Marie Stopes International Blogs

After the hype, Copenhagen provides cold reminder of political reality

21/12/2009 00:00:00

COPENHAGEN, Denmark — My experience of the conference against global warming had an aptly chilly start — seven hours of queuing outdoors in the Danish winter. To my surprise, informing the guards that I had to give a scheduled presentation on the integration of rights-based family planning into climate change adaptation efforts yielded neither fast-track entry nor sympathy. COP15 had accredited over 40,000 delegates to attend a conference venue with a capacity for 15,000 and the consequences were dire. A huddled line of NGO workers, journalists, academics and civil servants stretched over a kilometre, waiting for hours in sub-zero temperatures in a queue that didn’t move – with incredible good nature – to participate in the conference that they hoped would save the world. If this conference was any indication of COP15’s ability for organisation, the world’s prospects were looking very bleak.

After more than six hours without food or water in intermittent snow, I was finally allowed entrance to the official registration hall. Although I had missed my presentation by several hours, queuing in the warmth now felt like relative luxury. And I have never felt so grateful for a cup of tea in my life. I eventually received my registration pass and, while saddened and angered to have missed the opportunity to discuss the ecological relevance of family planning with other NGO reps, I still had a session to look forward to tomorrow with Members of Parliament (MPs) from around the world.

The next day, entrance passed more smoothly for me (although this was not the case for many others and some were talking of seeking legal redress with the UN). At a lunchtime talk arranged by a Danish sexual reproductive health and rights organisation Sex&Samfund, I had a chance to address almost fifty MPs on how rights-based family planning programmes can make a difference in meeting the ecological challenges faced by countries worst affected by climate change.

I read from an official adaptation strategy document of the Rwandan government. “Adaptation” refers to efforts designed to help countries to cope with worsening climatic conditions, as contrasted with “mitigation” efforts to reduce carbon emissions. The document explained how rapid population growth in Rwanda – which has a contraceptive prevalence rate around 10% – is causing soil erosion as agrarian land use in high population density areas intensifies. The identified consequences include declining agricultural production, landslides and migration to less hospitable areas that are increasingly prone to flood and drought due to extreme weather.

After referencing a few examples of how rapid population growth is exacerbating the challenges of climate change – such as in Bangladesh where rising sea levels are contaminating fresh water sources with salt even as a growing population demands ever more drinking water – I returned to my seat. Attempts to discuss the macro-level consequences of the ongoing failure to ensure universal access to family planning can often be met with hostility, so I was anxious to learn how the MPs around my lunch table would react to the suggestion that slower population growth rates could assist in adapting to environmental challenges.

A veteran MP from Guatemala spoke first. “You spoke well,” he said with a kind but dismissive wave of the hand. “We agree with the need for family planning. But there are those who say that we must use it to reduce our carbon emissions. There are more than thirty vectors and pathogens in Guatemala being found at higher and higher altitudes because of warmer temperatures. Soon nowhere in Guatemala will be safe from these diseases and it is the indigenous people in the mountains who will die. Why? Because in Europe and America they pollute. And they tell us we must reduce our carbon. I ask you, where is the justice?” His age prevented him from shouting his last four words but he shook with emotion when he spoke them. I considered an argument I had seen recently in the papers – that family planning could reduce Guatemala’s carbon emissions by limiting the number of Guatemalans – and just how offensive it seemed at this point. His invocation of moral justice felt frankly unassailable.

Fortunately, an MP from Bangladesh came to my rescue. “In Bangladesh we believe family planning is very important,” he began. “We have very high population density and not enough land or natural resources. We do not want the density to increase as it will be more difficult when the glaciers in the Himalayas melt and we lose rivers. We want family planning everywhere and we want development programmes and resources to adapt. For this we need your support.” I was relieved the conversation had returned from carbon emissions to adaptation but was also keen to avoid the role I appeared to be heading for of representing Western donor interests.

“I work for Marie Stopes International” I told them, “and we would like to assist in countries struggling to adapt to climate change but there is little recognition that family planning has anything to contribute. What would you suggest we do?” I hoped that this might turn the conversation towards the means of integrating family planning into environmental sustainability and land management programmes. The MP from Bangladesh read my mind: “We don’t want family planning to be counted as an adaptation strategy” he said. “Yes it would help with the demand for natural resources but that is not the point. Donors would just say that the money they already give for family planning counts as adaptation support and then leave it at that. We need more resources for adaptation and for family planning.” Thus, my carefully crafted advocacy strategy was undone by a dose of political reality from the South.

Back in my hotel room reflecting on what I had learned, the cold logic of the argument for using family planning to reduce carbon emissions remained hard to refute, but it clearly raised moral questions and what’s more had no traction amongst the politicians I had met from the South. On the other hand, the argument for using improved access to family planning services to help adaptation to local environmental challenges (which I had thought was quite novel) seemed already an accepted concept, a t least in Bangladesh and several other countries. But a tired cynicism for the way bilateral donors are perceived to avoid genuine, overall increases in financial support was obstructing innovation for a multi-sector approach to supporting communities better cope with their local environment. People in the world’s poorest countries are under no illusion about who is responsible for their worsening climatic conditions. Unless, post-Copenhagen, donors find new commitment to genuine increases in ODA that reaches both environmental management and family planning, innovative programmes integrating reproductive health, women’s empowerment and environmental sustainability are unlikely to become a large-scale reality.

A global decline in abortions - fact or fiction?

07/12/2009 00:00:00

Following the overwhelming success of my earlier blogs (zero comments, three hits and one lukewarm response from someone in the office), I am starting a more regular blog about evidence and research in Sexual and Reproductive Health. Yes, I am going to try and make numbers and science sexy.

First post has to be around the new global abortion estimates released by the Guttmacher Institute . The bible for anyone working on safe abortion, the new estimates have received some impressive news coverage and are generally being heralded as a success for family planning and public health efforts. The Economist magazine concludes that the numbers show us a “glimmer of hope” and that we now know how to reduce the rate of abortion.

Unfortunately, a closer inspection of the statistics reveals a rather more bleak picture: overall, the rate of abortions globally has decreased but it is mostly due to changes that happened in the late 1990s in Eastern Europe. Fifteen years ago, access to contraception in Eastern Europe was very low and therefore abortion was the primary way to limit the size of families. Thankfully, this has changed with more family planning methods available and consequently, we have seen some large decreases in abortion numbers. However, this sub-region continues to have the highest abortion rates in the world, so we have some ways to go. More disappointingly, there have been no real decreases in the number of unsafe abortions globally, which mostly means Africa, Asia and Latin America.

The numbers are sobering. But what worries me when I look at the stats is that we don’t really know what is going on at all. We all know it is difficult to come up with estimates for abortion in legally restricted environments and The Guttmacher Institute is doing the best it can with little data. Yet these latest state-of-the-art estimates are based on 2003 data and are often sub-regional or regional. This is an outrage. The latest data are seven years old and we don’t even have many national estimates. And all this is in the context of five million women a year being hospitalised because of abortion-related complications¹ and over one in eight maternal deaths caused by unsafe abortion.²

Is there a good reason why we can’t have better estimates? Methodologically, it is difficult to get estimates in legally restricted environments in which people are often hesitant to talk about such a taboo issue. Guttmacher (like WHO) use a combination of approaches such as analysing hospitalisation data or talking with abortion providers and other key stakeholders. This type of incomplete information can only provide an indirect estimation at best.
So it is difficult to do but that doesn’t mean it can’t be done. Ten years ago, we had equally shoddy statistics on HIV – another highly taboo subject. Yet, with enough political mobilisation and investment in surveillance systems, this has turned around with HIV now being one of the best monitored diseases in public health.

We need better data on trends in safe and unsafe abortion. This isn’t just the geeky research side of me talking : it is simply unacceptable that we don’t have a good grasp on such an important public health issue.

Next time, something more light-hearted, I promise!

¹Singh S, Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries, Lancet, 2006, 368(955):1887–1892.
²

Investigating maternal health (and death) in Nepal

07/09/2009 00:00:00

Monday morning, 7^th September 2009

Fainting dead away on the floor of a Marie Stopes International (MSI) clinic wasn’t how I imagined I’d begin my experience as an intrepid aspiring journalist. In doing so, however, I was able to experience first hand the care and expertise of the medical professionals that work there…

MSI are a leading reproductive health provider in Nepal and, through their local Partner Sunaulo Parivar Nepal (SPN), operate 61 clinics in 45 of Nepal’s 75 districts. MSI is sponsoring the 2009 Guardian International Journalism Competition and were responsible for setting assignments for two of the finalists. At the briefing day at The Guardian offices in London earlier this year I was randomly allocated, as a finalist in the amateur category, an assignment to explore the issues around the impressive drop in Nepal’s maternal mortality ratio (MMR) since the beginning of this century.

Having spent an intensive week prior to the trip researching this issue (as a research assistant for the Teacher Education in Sub-Saharan Africa (TESSA) consortium it was both a subject and geographical area about which I knew very little) I started this trip overwhelmed. Not only are there many factors that contribute to a country’s maternal mortality ratio but there appear to be so many issues impacting on these factors, and of course the usual interplay of rural/urban, male/female, educated/non-educated, ethnicity, prestige… as well as the differing opinions and allocations of responsibility by different stakeholders.

