Johannesburg — Health-E News hosted a question and answer session to answer pertinent questions on why South Africa's public health facilities are experiencing frequent contraceptive stockouts and how the department of health is addressing the shortages. Dr Manala Makua from the National Department of Health was in among the panelists to address the issue and tell the media about the government's new policies and guidelines that have been put in place to solve this problem.
Questions on pregnancy terminations and how healthcare professionals are working to de-stigmatise the service were answered by Kgaladi Mphahlele a professional nurse who works for the international humanitarian organisation Doctors Without Borders' (MSF) and manages their termination of pregnancy programme in North West. and Whitney Chinongenywa, a marketing and brand manager for Marie Stopes. Sibongile Tshabalala an activist with Treatment Action Campaign organisation tackled questions on women's rights especially when it comes to accessing sexual and reproductive health services.
Questioning the panel was Pontsho Pilane, a Digital and Online Editor at Health-E News.
How are the current and new sexual and reproductive health policies and guidelines that will be introduced improve sexual and reproductive health for women. What are the government's plans?
Dr Makua: For the first time in South Africa there's a combined policy on contraceptives and sexual health. The policy says every health facility that has been declared to offer contraceptives should have at least 5 methods because the guiding principles in the policy call for expanded choice method mix. If you have less than 5 methods you are not fully complying with the implementation of the policy.
But then unforeseen circumstances like international space, unavailability of some commodities struck in. The government realised that setting a minimum of 5 methods is setting itself for failure. There was an agreement to double up choices, 5 more new methods were added so that when challenges like shortages of commodities happen facilities can still comply with the minimum standard in the policy.
Are health facilities complying to this policy?
Tshabalala: The only contraceptives that facilities are providing are the Implanon and oral contraceptives and the loop. Injectables are still not there i.e Nuristate and Depo-provera, SA has good policies and guidelines but when you get to the ground it's a different story. If you go to these facilities and ask the managers they will tell you they don't know why these contraceptives are missing, it's been on and off. Others have written on their doors that Nuristate has been phased out without even communicating with communities.
Is the lack of contraceptives one of the reasons you find yourself providing pregnancy termination services?
Mphahlele: The lack of contraceptives play a huge role. Even though the methods are available, nurses are not trained on how to administer them e.g the Implanon. If you go to the clinic sometimes nurses will not even tell you that it is available because they don't know how to insert them. You go to depots you find that thousands of batches have expired even.
Do you think that the fact that nurses don't know how to administer some of these contraceptives is the reason why some women are forced to use only certain methods?
Mphahlele: Sometimes the myths surrounding some of these contraceptives also play a big role for example stories are circulating that the Implanon can travel up to your lungs or once you use it you'll never fall pregnant after that. Professionals are not even able to correct some of the myths.
How do you go around de-stigmatising your brand, how do go around informing women about what sexual reproductive health is and what their rights are and what services they can get from you?
Chinongwenya: Yes we are not just an abortion clinic, and there's always an internal debate within the organisation about whether we want to de-stigmatise the brand? Is there anything wrong with being known as an abortion provider? We think not, but we do provide all the other services.
We were impacted by the shortage of contraceptives as well. We do a lot of work on information sharing because we've seen that there's a gap, there's not a lot of information available. We have localised the information on contraceptives to the women in South Africa. We are an NGO, we are no part of the government so we do what we can and we do not always reach the amount of people that we should. We do a lot of school talks, activations in communities just to share information because that is where the big gap is.
A lot of information is not available, when we look at abortion care we look at HIV. It was stigmatised at one point, people did not want to work with or treat patients with HIV but a lot of work went into it. When we look at abortion care there hasn't been enough effort put into de-stigmatising the service.
Do you in your communities that operate in work with the local departments to try and educate health workers around not being anti-abortion?
Mphahlele: What we did as MSF in 2017, in the clinics that we work in where we did a values clarification workshop with all the healthcare providers in those facilities because you'd find sometimes they'd be the barriers to clients receiving the service. We make them understand why this service is available, what the benefits of having this service are. We teach them not to question the clients if they are not providing the service but to refer them to the facility where they can get help.
Over two years that we've been working with 11 clinics in Rustenburg we can actually see that the values clarification workshops that we've been doing they now understand that it is not only about their feelings but it is about providing a service and it is a woman's right to access that service.
Chinongwenya: The first thing we do as Marie Stopes after recruiting a service provider is making them go through training for safe abortion care which includes the values clarification. We see a lot of people fall out of the process and end up not being in a clinic. What we've done in the Western Cape and Durban, it has been opened up to public health providers so we train some of the people who just join Marie Stopes staff. We use some of them in our clinics as temporary workers. We try where we can, we have a particularly good relationship with the Western Cape government where we work with health care providers to do values clarification.
What are some of the challenges that you both face when you are trying to change values? For example bridging the religious/spirituality barriers to access to your service, be it abortions or access to contraceptives.
