Contributors Katie Gifford Yahya Kane Geeta Lal Enora Marenne

Contributors: Katie Gifford, Yahya Kane, Geeta Lal, Enora Marenne, Ann Nunes, Kate Ramsey, Magali Romedenne, Saira Stewart, Christina Vrachnos, Julie Weber Editor: Allyson Velez Additional thanks to Yves Bergevin and Mary Finalborgo for reviewing the report. Contributing Writers: Lydiah Bosire, Yahya Kane, E d Saira Geeta Lal, Ann Nunes, Kate Ramsey,i t i n g : Stewart, Tina Johnson Suzanne Suh, Allyson Velez, Julie Weber Cover Photograph: Dima Gavrysh/UNFPA Cover Design: Allysson Lucca Cover photograph: Chris de Bode/Panos Pictures Cover design: Allysson Lucca Design and Layout: Pauline Spinelli-Brandt Pauline Spinelli-Brandt Design and Layout: TABLE OF CONTENTS Executive Summary ............................................................................................................... 2 I. II. III. IV. V. Introduction ................................................................................................................... 3 Key Achievements ......................................................................................................4 Challenges ................................................................................................................... 19 Lessons Learned ........................................................................................................ 19 Moving Forward ....................................................................................................... 20 Annex Donors to the Campaign to End Fistula, 2007 ................................................ 21 Campaign to End Fistula: New Allocations, 2007 ......................................... 22 Campaign to End Fistula: Expenditures, 2007 ................................................ 23 Tables and Figures Table 1. Campaign countries – April 2008 ..................................................... 5 ;fistula elimination .................................................................................... 6 6 Table 3. Fistula cases managed annually in selected countries ................................................................................... 10 Table 4. Personnel trained in fistula management in 2007 ...................... 11 Table 5. Personnel trained in rehabilitation and social reintegration in 2007 .............................................................................12 Figure 1. Campaign growth: Status of countries ..............................................4 Figure 2. Increase in percentage of women delivering with a skilled birth attendant in intervention vs. control communities in Eritrea community mobilization pilot ..................8 Figure 3. Campaign growth: Number of women treated .............................. 9 Table 2. National policies and plans integrating The Campaign to End Fistula – 2007 Annual Report 1 EXECUTIVE SUMMARY A wave of support for realizing Millennium Development Goal (MDG) 5, for improving maternal health and for tackling obstetric fistula is now gathering momentum. The official addition of the target of universal access to reproductive health to MDG 5 has brought renewed and expanded attention to this goal. The 20th anniversary of the Safe Motherhood Initiative in 2007 led to a strong call for intensified commitment to prevent and address maternal mortality and morbidity, resulting in new and greater pledges of assistance. By drawing attention to fistula, the United Nations Population Fund (UNFPA) and partners in the Campaign to End Fistula have turned the spotlight on maternal morbidity as well. Now, the voices of women who have lived with fistula are joining the global call to urgently make maternal health care accessible and affordable for all. This momentum can be seen in increased commitments and actions at global, regional and national levels. In 2007, the Campaign to End Fistula was active in more than 45 countries in Africa, Asia and the Arab States, preventing and treating fistula and rehabilitating and empowering women after treatment. Since 2003, the Campaign has secured more than $25 million in contributions that go to support countries’ efforts. The goal of this ambitious Campaign is to eliminate fistula by 2015. Significant progress is being made toward this goal, as shown by some of the following results to date: • • • • • • • Thirty-six countries have now assessed the national need to address fistula Sixteen countries have integrated fistula in relevant national health policies and plans More than 7,800 women have received fistula treatment In 2007 alone: Tens of thousands of individuals, community leaders and policymakers were sensitized about maternal health More than 3,300 women received fistula treatment with support from UNFPA[1] Support was received by 89 health facilities in 19 countries to strengthen capacity to provide treatment services Training was provided for more than 500 professionals in fistula management – involving over 130 doctors, 170 nurses and midwives, and more than 200 social workers and paramedical staff Other accomplishments in 2007 include: • • The Third Committee of the General Assembly adopted a resolution, co-sponsored by 137 countries, in support of efforts to end obstetric fistula UNFPA supported the first-ever delegation of fistula survivors to attend the global Women Deliver conference, where advocates bravely shared their experiences in panel events and interviews While the task ahead remains large, this progress – as well as the recent launch of a UNFPA-led Thematic Fund for Maternal Health and expanding work by governments, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the World Bank and other members of the Partnership for Maternal, Newborn and Child Health – provides hope for substantial change over the coming years. Support for governments’ efforts to improve maternal health, including the Campaign to End Fistula, can help bring the world closer to the day when safe and healthy childbirth is a reality for all women, not just the lucky few. [1] Treatment services supported by UNFPA may have also received support from governments and other partners. 2 The Campaign to End Fistula – 2007 Annual Report I. INTRODUCTION L arge numbers of women and adolescent girls around the world face genuine and daunting challenges in maintaining their sexual and reproductive health. Many are married and become pregnant too young. Nearly half of all women giving birth every year do so without the support of a health professional. Women experiencing complications in childbirth who seek care may encounter disapproval or outright refusals by their families, long distances separating them from the nearest facility, catastrophic costs and poor quality services. Some will survive this ordeal; too many will not. And some will be left with life-shattering conditions like obstetric fistula. For the poorest women and adolescent girls in the world in rural and resource-poor settings, these are regrettably daily realities. Women who have lived with obstetric fistula can testify that such realities have dramatically shaped their lives. The Campaign to End Fistula strives to ensure that these women are not left out of the equation when choices are made about who has access to care and who does not. Now, with support from the Campaign, women who have lived with obstetric fistula are speaking out for those who have been silenced, and their voices have joined the worldwide call to urgently make maternal health care accessible and affordable for all. The year 2007 showed renewed commitments to improving global health, supporting the health MDGs and strengthening health systems. These are welcome adObstetric fistula is a severe morbidity caused by prolonged obstructed labour unrelieved by timely medical intervention. It exposes the challenges that persist in reducing maternal mortality and morbidity. With timely access to skilled assisted delivery and emergency obstetric care, these injuries could have been avoided. Unfortunately, the condition affects more than 2 million women and girls in developing countries, with as many as 100,000 new cases each year. vances that have the potential to make substantial changes in people’s lives, notably in the area of maternal health, which depends greatly on a functioning health system. This also means that intensified advocacy is needed to ensure that poor women, particularly those marginalized by geography or circumstance, continue to be factored into any plans and decisions. Decisions on issues ranging from human resources to financing to commodities management will have an impact on accessibility and affordability of care. This will ultimately affect whether the goal of fistula elimination is achieved. In addition, there is a need to continually support women to exercise their reproductive rights and tackle underlying social and economic inequities that perpetuate poor health outcomes and affect utilization of services. As part of its commitment to universal access to reproductive health – in particular to improve maternal health – UNFPA has supported the global Campaign to End Fistula since 2003 to prevent and treat fistula and to rehabilitate and empower women after treatment. With growing interest and support for the issue, UNFPA continues to lead global efforts on fistula elimination, working with a range of partners across disciplines and sectors. By drawing attention to fistula, UNFPA and partners have turned the spotlight on the necessity of reducing morbidity as well as mortality in order to improve maternal health. In addition, a focus on fistula has contributed to promoting equitable access to maternal health care that responds to women’s needs. This annual report summarizes key 2007 achievements at national and global levels resulting from support provided to governments and partners by UNFPA as part of the Campaign to End Fistula. They are divided into the following essential components of the Campaign: national leadership, prevention, treatment, reintegration, research, advocacy and partnerships. The report additionally analyses programmatic challenges and lessons learned. Provisional financial