 So thank you everyone for coming. I'm going to ask everybody to take your seat so we can get started with this event. Thank you very much all of you for coming. Those of you in the back, you're welcome to move up toward the front if you'd like. But I welcome you all to the CSIS Global Health Policy Center. We thank you for coming. This promise is to be an important and very informative event. We also want to welcome our viewers online who couldn't be here with us today. And special thanks to the Christian Connections for International Health, CCIH, for collaborating with us and most especially for bringing our special guests to Washington for their conference and for allowing them to come join us here at CSIS with you all today. I'd also like to thank Bre Bacchus and Joe Jordan from CSIS for all they did to make this event possible. The benefits of family planning are numerous, not only for women's health and reducing maternal mortality, but for increasing child survival, nutrition, education, economic empowerment, and preventing mothers-to-child transmission of HIV. This is why family planning is a core component of sustainable development. And today we're here to explore the role that faith-based organizations can play in advancing family planning in their own communities, specifically looking at the cases of Nigeria and Uganda. This is an area that is too often overlooked when we're discussing family planning here in the United States. And this was brought home to me when I was in Ethiopia earlier this year. I went with an Orthodox priest and asked him how he discussed his family planning with his followers. And his reply was direct and powerful. He told me, people say family planning is a sin. What is a sin is if you can't feed your children or send them to school. And then he went on to say, from experience we see that in families with limited children, they grow up well. Women are physically stronger with faith's birth. In many communities around the world, a woman's ability to access family planning and contraception is heavily influenced by religious leaders and traditions. So understanding the intersection between faith and family planning is an essential part of advancing women's access to information and services about family planning. We know that in many developing countries, faith leaders play a significant role in shaping opinions and decisions about marriage, about families, about childbearing and about health. And we also know that in many countries, faith-based organizations undertake a significant share of the health services, often in partnership with the governments. So learning how faith-based organizations are helping to advance family planning is critical, just as it's critical to understand the barriers they face and the advantages and disadvantages that they see in their current situations. There's also great diversity in faith-based efforts from a range of religions and denominations and organizations. Today we'll be looking at this from the perspective of two Christian-affiliated organizations, medical, FBO medical organizations. And we are honored today to be joined by two such leaders from Nigeria and Uganda, Dr. Daniel Gabgab from Nigeria and Dr. Tony Tumasidwe. Excuse the pronunciation. You have, I think, their bios out front, but just to recap briefly, Daniel is the Secretary General and Chief Executive Officer of the Christian Health Association of Nigeria. He's trained as a physician and holds a post-graduate qualification in public health and ophthalmology. He spent 22 years working as a health expert at the Church of Christ in nations and as the Director of Health and Social Services and the past eight years working at Chan, first as the Director of Programs and now as the Secretary General and the CEO. Previously, Daniel served as the Project Director for managing the implementation of integrated reproductive health and HIV AIDS and adolescent reproductive health projects in partnership with SEDPA with funding from USAID and the Church of Christ in nations. Tony is the Executive Director of the Ugandan Protestant Medical Bureau, a national umbrella organization for Protestant Adventist Pentecostal health facilities in Uganda. He holds a master's degree in public health and a post-graduate diploma in public health from the University of London and the London School of Hygiene and Tropical Medicine. He also holds a Bachelor of Medicine and a Bachelor of Surgery degree from Macari University in Uganda. He's an experienced program manager with years of experience working as a frontline general practitioner in rural and resource limited settings. So we welcome you. We are very honored to have you here and as we were discussing beforehand the opportunity to have their voices to learn from them, to hear their experience and how they themselves got involved in this area of health. I think we'll help inform our own thinking and the policy discussions here in Washington. So the way we're going to run this is we're going to give each of them a short opportunity to make opening statements three to five minutes and then we're going to have a short discussion and ask some of the questions about their work and about family planning and the issues they face. And then of course we'll open it up to the audience because we're very eager to hear from you and we know you'll have a lot of very interesting things to add to this discussion. So let's begin with Daniel. Okay, I think I want to start by saying I feel honored and quite privileged to be engaged in this dialogue. Not just to tell you what we are doing but also why we are passionate about what we are doing. And I would like to start by telling you my own story and what took me into the realm of maternal child and family health in particular. In my family there are eight of us and my mother was pregnant for the ninth pregnancy. She lost that pregnancy and she almost died as a result of severe hemorrhage. That was only my early age in the medical school and I came and confronted my father who is a local pastor and I said look we still want to have our mother alive. If anything is to be done she needs to be helped so that she doesn't get pregnant again at this age. I think he was able to listen to me and we took my mother to a mission hospital and she had a tuber ligation. Today my mother is alive but my father has already gone to glory before her. If she had continued that way I want to believe she would have gone before him. Now that is part of the passion that has made us to see what can I as a person do to save the lives of mothers and their children. Now from the organization I work with I work for the Christian Health Association of Nigeria. It's a combination of both Catholic and Protestants, 20 denominations in all. We are working together in promoting healthcare services generally in our country. The Christians provide not less than 40% of healthcare delivery services in Nigeria through over 500 different health facilities at different levels and categories. And through that we are able to offer a range of health services including family planning. Now what is clear is that for all of us we have a common understanding of the fact that whether we call it family planning or child spacing both and all denominations practice what they believe and their doctrine allows them to practice within that context. Nobody is coerced to do anything. It is highly voluntary and it is whatever you believe in it is promoted and we have seen what can we do among our church congregations and in the midst of our health facilities to see what we can do to offer these services to mothers so they can stay alive to take care of their children. Thank you. Tony. Yes, thank you very much. I'm honored to be here. I work for an organization that basically as you rightly mentioned looks at health facilities that are about 300 and they are mainly 80% of those are in the rural setting. And we offer as my colleague already mentioned a continuum of care. And we look at the way the country is, we are in those areas that the need is required most for the very hardest to reach areas. I'm the total opposite of my colleague in the way I grew. My family had three children and I was the third of all of the three. However, as we went through life my father died at a point in need when I was supposed to go to senior six. Senior six is the last class before you go to university in Uganda. So I was in senior five when he died and I lost a year to go to senior six as my mother was working hard to ensure that resources would be generated for me to continue with my