Acknowledgement

Challenges and Lessons Learnt

The main challenges and lessons as highlighted by almost all countries under each priority area relate to inadequate resources, weak health systems, inequities in access, weak multisector response, low priority accorded to health in national development plans, and inadequate data. These are echoed, as well, in the 2008/09 UNFPA Report on the MPOA Review (UNFPA, 2008).

National Level Challenges

The implementation of the Maputo Plan of Action encountered significant challenges at national level. Arranged by broad categories, these include the following:

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  Human resources
  

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  Inadequate health workforce as a result of limited training, lack of incentive particularly to work in rural settings, quick turnover and migration.
  
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  Shortage of skilled health workforce, especially midwives.
  

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  Weak health systems
  

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  Weak general infrastructure.
  
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  Weak intersector cooperation.
  
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  Inadequate involvement of communities.
  
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  Limited centres offering comprehensive services.
  
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  Low integration and decentralization.
  
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  Weak and inadequate health information systems.
  
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  Conflicting priorities with other health programmes.
  
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  Difficulty in setting standards and removing barriers such as user fees in the private sector.
  
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  Weak management and coordination.
  
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  Limited operational research.
  
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  Inadequate implementation of recommendations on mortality reviews.
  
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  Poor service delivery and under-utilization of existing services.
  
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  Under-utilization of contraceptives including condoms.
  
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  Reduced access to health services because of poor infrastructure and communication.
  
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  Low utilization of available services by communities.
  
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  Problems related to procurement and distribution leading to stock-outs especially at district level.
  
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  Poor health outcomes resulting from underlying diseases and conditions such as HIV/AIDS and malaria, especially among pregnant women.
  

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  Inadequate health financing
  

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  Limited financial resources.
  

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  Limited national budgets with heavy donor dependency.
  
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  Poor planning and non-rational use of available resources.
  
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  Among the various lessons learnt during the implementation of MPOA is that sexual rights are compromised through cultural values and practices that limit women’s understanding of their sexuality and thus reduce their ability to make informed decisions.
  
  Shortage of funds as a result of the global financial crisis.
  

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  Poor coordination of interventions
  

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  Continued existence of vertical programmes.
  
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  Weak political leadership.
  
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  Inadequate community mobilization.
  
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  Weak coordination of partnerships.
  

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  Unfavourable legislation
  

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  Limited implementation of legal instruments, some of which are archaic or outdated in many countries.
  
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  Lack of commitment by policy makers.
  
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  Safe abortion not supported by laws.
  

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  Traditional harmful practices
  

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  Gender-based violence in a number of forms.
  
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  Negative socio-cultural attitudes towards SRHR.
  
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  Low male support and participation in SRHR issues.
  

• Behaviour change communication

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  High rates of teenage pregnancies and unplanned pregnancies.
  
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  Limited programmes for both in-school and out-of-school youth.
  
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  Inadequate community mobilization (men and women), including the use of IEC.
  

Lessons Learnt

Among the lessons learnt were those that either facilitated or impeded progress towards to the implementation of the Maputo Plan of Action on SRHR.

Lessons from Zambia:

Maternal, newborn and child health should be put as a priority second to human resources for health if MDG 4 and 5 are to be attained.

Facilitating Factors

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  Partnerships at all levels have contributed significantly to the achievements made by Member States and the AU in rolling out the Maputo POA. Increased partnerships with good coordination, supervision and harmonization (including regional cooperation), all following the same road map, are important for scale-up and rational use of scarce resources.
  

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  Promotion of integration with comprehensive coverage of all SRH services (including family planning) at all levels ensures the implementation of a single focused plan.
  

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  Leveraging resources from different programmes that are better funded has helped promote SRHR, while sector-wide approaches provide predictable funding for services.
  

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  Developing and implementing the road map for accelerating the reduction of maternal, neonatal and child mortality (including maternal death reviews) provides information to use as a resource mobilization tool.
  

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  Resources alone are not enough, however. In addition, there should be a plan for the rational use of resources, as well as for enhancing demand as implied by the unmet need for family planning.
  