Most perplexing for me is the fact that my brief instructs that I explore this issue in the context of the Millennium Development Goals (MDGs) (of which number 5 states an ambition to halve maternal deaths by 2015 and provide universal access to reproductive healthcare services). The MDG framework uses official UN statistics which, while they do still report a drop in maternal deaths in Nepal, are considerably less impressive than the ones issued by the Nepalese Government Health Survey, and therefore the ones used by organisations such as SPN. This difference of up to 500 women per 100,000 cases of maternal death is something I am particularly interested in exploring while I am here in Nepal.

But, back to this morning, more specifically to the beginning of the day and a point at which I was still conscious…

Tony Kerridge (Senior Communications Manager from MSI London), Matthew Race (Business Development Manager for The Guardian) and I visited the SPN headquarters in Kathmandu. Kamala Thapa, the SPN Director, gave an overview of the issues and emphasised that SPN’s mission was to enable women to “have children by choice, not by chance”. MSI in the UK are perhaps best known for their abortion provision. They also provide 70% of registered abortions in Nepal but there are also key providers of sterilisations (providing over 45,000 in 2008) and non- and semi-permanent contraception. Between in 1994 and 2008, SPN has served over 1 million (male and female) clients in Nepal.

After the presentation I was given the opportunity to interview Kamala on a one-to-one basis. Kamala is so knowledgeable and passionate about her work. She introduced me to so many more complexities in reducing MMR that when the allocated hour was up I had more questions than when we began. I suspect this may be a recurrent theme this week.

After the interview we were taken by Pushpa, SPN’s Assistant Director to a clinic. Actually, in writing this I have just realised that both the Director and Assistant Director of SPN are female. I wonder if this is unusual for a Nepalese NGO? Something else to add to the list headed “To find out……”.

At the clinic, I managed to bring the tour to an abrupt end when I ended up coming-to in the recovery room feeling awful (physically awful, as well as awfully embarrassed). Not all was lost however, and arguably some things were gained as I ended up lying next to some SPN clients who agreed that I could interview them. I don’t want to write too much about this because this could be important case study information for my article, but I was struck both by how openly they discussed their family planning (and one of them had just had a medical abortion) and by the range of options available to them. Each had chosen a different method of controlling their fertility (and of exercising their right to have children by choice, not chance, in SPN speak). After a morning of speaking to the people at the organisational level, it was really interesting to speak to those who access these services.

After fully recovering, helped by a delicious lunch of Nepalese curries back at the SPN Headquarters, we drove out to the SPN training clinic: Satdobato. More of this later….

Victor - a victim of ignorance

17/06/2009 00:00:00

I was surprised when the front door of the Reception room swung open and in walked my taxi driver. It was Saturday morning, the Marie Stopes International Ghana Accra Centre was about to close and the taxi driver had been settling himself into his seat for forty winks when I got out of the car.

Ostensibly, Victor (the taxi driver) had come into the Centre to give me my pen, ’which you left on your seat.’ As he had not brought with him the notebooks and bag I had also left on the seat, I thought this unusual.

My main reason for sitting in the reception was to directly steal every good idea the Team in Ghana have had – and to transplant them right into the new Marie Stopes International programme we were launching in Nigeria!

But Victor was having none of that. He sat down, casually flicked through a brochure on family planning methods and asked, ’what do they do here?’ Putting on my best promotional face and injecting enough energy into my delivery to launch a rocket, I told Victor about the importance of the work of Marie Stopes International in general and Marie Stopes International Ghana in particular.

I noticed, however, that the more enthusiastic I became, the more furrowed his brow. As I finished my by now somewhat limp delivery, Victor looked at me and said

‘I am a victim of ignorance’.

I asked him to explain.

Victor gave me his life story and I was struck by the fact that at an absurdly young age – he was about 15 – he ‘met a girl at school’ and ’one thing led to another – really, I had no idea what was happening’ and the unhappy couple (as he described them at that time) had twins.

Victor’s life changed almost overnight. From a promising student to essential 24/7 breadwinner, with no room to think about the future when the demands of the present were so pressing. The twins also took their economic toll and although Victor never descended into absolute poverty, he only just managed to keep himself and his family above the breadline.

Still looking incredibly young – those still had to be his first teeth – Victor looked at the Marie Stopes International brochures again and wished that they had been available when he had been a teenager. With the increasing ‘sexualisation’ of youths and adolescents, Victor felt that there was no time to waste in terms of getting the ‘safe sex’ message ‘out there’.

Victor was even aware that this age group suffers most from STIs, including HIV, as well as unsafe abortions and unwanted pregnancies. In his youth, it was ‘what to do about it’ which had always had Victor stumped. Until now.

Waving farewell to Victor (who by this time had a fistful of brochures to take home to his teenagers), I was struck by his curiosity and awareness of ‘reproductive rights’ and how – as a man – he was one of the many who, far from being an obstacle to ‘development’ wanted to embrace it fully.

Victor was living proof that the common belief that men want nothing other to maintain the ‘large family’ status quo in Africa is perhaps not as widespread as was once the case.

Global Health Conference - Day 4

01/06/2009 00:00:00

Greetings from Washington Dulles Airport. I am packed-up and heading home after four whirlwind days at the International Conference on Global Health.

My “Best Panel Award” goes to a session today on private-public partnerships. It was based more on research than some of the other sessions and the panellists presented some thought-provoking conclusions.

One presentation was on a confidential perceptions survey of international health stakeholders (private/ public/ government/ donor). The findings showed that the vast majority of public health professionals have a highly negative attitude towards the private sector, reporting that the private sector is:

unwilling to collaborate
profit-driven
not health system strengthening.

At best, the private sector is seen as a means to an end: a short-term solution to compensate for overburdened government services. An underlying ideological scepticism leads to the belief that the private sector should not be trusted. This viewpoint is particularly common in Europe and Africa.

The survey also revealed that the private sector is generally fearful of government interference and considers government to be inefficient, corrupt and lacking in capacity. Mutual scepticism prevails.

So what is or should the role of the private sector be in the provision of health services? What form should the relationship between government and private providers take?

The panellists argued strongly that the government should play a stewardship role over private healthcare providers in a mixed health system. Their rationale is as follows: private providers are here to stay and are an important component of most health systems in low-income countries. However, an unregulated sector poses serious problems and therefore government should play a role in monitoring and controlling the private sector.

But the studies presented suggest that this is a long-term vision due to information, political and administrative barriers which prevent most national governments from assuming this stewardship role. In the short-term, the two most promising strategies are:

Encourage independent organisations to develop networks of private providers through accreditation and quality assurance.
Foster the development of professional organisations which can set standards.

The first point is pretty much what we are doing at MSI with our social franchising programme. By training and monitoring private providers, MSI is providing this interim support and maybe one day government could take over the regulation part. For me, the session really helped me understand how we as an INGO fit in with both the private and public sectors in order to build an integrated health system.

The final session of the day was also strong. It was all about product registration and procurement bottlenecks. Not exactly the sexiest of topics but a shocking and neglected issue in international health. One of the panellists talked about trying to register generic ARVs for HIV treatment in Botswana.

At the time, there was a backlog of over 2000 dossiers for registering different drugs. Each dossier took 30 hours to review and because there were three paper copies of each submission, the paperwork took up six entire offices. There was only one staff member to review the dossiers and he/she lacked any specialised training.

The panellist was part of a team which went in and prioritised 400 key dossiers and set up a system to process the backlog. As a result, all the priority dossiers were approved in six months and the price of ARVs dropped six times as cheaper generics became available.

FHI presented on their attempts to register Sino-implant (II) in 14 countries. MSI is leading registration in seven of these countries, having successfully registered the product in Kenya. Traditionally, implants have cost about $10 per year but with this cheaper Chinese version, the costs will be 70% lower. Despite the potential for massively increasing access, the national registration process remains time-consuming and complex.

Well, that is it from me. Until next time.

Global Health Conference - Day 3

29/05/2009 00:00:00

Today was a lot of fun. The theme of the conference is about new technologies and it is mind-blowing what the potential is. I must admit that I was a bit of sceptic beforehand. MSI has a pilot project in Kenya to send routine data through text messaging and I just wasn’t convinced that it would work – or else that it would be too much work.

Now I realise that I have been stuck in the dinosaur age. Take these crazy facts and statistics:

it is now easier and cheaper to get connected through a mobile phone in Africa and Asia then in Europe and North America;
there are 4 billion mobile phones in the world – this represents the most sustainable infrastructure for information transfer; and
20-30 million texts are sent a day in South Africa. HIV behaviour change messages are now included on one network, leading to 1.5 million people a day receiving health information and advice.

The public health community has started to realise the potential of using mobile phones to improve operational information systems – i.e. to make our current systems work better so that we can deliver services more efficiently. This is great and I am all for improving our data collection systems. However, the really exciting and unexplored territory is how mobile phones can be used to reach people directly with health-related information and services.

Essentially this represents a seismic shift in how healthcare is provided and places power in the hands of the individual rather than the healthcare provider.

This isn’t all just theory but is already happening – for example, people often don’t want to go for HIV testing in South Africa because they fear being seen in the queue for the VCT clinic. In fact, 78% of men would prefer to take the test at home. However, pre- and post-test counselling is an essential part of HIV testing and so people can’t just administer the tests themselves. The answer is to provide the counselling services over the phone. This ensures confidentiality and allows the person to decide where and when to take the test.

Anyway, I could go on and on but need to also tell you very briefly about the exciting research that is taking place in saving newborn lives and why MSI should be doing more in postnatal care. Some distressing facts:

more than 4 million newborn babies die within in their first month of life;
99% of these deaths are in low-income countries; and
most of these deaths are preventable.