studies. I always remember one word that she said that when I went back to school we are three sons and she was always saying I wanted more children. I wanted more daughters. However, God did not allow me to have more children. And at that point it was quite hard taking when she said I've managed to secure resources for you to go to your final class. Now I'm a medical doctor. Now had we been many, she's very clear that maybe I would have gone to university at that material point. So that turned my life around. I come from a community that is heavily or highly densely populated. The Bachiga community, we are known to be migrants. An average family in my village has about eight to ten children and my family, my father was the total opposite. But despite all that he didn't seek out for another woman and that is one of the things that helped us. So when I finished my university I thought I needed to do something about it. And so I spent ten years of my early career in the hospital in Uganda helping and supporting mothers. And seeing what was happening in our community in southwestern part of the country I developed depression. I thought initially I would study obstetrics but by virtue of my role as a medical director it became very difficult for me to do obstetrics. So I went into public health. But even when I went into public health I had reproductive health and family planning issues that reflect the lives of the common person in our context being the women became one of the frontline issues. So even as I moved on to become the Executive Director at the national level we feel as an organization that that's an area that we need to passionately work on and see how we can help our country. Uganda is one of those countries with one of the fastest growing populations in the world. And we think that unless we are able to control that growth in a manner that can both balance the numbers of people with the economy that we have it will be very difficult for us to live a better life in our country. Thank you very much. I think you agree that it's very compelling stories in terms of how you got involved in this work. And now both of you are leading faith-based medical organizations in your country. And I thought it might be interesting to start out describing what kinds of family planning services you provide and what kind of contraceptive methods are available through your clinics. Okay. Like I said earlier we're both Catholic and Protestant and therefore we provide all both the natural family planning methods and the other contraceptive devices. Now there was common in Nigeria generally there was common family planning method that is used at the male condoms followed by the injectables and the pills. These are very commonly used and they are available. The implants and IUCDs come next and that is related to the skills of the workers that are provided but they are there in particularly where these services and those who are trained are able to provide that. So that is about a range of family planning services that we are able to offer. And our staff within the health facilities and others are trained to be able to provide these services based on their faith whether it is the natural method or the modern contraceptive method. And that range is available for all those who are interested in whatever method that they would want to go into. The government of Nigeria provides all these contraceptive methods but something that is coming up newly is the standard days method and also the beads method. These are coming up and a lot of people are being trained particularly for those who are interested in the natural method so that it makes it available to them. And that basically is the range of services that we are able to provide through the health facilities but what we do most through the congregations is giving adequate and proper education and awareness for them to know what to do, where to go and select the method that they think is most appropriate for them within their faith. And so there is often a cross-reference of clients from a Catholic facility to a non-Catholic facility to get about whatever method they are interested in and the other way around also happens because we do not segregate and say Catholics go to Catholic facilities alone or Protestants go to Protestant facilities alone but rather people go based on the facilities that is closest to them based on need and from there through counseling and the rest and you know what they need then you do the cross-references appropriately so they can get the service made available to them according to their choice. It is very voluntary and therefore after the counseling one-on-one the client chooses what method she wants to use. Can you describe to us some of the different ways that you provide different methods at the different levels of your hospitals? Yes, we provide all methods throughout our network. Our facilities range from the primary healthcare level all the way to hospitals and the hospitals are also segregated from highly specialized to general hospitals. So currently the system, rather before the system was such that the hospitals would be the ones to give the permanent for example the jubilizations and the vasectomies that would be hospital best and then the commodities like pills, condoms would be for the level 2s which is part of the primary level care and then the level 3s and level 4s would then give the IUDs and the injector, the injector plans. However currently through support of one of the grants that we have from the Packard Foundation US we are now redefining the delivery of family planning methods. We are now moving to the communities, unlike what has been happening that has been facility best. So with that grant we are now going to the communities in the sense of training community health workers and allowing them to be able to distribute resources. So basically we are trying to close the gap between the facility and the communities. Now in addition to that we are also taking the permanent methods to the communities through conducting camps or what you may want to call as surgical camps. So we have a camp of specialized, a team of specialized people, nurses, with doctors going together with the community health workers in a particular community and offering a whole range of care. And that would be after the counseling session and when people feel decide on the services they want to take we then be able to do tubal ideation, we then do the vasectomies and then we are able to do the IUDs, the implants and other commodities with a view that another team will come in as a follow up to see how patients are doing. So with that grant we are now transforming the method of delivery to the community level, unlike the past. Maybe let me add to say that in some of our resource limited areas we have been able to do some task shifting of training community health extension workers to be able to provide injectables at that level which a couple of years back was not happening. The curriculum was developed for them to be able to at least provide injectable methods at the community level and that has helped a great deal of reducing distances for mothers to go to secondary facilities to be able to access that. Is there, do you see a difference in the attitude of the communities learning about family planning through organizations like yours that are linked to faith institutions? Is there a difference in the way you talk about family planning and is there a difference in the uptake you see in services? Certainly because we are a faith community we try to use the politically based messages for them to understand why has God created us, God has made us in his own image, he loves us, are we at the temple of God and therefore God expects that if we are his temple we should take care, good care of that temple. Now mothers are a temple of God and they ought to be taken good care of. Their health must be optimal for them to be able to do their biological function of reproduction and so using a lot of Bible verses and reasons why they need to make sure that they space their pregnancies and deliveries in such a manner that they are strong and healthy enough to expect another pregnancy to come and they are also strong enough to take care of their babies so they are taken care of and so on and so forth. There's always the aspect of yes God and say we should multiply and fill the up, agree. But then on the other hand the Bible says he who does not take care of the immediate need of his family is worse than an infidel and we don't want to be infidels, we are people of