Introduction

HIV has spread slowly in Pakistan since it was first reported in 1987.  Although the incomplete evidence shows that the prevalence of sexually transmitted diseases is low amongst women in low income communities in Pakistan, other social and economic conditions exist which are associated with the vulnerability for HIV/AIDS.  Poverty, low access to health care, inadequate information and awareness, and women who are disempowered within and outside the family, create a high potential for the spread of HIV. 

Experience from other developing countries has shown that one of the key strategies in the prevention and control of HIV/AIDS is improving the sexual health of communities.  A population with good sexual health is automatically less vulnerable to HIV/AIDS.  It is for this reason that the Commission for European Communities has invested in the development of a project to work for the sexual health of women. 

The Karachi Reproductive Health Project (KRHP) is the only project in Pakistan to work solely for the sexual health of women.  Pakistan is a conservative society where social  and cultural taboos prevent open discussion on topics related to sexuality and sexual behaviour.  At the start of the project, the biggest challenge facing the project staff was overcoming the fears regarding discussing sexual health issues openly. KRHP has responded to the challenge successfully. 

Structure and Background of the Project

Structurally, KRHP is a project of Aahung, a legally registered NGO which has been funded by the European Commission.  Aahung plays a low key role with the project and allows it to be managed professionally.  In addition to KRHP, it has another project called the AIDS Awareness Program (AAP) which is aiming to develop a sexual health curriculum for adolescents in secondary government schools. 

The project started in November, 1994.  Funds were made available by the European Commission through an organization in the UK called NHSOE to establish a two-year pilot project in Karachi to promote women’s sexual health.  NHSOE has played the role of financially managing the project and providing technical support through consultants to the project.  The project established an office in Karachi and has a small team of staff responsible for carrying out project activities. 

KRHP subsequently had a three year extension to its contract in January 1997.  During this period, the model developed during the pilot phase, will be consolidated and its impact on the sexual health of women will be measured.  The project will also support new initiatives in other parts of the country during this phase. 

KRHP is implementing its model in four low income, urban communities of Karachi.
 

KRHP Objective

To test models and use mechanisms whereby the sexual health of women in low income communities can be established, promoted and maintained. 

Selection of the Intervention Sites

The KRHP team identifies certain criteria, according to which various areas are visited and ranked.  The area fitting the criteria most closely is chosen as the intervention community.  Once identified, a number of participatory approaches, as illustrated below, are used to gain entry into the community.

Lane Meetings

The KRHP staff holds lane meetings throughout the area, to inform people about the project.  Representatives for male and female committees are also elected in these meetings.

Walking Survey

The KRHP team walks through the areas accompanied by a group of men and women in the community, who in turn define the area where the CFPs will work.  The existing health service facilities of the area and other landmarks (such as schools, mosques etc.) are also identified during this walk.

Focus Group Discussion

Following this, focus group discussions are conducted with men and women of the area.  The purpose of this activity is to collect initial information regarding the demographic and social characteristics of the area, and to learn about the existing health system and the knowledge about sexual health and sexual behaviours of the area. 

Strategies and Activities

KRHP has two broad strategies through which it aims to achieve its objectives.  Both aim to improve the health-seeking behaviour of women in the communities in a number of ways.  These are to gain better knowledge about where doctors are available, to better recognize and know their own needs, to increase confidence to be able to discuss sexual health related problems if and when they arise, or to better nurture a loving relationship within their families.  The first strategy is an intervention to raise women’s awareness.  The second strategy is about improving the existing health system in each community.
The KRHP Model

Strategy I : Community Based Women’s Awareness 

In each of the areas of intervention, local women (Community Focal Persons – CFPs) have been hired by the project.   These CFPs are supported by the project through training, networking and skills-building to provide awareness, referral, and counselling services within the communites.

