Decentralization: The Players and
Their Roles
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In an ideal world, access to PAC is an integral part
of the national health strategy. Every player in the health sector should be involved.
This, however, is not yet the case. There are several critical players that have helped
move PAC agenda forward. Each one of them has the capacity and opportunity to do more.
There are also important potential players still sitting on the fence. They have to be
pulled into the game. |
| Figure 2. Decentralization of Postabortion
Care 
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National
Governments |
The MOHs have a critical role to play in PAC. They set policy. They
license. They provide guidelines and set standards. They have the primary responsibility
of providing resources, training and coordination. In countries where PAC is still
marginalized, attitudes of MOH officials remain a major stumbling block to
decentralization. Decentralization is made much easier whenever the MOH lends it
unqualified support. |
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Health
Professionals |
Physicians, nurses, clinical officers and counselors are critical players
in decentralizing PAC, irrespective of the aspects mentioned above. It is important for
physicians to accept their limitations and delegate. It is equally important for nurses
and clinical officer to embrace the new challenges responsibly. The need for
professional associations to be involved in this dialogue cannot be overemphasized. They
need to take a clear position and provide leadership to their members on issues of
decentralization and the pace and reach of decentralized services. |
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Donors |
PAC remains an integral part of the ICPD promise of support for
comprehensive RH approach. PAC has, however, remained peripheral in funding considerations
even after Cairo. And although a few agencies have responded positively their input has
been rather small and unpredictable in comparison to FP and the Safe Motherhood Initiative
(SMI) programs. Interestingly, PAC has fallen through the programmatic crevices between FP
and SMI. It is denied funding via FP as well as via SMI. Donor support is critical to
expansion of PAC in Africa. It should be increased focusing on the long haul. Programs
should be supported not for a year or two but for 5 to 10 years. Support must also be made
innovative, reaching out to all the aspects of decentralization mentioned above and not
limited to the district level. |
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Women’s
Groups and Information |
Advocacy and information are key components to the success of PAC programs
and decentralization. There are, unfortunately, not enough women activists in Africa
committed to this issue. They have a critical role to play in advocacy to move forward
policies and disseminate information to empower women to use decentralized services.
Professional women’s groups such as the International Federation of Women Lawyers
(FIDA) should be called upon to provide support to efforts of health providers. The
critical roles of these groups were evident in the activities leading to the TOP Law
Reform in South Africa. In Kenya, recently initiated collaborative efforts between the
Kenya Medical Association and FIDA look promising and need to be supported. Women’s
health activists in host countries also need to take a closer interest in the welfare of
refugees and the provision of comprehensive RH services as a basic human right. |
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Religious and
Traditional Groups |
The critical role of religious and traditional leaders in sharpening or
blunting public opinion on sensitive issues such as abortion has been highlighted in the
Communities’ Basic Abortion Care (COBAC) study in Western Kenya. These leaders and
the positions they take greatly influence the pace at which PAC will expand in all African
countries for the foreseeable future. Politicians and senior MOH officials keep their ears
open to any grumblings from these leaders. On our part we can only ignore them to the
detriment of PAC programs. Through advocacy and dialogue they can be made to see the need
for PAC and the difference between PAC and TOP; their voices can be used more positively
to enhance rather than repress women’s health. The issue of refugees is one vital
area where immediate consensus is needed from religious groups. |
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Disaster Relief
Organizations |
Disasters, especially man-made, have become a surprise epidemic at the
sunset to the twentieth century. Disaster relief organizations have therefore increased
both in numbers and stature. And as our understanding of the needs of victims of these
disasters expands, it has become increasingly clear that RH needs are no less important in
these circumstances and cannot be ignored. In any case, resolutions to problems that give
rise to these instabilities, especially when man-made, are rarely quick. A generation or
more may find itself still confined to a temporary refugee camp. A general change in
orientation by these agencies, including their perception of the needs of female disaster
victims, is urgently called for. There are also compelling moral and ethical issues
surrounding the deliberate withholding of certain aspects of healthcare from refugees who
are in obvious need and have no alternatives. This is one area that I believe this meeting
should have the courage to address. We are encouraged by recent reports that Médecins
Sans Frontières (Doctors Without Borders) has resolved to include MVA equipment in its
inventory of essential drugs. |
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