faith. And using such methods for awareness creation and teaching it has brought in a lot of difference and changes in the perception of what mothers would expect and what also the main would also expect because we have tried to see in what way the African setup, the Nigerian setup is dominantly male and therefore these messages are passed on both sides not just to the woman. In order to try and see how we can balance it and then promote acceptability and then the practice as I've said earlier will be based on their theology and doctrine appropriately. Do you want to add that? Yes, just to add something on that. The way our facilities are established as a result of the need within that particular community. Now you find a community that has a church and that community realizes the need in terms of healthcare and then they come up with initiative of establishing a facility. So wherever you would go within our network you would find that almost 60 to 70% of the facilities wherever they are there is a church. So that is the way the setup is. So in other words whenever you're taking any service to any particular facility there is no way you're going to run away from the church. So the family planning work that we are doing we realize that we cannot run away from the church and that's why the method we are using is involving the church leadership as part of the entire process. So we are training church leaders to be messengers to understand what family planning is all about because one of the biggest challenges that we have realized that is in the church leaders in our context were having many more children than anybody else in the community. So we thought that before you go to the community you have to start at the leadership level because it is some church leaders who are wedding the young girls in the communities. So that's why we've come up with the method, a training mechanism where we even identify what I may want to call not pioneer but champion church leaders who then go on even to be part of the training of other church leaders. So that is the mechanism that we are using involving the church. We are causing them to be part of the entire process. And even we are seeing the summons that are being given are also beginning to look at family planning as a critical issue in our setup. Have you seen any change in uptake in family planning services since you began to work in this training of the religious leaders? Yeah, we did a baseline survey when we were starting this work with the church. It's just now one year down the road that we are seeing the uptake we're considering the baseline that has been done. We are already seeing changes. We are already seeing also messages coming from the congregation. Even the religious leaders themselves, like for example we've had captions of religious leaders quoting their Christians who are even asking them why the messaging in the church is changing. So we are beginning to see some of those things and I want to believe that by the time next year, possibly by mid next year or early next year when we'll be doing a midterm review of the work that we are doing we'll be able to demonstrate significant changes. And my understanding is you're going beyond just the Christian religious leaders. Can you describe the range of leaders who you've brought into some of these training? Yes, when we decide to zero down on a facility that is going to be the primary focus of the particular of the work we look at the entire community around that facility. And that community does not only involve the Anglican or Adventist or the Pentecostal religious leadership but it also has the other things. We have the Catholic, we have the Muslim, we have the Orthodox. At national level we've been working very well with them so even when we go down through the trainings we do the training with them. And we've seen significant interaction where religious leaders are discussing this issue and the way they perceive it and the way they are working, they are seeing themselves working together because as you know one of the biggest challenges that we've been seeing has been looking at numbers. Each faith for example was looking at what is the population in terms of percentage of this faith versus the other faith was seeing those issues. But at the grassroots level as we do the training we are involving all of them and we've seen interesting scenarios where the Muslim leadership together with the Anglican and the Catholic leadership in terms of faith discuss for example the family planning tool under the nature of family planning using the psychobate you know debating about it and coming up to an agreeable position on the psychobate. So we're really seeing some significant movement towards uptake of family planning as well. Let me let you comment on that. For us in Nigeria particularly in the northern part of the country which is dominantly Muslim we've not really gone into say we do a joint training with them but we have a significant number of health facilities in the far north. The way we run family planning services is that particularly for women who are importer who cannot come out in the daytime these services are offered to them at night. They would move into the health facilities the health workers will cancel them and at the end of the day if they choose a method it is offered to them. That is something that we have seen that works because about 90 to 95% of attendance in our health facilities in the northern part of the country in my country are Muslims and those of them and we are grateful that at least there are some community-based organizations and civil society organizations from among those communities that support these services and therefore the church works through those community-based organizations in order to reach their own members and then they create demand from there and we are available to provide the services. Dan, you had mentioned that there are obvious advantages and disadvantages of being both a faith-based organization providing family planning as well as both representing Catholics and Protestants and you've talked about some of the advantages. What are some of the disadvantages? What are some of the challenges you face both as your organization and as a faith group trying to promote these methods? Yeah, I think one key challenge is the understanding of what family planning is. Now, some sort of thing family planning has to do with abortion but we are always saying that family planning actually prevents abortion and sometimes the word family planning therefore seems to be confusing and people sometimes feel okay, we are talking about child spacing. Okay, if you spell your child, space your pregnancy, let's say three years interval, at the end of the day the fundamental issue is that the number of children that you would have would be such that both mother and child are healthy. One of the key target is how healthy would be the mother before the next pregnancy and through that activity we'll be able to achieve what we really would need and therefore that's one key challenge of people thinking and therefore it's taking us a lot of efforts to explain and teach why family planning has nothing to do with abortion. So that's one key issue. Now, the other aspect is a factor because the fact that the Catholic have their standing policy, no family planning except the natural one, for a child as an organization, for us going in full fledged is taking us so long to really work with partners to now say we are making a breakthrough towards saying that our central procurement department which brings in drugs and other supplies have not been able to centrally procure family planning commodities for the faith communities in Nigeria because of that policy of being together with the Catholic group. Now we are working on that and gradually I think we are understanding one another and we are praying and hoping that in no time this will be made available. The major constraint there is that family planning commodities come only through the government, the public sector and often times they don't even have enough for their own facilities and therefore they will conserve that for the public health facilities and just give a little to us and you find out that we end up bridging by buying in the open market in order to continue the services. So if today they come and it is free, tomorrow they come and charge a fee because the source that they usually get from is limited that has resulted to limiting sometimes our reaching those who would really access some of these services. I think these are some