The good news is that there is now very strong evidence based on a cluster randomised controlled trial with over 400,000 women in Bangladesh which shows that there are simple and cheap strategies to prevent these deaths. The study examined a range of strategies such as community education, home versus clinic antenatal and postnatal visits and counselling.

All of these interventions had some impact but the thing that made the most difference was a single home visit to the mother and newborn within 48 hours of birth (the postnatal visit). This alone contributed to a 30-40 % decrease in newborn deaths. Just having a trained community health worker come and check the baby’s weight and check for signs of infection or other ill-health made an incredible difference.

MSI delivers tens of thousands of babies in our clinics every year. We also have strong networks of community-health workers. We could make a real difference in saving newborn lives.

Global Health Conference - Day 2

28/05/2009 00:00:00

Day 2 at the International Conference on Global Health and your faithful blogger is officially exhausted. Non-stop sessions today mixed in with frenetic stall action and my brain is whirring. All good though and the Marie Stopes International exhibition stall was a great success.

Contrary to my predictions, everybody loved the free spikeys (free things to stop people spiking your beer in bars) and they were the centre of many colourful conversations.

The official programme started today and there was a good session on vouchers for healthcare. The panel consisted of four speakers who each outlined their particular voucher model. What struck me was how different each model was and how the concept of what a voucher is varied so much. In Nicaragua, the voucher is a free piece of paper that is given out to all teenagers in order to increase access to family planning services.

The programme literally handed out hundreds of thousands of vouchers without much targeting and the redemption rates were below 50%. This was completely different to the model in Kenya (which MSI partnered on) in which women paid a significant monetary contribution for the voucher and the redemption rates was over 80%.

Despite the differences, there seemed to be some consensus over the necessary elements to a voucher programme:

reimbursement follows services (output-based aid)
a network of healthcare providers is mobilised to increase access
there is some sort of voucher circulation system (e.g. a management agency)
promotion activities are used to generate demand

The role of the management agency is inherently complex and usually includes responsibility for accreditation and quality assurance; claims and reimbursements; marketing and internal monitoring and evaluation.

Unfortunately, corruption of some sort seems inevitable given the large amounts of money flowing through the voucher system as well as the monetary value of the vouchers. In Kenya, the vouchers are targeted for poor women.

Initially, screening took place in health facilities but it soon became apparent that people were not being entirely honest about their circumstances. The only way to actually verify the screening was to conduct a home visit which became necessary albeit expensive and time-consuming.

This challenge of targeting the poorest community members was a reoccurring theme: in Tanzania, the programme provided vouchers for insecticide treated nets (for malaria prevention) and was supposed to target the poorest of the poor but failed to do so because of financial barriers, lack of education and distance.

Reflecting upon the presentations and our own experience in MSI in managing voucher programmes, I remain optimistic that this type of demand-side financing is an important way to provide services to those who are normally excluded due to poverty or discrimination. However, we still have a long way to go before we can know whether or not such programmes are either cost-effective or sustainable.

Finally, I went to the only scheduled session with the word “abortion” in it which was on youth-friendly post-abortion care. Youth-friendly programmes in Ethiopia and Nigeria have made a real difference in increasing the rate of post-abortion family planning (from 34% to 100% in Nigeria) although in most cases, it seems that young people are walking out of the clinic with a handful of condoms rather than a longer-term solution such as an IUD or implant.

Gynuity presented on a randomised trial comparing the outcomes between misoprostol and MVA for the treatment of incomplete abortions or miscarriages in Egypt. The success rate for misoprostol (measured as complete uterine evacuation) was 98.3% compared to 99.7% for MVA – in other words, there was no significant difference between the two procedures. Moreover, women were generally more satisfied and more likely to recommend misoprostol than the standard MVA procedure.

These findings were particularly timely and cause for celebration with the recent announcement by WHO that misoprostol is now included on the essential drugs list for the treatment of incomplete abortions.

On that good note and with drooping eyelids, I will sign off. More anon.

Global Health Conference - Day 1

27/05/2009 09:56:43

Okay, so here is where you can read all the exciting news from the 36th Annual International Conference on Global Health as it unfolds.

We haven’t actually had the “Grand Breakfast Gala Opening” yet but already there have been a plethora of workshops and auxiliary sessions… and unlimited coffee and chocolate brownies! In fact, there definitely seems to be some sort of competition between the different workshop sponsors on who can provide the most lavish feast and I am certainly not complaining… by the way, you will be pleased to know that our MSI stand is giving away free British sweets so hopefully that will draw in the crowds.

As for the sessions, we had a really good panel discussion this morning on public-private partnerships - a topic close to MSI’s heart. We discussed the urgent need for mobilising the private sector in the rollout of treatment for TB and AIDS.

An Abt Associates study in Ethiopia showed how the private sector is keen to be involved in TB treatment – not just because of financial gain but also because of a sense of social responsibility and in recognition of the skills they could gain by working with the government.

Following a capacity-building programme, the outcomes (both clinical and quality) were comparable between the private and public providers. This evidence counteracts the common perception that private providers will provide low-quality services with lower success rates. The challenges in working with private providers are to:

ensure private providers follow national guidelines;
collect monitoring data consistently;
encourage private providers to participate in government planning exercises;
communicate new policy or protocol changes to private providers
develop sustainable solutions for when the “honest broker” disappears

Of particular interest to MSI, is the role of NGOs. The panellists stressed the importance of distinguishing between the “private not-for-profit” sector and the “private-for-profit” sector. An obvious role for us non-profit NGOs is as an “honest broker” between government and private providers.

In addition, NGOs can play an important role in training, accreditation and coordination of private providers. Sound familiar? Basically, this chimes really well with all the lessons that we have learnt from our own MSI BlueStar programme.

As well as approval and accreditation, there are four other main types of public-private partnership:

employees schemes;
partnerships combining private and public resources;
health insurance schemes; and
contracting-out public sector services to the private sector.

Clearly, MSI is already an innovator in many of these areas and the panellists recognised that lessons from family planning programmes should be used now in scaling-up access to HIV treatment.

The second session that I attended today was the Biannual Meeting of the Postabortion Care (PAC) Consortium. We had three USAID staff talk through the recent policy changes. They explained that the Helm’s Amendment is still in place (which prohibits any funding to be used for abortion which is coercive or used for family planning) and that USAID still does not fund any safe abortion programmes and this is unlikely to change in the near future.

They do fund post abortion care but won’t fund any of the supplies needed for emergency treatment. The good news is that they explicitly welcomed new partners and various people mentioned MSI. Dana and I are off to talk with them on Thursday so hopefully this will be the beginning of a new era!

The session was really participatory and there were lots of people from countries such as Egypt and Jordon who are currently trying to introduce PAC programmes and facing similar problems. One of the major challenges seems to be that governments will not support the introduction of MVA equipment which makes PAC impossible. Clearly advocacy here is important and ministries that have successfully started programmes and included MVA equipment on the national supply lists play a pivotal role in sharing those experiences with other countries.

Quote of the day goes to one participant who asked “ Why are we going for cable when we could go straight to digital?” as an analogy for why are we wasting our time trying to get countries to introduce MVA equipment for PAC, when we could go straight for medical abortion. Bring on the digital age!

Out to 8 Mile

20/05/2009 00:00:00

It was a long and dusty ride to 8-Mile, a settlement of about 7,000 people located on the outskirts of Port Moresby. This was my fourth trip to the area, but it was the most memorable and exciting. I was driving there with Senator Claire Moore of the Australian Parliament and Dame Carol Kidu, the only female member of the PNG Parliament, to visit the Orinamaoro Hausbung, which in local slang means ‘gathering place for good, young people”, a youth friendly centre.

The community, with the help of Marie Stopes Papua New Guinea, had set up the centre. The building itself had been donated by a big-hearted resident whilst local young people provided the labour to improve and clean up the place. Community residents had collected money for paint and lumber and two local businesses had donated ceiling boards and gravel for cementing the floor. UNICEF PNG had also provided some small seed funding to go toward the centre’s refurbishment.

Senator Moore was so touched by the residents’ enthusiasm and joy in welcoming her to the Orinamaoro Hausbung, which was the pride of the community as the community had been so involved in establishing it. She learned that the Orinamaoro Hausbung is a place for young people to hang out and learn more about the pressing issues that affect young people in PNG. Issues like HIV/AIDS, sexually transmitted infections, teen pregnancy, peer pressure, gender equity, and the effects of violence against women. The community turned up in big numbers and put up a large welcome board for the Senator. They really appreciated that someone from another country cared enough to visit them and encourage them and there was a clamor for her to address the crowd.

In her speech, Senator thanked Marie Stopes PNG for taking the initiative to start such programmes, especially in communities were such services are lacking. She also thanked the community for their part in supporting Orinamaoro Hausbung, thereby ensuring its sustainability. She said, and I quote, “The good partnership between organisations such as Marie Stopes PNG and communities is an effective step in bringing about lasting development, and Australia can learn so much from PNG”. The success of Orinamaoro Hausbung has already resulted in some small extra funding to use music, theatre and drawing to deliver key health messages, Later on Senator Moore and I were shown the proposed open theatre, right beside the centre.

Talking to the young people of 8-Mile, Senator Moore found that the Orinamaoro Hausbung was where sports clubs like the rugby teams and the girls’ volleyball teams meet. She was not surprised to learn that many of the boys and girls were mad fans, like her, of her home state team, the Queensland Maroons. This camaraderie brought her, and all of us with her, walking to the sports field under the glaring sun. She was so touched by the very rudimentary field and the rugged balls being used by some girls and boys that she whispered to me that she would donate some volleyballs and footballs to Orinamaoro Hausbung. Who knows, with the strong rapport that she developed with the young people of 8-Mile, she might just get some autographed and framed posters of the Maroons team to hang in the Orinamaoro Hausbung!

The story of Mattu. It's never too late

06/03/2009 00:00:00

Kinema, Eastern Sierra Leone, near the Liberia/Guinea border
March 6 2009. 6:30AM

I met Mattu yesterday afternoon in the village of Gala, a 4 hour drive from Sierra Leone’s capital of Freetown, and an hour on a dirt road outside of Sierra Leone’s 2nd largest city, Bo. Mattu is 35 years old. Pregnant 8 times, she has 7 living the children. She brought the youngest, a 6 month old girl, with her to see Marie Stopes Sierra Leone’s clinical outreach team.

Mattu had wanted to stop having children some time ago. But she was unable to decide the number and spacing of her children. There were too many obstacles in her way, for too long -- a husband who refused to let her use contraception; illiteracy, and misconceptions about family planning; poverty. And perhaps most importantly, comprehensive family planning services were not available near her rural village.

A year earlier, she had managed to overcome nearly all of these barriers, and showed up at the Bo regional government hospital for a tubal ligation (sterilisation). She was told that she would need to pay 200,000 Leones ($US65). So she returned to her village, and had another child…..

Mattu heard that a Marie Stopes Sierra Leone rural outreach team would be visiting Gala, a small village with a rural health post. So she travelled the 8 miles there to have a tubal ligation. Mattu had finally overcome the last barrier to taking control of her fertility and her reproductive rights – access to services.

Mattu’s story is told millions of times over in Sierra Leone and around the world. In Gala alone, around 40 other village women had shown up for a tubal ligation or an IUD (intrauterine device) on the day that MSI’s clinical team arrived to provide services. Too many of these women had waited for far too long for family planning.

Yesterday, I also met Marianne at one of Marie Stopes’ Blue Star network private providers. MSI has introduced contraceptive implants to Sierra Leone via this private provider franchised network. Within a few weeks, 12 women had already received implants from this private provider alone. Marianne, 27 years old, has been pregnant 7 times, with 3 living children. With the implant, and because of Marie Stopes Sierra Leone and the Blue Star franchise, she is safe for the next 4 years.

In Freetown a day earlier, I visited MSI’s maternity centre, perhaps the best facility of its kind in this city of 2.5 million people. Obstetric emergencies and the riskiest births come to us. There, I saw a tiny baby, born prematurely at 28 weeks gestation and weighing 1 kg. Her mother was 15 years old. The baby now weighs 1.4 kg, and is one of the lucky ones.

We have all showed up late for Sierra Leone’s women, and we have let them down. After the war and chaos of the 1990s in Sierra Leone, it has taken far too long for women to get basic maternal and reproductive health services. Sierra Leone has amongst the highest maternal mortality rates in the world; and modern contraceptive use is a paltry 7%. And the two most popular and widely used methods in the world – IUDs and sterilisation -- almost don’t show up in surveys because their use is so small in Sierra Leone.

But it is better to show up late than to turn our backs on Mattu, Marianne, and the 15 year old mother in MSI’s Freetown maternity centre. MSI is doing what it can – around 1 in 6 of all Sierra Leonian women using modern contraception today are doing so because of MSI services. We would have done more, sooner, but there was too little funding for family planning in Sierra Leone. And too many donors prefer to fund only government health services, rather than pragmatically fund whatever works. So we have had to use MSI’s own discretionary funds, coupled with some European Union support, to scale up nationally, and to reach Mattu in her village with the life saving and life changing family planning services she has been waiting for.

I am proud to be part of MSI, and proud of the energy, drive, and commitment of the Marie Stopes team in Sierra Leone. We are making a difference in the most challenging places. In 2008, we provided over 1.2 million IUDs, sterilisations and implants to women just like Mattu and Marianne. Indeed, around 75% of MSI’s family planning impact is for underserved, largely rural and poor women. We are delivering family planning services that matter to the future of countries such as Sierra Leone, and that matter to women such as Mattu.

Outreach in Nuguni

04/03/2009 00:00:00

This morning I’m zooming off out of Nairobi (well as much as you can ever zoom out of Nairobi) in the direction of Nunguni, a small town up in the mountains. I’m with the Marie Stopes Kenya outreach team who are going to be providing family planning services there for the day and they’ve invited me to join them.

The journey to Nunguni is going to take us just over 3 hours, but it certainly isn’t tedious. A combination of amazing scenery, the chance to spot some game and the driving ‘style’ are keeping me very much alert! I’m travelling with Anne, the Outreach Team leader. Anne’s a nurse and she’s worked for Marie Stopes Kenya for many years so I’m going to use this opportunity to pick her brains.

In the car ahead are the rest of the team; Fred (the doctor), Julia (another nurse), Peter (the clinical officer) and Lucas (driver, surgical assistant and comedian).

As we finally escape the heavy traffic we start to climb up and up a mountainside, through the switch-backing road, up and up there, eventually, ahead of us is the sub hospital of Nunguni.

As we pull up, Fred, Julia, Peter and Lucas are already beavering away, setting up the procedure room, scrubbing up and preparing instrument sets. News of the outreach team’s arrival has been publicised well in advance throughout the villages surrounding Nunguni and a group of about 40 people have turned up.

Peter gathers the group around him and starts to deliver a health education talk, focussing on family planning choices. The talk will enable the women (and men) to decide which option best suits their needs be it, bilateral tubal ligation (female sterilisaton), contraceptive implants or an IUCD (interuterine contraceptive device). As well as these options the team is also able to offer Voluntary Counselling and Testing for HIV as well.

Everything is really well organised, and not a moment is wasted. That way, the team is able to see as many clients as possible. By the end of the day, a total of 26 women have had a bilateral tubal ligation. I talked to a number of the women as they were waiting and many had already had 4, 8 or more children and were extremely happy to be able to receive this service which is provided free of charge. The procedure takes approximately 7-10 minutes, and then the woman is given some paracetamol, a sugary drink, and rests for half an hour and before heading off home. I watch in amazement as these women simply picked up their bags and headed off back up the hills to where they live to carry on with whatever chores were awaiting them at home or in the fields.

The team work through the clients without a break and with good spirits and humour, even though they must be exhausted. They’ve been on their feet for almost 5 hours and there’s still over a 3 hour journey to get back to Nairobi through the crazy traffic again. On the way back the roads are extremely congested coming into the city and the police were on every corner. The President of Iran is paying a visit. One way of traffic calming (as I discovered) is simply to close the roads until the VIP has arrived in town from the airport. Then, it’s every man for himself. One team member explained to me that ‘People in Nairobi just drive to move’; hard shoulders, roads closed for resurfacing, petrol station forecourts and imaginary spaces between cars are all used to their maximum potential. You just gotta keep on moving in Nairobi.

The slum clinics

02/03/2009 00:00:00

I've just spent the morning visiting the Marie Stopes Kenya clinics in Kibera and Kangemi.

The clinics are in the slum areas of the city and provide the same selection of services as in other clinics but at somewhat subsidised rates, in line with the average household income. It was particularly interesting to visit Kibera, which had appeared so much on our television screens last year during the post election violence, yet now is calm and back in a ‘business as usual’ mode.

The Marie Stopes Clinic in Kibera is diminutive but it packs it all in with no space is wasted and the full range of reproductive health services being offered.

I'll be spending the next couple of days with the team here in Nairobi and then heading off out of the city with the outreach team.

RAISE of Sunshine in Kenya

24/02/2009 00:00:00

I have come to Nairobi on my first trip with the RAISE Initiative. The main purpose of this trip is to acquaint myself with the RAISE training centre and the team in Eastleigh, Nairobi but also to visit the Marie Stopes Kenya centres, their staff and to learn more about the partners and the MSI ‘way’. It is also my first time in Nairobi, and as it turns out my first time to eat Ugali, after several failed attempts of stomaching Foofoo in West Africa.

After an overindulgent one hour sleep on the overnight plane and one hour power nap on arrival at the hotel (I think sleep is overrated anyway) I am collected by the lovely Carol and delivered to Eastleigh where my new colleagues await me. Dr Fred Akonde is the chief ‘meeter and greeter’ and after a brief briefing takes me on a tour of what I find to be a spectacular facility.

The RAISE Eastleigh Training Centre nestles comfortably on top of the Eastleigh Nursing Home, which offers Reproductive Health services of all natures to woman and men. The staff are upbeat and friendly (despite the droves of visitors they must have encountered before me) and I am encouraged to discover that many have worked for Marie Stopes Kenya for several years.

The RAISE Training Centre was set up to deliver high quality Reproductive Health training to providers working for partners of the RAISE Initiative. In addition to the RAISE staff, I meet the participants of a Family Planning Training currently underway. They have come from South Sudan and Uganda.

They have already spent 4 days on theoretical practice in the classroom and then spend 5 days working with clients, offering a range of long term contraceptive options, mainly implant and IUCD.

The Marie Stopes Kenya Centres are utilised for these practical sessions. It is thanks to good collaboration with the highly skilled and experienced providers at these centres, plus the RAISE trainers that make the practical sessions fabulous learning experiences, equipping the participants with the practical skills they need to boost the reproductive health services in the contexts they work in.

