Essential Elements of Ensuring Equitable Access to High-Quality Primary Healthcare in Ethiopia’s Pastoral Regions Part 2
Transforming Gender Norms and Strengthening Community Resilience
In Part 1 of our blog series, we examined ways EngenderHealth helps strengthen health infrastructure and service provision to ensure access to high-quality healthcare for pastoralists in Ethiopia, including adapting traditional service-delivery models to meet pastoralists’ unique needs. While such measures are critical to building an accessible health system, they have limited impact if prevailing sociocultural norms or other environmental factors discourage or prevent individuals–especially women and girls–from using health services, including those related to sexual and reproductive health (SRH). Making access to such services a reality also requires ensuring a sociocultural environment that encourages individuals to access care and establishes a sustainable, resilient health system that can quickly respond to crises and emerging health needs.
In Ethiopia and globally, EngenderHealth’s comprehensive approach to promoting sexual and reproductive health and rights (SRHR) is grounded in our commitment to gender equality and to a socioecological model of sustainable change. We integrate gender-equitable and socially-inclusive approaches across our work at all levels—with communities and individuals, health systems and institutions, and policies, laws and processes—including emphasizing male engagement.
Addressing harmful sociocultural and gender norms from within communities
As with any population, efforts to promote better health-seeking behaviors among pastoralists must address longstanding social, cultural, and gender norms that limit women’s and girls’ autonomy and encourage harmful traditional practices (HTPs), such as child, early, and forced marriage (CEFM); early childbearing; home delivery; female genital mutilation/cutting (FGM/C); and gender-based violence. Inequitable gender norms and HTPs are common within pastoralist communities in Ethiopia. For example, women and girls may lack access to SRHR information and may be discouraged from accessing SRH services, including family planning.
“It requires long-term investment to change social norms, even to understand the entry point,” Kassaw said. “We identify key influencers—religious and clan leaders, traditional birth attendants, youth leaders, parents, and others—and collaborate with them for positive change. Many become volunteer community health workers addressing problems they were previously a part of.”
For example, after the A’ago program trained 200 religious leaders in Afar on the health risks of HTPs and the benefits of changing them, many used their positions of authority to encourage youth to use sexual and reproductive health (SRH) services and to promote other positive SRH behaviors. One sheikh not only began speaking out against FGM/C and CEFM, and in favor of HIV testing, but also stopped endorsing marriage contracts for unwilling or underage girls. His community has since prohibited FGM/C.
A’ago also enlisted traditional birth attendants (TBAs) as allies, training them as community health volunteers in Ethiopia’s Women’s Development Army (WDA). Now, instead of performing unsafe home deliveries, some former TBAs accompany pregnant women to health facilities to deliver their babies; some who previously performed FGM/C now denounce the practice. This strategy has the additional benefit of significantly easing the load on heavily burdened health extension workers (HEWs). In total, the program trained nearly 3,000 members of the WDA, more than 300 HEWs, and almost 800 health workers, and served about 172,000 clients with contraceptive and obstetric care over a two-year period.
To improve awareness of SRHR issues among youth and encourage more equitable gender norms, EngenderHealth worked with 34 schools to implement comprehensive sexuality education and life skills courses that taught 6,920 students about puberty, relationships, SRH, HTPs, and more. The program also reached out-of-school young people through peer-to-peer approaches including youth clubs and youth advisory councils that reached 349,998 young people with comprehensive information on sexuality, sexually transmitted infections, pregnancy, and other SRHR-related topics.
Preparing for crisis
Reaching pastoralist communities with much-needed reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) care also requires taking a multi-sectoral approach to build local resilience and the ability to mobilize and respond quickly, in an integrated manner, to crises.
“These remote areas are fragile and vulnerable to emergencies, conflict, and droughts, so we have to enable local actors to be adaptive and respond to humanitarian needs,” Kassaw said.
In recent work with internally displaced persons in Somali, amid a complex humanitarian emergency, EngenderHealth also gained valuable experience navigating the humanitarian-development nexus and helped ensure the integration of SRH into humanitarian response. The initiative reached more than 50,000 people with SRHR information and helped more than 22,400 women and adolescent girls access related services. It also improved the sustainability of these services by training a pool of 13 master trainers and 88 healthcare workers on SRH issues, including basic emergency obstetric and newborn care and contraceptive care. We also conducted research on the SRHR needs of internally displaced persons and generated recommendations for strengthening SRHR service integration in future humanitarian response efforts.
Reversing neglect, empowering pastoralists
Pastoralists’ needs for high-quality, integrated, and accessible RMNCAH-N services have been neglected for too long. In this blog series, we have outlined elements that EngenderHealth’s experience has shown to be essential in meeting these needs, both within and outside the health system. We will continue drawing on our experience in Ethiopia and around the world to make high-quality SRH services available to pastoralist communities and to empower them and all Ethiopians to take charge of their SRHR.