of the key constraints but I think we will be praying and I think God is answering our prayers very shortly we should be able to understand and now say let's have the range of commodities and whatever you think you need and want to use it. The other one that is Libra that wants to use it please take. You that will prefer the natural methods whatever it is we are conducting training so that those services are also available that will be safe and also appropriate for people according to their faith. Do you currently also have problems with stockouts? Yes as you mentioned within the national supply chain mechanism it is mainly what we call the national medical stores that mainly stocks commodities under family planning and there has been a problem in how much of those commodities trickle down to our side which is the faith best side. However last year we were able to have a breakthrough whereby we now have a public-private partnership for health policy which was not there and by that it meant that the mechanism of working between the private not-for-profit sector and the government was not clear. So we were there offering a service but within what somebody was asked what context are you doing this but at least now that that has been defined now it is clear that we can access the commodities. So the challenge now that we still have is how do you move those commodities from Kampala which is the center of the country to 500 kilometers, 600 kilometers away where I held Facility 2 is situated, Facility 3 that is offering such care. So that has been the biggest challenge. However we are grateful that through PEPFAR there is now a program under the USID that is funding what we call the Grand Health Marketing Group to provide commodities to the private sector and those commodities are taken all the way to the facilities that qualify for that. So we are engaging with them and they are very positive and through that mechanism we are trying to see the streamlining of the supply chain of public planning commodities coming to free shop. Do you integrate family planning into your HIV work? Yes we do that is part of the work that we are doing. As part of the MCH package which is under the comprehensive HIV work that we are doing family planning is a core area there and when you test models we also look at family planning as part of the package. For example a mother is positive and they are supposed to come and deliver we say okay fine you are positive but then you have to make sure that remember every time they conceive that is the risk. So we try to prevent as many risks as possible. So if it is a mother and she is positive even if she has the right half maybe a child we still give them the antitroviral treatment to ensure that they are coming to anti-mental clinics but we provide other mechanisms to ensure that they are not able to come the following year to deliver again because we know that delivery as a process is also a risk to the unborn baby. So that we ensure that family planning is part of the work and for those ones in particular we look at the condom but also we help them get a second method so that they are usually working on a dual sort of family planning undertaking. Something just came up but remember one key challenge that we have is providing sexual and reproductive health services to our youths. We have a major issue in the church and we are struggling with it and we are trying to see how best that aspect can be penetrated to provide appropriate and good information to our adolescents about their sexuality about reproductive health and family planning. That is a very sensitive area for our church and we are very careful about that with our church leaders to make sure that until we are really able to understand why and why and what is something that still needs to be explored so that it is expanding and with that we are still a lot of teenage pregnancies 12, 13 year old coming with a pregnancy, legally married so what do you do? You just have no information about family planning and all that so that is a key area of the challenge that we are praying and working to see how best we can balance our theology with the real practice of those adolescents that are very sexually active. That was actually my next question to you. It was about not only youth broadly but particularly the young girls the adolescent girls, the young women and maybe can you talk to us about some of the opportunities you see and some of the challenges that you, some of which you just described in reaching not just youth which is important in itself but also finding the safe ways, safe spaces so that the young women, the girls can get the information they need to protect themselves. Yeah, one is integrating those services among youth programs in schools family schools, secondary schools there are lots of youth programs at that level that usually when you are talking about HIV AIDS which is permissible and acceptable we integrate some of these sexual and reproductive health messages at that level a few people have also been able to establish youth friendly centers where youth gather to play indoor games and other games together and then while they are interacting among their peers and the groups there's always a counselor available by the corner to talk to them one on one for those who want one kind of counseling service or the other and that has been an opportunity which we have used. Within the church structure too there are lots of youth groups who organize special activities and programs for themselves and sometimes we use, make use of that opportunity to have an opportunity to say what or to them about their sensuality and reproductive health issues so that from there you'll be able to know that okay there are areas that they can access some form of further counseling and services where they think the need will arise I think these are some of the opportunities that we have had and we are catching it or need to see how we can reach these young people We know that often reaching the girls is harder than reaching the boys because the boys come and play the game congregate often in a way that's not as easy for the girls Can you describe some of the ways that you're trying to reach out especially to adolescent girls and young women? Yes, in some of the areas where we are working we have very high fertility rates to such an extent that by the time a girl reaches her 30th birthday they already have 8, 10 children It's a very sad situation indeed because you find a girl being married off into being married off at an age of 12 at an age of 13 in such communities the moment the girl starts menstruating then to them they think those are cows cows in the sense of riches When a girl starts menstruating the parents already start thinking of money It's time for this girl to go so that we can get resources in So the challenge has to be at the community level You have to look at the leaders you have to look at the church leadership you have to look at the leaders themselves in the communities who are also part of the entire process So yes, as we've tried to do the youth-friendly services but even with the youth-friendly services you tend to see only boys in those youth-friendly services and the girls have been left out Within the church structure we have the mother's union the mother's groups that are trying to reach out to this girl But again when you look at the way they are doing it it's a mother's, you know, by definition it is a mother's It's a mother's union, it is a mother's group So it's like even to the girl that's a thing for the mothers it is not for us the young girls So currently we are engaging with the church leadership so that we can have a clear mechanism clear space that specifically targets this particular group of young girls Otherwise the way it appears is like for the young girls is only holiday time when you have to go to the beaches and then maybe you minister to them but there is no concrete program that is there specifically targeting the young girls that girls in the communities are being followed up are being taught, you know, they are left Of course traditionally we had those aunties who were there but the way the world has moved we've closed off many of those mechanisms that were there to train the girls and I think we just have to go back to the drawing board look at what is happening together with the leadership that is there in our context the church leadership and then develop specific and tailored programs for the girls It might be interesting before we turn to some of what you've learned here while you've been