One of the South Sudan doctors has come for the first time to RAISE training. She says “It is a very good training, I have gained lots of new information and great experience. I have also learnt the importance of counselling the client through the available options, something that is often missing. I am happy and confident to return home to help the women in my community.”

It is very encouraging to see the high levels of energy and motivation of the participants and to also hear from the trainers of how far they have developed in such a relatively short time. After returning to their own settings their progress will be followed up with an onsite visit from a RAISE trainer in 6-12 weeks. The participants clearly also gain from their interactions with each other, learning about provision of healthcare in other countries and regions not to mention the cultural exchange that takes place.

The course ends today and the participants will start to head home tomorrow. I will remain in Nairobi to do some work with the team here and explore the Marie Stopes Kenya programme a little more. Then, for the last day, I'll come back to spend a bit more time with the RAISE team (Fred, Pamela and Lilian) planning for the next couple of months.

I thought that Nairobi would still be high with ‘Obama fever’ but the temperature seems to have dropped on that story for the moment. Domestic politics and the soaring price of maize are more pressing for now.

From London to Dhaka

11/12/2008 00:00:00

London & Dhaka - a little while ago, MSI’s UK programme held a competition to send a team member to visit one of the MSI programmes in Africa or Asia. The aim was to encourage a greater understanding of the work done
internationally, which part of the surplus from the UK helps to support. Collette Doyle came joint fi rst in the competition and spent time with Marie Stopes Clinic Society (MSCS) in Bangladesh. Here she talks about her trip and the impact it had.

“When I won, I didn’t fully appreciate what an amazing and rewarding experience it would be. I now have first hand knowledge of the amazing work which Marie Stopes Clinic Society carries out.”

Despite being a short trip, Collette saw a variety of services. On her first day, she visited an Urban Primary Healthcare Project, and a premium maternity centre, as well as observing MSCS’ homeless programme.

“I was lucky enough to travel in one of the MSCS vans which drive out to areas where homeless people congregate. I was surprised by the number of clients who can be seen. About 70 people were helped during my visit. Actually seeing all the families sleeping on the floor made me very sad but I was uplifted by the amazing work carried out by my colleagues.”

During the next three days Collette travelled to some of MSCS’ mini centres (which are often in the slums) as well as visiting one of the factories where the team in Bangladesh run a mobile health card scheme. Under the scheme, the team go into the factories and on-site provide the workers there with healthcare services; services, that they would otherwise not be able to access as taking time off work to go to a health centre would mean that they would lose pay.

The MSCS team also run information and question & answer sessions as well as referring the workers on for other, more specialist services if need be.

Collette’s favourite part of the trip was a visit to a programme for young people; a network made up of twelve centres located in deprived parts of Dhaka and Chittagong which provide recreational activities, peer education and life-skill training.

“I was shocked by the poverty in the area surrounding the centre I visited, but will always remember seeing the MSI sign in the middle of the slum. There was such a warm and happy atmosphere inside the centre and it was
immediately clear how much the young people enjoy spending
time there.

“I was treated to some group singing and the young people proudly showed me paintings, candles and bags that they had made. I was so impressed by the centre and the wonderful, dedicated team members there. The young people explained how they line up outside waiting for the centre to open and told me it is their favourite place to have fun and learn essential life skills.

When I won the trip I didn’t realise just how much of an amazing
opportunity it would be. I will never forget it and the innovative work done by the MSCS team. I hope the work they do helping the poor and vulnerable will continue to grow and expand. It’s very rewarding to know the work done here in the UK is helping to make such a positive improvement to the people of
Bangladesh.”

Collette Doyle

Irene and Natasha: the forgotten women of Gori

29/09/2008 00:00:00

Gori Tent City, Saturday 20th September.

At the tent city I talk to Irene who smiles shyly as she waits to be seen in the small tent that is the reproductive health clinic. She is 21 years old and is nine months pregnant with her first baby. Her baby is due in the next few weeks and she wants to have it in hospital when the time comes. Fortunately, the hospital in Gori wasn’t destroyed unlike many others in the areas to the north of the city.

Irene fled her home with her husband and his family when the fighting between the Russian and Georgian forces came too close for comfort. Fearing for their lives, they fled first to her husband’s sister’s house and then to a camp for displaced people. The camp is near their home in Gori and they’ve been living there for the last month. “We are all staying together in one tent, with other people” says Irene. “There are eight of us in one tent. It is ok, but noisy and there’s no privacy” she adds .

Some of those, like Irene and her family, have moved to the tent city which is at the edge of the “buffer zone”. More than 2,200 people are living there now but that still leaves many thousands displaced.

In the tent city some people are alone but families have fled together and at night in there are empty beds in many of the tents as husbands and wives are sleeping together as they would if they were at home. Yet many will not be using contraception, as remembering to pick up your pills or condoms is not high on most peoples’ list of things to bring when you are fleeing your home in the middle of the night.

I also talk to Natasha, a 27 year old mother of three young children who has just received a dignity kit. She and her husband and children have spent the last month in a school near Tbilisi airport which was being used to house displaced people. Conditions were basic, with little in the way of sanitation and it was noisy and crowded. When the authorities told them they must leave as the school was needed for its proper function, they decided to return home. However, when they got to Gori, they heard that there were still many soldiers in the village. “I was happy when I heard our village was not so badly damaged by the bombs” said Natasha. “But then I heard that the soldiers are still in the village. They get drunk and then no one knows what they will do. I have heard of many cases of women being raped. I am too scared to go home. My husband goes to the village every day, but he comes back to sleep here in the camp at night. He says it is not safe in the village. It is best for me and the children to stay here.”

Before I leave the camp to move on to a newly opened youth centre, where I bump into Irene again and her mother in law, also called Irene. She tells me how excited everyone is about the new baby. “I already have one grandchild” says Irene senior. But this one will be special.” Both smile broadly as they think of the new bundle of life that will soon be part of their family and the hope of a better future ahead.

As for me, I’m returning to London tonight and will be keeping in touch with parliamentarians on the tour to encourage them to raise these issues with their governments to ensure that the needs of women in Georgia and other emergency settings are not forgotten.

To read Louise's first blog on this trip titled 'Georgia', please click here

Georgia

19/09/2008 00:00:00

If your house was on fire what would you rescue as you ran from the smoke and flames? A family photograph? Or a keepsake, a special piece of jewellery perhaps? What about your contraceptive pills? Of course not the pills, it will be possible to get more from the health centre. But what if the cause of the fire is a bomb and the health centre was also hit? For the women of Georgia who are pregnant or use the contraceptive pill as their method of contraception, this in the situation they face.

I’ve come to Georgia as part of a fact finding delegation from the European Parliamentary Forum on Population and Development to assess the reproductive health needs of those who have been displaced by the recent fighting between Russian, Georgian and South Ossetian forces. The rest of the delegation is made up of MPs and MEPs but I am representing Marie Stopes International (MSI) which is the only NGO to have been invited.

I've been invited because I work on the RAISE Initiative which MSI coordinates along with Columbia University. RAISE is a multi agency, multi country programme which brings together 10 leading service delivery and advocacy organisations to scale up comprehensive reproductive health services in crisis settings. RAISE, which stands for Reproductive Health Access, Information and Services in Emergencies, helps refugees, internally displaced people (IDPs) and returnees in crisis areas such as Colombia, Northern Uganda, and Darfur in Sudan.

Here in Georgia, an estimated 128,000 people were displaced within Georgia and South Ossetia and more than 30,000 fled to North Ossetia in the Russian Federation. Approximately half of those have now returned home, but for many this remains impossible.

Many women fled with their husbands and children to Tbilisi where they have been living in “collective centres” - schools and other public buildings that have been converted into temporary shelters.

Today, we visited one of the collective centres, a school in Tbilisi where 100 families are now living. Many of the people living in the school are from the villages to the north of Gori city. Conditions are basic, with only one toilet and one washbasin on each of the four floors. Wherever possible, families stay together, but often there are two of more families in each room. Late at night, husband and wife talk about when they may be able to go home and what they might find when they get there. They talk about plans for the future and they come together to comfort each other. But she has not taken her contraceptive pill since the day she left her burning home over a month ago.

Reproductive health services are recognised in humanitarian guidelines as an essential part of emergency response. Priority activities are primarily preventive – preventing gender based violence, HIV transmission and preventing unwanted pregnancy. Although abortion is legal on demand up to 13 weeks in Georgia, health services have been disrupted and prevention (contraception) is the better option.

We also went to Gori where we saw the bombed houses and schools from which many had fled. Tomorrow, we are going to see the tent city there where over 2,000 people are now living.

It's been an exhausting day.

Millennium development goals

18/09/2008 00:00:00

Well, it's goodbye for the moment: I'm back at my desk in London now, my head spinning with all I've seen.

As well as this blog, as a result of my own travels I'll be writing two long features about the progress of the Millennium Development Goals (http://www.un.org/millenniumgoals/) in Tanzania and Bangladesh respectively.

Most of the finalists are back in the UK now, their trips over, with the hard task of condensing hundreds of words of notes into 2,000 word articles. Good luck to them all, and happy writing!

The two overall winners will be announced in an awards' ceremony on November 20; all the finalists' features will appear in one of the two special supplements published in the Guardian on November 22 and 24.

There will be more information about them on this site then: don't miss it!

For updates on the Guardian Independent Development Journalism competition, please visit News in the international section of our website.

