Catalysing change for reproductive health in Chad through a multi-stakeholder coalition

Introduction

In 2002, the Government of Chad passed a reproductive health (RH) law¹ which upholds the right to RH services, including Article 14, which defines access to therapeutic interruption of pregnancy (therapeutic abortion).² It was noted that implementation of the article would be activated through a decree of application outlining the processes, guidelines and technical specifications for provision of RH services, adopted by the Council of Ministers, and signed by the President of Chad. Chad has also signed the Maputo Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, which affirms commitment to ensure full access to RH services. The government has yet to ratify the Protocol, which would require entering into legally binding commitments to the provisions within the Charter. Discussion of the decree of application has been set back by continual staff turnover within the government, specifically, the Ministry of Health, and by other priorities, such as internally displaced and refugee populations in the south of the country.

While the 2002 law and signature to the Protocol carry symbolic meaning for the promotion of RH and rights in Chad, official discourse has not translated into effective implementation. The failure to develop the decree of application created a gap between the law and its implementation, limiting reproductive rights, and leaving healthcare providers without guidance and protection. Concerned with this state of affairs, a multi-stakeholder coalition made of up RH activists in Chad catalysed a process to draft the decree of application. In July 2018, 16 years after the RH law was first put in place, the decree of application associated with Article 14 was finally approved by the Council of Ministers. This article explores how the coalition was created as a platform for change to mobilise action for moving forward.

Creating a coalition

CARE International has implemented RH programmes in Chad since 2011. To further understand the state of RH in Chad, specifically on unsafe abortion, CARE hired two well-respected Chadian women, with expertise in both medical and legal structures related to RH, to conduct a landscaping study. In 2014, the two consultants investigated the legal framework and political and social environment for unsafe abortion in Chad. Their report laid out the historically restrictive context around abortion and uncovered widespread misunderstanding and lack of knowledge regarding the 2002 law. They found that while the law stipulates legal grounds for therapeutic abortion, the Ministry of Health had not produced a clear set of guidelines for how the law should be operationalised and enforced. The report identified that the decree of application, including the conditions under which therapeutic abortion is permitted and who is permitted to provide the service, was a critical missing link.

To validate and share the findings from the report, in 2014 CARE convened a group of stakeholders, including the two consultants and the Ministry of Health, to discuss the landscaping report and define next steps. From this initial meeting, a working group formed to continue discussion on unsafe abortion, and to develop a workplan to ensure that the RH law and all its articles would be fully implemented in the country. CARE’s years supporting the government to provide quality family planning and post-abortion care services, had made it a trusted partner of the government, able to communicate and connect directly with key actors, including the Ministry of Health. RH actors were loosely connected through various working groups, though lacking jointly defined objectives and goals. With expertise in RH programming and local knowledge, CARE was able to convene a multi-stakeholder coalition of obstetricians and gynaecologists (OBGYNs), jurists and non-governmental organisations (NGOs) interested in drafting the decree of application and advocating for its approval by the government.

Coalition roles and responsibilities

In 2015, with this platform for collaboration, the coalition began work on filling the critical gap identified in the landscaping report. The Reproductive Health Division within the Ministry of Health formally recognised the group and approved the workplan for the coalition to begin drafting the decree of application. Various diverse perspectives and insights, described below, coalesced in one space, with the common aim of drafting the decree to fulfil the next step for implementation of the law.

As medical providers, OBGYNs understood that their role was to provide quality RH services, within the parameters of the law and national medical protocols, and to support and inform other health providers. OBGYNs desired clarity on the kind of providers who could perform therapeutic abortion, and under what conditions. Given the limited number of doctors in the country, it was critical for the decree to clearly delineate that a qualified and trained provider other than a medical doctor (e.g. a nurse) could perform the procedure. The conditions under which the procedure could be performed were also a priority, and the OBGYNs wanted some sort of regulation in place. However, it was noted that it would be unrealistic and unfeasible for a woman seeking a therapeutic abortion to obtain approval for abortion by three different providers (as stated in the RH law), and thoroughly debated within the coalition. After much negotiation, and considering the evidence and statistics on unsafe abortion, it was agreed that the decree should state that any trained and qualified provider could perform the procedure without needing to obtain medical and judicial approvals, if the need was time-sensitive and acute.

The jurists and legal professionals wanted clear guidance and accountability of the government to uphold the laws they created, and provided significant leadership. They supported drafting a decree of application that upheld rights to access RH services and, specifically, therapeutic abortion. The jurists were concerned to ensure that the decree was a legally sound document, noting who could receive a therapeutic abortion and under what conditions. Their contribution included drafting language that would align with other legal documents in the country, while also prioritising the rights of women and girls to access services.

The concern of NGOs such as the Association Tchadienne pour le Bien-Être Familial (an International Planned Parenthood affiliate) and the Association des Femmes Juristes was that provision of support to medical providers was made more difficult when services and providers were not fully protected by law. The Association Tchadienne pour le Bien-Être Familial was working to ensure women could realise their rights to freely access RH services, some of which were not available, or obtained with great difficulty, given the lack of implementation of the law. In addition to its convening role, CARE supported alignment of the decree with the Maputo Protocol, which Chad had signed but not yet ratified. Alignment between regional and national level policies on RH would facilitate an enabling environment for the availability, accessibility and acceptability of RH services and information.

The Reproductive Health Division’s role was to draft the decree of application. Their participation in and validation of the coalition supported their mandate to ensure the law was fully implemented. They ensured that various drafts of the decree and updates of the coalition’s progress remained on the agenda for the Ministry as a whole. Staff turnover remained high within the Ministry during the time the coalition was working on the decree, but communication amongst the coalition allowed continuity despite this instability.

Approval of decree

After nearly three years of significant and persistent effort from the coalition, the Council of Ministers approved the decree of application in July 2018, 16 years after the RH law was passed. Once the decree was finalised and translated into French and Arabic, the coalition worked with the Ministry of Health to prioritise the decree and move it through the government hierarchy, to reach the Council and President. This was a challenging time, as there were several interim Ministers of Health and turnover meant that the coalition had to frequently re-engage the new individuals within the Ministry. The coalition members felt discouraged at times during this process but continued their efforts to catalyse support by having meetings and re-presenting the decree of application every time there was a new minister or change in cabinet.

Approval of the decree by the Council of Ministers was shared through an announcement on public television on 5 July 2018. This was the first time something like this had been done, as laws – much less a decree of application – are not usually announced on television. Promotion of the decree’s approval on television reflected the importance of reaching the Chadian public with this information.

The decree must now be validated and signed by the President of Chad but this had not yet been completed at the time of writing this paper. From there, guidelines will need to be developed for health providers and the decree itself should be disseminated further. Approval of this decree secures the legality of provision of services and signals a critical step in the progressive realisation of reproductive rights to enable future advocacy and action.

Conclusion

Significant improvement in the RH and wellbeing of women and girls in any country is only possible when laws and policies “on the books” are fully adopted and implemented. In Chad, the lack of prioritisation for RH by government failed to create a decree of application for a law developed 16 years previously. The success of this coalition’s efforts may have been possible due to diversity of expertise within one space, a single convener trusted by the government, establishment of a neutral platform and availability of evidence generated through an initial landscaping study. The coalition worked within a context of high turnover within the government and competing priorities, but with persistence, these challenges were overcome. The coalition in Chad will continue to work and advocate for the President’s signature. The authors and parties engaged with this process call on the Government of Chad to act swiftly to have the President sign the decree so that women in Chad can have full access to RH services and providers can act with authority to provide life-saving services.

Disclosure statement

No potential conflict of interest was reported by the authors.