figures on Campaign contributions, allocations and expenditures are also detailed in the Annex. The Campaign to End Fistula – 2007 Annual Report 3 II. KEY ACHIEVEMENTS he global Campaign to End Fistula has grown at a fast pace since its launch in 2003. While it began with 12 countries, there are now more than 45 countries in Africa, Asia and the Arab States engaged in activities around fistula, including prevention and treatment as well as rehabilitation and women’s empowerment after treatment. At the beginning of 2006, when the current thematic funding period began, there were approximately 15 countries in full implementation phase. This number has nearly doubled, with 28 countries currently at or entering the implementation phase. Since 2003, the Campaign has secured more than $25 million in contributions to support countries’ efforts. The goal of this ambitious Campaign is to eliminate fistula by 2015. Progress is being made toward this goal, as shown in the following results. T FIGURE 1. CAMPAIGN GROWTH: STATUS 30 25 20 15 10 5 0 OF COUNTRIES Phase I Phase II Phase III Note: Phase I: Needs Assessment Phase II: Planning Phase III: Implementation Jan-05 April-08 P ROMOTING N ATIONAL L EADERSHIP Integrating Fistula into National Strategic Plans and Country Programmes The integration of obstetric fistula into national policies is key to securing political and financial commitment. In most countries, the fight against obstetric fistula has over time become an important component of reproductive health and maternal health national agendas. The elaboration of National Strategies to End Fistula remains an important step for consolidating all aspects of interventions: prevention, treatment and social reintegration. Sixteen countries have integrated fistula in relevant national health policies (see Table 2) and often generate significant support for their implementation. For example, the Government of Equatorial Guinea demonstrated its commitment to maternal health and obstetric fistula by allocating $300,000 of national resources to the national fistula elimination programme. [2] [3] National Roadmaps for Accelerating the Attainment of the MDGs related to Maternal and Newborn Health (completed in 40 countries)[2] and political commitments such as the Maputo Plan of Action[3] lay out specific frameworks in Africa through which national governments can take leadership for significant improvements in the structure and delivery of healthcare services. Roadmaps developed in Côte d’Ivoire, Liberia, Malawi, Mali, Niger and Senegal recognize obstetric fistula as a preventable and treatable maternal morbidity. In additional countries, such as Zambia, the Ministry of Health acknowledges fistula prevention as a priority in its own action plan and reproductive health policies. The year 2007 also saw greater integration of obstetric fistula programming into UNFPA-supported Country Programmes, such that Eritrea, Mali and Somalia now reflect obstetric fistula as an integrated component of the reproductive health sub-programme. Obstetric fistula is also gaining attention through joint programming efforts within the United Nations Country Teams, for example in Afghanistan, where fistula prevention activities are now included in the United Nations Joint Programme on Maternal Mortality. See http://www.afro.who.int/whd2005/mdg-roadmap-eng.pdf. See http://ec.europa.eu/europeaid/where/worldwide/health/documents/maputo_poa_en.pdf. 4 The Campaign to End Fistula – 2007 Annual Report Securing High-level Government Commitment for Maternal Health The commitment of high-level government and political leaders is a key factor in securing and implementing political change. Since its inception, the Campaign to End Fistula has attracted the attention of Presidents, First Ladies and Ministers of Health, encouraging national-level action from the highest office. In December 2007, for example, the Africa Regional Conference on Fistula and Maternal Health was co-organized by the Government of the Islamic Republic of Mauritania and UNFPA. The opening ceremony of the conference was marked by the presence of the First Lady, Her Excellency Khattou bint El Boukhary. In Liberia, the high profile launch of the fistula programme was attended by the Minister of Health as proxy for the President, Her Excellency Ellen Johnson-Sirleaf. The wife of the Prime Minister of Burkina Faso, Priscille Zongo, and the wife of the Minister of Finance launched an outreach service campaign in Koudougou town, stimulating the participation of local leaders. The First Lady of Nigeria commissioned the rehabilitation centre in Babbar Ruga, Katsina, while wives of State Governors committed to facilitate obstetric fistula interventions and the Federal Government waived payment and allocated a piece of land for the establishment of a national fistula centre. Her Excellency Olive Lembe Kabila, First Lady of the Democratic Republic of the Congo, sponsored the launch of the information and treatment campaign in Kinshasa. GENERAL ASSEMBLY RESOLUTION The Third Committee of the United Nations General Assembly covers social, humanitarian and cultural issues, including human rights. On 20 November 2007, the Committee adopted the resolution ‘Supporting efforts to end obstetric fistula’ (A/C.3/62/L.21/Rev.1). Co-sponsored by 137 countries, the resolution recognizes the links between poverty, malnutrition, poor health services, early childbearing and gender discrimination as root causes of obstetric fistula. It further underscores the obligation of member States to promote and protect the human rights and fundamental freedoms of women and girls. Member States were invited by the Committee to contribute to efforts to eliminate obstetric fistula, in particular the UNFPA-led Campaign to End Fistula. PREVENTING HARM Ultimately, optimal maternal health and the elimination of obstetric fistula will be achieved when all women have access to sexual and reproductive health, particularly the continuum of maternal health care. The Campaign to End Fistula thus emphasizes preventing both new and recurrent cases by increasing access to quality maternal health services, including family planning, assisted deliveries by qualified health personnel and emergency obstetric care. In addition, UNFPA and its TABLE 1. CAMPAIGN COUNTRIES – APRIL 2008 Campaign Phase Phase I: Needs Assessment Phase II: Planning Phase III: Implementation of National Strategy Africa Guinea-Bissau, Lesotho, South Africa, Swaziland, Togo Angola, Burundi, Gambia, Madagascar, Mozambique, Rwanda, Sierra Leone India, Nepal, Timor- Djibouti, Somalia, Yemen Leste Sudan Asia Arab States Benin, Burkina Faso, Cameroon, Central African Afghanistan, Republic, Chad, Congo, Côte d’Ivoire, Democratic Bangladesh, Republic of the Congo, Equatorial Guinea, Eritrea, Pakistan Ethiopia, Ghana, Guinea, Kenya, Liberia, Malawi, Mali, Mauritania, Niger, Nigeria, Senegal, Uganda, United Republic of Tanzania, Zambia The Campaign to End Fistula – 2007 Annual Report 5 Lisa Russell/UNFPA COUNTRY IN FOCUS: DEMOCRATIC REPUBLIC OF THE CONGO Through a campaign in the Democratic Republic of the Congo (DRC), supported by the country’s Ministry of Health and UNFPA, 36 women were treated at two health facilities: Nganda Hospital and Saint Joseph Hospital. Speaking at a launch event in June 2007, Her Excellency Olive Lembe Kabila, the First Lady of DRC, called on all affected women to take advantage of the free treatment offered through the campaign. partners seek to involve communities in promoting universal access to reproductive health. As part of the overall mandate, UNFPA works towards reducing the social and economic inequities that underlie maternal mortality and morbidity. UNFPA launched a new Thematic Fund for Maternal Health in January 2008. It aims to mobilize $500 TABLE 2. NATIONAL Country Afghanistan Bangladesh Benin Cameroon Côte d’Ivoire Congo Democratic Republic of the Congo Equatorial Guinea Eritrea Malawi Mali million over four years to support countries with some of the poorest maternal health indicators in expanding access to life-saving maternal health interventions. The Thematic Fund and the Campaign to End Fistula are both part of UNFPA’s overall efforts to support countries in achieving MDG 5. They will work complementarily to prevent maternal mortality and morbidity, while the POLICIES AND PLANS INTEGRATING FISTULA ELIMINATION Policy or Plan Reproductive Health Strategy (2006–2009) Health, Nutrition and Population Sector Programme (2003–2010) National Strategy to End Fistula Ministry of Public Health, Sectoral Health Strategy National Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity National Roadmap for Accelerating the Attainment of MDGs 4 & 5 National Strategy for Reproductive Health National Plan to Fight Sexual Violence National Strategy to Fight Obstetric Fistula National Programme for Reproductive Health National Reproductive Health Strategy National Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity Strategic Plan for Reproductive Health (2004–2008) National Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity (2008–2015) National Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity (2007–2015) National Health Development Plan (2005–2009) National Reproductive Health Programme National Roadmap for Reduction of Maternal Mortality National Reproductive Health Policy (2006–2009) National Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity Mauritania Niger Pakistan Senegal 6 The Campaign to End Fistula – 2007 Annual Report Campaign will continue to ensure treatment and reintegration of women who are living with fistula. From emergency obstetric care training for midwives to specialist surgical fellowship programmes, the Campaign supports continuing education for inservice maternal health-care providers. In 2007, this included a programme in prevention and treatment of fistula cases at Malalay Hospital in Afghanistan, and a collaborative effort with the Kenyan Ministry of Health to integrate obstetric fistula management services into ongoing Safe Motherhood Initiative sites, maximizing the efficiency of community midwifery