Introduction
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This paper begins with a picture of a sweet potato. Many of you will
wonder how on earth a sweet potato is related to PAC. In my rural community in Western
Kenya the sweet potato has a bittersweet story. It is a most lethal weapon used for
settling scores in cases of unwanted pregnancy. If a young girl gives birth in such
circumstances before marriage, especially if it is to a baby boy, tradition mandates the
killing of that child. This will be planned by other women, and be done when the mother
has gone to fetch water from the river. As prearranged, the baby would be given porridge
and suffocated in the act, or a big sweet potato would be used to hit him on a vital part
of the head, leading to instant death. As planned, the women would start wailing
immediately. One of them would run to the river to fetch the mother. She would be informed
of the sad accident and the village would grieve together with her. That is the very
special use of the sweet potato in my community. As the potato was central to this
scheme, so has the issue of unwanted pregnancy and its management been central in most
traditional societies. In the story, the community women cared enough to insist on taking
action, even if it was what you may consider to be premeditated murder.
Unwanted pregnancy and its management were always central issues in caring societies.
But have they remained so in modern times? I submit that today unwanted pregnancy is a
marginalized issue, even as a RH concern. Its management, on the other hand, is severely
centralized. Here then is the contradiction.
We have marginalized a problem but centralized its solution; very much unlike in my
traditional community where management of unwanted pregnancy was not just within
communities but in villages and even by families or individuals.
Issues of PAC decentralization are therefore manifestations of conflicts arising from
trying to decentralize the management of a marginalized problem. Are these two positions
compatible or tenable? |
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Ipas And PAC in Africa
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Ipas has spearheaded the introduction of PAC in Africa over the last
decade. In the mid- and late-1980s, before PAC became an integral part of RH, Ipas was
already introducing MVA in Egypt, Kenya, Nigeria and Zambia. In the early 1990s, before
Cairo and the eventual ratification of the PAC concept at the international level, Ipas
had moved to Ethiopia, Ghana, Tanzania, Uganda and Zimbabwe. MVA was already moving to the
Districts in Kenya and Zambia. And after Cairo and Beijing, Ipas made its way into South
Africa and remains an active participant in the operationalization of the 1996 Choice of
Termination of Pregnancy Act. From North to South, East to West, Ipas has been all over
Anglophone Africa. Typically, the entry point for Ipas in most countries has been
through university teaching hospitals. Through advocacy and information, the first few
disciples are recruited from the teaching staff. They are trained in MVA/PAC. They pilot
the project, train colleagues and encourage students to learn. As soon as it establishes
itself in the Ob/Gyn department, PAC is included in the undergraduate training curriculum.
Before long, all the newly qualified doctors have embraced PAC. They miss it when posted
to regional hospitals for internship and start demanding it. Recently trained specialists
from the same institutions are also familiar with MVA. They know what impact it has made
in the management of incomplete abortion at the teaching hospitals. They support the
interns and petition the MOH to procure MVA equipment, but this requires external support.
The MOH lacks funds for equipment, training and renovations.
We have hit the first formidable hurdle to the decentralization process. In many
countries, PAC programs have become stalled at this level. |
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Avenues of Decentralization
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We define decentralization as extending services to the most local level
of care in order to increase access. In the last decade, five different but complementary
facets of PAC decentralization have emerged in Africa. |
| Figure 1. Avenues for PAC Decentralization 
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Facility Level
Decentralization |
This is the most obvious and sought after form of PAC decentralization in
Africa. It follows naturally on the hierarchical organizations of health services in most
countries which move downward from central (teaching/referral) hospitals to
regional/provincial hospitals, to district hospitals, down to the health center. The main
advantage of this approach is that it follows the established, accepted order. It is the
one that has been tried most often. It has not worked as well as would be expected,
however, for the following reasons:
Wide variations between central/regional hospitals and district/health
centers in terms of staff, skills and resources.
Unclear training mandate of central/regional hospitals for
district/health centers.
Limited opportunities for sharing of experiences between
central/regional hospitals and district/health centers.
Limited trickling down of donor support from central level to the
district.
Ambiguous administrative/legal guidelines for provision of PAC services
at these levels.