To visit the Guardian website, please see:
http://www.guardian.co.uk/journalismcompetition/finalists

Dhaka for dummies

17/09/2008 00:00:00

Day 1 - Sunday

Upon arriving at Zia International Airport, Dhaka, after a comfortable but long flight from London via Dubai, we are directed out of the airport and promptly walk into a wall of heat. My travel companions (Diana Thomas, competition finalist Sophie, and Guardian editor Sue George) and I eagerly give our bags to the driver (as lifting them into the car may cause a fatality), and seek sweet relief in the air-condioned car.

Our driver masterfully negotiates the chaotic mess of private cars, tuk-tuks, rickshaws and motorcycles that fill the 4 “lane” highway. Driving in Dhaka appears to be quite a skill and we are impressed by the mere fact that we get to our destination unscathed. Many journeys since have revealed something of a road hierarchy (everyone gives way to buses; pedestrians cross at their own risk) and I have come to recognize the simple (or complex?) hand signals that ensure a slow but steady flow of traffic. Although I do mean slow because despite Bangladesh’s dense population, it is not the streets that are overcrowded but the roads.

After quickly checking in and freshening up at the hotel, we are whisked off to meet our colleagues at Marie Stopes Clinic Society (MSCS). We meet with Dr Golam Rasul, Abdur Khan, Dr Reena Yasmin, and Shahid Hossain who give us an overview of their very impressive and successful program: 42 referral clinics, 42 mini clinics in slum areas, 46 upgraded clinics, 6 drop in centres and 6 premium (higher income) centres.

We learn about their outreach services, which include 32 adolescent programs, 96 satellite sessions per month to the homeless population over 12 locations, 53 NGO partnerships providing STI services, and activities to 121 factories via the ‘Health Care Card' scheme. Fortunately, we are scheduled to visit many of the centres over the course of the week where we’ll see first hand how MSCS provide reproductive and sexual health services and awareness to the poorest and most vulnerable communities in Dhaka.

Day 2 - Monday

Today we visit our first MS mini clinic, which is based in the slum area of Kallyanpur. Dr Masud joins us, and introduces us to the paramedic and the 3 volunteers who are recruited from the slums and trained by MSCS. Sophie interviews a newly married 19 year old woman who is visiting the clinic with her husband to pick up contraception - they have decided not to have children for 5 years until he has finished studying and they are able to afford better living conditions. Theirs is a romantic story as he disowned his very wealthy family who disapproved of his marriage to a poor girl, and as a consequence they now have struggle and support themselves. Despite this, they are a lovely young couple with eyes only for each other.

Next, we make a quick visit to a UPHCP satellite session before heading to Dustha Shasthya Kendra (DSK) where a very lovely Dr Lovely gives a presentation on primary healthcare and DSK health activities. DSK, an NGO with a strong development focus on primary health care, water, sanitation, skill development training and primary education, have established a revolving credit scheme which provides (for a small weekly fee) affordable health services to urban slum dwellers and squatters.

Our next visit is with Assistance for Slum Dwellers (ASD), a non-profit and non-political development organisation that attempts to provide basic facilities to slum dwellers in order and have undertaken programs in slum areas providing access to education, nutrition, health and income earning opportunities.

We move on swiftly to our final appointment for the day, a visit a slum-based MSCS Adolescent Program. Getting there involves an unexpected but highly entertaining cart ride over a flooded section of road. Arriving at the centre, we are greeted by the dozen adolescents who come 6 days a week to learn about health and social issues, and personal and physical development.

As Diana and Sophie interview individual teens, I spend an awkward half hour with the 10 that remain. Feeling much like a teenager myself, I’m paranoid I’m being talked about as they giggle and stare, and became terrified I’m about to break out in spots and bad clothes. My two words of Bengali are proving of little use (there are only so many times you can say hello and thank you) until one of the more courageous of the group breaks the long, awkward silence by showing me various arts and crafts they’ve made (they are taught skills such a making envelopes, candles, small handicrafts and incense).

My self-consciousness returns however when they ask me to sing – and it’s one of Michael Jackson's hits preferably. I figure if these kids know who he is then I can’t pretend I don't and I stammer my way through a couple of lines of 'Heal the World'. Clearly I'm more NGO than I thought. I’m rather offended however when all the kids suddenly jump up and run out the room, but as it turns out fast has broken and the kids are in the next room eagerly quaffing RC cola and handfuls of rice. Then it’s time to leave but not before we’re treated to a song by the entire group, followed by photos, kisses, and a sad goodbye.

Day 3 - Tuesday

A visit today to two slums, one in the city and one on the outskirts. We walk precariously on the bamboo planks that connect the houses, a makeshift floor raised 1/2m above the filthy, smelly sewerage water that lies beneath. We visit the communal cooking area and are invited into a number of homes which are surprisingly tidy and well decorated.

Women emerge from their houses carrying half-clothed children but when we start taking photos, the kids are ushered back inside before reappearing in their "best" clothes. The woman who is head of the slum invites us to gather with the other women in her house; a large and well kept room furnished with a television set and ceiling fan. The women know quite a bit about family planning, how and where to access it, and use a variety of methods between them.

As we listen to the women’s stories, it emerges that they are clearly dependant on the wages earnt by their husbands who work as either rickshaw pullers or day labourers. Often they can't eat or feed their children until their husbands return from work with their earnings. Others speak of husbands who spend their wages on drugs, and of the problems these addictions cause.

After next speaking to a group of men, we make a long journey across town to next slum. The conditions are much the same and we poke around the houses and speak to the men and women who live there. There are 3 health care facilities nearby (MSI clinic, government health complex and a pharmacy) and everyone here knows where they are located and what services they offer.

We speak to a woman with 5 children who has recently had TL (with her husband’s blessing), and others who say that they speak quite openly with their husbands about contraception. This is good news, even more so when they state their preference for the MSCS clinic for their FP needs. We are then led to a building which is used as the school and admire the pictures painted by the students that adorn the walls. Numerous photos are taken and discussions with accompanying MCSC volunteers from the nearby clinic follow before we bid everyone farewell.

Arriving back at the hotel in the late afternoon we venture out for dinner at a local restaurant. The streets are quiet and the restaurants empty as it is past 8pm and everyone has broken fast and eaten already. The restaurateur kindly sources a couple of beers for us, an evidently difficult task given the 20 minutes it takes for him to return. After a delicious meal for a very cheap £8 each, we head back to the hotel and straight to bed.

Day 4 - Wednesday

Day 4 of our visit to Bangladesh visit and we’re temporarily one man down. Sue has taken ill but we hope that she will be well enough to join us again tomorrow. Diana, Sophie and I start our day with a visit the referral clinic, which has a client breakdown is approximately 50% middle class, 40% factory workers and 10% high income earners.

We leave Diana to make her way to the maternity centre as Sophie and I travel to our next appointment with Mr Mostafa Quaium Khan, Executive Director for the Coalition for Urban Poor (CUP), an organisation working on the rights based issues of slum dwellers. Poverty assistance is a top priority of the BDG government, and although was initially a rural issue, there has been significant a growth in urban poverty since the 80s.

At present, largely due to migration from the rural to the urban areas in search of employment, there are 4.5million people living in poverty in Dhaka – 4million of who live in the slum areas and 500,000 “floating”. These numbers are increasing due to recent natural disasters in the rural areas and also for other socio-economic reasons.

There was no government policy for the urban poor in the 80s so in 1989 53 organisations (including Care & Action Aid) formed the Coalition for Urban Poor which today focuses on advocacy and lobbying for the rights of the urban poor.

The urban poor live with a high level of insecurity due to their lack of tenancy rights leading to regular evictions. There are also the problems of impoverished housing and sanitation condition, high rates of unemployment, spread of disease and unsafe water supplies. The CUP attempts to lessen these sufferings by undertaking appropriate programs addressing their basic needs. Mr Khan proves to be an engaging storyteller as we listen to the ongoing frustrations of the CUP with the coalition government following a slum eviction in 2007.

Our meeting runs just long enough to ensure that we are racing to our next - not literally of course – we’re simply sitting in traffic. Fortunately, the person we were visiting, Ms Fran McConville (Health Advisor DFID) is also stuck in traffic, although unfortunately this means we were only able to speak with her briefly. Only 5 weeks into her new role with DFID Bangladesh, Mrs McConville had already visited an MSCS clinic and was impressed with what she saw there. We leave the very fancy, but surprisingly security-tight DFID office and make our way back to the office.

Again we’re up early for an appointment with the DP Family Planning. I don't join Diana and Sophie for this meeting with Quamrun Nessa Khanam, largely because I am intimidated by a woman who insists on being called 'sir' and also because I have business to sort out with the hotel. My very few responsibilities on this trip include carrying computer equipment, taking photos and trying not to say stupid things. Nevertheless, this has seemingly proven too much for me, and today I have forgotten the camera batteries.

I’ve also endeared myself to my travel companions up to this point with the following intelligent remarks: “gosh, your hotel room is tiny”, and “I didn’t know slums even had electricity – his fridge is bigger than mine!”, and in a less focussed moment: “what’s this about a cyclone?” Ok, the last one isn’t true but I don’t think anyone would have been surprised to hear me say it. Needless to say there was no confusing which one of us was the journalist.

In an effort to redeem myself, I sort out the business with the hotel before making a quick solo journey down the market place, drawing the attention of a largely male audience. Not to get big headed about it however - I suspect the sight of a sweaty, disoriented foreigner feigning interest in what turned out to be an industrial goods market was more a source of amusement than anything else. Diana and Sophie's meeting is brief (cut short once Sophie announces herself as a journalist) and we are once again on our way..