projects by including obstetric fistula awareness-raising efforts. Through the support of the Campaign, dramatic increases in the numbers of skilled birth attendants have occurred in certain countries, such as Bangladesh, where 2,800 skilled birth attendants from 28 districts have been trained since 2002 to promote safe home deliveries and ensure timely referrals through a programme supported by the Government, UNFPA, WHO and UNICEF. In 2007, UNFPA in collaboration with the Government and WHO launched a pilot maternal health voucher scheme for pregnant women in one district to ensure access to antenatal care and to promote institutional deliveries. While provision of specialized training builds national capacity to prevent and treat obstetric fistula, the Campaign to End Fistula also works to strengthen facilities delivering care through rehabilitation and procurement of equipment and supplies. In Malawi, 27 health centres have been renovated to meet the criteria for provision of basic emergency obstetric care services, and in Côte d’Ivoire, the capacities of the gynaecologic and obstetric department at the Regional Hospital of Man were reinforced through the rehabilitation of the maternity ward and its equipment. To complement the services offered in Addis Ababa specifically in the area of prevention, UNFPA Ethiopia works at the community level to sensitize communities on the importance of access to maternal health services. Through national non-governmental organizations (NGOs) such as the Kembatta Women’s Self Help Centre, emergency obstetric care and fistula treatment services are offered. Additional fistula detection and referral outreach are also offered within the context of UNFPA Ethiopia’s broader programme promoting safe motherhood. Community mobilization is crucial to build capacity for obstetric fistula prevention and to address social and cultural determinants that perpetuate maternal mortality and morbidity. In Nigeria, 123 community educators were trained on prevention of obstetric fistula; between 350 and 400 gatekeepers and another 720 men were reached with information on safe motherhood and obstetric fistula prevention, treatment and rehabilitation of women in their communities; 337 pregnant women received birth preparedness and referral information for health-care centres; and 40 health workers were trained in emergency obstetric care and referral. In 2007, after two years of implementation, a pilot community mobilization project in Eritrea was evaluated. [4] The project involved mobilization of [4] Janet Molzan Turan with the Eritrean Ministry of Health and UNFPA, ‘Final Report on the Pilot Community Mobilization/Education Project for Promotion of Safe Motherhood and Prevention of Obstetric Fistula in Eritrea’, November 2007. Chris de Boda/Panos Pictures COUNTRY IN FOCUS: NIGERIA Thanks to the £570,000 raised by Campaign Spokesperson Natalie Imbruglia and Virgin Unite, UNFPA launched a fistula prevention and treatment project in Nigeria in August 2007. By the end of the year, the project had already seen impressive results: more than 120 community members had been trained to educate their peers about fistula and maternal health; more than 300 pregnant women had been provided with birth preparedness information and linked up with local health centres; and more than 60 women had benefited from free fistula treatment. The Campaign to End Fistula – 2007 Annual Report 7 community leaders and training of male and female health educators in safe motherhood. As it was a pilot, pre- and post surveys were conducted in both a control and intervention community. Findings from the evaluation show promising results. Evaluators found that if utilized in combination with improvements in access to quality maternal health care, the intervention could contribute to improved knowledge and healthseeking behaviours. They emphasized the high activity levels and continued motivation of the maternal health volunteers, increased utilization of antenatal care and delivery services and increases in knowledge and attitudes related to safe motherhood. Statistically significant differences were found between the control and intervention communities for these and some other indicators (see Figure 2). The intervention is now being expanded to nine other health districts. FIGURE 2. INCREASE IN PERCENTAGE OF WOMEN DELIVERING WITH A SKILLED BIRTH ATTENDANT IN INTERVENTION VS. CONTROL COMMUNITIES IN COMMUNITY MOBILIZATION PILOT ERITREA 100 80 60 40 20 0 Kamchewa Intervention Haboro Control Baseline Final Source: Janet Molzan Turan with the Eritrean Ministry of Health and UNFPA ‘Final Report on the Pilot Community Mobilization/ Education Project for Promotion of Safe Motherhood and Prevention of Obstetric Fistula in Eritrea’, November 2007. HEALING WOUNDS Although prevention is key to fistula elimination, the Campaign to End Fistula also actively seeks to alleviate the suffering of women living with fistula by making surgical treatment available and accessible. Providing treatment services involves a comprehensive package ranging from surgical interventions to postoperative care. UNFPA’s treatment strategy consists of national capacity development through upgrading of health facilities, provision of equipment and supplies and team-based training of health service providers that emphasizes quality of care. In 2007, more than 3,300 women received fistula treatment with support from UNFPA.[5] UNFPA provided support to 89 health facilities in 19 countries to strengthen their capacity to provide quality fistula treatment and care and supported the training of nearly 400 health professionals in this field, including 130 doctors, 170 midwives and nurses, and clinical officers and anaesthetists. Some of these providers were trained in fistula treatment for the first time, while others received training as a refresher or to strengthen their skills. Great strides have been made toward harmonizing existing training and treatment protocols and stan[5] dards as well as collecting evidence-based data to inform planning and decision-making. UNFPA is currently field testing outreach campaign guidelines to assist service providers, health ministry officials and programme managers in managing outreach treatment service events, aiming ultimately to clear the backlog of cases waiting for treatment, to bring care closer to clients and to build the capacities of key human resources in the management of fistula. UNFPA has also begun a joint effort with the International Federation of Gynaecology and Obstetrics to develop a competency-based training manual for obstetric fistula treatment and care. As national treatment centres become better established, decentralization of services to ensure greater access characterizes the national campaigns in a number of countries. In Bangladesh, a national centre of excellence is being established at the Dhaka Medical College with treatment decentralized to nine regional medical college hospitals. As part of the process, 25 doctors and 44 nurses from medical college hospitals received training in 2007 and 336 fistula cases were treated. In Kenya, using the official national training curriculum, a core team – 12 doctors, nurses, anaesthetists, nurse-counsellors, social workers and occupational therapists – was trained as trainers. The providers are from three provincial hospitals and one teaching hospital, which also received equipment and supplies and are now serving as referral centres for the treatment of obstetric fistula cases for the surrounding Treatment services supported by UNFPA may have also received support from governments and other partners. 8 The Campaign to End Fistula – 2007 Annual Report FIGURE 3. CAMPAIGN OF WOMEN TREATED GROWTH : NUMBER 3500 3000 2500 2000 1500 1000 500 0 2003 2004 2005 2006 2007 medical supplies, beds, linen and essential drugs. Following one-month training in fistula treatment and case management in Dhaka, staff had treated 30 patients at Malalay and Badakshan hospitals by December 2007. In the Democratic Republic of the Congo, several health facilities were fully equipped and provided with the supplies to deliver quality services over the course of the year. In total, 12 doctors and 30 support staff (including nurses) were trained and 303 women received surgical treatment, with a success rate of 90 per cent. Outreach service campaigns are also providing an important means to bring services closer to women and train health providers. Twenty-seven outreach service campaigns for fistula patients were organized in Pakistan, resulting in the training of 86 medical professionals (16 doctors, 28 nurses and 42 operating theatre staff). By December 2007, 660 fistula surgeries had been performed, with a 90 per cent success rate. Extensive networking among district hospitals, the private sector, NGOs and regional centres has also been enhanced, resulting in identification and referral of women living with fistula for treatment and care. Three training workshops were organized in Uganda in 2007 – two through Kitovu Hospital in Masaka and one through Mulago Hospital in Kampala. At Mulago, support was also provided for outreach service campaigns by the hospital staff to four sites: Kagadi, Gombe, Mityana and Mubende hospitals. A total of 331 fistula surgeries were completed and six doctors, six nurses and two anaesthetic assistants were trained. Outreach services have been particularly useful in conflict and post-conflict settings. In November 2007, UNFPA together with the staff of Hargeisa Group Hospital and the Ministry of Health Warrick Page/Panos Pictures districts. It is hoped that eventually the simplest cases will be handled at the district level. Each of the referral sites conducted two-week long obstetric fistula outreach service campaigns, where 65 health providers from 10 facilities received initial training. Consequently, 119 patients were treated, with a success rate of 90 per cent. As part of a decentralization strategy in Niger, the fistula programme expanded its geographic coverage, increasing capacity from four to six sites with necessary equipment and expertise to provide