Desire by central/provincial level specialists to own PAC and jealously
guard MVA equipment.
Difficulty in accessing MVA equipment and infection control chemicals at
peripheral levels.
What Is Recommended?
Efforts along this avenue of decentralization must address these constraints
individually and collectively. While an administrative relationship between levels of care
can be improved by MOHs, direct donor support to the districts is recommended. Ipas is
working hard to improve the availability of the MVA kit using better distribution
channels. |
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Professional
Delegation |
If the aim of decentralization is to bring services closer to the people,
physicians on their own cannot do it. Typically in Africa, the physician-population ratio
stands in excess of 1:10,000. Ninety percent of the physicians work in large urban centers
while 80 percent of the population lives in rural areas. Delegation of PAC skill and
services to nonphysicians is therefore an imperative step in decentralization. It is only
within the last 3 years that definitive efforts have been put into this aspect of
decentralization. In South Africa, following the 1996 legal reform, nurse midwives were
allowed by law to perform first trimester termination of pregnancy (TOP). In Ghana, a
study among midwives confirmed their ability to provide PAC efficiently. In Kenya, a study
of Clinical Officers in three district hospitals confirmed their competence. In both Kenya
and Uganda, major pilot studies are in progress assessing the viability of training nurse
midwives in both private and public practice to provide PAC.
While justification for professional delegation of PAC appears compelling, its exercise
has met formidable resistance. Reasons for this resistance include:
Professional ego on the part of physicians.
Lack of trust in the ability of nonphysicians.
Suspicion that PAC skills will be abused by the nonphysicians.
Strict interpretation of legal and professional policies on abortion by
regulating bodies for nonphysicians.
Inadequate comprehension of the magnitude of the problem of unsafe
abortion in rural areas.
Poor staffing and equipment at peripheral facilities where nonphysicians
work.
What Is Recommended?
The FP movement in Africa deliberately ignored physicians in the early days of its
introduction. This has resulted in continued marginalization of physicians in RH issues,
hence their suspicion. Dialogue with medical associations and between medical and
nurses’ associations should be encouraged and supported. This has worked well in
Ghana and is continuing in Kenya. |
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Private Sector
Participation |
The relationship between public and private sector providers has been
uneasy in most African countries. Public sector workers see the private sector as rich and
opportunistic. The private sector on the other hand regards the public sector as lazy,
inefficient and unaccountable. It is only during the ongoing health reform process that
most African countries have finally acknowledged the inevitability of private healthcare
and its complementary role in service provision. In Kenya, for example, the private sector
provides 40 percent of health services and in some instances runs the only facilities in
the remotest parts of the country. A sector that provides nearly half of the services
cannot be ignored. Movement of PAC from the centralized public system to the private
sector is one aspect that has only recently been attempted.
International Family Health is working with Christian Health Service Institutions in
Nigeria to provide PAC. In Kenya, the Kenya Medical and Education Trust (KMET), with
support from Family Planning International Assistance, has piloted a unique project
through which 70 private physicians and nurses have been trained in the last two and a
half years to provide PAC and emergency contraception. Over 100 nurses/nurse-aides were
also trained in IP, instrument maintenance and counseling. The project has to date served
over 15,000 FP clients and provided over 8,000 clients with PAC services, 40 percent of
whom accepted postabortion FP. These providers are now linked to communities through
community-based distributors.
The USAID-supported PRIME project is currently running a project in Kenya patterned
along the KMET model for private nurse/midwives in Kenya. Within the first month of
training, each of the nurses had reached a minimum of 20 PAC clients, indicating that they
could easily provide more units of services than physicians.
Private sector participation in PAC has many advantages, including a high quality of
care and sustainability. It has however not met universal approval due to:
Fear of abuse of MVA equipment in countries where abortion is illegal.
Ambiguity in the legal status of PAC.
Lack of an effective framework for collaboration between the private and
public sectors, including monitoring and supervision.
Donor reluctance to fund the private sector.
Unclear training mandate of public sector experts over the private
sector.
Belief that the private sector will not share data/statistics.
Religious/moral objections to PAC by certain religious groups.
Fear of stigmatization by some private providers.
