Elders, kings, bishops and imams (Muslim clergy) are opinion leaders in Uganda's complex cultural environment. UNFPA has successfully reached out to partner with them in promoting healthier behaviours and the elimination of harmful traditional practices. UNFPA's work in this country, which has successfully grappled with its HIV/AIDS epidemic, is a model for working within existing cultural constructs.
Though some of Uganda's elders had been strong supporters of female genital cutting, they eventually became advocates for the elimination of this harmful traditional practice. The transformation came about through a UNFPA-supported project known as “REACH” (the Reproductive, Educative and Community Health Project), carried out in partnership with the Sabiny Elders Association, starting in 1996. The association comprises the heads of 161 Sabiny clans, whose mission is to promote the welfare of the Sabiny people and preserve their language and culture.
Previous efforts at discouraging female genital cutting in Uganda met with considerable resistance. The difference with the REACH project is that it worked to eliminate the practice while reinforcing the cultural dignity of the community.
To accomplish this task, the importance of involving local people was recognized from the start. Early on, a conference for nearly 300 elders was held, followed by a series of workshops and seminars for women and young people. At first, the broader topic of improving reproductive health was addressed. Only gradually was the subject of the female genital cutting introduced and community involvement solicited in an analysis of both its harmful effects and the positive values it helps to promote. District officials drafted the project document, backed up by technical support from Uganda's Population Secretariat and UNFPA.
Other stakeholders were also identified and brought into the process. An “ally group” of peer educators was established to support girls' education and to disseminate messages about reproductive health. Traditional birth attendants,midwives and nurses were also trained and sensitized on issues surrounding harmful practices.
When addressing harmful traditional practices, it is important to emphasize that both harmful and positive practices are found in all cultures.
Soliciting the advice of the local community in the design of a project ensures that the strategies and advocacy messages developed will be culturally acceptable.
Publicizing successes can create a sense of pride and reinforce community involvement.
Relying on local project managers helps to ensure acceptance of a programme in the community.
Using a non-prescriptive approach that involves people who have experienced the practice (either directly or indirectly) instils a sense of ownership.
Providing hard evidence of the impact of harmful traditional practices helps the community internalize the need for change and make informed choices.
At all times, the project staff took care to show respect for the elders and their concerns so that the project's goals were not misinterpreted as a value judgement on the society or its culture. The idea of celebrating an annual “culture day” in one district was promoted as a way of positively reinforcing local customs and traditions. Moreover, attention was paid to providing alternative cultural roles and sources of income to those who were performing female genital cutting. As a result, their values and prestige were not compromised or undermined when the practice was discarded.
In fact, by the project's end, male youths and even many former practitioners spontaneously formed pressure groups to oppose it. And female genital cutting in the district had decreased dramatically. An evaluation conducted 15 months after the project was launched concluded that cutting had been reduced by 36 per cent. In 2002, out of 12,000 potential candidates, just over 5 per cent were subjected to cutting in a district that had, at one time, a by-law making genital cutting compulsory for all women.
Prior to 1967, Uganda was composed of five kingdoms that functioned like present-day federal states. Kings had full control of resources and revenue within their regions, and their chiefs were in charge of day-to-day governance. In 1995, upon repeated requests from kingdom constituencies, the Government of Uganda agreed to re-establish the kingdoms on the condition that kings and tribal chiefs would only serve as cultural leaders and agents for development. They were not to engage in political activities.
Under the current arrangements, the Government is working in close collaboration with kingdom representatives, particularly in the social sectors, on issues such as immunization campaigns and the prevention of HIV/AIDS. As revered cultural institutions, with a strong interest in the well-being of their constituents, the kingdoms were natural partners for programmes in reproductive health and rights. The most recent UNFPA-supported projects, involving the Bunyoro and Tooro kingdoms, address early marriage and cultural practices that expose adolescents to the risk of HIV and other sexually transmitted diseases. The projects entail a variety of research and advocacy activities, including seminars for kingdom and youth leaders on topics ranging from early marriage and related cultural practices, to parenting, drug abuse and sexuality. Other activities include radio programmes and the establishment of youth groups to foster discussion.
As with other projects that address culturally sensitive issues, local decision makers were presented with hard data on the population situation of the kingdom. In Tooro Kingdom, for example, evidence was provided on the links between educating girls and reducing the rates of early marriage. This helped to create consensus on the priority issues to be addressed.
An important achievement of the project has been the institution of a new by-law in Tooro Kingdom that stipulates 18 as the earliest age for marriage. Three other kingdoms quickly followed its lead. The Tooro Kingdom also spearheaded passage of the “girl-child ordinance 2000” that promotes girls' education and discourages early marriage. Youths themselves are getting organized and putting funds from a community-led HIV/AIDS initiative to good use. In general, the stigma surrounding HIV/AIDS has lessened, and drugs are increasingly being used to treat other sexually transmitted infections. Also noteworthy is the respect now accorded by community members for women's legal rights.
Patience and perseverance eventually pay off. A great deal of dialogue and sensitization may be required to break new ground on issues that are deeply rooted.
To bring cultur al leader s on board, provide evidence during pr eparatory phases of the potential value of a pr oject.
It is essential to understand the thinking of both your allies and adversaries. Be ready to engage in an ongoing and constructive dialogue with those who oppose your views.