quality treatment. In 2007, 220 women were treated, with a success rate of 75 per cent. A team-based approach to capacity development was applied, allowing doctors, nurses, midwives, social workers and anaesthetists to be trained as a fistula management team. When establishing facilities for treatment services, there is often a need to refurbish wards and operating theatres and provide basic equipment and supplies for high quality care. At Malalay Hospital in Afghanistan, an operating theatre, recovery room, two post-delivery rooms, the health education unit and a nurse station were refurbished and equipped with # of women treated COUNTRY IN FOCUS: PAKISTAN UNFPA Executive Director, Thoraya Obaid visits Pakistan, where an estimated 5,000 new cases of fistula occur each year. UNFPA is supporting efforts to provide treatment and care and to rehabilitate fistula sufferers at seven regional centres in Islamabad, Lahore, Quetta, Karachi, Peshawar, Multan and Larkana. In 2007, 660 fistula patients were treated at the regional centres, with a 90 per cent success rate. The Campaign to End Fistula – 2007 Annual Report 9 TABLE 3. FISTULA CASES MANAGED ANNUALLY IN SELECTED COUNTRIES Country-sites One year of implementation Afghanistan–2 facilities Liberia–JFK Hospital, Monrovia and 6 outreach sites Two years of implementation Ghana–2 facilities Three years of implementation Burkina Faso Pakistan–7 facilities Four years of implementation Kenya–4 facilities Uganda–6 facilities a Number of Number of cases treated cases treated at time in of assessment 2007 partnership with the Galckayo Medical Centre, ongoing treatment services are being provided in Galckayo, an area in which several large communities of internally displaced people reside. Fistula treatment services were provided to 30 women there in 2007. 0 No data available in project sites 30 154 RENEWING HOPE In addition to the physical scars, women affected by obstetric fistula are left facing severe social consequences, among them isolation and stigma, abandonment by husbands and families, limitation of opportunities and psychological trauma. To ensure effective reintegration into society, UNFPA applies culturally sensitive rights-based approaches that respect the values in the community while also giving voice to the survivor’s rights. UNFPA partners with civil society organizations (CSOs) to help treated women reintegrate into society and resume full and productive lives. The strategy is based on the principle of addressing the survivor’s needs and wishes. Rehabilitation focuses primarily on rebuilding women’s self-esteem and feelings of self-worth through socio-economic empowerment, as well as literacy or vocational training, psychosocial counselling services, and health education to promote health-seeking behaviour. It is intended that these combined interventions will not only assist with reintegration into society but also contribute to preventing recurrence in future pregnancies. Perhaps the most fundamental support offered to women living with fistula comes in the form of community support and psychological counselling at the treatment site. Rehabilitation services were provided to 68 patients treated in Dhaka, Bangladesh in 2007. In partnership with the Government and the Bangladesh Women’s Health Coalition, a centre near the hospital provides women waiting for treatment with care that includes food, accommodation, counselling and a package of quality training on income-generating activities and functional education. A strategic partnership has been developed between the National Fistula Centre and the rehabilitation centre to ensure continuity of care. In addition, there is a community component aimed at raising community awareness, with periodic visits to follow up with patients and counselling of family members, among other elements. During the first outreach services campaign in November 2007 in Hargeisa, Somalia, each of 43 patients was 27 111 38a NA b 69 660 41 133 119 331 Baseline is from 2005, as exact data from earlier years are not available. b Exact information is not available, but most of the sites only treated a few cases each year. launched the first fistula treatment outreach campaign in Somalia. Beginning in October, awareness-raising activities were implemented in rural regions, encouraging women living with obstetric fistula to seek care at the Hargeisa Group Hospital. Guided by an expert Sudanese fistula surgeon, six Somali doctors, ten nurses and two anaesthetists were trained in fistulaspecific treatment and care. By mid-December, 43 surgeries had been performed. Additionally, in In spite of the challenges of the ongoing humanitarian crisis in Darfur region and the reconstruction setting of southern Sudan UNFPA Sudan, offices in North and West Darfur and in southern Sudan partnered with the local governments to implement fistula campaigns in El Fasher, Zalingei and Juba in 2007, resulting in the successful surgical treatment of 124 women and the training of more than 20 health-care providers. UNFPA also began negotiations with the state government of South Darfur on the rehabilitation of a wing of the Nyala Teaching Hospital to be used as a fistula treatment and care facility. 10 The Campaign to End Fistula – 2007 Annual Report TABLE 4. PERSONNEL TRAINED MANAGEMENT IN 2007 Country Afghanistan Bangladesh Benin Burkina Faso Côte d’Ivoire DR Congo Ghana Kenya IN FISTULA Nurses/ Doctors midwives 5 25 3 4 9 12 2 19 4 27 30 2 44 Other personnel 2 anaesthetists counselled by a clinical psychologist prior to surgery, during her recovery and upon her discharge from the hospital. Spouses accompanying the patients also participated in the counselling. NGOs are strategic entry points to reach out to communities through prevention and social reintegration activities. In the Democratic Republic of the Congo, UNFPA supported local NGOs in the provision of social reintegration services. Sixty-eight fistula survivors were provided with vocational training in embroidery, braiding and bread and soap making. Others were enabled to trade in the Kinshasa and Adi treatment centres. UNFPA supported the NGOs Dimol and Solidarité in Niger in the socio-economic empowerment of women, including a comprehensive package of economic empowerment and reproductive health services to prevent the recurrence of fistula. Through these partnerships 131 women were provided with small grants to carry out income-generating activities. In Mauritania, six NGOs were subcontracted to help more than 100 treated women reintegrate into society. Efforts focused on rebuilding the self-esteem of the survivors through counselling and psychosocial support, vocational training and income-generating activities. As part of its efforts to empower women, UNFPA supported Halima Gouroukoye, a fistula advocate from Niger, to raise awareness about fistula at the community level, help increase the demand for services at the health facility level, and advocate that community and traditional leaders support maternal health and abandon harmful traditional practices. In preparation for the regional fistula conference held in Mauritania, women who had lived with obstetric fistula were trained in messaging and advocacy. Today they play a critical role in creating demand for 46, including nurses, social workers and others 2 3 15 15 10 1 anaesthetist 1 anaesthetist Liberia Malawi Mali Mauritania Niger Pakistan Senegal 3 5 13 6 2 16 8 28 13 1 anaesthetist 7 anaesthesia assistants 2 anaesthetists 2 clinical officers 2 anaesthesia assistants 74 Somalia Sudan Uganda Total 6 7 6 151 10 10 6 209 COUNTRY IN FOCUS: SOMALIA In November 2007, UNFPA together with the staff of Hargeisa Group Hospital and the strong support of the Ministry of Health launched the first fistula treatment campaign in Somalia. By mid-December, 43 surgeries had been performed. In spite of the lack of training and provision of psychosocial care in the country, UNFPA was able to identify a clinical psychologist to provide each patient with counselling prior to surgery, during recovery and on discharge from the hospital. Spouses accompanying the patients were included in the counselling sessions. The Campaign to End Fistula – 2007 Annual Report 11 Ali Gaffar TABLE 5. PERSONNEL TRAINED IN REHABILITATION AND SOCIAL REINTEGRATION IN 2007 Country Burkina Faso Type of provider/training 153 paramedical staff trained in screening of fistula patients and psychosocial management 46 paramedics, including physiotherapists, counsellors and social workers from 10 sites 6 social workers in psychosocial support for women living with fistula 40 social workers in couselling for obstetric fistula rehabilitation 6 social workers Kenya Mali Nigeria munity understanding of maternal health. Conducted in four provinces, it surveyed 124 health units. Health system level barriers to emergency obstetric care services included frequent electricity cuts, shortages of potable water, inadequate transportation, unaffordable service fees and human resource shortages. Only 9.8 per cent of the health units surveyed were able to provide a caesarean section. Just one hospital, located in the capital, was capable of managing obstetric fistula. The study further identified three national doctors and two missionaries with fistula treatment expertise and 39 women living with fistula. Visiting surgeons have provided fistula treatment services in the Gambia[7] at the Royal Victoria Teaching Hospital since 2003, with an increase in cases each year. The needs assessment examined the magnitude of obstetric fistula, as well as the capacity to prevent and treat fistula and socio-cultural factors contributing to poor health. Both quantitative and qualitative analyses were used, including a survey of 5,000 households, facility assessments and interviews. The household assessment included 12,116 women of reproductive age. Twenty women living with fistula were identified, but only four women were willing to be interviewed due to the stigma and shame associated with the condition. Women relayed stories of waiting at home during prolonged labour from 5 to as many as 40 hours. Unaffordable and