What Is Recommended?
What must be remembered is that in many African countries the private sector is already
providing most of the PAC services. The issue therefore is not whether or not they should
participate. Rather, it is why their participation should not be enhanced and made safer
through appropriate acknowledgment, training and monitoring. |
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Involvement of
Local Authorities |
Local authorities (City Councils, Municipalities and County Councils,
etc.) provide healthcare services to various degrees in every country in Africa. In some
cities the local authority runs the largest maternity hospitals in addition to many of
health centers, dispensaries and outreach services. In some countries, County Councils
have the full responsibility for providing healthcare beyond the district hospital. The
efficiency of local authorities in healthcare provision varies but is often no better than
the central government. Theoretically, being smaller, local authorities should be more
efficient and their facilities better maintained. In practice this has not always been the
case, although they continue to retain a large number of health professionals in their
employment. Facilities run by these authorities provide myriad RH services such as
antenatal care, delivery and FP, but not PAC. In the City of Nairobi, for example, the
Pumwani Maternity Hospital handles up to 70 deliveries daily but refers all incomplete
abortions to the Kenyatta National Hospital. The City Council also runs another seven
large health centers staffed by physicians and midwives but handling only normal
deliveries. These health centers have adequate space and staff for PAC. A similar
situation prevails in Kampala, Jinja and Lusaka.
Urban centers in Africa record some of the worst cases of unsafe clandestine abortions.
The vast slums are often home to up to 70 percent of the population of the town, have no
public health facilities (because they are illegal settlements and therefore do not exist
in official records!) but have a large number of informal providers. Central hospitals in
these cities are invariably overwhelmed with cases of incomplete abortion. And yet next
door are relatively empty local authority clinics. Surely, it should be obvious to share
this workload!
Several constraints have prevented the spread of PAC into local authority clinics:
Lack of functional linkage between local authorities and MOHs in terms
of policy and planning
Underestimation of responsibilities and potentials of local authorities
in health provision
Poor planning of health service provisions by local authority
Limited budgetary allocation to health in local authorities
Invasive political interference by councilors
Conservative leadership in departments of health in local authorities
Failure of local authorities to embrace critical RH issues
Limited direct donor support to local authorities
What Is Recommended?
To date, all PAC programs in Africa have continued to ignore local authorities. This is
a mistake that needs immediate redress. PAC services cannot reach urban slums if we deny
involvement of local authorities. |
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PAC for Women
Living Under Difficult Circumstances |
As Africa continues to experience a disproportionate share of both
natural and man-made disasters, the population of displaced people, especially women and
children, has reached unmanageable levels. Under these circumstances high incidence of
rape and unwanted pregnancies is expected. Ipas is currently working with the United
Nations High Commissioner on Refugees, the United Nations Population Fund (UNFPA) and the
National Council of Churches of Kenya to introduce PAC in two separate refugee camps in
the Northeastern part of Kenya. These camps, Dadaab and Kakuma, were opened in 1991 and at
their peak hosted up to 700,000 refugees. Today they still are home to over 200,000. The
camps now have schools, hospitals and dispensaries and report 10 to 15 cases of incomplete
abortion every week. There are a few doctors and one gynecologist. Postabortion services
have not been a priority and attempts to introduce PAC have met resistance on the grounds
that it would encourage immorality. Ipas has succeeded in convincing the authorities to
introduce PAC, and the camp staff and those from neighboring district hospitals have now
been trained and their facilities equipped. The exercise has however been undertaken under
a thick air of suspicion and bureaucracy and is unlikely to be expanded to all refugee
camps in the region for the following reasons:
Emergency response to disasters has traditionally ignored RH, let alone
PAC.
Many organizations operating health services within refugee camps are
strongly influenced by religious groups uncomfortable with any aspect of abortion, even if
it is to save the lives of women.
The mistaken expectation that refugee camps are temporary and therefore
not in need of RH services.
Orientation and lack of experience of refugee agencies and staff on RH
issues.
Ad hoc organization of health services at the camps generally and
limited integration of these services with those of the host country.
Limitation of resources for medium- or longer-term planning.
Paucity of concern for the health of refugees by women’s health activists and
advocates. |
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