Selection of the Community Focal Persons (CFPs)

Initially, the selection criteria for the CFP was project-led.  Through its linkages, KRHP identified suitable candidates.  Three of the present CFPs were selected in this way. 

Subsequently, this selection method was changed for the community led model.  This meant that the local women themselves develop the criteria for the kind of CFP they would like and then  propose suitable candidates.  A local women’s committee, in turn selects the appropriate candidate.  As it happened, the local women drew up a similar criteria for selection as the project-led model. 

The basic requirement for CFPs is that they should be able to read and write.  On average, the CFPs have studied up to early secondary level.  Other criteria are that they live in the area covered in the project, they should be married or have been married (widowed, divorced or separated) so that they are freely able to speak about sex which is a taboo topic for unmarried women.  Finally, they should be mobile so that they can accompany the women in the community to access services, attend meetings and training programmes. 

The CFPs' role is that described by her title.  She is the focal person for sexual health within the community.  The aim of the project is that her reputation and skills be developed so that her role as the focal person is established during the project period.  This complements the traditional practice of women approaching other women for their personal needs and is similar to the role of the dai or traditional birth attendant in the area.

Sessions on Sexual Health

CFPs are trained to conduct modules on sexual health with women in the communities.  The modules are developed by the KRHP team along with the CFP, who in turn, discuss these topics with groups of 8 to 10 women in their area.  The women themselves make decisions regarding where they should meet, how new members who joined later in the process would be integrated etc.  After practising the process in the CFPs' meeting (using techniques such as feedback, role play, tape-recording etc.) the CFPs conduct the meeting themselves in the communities.  The first meeting is attended by the Community Development Co-ordinator from KRHP so as to support the CFP.  Subsequent meetings are conducted by the CFP on her own.  Often, meetings are held in the homes of the CFPs and animated extensive discussions take place on topics such as infertility, irregular menstruation and prolapsed uterus, vaginal discharge, breast feeding, and pregnancy loss.  These modules run for approximately 2 hours.  The project hopes to introduce more sensitive and controversial topics such as sexual abuse and rape in the near future. 

Much time and effort has gone into training and improving the CFPs facilitation skills, so that they are better able to share their information in a participatory way.  This is especially difficult as most of the women the CFP is working with are illiterate, and not used to formalized learning.

Women’s and Men’s Committees

In each area of intervention, a women’s and men’s committee has been formed.  Both these committees are an outcome of lane meetings where the project was introduced, and representatives elected to the committee.  The role of the committee is still evolving, however, one of its major functions is to support the CFP and ensure that she does not remain isolated within the community.  Another role is that as representatives of the community, the CFP is accountable to them.  The male committee is especially important to add legitimacy to the programme in a society which is very male dominated. 

Strategy 2: Improvement of Health Services

In each intervention site, KRHP is also working to support the local health system so that it is better able to respond to the sexual health needs of the local women.  The Health Services Manager of the Project seeks to develop links with the local health practitioners and other services in the area both at government and private levels.

Training

A series of training on various topics related to sexual health is conducted for health practitioners who provide services to the communities where KRHP works.  These topics include vaginal discharge, psycho-sexual issues, HIV/AIDS, STDs etc.  Each topic is addressed in sessions conducted in a local hospital close to the area of intervention.  Local practitioners working in the area are invited to attend the sessions. 

In addition to allopathic practitioners, other health practitioners such as local birth attendants (dais), traditional healers, homeopaths and chemist stores are also being approached by the project, and training programmes being developed for and with them.

CFP Services

In addition to their role in awareness raising with women, the CFPs also refer women to local health practitioners, give health advice, accompany women to health facilities and maintain links with the local practitioners.  This role not only motivates women to access healthcare but also enables them to make a better informed choice about which facility to go to on the basis of doctors' fees, ability/qualification etc.  Each CFP has a data sheet about the local practitioners which lists the services they offer, how much they charge, their timings and which issues specific to sexual health they have been trained in (by KRHP or otherwise). 