unavailable transportation was also reported, as were shortages of skilled staff at the facilities. Only one site offered comprehensive delivery care 24 hours a day. A fistula needs assessment report for Guinea [8] was released in July 2007. The assessment was national, including the country’s seven administrative regions and the city of Conakry. Data were collected through structured questionnaires and focus group discussions. The regions of Faranah, Kankan and Kindia reported the highest percentage of maternal complications following prolonged labour. Uterine rupture was the most common maternal complication (28.9 per cent) followed by fistula at 11 per cent. The study found the highest proportion of fistula cases in Faranah Senegal services as they seek out hidden women and help raise awareness about fistula at the community level. BROADENING THE KNOWLEDGE BASE Assessing the Needs To date, 36 countries have conducted fistula needs assessments. In 2007, reports of needs assessments were published from Angola, the Gambia, Guinea and Madagascar, as well as rapid assessments conducted in Somalia and Sudan, including the Darfur region and southern Sudan. In addition, India completed an epidemiological study with 1,500 women on chronic obstetric morbidities in Nasik District, Maharashtra, and Malawi conducted an assessment of the availability, accessibility, utilization and quality of the country’s emergency obstetric care. Findings from a selection of the assessments are detailed below. The needs assessment in Angola[6] aimed to estimate the extent of obstetric fistula and the health system’s capacity to offer emergency obstetric care and treat fistula and to analyse the social, economic and psychological consequences of fistula and com- [6] Angolan Ministry of Health/National Reproductive Health Programme and UNFPA, ‘Rapport sur l’Evaluation de la Situation des Fistules Obstétricales et Soins Obstétricaux d’Urgence en Angola’, December 2007. Gambia Department of State for Health Reproductive and Child Health Programme Unit, UNFPA and WHO, ‘Situational Analysis of Obstetric Fistula in the Gambia’, January 2007. Guinea Ministry of Public Health and UNFPA, ‘Analyse Situationelle des Fistules Obstétricales en République de Guinée’, July 2007. [7] [8] 12 The Campaign to End Fistula – 2007 Annual Report and Kankan. Multi-faceted causes and effects of fistula were found, and the recommendations emphasized the need for integrated interventions incorporating treatment and rehabilitation. To estimate the prevalence of obstetric fistula in Madagascar,[9] an exploratory study was conducted in 6 of the 22 health regions on the island. Over a period of six weeks, this examined the impact of fistula, knowledge among providers and the structural capacity for fistula management. In addition, the assessment completed a retrospective review of policies and programme plans addressing obstetric fistula. Findings included low levels of theory-based knowledge about fistula and very limited knowledge among traditional birth attendants regarding danger signs in pregnancy. Women from rural communities, especially isolated areas, were more likely to experience obstetric fistula. Lack of information and high levels of poverty compounded the connection between rural dwelling and increased risk of fistula occurrence. To complement needs assessments already completed in Somalia and Sudan, fistula intervention planning missions were undertaken in both countries in 2007. These missions sought specifically to examine the existing capacity in the Darfur region as well as in southern Sudan, and to assist UNFPA Somalia in the design of interventions within the context of the ongoing humanitarian situation. In southern Sudan and Darfur, significant need for prevention and treatment services was identified as well as potential additional sites for treatment care. The mission to Somalia laid the groundwork for an outreach service campaign in Hargeisa and ongoing fistula treatment services in Galckayo. Following the 2006 cross-sectional reproductive morbidity study in Nepal, questions on fistula were incorporated into the household survey conducted in six districts. The information generated will assist in bridging the gap in prevalence data and will be useful for further defining activities in 2008 and beyond. Programme Evaluations An external evaluation team assessed the 2004–2007 fistula programme period in Uganda in 2007, with a [9] specific focus on collaboration and coordination among partners. The findings provided data on the effectiveness of the strategies and activities and have informed plans for next steps in the country. The evaluation noted an increase in the national visibility of obstetric fistula, greater ability to deliver fistula services through outreach service campaigns and partially through routine services – illustrated by a consistent increase in number of surgeries provided each year and capacity development through training and equipment provision – and the creation of a national coordination mechanism. Challenges included issues related to the poor quality of equipment such as operating beds and lamps, the lack of standardized fistula training curricula, uncertainty about national fistula treatment protocols, and coordination. It recommended making the fistula programme more comprehensive, with an emphasis on increased prevention efforts, greater integration with the maternal health programme and support for social reintegration services. Institutional capacity development, stronger reporting mechanisms and supervision systems and improved coordination efforts were also recommended by the team. Chad began its fistula programme in 2002, and five years after its initiation the UNFPA country office embarked on an external evaluation. The findings showed increased treatment care at the national hospital and through outreach service campaigns. Several health professionals had been trained in fistula treatment and the national hospital was equipped and rehabilitated to integrate fistula treatment in the maternity unit. Several outreach campaigns were organized in north-eastern Chad with great success and involvement of the local community. Due to institutional constraints, however, the activities remained as pilots rather than being scaled up to national level. All but one of the trained doctors had been transferred to other districts where they were unable to continue surgeries. Political instability resulted in the suspension of not only outreach service campaigns but also the equipping of four additional centres. The evaluation recommended strengthening the national strategy by elaborating a plan of action, creating a national technical committee and building stronger partnerships. Sharing Experiences and Knowledge The Campaign to End Fistula makes a practice of Madagascar Ministry of Health, Family Planning and Social Protection and UNFPA, ‘Analyse de la Situation de Base Sur L’Ampleur et Les Impacts des Fistules Obstétricales à Madagascar’, September 2007. The Campaign to End Fistula – 2007 Annual Report 13 disseminating lessons learned and encourages sharing valuable experience among partners on all aspects of prevention, treatment and reintegration. The Campaign seeks to identify gaps in research and to include a wide variety of perspectives to ensure the most holistic approach to the issue. The Africa Regional Conference on Fistula and Maternal Health (Nouakchott, Mauritania, 10–13 December 2007) brought together over 150 participants from 40 countries and partner organizations. This provided an opportunity for colleagues to share experiences, lessons learned and challenges in obstetric fistula efforts. Outcomes of the meeting include: a common understanding of effective approaches for partnership with CSOs, the media and fistula advocates; laying of the groundwork for a regional network of CSOs working on fistula and maternal health; discussion of effective approaches to integrate fistula into existing national frameworks, particularly National Roadmaps; and production of a conference documentary film. In partnership with Family Care International, the Campaign produced an advocacy publication entitled Living Testimony: Obstetric Fistula and Inequalities in Maternal Heath, [10] which highlights key findings of country-level needs assessments from 29 countries in Africa, Asia and the Arab States from 2003 to 2006. This unique publication documents the voices of fistula survivors and brings their stories to the global community. Along with the forthcoming accompanying toolkit, the publication provides important guidance for policymakers, programmers and researchers to strengthen fistula elimination programmes. UNFPA also maintained and updated an internal web-based knowledge asset on obstetric fistula programming. The asset provides technical guidance and tools on fistula programming, with distinct sections for each stage of the programming cycle. In addition, an internal initiative promoting documentation of country-level lessons learned in the area of maternal health was launched. Addressing Research Gaps In response to the acknowledged gaps in obstetric fis- tula data, Johns Hopkins University, UNFPA and WHO have embarked on a landmark research study entitled ‘Prognosis, Improvements in Quality of Life and Social Integration of Women with Obstetric Fistula after Surgical Treatments’. The research will be conducted over a two-year period in seven countries: Bangladesh, Benin, Ethiopia, Mali, Niger, Nigeria and Sudan. The study aims to measure clinical and quality of life outcomes for obstetric fistula treatment, with follow-up at 3, 6 and 12-month intervals post-surgery. The data will be used to inform technical guidance and support evidence-based advocacy, and the study provides a unique opportunity to compare obstetric fistula outcomes both within and across countries. The data will also be used to validate an international standardized fistula classification system. One of the objectives of the Data, Indicators and Research committee of the international Obstetric Fistula Working Group (OFWG) is the development and