Chinongwenya: It's a very difficult thing to do, you cannot change the mindsets of religious people. It's very hard to bridge that gap. I'm sure our service providers are religious, so I think it's a bit more than religion, it's a mindset that is difficult to change.
Mphahlele: In one clinic that we work in they have prayer meetings in the mornings and this one nurse, every time she prays she prays for the people at the abortion clinic asking God to forgive the nurses there for the souls they are killing. The one thing that has helped me and some of the providers is that respecting the oath that we took when we became services providers that says we should not put any religious views before ourselves or anything else that will disturb us from doing our duties. Once you start putting your religion before your work it's actually going to start being a barrier, there are certain things that you will start refusing to do.
What is the process of raising awareness and empowering women about what their rights are? What is the kind of work that you do with TAC and other organisations that you work with to make sure that women know their right so that they can demand the right treatment when they visit public health facilities?
Tshabalala: We run workshops in schools and communities especially for young people. We don't specialise in women but we have champions which are young women that are trained to educate. When we do these workshops, we train people on sexual reproductive health rights, sexuality, gender. We talk about the whole component so that people will understand that it is not about one thing e.g accessing abortion but it is about the whole package. We teach people about understanding their bodies, in simpler terms we unpack and we want everybody to understand themselves and that conversation is not only for women and at the end of the day sexual activities happen between two people which mostly happen between a boy and a girl.
Everybody needs to understand where they fit in , how their bodies work and if they are taking contraceptives what are the contraceptives doing to their body. We try to bring everybody into a conversation and not only young people. We bring everybody, religious leader, traditional leaders into the conversation hence we now have dialogues with different stakeholders.
Questions from the floor
Is there a way the government can get involved in training healthcare providers to eliminate stigma?
Dr Makua: I think the barriers to sexual and reproductive health go beyond nurses and pharmacists, sometimes even doctors refuse to write a script. Value clarification goes a long way. We need to also include cleaners, even the security guards because people are told there's no abortion services here, and when you go back to ask you find that it's the security guard.
Is the DOH considering introducing the male pill?
Dr Makua: Contraception and sexual and reproductive health is not yet a global move to make it a dual responsibility. It's still too biased that it is a woman's responsibility. A lot of trials have happened, it was almost almost there, when it started showing side effects they cut it off because the people at the high rank of the ladder, who run the countries happen to be mainly men. The don't want anything that has them, they only want money and comfort.
What is the attitude of the government when it comes to the side effects that come with the implanon contraceptive i.e blood clotting? Are discontinuing it or you will continue with it as if nothing is happening? Also, does it not become a danger to a woman if the implanon sticks to the bone?
Dr Makua: The implanon will not hurt your bone. It has been confirmed that it won't go beyond your muscle tissue. In an extreme situation the implanon will get into your blood vessel that is when it will cause clots. When inserting the implant the clinician should sit down to get a perfect angle of insertion for the implanon to go right under the skin. if it's done right there are zero issues.
Do health providers consider the rights of men when offering abortion services as there are men who might not want their babies to be aborted?
Tshabalala: If a woman does not want a baby, it's her right to say no. A man has no right to tell a woman what she should do with her body. Whether a woman wants to have a baby or termination of pregnancy, no man should have a say.
Mphahlele: The Choice on Termination of Pregnancy Act says it's a woman's choice to request a safe termination without informing the parents of the father but looking at it at a different perspective, there needs to be a way to involve men but if the woman decides to terminate it's her choice. There should be forums where men discuss these things and talk about contraceptives. We need to involve men as allies to women's choices and not necessarily as people to make choices for the women.
How far is the government with distributing condoms to schools? Is there any clause in the policies that allows the department of health to work hand in hand with the department of education in terms of making condoms to be available in schools to prevent pregnancies in schools?
Dr Makua: Actually we have gone beyond the condom. What we argued was that we cannot advocate comprehensive 5 methods of contraception when yopu are outside school then when you go to school you distribute one method, so we need to be consistent. 5 methods should remain 5 methods across the board. Between January and March we've been trying to put it to the ground, dealing with school governing bodies to say we've landed. It's no longer a negotiation.
Tshabalala: It's not yet implemented, we are still pushing for it because comprehensive sexual education in schools is important. Young people are falling pregnant whether we like it or not but most of the time we got from push back school governing bodies. Parents are the ones who do not understand but at the end of the day they are the ones who suffer consequences. What we are trying to do now is have conversations with parents even outside school because when they are at school it's easy for them to influence each other, so by the time they go back to school they will be sensitised and understanding what we are talking about.
To wrap up the conversation, Tshabalala called on the media to assist in disseminating information on sexual and reproductive health as it is everyone's responsibility. Diseases like cervical cancer need to be reported more and given more attention but not only on women's month. She asked the media to make topics on contraceptives, abortion to be everyday topics and not be discussed on certain months, so that the challenges surrounding these issues can be easily overcome. People have sex everyday so these issues should also be discussed everyday also.
Dr Makua called upon journalists to use the "immense power that they have to change the world" and promised to answer any questions they have at any given time.