Rwanda - Counting What Counts: Tracking Access to Emergency Contraception

Publication date: 2015

January 2015 Emergency contraceptive (EC) pills are included in Rwanda’s Essential Drug List and EC can be purchased through the public, private, and NGO sectors. However, knowledge and use of EC are low, and national family planning policies do not consistently include EC. ABOUT RWANDA Rwanda is the most densely populated nation in Africa, with a total population of 12,337,138.1 After many years of civil war culminating in the 1994 genocide, Rwanda is currently stable and rebuild- ing its economy. It is largely rural, with only 19.1% of its population living in cities.1 Only 2.8% of all women have completed secondary education.2 CONTRACEPTIVE AND EC KNOWLEDGE & USE POLICIES Essential Drug List: The 2010 EDL includes levonorgestrel in the proper dose for EC.4 National norms and guidelines: Rwanda’s Na- tional Family Planning Policy does not include specific directives regarding EC; however, Rwanda’s National Training Module for Fam- ily Planning (March 2008) includes a chapter on EC.5 EC was not mentioned in Rwanda’s Health Sector Strategic Plan for 2012-2018.6 Prescription status: It appears that EC can be purchased without a prescription. Post-rape care: A 2014 review of post-rape care policies in Sub-Saharan Africa states that Rwanda’s 2009 national guidelines for the management of sexual assault include EC as an essential element of care.7 A 2012 report states that EC information is currently included in the police protocol for survivors of sexual violence/rape.5 A baseline assessment conducted in 2009,8 however, showed that only 13% of clinics surveyed had guidelines available for the clinical management of sex- ual violence. All of the surveyed facilities had dedicated rooms for sexual violence services but EC was not available in the rooms. How- ever, the Yuzpe method of EC (higher doses of certain regular oral contraceptives) was available in 62% of the facilities. Rw an da RWANDA COUNTING WHAT COUNTS: TRACKING ACCESS TO EMERGENCY CONTRACEPTION IN RWANDA • Total fertility rate: 4.6 births per woman (3.4 urban, 4.8 rural) • Unmet need for contraception among currently married women: 19% • Among married women, the use of modern contraceptives rose from 10%3 to 45.1% between 2005 and 2010 Source: Demographic and Health Survey, Rwanda 2010 unless otherwise noted.2 KNOWLEDGE AND CURRENT USE OF MODERN CONTRACEPTION AND EC 0 20 40 60 80 100 ECAny Modern Method Knowledge Current Use Source: Demographic and Health Survey, Rwanda 2010.2 % o f A ll W om en Type of Contraception 99.3 25.2 23 Not Available Rw an da 2 PRODUCT AVAILABLITY Registered Products: The Ministry of Health Pharmacy Task Force oversees pharmaceuti- cal drug licensing and registration. NorLevo and Postinor – both levonorgestrel-alone dedi- cated EC products – are available in Rwanda via import licensing rather than through in-county registration.9 Locally manufactured products: None available. Poor quality or counterfeit EC products: While not specific to EC, a February 2012 article on counterfeit drugs in East Africa mentioned that Rwanda is particularly at risk for having counterfeit drugs on the market because it has no quality control laboratory for drugs.10 WHERE WOMEN CAN ACCESS EC EC in the commercial sector: EC can be purchased at pharmacies and through private providers.11 EC in the public sector: Rwanda’s Essential Medicines List stipulates that EC should be available in the public sector, but the Service Provision Assessment (SPA) Survey of 2007 found that only 16% of facilities surveyed had ever offered EC, and on the day of the assess- ment, only 5% had EC available.12 EC in the NGO, social marketing and social franchising sectors: IPPF’s Rwandan member association, the Association Rwandaise pour le Bien-Etre Familial (ARBEF), stocks ECPs.13 Rwanda’s listing in DKT’s 2013 Contraceptive Social Marketing Statistics does not include EC.14 Community-based distribution of EC: EC is not distributed at the community level in Rwanda.15 MEDIA COVERAGE OF EC Approximately 70% of women are exposed to one type of mass media communication (radio, TV, or newspaper) at least once per week.2 Our search revealed little media coverage of EC in Rwanda. PROVIDERS A 2012 study5 published by the Rwanda Minis- try of Health, the National University of Rwanda School of Public Health, and IntraHealth Interna- tional reported on interviews with 368 health care professionals, including providers and decision- makers, that