Demonstrating sensitivity in the choice of language and topics for discussion, especially in the early stages of project formulation, helps to get a joint initiative off to a good start. The concept of family planning, for instance, may have negative associations. Instead, frame the issues in the larger—and more positive—context of reproductive health and healthier families.
Identifying an effective “agent of change” within a partner institution who can serve as a compass and guide on sensitive matters can ease project implementation.
Why wasn't the Muslim community taking full advantage of the services and activities that Uganda's 1995 population policy initiated? The Ugandan Muslim Supreme Council approached the Mufti of Uganda (the highest Islamic religious leader in the country) to find out, and did so, with UNFPA's support.
The Supreme Council, jointly with UNFPA, convened a series of workshops targeting Muslim leaders to explore the low utilization of reproductive health services. A major factor, it turned out, was the low level of priority that reproductive health was accorded in religious leaders' programmes. Another factor was their inability to reconcile specific population and reproductive health issues with their interpretation of the precepts of Islam.
The project that eventually addressed these issues took a three-pronged approach: advocacy, to persuade religious leaders to give greater emphasis to reproductive health issues; behaviour change communication, to inform the Muslim community about their reproductive health and rights and to encourage them to use existing facilities; and enhancement of services, to improve the quality of care provided at Muslim health units and to make reproductive health services accessible and affordable.
From the start, UNFPA recognized the sensitivity of these issues and was willing to address them in a gradual manner. This created an environment of trust and mutual respect among partners. Once the Supreme Council fully understood the benefits of incorporating reproductive health into broader health services, they spread the message to the entire community. Special workshops were offered to men, who, in turn, were invited to send their wives to similar meetings. The turnout of women was overwhelming.
Under the guidance of the Mufti, religious scholars, in a series of meetings involving religious leaders at various levels, studied specific reproductive health messages and related them to Koranic texts. The messages used in the project were those found to be in accordance with Islamic teachings.
As a consequence of this initiative, reproductive health and rights are now on the agenda of the Muslim Supreme Council, and resources have been allocated for activities to support this new priority.
Acquiring a deep understanding of community values and needs is the basis for an effective project strategy.
Securing the commitment of top leadership is often necessary to win over a community.
Identifying specific religious leaders as agents of change and involving them from the outset can facilitate project implementation.
Providing evidence based on operational research is often the most effective way to approach controversial issues.
Using religious references can reassure community and religious leaders that project objectives are in line with religious teachings.
Asking religious leaders to do what they do best (in this case, mobilizing the community) and letting health workers manage the technical aspects of reproductive health activities is an effective division of labour.
In many societies it is necessary to make a special effort to reach women. In this case, it was by getting the men to buy into the concept of reproductive health first.
Building capacity can help ensure sustainability. This includes training for health services providers and peer educators.
Sexuality and reproductive health continue to be sensitive topics, but they are no longer taboo subjects for public discussion. This is due, in part, to the unwavering support of the Mufti, who not only attended workshops but also encouraged other religious leaders to do so. The involvement of top religious leaders, in fact, was key to growing local acceptance of project objectives. The most tangible achievement is the provision of health services to those most in need, with noticeable improvements in the health status of the community.
Problems of young people in Uganda abound— among them, sexually transmitted infections, teenage pregnancies, school leaving and early marriage. Nevertheless, there is a low level of awareness about these issues and little support for reproductive health programmes targeted to youths. Doing something about that was the impetus behind a five-year project funded by UNFPA and the Kinkizi Diocese of the Church of Uganda.
The project was conceived over a four-month period and involved intensive consensus-building among all diocese heads. As a result, the project is guided by values held close to the community: conformity with religious teachings, volunteerism and wide participation among Church members.
The focus of activity was the dissemination of advocacy messages through the administrative and service structure of the Kinkizi Diocese, including confirmation classes, youth clubs, boys' brigade, the mothers' and fathers' union, schools and health units. Among the most successful vehicles for sharing information were music and drama troupes, which have been used extensively by the diocese to spread the word about sexual and reproductive health, including HIV/AIDS, to all socio-economic and age groups. Music and theatre pieces have been recorded and are broadcast on the radio, creating an even wider audience and attracting other artistic groups into the process.
One clear factor in the project's success has been the credibility of the Church within the community. In the words of one bishop and project manager: “As the Church, we do not need to explain why we are calling people for an activity. They just come.”
As a result of the project, there is a marked increase in awareness, both in the Church network and the community at large, about sexual and reproductive health. A new by-law of the Church, requiring couples to be 18 years of age or older before they can be married in the Church, is being enforced in the project area among Church of Uganda followers. Girls are staying in school longer, and those who do drop out are now offered a way to continue their education. In addition, young people themselves are demanding voluntary and confidential testing for HIV.
Using established networks and structures to deliver advocacy messages within the community can maximize the outreach of a project at minimal cost.
Reaching out through popular culture, including music and drama groups, can have particular appeal to youths. Be sure to involve young people in the creative process.
Soliciting the support of custodians of culture can help overcome obstacles. In this case, the strong involvement of top religious leaders led to noticeable changes in community attitudes, especially regarding the right of girls to remain in school and refuse early marriage.
Convincing faith-based partners to make a financial contribution to the project, even if it is only symbolic, can enhance their sense of ownership and increase the chances that a project will be sustainable.