3.3Low modern use, high abortion rates, and potential demand
The term “Unmet Need for Modern Methods” is defined to include married women who both do not want to get pregnant and who are using relatively ineffective traditional methods (in Azerbaijan mainly withdrawal and to a lesser extent, the “rhythm method”) or no method at all. Figure 3 shows the Unmet Need for Modern Methods in Azerbaijan as compared to other countries.6
In Azerbaijan, 53% of women fall into this category. Of this group 85% of this need is for “limiting”, meaning that the women stated they want no more children. In Azerbaijan the unmet need for limiting is almost six times the need for spacing births, consistent with Azeris’ low desired family size and strong desire to terminate childbearing after achieving their ideal number of children.
The high levels of unmet need for modern methods suggest use of modern contraceptives could rise rapidly if provider knowledge and attitudes regarding modern family planning were to be changed and voluntary family planning services and commodities were to be made readily available to women, including women in the villages, in Azerbaijan.
4.Public Sector Findings
This section presents the findings according to the key components of contraceptive security. The private sector findings are included in summary within this section and are presented in more detail in Section 4.
There is a lack of interest and investment in reproductive health, specifically family planning among senior leadership in the Government in Azerbaijan. Overall the government is committed to goals that will help put them on a par with European countries. For example, as indicated in the introduction, the TFR is 2.1 and comparable to many countries in the EC. However, due to a lack of investment in family planning, couples are largely relying on traditional methods, and when these fail, abortion, to achieve their desired fertility. The GOA should be aware that the high abortion rate was cited as a barrier to Romanian entry to the EU and was a major motivator in the Romanian Government taking an active interest in contraceptive security.
The imminent stock out of donated family planning commodities exemplifies the lack of commitment to FP at the highest level. During their phase out of commodity support, UNFPA sponsored several interventions to increase awareness and commitment to family planning targeting high-level stakeholders. Despite these efforts, no action has been taken to address the imminent stock outs of donated methods in the public sector and there does not appear to be interest in the Ministry in pursuing GOA funding for contraceptives in the near future. The head of the international department at the Ministry of Health did express concern that there are no donor commitments for future contraceptive donations to the public sector but this unfortunately has not translated into any real commitment.
Many stakeholders felt that opposition to family planning stems from a lack of knowledge of both the situation and preferences of women and the benefits of FP for the country. For example, the Deputy Minister of Health seems to be ill-informed regarding the fertility preferences and practices of women in Azerbaijan, including the country’s low fertility, high levels of traditional method use and role of traditional method use failure as a driving factor behind abortion. In an interview, he spoke of the strong desire of Azeri women to have large families. The most recent survey data indicate desired fertility size is low, 2.1 children. Ministry of Finance policymakers are suspected to suffer from similar misconceptions and to hold generally conservative views about family planning and women’s issues.
With no senior leadership in the Ministry of Health backing family planning, it is lower still on the agendas of the Ministry of Finance and the Cabinet of Ministers who approve national budgets.
As decision-making inches forward regarding the implementation of the joint World Bank-GOA health project, it remains unclear who, if anyone, participating in high levels meetings will ensure that reproductive health and family planning are included in discussions about the integrated basic package of services being considered. Furthermore, at present no forum exists for raising visibility of family planning generally or contraceptive supply issues in particular.
Despite the lack of awareness in the upper echelons of the MOH about reproductive health and contraceptive security there are a number of potential champions.
The recently named Minister of Health, Dr. Oktai Shiraliev, is widely regarded as reform-minded and serious about improving access to health care in Azerbaijan. There are some key reproductive health champions occupying mid-level advisory positions in his Ministry and related agencies. Moreover, there are at least two Parliamentarians, both of whom participated in USAID-funded reproductive health study tour to Turkey, who are strong advocates for women’s health and gender issues, including family planning and are committed to increasing public funding for women’s issues. However, it is important to note that despite this commitment; at least one of the key parliamentarians is not optimistic that public funding would happen in the near term.
The establishment and placement of the National Reproductive Health Office (NRHO) within the MOH shows at least some government support for reproductive health. While the MOH must focus on numerous products and programs, an organization such as the NRHO has the mandate to focus exclusively on family planning. The NRHO was established in 1994 and is considered part of the MOH structure, coming under the auspices of the Department of International Relations. A Memorandum of understanding (MOU) was signed between the MOH and UNFPA in April 2006 defining the terms of future collaboration. The NRHO is responsible for managing the distribution of (UNFPA) donated contraceptives to districts and service delivery points, coordinating implementation and supervision, and providing training for RH/FP service delivery. For the most part, the NRHO provided a mechanism for UNFPA implementation of its family planning assistance to the government. .
Commitment is also evident in the appointment of such a strong family planning champion as director of the NRHO. Dr. Faisa is widely regarded as an FP pioneer and leader in Azerbaijan. She is credited with helping to foster more positive attitudes toward family planning among clients, communities, municipalities and health care providers. She is the principal author of a draft RH strategy recently submitted to the MOH. Although the team has not seen the RH strategy, there was concern that it may not be approved because of potential overlap with the basic package reforms and the associated reorganization of the MOH being discussed as part of the recently embarked upon program of health reforms.
Depite this recognition of NRHO within the MOH and the appointment of such a champion as its director, there is little commitment to funding family planning. f For example, while the NRHO Director draws a state salary, NRHO staff salaries appear to be paid for by donor program funds, e.g. in the form of fees from UNFPA for NRHO training activities, and the future role and existence of the NRHO are uncertain.
The principal advocate for wider maternal health within the MOH appears to be Dr. Tarana Taghizadeh, the coordinator for Maternal and Child Health in the Ministry of Health. The team understood that she is involved in preparing a maternal health initiative, which while still in at a formative stage, is said to have the possibility of receiving funding through the President’s Fund. Although our information is incomplete, if confirmed, there could be a window of opportunity for family planning to be included in the initiative as a key component of maternal health.