ASTRA- Reproductive Health Supplies in the Central and Eastern Europe

Publication date: 2007

RepRoductive HealtH SupplieS in tHe centRal and eaSteRn euRope ASTRA Network has carried out the survey on reproductive health (RH) supplies’ accessibility in Central and Eastern European (CEE) countries. The concept of reproductive health (RH) supplies is understood here as fac- tual access to contraceptives, condoms, safe motherhood supplies, supplies needed for safe abortion, HIV/AIDS prevention supplies, i.e. HIV testing kits as well as to relevant services. The following ASTRA members have par- ticipated in the project: Albania – Albanian Family Planning for Population and Development/ Tirana Armenia – Women’s Right Center/Yerevan Bulgaria – Gender, Research and Technologies/Sofia Georgia – Women’s Center/ Tbilisi Hungary - PATENT (Men and Women Opposing Patriarchy) Human Rights Association/ Hungary Macedonia – Shelter Centar/Skopje, Poland – Federation for Women and Family Planning/Warsaw Ukraine – Women Health and Family Planning/Kiev The questionnaire contained questions regarding: access to contraception including emergency contracep- tion, condoms, HIV/AIDS tests, abortion, sexuality education, safe pregnancy supplies, services within and out- side public health systems as well as relevant information policies, programs and campaigns. The results of the survey confirm that access to RH supplies is very limited in CEE countries. The region of Central and Eastern Europe faces many barriers in accessing satisfactory reproductive health services. The issue of RH supplies is not prioritized in government’s policies. Governments lack commitment to recognize RH supplies as important component of public health and human rights. There is no adequate legis- lation and policy in this area, the access to family planning services is very limited. It is important to underline that access to RH supplies is key not only to guarantee observance of human rights, including the right to information, but also to curtail the HIV/AIDS pandemic. Central and Eastern Europe faces the fastest growth of the pandemic in the world. Women and young people are particularly vulnerable to the infection, what is connected to social and biological factors. One of the key strategies for preventing the further spread of HIV virus is education, better access to contraceptives and condoms and to STI’s testing. �access to RH Supplies Most of the countries which took part in the survey on RH supplies have very limited access to them. The public attention is not focused on sexual and reproductive health and rights (SRHR) in general. The countries do not have specific laws regulat- ing access to RH Supplies or regarding SRHR in general. The references are included mostly in general public health or drug regulations (or, like in Poland, in the antiabortion law). With the exception of the Armenian “Law on Reproductive Health and Reproductive Rights of Humans”; Ukrainian “National Program – Reproductive Health 2001-2005 with its extension to 2006- 2015” and Bulgarian 2nd Part of the Reproductive Health in the document “Health Law” no documents are even using the con- cept “reproductive”. These legal limitations lead to many obstacles in receiving the proper access to the services guaranteed to all people by international documents. Moreover, in some countries (Poland) the language on SRHR is ideologically biased, judgmental and influenced by the Catholic teaching. For example the phrase “mother of conceived/unborn child” is often used instead of the phrase “pregnant woman”. In fact, this term has been introduced into Polish law. In other countries like Albania, Ukraine information about SRHR is very limited so people do not know proper terms in this area. CEE inhabitants have limited access to information regarding rights and supplies the access to which they have guaranteed even by national law. The lack of information often leads to many problems that could be avoided. Only in the Ukrainian report can we find the opinion that the society is well informed about contraceptives. European countries experience low birth rate. This phenomenon increasingly called by politicians demographic crisis is believed to be one of the major population problems of Europe these days. Many policy-makers are using this as an argument against improving access to SRHR when putting the issue on the agenda. As the result, the access to reproductive health sup- plies is not addressed in state policies. SRHR are under attack these days because they are recognized as the reason of demo- graphic depression. Importantly, Albania and Ukraine seem to be the only countries to have national policy to increase the level of contraceptive use. It is important to underline that there are NGOs in the region active in the field of RH supplies and they are filling the gap in this area especially in education and counseling services. In most researched countries the governments are not making enough efforts to educate the societies about sexual and reproductive health issues. Furthermore, in countries like Poland, where the Catholic Church has a very strong influence on the national policy and private life of citizens and the government is mostly conservative - the financial support for family planning related activities can be hardly raised. NGOs activities is run mostly without any financial support from the government (Poland), most of the non governmental organizations’ programs are covered by foreign founds. Currently, the highly conservative Polish government set up a special Task Force within the Ministry of Health structure for the Promotion of Natural Methods of Family Planning. Moreover, the Polish Parliament is currently working on “National Plan for Supporting the Family” which can seriously limit access to contraception. According to the draft, every package of contraceptive pills and condoms should contain a warn- ing about their harmfulness, similar to warnings on cigarettes packets. There is no monitoring mechanisms created specifically for SRHR services in the surveyed countries. In most of them there is none, like in Hungary, Armenia, Ukraine, Bulgaria, Albania, Georgia. The countries have the laws which guarantee the right of the citizens to contraception, but often the right is present only on paper. Access to contraceptives is very restricted by social and mental barriers. This leads to numerous problems with access to contraceptives for all. private sector Some organizations from the private sector have subsidized contraceptives in the region (pills, condoms, injections). NESMARK carried out such activity in Albania, currently UNFPA has a limited stock of such supplies and the area of its influence is small. In Georgia only UNFPA provided the free distribution of two types of oral contraceptives (Ovidon and Rigevidon) and one type of condoms. Also Depo-Provera and Norplant have been provided. In all researched countries the possibility of receiv- �ing subsidized or free contraception was defined as hard. Private companies are often not allowed to offer free supplies, except condoms. In Poland no subsidized or free contraceptives are distributed through schools and rarely through other organizations – sometimes condoms are an exception, they are available at drug stores, shops, and in some NGOs (especially working on LGBT, Sex Workers, rarely Family Planning ones). No contraceptive supplies are provided by the governments so the financial barrier plays an important role in limiting access to contraceptives. Furthermore, all contraceptives and condoms are taxed. In the context of the poor material conditions of these societies, this additionally decreases their use. condoms and Sti’s Condoms are widely available in the surveyed countries. You can buy them in drug stores, shops, sometimes in vending-ma- chines (in Hungary, Bulgaria and Georgia). Except in Armenia, where condoms are available only in Drug Stores, what can cause serious problems with buying them. Condom advertisements are very rare if any in all researched countries – occasionally in the biggest cities of Poland you can see the billboards with condom advertisements, but when they are in the media like TV spots, they are presented very rarely and only at late hours (what is underlined in the Polish, Hungarian and Armenian questionnaires). Ukraine says that there are al- most none such advertisements. In Georgia there are no condom advertisements in the media. Since NESMARK left the Albania area, there are no condom advertisements in thr media in this country. The cost of condoms is relatively high for CEE countries citizens, especially for young people. and the access to subsidized or free condoms is very limited – in Poland only a few organizations are providing people with such supplies, but even they only reach out to certain target groups, such as men who have sex with men and sex workers. In Poland a limited number of condoms can be accessed on request for educational and promotional campaigns from private companies. In Georgia only NGO Tanadgoma distributed condoms to sex workers in 2006. In Bulgaria condoms are distributed for free as part of promotion and under NGOs activities, mainly under GFATM and UNFPA/UNAID programs. Contraceptive Social Marketing (CSM) attempts were made in Bulgaria with the active participation and input of some NGOs. Due to low access to sexuality education, condoms are very often underestimated as an effective STI prevention method. The issue of condoms is mostly addressed within sexuality education programs. The situation is especially hard in Poland, where the government not only does not support condom use as a preventive method against STI’s but undertakes initiatives against free access to condoms. The campaigns which should focus mostly on condoms like HIV/AIDS campaign are mostly connected with fidelity and ab- stinence, not condoms – what is mostly underlined in the Polish report. Moreover, the HIV/AIDS campaigns organized around International AIDS Day on 1st December do not adequately promote condom use. Usually, they allude to it very indirectly focusing on general reference to responsibility. Moreover regarding HIV/AIDS pandemic – in Poland condoms are not recognized as the only good way to protect against HIV during sexual intercourse. The HIV prevention campaigns are mostly focused on abstinence and faithfulness rather than on protection against risky sexual behaviors which are social fact. Better