dissemination of indicators to capture the need for obstetric fistula care and measure progress in fistula programming. Through a highly consultative process with expert surgeons, ministries of health, NGOs and experts in monitoring and evaluation, a priority list of indicators has been generated, reviewed and incorporated into the current obstetric fistula indicator frameworks. Moving forward, the indicators will be compiled into a short, user-friendly publication. In Asia, UNFPA and the Indian National Institute of Medical Statistics organized a regional meeting in Delhi in April 2007 to review methodologies to measure prevalence of reproductive morbidities and to propose methodologies for measuring fistula prevalence. Experts in epidemiology, biostatistics and survey design and sampling from Afghanistan, Bangladesh, India, Pakistan and global organizations exchanged experiences in different methodologies for the measurement of obstetric fistula and developed a plan to fill data gaps on prevalence in the region. Additionally, several countries are undertaking initiatives to strengthen monitoring and evaluation. In Ghana, all cases of obstetric fistula treated in any district, regional or teaching hospitals in the country will now be reported through a new Reproductive and Child Health database developed with support from UNFPA. In Malawi, representatives from the Ministry of Health are actively promoting the integration of obstetric fistula into the national health information system. [10] Available at http://www.endfistula.org/download/ living%20testimony_english.pdf. 14 The Campaign to End Fistula – 2007 Annual Report ADVOCACY Since the launch of the Campaign in 2003, advocacy has been key to draw support for this once-neglected condition. Effective promotion of the Campaign’s aims has generated significant interest from a wide variety of partners, ranging from donor governments and national and international NGOs to the private sector and celebrity spokespeople. Increasingly, the Campaign is supporting and relying on the first-person perspective of fistula advocates – strong, powerful women who draw on their compelling personal experiences living with fistula – to convince communities and policymakers alike of the right to treatment and the importance of preventing maternal death and disability. Advocacy at the National Level The media is a powerful tool to spread and promote prevention messages within communities. It is widely used to raise awareness about the issue, both in the form of news information as well as through popular and effective ‘infotainment’. In Pakistan, fistula awareness messages including health promotion, family planning and skilled attendance are disseminated widely through electronic and print media nationwide. A video on obstetric fistula and its consequences was screened during a sensitization workshop conducted in Zambia targeting journalists to provide information on reproductive health and rights. Throughout the Democratic Republic of the Congo, trained promoters sensitize communities to the importance of maternal health services in diagnosing women living with fistula and of refering them to centres providing treatment. In Niger, 16 sensitization sessions were organized in regions with high prevalence of obstetric fistula. Some 10,000 women and men, including religious and traditional leaders, participated in the discussions following the screening of films highlighting the causes and consequences of obstetric fistula and powerful testimonies from fistula advocates. Such gatherings provided important opportunities for health providers and midwives to stress to the audience the advantages of pre-natal care and assisted delivery by qualified health staff. Radio continues to be an important means of communication to reach the populations most affected by fistula. It was utilized in many countries across the three regions, including Côte d’Ivoire, Ghana, Liberia, Pakistan and Sudan, to raise awareness on maternal health and obstetric fistula and to inform women living with fistula about available treatment and care. In Nigeria, 10 fistula survivors were trained as advocates to participate in radio programmes on maternal health through a joint effort with the Population Media Centre. Key partnerships have been formed with the media in Ghana through the national Media Communication and Advocacy Network. Six meetings were held in 2007 to discuss obstetric fistula, and a capacity-building workshop was organized, strengthening participants’ resolve to support advocacy on obstetric fistula and resulting in increased reporting on the issue in print and electronic media. Sensitization talks, public education programmes and social religious gatherings were organized in three regions during the year. Over 600 people (from the media, CSOs, religious and women’s groups and community leaders) received information on fistula, and three short documentaries on obstetric fistula were aired during prime time on national television. Miss Ghana@50 (Frances TakyiMensah) has become an advocate for resource mobilization, awareness creation, treatment and rehabilitation for obstetric fistula in Ghana. Her year-long project on fistula will be presented at the Miss World beauty pageant in October 2008. Global Advocacy In 2007, UNFPA continued to raise awareness of obstetric fistula and the global Campaign to End Fistula through a variety of media, including the Campaign website (www.EndFistula.org/; www.fistules.org/), a biannual newsletter, videos and a new campaign brochure. The Campaign was covered more than 50 times in international media – print, television, online and radio – including many top tier global news outlets such as the BBC, Reuters and Sky News. The Campaign collaborated with partners on three major advocacy events in 2007: the Women Deliver conference, a public awareness campaign in Belgium and a Campaign Spokesperson trip to Nigeria. Women Deliver Conference The October 2007 Women Deliver conference brought together over 1,800 participants from 109 countries to spread the message ‘Invest in Women – It Pays’. To The Campaign to End Fistula – 2007 Annual Report 15 FISTULA ADVOCATES AT WOMEN DELIVER UNFPA is committed to bringing forward the voices of fistula survivors – empowering them to speak out and assisting in creating platforms for them to be heard. In October 2007, UNFPA sponsored the participation of a delegation of six fistula survivors from across Africa in Women Deliver, an international conference focused on curbing pregnancy-related death and disability. Each woman had the opportunity to tell her story in panels, plenaries and media interviews, building awareness – on a global platform – of this preventable and treatable injury and personifying the inequities in maternal health. “I came here to raise awareness of poor maternal services in southern Sudan,” Marietta Kiden told United Nations Radio. “I pray that no one else will suffer from this condition.” Niger echoed the sentiment: “For a long time, I had hoped to speak out in public. I feel so relieved – like a burden that was there before has been lifted.” While in London, the delegation attended a special reception with five U.S. Congresswomen, hosted by the United Nations Foundation. “For 12 years, I suffered rejection, isolation and discrimination,” said Kenyan fistula advocate Sarah Omega Kidangasi, who was invited to share her story at the reception. “I didn’t have a place in society.” Since Women Deliver, many of the delegates have continued their advocacy. Halima Gouroukoye is working closely with Dimol, a local NGO, to do communitylevel awareness Prior to the raising. She conference, the shared her exdelegation of periences at fistula advothe Regional cates particiFistula Conferpated in a ence in Maurithree-day adtania and the vocacy work2008 Commisshop hosted by sion on the UNFPA and the Status of Centre for DeWomen at the David Rose/Panos Pictures velopment and United Nations Fistula survivors and their companions at the Women Deliver conference. Population in New York. Activities (CEDPA). Following group sessions on Fatima Lawal Aliyu of Nigeria has been an active leadership, self-identity and public speaking, the participant in community mobilization projects in women reported feeling a sense of empowerment northern Nigeria, and Sarah Omega Kidangasi of and an eagerness to share their stories with a wide Kenya participated in May 2008 events at the audience. United Nations in New York and on Capitol Hill “I am very happy. I can now speak bravely in front in Washington, DC. UNFPA will continue to supof people,” said 62-year-old Martina Labia, a port the advocacy efforts of fistula survivors and mother of 11 who lived with fistula for 35 years. identify new forums in which their voices can be Fistula advocate Halima Gouroukoye, 18, from heard at both global and national levels. 