in the U.S. to talk a little bit about the situation in your own countries in terms of the political leadership and the support or lack of support for some of the family planning programs Do you want to start with describing the Nigerian government's attitude? Well for the Nigerian government even though there are efforts two years back we are forced to see how they can enhance and step of family planning services there is no direct whether agreement or memorandum of understanding in any form with the faith-based groups So everything based on good will of whatever we are able to get at any given time and that has been a key issue between us the political will of adequate and proper partnership to support the faith-based seeing that they are serving the generality of Nigerians has not come out very clearly and therefore there is no definite MOU agreement as to what the government can do along with faith-based to really work out the issue of family planning services in Nigeria You know we are a very populous country estimated at 170 million and so now if in this room we were all black Africans possibly one out of five or six would have been in Nigeria and so were quite many and so there is a lot of competition for resources and advocacy that we make hardly often falls short because of the competition for the resources for one thing or the other and therefore their priorities are not really facing some of these things appropriately Now in the Nigerian context too we have very weak health systems the treasury secondary and primary health systems there the structure is there but the health systems are still weak and therefore we that has affected a lot of service delivery both in the public and for those of us who are faith-based but then in the recent time you are aware of the insurgency that is going on in Nigeria some of us call it a political war with a religious government and that has affected services in the northern particularly north-eastern part of Nigeria and as you know the international community's attention is geared towards that and we are hoping and praying that something definitely is done because a lot of there is virtually no functional faith-based facility that is standing in this core area of the Boko Haram insurgency the health workers escape with their lives narrowly and the service, the health facilities are virtually destroyed including churches so those are some of the political situations that are really affecting service delivery in general you can imagine what is happening in those displaced camps of mothers and children and what will be happening in those areas with issues that are really serious and especially in the government of Nigeria and we are hoping that these issues really come to an end soon so that the common people are able to access the services that they dare need government have not really been there physically with services except for the first base but we are hoping that it will end soon and people will go back to see what we can do to help these people but we are working in some of those displaced camps so providing the kind of rehabilitation that we are able to do appropriately as the base organizations and in Uganda what is the level of political support for family planning from the government yeah Uganda is one of those interesting countries where as a country we have signed so many chatters I think we are part of the coalition of these, the coalition of that but to me I look at that as the technical side of things but when it comes to the practical aspects our political leadership has not been very supportive in line with the issue of family planning that's the practical aspect because on many occasions the key leadership have been quoted as looking at numbers as critical because they are looking at numbers with economics and not looking at it in other context so I would say it's a mix you are the technical people you are hearing this and then tomorrow you hear something from the political and then the following day you hear the political leadership again supporting you so it's not been very clear it's not been coming out clearly in terms of where things are going but also I think it's also the result of much of the northern part of the country having been through a long standing war and when you look at the population in those areas it's been a real disaster so talking to those people about family planning considering that many of them don't have children is also difficult but then at the same time when you look at the Uganda demographic health survey and look at the poverty levels it is now clearly coming out with the regions that are doing well in terms of poverty eradication also child spacing is coming out clearly so it's a bit of a mix and to me I think what I would love to see is the political leadership looking at it in the context of yes there is this in this region but what message should be going out in this region versus what message should be going out in different regions other than just going out openly to either go against family planning completely so the messages are against family planning you hear some of that I think I know that there's a lot of people who are going to want to ask questions I think it would be very helpful to hear a little bit from you about your meetings here in Washington I know you were here for the CCIH conference over the weekend and then you had an advocacy day yesterday and you were able to meet with Republican and Democrat offices can you tell us a little bit about what you discussed with them in terms of family planning what you may have heard that surprised you some of the messages that you tried to convey to them we my team met a couple of people and one thing that I saw that was quite different from the Nigerian context was the ease with which you see people and they receive you very easily at that political level which is so difficult for us but when it comes to family planning specifically I think what I got which starts out when we were talking about it somebody said no we are a bit careful talking saying anything around family planning I think personally I understand if you talk about child spacing so we said okay child spacing if we can space our children that would be good enough through whatever way that we space so it was like for me coming from Africa Nigeria and then child spacing and not family planning it was something that hit me a little bit on the face but then it gave me the opportunity to know that I think that is why CCIH made it as an important aspect to go and talk so that people would know that family planning is relevant and it's important it should be supported through whatever means thank you I share some of those feelings and one of the things that I found quite fascinating is you go to this office and the senator or congress person has a list of stuff working behind to ensure that they are well informed or they have all the right information and issues around what they are going to talk about I thought that was very interesting also what I found quite interesting is the way we were able to interact with the staff with openness at least at that point I'm not sure what happens after that but at least at that point the interaction the tackling of the issues that was quite interesting but also one of the things that I thought was interesting was that one of the areas that we visited was not understand that religious leaders are also talking about this thing so I thought that was also very interesting and to see that there are all these issues going on and to me I think CCIH gave us an opportunity to show that actually even for us in the faith sector it's not that we are just occupying space but we are doing something about it you can see I could ask questions to these gentlemen all day but I think that's a perfect segue to maybe before we open it up to the audience maybe to give Ray Martin from CCIH an opportunity to explain a little bit about how CCIH has been working to advance these issues in this country through the faith community for those of you who aren't aware of it maybe Ray could give us a second wait for the microphone so that people online can hear you yeah thank you Janet I have to say initially that I'm absolutely thrilled that an event like this can happen thank you to CSIS and Janet to you for organizing and hosting us and Danielle and Tony thank you for joining us at the CCIH conference helping us in the advocacy day and sharing your stories and your experience in your respective countries with all of us today you know I've been with CCIH actually for about 20 years