Our next stop is Antanta Fashion Ltd, a denim producing factory who joined MSCS's Factory Health Insurance Scheme in 1993. The Factory Health Insurance Scheme aims to provide free, quality reproductive and general health services to workers on-site (who are mainly females of reproductive age), financed through monthly health insurance payments made by factory owners.

We meet with Abdul Malek, the Chief Engineer, who gives us an overview of the garment industry and its future in Bangladesh (strong, due to demand from China which now produces more sophisticated products, coupled with the abolition of the Quota System) and the services provided by MSCS.

Antanta Fashion were attracted to the scheme due to the high rate of illness amongst the poor, many of whom work in the factories. Joining the Scheme means that workers don’t lose earnings due to sickness (and also pay for private medical assistance), and therefore the factory doesn’t have to suffer the knock-on effects of reduced productivity and increased absenteeism.

Day 5 - Thursday

Again we’re up early for an appointment with the DP Family Planning. I don't join Diana and Sophie for this meeting with Quamrun Nessa Khanam, largely because I am intimidated by a woman who insists on being called 'sir' and also because I have business to sort out with the hotel.

My very few responsibilities on this trip include carrying computer equipment, taking photos and trying not to say stupid things. Nevertheless, this has seemingly proven too much for me, and today I have forgotten the camera batteries.

I’ve also endeared myself to my travel companions up to this point with the following intelligent remarks: “gosh, your hotel room is tiny”, and “I didn’t know slums even had electricity – his fridge is bigger than mine!”, and in a less focussed moment: “what’s this about a cyclone?” Ok, the last one isn’t true but I don’t think anyone would have been surprised to hear me say it.

Needless to say there was no confusing which one of us was the journalist. In an effort to redeem myself, I sort out the business with the hotel before making a quick solo journey down the market place, drawing the attention of a largely male audience. Not to get big headed about it however - I suspect the sight of a sweaty, disoriented foreigner feigning interest in what turned out to be an industrial goods market was more a source of amusement than anything else. Diana and Sophie's meeting is brief (cut short once Sophie announces herself as a journalist) and we are once again on our way.

Our next stop is Antanta Fashion Ltd, a denim producing factory who joined MSCS's Factory Health Insurance Scheme in 1993. The Factory Health Insurance Scheme aims to provide free, quality reproductive and general health services to workers on-site (who are mainly females of reproductive age), financed through monthly health insurance payments made by factory owners.

We meet with Abdul Malek, the Chief Engineer, who gives us an overview of the garment industry and its future in Bangladesh (strong, due to demand from China which now produces more sophisticated products, coupled with the abolition of the Quota System) and the services provided by MSCS. Antanta Fashion were attracted to the scheme due to the high rate of illness amongst the poor, many of whom work in the factories.

Joining the Scheme means that workers don’t lose earnings due to sickness (and also pay for private medical assistance), and therefore the factory doesn’t have to suffer the knock-on effects of reduced productivity and increased absenteeism.

As we made our way to the factory floor I cross my fingers for good working conditions and happy employees to counter the guilt I feel for being a purchaser of the garments they are producing (the factory is 100% export, with the main customers being H&M and GAP).

But my guilt is doubled when I discover that the 4,200 workers work 10hr days, 6 days a week, and for the measly sum of 60p per day. Nevertheless, we’re encouraged to continue buying these good because the garment industry is paramount in revolutionising women's economic empowerment, giving the women jobs and independence.

Once again running late for our next appointment, we finally arrive at the well-kept grounds of the local government offices where we meet with Md. Sirajul Haider, Deputy Project Director for the 2nd Urban Primary Health Care Project (UPCHP-II). The purpose of the UPHCP-II is to improve the health of the urban poor by providing greater access to services for those living in urban areas.

The main objective of the project is to strengthen primary health care infrastructure in an effort to reduce preventable mortality and morbidity, and also to change the role of Government in the provision of health care services.

As the days nears to a close, we return to office for a de-brief and to say our goodbyes to the wonderful staff at MSCS

Day 6 - Friday

Our last day in Bangladesh – Sophie and Diana fly out to India this afternoon and I’m going back to London. After a quick bout of sari-shopping, we say goodbye and head our separate ways. At 2am I’m wandering Dubai International Airport (en route to London), marvelling at the gross consumerism taking place around me (does anyone really need a 10kg Toblerone?), and thinking about my past week in Dhaka.

Thinking that despite the traffic jams, random power surges, oppressive heat, and harassment by the wretchedly poor and disabled, Dhaka is a vibrant, bustling city with a heart of gold. That the Bangladeshi people are hardworking and gracious, hospitable to a fault, and surprisingly opportunistic and optimistic. And realising that with so many people living in such difficult (and for me, previously unimaginable) conditions, it’s thanks to the relentless work by organisations such as MSCS, CUP, ASD and DSK that the poor people of Bangladesh are gradually gaining access to more and more essential services.

At the risk of sounding cheesy, having seen first hand the work of the impressive MSCS team and having heard personal accounts of how their services had improved the lives of so many people, I am proud to say that I work for such a dedicated international organisation. And I now see that the success of our program in Bangladesh is largely due to the fact that it is run by Bangladeshi people – intelligent, driven individuals whose passion to improve the lives of their fellow countrymen is fuelled by the suffering they see every day.

Nicole.

Out of it

15/09/2008 00:00:00

I already know I feel a bit shaky when, in the car to a meeting with a government advisor, I am violently sick into a fortuitously, and bizarrely, available Fortnum & Mason's carrier bag. Thankfully it is sturdy and hole-free. I discover later that the meeting is postponed anyway.

Still, that's me out of it until the next afternoon. At least the don't-eat-anything-for-24-hours treatment seems to work, and I just sleep it off. I'm a bit cross about the waste of time though: there's so much to see and do, and so little time to see and do it in. For instance, I see on MSI's website that they are featuring a Dhaka woman who went from sex worker to Marie Stopes's volunteer:
http://mariestopes.org/News/From_sex_worker_to_Marie_Stopes_volunteer_-_Kohinoor's_story.aspx .

I missed the interview with sex workers. Drat

For updated information on The Guardian International Development Journalism competition please visit our International website.

or please visit http://www.guardian.co.uk/journalismcompetition

In the slums

12/09/2008 00:00:00

Today I'm going with two people from Marie Stopes International, and the finalist who is travelling with then, to see the work MSI is doing in several slums inside the city.

First, it's off to the old-established Sadea Khan slum, down the side of an embankment next to, and indeed on top of, the river. Gaudily decorated lorries roar past, and about a dozen rickshaws – the employment of many Sadea Khan husbands – are parked up nearby.

Walking through the mud, and past the pipe with clean water where women are doing the washing up, we step on to the bamboo walkway. This is all that separates us from the filthy river, and underneath you can see water, plastic bags of various shapes, sizes and colours squashed up together, and all kinds of mess you wouldn't want to look at too closely. All the houses are supported on stilts, just slightly higher than the walkway. Let's hope there's no flooding here…

We go into Shahida's house. She is 26, and has three children – the oldest 12. She was married at 12, and is determined her children will not marry until they are 18. Nor does she intend to have any more; she has had a contraceptive injection. There is a double bed in her house, on which her two youngest children sleep. She, her husband, and the eldest child all sleep on the floor – and you can see straight through the gappy, rotting floorboards to the river. No wonder they are all constantly ill and that she and her husband are unhappily married. "There is no privacy, no humanity, no morality here," she says.

But Shahida has, as we would say in the UK, a real "eye". The floorboards are painted with flowers, and the family's few clothes are folded on rails and colour-coded so they look like a display in a shop. Fairy lights are draped everywhere – Shahida has done everything with that one room that she could. What a waste.

We move down to a bigger house to meet more of the women. Apparently they give birth on those beds, just inches from the dirty water, the river which is making me feel more and more queasy with its sickly, stale smell. They don't go to the hospital – unless there is an emergency, such as one woman who had a caesarean section – and are seen through their labour by traditional birth attendants who don't have medical training. They do, however, have sterile delivery kits and infant mortality has gone down.

A couple of hours drive through often static traffic, we reach Shampur slum. This is just outside central Dhaka, and is in an area of factories and workshops, all crowded together. While the last slum was constructed from bamboo, these houses are right against the factory where many of them are employed, and all seem to be made of corrugated iron.

The heat is extraordinary. There are small open fires cooking the meals with which they will break their Ramadan fast; environmental pollution and smells of burning from the factory, plus the paths are very narrow and muddy – although presumably just from the rain. And the houses are all jammed up close to each other, getting hotter and hotter. With clinics on hand, the textile workers and their families – in this area anyway - have generally reduced their families to two children although, again, this is a tough way to bring up children. Beyond tough really.

The humidity leads sweat to drip down the faces of many of us, and I particularly feel for our translator, Dr Farzana. Not only does she talk for hours on end in this heat, but it is Ramadan and she is fasting during daylight hours. This means eating and drinking nothing – not even a sip of water. We Brits, on the other hand, gratefully gulp down cola when it comes – and none of us likes the stuff!

For updates on the Guardian Independent Development Journalism competition, please visit News in the international section of our website.

To visit the Guardian website, please see:
http://www.guardian.co.uk/journalismcompetition/finalists

In flight

10/09/2008 00:00:00

Time for me to go on a l-o-n-g flight – Dar es Salaam, Tanzania, to Dhaka, Bangladesh and the next stage of the competition. I have to write two different introductory features for two supplements, and concentrating on two contrasting countries seemed like the best way to do it.