16 The Campaign to End Fistula – 2007 Annual Report ensure that issues related to obstetric fistula were taken into account and to share experiences from the Campaign to End Fistula, UNFPA collaborated with partners in the OFWG to sponsor two panels. One session explored the importance of fistula as a visible reminder of inequity in maternal health and what is being done to address it. The second panel focused on lessons learned from campaigning for a neglected issue. Speakers on the panels came from Bangladesh, Kenya, Nigeria, Uganda, United Republic of Tanzania and several international organizations. UNFPA also supported the first-ever delegation of fistula survivors to attend the conference (see ‘Fistula Advocates at Women Deliver’). Raising Awareness in Belgium Building on the success of a July 2006 public awareness campaign in the United Kingdom, UNFPA sponsored a similar campaign in Belgium targeting the general public and European policymakers. Several private sector and civil society partners contributed substantial in-kind support to this effort. Considerable visibility was generated through a month-long advertising drive across Belgium in May 2007. Speeches and interviews with Campaign Spokesperson Natalie Imbruglia and UNFPA Goodwill Ambassador Goedele Liekens resulted in articles on fistula and the Campaign to End Fistula in multiple national and international newspapers, magazines and journals, as well as significant national and global television coverage. Through preand post-campaign survey results, UNFPA learned that 79 per cent of the target audience reached reported better/increased understanding of fistula as a result of the campaign; of those reached, 97 per cent agreed that the international community should raise awareness about fistula. As part of the campaign in Belgium, UNFPA helped bring this issue to the attention of a variety of decision makers and stakeholders by co-sponsoring special sessions on fistula and maternal health at the European Parliament and the Belgian Senate. The event at the European Parliament resulted in a draft written declaration, signed by women Members of Parliament from all political parties, urging the European Commission and the Council of the European Union to support the Campaign. In recognition of its efforts to raise awareness of fistula in Belgium, UNFPA received the European Voice 2007 ‘EV 50 Award’ and a monetary prize of ¤32,000. Celebrity Spokesperson Visit to Nigeria In December 2007, Campaign Spokesperson Natalie Imbruglia visited Kano and Katsina states in northern Nigeria, where she met women and girls directly benefiting from the fistula prevention and treatment project she has launched jointly with UNFPA and Virgin Unite. The visit garnered extensive press coverage in global news outlets, including Reuters, Sky News, MTV and the BBC World Service, and was covered widely by the national media. UNFPA Goodwill Ambassador Goedele Liekens also participated in the mission and produced a report for Dag Allemaal, a weekly magazine with more than 1.5 million readers. PARTNERSHIPS Obstetric fistula provides a good example of the need for partnerships and a multi-sectoral response to achieve the international health goals. It touches on health, education, economics, transportation, communications and social and cultural norms. Consequently, all levels of the Campaign strive to forge solid partnerships encompassing a range of expertise and perspectives. Partnerships at National Level All of the programmes at national level are conducted in partnership with the government, public and private health facilities and civil society. National partnerships Burntwood School, a large girls’ school in south London, made the Campaign to End Fistula its chosen charity for 2006–2007. An appeal was launched to the student body in 2006, and over the course of the year the girls raised more than $3,000 for the Campaign. In addition, the school raised awareness of the issue in the local press. Burntwood continues to support the Campaign through fundraising activities in 2008. The Campaign to End Fistula – 2007 Annual Report 17 in the form of task forces, networks and technical working groups continue to function in countries such as Kenya, Malawi, Niger and Uganda, providing strategic guidance and monitoring national fistula programming. A National Fistula Working Group has been established in Pakistan, and UNFPA, EngenderHealth and the Government are developing a similar partnership in Bangladesh. Partnerships with civil society have become increasingly important in the Campaign to spread awareness and mobilize communities on maternal health, and to identify women living with fistula, assist them to seek treatment and facilitate their social reintegration. In Côte d’Ivoire, a local NGO, Génération Femme du 3ème Millénaire, assists in identifying women who are living with fistula in the communities. One of the outreach service campaigns in Burkina Faso was carried out in partnership with the national affiliate of the International Federation of Business and Professional Women. For women in Liberia, international NGOs such as Merlin, the International Rescue Committee and Doctors Without Borders have been instrumental in providing transport to health facilities that provide treatment. CSOs in Mauritania have launched a special initiative to fight against fistula in the country. In Niger, a collaborative effort with Cinéma Numérique Ambulant (Mobile Digital Cinema) is spreading the word about maternal health and obstetric fistula. Partners in Zambia include faithbased hospitals, which make up the majority of the sites providing treatment and care. Global Partnerships Global efforts to eliminate fistula are coordinated among partners via the international OFWG. Established in 2003, the group is comprised of approximately 20 institutional members including international and regional NGOs, universities, health facilities and United Nations agencies who work to ensure coordination of efforts to eliminate fistula. UNFPA serves as the secretariat and ensures regular communication among the members. Several sub- groups are coordinated by UNFPA and partners as well, including the aforementioned Data, Indicators and Research committee led by the U.S. Centers for Disease Control; a group on Training and Treatment led by the Addis Ababa Fistula Hospital; and a group on Partnership led by UNFPA. As noted throughout this report, UNFPA has collaborated with a range of partners, from international NGOs such as Family Care International to professional associations like the International Federation of Gynaecology and Obstetrics to private sector organizations such as Virgin Unite to academic institutions like Johns Hopkins University. These partnerships have enabled the development of materials for advocacy and technical guidance, the training and empowerment of fistula survivors, new research and the mobilization of support for efforts to end obstetric fistula. Support for the Campaign Since its initial launch, the Campaign to End Fistula has secured more than $25 million in contributions from a wide variety of donors, including governments, the private sector and private individuals. In 2007 alone, the Campaign raised over $8.5 million in new funding. Donors in 2007 included AGFUND (the Arab Gulf Programme for United Nations Development Organizations), Americans for UNFPA, the Autonomous Community of Catalunyaa (Kingdom of Spain), Iceland, Ireland, Luxembourg, One by One, Poland, Norway, the Republic of Korea, Spain and the United Nations Foundation. Advocacy activities and fundraising events generated donations and pledges of more than $1 million. Virgin Unite and Johnson & Johnson also continue to offer generous private sector support. UNFPA core resources at global and national levels were also allocated to the Campaign to End Fistula in 2007. In addition to funds raised at the global level, guidance has been provided to UNFPA country offices to facilitate mobilization of resources at the national level. 18 The Campaign to End Fistula – 2007 Annual Report III. CHALLENGES D espite increased opportunities for broadening the scope of fistula elimination efforts, clear challenges persist in the implementation of effective programmes that address fistula in a comprehensive manner. Prevention of fistula, the ultimate solution to this public health problem, continues to remain the largest challenge. Inadequate political and financial support hampers the ability to systematically address the issue. In addition, sustained health system investments are required to provide the 24-hour care that is needed for deliveries as well as improved access to family planning. Limited capacity to respond to increased demand at the facility level poses a key challenge in terms of prevention and treatment strategies as well as ethical considerations for programme implementation. Awareness-raising interventions lead to an increase in the number of patients seeking treatment. However, the limited capacity of existing infrastructure results in long waits for fistula operations. Despite training and equipping facilities, services are often not available on a routine basis. In many locations, fistula treatment interventions are offered only during annual or bi-annual missions of a visiting surgical team, resulting in prolonged delays for women awaiting treatment. The scarcity of human resources continues to be an overwhelming obstacle in achieving results in many countries. Insufficient training and lack of motivation or incentives constitute key challenges in retention of health staff and provision of high quality care. Additionally, the investment in training staff in fistula-specific care may be lost if they are transferred to new locations that lack the supporting infrastructure to offer such care. Training of new staff creates delays in the treatment process. Globally, few doctors are being trained in fistula-specific care. Strengthening social reintegration and rehabilitation efforts remains an area of programmatic challenge. Reintegration has yet to be clearly defined, resulting in ambiguity of parameters in post-operative care, and rehabilitation interventions are often encumbered by weak institutional capacity, including lack of skills or knowledge about fistula among social workers. Patient follow-up remains especially difficult, and data collection and evaluation are all but absent, due to weak linkages between the communities and local hospitals, as well as the rural and remote locations of women who may choose to remain anonymous. In some countries, external factors can constitute important obstacles for the implementation of fistula programmes. In Uganda, the outbreak of an Ebola epidemic in the second half of 2007 forced the cancellation of some of the fistula outreach services. Political instability surrounding the election campaigns in Kenya resulted in a low turnout for treatment. IV. LESSONS LEARNED The media constitutes a powerful tool for social change. Targeting decision makers, community leaders and the wider population, effective partnerships with the media result in a better understanding of fistula, thereby reducing social exclusion and enhancing access to treatment services. Additional efforts are needed to map out the communication resources available and tailor messaging for a variety of audiences. The voices of fistula