and maybe 8-9 years ago I was giving a lot of thought to how the first weather before the how CCIH should start talking about family planning some of you know that at USAID I was a population officer so I had plenty of experience in population and family planning but not so much in a faith context and what was going through my mind was that if family planning child spacing or healthy timing and spacing of pregnancies or whatever term you use is unequivocally good health for mothers and babies and families and communities it has to be Christian how can it not be and so despite all the risks and sensitivities in taking on a topic that is challenging it seemed to me that an organization that's a large network of Christian organizations and individuals with the mission statement of promoting global health and wholeness from a Christian perspective we have to be brave and talk about family planning so Henry Mosley, Douglas Tuber some of you know these people you know we all sort of strategized and our board said why don't you organize a session at the next CCIH conference on family planning so we did that and there were no lightning bolts striking from the sky so that emboldened us a little bit and we sort of expanded cautiously from there and our board got more and more comfortable with family planning we were very careful to position family planning in a way that was the way we heard it discussed today that was both evidence based data based in a public health sense but also respectful and sensitive to the religious or theological or cultural realities of various denominations or various communities and that I think was key in the success that we had in advancing family planning as something that was not only public health justified but was also consistent with Christian values so in 2008 we conducted a survey of our members and found a bit to our surprise that actually none of them were opposed to family planning if properly positioned yes there were risks, cautions, challenges you had to talk about it carefully but the concept of family planning was acceptable so we got more involved we then got a grant from the UN foundation to publicize our views we worked with congress and capitol hill and that program has been quite accepted and I think has changed attitudes to some degree I mean there's no question in my mind that people or organizations that would not have talked about family planning five years ago some more conservative circles, denominations and so forth are now talking about family planning again in a way that's respectful of cultural and theological differences and realities but the underlying importance of child spacing healthy timing, spacing of pregnancy, whatever you want to call it we don't care that is becoming more and more established and I think acceptable in conservative and faith circles and so our interest now is in continuing this effort here in the United States to change perceptions of family planning and of course always making sure or trying, it's difficult sometimes that family planning is not conflated with abortion that's in this country in the political sphere in this country is unfortunately a problem and we're looking for opportunities and slowly finding them to work with partners in Africa and elsewhere Christian health associations like UPMB and Chan and so our commitment now is to work with faith communities, our membership around the world in expanding and strengthening and promoting family planning as an integral part of maternal and child health thank you Ray and I do want to say our chief coordinator for a lot of this effort is Mona Bormet right here and Mona Bormet is all around Washington conveying this message and we're going to be continuing to push forward in this area thank you Janet thank you Ray and thank you Mona for all your help so now we're going to open it up to questions from the audience please identify yourself when you ask a question and I think we'll take groups of three and then we'll turn it over for some responses so we'll start back here it's hi, Britt Menchel, Pastor Britt from the Renaissance Institute in Baltimore when I was doing my last book about eight ten years ago I made reference to a breaking story at the time when the U.S. Government defunded a program that was helping young girls that had been prematurely impregnated and as a result they were having terrible incontinence problems and were being thrown out by their families it was a horrible story I often wondered I never followed it up I should have are you the guys that came along and rescued that effort or is it being done or did it just languish thank you question up here I'm Hannah Claus I'm from the Teen Star Program and I'm wondering have you looked at all at what this happens to the status of women when they use various methods of family planning and also when the time comes would be happy to tell you about our Teen Star Program in Uganda we just finished a PEPFAR grant but that's a separate issue Hi, Beth Robinson from the Futures Group Health Policy Project I wonder if the years long effort to reposition family planning in West Africa has had a noticeable impact in Nigeria for example in your experience sir okay so why don't we start with those three we had the fistula question the status of women using family planning and then the repositioning family planning in West Africa the fistula program there are two main fistula treatment services in Nigeria one in the north and one in the southeast and they are doing a great work of making thousands of repairs of these fistulas irritating them thereafter and reintegrating them into their societies and that is going on one is a public government hospital and the one up north in jobs where I live is actually a Christian hospital and they are doing a very great job and that is continuing a lot yesterday we were with a fellow from Niger Republic they are also doing something like that and I think Niger has the worst case in Nigeria within the sub region and I think they are also doing a lot of work the key thing is not just repairing the fistulas but also ensuring that at least a lot of community-based activities are going on to see how much of the prevention of those things occurring would happen but it's an uphill task because we are working a lot of these fistulas are prevalent in communities where these things are like tied with cultural practices and until those cultural practices are completely changed repairing those fistulas will not end the matter and I think that is the greater job that an effort that is being done reaching the men and women and religious leaders within those communities where these practices are very prevalent because it is associated with girls that are given out in marriage too early and of course they have prolonged labor during the league and they become outcast in their communities and at the end of the day they are just wandering everywhere some of them come voluntarily when they hear about it some actively search for them and bring them into law and there is hope and a lot of that work is still on it's not just going down the drain a lot is still being done to assure you on that because and within the city where we are engaged in this VVF program Tony do you want to take the question about the status of women when they use family planning and whether there is any change that you see yeah I would start by saying my wife is one of those I would start with my family we have we have three sons they are well spaced recently I was with my wife and my colleagues and one person made an interesting comment I will be ten years in marriage in August and one person made a comment say you look younger than I thought you do and actually I had not told my wife that but one of the other people told my wife that so already and I don't think it was just out of context I want to believe it really reality so I want to say that yes it happens people look better people live better lives compared to other women they are already stressed people are always in hospital so of course I haven't done any particular research but that's just observatory that's what I would mention but also in Uganda we are doing some work we are doing some work some of our hospitals are involved but as you know these are very poor young girls 101 educated they have gone into this they don't have any income so definitely somebody has to come in to support them to see that they get the treatment now surgery is very expensive sometimes it has to be done twice twice for them to eventually have the whole process underway so in a support in that line we think is very important yeah maybe on the issue of repositioning family planning in West Africa I don't know how much that came up in the time that you are here but there has been new efforts to focus on the need for family planning in West Africa from the US government and are you seeing any impact on the attention to these issues in Nigeria I would say I have not seen anything directly because that is being done directly by the public health sector, the government and we are not directly involved as faith based organizations in that regard so I don't have enough information to be able to say whether or not something is happening but for the fact that we are doing and I don't know anything about any church at all is engaged in this activity so I will not be able to comment on that because I don't have facts about it another round of questions thank you Janet, Carl Hoffman the president of PSI in Uganda we work through PACE and in Nigeria our partners in the society for family health so delighted that you are here I want to congratulate Ray and CCIH for organizing your visit and particularly to the Hill because you were able to experience the difficulty of this conversation in our geography and it puts yours in a different context I think but I can't resist asking the question of the two of you since you are here representing Uganda and Nigeria in particular and you are obviously working with faith based organizations that are invested in the health of their communities and not just family planning but I suspect also in the fight against HIV I'd be interested in your perspectives on the recent public policy changes in the two countries the criminalization of same sex relationships and what that means from a health perspective my name is Margarita Chiquina I'm a public health student I had just returned actually last month from doing my thesis project in Uganda and I was working with a local surrounding pure education for HIV prevention and so this is more for Dr. Tumasi here but maybe for both as far as family planning how are you working to be creative and innovative you mentioned this idea of the cultural practices and I ran into this a lot in the villages still family planning is a new idea people are resistant to somebody telling them to have a viewer so what are you doing to be just approaching it in a new way or to change some of those cultural norms and is pure education a part of the work we have one more in this round I think we have one more over here Shepard Smith Institute for Youth Development I'd like to thank Ray Mona Hannah Catherine and all the rest who helped Ananita who helped me evolve on this issue first of all two quick questions one for Donnie and that's a curiosity question if you're related to the honorable Iliota and the other is a general question related to tribes in Africa I'm really fascinated by the differences in every country of the different make up and how important are tribal leaders in what you do sometimes they are spiritual leaders but more often they are not and the differences is important for us from the west coming in to try to help to know some of the differences between tribal attitudes on the issue thank you ok so we have three big questions first the homophobia laws the new approach to addressing cultural norms particularly in Uganda and then the last question about the differences in some of the tribal attitudes so who would like to begin it's a very issue start for those who don't know Moseven is the president of Uganda but I'm not the president of Uganda but are you related to this thank you very much for those questions I'm not related to Iliota but we come from we are all from the southwest he comes from the western part of the south and I come from the deeper south but through the what I would call under the theological line there was a lot of movement in terms of Christian faith in the southwestern region and as a result of that many of the names were changed because of that so you would hear names of which means we trust which means we trust in God we are God's so there was that tribes are rather semi clans or semi tribes in the same region we have the same names yeah it is I want to say that we are working within the context that it is at the moment the law the anti homosexuality act was passed in Uganda and we have to work within what was passed for us as a technical organization one of our roles has been we have been asking the government now that you have passed this law how are you going to implement it and suddenly even as I speak now the law was passed without a clear mechanism of implementing the law and for us in the health sector what we have so far seen is that there are lots of there are a number of press releases like yesterday or the day before we saw a release of a policy statement by the Minister of Health in view of what is supposed to happen in the health sector vis-a-vis the law so by that policy statement for us we are more relieved because one of the things that we were fearing we had significant fear before is that as health workers we are mandated to provide care to everybody irrespective of their sexual orientation and that's the message that my organization has been pushing for we never ask patients what is your orientation when they come to us we've never asked historically and it is our faith whether it is our network that has been there over the years even when situations were very difficult everybody was running to us during the war when people were abused they all run to us so we've been there for those who are marginalized in the community and so even as I speak now for us our organization came up with a statement already in view of that throughout the entire network ensure that whoever comes and seeks services ensuring confidentiality ensuring care is given and so at leadership level the main concern that we had was that now that this law has been passed what is it for me and the healthcare provider who is going to see this patient my ethics demonstrates that I'm supposed to give care I'm supposed to be confidential so are you saying that for us as health workers we no longer exist because of this so good enough we've seen our policy statement that is coming in to say all health workers should not give should not be complacent in assuring that the code of ethics is implemented so to me that's the positive despite the law that has been passed yeah and for us we've been very clear on that and our border has sent out a message and I'm grateful that the government is also beginning to listen because I represent the network at the health police advisory committee of the Ministry of Health so the voice is there despite the law being passed at least now I've seen the Ministry of Health come again I want to believe that that this law was passed amidst a lot of a lot of which one would I say I think there was a lot going on at that time maybe there was some evidence maybe the government wants to reverse but maybe there is an election coming maybe people feel they cannot reverse what has already been done but their voices inside there that feel that this went beyond what it should have been but suddenly as democracy dictates the bigger the numbers take the day so not everybody in Uganda supported the law but because democracy dictates that the majority take the day even those that are minorities have to be there but the question is how do we ensure that the rights of those minorities are protected and I think for us that's our concern I know in Nigeria we are very good at making laws but a lot of our laws are kept on the shelf and it takes a while until somebody deviates then you remember that there is a policy and this is the way it is done so just like he talked about issue of implementation I think it is the same goals for us in Nigeria but we know that the people who have this orientation are known to us for years they've been there and with this law we know that they will go underground and a lot more damage can be done but as a faith community we know that we have to operate within this law at the national level but as Christians we are following in the steps of the Lord Jesus Christ to bring and service to whoever comes that is in need of help and generally nobody will come up front to tell you this is my civil orientation it is when you go on one on one that you are able to know okay this is the situation and nobody will turn them around agreed our religious leaders have spoken a lot against that but then we are at the receiving end and as professionals not to reject anybody that comes to me for whatever sort