The first leg of the flight is to Dubai and when I get off the plane I almost laugh at the heat. 11.30pm, and it's about 35C. Thankfully, air conditioning is never more than a step away. Flying in, I had been expecting to see some of that amazing architecture, such as the world's tallest building

There is nothing like that, but the airport is enough: gold shops, cigar shops, oyster shops, designer whatever you like shops, what seems like hundreds and thousands of purchasing solutions. I have never wanted multiple gold bangles in different sizes, but no doubt plenty do. There are life-size (ie enormous) palm trees, with Arabic-style mock palaces and fancy glittering lights.

Would this have made such an impact if I hadn't spent five days surrounded by absolute poverty? I don't know.

Anyway, I meet up with some people from the sexual and reproductive health NGO Marie Stopes International www.mariestopes.org.uk, together with another excited and anxious-looking finalist - soon we're on to the 2am flight and what seems like mere seconds of shut-eye.

We arrive on Sunday – a working day in Bangladesh. It's a whirlwind of brightly coloured glittering bicycle rickshaws, little bicycle-buses that look rather like open-air cages, and many many private cars. All the traffic seems to drive directly at each other, and the only thing preventing absolute chaos is the occasional traffic cop.

An hour's sleep later, and we're in to the MSI offices to get a run down of our schedule – although I will be meeting other NGOs too. During lunch, we hear what sounds like hundreds of horses galloping over a tin roof – it's still the monsoon season here and although we can't see the rain inside the conference room, it's so loud that we have to move our chairs together in order to hear above the din.

We collapse into bed very early…

For updates on the Guardian Independent Development Journalism competition, please see News in the international section of our website.

To visit the Guardian website, please see:
http://www.guardian.co.uk/journalismcompetition/finalists

Chonde: Champion of tubal litigation

15/07/2008 00:00:00

Bertha Saikonde ('Chonde'), is Group Village Headwoman in Chonde. She does not believe the old Malawian saying 'having scores of children is a sign of wealth' - she chose to be sterilised in 1995 using tubal litigation, after an outreach team from Banja La Mtsogolo (BLM), MSI’s Partner in Malawi, visited her community.

“I’ve had no regrets; I haven’t lost the person I used to be. By that time I already had six children and I knew that was already too many. I would have continued child-bearing had it not been for BLM.

BLM really empowered me; I wanted to have a sterilisation after four children, as I had experienced how my parents struggled to raise us because we were many. But relations and friends scared me off. BLM put right these misconceptions and I have reaped the benefits.

I am able to travel and meet a lot of people because I am no longer child-bearing and I can support my children. I am not very educated because my parents couldn’t afford school fees and I don’t want my children to go through the same ordeal.

My message goes out to churches that denounce modern family planning. They preach about making donations to their churches but how can they expect money from people already burdened with supporting big families? I don’t understand their logic for try to stop tubal litigation.”

Sima's passage to India

10/05/2008 00:00:00

Sima Patel, Learning & Development Manager for Team Development at the London Support Office, recently visited Population Health Services India (PHSI) in Hyderabad to carry out a human resources audit at their offices and spent an afternoon at one of PHSI’s nearby centres. Although Sima has been with MSI for 10 years, this was her first trip abroad for the organisation.

“I didn’t know what to expect but I was amazed by the experience; it was a real eye opener for me as I have only worked with the UK centres before and now I can understand first hand what excellent work is being carried out internationally.

There was such a positive atmosphere in the centre which was bright and very clean. The team members were all extremely friendly and hospitable and really proud to show how well they work as a team. They have such limited resources compared to the UK centres but they provide an excellent and efficient service and are clearly determined to make their centre work."

Anaesthetic is not readily available so pain has to be managed with the vocal/local technique, in the development of which MSI has been a pioneering force.

"It’s obviously effective as not a sound or cry came out of the procedure room and each procedure was completed very quickly. Most of the clients I saw had come alone, resolute in their decision to go through with the termination and extremely relieved to have found a safe solution. Overall, this felt like the perfect time for me to go abroad for MSI and it has inspired me further. I will be taking part in management training in Ghana in June which is a wonderful and exciting opportunity.

Many thanks to Vivek Malhotra and his team for their warm welcome and their hospitality.”

"Inspirational and Important" - an independent view of MSI's work

30/11/2007 00:00:00

Dr Elizabeth Bianchi was recently engaged as a consultant to review clinical services in the Nepal programme. Here, she recounts her experience and impressions of Sunaulo Parivar Nepal

“I got to see MSI in action for the first time from the back seat of a pick-up truck on a bumpy road in 38 degree Celsius weather and 100% humidity, with sweat dripping freely off the bottom of my ear lobes!

I saw with fresh eyes what everyone who works for MSI already knows, something truly important and inspirational is happening everyday while you work for this organisation. You already know that MSI serves almost five million people a year in 38 countries, but what I saw with my fresh eyes is a unique organisation with special people that are more than just dedicated to a mission.

I recently met some of these extraordinary people while I was in Nepal for a midterm review of clinic services being provided by Sunaulo Parivar Nepal. We travelled for nine hours by truck over bumpy roads in stifling heat to see one of the more remote clinics. But the most amazing thing was that the staff was still waiting for us when we arrived to see their clinic, more than four hours later than we were expected.

Even though we were hot, dirty, sweaty and a little cranky, compared to their crisp uniforms and clean smiling faces, we couldn’t help but be infected with their enthusiasm. They had an intense pride in their clinic that was evident as they showed us around.

They wanted to show us everything: How they cared for clients in a warm and friendly reception room; their efforts to provide a comfortable and private recovery area. They truly cared about the comfort and safety of the clients they serve. From potted plants, pictures on the walls and grooming products available in the recovery room, they did everything they could think of to make their women clients feel more confident and well taken care of while they are visiting the clinic.

The clinic was nestled in a typical overused and dingy area of the small town. As I imagine most MSI clinics are, it was a bright blue sparkling destination that women can recognize as a safe and comfortable place to get the information and services they need. In all the clinics I visited I saw the same enthusiasm and dedication to the detail that make MSI clinics stand out as a special haven for men and women in these communities.

In sharp contrast, I had the opportunity to see a government run clinic. Abortion services have been legal in Nepal for three years now, and the government is trying to provide abortion services that are safe as well. However, the difference between how MSI and the government delivered services is remarkable.

The government clinics see multiple clients with assembly-line like procedures being provided by physicians in bloody aprons. Client after client. And then women recover in a room with multiple cots lined up in rows with two women lying side by side on each cot until they have recovered enough to leave.

This was nothing like the services I saw at the Marie Stopes clinics. Both organizations have a similar mission, but the people who work for MSI are remarkable in their dedication to the clients and the actual delivery of services.

The attitude of the dedicated staff to provide an uplifting experience in a safe environment was not just reserved for a developing country. When I arrived back in London for debriefing, the same energy and enthusiasm met me there.

From the clinic manager who warmly conversed with clients and staff, to the physician who actually provided the abortion service with kind words and gentle hands, to the medial director’s compassionate struggle with a major client complication, I could see through each of their actions that MSI is not just an organization with a mission - MSI is a group of people at all levels of the organization who have a passion for helping women get safe abortions, sterilizations, and education about reproductive health that surpassed all my “fresh eye” expectations.

Thank you everyone, for the remarkable work you are doing!”

Faustina Fynn Nyame travels to Sierra Leone to learn more about the MSI programme there

20/10/2007 00:00:00

Friday 14th September 2007

Arrive in Sierra Leone.

My first impression of Sierra Leone was how beautiful she is. Although she has been through a decade of war she still shines. The beaches remind me of Caribbean’s, but with the vibe of West Africa. To get to Freetown I had to take the helicopter- what an exciting, scary ride.

Being the youngest MSI programme and as the new Programme Director for MSI Ghana it’s imperative I visit our neighbouring country programmes to see and learn good practices. Marie Stopes Sierra Leone has been providing sexual and reproductive health care and obstetric care for 20 years. The programme provided services all throughout the war, which must have been very difficult for the team. Some of those team members are still working for programme. I have a lot to learn from them.

Monday 17th

I spent part of my day meeting with the senor management team discussing their roles, the challenges that exist in Sierra Leone and how as a team they have resolved them. Dr Yvonne Harding, the Programme Director, give me an excellent insight into how to bridge the gap between NGO’s (non government organisations) and the government.

After lunch I spent time in the obstetrics department in Ahmed Drive. I got the opportunity to hold same babies which always makes my day.

Tuesday 18th
I particularly enjoyed today as I got the opportunity to visit our clinics in Waterloo Road and Kissy (both in Freetown). Both were packed with clients who needed help. I was really impressed that while clients wait for their turn to be seen they are shown educational videos on reproductive health. I think this is an excellent idea and will taking this back to Ghana with me.

Later I had the privilege of meeting some very important representatives who work at the Ministry of Health (MoH) to discuss private and public partnerships. I gained insight into how beneficial this can be for a country like Ghana and I have a lot to have a do when I get back!

Wednesday 19th

I met a gentlemen from the MoH planning department - I was very motivated by him as he shared his experience about how the MoH and how it and Marie Stopes Sierra Leone have been working in partnership.

Thursday 20th

I spent most of my day discussing logistics with the senior management team followed by a debriefing session with them.

I spent the evening with the team at a beach restaurant, enjoying my last night in Sierra Leone.

Friday 21st

Back to Ghana armed with ideas and even more motivated than before, watch out team here I come. Sierra Leone - I’ll be back!