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  Communities are ready and willing to accept and institute behaviour change, and to be involved in promoting their own health. All they need is a peaceful environment and facilitation. Actions should be geared towards both men and women.
  

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  Micro-finance projects, especially for women, are a useful tool for promoting maternal and child health.
  

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  The fight against violence and harmful traditional practices is slowly but surely taking off in many countries, some of which are revising or developing related laws/instruments.
  

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  The launch of CARMMA is creating more awareness, and the UN and other agencies’ support for this or other programmes makes a difference.
  

Impeding Factors

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  Weak health systems continue to be a major challenge to quality service delivery.
  
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  Top-down (vertical) approaches negatively affect community participation.
  
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  The lack of a dedicated budget for SRH has a negative impact on service delivery.
  
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  Inadequate legislation on safe abortion or criminalization of abortion does not reduce the incidence of abortion.
  

Recommendations to Address the Challenges

In line with the identified challenges, a number of recommendations are made to implement SRHR strategies more comprehensively. By general category, these included the following:

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  Lessons from Kenya:

  Government stewardship and ownership are imperative.

  
  Human resources
  

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  Ensure availability of adequate skilled human resources for SRH.
  
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  Motivate health workers and put retention incentives in place.
  

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  Health systems
  

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  Promote adequate, integrated and comprehensive health systems.
  
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  Strengthen health information with emphasis on establishment of M&E offices/committees.
  
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  Promote research as a priority.
  
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  Ensure that emergency preparedness and response plans for undertaking activities upon demand are always in place.
  

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  Service delivery
  

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  Strengthen emergency obstetric care.
  
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  Make adequate funding available for reducing unsafe abortion.
  
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  Improve logistics and commodity management and integrate HIV/STI and other disease programmes into reproductive health.
  
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  Mobilize the community – including men – to participate in and utilize available services.
  
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  Lessons from Sudan and Uganda:

  Availing services is necessary but not sufficient for improving access to services: Demand has to be enhanced as shown by the unmet need for family planning services.

  
  
  Include SRH products and commodities in the list of essential medicines.
  

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  Health financing
  

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  Strengthen financial systems with resource mobilization.
  
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  Increase the percentage of national budget resources allocated to health care to at least 15%, as called for in the 2001 Abuja Declaration.
  

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  Coordination of interventions
  

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  Ensure national ownership – i.e., government not donors – of the reproductive health programme, including regulating the health sector.
  
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  Promote coordination through the establishment of Intersector Committees.
  
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  Improve coordination and supervision of people, activities and expenditures.
  

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  Legislation
  

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  Undertake advocacy towards the adoption and implementation of more tolerant laws and instruments.
  
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  Decriminalize abortion in order to promote SRHR and prevent back street abortions.
  

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  Harmful traditional practices
  

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  Put in place or revise appropriate legislation as might be required in certain instances, in such matters as gender-based violence (including FGM), abortion, early marriage and inheritance.
  
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  As a corollary, scale up IEC campaigns against gender-based violence including harmful traditional practices.
  

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  Behaviour change communication and education
  

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  Promote the development of strong school health programmes.
  
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  Increase the focus on the empowerment of youth and adolescents (both in and out of school) through SRHR education.
  
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  Promote and facilitate communication among health care providers including peer educators at various levels.
  
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  Promote community mobilization and participation, including income generation, and with a special focus on the involvement of men.
  

General Recommendations and Way Forward

The following recommendations are made to achieve the realization of the Maputo POA on SRHR:

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  The Maputo POA should be extended for the period 2010–2015 to enable further and more effective implementation of the POA, and to coincide with the targets of the MDGs. In that regard, the Maputo POA indicators should be revised and harmonized with those of the MDG targets.
  

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  Implementation during the period 2010–2015 should be comprehensive and integrated, and undertaken with more zeal. It should cover maternal, infant and child health, and incorporate relevant national, continental and regional policies on maternal, neonatal and child health and development.
  

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  Nutrition and food security, as well as HIV/AIDS, TB, malaria and other infectious diseases, should be simultaneously addressed. The linkages with cross-cutting issues such as poverty reduction and financial crises, civil strife, armed conflict, and climate change should be taken into account.
  