The CFP is also being trained in basic health services such as measuring temperature, blood pressure, pulse etc.

Referrals

Referral links are also being established for the practitioners between primary, secondary and tertiary levels.  This ensures that the local practitioner is able to refer patients with reproductive or sexual problems to the right place, and in turn if requiring follow-up the specialists can re-refer back to the local practitioner. 

Referral linkages between organizations providing support for sexual abuse and rape will also be set up.  Similarly, contacts are being developed between psychologists, places for HIV/AIDS testing, human rights organizations etc. 

Other Programmes and Activities

In addition to the testing of the KRHP model and the two community based strategies, KRHP has also initiated other programmes and activities, which serve to meet the broad objective of the programme. 

Prevalence Study

A community based STD prevalence study was conducted in one of the communities of intervention during Phase I, in 1996.  Six hundred women were randomly tested for four marker pathogens, gonorrhoea, syphilis, chlamydia, and trichomoniasis.  The prevalence found was extremely low, i.e. at approximately 5%.  This study is the first of its kind in Pakistan, and one of the few studies conducted randomly in a general population.  It would not have been possible without the linkages established by the project. 

Study to Revise the WHO Syndromic Protocol for Vaginal Discharge

KRHP in collaboration with the Provincial AIDS Program, Sindh is at present designing and implementing a study by which the WHO syndromic protocol for vaginal discharge can be revised to better suit the local situation.  This study was developed based on the results of the prevalence study which found that present protocol was inappropriate, and resulted in the over-treatment of women complaining of vaginal discharge. 

KRHP Resource Centre

The project is a resource to other organizations wishing to work with sexual and reproductive health in their respective areas.  The project office has established a small library with audio-visual materials.  A series of training of trainers, in sexual health, in STD diagnosis and management etc. have been conducted under the aegis of the project by specialist consultants.  The project staff also provides training to NGOs and other organizations in sexual health.  Publications and seminars are organized by the project to spread awareness regarding sexual health issues. 

New Initiatives

As part of the support for the European Commission, funds have been made available for initiatives to improve women’s sexual health, outside of Sindh.  This is at a very early stage, and at the moment interested organizations are being identified.  It is hoped that these projects will build upon the experience of KRHP. 

Monitoring and Evaluation

Several mechanisms are in place to monitor and evaluate the progress and outcomes of the project such as the following: 

Working Committee

A working committee has been established in Karachi.  The committee is made up of representatives from the provincial health ministry, the provincial AIDS control programme, the CFPs, the female committees and the project staff.  The purpose of the working committee is to review the activities of the project each quarter, and to advise on issues and problems faced in the project.  In addition, it is a mechanism to strengthen the relationship between the government and the project. 

National Steering Committee

The national steering committee meets once a year and consists of the European Commission representative in Islamabad, the National AIDS Control Program, the UNAIDS representative, the manager from NHSOE, UK and the KRHP staff.  It is hoped that once new initiatives are under way in other parts of Pakistan, they too will be invited to participate in this forum.  The purpose of this forum is also to review the broad strategies of the programme. 

Monitoring the CFPs

Monitoring and supervising the CFPs has been a continuing challenge for the KRHP team.  The project does not wish to take on the role of the supervisor with the CFPs as it would not be sustainable nor is it very motivating.  Instead, mechanisms are being developed whereby the CFPs are made accountable to the local community.  Therefore, male and female committees have been set up in the areas, and attempts are being made to develop a reporting relationship between the CFPs and the committees. 

Weekly meetings are held at the project office where CFPs share experiences, seek advice, and develop work plans.  Office staff also extend support into the intervention sites when CFPs conduct training modules or hold meetings. 