campaigns promoting condoms directly are run in Albania, Bulgaria or Ukraine. In all researched countries HIV/AIDS testing is quite well accessible. On the other hand, testing for other sexuality transmit- ted diseases e.g. Chlamydia, a pandemic which is still out of control in CEE countries, is not popular. There is no good preventive policy in the area of other STIs , the tests are mostly suggested by doctors when pathological symptoms have already occurred. The situation is very hard in Georgia, where only the cost of STI testing for pregnant women is covered by the government. �contraceptives The use of modern contraceptives is very low in CEE countries. Most of the countries which took part in the project mention very low contraceptive use and lack of current research and reliable data on the issue. Only 1 percent of Albanian married wom- en use hormonal contraceptives or 2 percent of spouses use condoms. Moreover, about 70 percent of them use withdrawal. Only 5 percent of Macedonian women use hormonal contraceptives and 24 percent use condoms. About 7 percent of Armenian women decide to use hormonal contraceptives. According to the Georgian report, only 25 percent of women aged 15-44 (41 percent of surveyed women were married) are currently using any method. Half of these users use modern methods like IUD or condoms, but the other half choose traditional methods like withdrawal and rhythm. The prevalence of modern methods has been increasing but very slowly. Regarding Poland, about 26.9 per cent of Polish women are using hormonal contraceptives, 25.9 per cent still choose natural methods. abortion In most of the CEE region countries, which took part in the project, abortion is legal. Only in Poland is abortion restricted. Legal abortion is relatively cheap or free of charge and access to it is very easy – in contrast to contraceptives methods. This leads to a high number of abortions in most CEE countries. Due to limited access to contraceptives abortion has become one of the most popular birth control methods. Because abortion services offer a low standard in the region, what was underlined by partners from Georgia, Macedonia, Armenia – most popular method is dilation and curettage (D&C), the conditions under which the abortion is performed are very bad, which, in turn, very often leads to post abortion complications like infections, which can cause infertility. In Poland abortion is legal only for three reasons: when the pregnancy constitutes a threat to the life or to the health of the pregnant woman, which is confirmed by the doctor other than that involved in the abortion, prenatal examinations indicate heavy, irreversible damage of the embryo or incurable illness threatening the life, there is justified suspicion, confirmed by a prosecutor, that the pregnancy is the result of an illegal act. But anti-abortion law in practice is much more restrictive than the written word. Women who are entitled to abortion for the reasons mentioned in the law, cannot exercise their right because doctors refuse to perform the procedure, on the basis of the “conscience clause”. Most of the researched country organizations mention that the conditions in which abortions are performed in their coun- tries are bad due to the use of outdated abortion methods, lack of choice of the method, poor working conditions in many hospitals, doctors’ negligence, abortion performed by inexperienced doctors. There is no research on post abortion complications and no information about governmental initiatives to improve the qual- ity of abortion services by legalizing medical abortion or running trainings for doctors on the vacuum aspiration method (VAM). Only Women’s Center from Georgia and Women’s Rights Center from Armenia are in a dialog with governments to implement Medical Abortion in their countries. In Armenia the process is in a very initial phase. In Poland legal and illegal abortion services are carried out by D&C method. The use of the vacuum method is limited. Because of very restricted anti-abortion law there are no programs improving this procedure. Medical abortion is not legally accessible. Increasingly women are able to access medical abortion in private clinics or on the black market. In newspapers you can find advertisements in special code language “pharmacologically, cheap”, “full-range, cheap”, “inducing period pharmacologically”. Safe pregnancy Regarding safe pregnancy, there is a very big problem with access to prenatal tests in CEE countries. The number of per- formed tests is very limited, this situation is mostly caused by financial barriers. Doctors in public hospitals very rarely suggest such tests even if there are indications to perform them – the reasons can be ideological ones (like in Poland, where these kinds of tests are often feared by doctors to be the first step leading to an abortion) or financial, because the cost of the tests is high. In CEE countries there are different insurance systems, in some of them they are obligatory and subsidized, in others they need to be paid for by the woman. Shelter Center from Macedonia suggests that doctors in public clinics have an ignorant attitude to this kind of tests and pa- tients are often not aware of the need of performing them. Only researchers from Armenia, Ukraine and Hungary do not find problems in the field of prenatal tests. Moreover PATENT from Hungary mentioned that they are obligatory for pregnant women which also causes problems sometimes. Bulgaria finds access to this kind of tests better in big cities. �Post-delivery care in the filled questionnaires is assessed as poor, especially in rural areas. In big cities the delivery care is much more better but also more expensive. Reasons of the low modern contraceptives and condom use: ineffective system, lack of information and high prices. ineffective health systems: From the researched countries, only in Poland, Macedonia and Hungary women need prescription to get hormonal con- traceptives. Moreover, doctors in these three countries have the right to refuse a prescription on moral grounds. Especially in Poland doctors in public hospitals exercise this right and refuse prescriptions and/or reliable information on modern contracep- tives. The access to modern contraceptives is limited by medical providers (Poland), who often refuse to issue the prescription for hormonal contraceptives on conscientious objection grounds. Therefore, the need of having the prescription to get con- traceptives is a major barrier in Poland. Additionally, Polish women have to regularly visit a doctor and very often to pay for a visit in private clinics and to realize the prescription within 30 days from the date when it was issued. It is impossible to receive prescriptions for contraceptives for more than 6 months of treatment. Some drug stores are breaking the law by not provid- ing emergency contraception on religious grounds since this kind of contraceptive is still treated as medical abortion by many people. Polish Federation for Women and Family Planning is receiving this kind of information from clients. In countries like Georgia, Bulgaria, Albania, Ukraine women can get contraceptives without prescription, which is a big ad- vantage. In some countries women need prescriptions to buy contraceptive pills according to the law, but in practice women can get them in the pharmacies even without prescription. Hormonal contraceptives come under the drug law, which means that they can be distributed only under specific regula- tions. Except for condoms and IUDs, all other contraceptives are considered as medications. In Poland all contraceptives (except for condoms) are distributed by pharmacies, on similar rules as medications. There are no organizations and family planning centers where such resources would be available for a lower price or for free. There are restrictions regarding channels of distribution of contraceptives, that’s why they are available mostly in Drug Stores and Health Clinics and very rarely from family planning organizations – this is the reason why NGOs in the region do not often have the possibility of distributing hormonal contraceptives to women in need. In Georgia one medical clinic (supported by Georgian Church) not only does not perform abortions because of religious rea- son, but also cannot offer any contraceptives to the patients – doctors of this clinic do not have the right to do so. Moreover, Albania is running out of emergency contraception supplies – Postinor is off the market for one year due to lack of agreement over pricing between the company and the Ministry of Health. Except for Albania, emergency contraception is available on the markets of all researched countries. Mostly what is available - Postinor, but in some countries there is more than one emergency contraceptive registered, like in Armenia (Postinor, Escapel, Ovistin, Pharmatex), Hungary (Postinor, Fertilan) or Poland (Postinor, Escapelle). information barrier: One of the most important barriers for all project countries is the lack of a good information system about possible contra- ceptive methods and about system how to get them – all project partners mentioned that the awareness about contraceptives is poor. Women from CEE region are not well informed about this kind of contraception, doctors often do not recommend it in public hospitals. Moreover, in Poland the government not only does not run programs which could raise awareness among citizens, but initiates ones which make the access to information even more limited due to conservative forces presently in power. In all researched countries there is still need to improve access to information on contraceptives and emergency contracep- tives to the society, which has been confirmed by all participants of the survey. All project partners declare in the question- naires that contraceptives are not promoted sufficiently and societies of researched CEE countries are not well informed about contraceptives and condoms. Women’s Center from Georgia and Women Health and Family Planning from Ukraine find the information barrier as the most important obstacle in receiving contraceptives supplies – health providers from this country are not sufficiently educated in the area of family planning methods. �The most important factor of this situation is the lack of regular and reliable sexuality education lessons at schools in CEE countries. People, especially young people, are not sufficiently aware of all the