of help irrespective of his race his religion, his orientation or whatever I think I better obey the oath that I have taken and it is also better for me to obey God than obey my and within that context within also the Christian community I see nobody sending away anybody from accessing services in the faith based health facility in Nigeria we are always there to receive those who have been rejected elsewhere in fact many times they will come they will say I rather go and die in the mission hospital than stay in these other places because they will take better care of me and they will show me more love better love and care than if I sit somewhere else that is what makes us different in going into health service delivery as Christians to show and demonstrate our faith and what the Lord Jesus Christ did when he was on health he never rejected anybody that came to him including the children that were coming when the disciples were sending them away so that is the way we see ourselves but then we have to operate cautiously, nobly well that officially if something goes wrong there will be consequences maybe we can turn to the question about new approaches to addressing cultural norms in Uganda yeah culture I think as we mentioned earlier is quite a difficult difficult area to get in but I want to believe that slowly by slowly we will get there for example in some of our country we have female genital mutilation which is a very very bad culture that that has really been a problem we have begun to see that change we saw the passing of the law criminalizing anybody who does that but also the other challenge has been that you have people who have been in these communities and that is the work that they are doing ok so if you stop them from doing that work what is the alternative for some of them live on that work ok they have never done anything else that is their source of income so as we change the culture we have to provide for alternative issues so I think usually it's the economic part of it that tends to move certain things you also the other area that we have seen is in children who are born and where people have to to extract what they call false teeth because sometimes children grow teeth quickly and then people in the community say that is those are false teeth children will not have develop teeth other cultural practices for example what they call extraction of millet in children who come in with pneumonia the child comes in with pneumonia can't breathe and the community feels that you must extract there is millet in that chest which must be extracted fast and by causing that extraction you're damaging father the child so there are cultural practices that to me considering the experience I worked in the rural setup have more to do with economic gain and until the economics have been certain I think it's going to be very difficult to do with some of those cultural practices that's my take I think in my experience over the years attempt to change cultural practices are difficult and takes a long time and some of the key issues that we must address which some of us within the country are trying to do is girl child education empowering of women if these people are properly equipped and the women are economically equipped and have some level of social status within their community they can take their decision and stand up straight and the best way therefore is really continuous education empowerment of women girl child education at least that will help and if they know and they have the knowledge they will be able to take a better and a more informed decision on their own rather than allowing themselves to be twisted by cultural practices so that is key but at the same time what we have tried to do I think I showed a slide to some of the people who use some mothers as role models within the community PMTCT has been a key challenge in Nigeria and there are women who have attended and have access to prevention of mother to child infection by HIV because they have attended anti-natural services they have been discovered early family planning services they have also introduced to them so that they don't get immediately pregnant and then even when they want to get pregnant they have a chance of having a baby that is not infected now we have made use of these role model mothers and for family planning as well like somebody mentioned about what are we seeing any changes in these women there are role models in communities particularly in rural areas that we use them and they are able to interact with their peer groups and they are able to break some of these practices that happen but I think in a lot of African society girl child education and women empowerment is key for them to have the knowledge and the ability to take decisions based on those information and knowledge that they have so there was one last question that was about the differences in ethnic groups and tribal groups that maybe you want to wrap that into some final remarks because I am conscious that we are running out of time though it would be great to continue the discussion for a long time so maybe you can any comments you have on that last question you can include in some final remarks about the way you see the way forward well in Nigeria there are more than 250 ethnic groups and if you break down to different dialects you are talking about 500 or more and there are those differences are there and therefore it is difficult for you to model any kind of standard of things that you will be able to penetrate that will be acceptable to the different various ethnic groups but when it comes to health education messages often times we see ourselves having different messages for different ethnic groups and communities so that they can understand the way within the context of their culture if you make a poster in northern Nigeria and you take it down to the southern Nigeria nobody will understand really what you mean by that because of the cultural context within it so we are often customizing health education materials BCC materials and other things customized based on those various diseases and key among such the other to bring about harmony is that even though we are health we partner with conflict and peace development organizations to see how we can also mainstream these issues amongst the various ethnic groups it is very easy to see one tribal group rising against the other and so on and in the absence of peace I think there is a lot of conflict resulting in into wars situation is even worse and therefore mainstreaming of conflict resolution issues and customizing messages be family planning or whatever to the various ethnic and tribal groups has helped a great deal in passing a lot of messages to our people on a final note I want to say that family planning is a gateway to reducing maternal mortality and also reducing child mortality what are those things that kill them hemorrhage unsafe abortion infection and wanted pregnancy that results in abortions but we are aware and we know that if we offer them family planning a lot of these complications that occur during pregnancy and delivery would be prevented and our mothers will stay alive to take care of us the husbands and their children final thoughts Tony about the way forward I want to thank the team here for me one of the things that I think is critical yes we have different tribes in Uganda but we cannot work alone as a Christian organization we must work together in the same sector irrespective whether they are Christians and that's the line we are taking in Uganda and I think it is very important because once we join hands with the different groups that are doing different things within the same context we should be able to achieve more so whether we are Christians or others are looking at themselves as non-Christians I think there is a common point if we are in health we could serve Christians looking at holistic health but what about the non-Christian what sort of health are they looking at it is still health so can we synergize together and maximize where we want to go I want to believe that if we can have children that we can manage we should be able to live better lives and support our country to reach them and to anybody that we perform so I want to thank you very much I wish you all the best and welcome you to Uganda well I hope you all will join me in thanking our panelists this has been and I want to thank all of you because I think those questions help delicit a very interesting conversation that we hope to continue with all of you thank you again safe travels back home thank you