survivors represent a tremendous asset for programming. Given leadership and media training skills, fistula advocates can be good spokespersons for maternal health at all levels. Many already belong to CSOs or can be connected to organizations that will provide them with a sustainable platform from which to advocate. Increased involvement of fistula survivors can contribute to the promotion The Campaign to End Fistula – 2007 Annual Report 19 of community ownership and programme sustainability; however, more careful discussion is needed on how to ensure that fistula advocates are involved as equal partners in the effort to eliminate fistula. Increasing access to fistula treatment and care requires a health systems approach. While infrastructure improvements, provision of equipment and supplies and training for health professionals have been vital to increasing access, other elements will be needed to ensure that these services are routinized over the long term. This includes ensuring the necessary administrative support within facilities for an enabling environment, addressing motivation and retention of trained health professionals, establishing continuous quality improvement mechanisms, strengthening data collection and referral systems and improving networking and linkages between sites that provide fistula treatment. Strengthened collaboration with CSOs represents an area of great potential for innovative and effective partnerships to mobilize support both for prevention of fistula and improved maternal health as well as effective social reintegration. The Campaign will need to pay increased attention to determine their strengths and comparative advantages in view of assessing the gaps and capacity-building needs. V. MOVING FORWARD he Campaign is now in full swing, with the majority of countries taking concerted action to bring about the elimination of fistula. The year 2008 will focus on consolidating and learning from the progress to date, including contributing to the launch and growth of the new Thematic Fund for Maternal Health. Efforts will continue to integrate fistula into reproductive health plans and programmes, particularly those related to maternal health, while maintaining some specificity so that this once-overlooked issue does not again fall prey to neglect. Plans for 2008 call for greater work with fistula advocates and civil society to spread the message of equitable maternal health access for all and to mobilize communities on improving maternal health. In the area of treatment, strategies will focus on improving the quality of care and training as well as increasing access to care through decentralization of services and outreach treatment campaigns. The newly launched research study will begin to fill some of the major gaps in knowledge as well. A mid-term evaluation of the Campaign will also be undertaken to document lessons learned and assist in adjusting strategies for national programmes on obstetric fistula at policy, service and community levels. The Women Deliver conference closed with the T commitment to invest in women, as illustrated by the pledge made by 70 cabinet ministers and parliamentarians to make the achievement of MDG 5 “a high priority on the national, regional, and international agendas”. Now this commitment needs to be translated into action. And there is much still to be done. Countries recently met in South Africa to review progress towards MDGs 4 and 5. The participants found that in the 68 countries that account for 97 per cent of maternal and child deaths, only 16 were on track to reach these MDGs. Not surprisingly, 70 per cent of these countries are also part of the Campaign to End Fistula and have maternal mortality ratios greater than 300 per 100,000 live births. The picture fortunately is changing as support grows for maternal and child health. In the past few years, donor funding for maternal health, including obstetric fistula, has begun to increase and political support from governments around the world has grown. However, these advances need to be maintained and accelerated to a rate of $6 billion per year for maternal health services and $1-2 billion per year for family planning to truly make a difference in women’s survival. To do so would help bring the world closer to the day when safe and healthy childbirth is a reality for all women, not just the lucky few. 20 The Campaign to End Fistula – 2007 Annual Report ANNEX DONORS TO THE CAMPAIGN TO END FISTULA, 2007* GLOBAL LEVEL Donor Americans for UNFPA1 Catalunya, Autonomous Community of, Kingdom of Spain Iceland Ireland2 Korea, Republic of Luxembourg Norway Poland Private Contributions3 Spain4 United Nations Foundation Virgin Unite Grand Total * 1 2 (US$) 116,831 516,224 100,000 737,463 500,000 466,667 3,642,987 40,000 4,654 1,474,926 180,952 246,956 8,027,660 Provisional, subject to certified financial statements issued by UNFPA. Contributions received from individuals in the U.S.A. The contribution made to the Fistula Thematic Trust Fund was received by UNFPA on 18 December 2007 and will therefore be applied to 2008 Campaign activities. These private contributions were made by individuals directly to UNFPA. The contribution made to the Fistula Thematic Trust Fund was received by UNFPA in November 2007 and will be applied to 2008 Campaign activities. 3 4 The Campaign to End Fistula – 2007 Annual Report 21 CAMPAIGN TO END FISTULA: NEW ALLOCATIONS, 2007* 2007 Allocations, in US$ Country Level Funding Source Country/Global Activity Bangladesh Congo Côte d’Ivoire Democratic Republic of the Congo Equatorial Guinea Kenya Liberia Malawi Mali Mauritania Niger Nigeria Uganda Zambia Country Sub-Total 103,659 180,000 321,000 519,000 112,600 135,000 20,000 552,120 267,500 174,046 173,340 208,172 90,513 246,956 141,417 47,952 83,063 3,376,338 Luxembourg Sweden Fistula Thematic Trust Fund Fistula Thematic Trust Fund Sweden Luxembourg Sweden Sweden Fistula Thematic Trust Fund Fistula Thematic Trust Fund Luxembourg Sweden EngenderHealth Virgin Unite Fistula Thematic Trust Fund EngenderHealth New Zealand Global/Regional Level Africa Division (including Programme Specialist) Asia and Pacific Division Division for Arab States, Europe and Central Asia (including Project Analyst) Media Services Branch (including Media Specialist) Resource Mobilization Branch (including RM Specialist) 950,500 50,000 148,730 22,275 214,000 230,308 25,928 58,798 79,000 47,000 260,063 180,952 24,842 2,292,396 5,668,734 Fistula Thematic Trust Fund Sweden Fistula Thematic Trust Fund Australia Fistula Thematic Trust Fund Sweden Fistula Thematic Trust Fund Americans for UNFPA Luxembourg Fistula Thematic Trust Fund Sweden United Nations Foundation EngenderHealth Technical Support Division (including Technical Specialist) Global Sub-total Grand Total * This table does not include multi-year allocations made in previous years, such as the United Nations Human Security Trust Fund and Austrian Funds for Ethiopia. Figures are provisional, subject to certified financial statements issued by UNFPA. 22 The Campaign to End Fistula – 2007 Annual Report CAMPAIGN TO END FISTULA: EXPENDITURES, 2007* 2007 Programme Funds Country Level 2007 Expenditure Country/Division Donor Balance Bangladesh Burkina Faso Congo Côte d’Ivoire Democratic Republic of the Congo Equatorial Guinea Luxembourg Sweden Luxembourg Sweden Sweden Fistula Thematic Trust Fund Catalunya Sweden Fistula Thematic Trust Fund Luxembourg Sweden Americans for UNFPA Johnson & Johnson New Zealand Austria Luxembourg Sweden Sweden Fistula Thematic Trust Fund Fistula Thematic Trust Fund Human Security Fund Luxembourg Luxembourg Sweden EngenderHealth Australia Human Security Fund Sweden 103,659 50,000 64,487 14,344 201,350 321,000 1 292,600 321,000 135,000 0 58,495 139,314 310,561 193,984 101,950 4,856 545,236 267,500 321,431 163,500 173,206 2 198,630 126,001 21,001 933,975 1 206,079 178,695 199,944 3 68,267 47,000 48,174 106,831 55,186 47,776 15,265 13,014 201,412 255,756 (14) 311,680 341,310 127,054 (3,557) 48,920 81,579 227,066 121,711 41,377 4,970 549,822 178,682 117,908 90,114 178,552 (685) 134,714 124,348 21,228 14,641 (1,218) 82,075 138,985 199,944 (3,629) 39,270 46,935 0 12,508 48,473 2,224 49,223 1,330 -62 65,244 15 (19,080) (20,310) 7,946 3,557 9,575 57,735 83,495 72,273 60,573 (114) (4,586) 88,818 203,523 73,386 (5,346) 687 63,916 1,653 (227) 919,334 1,219 124,004 39,710 0 3,632 28,997 65 48,174 94,323 Eritrea Ethiopia Ghana Guinea Kenya Liberia Malawi Mali Mauritania Niger Nigeria Pakistan Senegal Uganda Zambia Virgin Unite Fistula Thematic Trust Fund Human Security Fund Canada Luxembourg EngenderHealth Australia New Zealand * Provisional, subject to certified financial statements issued by UNFPA. The Campaign to End Fistula – 2007 Annual Report 23 CAMPAIGN TO END FISTULA: EXPENDITURES, 2007*(CONTINUED) 2007 Programme Funds 2007 Expenditure Country/Division Donor Balance Global/Regional Level Australia Africa Division Asia & Pacific Div. Division for Arab States, Europe and Central Asia Australia Media Services Branch Resource Mobilization Branch Luxembourg Fistula Thematic Trust Fund Sweden Fistula Thematic Trust Fund Sweden Australia EngenderHealth Technical Support Division Johnson & Johnson Luxembourg Sweden United Nations Foundation Grand Total 22,275 82,917 124,593 240,787 25,928 54,847 10,700 41,746 1 17,000 278,267 167,017 8,714,316 7,313 53,593 80,273 235,448 25,928 54,847 0 46,716 (1,594) 15,918 254,672 151,586 6,416,312 14,962 29,324 44,320 5,339 0 0 10,700 (4,970) 1,595 1,082 23,595 15,431 2,298,005 Fistula Thematic Trust Fund 148,730 132,313 16,417 Luxembourg Fistula Thematic Trust Fund Sweden 0 150,000 1,295,335 136,096 709 164,246 1,245,373 134,981 (709) (14,246) 49,962 1,115 * Provisional, subject to certified financial statements issued by UNFPA. 24 The Campaign to End Fistula – 2007 Annual Report ACRONYMS CSO DRC MDG NGO OFWG UNFPA UNICEF WHO civil society organization Democratic Republic of the Congo Millennium Development Goal non-governmental organization Obstetric Fistula Working Group United Nations Population Fund United Nations Children’s Fund World Health Organization