Availability of long-acting and permanent family-planning methods leads to increase in use in conflict-affected northern Uganda: evidence from cross-sectional baseline and endline cluster surveys.

Humanitarian assistance standards require specific attention to address the reproductive health (RH) needs of conflict-affected populations. Despite these internationally recognised standards, access to RH services is still often compromised in war. We assessed the effectiveness of our programme in northern Uganda to provide family planning (FP) services through mobile outreach and public health centre strengthening. Baseline (n=905) and endline (n=873) cross-sectional surveys using a multistage cluster sampling design were conducted in the catchment areas of four public health centres in 2007 and 2010. Current use of any modern FP method increased from 7.1% to 22.6% (adjusted odds ratio [OR] 3.34 [95% confidence interval (CI) 2.27-4.92]); current use of long-acting and permanent methods increased from 1.2% to 9.8% (adjusted OR 9.45 [95%CI 3.99-22.39]). The proportion of women with unmet need for FP decreased from 52.1% to 35.7%. This study demonstrates that when comprehensive FP services are provided among conflict-affected populations, women will choose to use them. The combination of mobile teams and health systems strengthening can make a full range of methods quickly available while supporting the health system to continue to provide those services in challenging and resource-constrained settings.

Family planning in conflict: results of cross-sectional baseline surveys in three African countries.

BACKGROUND: Despite the serious consequences of conflict for reproductive health, populations affected by conflict and its aftermath face tremendous barriers to accessing reproductive health services, due to insecurity, inadequate numbers of trained personnel and lack of supplies. Family planning is often particularly neglected. METHODS: In six conflict-affected areas in Sudan, northern Uganda and the Democratic Republic of Congo, household surveys of married or in-union women of reproductive age were conducted to determine baseline measures of family planning knowledge, attitudes and behaviors regarding contraception. Health facility assessments were carried out to assess baseline measures of family planning services availability. Data were double-entered into CSPro 3.2 and exported to SAS 9.2, which was used to calculate descriptive statistics. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured. RESULTS: Knowledge of modern contraceptive methods was low relative to other sub-Saharan African countries, and use of modern methods was under 4% in four sites; in two sites with prior family planning services it was 12% and 16.2%. From 30% to 40% of women reported they did not want a child within two years, however, and an additional 12% to 35% wanted no additional children, suggesting a clear need for family planning services. The health facilities assessment showed that at most only one-third of the facilities mandated to provide family planning had the necessary staff, equipment and supplies to do so adequately; in some areas, none of the facilities were prepared to offer such services. CONCLUSIONS: Family planning services are desired by women living in crisis situations when offered in a manner appropriate to their needs, yet services are rarely adequate to meet these needs. Refugee and internally displaced women must be included in national and donors' plans to improve family planning in Africa.

A review of global mechanisms for tracking official development assistance for health in countries affected by armed conflict.

BACKGROUND: Poverty is highly concentrated in countries affected by armed conflict which are the furthest from reaching the Millennium Development Goals. Tracking aid patterns for health is crucial for improving the effectiveness of external aid to countries affected by armed conflict which tend to depend heavily upon external assistance and also have particularly acute health needs. OBJECTIVES: This study systematically assesses the reliability of global aid databases which are commonly used for tracking aid to countries affected by armed conflict. It offers analyses of two main databases - the Creditor Reporting System (CRS) and the Financial Tracking System (FTS) by reviewing the strengths and weaknesses of these data sources. METHODS: A literature review was conducted to assess the existing evidence on aid tracking generally, and aid databases more broadly. Interviews were also conducted with experts involved in health resource tracking, donor agencies, and NGOs. RESULTS: Despite limitations, the CRS and FTS are appropriate for tracking aid for conflict-affected countries as they are comprehensive and allow analysis of different aid activities, countries, years, and donors. CONCLUSIONS: The study offers recommendations on how CRS and FTS might be enhanced to try and improve the accountability and effectiveness of aid to countries affected by armed conflict.

Tracking official development assistance for reproductive health in conflict-affected countries.

BACKGROUND: Reproductive health needs are particularly acute in countries affected by armed conflict. Reliable information on aid investment for reproductive health in these countries is essential for improving the efficiency and effectiveness of aid. The purpose of this study was to analyse official development assistance (ODA) for reproductive health activities in conflict-affected countries from 2003 to 2006. METHODS AND FINDINGS: The Creditor Reporting System and the Financial Tracking System databases were the chosen data sources for the study. ODA disbursement for reproductive health activities to 18 conflict-affected countries was analysed for 2003, 2004, 2005, and 2006. An average of US $20.8 billion in total ODA was disbursed annually to the 18 conflict-affected countries between 2003 and 2006, of which US $509.3 million (2.4%) was allocated to reproductive health. This represents an annual average of US $1.30 disbursed per capita in the 18 sampled countries for reproductive health activities. Non-conflict-affected least-developed countries received 53.3% more ODA for reproductive health activities than conflict-affected least-developed countries, despite the latter generally having greater reproductive health needs. ODA disbursed for HIV/AIDS prevention and treatment increased by 119.4% from 2003 to 2006. The ODA disbursed for other direct reproductive health activities declined by 35.9% over the same period. CONCLUSIONS: This study provides evidence of inequity in disbursement of reproductive health ODA between conflict-affected countries and non-conflict-affected countries, and between different reproductive health activities. These findings and the study's recommendations seek to support initiatives to make aid financing more responsive to need in the context of armed conflict.

Reproductive health: a right for refugees and internally displaced persons.

Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress.

A basic package of health services for post-conflict countries: implications for sexual and reproductive health services.

Health systems in countries emerging from conflict are often characterised by damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations. This can result in the disrupted and fragmented delivery of health services. One increasingly popular response to improve health service delivery in post-conflict countries is for the country government and international donors to jointly contract non-governmental organisations to provide a Basic Package of Health Services for all the country's population. This approach is being applied in Afghanistan and Southern Sudan and is planned for the Democratic Republic of Congo. The approach is novel because it is intended as the only primary care service delivery mechanism throughout the country, with the available financial health resources primarily allocated to it. Although the aim is to scale up health services rapidly, including sexual and reproductive health services, there are a number of implications for such sub-sectors. This paper describes the Basic Package of Health Services contracting approach and discusses some of the potential challenges this approach may have for sexual and reproductive health services, particularly the challenges of availability and quality of services, and advocacy for these services.