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  Member States should accelerate efforts to implement the Maputo POA within the framework of their respective national strategies on maternal, neonatal and child health through an integrated, and multisector approach. CARMMA should be consolidated as an advocacy tool.
  

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  Each stakeholder at regional, continental and international level should play its respective role in urging and supporting Member States to accelerate action to implement the Maputo POA in the period 2010–2015, as well as other strategies on maternal, infant and child health and survival.
  

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  More domestic and international resources should be mobilized and used rationally, with specific allocations made for maternal, infant and child health including family planning in Member States. The AU, regional economic communities (RECs) and regional health organizations (RHOs) should also mobilize resources for Member States and their own respective programmes.
  

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  For effective implementation and rational use of limited resources, partnerships should not only be strengthened, but also coordinated and harmonized better at all levels, under government stewardship at national level and the AU at continental level.
  

Next Steps

The following actions will be undertaken to support the full implementation of the recommendations of this review:

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   After adoption by the AU Conference of Ministers of Health, the (extended) Maputo Plan of Action on Sexual and Reproductive Health and Rights (2010–2015) will be submitted to the Executive Council and Assembly of Heads of State and Government in July 2010 for endorsement.
   

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   It will then be disseminated for implementation with fresh commitment by Member States and other stakeholders and partners at all levels. Such implementation should be linked to the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA), the Plan of Action on Africa Fit for Children and other relevant commitments.
   

Subsequently, the following are also necessary to ensure the effectiveness of the endeavour:

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   Annual progress reports should be submitted to Ordinary Sessions of the AU Conference of Ministers of Health, and/or other relevant regional and continental forums.
   

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   A comprehensive five-year review report on the status of implementation should be submitted to the AU Organs in early 2015, in preparation for the review of the MDGs the same year.
   

References

AUC (1990). African Charter on the Rights and Welfare of the Child. Department of Social Affairs, African Union Commission, Addis Ababa.

AUC (2004). Solemn Declaration on Women and Gender Equality. Department of Gender Affairs, African Union Commission, Addis Ababa.

AUC (2006a). Continental Policy Framework on Sexual and Reproductive Health and Rights (SRHR). Department of Social Affairs, African Union Commission, Addis Ababa.

AUC (2006b). Plan of Action on Sexual and Reproductive Health and Rights (Maputo Plan of Action). Department of Social Affairs, African Union Commission, Addis Ababa.

AUC (2007). Call for Accelerated Action on the Implementation of the Plan of Action Towards Africa Fit for Children. Department of Social Affairs, African Union Commission, Addis Ababa.

AUC (2009a). Campaign on Accelerated Reduction of Maternal Mortality for Africa, Department of Social Affairs, African Union Commission, Addis Ababa.

AUC (2009b). Progress Assessment Tool (PAT) for the Review of the Plan of Action on Sexual and Reproductive Health and Rights (Maputo Plan of Action). Department of Social Affairs, African Union Commission, Addis Ababa.

UNAIDS (2007). Report on the Global HIV/AIDS Epidemic. Geneva: United Nations Joint Programme on HIV/AIDS.

United Nations (2008a). End Poverty 2015 Millennium Development Goals. UN Web Services Section. Department of Public Information. Available from: http://www.un.org/millenniumgoals/ [Accessed 20 March 2010]

United Nations (2008b). World Population Prospects: The 2008 Revision Population Database [online]. Populations Division. Available from: http://esa.un.org/unpp/ [Accessed 31 March 2010]

United Nations Population Division (2009). World Population Prospects, Revision 2008. United Nations, New York.

UNICEF (2008). The State of the World’s Children 2009. Division of Communication. New York: United Nations Children’s Fund.

UNFPA (2008). Sexual and Reproductive Health and Rights National Plans (Maputo Plans of Action – MPoA) Review. UNFPA Technical Division, SRH Branch and Africa Regional Office (ARO).

UNECA, UNFPA and AUC (2009). Fifteen-Year Review of the Implementation of the International Conference on Population and Development Plan of Action, ICPD/15. Addis Ababa: United Nations Economic Commission for Africa, United Nations Population Fund and African Union Commission.

WHO (2001). Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization.