Country Report: Angola

Hope for Our Sisters: Angola Country Report

Prepared by: Adam Ragozzino April, 25, 2020

Overview of Angola Angola in the 70’s was a fragile political situation on the verge of war. Three anti-colonialist ethnic groups were held together by a tenuous power-sharing agreement enforced by the Portuguese. The People’s Movement for the Liberation of Angola (MPLA) composed of the Ambundu people, the 2 nd largest ethnic group in Angola, and mestiqos (light-skinned people) was the most influential of the groups. This communist group of mostly affluent, coastal dwellers was also the most friendly to the Portuguese. The National Liberation Front of Angola (FNLA), a rural, right-wing militant group, was made up of the Bakongo people from the North. They fought to reestablish the Kongo Empire and benefited from support by China (at first), the US (later) and Zaire. However, after suffering several defeats the group disbanded by the late 70’s.1 The National Union for the Total Independence of Angola (UNITA) was also a largely rural, right-wing militant organization founded in 1966 by former FNLA leader Jonas Savimbi. This group was composed of the largest ethnic group in Angola, the Ovimbundu, and existed only to oppose the other two groups, whom they viewed as “mixed-race intellectuals from the coastal cities” (MPLA) and “the northerners” (FNLA). 2 The withdrawal of the Portuguese troops, in 1975, without a formal peace agreement, new elections, or selecting any group in particular to succeed them, left a power vacuum in the country. The MPLA’s early assumption of control immediately lead to fighting with the other two groups who viewed the MPLA as privileged descendants of colonists.1 From 1975 to 2002, the FNLA (at first) and UNITA fought with each other and the MPLA for control of the country. For most of that period the MPLA and Angola were run by President Jose Eduardo dos Santos (JEDS).

Despite intermittent peace agreements, the civil war lasted for almost 30 years. It wasn’t until the assassination of the UNITA founder and leader, Joseph Savimbi in February of 2002, that fighting ended. By April of that year, a formal peace agreement was signed that kept the MPLA as the ruling party, JEDS as president, and UNITA as a political party.1 For the first time in almost three decades, President dos Santos was free to lead the country without armed opposition but now with the backing of the international community. Additionally, Angola’s new found oil wealth should have empowered JEDS to rebuild the country. The country's gross domestic product (GDP) grew more than tenfold between 1997-2008, from $7.7 billion in 1997 to some $88.5 billion only 11 years later. 3 Dos Santos’s government needed to rebuild infrastructure, to satisfy the interests of a rising, voracious middle class, to redistribute the revenues of petroleum export to a predominantly poor population, to reintegrate thousands of refugees and people displaced by the war, and complete democratic reforms. But it also needed to accommodate the political and military elite that had been faithful to him for years.

Source: https://gga.org/angola-jose-eduardo-dos-santos/

President dos Santos instituted reforms to rebuild Angola and its economy. However, he also used each project as an opportunity to divert funds to himself and his associates. The result was an economy that only benefited the wealthy.4 Angola went from being one of Africa’s poorest countries to one of its’ wealthiest but most unequal.5 According to Human Rights Watch, “from 1997 to 2002, approximately US$4.2 billion disappeared from government coffers, roughly equal to all foreign and domestic social and humanitarian spending in Angola over that same period.” 6

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The toll of the war created simultaneous development challenges, that alone would have been enough to overwhelm any economy. However, when combined with the corruption of the JEDS regime and a lack of transparency and oversight, Angola’s rebuilding became impossible. Furthermore, the projects that were completed were done poorly by foreign corporations without passing skills on to Angolans.

Angola’s population, public services, education, healthcare and infrastructure were destroyed.

According to USAID, “by the end of Angola’s civil war in 2002, one million Angolans died, 4.5 million were internally displaced, and another 450,000 fled the country.” 7 “Since 2002, Angola has spent US$120 billion on reconstruction, from 2002 to 2015 Angola’s exports totaled almost US$600 billion; but from that same period US$28 billion is unaccounted for, $189 billion was invested overseas with no clear indication by whom or into what, and 35% of the money spent on roads vanished!”8 Chatham House describes some of the difficulty in sorting out the chaos: “Documenting what Angola gained from its investments in infrastructure in the first 15 years after the end of the civil war is complicated by the difficulty of accessing detailed public spending data. Most of the necessary data are not publicly available, and in some cases the data probably do not even exist due to poor record-keeping and the practice of significant off-budget spending (e.g. through credit lines and investments through Sonangol).”

(Source:https://reader.chathamhouse.org/angolas-infrastructure-ambitions-through-booms-and-busts-policygovernance-and-reform#financing-political-priorities-allocation-and-spending)

It wasn’t until 2016, after 37 years in power and at the age of 78 that President dos Santos finally stepped down. His legacy is complex. He brought peace to Angola, but he also left a government rife with corruption, an economy for the rich, and failing government services. 9 The new president, João Lourenço (“JLo”) now has the unenviable job of rebuilding all of the failed infrastructure and eliminating the corruption endemic to the JEDS regime. When he took office, he had the benefit of a robust economy. Angola’s primary source of income, Oil, has fallen far in recent weeks. As of April, 13, 2020, the price of Angolan oil was US$25 per barrel. 10 According to Bloomberg news, Fitch Ratings (a credit rating agency) estimated that Angola needs oil at US$82 per barrel just to balance its 2017 budget.11 Obviously, this will make it difficult for President Lourenço to enact any of his proposed reforms.

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Geopolitical Landscape Economy in Distress

Angola Economy Visualization Angola’s economy depends almost entirely on oil. It accounts for 94% of their exports and more than 75% of the government revenue.12,13 Diamonds make up another 4% of exports, leaving very little contribution from other parts of the economy. Commodity prices, and oil specifically, dictate how much Angola can spend on development projects, loan payments, infrastructure improvements, services, and save. Diversifying the economy remains a priority of the government. However, diversifying the economy of a resource rich country is not straight forward. 14 Oil extraction doesn’t always produce the skilled labor necessary to convert to more advanced production manufacturing.

According to Dr. Alan Gelb, senior fellow at the Center for Global Development, there are several common themes for successful diversification. Three standout for Angola. First, strong institutions, that is democracies with balances of power, transparency, and accountability, prevent patronage schemes and personal politics from subverting resource income. Second, investments in human capital, that is the creation of a skilled labor force, dictate the complexity of sectors available for diversification. The last theme is the importance of openness to foreign investors, skills and new markets. “The manufacturing industry, for example, is… more dependent on strong contract enforcement, a rule of law, and a generally strong business environment.”14 Agriculture is one example where that diversification is coming from. But some challenges remain. It’s already the main source of income for 90% of rural Angolans but more than half the country’s food was imported.15 Enabling small farms and agribusinesses to grow and connect them to supply chains and 4

markets would create jobs and economic diversification. 16 Unfortunately, a lack of skilled labor prevents commercial farms from hiring local Angolans. “[A] shortage of technical and management skills forces commercial farms to incur high personnel and training costs. Larger firms rely on an expatriate work force.”17 Moreover, a study by the World Bank found that most small holder farms (the majority in Angola) “lack capital, access to credit, access to transportation, and technical skills to farm more effectively.”17 Transportation is another potential sector for diversification. The World Bank reports, “Maritime and air transports are the sectors that have the most incidence on Angola’s capacity to attract private investments.” Related to this, Angola has a prosperous ship building industry. Recently the government formed a relationship with Privinvest to create a shipbuilding and maritime economy program. The program aims to redevelop the ports and shipping container industry.

Unfortunately, the state of road transportation in Angola is poor. The CIA estimates Angola has over 26,000 km of roads but less than half are paved. The World Bank’s International Finance Corporation estimated Angola had 76,000 km of roads but only 20% are paved. 17 The discrepancy arise from what is considered a road. In either scenario, the road network needs improvement as it is a drag on the economy, especially in rural areas. Angola ranks 139 out of 144 in a global competitiveness report. 17 Investment in these sectors has been hampered not only by oil prices but also a downturn in the economy. The economy has been in a recession for the past three years. 18 Furthermore, according to Trading Economics, it has experienced negative growth since 2017 (with the exception of one quarter of positive growth in 2020Q1). In order to reform the economy and “reduce the heavy dependence on Chinese capital,” President Lourenço needed new sources of funding. 19 After a meager $2M offer from the United States, President JLo had to agree to International Monetary Fund (IMF) austerity measures in exchange for $3.7B in loans. 19 The IMF agreement requires Angola reduce government spending and devalue its currency, a move that will raising inflation. “Under a $3.7-billion loan program agreed last year, the International Monetary Fund is urging the government to impose austerity measures such as reducing public debt, scrapping fuel subsidies and weakening the kwanza, which is expected to push inflation to 24% next year, from 17.5% this year....”20 The loans from China and the IMF increased Angola’s debt burden from 65% of GDP in 2017 to over 100% of GDP in 2019.3 The debt burden and crash in oil prices caused a credit downgrade from Moody’s Analytics. The significance of the downgrade is it makes interest payments on the debt more expensive and therefore more difficult to pay down. It is also a burden that ultimately falls on the Angolan people in the form of taxes. President Lourenço had previously committed to debt reductions that would bring government debt under 70% of GDP before 2025. 21 It’s is difficult to see how that can happen now.

The IMF noted in its 2018 Article IV Consultation that, “Angola’s external debt remains vulnerable to shocks, especially to unfavorable current account developments (e.g. unforeseen export losses or spikes in imports) and large exchange rate depreciation.” Basically, the drop in oil prices and an unusual need for food or medical equipment will have a serious impact on Angola’s economy. Furthermore, the IMF imagined Angola could reduce its risks through JLo’s reforms. “These risks would be mitigated by the government’s efforts to implement structural reforms to diversify the economy, boost foreign direct 5

investment (FDI), and strengthen external buffers.” 22 But JLo’s reforms haven’t really had an effect yet, so the shock will be that much worse.

Corruption Weighs on the Country Given the profound effects of the JEDS regime, Angolans and the world are looking to President Lourenço for a new direction. Accordingly, the new president is often asked about his position on corruption.23 In response, President Lourenço adamantly adheres to his mantra, “corruption, nepotism and self-aggrandisement in Angola [are] the number one public enemies.” 24 But after more than 2 years in power, his actions in office have left many in doubt.

Lourenço is doing many things to suggest a change from the old regime, privatizing many of the stateowned enterprises (e.g Sonangol), overhauling the MPLA’s Bureau Político (BP), clawing back misappropriated funds, and removing and prosecuting JEDS allies and family members. 25 Yet, in other ways, it is business as usual in Angola. The economic reforms Lourenço implemented have had little impact and the IMF reform requirements will negatively impact the lower and middle class the most.

Moreover, the continuing lack of transparency was highlighted recently when social media erupted in protest over awarding a US$120M telecommunications contract to a company that didn’t even exist until 1 month after the bidding process started. It turned out to be a company 90% owned by General João Carneiro, an affiliate of JEDS.26 The bidding process was reopened after the uproar but it exposed the extensive JEDS network still in place. Prominent JEDS cronies are still entrenched in the government and surround the president. Most notably the ‘triumvirate,’ the three most powerful members of the dos Santos regime outside of the presidential family. This includes Manuel Vicente, VP of Angola until 2017, General Manuel Hélder Vieira Dias Júnior ‘Kopelipa’ and General Leopoldino Fragoso do Nascimento ‘Dino.’ Each one mired in corruption, scandal and, despite Angolan law barring it, ties to private companies that stand to gain from State contracts. 27 Additionally, there are other “red-flags” within the Lourenço administration. While he has politely engaged activists previously harassed by the JEDS regime, protests are routinely suppressed by police. Lourenço has also made no move to weaken the extremely centralized powers of his office. The Africa Center for Strategic Studies adds making the judiciary more independent of the president would bolster JLo’s anticorruption mantra.28 The as yet unanswered question is, was the removal of the JEDS family members, at first seen as turning point in Angolan politics, really just JLo removing his enemies? An answer will be needed before the next election in 2022.

JLo’s Political Effectiveness Political effectiveness is a difficult metric even under the best circumstances. JLo inherited a fiscal and political quagmire. Moreover, Angola, doesn’t collect much information on policy effectiveness. Also, the measure of JLo’s political effectiveness may take more time to show effect. For example, the war and the JEDS regime took 30 years to destroy Angola’s systems. It will take much longer than 2.5 years to undo. With that said, there are some insights into JLo’s effectiveness. Additionally, data from the World Bank and the Brookings Institution’s Worldwide Governance Indicators (WGI) track six broad metrics across 200 countries to measure perceived government effectiveness. 29 They capture changes in the perceptions of corruption, quality, rule of law, overall government effectiveness, voice and accountability, and political stability then ranks them by country (worst 0 to 100 best). For more details about the WGI measures see the notes.

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Table 1: Political Effectiveness Measures For João Lourenço 2016-2018 Indicator 2016 2017 Political Stability and Absence of Violence/Terrorism 33.3 32.9 Voice and Accountability 16.7 17.7 Government Effectiveness 13.5 14.9 Rule of Law 12.5 11.5 Regulatory Quality 13.5 12.5 Control of Corruption 5.8 6.3

2018 34.8 22.7 13.9 13.9 13 11.5

Source: Worldwide Governance Indicators, Last Updated: 11/07/2019

Political Stability and Absence of Violence/Terrorism measures perceptions of the likelihood of political instability and/or politically-motivated violence, including terrorism.

Voice and Accountability captures perceptions of the extent to which a country's citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association, and a free media.

Government Effectiveness captures perceptions of the quality of public services, the quality of the civil service and the degree of its independence from political pressures, the quality of policy formulation and implementation, and the credibility of the government's commitment to such policies.

Rule of Law captures perceptions of the extent to which agents have confidence in and abide by the rules of society, and in particular the quality of contract enforcement, property rights, the police, and the courts, as well as the likelihood of crime and violence.

Regulatory Quality captures perceptions of the ability of the government to formulate and implement sound policies and regulations that permit and promote private sector development.

Control of Corruption captures perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as "capture" of the state by elites and private interests.

Summary of WGI • Control of Corruption, while perceived to be improving is still a pervasive problem in Angola.

This is correlated with attracting FDI and doing business in Angola, all integral to diversifying the economy.

• Regulatory Quality under the JLo administration hasn’t really improved much since the JEDS regime. This again effects FDI, and doing business in Angola from the individual to the MultiNational Corporation (MNC).

• Rule of law while up, also has a long way to go. Luanda is ninth on the “Most Dangerous Cities in Africa” list.30 • Government effectiveness is a broad category. The fact that it went up and back down is likely related to JLo’s partial anti-corruption campaign and the extent of the JEDS network still in power.

• Voice and Accountability is interesting given that perceptions show a major improvement since 2016 yet other sources suggest JLo is heavy handed preventing dissent.

• Stability is Angola’s highest rank but not most improved. It’s also in the bottom third for 200 countries, so still room for improvement. Civil unrest is an issue in the country. While the trend was down from last year, there have been 20 clashes in Luanda since the beginning of this year.

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Of those 20, 9 were violent and caused 8 fatalities. There is a potential for more as COVID-19 impacts the economy and society.31 You can visit the Armed Conflict Location & Event dashboard here.

Attracting FDI Other indicators of JLo’s performance comes from local and international interest in doing business in Angola. During his 2017 campaign for president, JLo promised 500,000 new jobs. The “One hundred thousand projects," campaign, a joint-project between the Ministry of Finance and the Business Association of Angola (CEA) to build project management skills, is one step towards delivering on that promise.32,33 A promise that large will require attracting more businesses to Angola through Foreign Direct Investment (FDI).

The president has enacted some reforms towards his goal. JLo passed laws no longer requiring foreign investors to have a local partner. The previous policy invited bribes and kickbacks. Additionally, many of the state-run companies—“sources of widespread patronage schemes under the JEDS regime”—are scheduled for privatization.34 The government relaxed the minimum financial requirement for doing business in the country. They now allow foreign companies to repatriate capital. They introduced laws to prevent State owned companies from dominating a sector and created an organization to oversee it.

The National Agency for Investment Promotion and Export (APIEX) aims to stimulate economic growth, diversify the economy, and expand private sector participation in Angola's economy. 35 Angola also formed a partnership with the EU and the United Nations Conference on Trade and Development (UNCTAD), the joint project is called “Train for Trade II.” It’s purpose to improve human and institutional capacities through economic diversification policies. Additionally, it will help the country build a more resilient economy geared towards leveling the wide disparity. 36 The petroleum industry still receives the bulk of FDI inflows from China, Portugal, the USA, France and the Netherlands. But the project leverages Angola’s other abundant natural resources—minerals, fisheries, agriculture, and hydroelectric potential—as areas to diversify the economy. APIEX added transportation, telecommunications/IT, energy, health, education, and tourism as priorities for investment.35 In addition to its vulnerability due to dependence on oil revenues, Angola suffers from an underdeveloped financial system. Since a banking scandal in 2014, Angolan banks have been limited in their ability to transfer money internationally. Consequently, foreign companies have been reluctant to do business in Angola if they are unable to transfer money out. 37 Additionally, the banking sector is concentrated around a few political elites within the industry. Of the 27 commercial banks registered with Banco Nacional de Angola – the central bank and sector regulator – five control over 80% of total banking assets, deposits and loans. In addition, the highly centralized structure prevents most Angolans and small businesses from accessing credit. Instead, the bulk of credit only goes to a select group of investors.

In response, JLo has introduced legislation that guarantees foreign investors the right to transfer income from direct investment out of the country.37 Also, Angola’s central bank ordered two state-owned banks

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to raise their capital levels to comply with the minimum requirements. The reforms aim to restore the industry’s credibility and help Angolan lenders re-establish ties with foreign banks. 38 These reforms have had some effect. FDI slightly increased in 2018, but still a net-negative inflow compared to 2017.36 In 2019, a large trading company Toyota Tsusho and export credit agency, Japan Bank for International Cooperation (JBIC) signed a deal to invest USD $650 million in a port reconstruction project (Namibe Bay), the first Japanese private sector’s investment in Angola. The project is expected to generate 1500 jobs over the next three years. 35,39 Effect on the People Income & Taxes Due to it’s oil wealth, Angola is listed as a middle-income economy. 40 Angola’s GDP per capita by purchasing power parity (PPP -which allows comparisons across countries) was US$5,725 in 2018.

Although, that’s not accurate for everyone in the country. The University of Oxford’s Global Multidimensional Poverty Index, estimates that 48% of Angolans were ‘poor,’ in 2019 and that was down from 77% in 2004.41 The result is the oil wealth of the few skews the GDP figure. Furthermore, the removal of subsidies to meet IMF requirements act as a tax on the people of Angola. The recent combination of high government debt, falling oil prices, and rising prices create higher inflation in Angola. High inflation and an increased tax burden diminish an already weak purchasing power, like for food, or healthcare services.

Employment & Entrepreneurship Unemployment is up to 32% overall and 56% for youth in particular. 3 While minimum wages are up for high-skilled workers, the majority of Angolans are low-skilled labor. Those that do get work receive some of the lowest wages on record.3 Angola ranks as one of the worst countries for doing or starting a business. Angola dropped from 173rd in 2019 to 177th out of 190 in the 2020 Doing Business ranking. 42 Part of the problem is access to credit. However, entrepreneur’s, like farmers, often can’t get their products to market. Either a lack of transportation, roads, or actual market availability are all barriers. While the list is long, sectors where investment would have the widest economic impact for people include electricity, roads, transportation, education, and healthcare. All of which are interwoven with attracting FDI, increasing economic diversity, and creating employment.

Education A strong economy is linked to the education of its participants. Angolans lack many of the skills of production, even for efficient farming methods. This keeps them from being able to supply larger food corporations (e.g. coffee, banana, sugarcane) and therefore from earning more. The Angolan government began investing in this area in 2014 through the Learning for All Project with the World Bank. The project will have invested US$80 million by 2021. The project “aims to improve teachers’ skills and knowledge, primarily in subjects such as mathematics and Portuguese. School management and pedagogy supervision are also key components of the World Bank-supported project.” 43 Health 9

Health is another important link to a strong economy. Angola lacks healthcare professionals. In 2019, JLo built hospitals but they remain under staffed.44 Additionally, emergency transportation services are poor. The US has partnered with Angola to achieve some of the goals set out in the National Health Development Plan (Plano Nacional de Desenvolvimento de Saúde) 2012-2025. The goals include reducing malaria morbidity, preventing the spread of HIV/AIDS, tripling the number of doctors per 10,000 citizens (from 1 to 3), and improving birth attendance by qualified staff (from 49 percent to 70 percent).7 Angola currently has one of the highest maternal mortality rates where 1 in 70 women die during pregnancy. USAID is working in conjunction with the Ministry of Health, Angola National Statistics Institute, World Bank, UNICEF and UNFPA to conduct the second Demographic Heath Survey (DHS). “The DHS will provide updated demographic and health indicators, including fertility, mortality indicators (maternal, child and adolescent), HIV/AIDS prevalence, malaria prevalence, and child anemia and nutrition status.”7 The survey is due out by the end of 2020.

COVID-19 This year the appearance of COVID-19 has changed everything. It’s disrupted social structure, economies, supply chains, and food supplies. The necessary quarantines, lock downs, and other restrictions cause unemployment. It’s stressed governments’ ability to respond economically, health systems ability to care for people, and public health’s ability to control the pandemic. It’s also had varying effects within different countries, from an enormous mortality rate in Italy, to younger victims in the US. The effect on Africa and Angola in particular is forecast to be extensive.

According to the Associated Press, Africa as a whole could undergo a “complete economic collapse.”45 Even if Angola were able to stop the infection from spreading, the effect in other African countries and trading partners will affect Angola. According to Angolan Finance Minister, Vera Daves de Souza, Angola is already adjusting their economic forecast due to the virus, “Vera Daves, who held a meeting with journalists this Saturday in Luanda, said that the Coronavirus could have an impact on public debt management-which could be a possible scenario of lower economic growth, reduced revenues, as well as treasury management.”46 Africa Intelligence reported on a confidential briefing given to several senior African officials during a virtual UN meeting earlier this month. The novel coronavirus pandemic is projected to cut the African economy almost in half, generating a loss of some $29 billion. Meanwhile, major lenders to Africa have been asked to waive tens of billions of dollars in interest payments due this year. 47 The EurAsia group’s G-Zero Media estimates the worst affected by the pandemic will be those in the informal economy, that is street vendors, drivers, and the self-employed. It’s estimated that 85% of Africans work in the informal sector. These workers aren’t able to work from home and often can’t stay home from work for very long. As a result, many must continue to work and risk exposure to avoid starving. According to Deprose Muchena, Amnesty International’s Director for East and Southern Africa “Without support from the government, the lock down could become a matter of life and death for those living in poverty. Currently, many are being forced to choose between complying with lock down measures and going hungry, or stepping out to access food and being penalized for it.” 48 What's more, even where governments are trying to provide support, many people lack bank accounts, complicating efforts to get them aid. For Angola, the highly centralized banking sector adds another hurdle in mitigating the effects of the virus.

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Food shortages are also a risk. Angola is listed as “most vulnerable” on the Famine Early Warning Systems Network (FEWS NET).49 Emergent Risk International (ERI) predicts a rise in commodity and consumer prices may push middle-income countries closer to poverty. Rising food prices will also force households to spend more on food, pushing them further towards poverty.

As of April, 22, Angola had 24 cases total, 6 recovered, and 2 deaths.

Risks of conflict again?

According to Garda World, the risk of another all out war is low. 50 However, ERI cautioned, rising food prices and food scarcity are early warnings of social or political unrest. Additionally, the wide economic disparity, continued corruption, high unemployment rates—especially among young people —mixed with the tension from the COVID-19 outbreak adds to the tensions. The Armed Conflict Location & Event Data Project (ACLED) predicts a rise in violence as restrictions are enforced. The ACLED reported, “On 11 April 2020, a Zambian police officer was attacked by three people at Okandjengedi informal settlement in Oshakati (Oshakati West, Oshana) while enforcing coronavirusrelated ban on the sale of alcohol.”31 Furthermore, Professor Carlos Oya of the University of London’s School of Oriental and African Studies (SOAS) describes a more nuanced existing political situation, “Although the recent political transition in Angola, from Dos Santos to João Lourenço, is regarded as exemplary by the MPLA ruling elite in Angola, the truth is that this replacement has heightened tensions within the MPLA that threatens the country’s political stability.” 51

Obstetric Fistula Status Obstetric fistula (OF) in Angola and globally remains a difficult phenomenon to measure. Repeatedly, the World Health Organization (WHO) statistics of 2 million cases worldwide and 50-100,000 cases per year are used. However, the Bulletin of the WHO reported in 2015 that these numbers were based on scanty outdated and inaccurate information. Better estimates of OF come from three meta-analyses: the first done in 2013 by Adler et al. and the other two completed in 2015 by Maheu-Giroux et al. and Cowgill, K.D. et al. Both Adler and Maheu-Giroux both surveyed 19 Sub-Saharan African countries, and determined that overall, OF is a rare occurrence and the incidence and prevalence of it is lower than originally measured.52–54 This finding is reinforced by Ballard, K., Ayenachew, F., Wright, J. et al. as well as by Tunçalp, O., Tripathi, V.55,56 However, variation by country can be much higher. For example, Maheu-Giroux both found Ethiopia had the highest rates of OF. 54 The Cowgill study determined more reliable sources of data were necessary as a wide range of prevalence and incidence values were reported across studies. They also confirmed OF occurs more often in rural communities, reaching them is difficult, they are at higher risk for labor complications and are most likely to go unreported. Additionally, many women who develop OF may die before they are included in any population health studies. Suggesting, counter to their findings, that OF is subject to under reporting. Prevalence turned out to have the widest range of values, implying prevalence is more prone to bias.52

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In 2020, Dr. Rachel Pope found that existing research demonstrates that access to care is the most important underlying cause of obstetric fistula.57 Also, Rosário, E., Gomes, M. C., Brito, M.,et al. came to similar conclusions for Angola.58 Their study found that despite most of the women having antenatal care, some at least 4 visits, about half of them didn’t give birth in a health facility. 58 According to the authors, Angola needs policies to address access to care. For example, more health facilities are needed in rural areas. The study determined distance to health facilities is strongly associated with the delivery location. Additionally, lack of transportation is a barrier to healthcare access in Angola. The authors also noted social programs that target the family are necessary in the short-term to raise awareness.

“Of the 10,289 pregnancy outcomes, 98.5% resulted in live births, 96.8% attended antenatal care, and 82.5% had four or more visits. Yet, 50.7% of the women delivered outside a health facility. Antenatal care attendance was a determinant of birth outcomes (stillbirth: unadjusted OR = 0.34 95% CI = 0.16–0.70; abortion: OR = 0.07 95% CI = 0.04–0.12). Older women, with lower education, living at a greater distance of a health facility and in rural areas, were less likely to use maternal health care.

Having had previous pregnancies, namely resulting in live births, also decreased the likelihood of health care utilization by pregnant women.”58 Dr. Pope concluded in a separate study with Beddow that OF surgery lacks standardized treatment guidelines and information coordination, collection, and dissemination is necessary.

The repair of obstetric fistula, though studied for hundreds of years, is a subset of surgical expertise that lacks evidence‐based guidance. Obstetric fistula are a heterogeneous group, with a variety of surgical approaches and outcomes yet to be described. Many experiences of expert surgeons are not submitted for publication, therefore limiting accessibility. An effort must be made to share best practices among the surgeons who care for these women to advance our field and offer the procedures with the best possible outcomes. Continued commitment to sharing ideas, innovations, and experiences will help to move our field forward and provide the highest quality care to some of the most vulnerable women in the world—those living with obstetric fistula.59 Additionally, Pope and Beddow observed the first attempt at closure holds the highest chance at success. Their findings support the idea of centralized care in skilled health centers, especially for complex cases. “Women who experience failure of the first repair likely have more complex fistula, making the first repair less successful and each successive repair more difficult.” 59 This is slightly counter to Dr. Laurence Bernard’s work with Dr. Foster at CEML in Angola. Dr. Bernard found OF surgeries subjectively rated as “difficult” by the surgeon were more likely to fail on the first attempt but success increased with repeated attempts.60 The combination of the two studies suggests an opportunity to train surgeons with standardized best practices, as provided by the International Federation of Gynecology and Obstetrics (FIGO) Fistula Surgery Training Initiative.61 Also, Dr. Bernard relayed through email that some OF are just too complicated to close the first time. A retrospective case review to determine “difficult” OFs may be useful for future resource allocation.

Guidance is lacking in other areas of care as well. In 2017, a global survey of skilled birth attendants (SBAs) found no international consensus on the definitions of prolonged and obstructed labor (P/OL), multiple ambiguous terms associated with P/OL exist, and conflicting guidance is present in WHO

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manuals.62 The inconsistencies lead to delays in identification, referral, and management. Before this survey, very little was captured regarding SBA knowledge and routine care.

Also in 2020, Anastasi E, Asiamah B, Lal G. addressed the feasibility of attaining the United Nations Sustainable Development Goals (SDGs) by 2030. They found the timeline of 2030 to be unrealistic but still a worthwhile goal. Additionally, they summarized areas to address in order to reach the SDG goals (not necessarily by 2030).63 •

Strengthening health systems

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Implementing and monitoring costed national strategies for eliminating fistula

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Integrating fistula into national SDGs implementation plans and operational processes to achieve the SDGs

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Strengthening national task forces for fistula

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Securing significantly increased, predictable, sustained, and adequate financial support (ensuring that a higher proportion of resources reach young women and girls)

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Strengthening awareness‐raising and advocacy

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Improving research and data

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Holistic social reintegration and follow‐up and empowerment for survivors (including engaging them as advocates, enhancing their voices and leadership)

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Increased focus on social determinants that affect the well‐being of women and girls, including eliminating gender‐based social and economic inequities; preventing child marriage and early childbearing; promoting education and broader human rights

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Fostering community participation in finding solutions, including through the active involvement of men as well as seeking the help of fistula survivors as advocates

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Monitoring and evaluation of programs to end fistula.

Rane, A., Browning, A., Majinge, P., & Pope, R. are more specific in their recommendations. They acknowledge the lack of collaboration or coordination among organizations (government and NGO).

The group recommended five practices for reducing OF; First, a standardization of surgical techniques using FIGO or the International Source of Obstetric Fistula Surgery (ISOFS). Second, implement a uniform training program for surgeons through FIGO or Baylor College of Medicine programs. Third, the team goes further to suggest a certification for surgeons and coordinating funding through government ministries for certified surgeons only. Fourth, ensure patients receive evaluation, and follow-up care as well as the benefit of research into techniques and available innovations. Lastly, NGOs, government ministries, and non-profits need to coordinate their efforts if OF is to be eradicated rather than treated.64

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Rosário, E., Gomes, M. C., Brito, M.,et al. who’s study explicitly addressed the barriers of maternal health care in the Dande Health and Demographic Surveillance System area of Angola, recommended taking advantage of existing national social programs, e.g. the Angolan Woman’s Organization (OMA) to raise awareness, and promote the use of health services and education programs. 58 Social programmes aiming to reinforce women’s empowerment and education are also essential. Shortterm measures, like awareness raising in communities and maternal education programmes are a priority, always involving different participants (women, families and health agents). Given the scarcity of health workers, and taking advantage of the existence of the civic organization Angolan Women Organization (OMA–Organização da Mulher Angolana) whose main objectives are to promote women's health care, legal education and the mediation of family conflicts, community-based initiatives aiming the strengthening of links between health services and women should be developed.

OMA is already present in most of the neighbourhoods in the entire country and has a recognised social role both by authorities and by the community. Their involvement in the improvement of maternal health care could be based on a joint strategy with health services, assisting in health education, awareness raising among pregnant women, acting as mediators and facilitating a monitoring/tracking of women at antenatal care, delivery and postnatal care. 58 The list provided by Anastasi E, Asiamah B, Lal G. (from above) was altered to align risk factors of OF with the UN’s SDGs, gaps identified by the current research, and the recommended best practices (below) and then prioritized to highlight the main drivers for prevention.

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Conclusions OF is not an outcome that occurs at a consistent rate around the world or even within regions. OF is an indicator of weak emergency obstetric care systems, and its occurrence is variable at national and subnational levels.52 The research regarding OF gives some indications that the effort can feel perpetual. Browning and Sayed describe the progress in OF over the past 20 years as, “a rocky road, with each step along the path bringing positives and negatives: one step forward, two steps back.” 65 In Ethiopia, where the Hamlin Foundation has focused all of its energies for the past 46 years, and many OF resources exists, suggests something similar. A study of six Hamlin fistula hospitals, which account for 80% of fistula care in Ethiopia, recorded about a 50% drop in new fistula cases over 4 year study period. 55 An excellent outcome to be sure. However, Ethiopia was still found to have the highest rate of fistula in Africa, according to Maheu-Giroux in 2015.54 Additionally, as OF rates came down, iatrogenic fistula rose in its place. Another example comes from the timeline posted on AmRef’s website. AmRef has been operating in Africa for over 60 years, has treated 80 million women and trained 12 million health workers.66 Yet, OF persists. Despite sustained efforts, enormous amounts of resources, and a multitude of organizations with the sole purpose of eradicating OF, it hasn’t been eradicated. Again, this is not criticism, just observation that something is missing.

In much of the international development community, the issue of “sustainability” is discussed.

However, if obstetric fistula is a problem to be eradicated, our efforts do not need to be “sustainable,” but rather impactful and long standing. To repair the backlog of cases in a successful way, we need to fund the trained and certified surgeons so that the majority of cases are healed at the first attempt. 64 In order to be more effective, organizations need to cooperate. Research from Fabien Ngendakuriyo and Georges Zaccour provides some evidence that this is true. 67 In fact, the government institutions were better off as well. But barriers to cooperation exist in that the awarding of funding is inherently competitive, and organizations operating in the same region are competitors for the same scarce resources (e.g. staff). Additionally, organizations were more likely to cooperate if they viewed the other as trustworthy, suggesting that potential partners need to be selected carefully. 68 Bunger also determined, once in a cooperative arrangement, organizations reduced costs of overhead and administration, and increased the effectiveness of scarce resources. The result resembles a contractor/subcontractor arrangement in the construction industry. One central entity coordinating efforts and payments. This would also address gaps in information collection and dissemination. There is some precedent for this arrangement as well. In April of 2005, the OF Working Group was formed in Niger. The UNFPA organized a group of 30 stakeholders including, country support teams from 11 neighboring countries, medical experts from 4 countries, as well as non-profits and NGOs including WHO, EngenderHealth, FIGO, UNICEF, and AmRef.69 The published report includes training recommendations and management guidelines and can be found here. The group was more of an alliance rather than a contractor/sub contractor relationship. It was intended to reduce duplication of efforts by integrating the initiatives of the group with activities to be carried out at national, regional and international levels then coordinating international OF elimination efforts as well as the individual 16

projects of each member organization. The group would convene periodically for updates on organizational activities, implement tasks based on recommendations developed at larger international forums, review and endorse joint publications, and establish small project committees to address different fistula-related issues. The model was used again in Uganda by EngenderHealth. The working group serves as a model for working in Angola and elsewhere.

In addition to cooperation and coordination, access to healthcare cannot be overstated. The Hamlin organization’s website states, “The number one way to prevent obstetric fistula is to provide the women and girls of Ethiopia with emergency obstetric services.”70 This year Rupley, D. M., Dongarwar, D., Salihu, H. M., et al. directly measured the affect of access on vesicovaginal fistula (VVF) in Malawi.

Their study found women without access to high quality care were 3 times more likely to suffer from OF and rural women were 8 times more likely to suffer VVF than urban women. “That is, women who had ‘insufficient’ grade health care access had almost three times the likelihood (OR = 2.64, 95%CI = 1.07 – 6.03) of suffering from VVF as compared to women with ‘sufficient’ health care access. For the covariates, it was found that rural women were 8 times more likely to have a VVF as compared to their urban counterparts.”71 Additionally, the focus on treatment of OF has contributed to an enormous backlog of cases. Rupley and colleagues concluded, Given the increasing number of obstetric VVF cases and the limited treatment centers, focus must be shifted from treatment of obstetric VVF to prevention. As current capacity to repair obstetric VVF is far below the incidence of VVF, the number of preventable fistula cases is rapidly increasing. It is imperative that strategies targeting the most vulnerable populations- those living in poverty, from rural regions, with low levels of education, far from adequate healthcare resources, must be implemented….71 In response, researchers have called for more prevention initiatives. In addition to increasing healthcare capacity, increasing physical access through road and transportation systems needs to be considered.

Raha Maroyi, Laura Keyser, Lauren Hosterman, et al. reported on the mobile surgical outreach (MSO) program in Democratic Republic of Congo (DRC). The program was in operation from 2013-2018 and was successful in bringing services to rural women. 72 However, the program was only designed to care for existing OF survivors—it addressed treatment not prevention. Using the current research and recommendations, a similar program paired with a registry of pregnancies could bring mobile ob-gyn and surgical services to remote areas as a means of prevention. As capacity builds, and transportation systems come online, the service could be converted to an emergency services only program.

What are other organizations doing in Angola?

The large non-profits operating in, and outside of, Angola, have varied missions that they address through focused categories. For example, AmRef focuses on health access though capacity building and operates among three “pillars,” human resources, health services, and investments. Despite my use of them as an example of perpetual OF interventions, they have an extremely holistic program. Fistula Foundation focuses exclusively on surgical treatment, and reducing the backlog of women living with fistula through community outreach, capacity building, and post-surgical patient support. Direct Relief, on the other hand, is a much broader organization with “a mission to improve the health and lives of 17

people affected by poverty or emergencies….” They focus on 17 different health topics, including maternal health. They limit themselves to 5 areas of relief: equipment, nutrient support, fighting fistula, access to emergency care, and family planning. Freedom from Fistula focuses on two components of fistula, treatment through free surgery, and prevention through maternity care. The treatment program is supported by efforts from “patient ambassadors” who encourage women suffering with fistula to seek care. The maternity care program implements capacity building in the form of free-standing clinics and fistula centers within existing hospitals as well as training programs. In the past, FFF created hot lines to request free transportation to care centers in Kenya. Unfortunately, FFF was unable to continue operations in Kenya. The transportation system was not copied in other operations. The Hamlin model is also a relevant strategy. The Hamlin project created clinics and hospitals, midwife colleges, and farms called “Desta Mender” for access, capacity building, and skills retraining.

Also, a common element among organizations is the training of skilled birth attendants (SBAs). They can be midwives, nurses or doctors. In the research literature they are generally referred to as healthcare extension workers (HEW) and are an important component of capacity building. Angola had a program designed specifically for this purpose, the Community Health Workers (CHWs) program— unknown if still operational. Additionally, WHO encourages the use of HEW in their guidelines on the subject.73,74 WHO guidelines can be found here and here.

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What updates could be made to current programs to align with current research, best practices, and SDG goals?

HFOS current programs align with addressing several of the risk factors for OF. Current HFOS Programs Prevention – Fistula prevention training sessions Prevention and Empowerment Facilitators Ultrasound empowerment program Aftercare program Treatment – Aftercare program Maternal health fund – funds surgery Fund for training new doctors in cooperation with PAACS Empowerment – Sexual gender-based violence groups in cooperation with World Relief Aftercare program The HFOS AfterCare program is the one initiative that spans all three strategic areas. Is it possible to expand the program to include farming? The sector is important for the diversification of the economy.

Additionally, large commercial Angolan farms might consider funding the expansion if it were a “feeder” program for skilled employees. Additionally, is it possible for husbands to attend AfterCare for job skills?

The Maternal Health fund covers the cost of emergency services, c-sections, and rehabilitation services.

Can it include non-emergency access? For example, during the fistula prevention and awareness sessions women could elect to have transportation to the hospital on the day they go into labor or integrate with the AfterCare program as a place to wait before giving birth.

It wasn’t clear if the fund for training new doctors already utilizes FIGO guidelines. If not, is it a possible addition?

HFOS can also align with best practices over time using the current recommendations as an expansion guide: • The research suggests expanding prevention strategies. The high number of treatment strategies aren’t doing enough to stop the backlog of patients from accumulating.

• The research also indicates OF is more prevalent the further one gets from a health center.

Transportation systems and skilled health centers are key for increasing access.

• As access increases so must the capacity to treat patients.

• And as capacity increases, a global standard of care and training should be enforced.

Across all HFOS programs seek opportunities to coordinate and collaborate when possible. The OF Working group formed an alliance with government and private organizations in order to share best practices and coordinate activities. Is something like that possible in Angola?

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The Fistula Foundation and Direct Relief created the Global Fistula Map (GFM). It is a web-based catalog of resources (hospitals, surgeons, and # of surgeries by country). It also houses a collection of open data to understand the causes and consequences of obstetric fistula. The project is open to everyone and is open to suggestions for changes. The map includes only a few resources within Angola.

Also, Angola has (had?) the Dande Health and Demographic Surveillance System (HDSS) which was set up as part of the Health Research Centre of Angola–CISA. 58,75 The center is a collaboration between the Angolan Ministry of Health, the Portuguese Institute of Language and Development and Calouste Gulbenkian Foundation. The project’s main goal is to conduct and track epidemiological research of diseases affecting the country’s population, as well as promote the integration of Angolan health professionals in national and international research projects. The project is an excellent model of a regional repository for information and dissemination.

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Notes Worldwide Governance Indicators How the indicators are measured The WGI cover 213 countries and territories and are based on several hundred variables produced by 25 different sources, including survey responses, expert assessments and commercial data providers.

For more information see, http://info.worldbank.org/governance/wgi/Home/FAQ. Political Stability and Absence of Violence/Terrorism measures perceptions of the likelihood of political instability and/or politically-motivated violence, including terrorism.

Voice and Accountability captures perceptions of the extent to which a country's citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association, and a free media.

Government Effectiveness captures perceptions of the quality of public services, the quality of the civil service and the degree of its independence from political pressures, the quality of policy formulation and implementation, and the credibility of the government's commitment to such policies.

Rule of Law captures perceptions of the extent to which agents have confidence in and abide by the rules of society, and in particular the quality of contract enforcement, property rights, the police, and the courts, as well as the likelihood of crime and violence.

Regulatory Quality captures perceptions of the ability of the government to formulate and implement sound policies and regulations that permit and promote private sector development.

Control of Corruption captures perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as "capture" of the state by elites and private interests.

Google search parameters used; Google Scholar Search Criteria: {("Obstetric Fistula" OR "Obstructed Labor" OR "VesicoVaginal" OR "Gynecologic Fistula") AND (Epidemiology OR Prevalence OR Incidence) AND (Africa OR Angola OR Global OR world OR International) -cancer} Use Custom Range Since 2013 Brief Conclusions from most recent studies 2020 Slinger, G. and Trautvetter, L. (2020), Addressing the fistula treatment gap and rising to the 2030 challenge. Int J Gynecol Obstet, 148: 9-15. doi:10.1002/ijgo.13033 Concluded: Expand pool of fistula surgeons. Use FIGOS traingin Iniative. SDG target end OF by 2030 is unattainable but should still work towards it. Governments should develop fistula elimination plans, dedicate resources, and address underlying drivers perpetuating social, economic, and gender disparities leading to obstetric fistula. Angola only has 1 FIGO Fellow: DRC has 4, Nepal has 4 Anastasi E, Asiamah B, Lal G. Leaving no one behind: Is the achievement of the Sustainable Development Goals possible without securing the dignity, rights, and well‐being of those who are “invisible”? Int J Gynecol Obstet. 2020; 148( Suppl. 1): 3– 5.

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Concluded: necessary interventions accessible health systems; costed national strategies; integrating fistula into national plans to achieve the SDGs; strengthening national fistula task forces; and significantly increased, sustained financial support. protecting women's/girls’ human rights addressing social determinants that affect women's/girls’ ability to “survive, thrive and transform,” including social and economic inequities; gender‐based violence; child marriage and early childbearing; access to education.

Enhanced awareness‐raising and advocacy; improved research, data, monitoring and evaluation; holistic social reintegration and survivor empowerment; community engagement 2019 Bernard, L., Giles, A., Fabiano, S., et al. Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola. Journal of Obstetrics and Gynaecology Canada V41, I12, Dec 2019, Pp 1726-1733. https://doi.org/10.1016/j.jogc.2019.01.025 Concluded: “Although fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.” FIGO training helpful to get past learning curve for new surgeons, many OF surgeons work in private clinics that are prohibitively expensive (email from Dr. Laurence). Incentives for Private surgeons to treat poor patients.

Rosário, E., Gomes, M. C., Brito, M., & Costa, D. (2019). Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola. PloS one, 14(8), e0221280. https://doi.org/10.1371/journal.pone.0221280 2018 Pope, R., Research in Obstetric Fistula: Addressing Gaps and Unmet Needs. Obstetrics & Gynecology: May 2018, V131, I5, pp 863-870 Concluded: Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.

Arnoff, E., Tripathi, V., “A Global Survey of Skilled Birth Attendants on Intra- and Post-Partum Bladder Care and Management of Prolonged/Obstructed Labor” – April 10, 2018. In 2017, the USAIDfunded Fistula Care Plus project of EngenderHealth conducted a key informant survey of skilled-birth attendants (SBAs) to better understand the range of intra-partum and post-partum clinical practices in low- and middle-income countries (LMICs). The survey examined SBAs’ training, knowledge, practices, and facility environment as they relate to intrapartum and postpartum bladder care and management of prolonged/obstructed labor. During this webinar, presenters Vandana Tripathi, Elly Arnoff, and Sheena Currie shared the findings from this global SBA survey and discussed programmatic and research implications, particularly for midwifery training and practice.

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(https://fistulacare.org/wp-fcp/wp-content/uploads/2018/07/Report_Survey-of-Intrapartum-andPostpartum-Clinical-Practices_Final_7.18.pdf) 2016 Ballard, K., Ayenachew, F., Wright, J. et al. Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia. Int Urogynecol J 27, 1063–1067 (2016). https://doi.org/10.1007/s00192-015-2933-0 Concluded: prevalence in rural Ethiopia is low and less than previously estimated. This report was significant because it was one of the few that randomly selected women for survey, it also had a large sample size n=23,023. It is also significant because it selected a sample that should have been biased towards higher prevalence and incidence yet found the opposite. This supports the findings of previous meta analyses indicating burden of disease is lower than previously estimated.

Wright J, Ayenachew F, Ballard KD. The changing face of obstetric fistula surgery in Ethiopia. Int J Womens Health. 2016;8:243–248. Published 2016 Jul 1. doi:10.2147/IJWH.S106645 Concluded: obstetric fistula in the Hamlin centers in Ethiopia is changing. OF caused by OL are decreasing while iatrogenic fistula are increasing. FIGO standards should be taught and physician training should be ongoing project 2015 Maheu-Giroux, M., Filippi, V., Samadoulougou, S., et al. Prevalence of symptoms of vaginal fistula in 19 sub-Saharan Africa countries: a meta-analysis of national household survey data. The Lancet Global Health V3, I5, May 2015, Pp e271-e278 (2015).

Concluded: prevalence of OF is lower than previously reported. Ethiopia had the highest levels of OF in the 19 SSA countries surveyed. Showed National Household survey data is useful for estimates, but may under-report rural areas and may suffer from cotanglement with urinary incontinence from other sources.

Cowgill, K.D., Bishop, J., Norgaard, A.K. et al. Obstetric fistula in low-resource countries: an undervalued and under-studied problem – systematic review of its incidence, prevalence, and association with stillbirth. BMC Pregnancy Childbirth 15, 193 (2015). https://doi.org/10.1186/s12884-015-0592-2 Concluded: Reliable data on OF and associated Still Birth (SB) in low-resource countries are lacking, underscoring the relative invisibility of these issues. Sound numbers are needed to guide policy and funding responses to these neglected conditions of poverty.

Tunçalp, O., Tripathi, V., Measuring the incidence and prevalence of obstetric fistula: approaches, needs and recommendations. Bull. World Health Organ. 93 (1) Jan 2015. https://doi.org/10.2471/BLT.14.141473 Concluded: OF is rare. Need routine monitoring integrated with health systems and national programs.

Core indicators are being incorporated into national health surveys. Original WHO prevalence and incidence estimates are outdated and inaccurate 2014 Giugliani, C., Duncan, B. B., Harzheim, E., Lavor, A. C., Lavor, M. C., Machado, M. M., Barbosa, M. I., Bornstein, V. J., Pontes, A. L., & Knauth, D. R. (2014). Community health workers programme in 23

Luanda, Angola: an evaluation of the implementation process. Human resources for health, 12, 68. https://doi.org/10.1186/1478-4491-12-68 Berhan, Y., & Berhan, A. (2014). Commentary: Actions in the pipeline and the way forward to reduce maternal and perinatal mortality in Ethiopia. Ethiopian journal of health sciences, 24 Suppl(0 Suppl), 149–168. https://doi.org/10.4314/ejhs.v24i0.13s 2013 Adler, A.J., Ronsmans, C., Calvert, C. et al. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy Childbirth 13, 246 (2013). https://doi.org/10.1186/14712393-13-246 Concluded: the most comprehensive study of fistula prevalence and incidence so far. Researchers found the prevalence of fistula is lower than previously reported.

Adam Ragozzino Acies Lumen email: adam@acieslumen.com Web: https://www.acieslumen.com Linkedin: https://www.linkedin.com/in/adamragozzino Twitter: @acieslumen

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