNANA listeners report that the
soap opera has made it easier for them to discuss issues surrounding sexuality
without fear or shame. They claim that for the first time subjects that were
traditionally taboo are now being discussed openly in households and social
gatherings while referring to the characters/actors in URUNANA who have faced
similar SRH problems/challenges.

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Based on its overall success, URUNANA could be a partner for CARE and other
stakeholders to work with in SRP/FP programs.

Recently, other theater groups have emerged; among them we can cite INGANZO
and MASHIRIKA Group. However, they perform on demand on different issues
affecting Rwandan population, among them health issues. However, FP and SRP
are not their specialization, unlike URUNANA DC.

In the context of FP, there is a need to strengthen all chains of information, mainly
through Community Theater. Indeed, ordinary Rwandan citizens, often illiterate,
would feel more attracted by such media that transmits knowledge without
demanding too much intellectual skills and understanding. The current organization
of a theater competition by the Family Planning Technical Working Group is a strong
indicator of the potential of community theater in Family Planning interventions in

5. Proposed methodological approach and tools

In this particular research, Focus Group Discussions seem to be the best choice to
use. We will also integrate ―Think like a Genius (TLG)‖ (Holman,P et al. 2007) and
―story telling‖ techniques in the FGDs to help research participants think out of the
box and give form to their thoughts, feelings, ideas, knowledge and experience on

The ―think like a genius‖ (TLG) provides a better way to:

            brainstorm and express ideas,
            invent and innovate;
            create and share knowledge;
            solve urgent problems;
            set and achieve goals;
            discover and apply people’s creative genius, which enables us all to
             realize potential;

In addition, Story telling will be exploited to reinforce FGD. According to CARE
&USAID (2006), in Storytelling, ―facilitators tell a story focused on a specific
topic/theme. The story often includes a key message and is intended to capture the
audience’s attention‖. Story telling will consist in giving opportunity to participants to
relate their experience and/or emotions in a way that can help them to express
freely on different topics.

In respect to ethical issues, when using story telling, we will allow each one’s story
as long as it is within the global context of FP and social and cultural factors. In case
someone goes ―out of the topic‖, the facilitator will try to bring the person back to FP

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and its social & cultural roots. It will be explained before the story telling, that the
debates would focus only on PF.

The primary intention was to use theater to generate ideas to complete FGD’s data.
However, budgetary and time constraints do not make it possible to go back to
communities with a theater play developed based on information previously
collected. It was therefore agreed that the CARE staff would be used to test the
theater play. So, information will be collected through FGD (enriched with ―Story
Telling‖ and ―Think Like a Genius‖ techniques) from communities (batwa and VSL
groups) and through individual interviews with Family Planning providers (ARBEF
and others, including faith based health facilities) and users (through ARBEF
clinics). Based on all this information, a play will be developed by professionals and
it will be played in front of the CARE staff and their spouses. CARE staff and their
spouses will be divided in groups by sex and potentially by staff category. After
having seen the play, discussions will be organized during which the staff’s
appreciation of the play and theater in general as an IEC strategy for FP will be
collected as well as complementary information on socio-cultural barriers to FP
which will have been generated during the debate following the play.

The consultant will be using professional actors to help prepare the play and of
course to act in front of the CARE staff. Then, with his team of FGD moderators,
they will facilitate discussions with the audience that will generate ideas and
opinions to complement the findings from FGD with communities. This will also help
in refining the play for future use.

In summary and based on the above, the main stages will be the following:

 1. Conduct Interviews & FGD with small groups of participants in all selected
    areas and with target research participants (VSL groups and batwa),

            a. Mix and/or reinforce these FGD with interactive techniques:Think like a
               Genius and Story telling.

            b. Interview Family Planning providers and users in ARBEF clinics and
               other clinics, focusing on faith based providers.

 2. Compile information collected in a draft report;

 3. Approval of draft report by CARE;

 4. Work with professionals who will develop a play based on draft report;

 5. Approval of play by CARE;

 6. Present the play in front of CARE staff and their spouses and organize debates
    following the play. This will be video recorded.

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 7. Compile information collected during debates with CARE staff to (1).
    Complement information on barriers to FP; (2). Assess feasibility of using
    interactive theater in FP interventions and to improve the play.

 8. Finalize research report including both findings on socio-cultural barriers and
    power relations between men and women and the feasibility of using various
    interactive participatory techniques in Family Planning research and programs
    (theater, story telling, think like a genius).

5.2 To develop mainstreaming strategy and intervention

The development of a mainstreaming strategy and intervention will be based mainly
on two elements: Individual interviews of CARE senior program staff and the Review
of existing projects. It will also reflect the ideas of the staff met during FGD and/or
discussions after the theatre play.

Target groups

As suggested in TOR, the FGD will be conducted with the following groups:

    1. ARBEF clients
    2. CARE staff,
    3. VSL members
    4. Batwa group
    In addition, interview will be conducted with health centers officials and other
    stakeholders around the target FGD participants.
FGD guides have a main part which is similar to all groups and there are additional
items depending on the specificity of each group. Moderators will be trained to be
flexible and able to adapt the guide to FGD participants.

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List of references

    1.      Addressing the social issues that influence sexual and reproductive health:
            an idea and action book;
    2.      Akand, M. (2007), Action Theatre: Initiating Changes, The center for
            victims of torture, New tactics in human rights projects, Minneapolis,
    3.      CARE (2006), Adressing the social dynamics of sexual and reproductive
            health: CARE’s explorations with social analysis and community action, in
            Sexual & Reproductive health, Working Paper Series, N° 3, June 2006;
    4.      INSR and ORC Macro (2006), Rwanda Demographic and Health Survey
            2005, Maryland,
    5.      Ministry of Health (2006) Draft of the National Family Planning Policy and
            its five years strategies (2006-2010);
    6.      Ministry of Health and The Institute for Reproductive Health of Georgetown
            University (2007), The Impact study of the introduction of the Standard
            Days Method (SDM) in Rwanda;
    7.      Ministry of Health et. al (2002), An in-country qualitative assessment of
            family planning in Rwanda, Kigali
    8.      Ministry of Health in collaboration with Intrahealth /PRIME II (2004), A
            study on the integration of FP in PMTCT services in the hospitals of
            Byumba and Kigoma‖,
    9.      Republic of Rwanda and GTZ (2004), The Family Planning needs in
            former Provinces of Butare and Byumba
    10.     Soldan, V. A. P (2004, How family planning ideas are spread within social
            groups in rural Malawi, in Studies in family Planning 2004, Volume 35,
            Number 4;
    11.     URUNANA and WWMP-AGLR (2006) Final evaluation, phase II (2000-
    12.     USAID, Achieving               the MDGs, The contribution of family planning,
    13.     Use of interactive drama in CARE peace building Project,

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