Impact Study

One of the key activities of Phase II is the design and implementation of a sexual health impact study.  The purpose of this study is to measure the impact of KRHP initiatives on the sexual health of women in the areas of intervention, and will be an essential instrument of evaluation to assess the degree of success of project interventions.  A local university was approached to take the lead in the implementation of the study over the next three years.  The KRHP team however, facilitated the development of sexual health indicators through focus group discussions with the men and women in the community and from that, developed a short questionnaire which will then be implemented at all four field sites as well as four control communities.  The questionnaire will be disseminated initially to establish a baseline of sexual health indicators, and then annually till the end of the three years of Phase II. 

Future Plans and Strategies

Two years remain of Phase II of the project and during these two years, the KRHP model will continue to be implemented in the four field sites.  The impact study will attempt to assess the change brought about by this model. 

One of the major outputs of Phase II should hopefully be a set of manuals/training protocols for community women, community men, local medical practitioners and other more traditional practitioners.  These need to be developed, tested and documented over this phase. 

Another major challenge is to help the CFP become more financially self-sustaining.  This at present seems to be the greatest challenge, as awareness, and the exchange of knowledge are not regarded as a service which merits payment. 

New initiatives in other provinces of Pakistan will also be implemented. 

Finally, effort will go towards developing the sustainability of the project.  Aahung will attempt to share the learning of Phase II with other NGOs, universities, government organizations and donors, in order to develop future strategies, and gain support from them towards their implementation. 

Conclusions and Lessons Learnt

The major lessons learnt by KRHP are as follows:- 

Introducing a difficult and sensitive topic in the community. 
Create the right environment. 
Women sit with women they can relate to.
 

• Take it slowly.  This  is  KRHP’s third year and there remains sev-  eral topics and issues to be covered such as domestic violence and   sexual abuse.
• Often,  the  barriers  preventing the programme are their own.  It is   therefore  important  to  be aware of one’s biases and to be comfort-  able  in  discussing  difficult  and sensitive topics with the community.

• The  topic  of  sexual  health  is one which is relevant to everyone,    and  as  long as cultural norms are respected, the community will    be keen to discuss the issues.
• The  community  must  take  responsibility.  If  the programme is    project  led,  then  interest in it will not be generated, nor will the    programme  be sustainable.
• Take  advice  from  the  community; develop strategies with them    and let them own the project.

• Probably, the most important in the list of skills required are com-  munication skills in the form of facilitation skills.  This is essential   in any work with communities, but especially in dealing with such   a   controversial topic.  Most  of  the work is about training, exchang-  ing  knowledge and exploring ideas and issues.  Facilitation  skills    help in making this happen. Technically,  little  expertise  regarding  sexual  health exists in the   country.  It  was  therefore necessary to build the technical (medi-  cal) expertise of the Health Services Manager in the team.

• Sustainability  is  viewed on two levels – firstly, on the community   level and secondly, at the NGO level.
• The community based programmes have been developed with sus-  tainability  as  being  one of the key principles.  It is for this reason   that no   clinic was set up in the communities.  Instead, existing serv-  ices are being  strengthened to provide sexual health services.  These    services are  much  more  likely to continue beyond the time of the   project.   In   addition,   the CFP is a local woman who is likely to   remain in the project area after the project period.  Once her iden-  tity  is established,  women  will  continue  to  use her services for   referral, and come to her for information and  advice.  The  project    encourages  the  CFPs   to  take payment from those willing to pay   for her services.  In   addition,   KRHP  is exploring the idea of the   CFP selling certain sexual health/reproductive health related items   such as underwear, gels, contraceptives, etc.  It  is  planned that this   issue will also be discussed with the communities to see what their   role should be.

• One  key  learning  in  this area is that there is a system of support   within  the organization and not one of supervision and hierarchy.There is a hierarchy but simply as a chain of accountability.   Most   decisions are taken collectively by the relevant staff.
• As  mentioned  earlier,  to work effectively with the topic of sexual   health,  it  is  essential  that the staff are comfortable with the topic   themselves.  Much input has therefore gone into staff training over   the last three years.

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