possible family planning methods and their rights in the area of SRHR. In most of the ASTRA project partners’ countries there is no universal and reliable sexuality education programs (except Albania and Ukraine). NGOs sometimes provide education services – mostly as pilot projects, but the area of their influence is very limited (programs focused on sexuality education is led by Shelter Centar/Macedonia, Federation for Women and Family Planning/Poland, Women’s Center/Georgia in very limited numbers of schools). Women Health and Family Planning from Ukraine has ran a number of projects for young people about their rights regarding access to contraception. GERT from Bulgaria underlined that although the Law on Health foresees special hours in school curricula (as pilot project), there is no mandatory sex education at schools. Unfortunately, these programs are still not widely implemented in the region but only run as pilot projects like in Bulgaria, Poland, Macedonia and Georgia, led by NGOs – which means they reach out to only a very limited number of people. Additionally, official educational programs, such as “Preparation for family life” in Poland, sometimes do not meet the stan- dards of modern scientifically-sound curricula. The content of textbooks for this program is full of ideology based on catholic teaching. This subject is facultative for students, parents need to sign a permission form for them to participate. The lessons contain information about the harmful influence of hormonal contraception and the ineffectiveness of condoms. Moreover, patriarchal model of relations between men and women and on family roles is promoted, where main role of the woman is motherhood and family. Natural methods of family planning , faithfulness and sexual abstinence, sex within marriage only are preferred methods of “contraception”. In Albania and Ukraine, the sexuality education classes in schools are obligatory, but they do not instruct about all accessible contraceptives methods, in fact none besides condoms – they are on the very basic information level. If there are any kind of lessons on sexuality education provided by school, they are run not by professionals (Poland, Armenia). As a result, young people and later adults do not have information they are looking for about sexual and reproductive life and the main sources for getting it are friends, media or internet. They do not know about their basic rights in this area or available reproductive services - do not have all tools available to protect themselves well. Information centers or actions provided by NGOs are located mostly in big cities or take place in a limited numbers of schools – other places and people, especially from the rural areas are totally deprived of information and services, also because of the lack of youth friendly centers in their areas of residence. Contraceptives are barely promoted in the media and often people are not aware of all accessible family planning methods. For example, in Poland you can sometimes find hidden advertisements of contraceptives patches, which are worn by models of selected clothing companies, due to legal restrictions on advertising prescribed medications. Many women from the region do not have free access to good medical care and they cannot visit a gynecologist and ask for advice considering contraceptive methods. In the most countries the state programs about this issue do not exist. The existing educational campaigns are mostly led by NGOs , in fact by some organizations taking part in the project. Most of these activities very often focus on young people. Financial barrier: ASTRA Member organizations, which took part in the project inform that modern contraceptives and condoms are rela- tively expensive for citizens. This fact is found to be a very important obstacle in access to contraceptive supplies. In almost all researched countries any hormonal contraceptives are not included on the Refunded Drug List covered by Health Insurance (or other governmental funds), which means that modern contraceptives cannot be afforded by most people. Polish non gov- ernmental organizations have tried to start a dialogue with the bodies responsible for creating the Refunded Drug List covered by Health Insurance. In 2004 there was hope that it would be possible to include contraceptives on the Refunded Drug List. Unfortunately, this proposal was rejected by the Parliament. For example, in Armenia there is no obligatory Health Insurance at all, so a lot of Armenians have to pay for all medical ser- vices except obstetrics (motherhood and childhood) - these services are included in the special package of services of Ministry of Health of Armenia, which covers all medical services for people on poor social-economical conditions. Ukraine has no Health Insurance either and private companies cover less that 1 per cent of the population. Ukraine has Law of Ukrainian Government regarding free contraceptives for young women under 18, women with high risk of pregnancy and delivery complications, women affected by Chernobyl disaster but in reality funding is not provided by the State. The NGO sector is lobbing for free �contraceptives for vulnerable groups (youth, poor, rural area). In other countries Health Insurance does not cover costs of contraception. In fact, only in Poland are there 4 types of contra- ceptives on the Refunded Drug List subsidized by Health Insurance. The only reason why these 4 kinds of contraceptive medi- cines have been included is because their main indication is preventing or curing other illnesses, not because of their contra- ceptive effect: Diane 35 (payment 50%) , Rigevidon (payment 30%), Stediril 30 (payment 30%), Microgynon 21 (payment 30%). According to the Hungarian report, we can see some regress in the Hungarian governmental policy, because until 2002 a young person could get emergency contraception for free. It is emphasized in the Macedonian report that women are facing serious financial obstacles, especially those from rural ar- eas. Most women do not use any contraceptive methods other than natural methods of family planning. The price of hormonal contraceptive pills is too high if we know the bad economic situation most Macedonians are facing. ASTRA organizations from Macedonia, Georgia and Ukraine find the financial barrier as a major obstacle to access to contra- ceptives in their countries. Women of the CEE region often live in poor social-economical conditions, which is represented by the level of average sala- ries (see below). Many women of the region are unemployed (like 30 per cent of Macedonian women) and live in very poor life conditions. There is only limited access to subsidized or free contraceptive supplies (like there used to be in Albania through NESMARK or currently in Bulgaria through Bulgarian Family Planning Association (even the quantities are limited). This barrier is mostly visible when we compare the average salary (with keeping in mind that the real situation is much more worse, many people do not receive average salary and a significant percentage of women are unemployed). Country Abortion Contraceptive pills Condoms Emergency contraception Average salary Albania 37$ 5-13$ 0,5-2$ 2$ 150$ Armenia 20$ 2-22$ 1-5$ 8$ 170$ Bugaria 35-100$ 8-9$ 2$ 7-8$ 200$ Georgia 25$ 7$ 3$ 5-7$ from 50$ Macedonia 190$ 13$ 2$ 13$ 260$ Poland 500-1000$ (ilegaly) 3-10$ 2-3$ 20$ 800$ Hungary 126$ 7-34$ 1-4$ 15-20$ 834$ Ukraine 126$ 8-15$ 1-3$ 5$ from 80$ Modern contraceptives are relatively expensive so financial barriers have a big influence on the low level of the modern con- traceptive use – especially when we compare the price of modern contraceptives and abortion in some CEE countries. In every researched country all contraceptives and condoms are also taxed, which makes their price even higher. The access to emergency contraception is much more restricted than to other family planning methods. The problem is the lack of information or, like in Poland, the fact that contraception has become a very controversial issue – oral emergency contra- ceptives are confused with the medical abortion pill and many doctors refuse to issue prescriptions for them. �conclusion Countries of CEE Region are facing many problems in the field of Reproductive Health Supplies. Among them are: lack of commitment of governments to address the issue of reproductive health properly, inadequate access to family planning infor- mation and services, high rate of unmet contraceptives needs, low priority of reproductive health and rights in youth education, including the lack of adequate sexuality education, low awareness of reproductive health issues of the societies. Most efforts to change the situation are undertaken by non-governmental organizations. There is a big need to start multi-sectoral advocacy on RH supplies, even through better dialog with politicians , policy makers and government officials Current research aimed at assessing the access to RH Supplies in CEE countries is the first step in the long-term strategy of improving SRHR in our region. Most project partners during roundtable meetings with policy-makers, governments and health providers discussed these issues and succeeded in raising awareness about the needs of strengthening state policies in this area. To find the data collected through RH Supplies Questionnaires, follow the link: January 2007 aStRa - central and eastern europen Womens network for Sexual and reproductive Health and Rights aStRa is a regional network of NGOs and individuals advocating in a collective voice for sexual and reproductive health and rights in Central and Eastern Europe. aStRa works for the advancement of sexual and reproductive health and rights as fundamental human rights and advocates for their observance, prioritization and implementation on the international, regional and national agendas. aStRa strives to increase awareness about SRHR issues and to ensure that the specific reality of women’s sexual and reproductive rights and health in Central and Eastern Europe receive the highest priority on international, regional and national agendas, in particular at the EU and UN. Contact: aStRa Secretariat Federation for Women and Family Planning ul. Nowolipie 13/15 00-150 Warsaw, Poland tel./fax. (+48 22) 635 93 95, 887 81 40 e-mail: Realisation of the project was possible thanks to the financial support of population action international (pai)

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