surveyed their knowledge, attitudes, and behavior regarding family planning, and EC in particular. Approximately 37% of provid- ers said they had ever provided ECPs; of these providers, 85.7% had provided it in the previous year (2010-11). Among government-supported facility employees, 34% have ever provided ECPs, while 25% of private facility employees have ever provided ECPs. The majority of provid- ers who said they have ever provided ECPs are from Western Province and Kigali City. Across all participants, only 5% said that they regularly include ECPs as part of family planning discussions. Almost 40% of providers said that they “never” include ECPs in the family planning discussion. Most of the respondents (86%) said that they did not have any guidelines for use of ECPs. Pharmacy employees are least likely to have any information, while government-supported facil- ity employees are most likely to have information available for clients. The study finds that EC information is currently included in family planning in-service training for Rwandan health workers, but that most pro- viders received training over 5 years ago. 93% of providers expressed interest in further EC training. They expressed particular interest in the mechanism of action and how EC differs from abortion. DONOR SUPPORT RHInterchange reported that IPPF shipped a small number of units of EC in 2004 and 2010, and UNFPA shipped 1,440 EC packs in 2014.16 We are not aware of any other substantial donor support. This fact sheet has been prepared by the International Consortium for Emergency Contraception and represents the best information we have been able to gather. We welcome your input for future revisions. Please contact us at info@cecinfo.org. Visit our website at www.emergencycontraception.org for more information on EC. REFERENCES 1 CIA The World Factbook. Africa: Rwanda. Retrieved 30 December 2014 from, https://www.cia.gov/library/publica- tions/the-world-factbook/geos/rw.html. 2 Rwanda Demographic and Health Survey, Rwanda 2010. National Institute of Statistics, 2010. (http://www.mea- suredhs.com/publications/publication-FR259-DHS-Final- Reports.cfm) 3 Rwanda Demographic and Health Survey 2005, National Institute of Statistics. (http://www.measuredhs.com/pubs/ pdf/FR183/FR183.pdf) 4 List Nationale des Médicaments essentiels, 5e edition 2010. Republique du Rwanda, PRINTEX Lt., Kigali, Rwanda, 2010. (http://www.who.int/entity/selection_medicines/country_ lists/RWA_LNME_2010.pdf) 5 Situational analysis of emergency contraception in Rwanda: Quantitative results. Ministry of Health of Rwanda, National University of Rwanda School of Public Health, and Intra- health International, February 2012. Internal report. 6 Third Health Sector Strategic Plan, July 2012 - June 2018. Rwanda. Ministry of Health. (http://www.moh.gov.rw/filead- min/templates/Docs/HSSP_III_FINAL_VERSION.pdf). 7 Thompson J, Undie C, Askew I. Access to Emergency Contraception and Safe Abortion Services for Survivors of Rape: A Review of Policies, Programmes and Country Experiences in Sub-Saharan Africa. Population Coun- cil. September 2014. (http://www.popcouncil.org/uploads/ pdfs/2014STEPUP_EC-SA_Report.pdf). 8 Keesbury J, Elson L. Health Care Providers in Uganda and Rwanda Are Knowledgeable about Sexual Violence and HIV, but Few Are Equipped to Provide Comprehensive Services. Rep. No. TUPE0536. USAID, Population Council. 9 Sacher S, Personal Correspondence, December 6, 2012. 10 Kaitesi M. Rwanda: Counterfeit Drugs a Major Burden. The New Times, February 23, 2012. (http://allafrica.com/sto- ries/201202230066.html) 11 Nsenga JP, Personal Correspondence, July 29, 2012. 12 Rwanda Service Provision Assessment Survey 2007. National Institute of Statistics’ Ministry of Finance and Economic Planning of Rwanda, Ministry of Health of Rwanda, and Macro International, September 2008. 13 Ndahinyuka J, Personal Correspondence, November 20, 2012. 14 2013 Contraceptive Social Marketing Statistics. DKT International, Washington, DC, August 2014. (http://www.dktinternational.org/wp-content/ uploads/2014/08/2013-Statistical-Mktg-Rpt-3.pdf). 15 Intrahealth International, Personal Correspondence, August 3, 2012. 16 RH Access – Rwanda Summary of Shipments. Retrieved 30 December 2014 from, http://www.myaccessrh. org/rhi-home?p_p_id=rhiuserportlet_WAR_rhiportlet&p_p_ lifecycle=1&p_p_state=normal&p_p_mode=view&p_p_col_ id=column-1&p_p_col_count=1&_rhiuserportlet_WAR_rhi- portlet__spage=%2Fshipmentsummary.do Rwanda 3

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