INTEGRATING STI/RTI SERVICES IN REPRODUCTIVE HEALTH/ FAMILY PLANNING PROGRAMMES TRAINING AND SERVICE DELIVERY DR. MIZANU

1. INTEGRATING STI/RTI SERVICES IN REPRODUCTIVE HEALTH/ FAMILY PLANNING PROGRAMMES TRAINING AND SERVICE DELIVERY DR. MIZANUR RAHMAN NATIONAL PROFESSIONAL PROJECT PERSONNEL UNFPA, BANGLADESH Nepal, 26 August, 2003 INTEGRATING STI/RTI SERVICES IN REPRODUCTIVE HEALTH/ FAMILY PLANNING PROGRAMMS

2. INTRODUCTION • Bangladesh with an area of 147,570 sq.km has a population 130 million with highest population density in the world. • Bangladesh is situated in Northeastern South Asia, surrounded by India, Myanmar and Bay of Bengal. • Bangladesh is geographically vulnerable to RTI/STI & HIV/AIDS due to its close proximity to India, Myanmar, Nepal, Thailand having various degrees of the epidemic. • The Family Planning (FP) program in Bangladesh is a success story and it has contributed in declining the total fertility rate (TFR) from 6.3 in 1975 to 3.3 in 1999. Similarly, the contraceptive use rate (CPR) has increased from 7 percent in 1975 to 54 percent in 2002.

3. Indicators Rate/Ratio Year Sources Populations (Total) 130.9 Million January 2002 BBS June 2003 TFR 3.3 1999-2000 BDHS CBR 18.9 2001 BBS June 2003 CDR 4.8 2001 BBS June 2003 NRR 1.23 2001 BBS June 2003 MMR 3.0 - 3.4 2002 NIPORT IMR 56 2001 BBS June 2003 Female Literacy Rate (15 +) 30.8 2001 2003, HDR, BD Youth Literacy Rate (15-24) 49.1 2001 2003, HDR, BD Skilled Birth Attendance (%) 15 13 1995-2001 2001 2003, HDR, BD 2001, BMHSMM Annual Growth Rate (%) 1.48 2001 2003, HDR, BD 2001, BMHSMM GNP per capita US$ US$ 380 2001 Ministry of Finance Maternal nutrition (% of mother with low BMI) 45.4 2000 BDHS 1999-2000 Gender Violence (%) 47 UNFPA Statistics Urban Population 25.5 2001 2003, HDR, BD Adolescent as % of Population 23% (29.5 mill) 2002 BLS, UNFPA, 2002 Abortion Rate 8 lakhs Every year DI, BDRC 1999-2002

4. Mile Stones of FP Programme (1953-2003) • Phase 1: Voluntary Effort (1953-1960): • Phase 2: Clinic-based Government Program (1960-1965): • Phase 3: Field based Family Planning Program (1965-1972): • Phase 4: Historical Liberation War and rehabilitation (1970-1972): • Phase 5 : Integrated Health and Family Planning Program (1972-1974): • Phase 6: MCH based Multi sectoral FP Program (1975-1980): • Phase 7: Functionally Integrated Program (1980-1985): • Phase 8: Intensive Family Planning Program (1985-1990): • Phase 9 : Participatory MCH/Family Planning Program (1990-1998):

5. Con’t • Phase 10: Health and Population Sector Program (1998-2003): In 1998, the government launched the Health and Population Sector Program (HPSP). HPSP provides a ESP package : • Reproductive Health, • Child Health Services • Behavior Change Communication • Limited Curative Care • Communicable Diseases NIPHP :The program collaborates with and is complemented by NGO and private for profit sector activities.

6. Reproductive Health Family Planning Shifting from Family Planning Programme and integrated RTI/STI services to Reproductive Health Programme?

7. Integrating STI and RTI Services with Family Planning Services? Long acting Family Planning methods such as the IUD should not be provided unless it has been determined that the client does not suffer from an RTI. Women often see symptoms of RTIs as an outcome of their contraceptive use and hence they seek assistance from family planning services when they experience possible RTI symptoms such as vaginal discharge.

8. Training Programme • Training Center- 14 • Training AID and Materials provided by UNFPA • Microscope • Joe, CPR, Penile, IUD, NSV, Norplant model • TV/VCP/Cassettes • NSV kit • OHP & Screen

9. Training & Skill Development • Training on Clinical Contraception, HIV/ AIDS RTI/STI case management. • Training on EmOC-64 MCWCs • Training on Skill Birth Attendants (SBA) • Establishing National Center of VVF. • Training on SRH Counseling, VAW, ARH, and Male involvement.

10. ADVOCACY • Community Level Advocacy meeting • Training/Orientation of Local leaders • Workshop on social mobilization • For rural community people-Folk Songs, Flim Show etc • Adolescent/ Youth- Advocacy/BCC • Youth Club • Garments Workers • Adolescent Mother through peer educator • Tea Garden worker

11. Who are the Participants (DGHS &DFP) • Divisional level : Medical Colleges and Hospital • District Level managers : District Hosp/MCWC • Upazilla Level managers : UHC/RD • Union Level : H&FWC • GOB physicians, Nurses/FWVs, and Medical Technologists on clinical contraception,HIV/AIDS and RTI/STI Case management. • SBAs training : Female- HAs, DGHS & FWAs-DFP • EOC : GOB doctors and Nurses from DGHS &DFP • Advocacy :GOB Divisional, District, Upazilla level manager and Community Workers, Youth, Religious Leader

12. RH Umbrella Project UNFPA: Save the Children UK, MSCS, FPAB, BRCS Training offered on: • Quality of Care - 4 days Training – 2 hrs RTI/STI/HIV/AIDS – MO (RHI Partner NGOs – 25 Trained) • Gender: 5 days Training - 4 hrs RTI/STI/HIV/AIDS – MO (RHI Partner NGOs – 140 Trained) • Others Training: Project Management, FP & RH Counseling, Quality Mgmt. Training

13. Adolescent Reproductive Health Project Training offered on: • TOT: - 5 days Training – 6 hrs RTI/STI/HIV/AIDS – DD, AD Youth Dev. Officers – 40 Master Trainer Received TOT • TOT for Peer Educators: 5 days Training – Youth from locality, (20 – 30 yrs) - 6 hrs RTI/STI/HIV/AIDS and Sexuality – 240 (120 male & 120 female trained) • Health Service Provider: GOB, Doctors & Paramedics from DGHS & DFP – 3 days – 2 hrs RTI/STI/HIV/AIDS – 180 trained • Community Workers: FWA/HA/NGO/Credit Supervisor (Youth) – DGHS & DFP – 4 hrs – 180 trained

14. Service Delivery: • Centers of Excellence at MCWCs : • Establishing Safe Delivery Centers at UHFWC. • Introduce specialized services at Medical Colleges-VVF, Cervical Cancer etc • Strengthen urban reproductive health services.

15. Reproductive Health Services at MCWCs • 24 hours EmOC, Safe delivery, • Clinical contraception including Emergency contraception at all MCWCs. • ANC, PNC services. • Sexual and reproductive health counseling services. • Services for Maternal Morbidities. • Services for Youths/ Adolescents. • SBA to ensure safe home deliveries. • Quality Assurance and Research. • Establish Client Data Record System.

16. RH Training and Services in the Urban Setting • Training on EmOC, CC, RTI/STI. • Training on SRH Counseling and management of VAW and ARH. • Support to City Corporation & NGO clinics to provide RH services. • Youth friendly services • VAW and ARH services • Quality Assurance.

17. Linkages of Training and Services within and among the projects of the Different Sub-Programs RH UNFPA 6th Country Program, Bangladesh Advocacy PDS

18. Challenges • The supply of these drugs at clinics and their purchase by clients are major problems. • Resistance of Antibiotic • Use Syndromic Flow Chart and Record Keeping • Condom Demonstration.

19. Experiences from Service Providers and Customer • It is easy to start dialog with the client regarding RTI/STI, while doing the physical examination. • ANC visit, Pregnant mother and his partner getting interest to listen the linkage of STI/HIV. • Dual protection of condom :Some times it lids to change the clients risky behavior.

20. Bangladesh Thank You