Using research to influence sexual and reproductive health practice and implementation in Sub-Saharan Africa: a case-study analysis

Background Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health (SRH) and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in SRH can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality. Methods The case-studies presented in this paper analyse findings from SRH/HIV research programmes in sub-Saharan Africa: 1) Maternal syphilis screening in Ghana, 2) Legislative change for sexual violence survivors In Ghana, 3) Male circumcision policy in South Africa, and 4) Male circumcision policy in Tanzania. Our analysis draws on two frameworks, Sumner et al’s synthesis approach and Nutley’s research use continuum. Results The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors. Conclusion Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximize research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical

Destigmatising Abortion: Expanding Community Awareness of Abortion as a Reproductive Health Issue in Ghana

Traditional and cultural values, social perceptions, religious teachings and criminalisation have facilitated stigmatisation of abortion in Ghana. Abortion is illegal in Ghana except in three instances. Though the law allows for performance of abortion in three circumstances, the Ghana reproductive health service policy did not have any induced legal abortion services component to cover the three exceptions until it was revised in 2003. The policy only had ‘unsafe and post-abortion' care components, and abortions performed in health facilities operated by the Ghana Health Service were performed under this component. Though the policy has been revised, women and girls who need abortion services in Ghana more often resort to the backstreet dangerous methods and procedures. Criminalisation of abortion and those who perform abortions has contributed to unsafe abortion, the second leading cause of maternal deaths in Ghana. Most of these are performed outside the formal health service structures. Traditionally, abortion is perceived as a shameful act and the community may shun and give a woman who has caused an abortion derogatory names. Would provision of legal abortion services be culturally acceptable within a Ghanaian community? Yes, if they are made aware of the reproductive health benefits of providing safe abortion services. Three major strategies that would help to destigmatise abortion in the community are (1) the liberal interpretation of the three exceptions to the law on abortion; (2) expanding community awareness of its reproductive health benefits; and (3) improving and increasing access to legal abortion services within the formal health facilities. (Afr J Reprod Health 2004; 8[1]:70-74) RÉSUMÉ Déstigmatisation de l‘avortement. Accroissement de la conscience communautaire de l‘avortement comme un probléme de la santé de reproduction au Ghana. La stigmatisation de l‘avortement au Ghana a été rendu facile par la tradition et les valeurs culturelles, les perceptions sociales, les enseignements religieux et la criminalisation. L‘avortement est illégal au Ghana sauf en trios cas. Bien que la loi permet l‘avortement en trios cas, la politique du Service de la Santé de Reproduction du Ghana, n‘avait aucun service de l‘avortement légal provoqué pour couvrir les trios exceptions avant sa revision en l‘an 2003. La politique n‘avait que des coustituants du soin pour ‘l' avortement à risque et le post-avortement' et tous les avortements pratiqués dans les institutions de santé gérées par le Service de Santé du Ghana ont été réalises sous ce constituant. Bien que la politique soit revisée, les femmes et les filles qui ont besoin des services d‘avortement au Ghana ont recours, le plus souvent, aux procédures et aux méthodes clandestines dangereuses. La criminalisation de l‘avortement et ceux qui se font avorter ont contribué à l‘avortement à risque, la deuxiéme cause principale des décés maternels au Ghana. La plupart d‘entre eux ont lieu en dehors des structures de service de santé formelles. Traditionnellement, l‘avortement est perçu comme un acte honteux et la femme qui se fait avorter risque d‘ être évitée et dénigrée par la communauté. Est.ce que l‘assurance des services d‘avortemet légal sera culturellement acceptable au sein d‘une communauté ghanéenne? Oui, si l'on la sensibilise aux avantages des services d‘avortement. Trois stratégies principales qui aideront à déstigmatiser l‘avortement dans la communauté sont (1)l‘interprétation libérale des trois exceptions à la loi sur l‘avortement (2) l‘extension de la conscience de la communauté sur les avantages de la santé de reproduction; et (3) l‘amélioration et l‘augmentation de l‘accès aux services d‘avortement légal dans le cadre des institutions formelles de santé. (Rev Afr Santé Reprod 2004; 8[1]:70-74

Operationalising sexual and reproductive health and rights in sub-Saharan Africa: constraints, dilemmas and strategies

BACKGROUND: The continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts. METHODS: The international case study focuses on the progress made by African countries in implementing the African Union’s Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders’ experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors’ reflections. The first national case study explores the processes involved in influencing Ghana’s Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors’ reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act. RESULTS: Based on the three cases, we argue that prohibitive laws and governments’ reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women’s issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism. CONCLUSION: The strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled