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H.E.R.A. – Health Education and Research Association

2009 - 2013 STRATEGIC FRAMEWORK

Skopje, June 2009

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Table of Contents Introduction ................................................................................................... 3 THE HERA – Background ..................................................................................... 4 VISION .......................................................................................................... 7 VALUES ......................................................................................................... 7 Mission.......................................................................................................... 7 Political Environment and the Sexual and Reproductive Health and Rights in the Republic of Macedonia ..................................................................................................... 8 The Role and Expertise of the HERA in Advocating for the Enhancement of Sexual and Reproductive Health ........................................................................................ 14 Abortion....................................................................................................... 16 HIV/AIDS ...................................................................................................... 21 Adolescents and Youth ..................................................................................... 24 ACCESS ........................................................................................................ 27 Advocacy...................................................................................................... 31

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Introduction This Strategic Framework covering the period 2009 – 2013 is a first written document of the Health Education and Research Association (HERA) whose purpose is to unify and structuralize the Association’s identification of the role and its the experiences from the past, as well as the vision for future action and the basis for the promotion and enhancement of sexual and reproductive health and rights (SRHR) in the Republic of Macedonia. The foundations for this Strategic Framework have been laid during a three-day workshop for Strategic Planning organized by the HERA in February 2009 with the support and in consultation with the International Planned Parenthood Federation (IPPF). Our vision defines sexual and reproductive rights as the highest possible values among the human rights which form the basis for the achievement of good health, freedom and prosperity for each individual, no matter his/her social status. The HERA has set the following five areas of priority which will be this NGO’s main field of work during the course of the next four years: • •

Abortion – in order to guarantee the right of choice to any woman, provide access to safe and legal abortion and increase the rate of use of contraception; Adolescents – in order to achieve greater consciousness among the youth with regard to their sexual and reproductive health and rights and provide access to comprehensive information, education and services for the enhancements of sexual and reproductive health among the youth; HIV/AIDS – in order to achieve lower rates of HIV/AIDS prevalence in the country, which is in accordance with the 2007 – 2011 National HIV/AIDS Strategy and provide full protection of the rights of the persons infected and affected by HIV. Access – in order to serve each person with valid information and knowledge in connection with his/her sexual and reproductive health and provide access to a variety of services in order for each person to be able to exercise his/her health, social, sexual and reproductive rights; Advocacy – in order to achieve full compliance with the different needs of each individual and to protect his/her rights and in this sense achieve highest possible standards, harmonize accordingly: national policies, regulations, laws and programs in connection with sexual and reproductive health and rights.

This Strategic Framework will become a guiding principle for the HERA and for the achievement of its Mission and Objectives it will use its members and volunteers, who will exercise firm determination and activism to meet this effort. The HERA, understanding the need for establishing partnerships hereby wishes to summon each organization, governmental or nongovernmental, as well as the media, private institutions, networks, coalitions and informal citizen groups and individuals, who share such similar values and objectives, to join the HERA in its efforts of making this vision a reality.

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THE HERA – Background Health Education and Research Association is established in January 2000 at an initiative of a group of 6 young volunteers – university students and medical doctors. The objectives set at the time were primarily focused on primary prevention and training on issues related to HIV/AIDS, promotion of healthy lifestyle among the youth, as well as providing access to treatment and care for people living with HIV and their families. Since its beginnings the HERA has recognized the need for promoting the concept of sexual and reproductive health and rights which was integrated, at an early stage of its existence in its Program and activities, stipulated as a comprehensive approach in the fight against HIV/AIDS epidemics introduced in the public health sector, based on the respect of human rights. Today, the HERA is a leading organization in the civil society sector working towards the promotion and enhancement of sexual and reproductive health and rights, especially in the area of provision of direct services in its centers and during its outreach work. Currently it is implementing a number of projects, primarily for the youth and the vulnerable, including those people who are at the brink of the social and economic ladder, the Roma and the people who live with HIV and AIDS, as well as men having sex with men and sex workers, providing them access to comprehensive information, sexual education, as well as free and confidential health and social services. During the course of the last several years the HERA concentrated its efforts in building the capacities of the civil society sector, the education and health systems all in order to introduce the concept of sexual and reproductive health and rights. Along with its direct service provision, the capacity building process in those relevant institutions and organizations and the awareness-raising in general, the HERA strongly committed itself to the lobbying in favor of introducing better national policies and legislation in order for the country to accomplish highest possible standards in the realm of sexual and reproductive health and rights for its people. Chronological Review of Noteworthy Results achieved by the HERA: 2000 – HIV/AIDS and STIs prevention Hotline launched. Today this hotline has been transformed into a free-of-charge public service; 2001 – In cooperation with the National Health Protection Institute a pilot initiative for free-of-charge, anonymous and confidential HIV testing launched countrywide, a service which was integrated into the national policy and strategy at its very early stage, implemented in a number of health-care institutions throughout the country as an integral part of the National Program for HIV/AIDS Prevention. 2001 – A service for psychosocial support through counseling and testing for HIV/AIDS for people who live with HIV/AIDS and their families was introduced. 2002 – Within the framework of the Balkans Project the HERA was selected by the IPPF as an implementing partner for the activities and the programs for promoting of SRHR in Macedonia.

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2002 – The first national training of trainers for peer education and SRHR was held. Currently the HERA is one of the leading civil society organizations working in the field of promoting the model of peer education, which is aimed at introducing the concept of informal training among the youth and adolescents. The HERA is an active member of the Y-PEER network. 2003 – Participation in the design and drafting of the first National Strategy on HIV/AIDS 2003-2006 in capacity of a member of the National Multi-Sectoral Commission on HIV/AIDS. The HERA was directly involved in the preparatory and development stages when the country applied in the Global Fund to fight HIV/AIDS Malaria and TB to gain funding for its project. 2003 One portion of the members of the HERA who worked on projects focused on HIV/STIs prevention among men having sex with men (MSM) established a separate NGO – Equality among Men and Women (EGAL) setting an objective for this NGO to promote sexual health among the LGBT population and decrease the homophobia against such population in Macedonia. Today, the EGAL is one of the leading civil society organizations working on HIV and STIs prevention among the LGBT community and on the improvement of their sexual health and rights. 2004 – The HERA became responsible for implementing a three-year project funded by the Global Fund to fight HIV/AIDS, Malaria and TB (2004 – 2007) within the framework of the following programs: HIV/AIDS prevention among the youth aged 15-24, HIV/AIDS prevention among the MSM and the program focused on voluntary counseling and testing for HIV, all in accordance with the obligations set in the National Strategy. 2005 – The first Sexual and Reproductive Health Youth Center “Sakam da Znam” was launched in the premises of the Public Outpatient Facility Vodno, a joint venture implemented by the HERA and the Skopje Public Outpatient Institution supported by the Ministry of Health. This Youth Center provides access to free and anonymous medical and training services for youth and adolescents aged 14 to 30. 2005 – In partnership with the Skopje Clinic for Infectious Diseases the HERA launched an HIV/AIDS Counseling Office and a daycare center for people living with HIV/AIDS. The Counseling Office provides access to free testing for HIV, psychological and social support for the people living with HIV/AIDS, as well as their families, and medical treatment and care. 2006 – Second Youth Center for Sexual and Reproductive Health “Sakam da Znam” launched in the outpatient facility Šuto Orizari in partnership with the Public Outpatient Facility Skopje and the Ministry of Health 2006 – The HERA becomes associate member in the International Planned Parenthood Federation, one of the leading international NGOs working in the area of SRHR.

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2007 – In co-operation with the National Health Protection Institute and a number of nongovernmental organizations the implementation of the program for outreach work – Mobile HIV Testing, commenced aimed at vulnerable and marginalized groups, including the general youth, IV drug users, prisoners, men having sex with men and sex workers, using a specially equipped vehicle for HIV testing. 2007 – Participation in the development and design of the Second National Strategy on HIV/AIDS 2007 – 2011 2008 – The HERA becomes responsible for implementation of the Program for Mobile HIV Counseling and Testing among vulnerable and marginalized groups within the framework of a 5-year project financed by the Global Fund to Fight HIV/AIDS, TB and Malaria (2008-2012) as part of the objectives and responsibilities stipulated in the National Strategy. 2008 – The HERA sent its representatives to take part in an Expert Group led by the Ministry of Health established for the purpose of analyzing the policies and programs on the use of contraceptives and performing abortions in the Republic of Macedonia. 2008 – Participation in the preparation of the 2009 Preventive Program against HIV/AIDS. Membership in National Bodies and Networks • • • • •

National Coordinative Mechanism to Fight HIV/AIDS and Tuberculosis National Inter-sectoral Commission on HIV/AIDS Y-PEER Macedonia Macedonian Harm Reduction Network Coalition for the Protection of Sexual and Health Rights of Marginalized Groups

Membership in International Organizations and Networks • • • • • •

Associate Membership in the International Planned Parenthood Federation The Y-PEER Network The Youth ASTRA Network Y-SAFE The European Group for Treatment of HIV/AIDS AIDS Action EUROPE

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VISION The HERA will work towards the establishment of a world in which sexual and reproductive rights are guaranteed and a world in which all men, women and young people are healthy and free, celebrating their sexuality and diversity as a basic principle of their way of living. VALUES The HERA believes that the sexual and reproductive rights are inseparable from any of the human rights and that each individual must enjoy the right of his/her sexual liberty, identity and right to have access to SRHR information and services. The HERA believes that the right of making free choices is a legitimate need of each individual to make free choices about his/her body, life and sexual and reproductive health. The HERA believes that sexual and reproductive rights are necessary for the enjoyment of high standards of mental, physical and social welfare. The HERA fully recognizes and respects the needs and concerns of the young, the vulnerable and marginalized groups, including those of the people who live with HIV, concerning their SRHR and commits itself towards their implementation. The HERA is an organization of volunteers which stimulates youth participation in the implementation of its mission and its objectives. The HERA believes that enhancement of sexual and reproductive health and rights is possible only through co-operation and mutual commitment on the part of each of the significant stakeholders in the country, such as governmental and nongovernmental organizations, civil society organizations or institutions. MISSION The HERA is inclined towards achieving enjoyment of basic human rights of women, men and the young who must be correctly informed and have appropriate access to high quality confidential services in order to make their informed choice regarding issues such as their sexuality, as well as the prevention, care and treatment of sexually transmittable infections and HIV, including achievement of full protection of the rights of people who live with HIV/AIDS and their close families, contraception, access to safe and legal abortion and exercise of sexual and reproductive rights.

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Political Environment and Sexual and Reproductive Health and Rights in the Republic of Macedonia 1. Demographic, vital and economic indicators in the Republic of Macedonia Population as of 31.12.2007: 2,045,177 Population Age Structure: 0-14 (19,2%); 15-19 (7.9%); 20 – 59 (57,3%); 60 – 64 (4,3%); 65+ (11,2) Natural Growth: 2% Birth Rate: 12 live newborns per 1,000 people General Mortality Rate: 9.1 Sex: 50.1% (men) 49.9% (women) Life expectancy in years: 73,8 Reproductive women (aged 15 – 49): 51,8% Total Fertility Rate: 1,5 Ethnic composition: 61,1 (Macedonians); 25,17 (Albanians); 3,95% (Turks); 2,66% (Roma); 1,78% (Serbs); 0,84% (Bosnians); 0,48% (Vlachos); 1,04% (others) Religions: Christian Orthodox (64.7%), Muslim (33.3%), all other Christians (0.37%), the rest and unpronounced (1.63%) Population below the poverty line: 29,4% Unemployment Rate: 34.9% (2007) GDP – parity of buying capacity: 17.35 billion US dollar GDP – real growth rate: 4% (2006) GDP – per capita : 8,400 US dollars(2007) GDP per sector distribution: Agriculture (11.9%), Industry (28.2%), products and services (59.9%) – 2007 During the last decades Macedonia went through a demographic transition in terms of an increased aging of its population and the increase of the rate of elderly people in the total population. The Republic of Macedonia’s population is still considerably younger than that of Western Europe with a median age of 35.3 according to the 2002 Census. However the number of older persons is on the rise. While the ageing average in the countries of the EU and those of Central and Eastern Europe is on the rise, the proportion of the elderly Macedonians is significantly lower than this average. Macedonia marks a great decrease of the rate of morbidity and mortality in breastfed infants from 28.2 per 1000 newborn infants in 1991 to 11.5 per 1000 newborn infants in 2006 (however, this rate is still markedly higher than the EU average especially in terms of prenatal mortality). The increased average age of first baby delivery in women, the decreased total fertility rate and the decrease of the specific fertility rate in girls 15 to 19 years of age, are fundamental features shaping the reproductive behavior of the population of the Republic of Macedonia. The fertility rate currently

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is assessed at 1.5 and the continuous decrease of newborn infants per 1 woman is becoming more and more apparent. According to the age structure of women who delivered their babies during the course of 2006, 64.5% of them were aged 20 to 29. The participation of teenage pregnancies was the same in 2006 as the year before, accounting for 7.2% of all pregnancies, featuring a specific fertility rate of 20.2 per 1000 women aged 15-19 years. The number of total registered liveborn infants delivered by mothers younger than 15 years of age in 2006 was 29. Although a tendency of a decreased rate of teenage pregnancy exists in Macedonia, it is continuing to stand significantly higher in comparison with developed European countries (the Netherlands -6.2; Switzerland -5.5; Denmark 8.1 and Sweden 6.5). Access to professional support is key for safe motherhood, from an aspect of maintaining the health of the mother, as well as the health of the newborn infant. In 2006 out of the total liveborn infants (22,586), 99% of the deliveries were performed in medical facilities and only 0.75% or 171 without the support of a trained professionals. The perinatal mortality rate is an important indicator of quality of postnatal care and the health of the mother, as well as the quality of obstetric care and protection of newborns after delivery. In 2006 a total of 201 dead newborns have been registered in Macedonia and 145 dead infants aged 0 to 5 days by which a rate of perinatal mortality of 15.3 per 1000 liveborn infants was reached. The perinatal mortality rate in 2006 was marked by a slight fall compared to 2005 (16.8%) and has been at its lowest during the past decade. The number of registered abortions in Macedonia during the recent period has been constantly dropping. In 2006 a total of 6,164 abortions were registered representing 27.3 abortions per 100 liveborn infants. The registered abortion rate per 1000 women aged 15 to 44 in 2006 was 13.6. While doubt has been cast on the fact that not all abortions are actually registered, the Macedonian average of 14.2 abortions per 1000 women aged 15 to 44 years is significantly higher than the EU one. 2. Current Policies Relating to Sexual and Reproductive Health and Rights The Republic of Macedonia does not posses an organized approach or no single strategy which will cover the main directions of action in relation to SRHR, towards which the country should be striving, but also it lacks a single coordinative mechanism and a system for monitoring and evaluation which would provide an organized, synchronized and coordinative action towards the realization of planned activities, as well as monitoring and evaluation of achieved results. The Ministry of Health and the National Health Protection Institute have been making urges towards the introduction of such strategic framework founded on sexual and reproductive health in humans. Furthermore, they are emphasizing the need of basing such strategies on interdisciplinary and inter-sectoral approaches, in which civil

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society will be an equal partner in implementing programs, especially with regard to advocating and protecting SRHR and raising awareness of the public concerning such rights 1 . The Republic of Macedonia has ratified a number of international strategic development recommendations, along with a number of documents which should contribute towards the development of SRHR in Macedonia, such as the Millennium Development Goals, the Convention on the Elimination of all Forms of Discrimination against Women, the Action Plan of the International Conference of Population and Development, the Universal Declaration of Human Rights, the Convention of the Rights of the Child, the European Social Charter and the International Covenant of Economic, Social and Cultural Rights, along with other international agreements. Macedonia has developed a number of inter-sectoral and multidisciplinary strategies and action plans, as well as other relevant Government papers have been published which are particularly significant for the sexual and reproductive health of its citizens, including the following: ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

National Action Plan for Human Rights National Plan for the Equality between the Sexes adopted 2002 National Program to Fight Trafficking in Human Beings National Youth Strategy National Strategy for the Roma National Strategy to Fight Family Violence Health Strategy of the Republic of Macedonia National Strategy on HIV/AIDS National Strategy on Tuberculosis National Policy for the Mental Health National Action Plan for the Prevention and Early Detection of Breast Cancer National Strategy for Adolescent Health 2008-2015 Strategy for Demographic Development of the Republic of Macedonia

In addition to such policies for development of sexual and reproductive health and rights in Macedonia the vertical preventive programs which will be adopted pursuant to the Law on Health Protection will be most beneficial. Each year the Government funds approximately 15 preventive programs from its Budget. The following programs will be especially interesting for the development of sexual and reproductive health in the country:

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Strategic Assessment of Policies, Quality and Access to Contraceptives and Abortion in the Republic of Macedonia, Ministry of Health, National Health Protection Institution and UN Population Fund (2007).

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Program for Active Health Protection of Mother and Child: The activities contained in this Program are aimed at promoting and enhancing the reproductive health among women, with special emphasis on the adolescent population and women from the country’s rural areas, by means of health education and training on how one should protect him/herself from unwanted pregnancy and practicing safe sex. This should cover 10% of all reproductive women, who approximately amount to 50,000 with an average of 2 visits per woman. Program for Early Detection and prevention of Diseases attacking Reproductive Organs in Women: Performing cervical screening in 20% of women who have not got any medical insurance aged 19 to 65 (12,800 women), awareness raising among women for timely detection and treatment of premalignant and malignant conditions, decreasing the mortality rate related to such diseases. Women who have health insurance have an opportunity to have a free-of-charge PAP test each year. Program for the detection and Treatment of Breast Cancer Within the framework of this program, 30,000 women over the age of 40 have an opportunity to have their breasts scanned with ultrasound and mammogram radiology. Program for the Prevention of the Population against AIDS This Program covers programmatic epidemiological research and oversight; laboratory research; training for health workers; health education for the entire population, and for most at risk groups. The major programs and activities for prevention, treatment and care of HIV/AIDS in the country receive funding from the Global Fund to Fight HIV/AIDS, Malaria and TB. These sorts of programs are mainly focused on HIV prevention among marginalized groups and hard-to-reach groups, including intravenous (IV) drug users, men having sex with men, sex workers and prisoners. The bulk of the activities are being implemented by civil society organizations. There are other preventive health programs which in some part relate to sexual and reproductive health, such as the: 1. Program for Preventive Health Care; 2. Program for Regular Medical Examination of Students and the Youth; 3. Program for Health Care for Persons without Medical Insurance.

3. Main Actors who may Influence the Development of Sexual and Reproductive Health in Macedonia a) Governmental Institutions The Ministry of Health (MH) and its line institutions and units excerpt most influence and create the major part of the policies for the enhancement of SRHR and HIV/AIDS in Macedonia, those institutions are the following: -

The European Integration Sector of the MH The Primary and Preventive Health Care Sector of the MH

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The National Institute for Health Protection The Institute for the Protection of Mothers and Children The National Coordinating Mechanism

It is noteworthy that the Parliamentary Commission for the Equality between Men and Women has played an active role during the last number of years in creating policies relating to family violence, as well as preventive programs for the prevention of breast cancer and early detection and prevention of diseases occurring in women’s reproductive organs. In comparison to all other ministries of the Government, except the MH, we may stress the role of the Ministry of Labor and Social Policy which, in some of its line of work, is taking part in sexual and reproductive health policy making, however its work is predominantly focused on the fight against family violence, trafficking in human beings and demographic development policies. Youth and Sports Agency is a Government agency, which is particularly important in the awareness rising in connection with health protection and the rights of the young, funding small-scale projects each year by giving grants to civil society organizations to implement substantial initiatives for enhancement and development of sexual and reproductive health of the youth. In addition to this, its role is also reflected in its National Strategy for the Youth and its Action Plan which was implemented in conjunction with the civil society sector, including the HERA. The decentralization process and the gradual take-over of obligations on the part of local governments aimed at their being able to independently plan and implement preventive social and health care programs is a processed marked with a very slow progress without distinctive differentiation of the roles and responsibilities of Municipalities. Nonetheless, during the last several years the municipalities, within the framework of their programs, did include some strategies and action plans for the improvement of the health care for their citizens. The matter of interest for SRHR at a local level is mainly focused on the adopted strategies for HIV prevention by a number of Municipalities, which did not have a major impact on other specific aspects relating to SRHR. b) Initiatives Submitted by Civil Society Organizations One of the best examples of initiatives for multi-sectoral cooperation in favor of SRHR performed by civil society organizations are HIV prevention programs aimed at vulnerable and marginalized groups. With the support of the Global Fund 15 NGOs have been included in the implementation of preventive activities regarding HIV among high risk vulnerable groups, including sex workers, IV drug users, men having sex with men and prisoners, acting locally throughout the country. In terms of action against family violence, trafficking in humans and the protection of women’s rights and reproductive health, the role of women’s organizations are especially important, including that of the ESE, Zdruzenska Action, Women’s Lobby of Macedonia and the SOZM. These are all well-

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established NGOs with already built capacities, working according to a unified platform of providing direct services, and influencing policy making. In terms of initiatives made by youth organizations and networks the Y-PEER Macedonia youth organization is present in the country working on promotion of sexual and reproductive health by delivering peer-education trainings, promotional and entertaining activities and marking of International days for the protection of the rights of the youth, as well as HIV/AIDS prevention. c) United Nations Agencies The role of several UN Agencies (UNFPA, UNICEF, UNAIDS and UNIFEM) is particularly important in terms of provision of technical assistance to the Government and its line ministries, in terms of policy making and policy enhancement, as well as establishing SRHR strategies and programs and some initiatives to the civil society sector, in terms of HIV prevention, strengthening the contraception and abortion policy, as well as policies relating to family violence and demographic development.

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The Role and Expertise of the HERA in Advocating for the Enhancement of Sexual and Reproductive Health а) HIV/AIDS The HERA is mostly recognizable as an organization whose main business is prevention, as well as care and treatment for HIV/AIDS. Its role and expertise is reflected in the following programs for which it has built its own capacities thus actively participating in policy and program making at a national level: •

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Confidential HIV counseling and testing by building capacities in civil society organizations and provision of direct HIV-related services, especially for the vulnerable and marginalized communities; Psycho-social support for persons living with HIV and provision of antiretroviral therapy Active membership in the National Inter-Sectoral Group for HIV and the National Coordination Mechanism Member of the European Network for Treatment of HIV

b) Adolescents and Youth Since its beginnings the HERA has setup a youth profile for itself strongly advocating for the introduction of a training methodology of peer-education as one of the leading approaches for successful prevention of HIV and enhancement of sexual and reproductive health. The HERA has established its peer-education program with a current staff of 15 peer-education trainers and 50 peereducators. The HERA is also responsible for establishing the Y-PEER network in Macedonia and HERA today is among the most active organizations taking part in the development and implementation of the activities of the Y-PEER network. On invitation of the Ministry of Health, it has also participated in the drafting of the National Adolescent Health and Development Strategy. c) Access The main place of HERA’s activities is reserved for the provision of direct services for protection of sexual and reproductive health and HIV/AIDS, as well as the introduction of youth-friendly services. It is also significant to stress that HERA is in charge of three on-site service centers, two of which are youth-friendly orientated, in addition to a mobile one offering free and confidential services for all groups, especially the vulnerable and the marginalized. Each of the service centers are supported by the Ministry of Health and are operated in partnership with the state-owned health institutions, including the Outpatient Facility of Skopje, the Infectious Diseases Clinic in Skopje and the National Health Protection Institute.

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d) Abortion During the last two years HERA worked hard to profile itself as an organization working on improvement the sexual and reproductive health of the population, particularly in terms of improving abortion and contraception policies and programs. More importantly it has given its input in the Working Group for Implementation of an Assessment of Contraception and Abortion Programs and Policies with the Ministry of Health which eventually submitted a Final Strategic Report on this topic. Many of the recommendations contained in that paper have been put as initiatives by HERA and have formed part of that strategic document. The HERA is also an active member of the Coalition for the Protection of Sexual and Reproductive Rights of the Marginalized Communities, partaking in the promotion and protection of the right of choice of women to have abortion. e) Advocacy While collaborating with civil society and international organizations, the HERA has set a good example through partnerships and experience in dealing with the administrations of the Ministry of Health, Ministry of Labor and Social Policy, Ministry of Education, as well as the National Health Protection Institute. The HERA was also responsible for organizing the first meeting of the Members of the Macedonian Parliament entitled Advocating in favor of HIV/AIDS prevention thus making a number of important contacts. Here we must stress the significant importance of establishing a contact with different diplomatic missions accredited in the country, especially those of Western European countries, who are strong lobbyists for human rights. During the course of the previous period the HERA established valuable contacts with local governments in several cities and towns throughout the country, giving its support for their efforts to introduce local policies for HIV prevention. It is particularly important to stress the cooperation with the largest Roma local community “Shuto Orizari.� Consequently the HERA has had an opportunity to act as an intermediary in its efforts to directly advocate in favor of achieving the objectives set by civil society in front of state institutions, for which evident success has already been made in terms of providing a place of civil society organizations to act as equal partners in the National Preventive Program for HIV/AIDS.

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Abortion During the course of the last decade the number of registered abortions performed in the country has severely dropped. In 2006 a total of 6,164 abortions have been registered, amounting to 27.3 abortions per 100 living newborn infants. In comparison with 1996 when 48.4 abortions per 100 liverborn infants were reported, a trend of steady decline was marked during the ensuing 5 years when in 2001 the number of abortions declined to 34.4 abortions per 100 liveborn infants. However the number of registered abortions does not reflect the real situation of performed abortions in the country, partially because of the inconsistent registration process and shortcomings in the state health service statistics, as well as reasonable doubts that immediately after the period of privatization of the primary health services and the introduction of private gynecological practices, termination of pregnancy was often performed in private health organizations who have not been licensed to perform such work according to the Law on Termination of Pregnancy. The most recent statistics of 14.2 abortions per 1000 women aged 15 to 44 years shows that while the number of performed abortions is in decline in Macedonia it is still a country that has more abortions per capita than other EU countries. Macedonia does not keep statistical records of the number of unsafe abortions performed countrywide, nor does it keep records in terms of any possible complications resulting from unsafe or illegal abortions performed in gynecological practices. There are examples of women having suffered complications from abortions performed in gynecologic practices, who are referred to gynecologic and obstetrics hospitals, which do not or fail to record statistics related to abortion complications in order to follow up or control the volume of illegal or unsafe abortions in the country. Methods of performing abortion • First Trimester (up to the 12th week of pregnancy) – Mechanical cervical dilatation followed by administration of electrical vacuum aspiration and curettage sharp (also called “sharp curettage”) • Second Trimester (following the 12th gestination week of pregnancy) - Intraamonium application of a hypertonic solution of natrium chloride These methods of abortion are not entirely in line with World Health Organization’s (WHO) standards for performing safe abortion and providing quality of care. The sharp curettage is a widespread

abortion method performed in Gynaecologic and Obstetrics Clinics up to the third trimester of pregnancy, a method not in line with WHO standards, which prescribe the use of manual vacuum aspiration. Vacuum aspiration although initially introduced in 2002 along with training on how to perform this method for the staff of the Gynaecologic Clinic in Skopje, it is not currently a standard practice. The Paracervical block, is not in use as a local anaesthetic, also in accordance with WHO recommendations for pain control, instead general (IV) anaesthesia is the practice of the day. Furthermore, much of the gynaecologists and obstetricians are not accustomed to the methods of performing a paracervical block or they express doubt about the possibility of performing abortions with local anaesthesia without inflicting significant trauma to the patient. Also women do not have a possibility to choose among the different abortion methods, baring in mind the fact that non-surgical or medication

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abortion remains unregistered in the country, although the medications used in this method can be purchased on the black market. There are no indications that untrained medical staffs are performing abortions because only specialist gynecologists or obstetricians are allowed by law to perform abortions and such staff, during their medical education receives adequate training and practice for proper performance of termination of pregnancy. The gynecologists and obstetricians generally agree to the incorporation of WHO standards and protocols for performing safe abortion, however many of them feel that existing methods are safe and satisfactory enough. It is noteworthy to express the lack of motivation for learning new methods and improving the knowledge and skills among this group of health professionals. The counseling before and after abortion is not always performed by gynecologists, especially in stateowned hospitals and there are no existing counseling protocols. Often such counseling is not considered as part of the service of performing an abortion. According to the Law on Health Insurance, if termination of pregnancy is not medically induced, such procedure will not be covered by the basic medical insurance scheme, thus all expenses must be covered by the patient without regard if the patient possesses medical insurance or not. There are no social or other criteria that will enable some groups of patients to enjoy discounts, or to pay participation fees or be exempt from paying medical fees for abortion. In public outpatient facilities the abortion procedure now costs between 65 and 95 US dollars, while in private clinics such fees may be as high as 170 up to 185 US dollars. The legal aspects concerning the performance of abortion are contained in the Law on Termination of Pregnancy adopted in 1972 and amended in 1976 and 1995. This law is particularly liberal in terms of its recognition of women’s rights of making a free choice with regard to their pregnancy up to the 10th gestination week of pregnancy. This law defines termination of pregnancy as special medical intervention that maybe performed on a pregnant woman who voluntarily agrees to it. According to this Law the right of choice may be limited only if there are indications that there is danger to the life of the pregnant woman in question. However during the course of 2008 a number of political religious groups forcefully staged attempts of delegitimization of sexual and reproductive rights of women, mounting a fierce campaign against the right of women to make free choice whether or not to terminate their pregnancy. With the appearance and intensification of an anti-abortion movement in Macedonia, as well as with the use of nationalist and religious rhetoric on the part of some groups, women’s rights of making free choice with regard to pregnancy termination was strongly condemned, attacking and underestimating the reproductive rights enjoyed by women to make free choices about their health, life and integrity. In short we may summarize the following events that took place:

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• Introduction of a no-name, aggressive, consistent and above all expensive awareness campaign in 2 phases: primarily with posting intimidating and monstrous depictions of fetuses followed by an emotional campaign celebrating life depicting a mother and a child; • Statement of points of view of the Macedonian Orthodox Church, in newspaper columns of leading representatives of the clergy and an address of the clergy during Christian holidays, by which our church carbon copies ready made models used by the Catholic Church, condemning women of child murder; • Intellectuals, who were previously renowned to have liberal views, extending their support against abortion; • The government has summoned bidders to who will mount an information campaign representing consequences from performing abortion; • News and media say that the Government is intending to change the current Law on Termination of Pregnancy and will introduce a restrictive policy for access to abortion services in Macedonia; • Appearance of a nongovernmental organization which publicly advocates abolishment of abortion for the purpose of increasing the birth rate and avoiding committing sins; Although abortion rates in the Republic of Macedonia are constantly declining, statistical data and surveys show that abortion is still substantially practiced as an unwelcoming “method” of fertility control. For certain, one of the reasons for this is shortage of conciseness and existence of prejudice, equally among the health workers and end users, for the use of more contemporary contraceptives, except the condom. According to the data collected during a survey of the National Statistical Bureau in 2007, only 9.8% of women in their reproductive period, aged 15 – 49 years used some of the more contemporary contraceptives, in comparison with the average rate of 70% of women in Western Europe.

Challenges • • •

Intensified anti-abortion movement among conservative political groups, religious leaders and individuals-intellectuals in the country. Possible limitations in the legislation for free access to abortion as a right of making a free choice on the part of women; Standards and policies of the World Health Organization for practicing safe abortion and quality of care, which are not yet included in the practice of performing abortions in the state-owned services; Low consciousness in favor of use of more contemporary contraceptives, excluding the condom and the existence of prejudice and stereotypes against their use;

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• •

Inexistence of policies and programs for increasing access to more contemporary contraception; Non-surgical or medication abortion is still unregistered in the country

General Objective: Guaranteeing the right of choice for women, providing access to safe and legal abortion and increasing the rate of contraception use Strategic Objective Strategic Objective 1 Provide strong public and political commitment for maintaining the right of choice of women to perform abortions, as well as accessibility to legal and safe abortion procedures

Main Strategic Interventions • Develop strong partnership with the civil society sector, particularly with those women’s organizations who are safe keepers of sexual and reproductive rights; • Lobby and advocate with the Government, among politicians, parliamentarians, in favor of continuing the recognition of the right of choice of women to perform abortions, as well as maintain access to abortion services; • Build capacities with volunteers and staff in the organization for advocating in favor of the right of having an abortion and countering the anti-abortion movement and conservative groups in the country • Achieving more visibility of the organization in the media and improving the cooperation and contacts with journalists;

Strategic Objectives 2 Improve access to high quality abortion services

• •

• • •

Advocate and lobby to achieve improved quality of safe abortion procedures within the framework of state-owned clinics; Develop and implement national protocols and standards for achieving safer abortion procedures and better quality of service in accordance with the recommendations of the World Health Organization in cooperation with the Ministry of Health, the UN agencies and responsible health institutions and clinics Advocate and lobby in favor of registration of non-surgical abortion in the country in cooperation with the Ministry of Health, the UN agencies and responsible health institutions and clinics; Provide support and better access to services for performing safe abortion for groups of lower-economic status and the marginalized; Improve knowledge and skills of the staff of HERA and service providers in terms of protocols and standards for practicing safe abortion Provide ongoing counseling before and after abortion procedures, as well as post-abortion contraception, for each client of HERA’s youth friendly services, especially for those lower income clients and marginalized

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groups. • Develop a referral system for performing abortion in state and privately owned gynecologic and obstetrics clinics Strategic Objective 3 Raise awareness among the general population and health professionals in terms of the benefits of increased use of modern contraception

• Promote the use of modern contraceptives among the general population, with a focus on the youth and those persons with lower income and the marginalized. • Familiarize health workers, especially gynecologists with more contemporary methods of contraception, including emergency contraception; • Enhance knowledge and skills of people on staff with the HERA, as well as service providers in terms of standards and protocols for use of modern contraceptives.

Strategic Objective 4 Increase access to affordable modern contraceptives

• Advocate and lobby in favor of inclusion of modern contraceptives in the Health Insurance Fun’s List of Refundable Medications and decreasing the regular price of such contraceptives • Establish a referral system among each of those service providers dealing with family planning in cooperation with the Ministry of Health and responsible institutions.

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HIV/AIDS The Republic of Macedonia is a country with low prevalence of HIV/AIDS. Since 1987, when the first HIV positive case was registered, and until the end of 2008, 111 HIV positive persons have been registered. Approximately 60 persons who lived with HIV/AIDS are already deceased. In 2008, 9 new cases have been registered out of whom 6 with AIDS and 3 HIV positive. Official statistics show that heterosexual intercourse is dominant manner of transmission of this infection. However during the course of the last few years an increasing trend of HIV transmission among men having sex with men has been recorded, and because of the stigma and discrimination such people avoid disclosure or hide themselves from official HIV/AIDS statistics. HERA’s Outreach Program for HIV Counseling and Testing is also a witness of this phenomenon, reporting 4 new HIV positive persons, of the group of men having sex with, who have not been included in the official statistics. During the last few years no new cases of HIV positive persons have been reported among the IV drug user population. The epidemiological outlook of the sexually transmitted infections in the country is incomplete and statistical data on the number of registered cases of STIs in the population is incorrect. For example in 2006, only 6 cases of Gohnoria, were reported countrywide, and 6 other of Syphilis. During the last 5-year period, a number of effective programs for prevention and treatment of HIV have been developed, owing to the grants of the Global Fund to Fight HIV/AIDS. The largest part of these activities are related to HIV prevention among the vulnerable and hard-to-reach groups, including outreach work with target groups, HIV counseling and testing, peer-education among the youth and training of health and social workers. The antiretroviral therapy and the therapies for opportunistic infections caused by HIV are fully covered by funds from the Global Fund. The Government and the Ministry of Health have expressed their intention to fully takeover the funding of antiretroviral therapy by 2010. The Ministry of Health within the framework of its preventive programs each year allocates funding for the National HIV/AIDS Prevention Program, in terms of conducting epidemiological surveys and monitoring; lab surveys, training for health professionals, as well as health education for the general population and most at risk groups living in the Republic of Macedonia. At present civil society organizations are not in a position to use any such funding provided by the Government for their HIV prevention efforts and the volume of direct preventive activities for the general population by the Government is also in decline because of the focus on the Global Fund project aimed at marginalized and most at risk groups prone to HIV infection. The Republic of Macedonia has 14 stationary centers for voluntary counseling and testing for HIV, throughout the country, integrated in the system of the National Health Protection Institute and its local branches. In addition to this the HERA in cooperation with the National Health Protection Institute together with a number of NGOs working with vulnerable and marginalized groups, are implementing an outreach program for HIV testing in a mobile ambulance vehicle, custom made for the target groups, aimed at achieving greater access to HIV testing for such groups. Presently this

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program is implemented only in Skopje. In addition to the access to HIV counseling and testing, evidently there is a lack of Monitoring and Evaluation of HIV testing and quality of service in the country, especially within state-owned health institutions in which such services is available. People living with HIV/AIDS are faced with stigma and discrimination, however because they feel intimidated they lack motivation and fail to exhaust legal means to challenge the denial of their rights. The HERA in its practice has reported of several cases of denial of rights for persons living with HIV, who have been discriminated against in their jobs and have experienced hindrance of access to health services. Furthermore it has been often the case the media itself to be involved in defying privacy and confidentiality laws in disclosing the identity of persons living with HIV. Tabloid sensationalist reporting about persons living with HIV is still present and it contributes the more to the intimidation of some citizens and widens the prejudice and stereotypes against such persons. Macedonia has no registered organizations or informal groups of people living with HIV who would act as safeguards and advocates of the rights and the interests of such a community or who would try to alleviate the stigma against persons living with HIV in the country.

Challenges • • • • • • •

Giving insufficient attention to HIV/STI prevention among the general youth and adolescents Civil society organizations are not in position to use funding from the National HIV/AIDS Prevention Program Insufficiently developed system of monitoring and evaluation in connection with HIV counseling and testing quality of service Provision of an ongoing antiretroviral therapy for persons living with HIV after the completion of the project funded by the Global Fund Stigma and discrimination against people living with HIV/AIDS Inexistence of organized action of persons living with HIV/AIDS who will safeguard and advocate in favor of the rights and interests of the HIV positive community Inadequate systems for recording STI cases in the country

General Objective: Maintaining low prevalence of HIV/AIDS and provision of full protection of the rights of the people infected with or suffering from HIV/AIDS. Strategic Objective Strategic Objective 1 Increase access to HIV/STI related preventive programs and activities with emphasis to the youth and all other vulnerable groups

Main Strategic Interventions • Extend preventive HIV/STI programs throughout the country, especially in semi-urban and rural areas. • Advocate and lobby in local communities for the raising of funds for implementing preventive activities by local civil society organizations • Build capacities of civil society organizations for performing HIV

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• •

• • •

testing, HIV prevention and human rights protection Enhance access and affordability of high quality condoms Improve inter-sectoral cooperation between civil society organizations and governmental agencies in an effort to implement HIV prevention programs (National Coordination Mechanism, National Inter-Sectoral Commission for HIV/AIDS) Improve access to HIV counseling and testing among the vulnerable and marginalized groups living out of Skopje Enhance quality assurance system for HIV counseling and testing, as well as monitoring and evaluation Enhance access to information and testing and STIs

Strategic Objective 2 Improve access and quality of services for persons living with HIV/AIDS

• Advocate for sustainable national system for provision of antiretroviral therapy (ARVT) and monitoring of ARVT • Enhance provision of palliative care and psychosocial support for persons living with HIV by having civil society organizations and social institutions take an active role.

Strategic Objective 3 • Strengthen capacities of persons living with HIV/AIDS in order to exercise and develop the enjoyment of their rights

Mobilize persons living with HIV/AIDS in order to achieve more organized advocacy for their rights Support the participation of persons living with HIV/AIDS in HIVrelated policy making; policy planning, implementation and monitoring

Strategic Objective 4 • Decrease stigma and discrimination against people living with HIV

Raise awareness with regard to the sensitivity of HIV/AIDS issues at all levels of public interest by various channels of action Advocate and lobby in the framework of the existing national legislation and the use of the legislation mechanisms in order to address and protect the human rights of the PLWHA and those who are vulnerable to HIV

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Adolescents and Youth Adolescents and the youth in general are not sufficiently informed about their sexual and reproductive rights. Adequate knowledge and skills for lobbying and advocating for their rights are neglected in young people. One of the reasons for this is shortage of developed and significant advocating for youth organizations and networks, as well as the fact that the HERA since its establishment was strategically orientated towards building capacities for the youth, however not in capacity of lobbyists for sexual and reproductive rights, as well as prevention and education. The educational activities in the area of sexual and reproductive health are primarily orientated towards HIV/STIs prevention and contraception, while the socio-cultural aspects relating to the sexual and reproductive health and rights of the youth have been largely neglected in the education process. The bulk of the topics relating to sexual and reproductive health are being delivered to that youth attending formal education and mostly by nongovernmental organizations and/or on initiative of some of the schools by project or curriculum activities. This is also indicative of lack of sexual education in the formal elementary and high school systems, as well as in the University syllabi in Macedonia. Numerous sexual education programs for the youth implement a peer-education syllabus as means of delivering STHR topics. Within the framework of the HIV/AIDS project funded by the Global Fund, capacities have been built within a number of civil society organizations for preventing the spread of HIV and for the enhancement of sexual and reproductive health among the youth, however many reports and surveys show the need of having a comprehensive strategy, implementing a multifaceted approach incorporating the peer-education model only as one of the segments of such strategy, enabling a more comprehensive and more permanent education and prevention. During the most recent period there are certain attempts to enhance the access to information relating to sexual education by organizing training for teachers and printing guidebooks. However such initiatives are only implemented as part of different projects in cooperation with Ministry of Education and the Education Development Bureau funded by the Global Fund for HIV/AIDS or other foreign donors, without a longer term vision which would be self sustainable. In the elementary school syllabus a nonobligatory subject of choice has been introduced entitled “Life-skills education” which includes some aspects of the sexual and reproductive health, although the effects of its implementation are not yet known, nor the manner of delivery of this subject. Generally speaking, the access to SRHR information and services for the youth is less available in the rural areas. According to some research the youth in the cities are well informed about HIV/AIDS and sexually transmitted infections even though (50% 2 of them) show interest to receive more information in terms of use of contraceptives, especially the more contemporary one, emergency contraception and dual protection. The rate of use of modern contraceptives (excluding condom use) is insignificant

2

International Centre for Reproductive Health (2005) Access of High School Students to Sexual and Reproductive Health Services in Four Capital Cities of Balkan , A Cross –Sectional Survey

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and only 1.6% of young girls aged 15 to 19 years has ever used oral contraceptives 3 . The issues relating to abortions among young women is a very sensitive one and many of them are not well informed which health facilities provide abortion services (only 29% of high school age girls in a Quantitative Survey for Assessing the Access to SRH in Skopje were familiar where abortions are performed) and about the legal possibilities of performing an abortion, as well as about the procedures of performing abortion and the right of making a choice of having an abortion. Most of the youth are sexually active and the largest part of them has steady relationship with one partner. Furthermore there is a shift in the age when the youth become sexually active and 10.5% of the respondents have stated that they have become sexually active before the age of 15, meaning that approximately 24,000 boys and 7,000 girls have started having sex before they turned 15. Because there is no complete and reliable state medical statistic and current data has not been tabulated according to age groups, the exact number of STI infected youth up to 25 years of age remains unknown. Nevertheless, according to some sources, estimates show that Macedonia possesses a trend of increasing STI occurrences among its youth, especially in terms of Chlamydia, Trichomonas and the Human Papilloma Virus. Out of 111 registered HIV positive cases, 19% are aged 20 to 29. The number of registered liveborn infants delivered by mothers younger than 15 years of age, during 2006 is 29 4 . Although there is a drop in the number of juvenile deliveries in Macedonia, it is still significantly high in comparison with the developed countries in Europe. The rate of performed abortions among the youth during the last several years is dropping, but this is mostly due to the fact that large number of youth, because they wish to stay anonymous, decides to perform their abortions in private clinics, which in the end remain unreported or unregistered with the responsible institutions.

Challenges • • • • • • •

Young people lack knowledge about sexuality and their sexual and reproductive rights; Improper information and skills for lobbying and advocating for sexual and reproductive rights and access to information and services; Lack of sexual education in the schools; Decreased access to information and services for the youth from rural areas; Less access to information and services relating to modern contraception, especially oral and emergency contraception and double protection; Sustainability of the network of peer-educators throughout the country Necessity to introduce new approaches and strategies in youth education and prevention program implementation;

3

International Centre for Reproductive health (2005) Access of High School Students to Sexual and Reproductive Health Services in Four Capital Cities of Balkan , A Cross –Sectional Survey 4 National Institute for Mother and Child Health Care (2006): Information on the health status of mother and children in the Republic of Macedonia, 2005;

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General Objective: All adolescents and the youth to become conscious about their sexual and reproductive rights in order to enable them to make free and informed choices and actively exercise SR rights Strategic Objective Strategic Objective 1 Increase access to comprehensive information about sexual and reproductive health and rights, as well as sexual education

Main Strategic Interventions • Increasing the volume and improve quality of peer-education for the youth within and outside the education system; • Identify, pilot, implement and evaluate innovative approaches and programs for providing adequate and comprehensive information about sexual and reproductive health and rights in accordance with different needs and diversity of the youth, especially in rural areas; • Advocate for development, evaluation and implementation of a syllabus for comprehensive gender-sensitive sexual education in schools • SRHR training of teachers in schools as well as other staff working with the youth; • Capacity building in terms of volunteers and staff, particularly among the youth, in order to provide and advocate for introduction of comprehensive, tolerant and gender-sensitive sexual education; • Development of education materials and text books for sexual and reproductive health and rights which will be tolerant, gendersensitive and appropriate to the age and needs of the youth; • SRHR Promotion and awareness raising among the youth with a focus of modern contraception, safe and legal abortion and sexual rights

Strategic Objective 2 Encourage young people to actively advocate for their sexual and reproductive rights

• Develop programs and training for support and recruitment of the youth in order to advocate and lobby in favor of youth sexual and reproductive rights; • Establishing partnership and networks with local civil society organizations, particularly youth organizations and state agencies in order to advocate for SRHR and enhance youth-related legislation and national programs ƒ Support HERA’s young volunteers in order to achieve more proactive participation in the development, implementation and evaluation of SRHR programs of the organization, as well as among the ranks of its executive bodies (e.g. Executive Board).

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ACCESS Until 2006 family planning activities have been implemented within health dispensaries that contained a counseling unit for family planning. The Health Dispensaries for Women were located in state-owned outpatient facilities in the cities and towns only. It is noteworthy that such family planning counseling services have ceased to exist after the implementation of the primary health service reform. Health care, family planning, counseling and prevention for women are now provided by family gynecologist. In rural areas where primary health care is provided by general medical practitioners (GPs) access to family planning services is even more difficult to come across. Since 2007, with the privatization of health care services for women, those measures for family planning which existed before, along with some other SRH services has been transferred to a polyvalent patronage service. The number of visits of the family planning counseling services has steadily declined during the last 10 years and with it the percentage of coverage of women. It has been assessed that family planning counseling coverage of women who are in their reproductive age is not fully conducted, and statistical data is missing in relation to such services provided by privately-owned gynecological practices. A possibility of subregistration also exists (improper or incomplete reporting on the part of health services). On the other hand there are no standardized protocols on family planning counseling, uniformity of knowledge in those who are responsible for performing such activities, nor any standards for respecting the rights of the client in terms of serving him/her with adequate evidence based information and according individual needs of patients. The inexistence of standardize protocols and inconsistencies with regard to the content of issued information, makes it impossible to conduct successful monitoring and evaluation of the effects resulting from this measure. According to the data collected in a 2007 survey conducted by the State Statistical Bureau only 9.8% of surveyed women in their reproductive period or mean aged 15 – 49, have ever used some form of modern contraception, in comparison with the current Western European rate of above 70%. One of the reasons for such low rates of use of modern contraception lies in the barriers which make access to modern contraception difficult, above all because of the inexistence of contraception regulation and programs and the fact that no type of contraceptive is part of the Health Insurance Fund’s Drug Refund List thus clients are forced into paying 100% of the price of each type of contraceptive. Also there is lack of emergency contraception on the market and prices a very high varying between 10 and 15 euros per doze. There is a weak interest for receipt of family planning counseling services in adolescents. According to statistical data only 1.6% of adolescent girls, younger than age 19, have been covered by some sort of family planning measures. Failure to make use of family planning services in the public health care centers (counseling offices) make us conclude that adolescents girls are not attracted to such services or such services are inappropriate for making use of them 5 . In the primary health care there are no 5

Strategic Assessment of policies, quality and access to contraception and abortion in the Republic of Macedonia, 2008, National Health Protection Institute.

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specialized or counseling services for protection of the sexual and reproductive health of adolescents and youth customized to the age and the gender. Girls 14 years of age have a right to choose their family gynecologist. Gynecologists working in the primary health care provide services for all the women in their reproductive period and there are no specialized services or centers intended exclusively for adolescent girls. In the country there are specialized services covering sexual and reproductive health issues, but they are located only in Skopje, intended only for young people 14 to 30 years of age, which is a good example for youth-friendly services which provide confidential services free of charge for the youth. The two youth centers are jointly organized and managed by the HERA and the Skopje Outreach Center. Although the centers are still funded by foreign donors and projects, they yet have to be included within the system of national health care programs of the Government and the Ministry of Health, in order to secure a self-sustainable future for them. Lower income groups, especially such Roma, as well as groups living in rural areas are social groups for which sexual and reproductive health services are not as accessible as are to other groups. Poverty, cultural and traditional beliefs are frequent issues that arise as causes for decreased access to such services. Stigma and discrimination against such groups practiced in health care services are also one of the reasons for hindered access to SRH services in marginalized groups, especially among sex workers, IV drug users and men having sex with men due to the fact that there are no specific or gender-sensitive programs and approaches which will be specifically oriented towards such groups. However this could not be said for HIV/AIDS programs because with the Global Fund Project specific approaches have been developed for HIV prevention and care among the vulnerable and marginalized. During the course of the previous two year period Macedonia has been facing a more and more conservative policy which is making access to SRH services more difficult. The Christian Orthodox Church has played a major opposition role to introduction of proper sexual and reproductive health policies and rights, as well as the Government with her demo-Christian platform. This is reflected in the introduction of a vigorous anti-abortion movement in Macedonia which struggles to abolish abortion rights by the use of nationalist and religious rhetoric condemning the right of choice of women to perform abortion and plotting to introduce limitations in the legislation for termination of pregnancy. The Government has also used its Ministry of the Interior to arrest sex workers and perform forceful HIV/STIs testing without their consent and to conduct procedures in which transmission of HIV/STIs are used as incriminating evidence.

Challenges • • •

Decreased access to SRH services, including family planning services, particularly in rural areas Reforms in the primary health care system and privatization of the state-owned health providers Inexistence of legislation, discounts, programs and standards for a widespread use of modern contraception which is a reason for a low rate of contraception use

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• •

Youth SRH services are not customized according to the needs of the youth and are not youthfriendly Gender barriers cause decreased access to SRH services which is strongly emphasized among Roma communities and marginalized groups such as sex workers, IV drug users and men having sex with men Stronger opposition towards SRHR

General Objective: All the people especially the youth and the vulnerable to have access to comprehensive and quality services, education and SRH services, including family planning based on sexual and reproductive rights; Strategic Objective Strategic objective 1 Decrease political, social and cultural barriers hindering access to information, education and services related to sexual and reproductive health and rights

Strategic Objective 2 Improve access and quality of information and SRH services, minding the needs of young people, those with lower socioeconomic status and marginalized communities

Main Strategic Interventions • Influence policy makers in support of SRHR and decrease barriers hindering access to information and services, especially among the youth, as well as the marginalized and Roma communities; • Advocate for introduction of policy and legislation changes which will enable the provision of high quality, financially affordable, tolerant and gender sensitive SRHR information and services • Promotion of sexual and reproductive rights • Strengthening existing and creating new partnerships among civil society organizations, informal groups, human rights activists, the media all with an aim of promoting sexual and reproductive rights • Improving knowledge among the volunteers and HERA’s staff in order to achieve better understanding of the political, social and cultural barriers which make access to information difficult, along with training and service provision related to SRHR and HIV, which in turn make the stigma and discrimination even more evident

• Development, implementation and evaluation of strategies and programs for the development of high quality, financially affordable, tolerant and gender-sensitive information services related to SRH, with a focus on rural areas, marginalized communities and persons with lowincome, including Roma communities • Program development and access to SRH services which will be easily reachable, customized to the needs of the youth and will be friendly orientated, as well as their promotion • Advocate for the improvement of SRH services within the framework of

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• • •

state agencies, customized to the needs of the youth and youth friendly and development of standards and protocols; Advocate for achieving greater sustainability of HERA’s youth centers and their incorporation in the state-owned health institutions programs and budgets Improve inclusion of young volunteers in the Youth Centers “Sakam da Znam” – I wish to Know; Developing innovative approaches, programs and advocating for the increase of access to services of the Youth Centers “Sakam da Znam” Establishing partnerships with civil society organizations and state institutions which work with marginalized and vulnerable groups

Strategic Objective 3 Strengthen the position of women in order to have them exercise their sexual and reproductive health rights and increasing responsibilities and inclusion of men in the field of sexual and reproductive health

• •

• •

Promote gender equality Develop approaches and programs to fight family and gender violence, particularly among different social and marginalized groups, including the Roma communities Partnerships with nongovernmental organizations working on issues connected with gender and family violence Provision of family and gender violence related services within the service centers of HERA and establishing high quality referral and follow-up systems Work with men in order to identify and appropriately address their needs related to their sexual and reproductive health

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Advocacy During its 10 years working in this line of business the HERA concentrated on the enhancement of SRHR in Macedonia at three levels; through action (provision of service), management (training delivery) and leadership (advocating). Nonetheless, in its activities it has rarely paid attention on inspecting the structure and processes of such action. This was especially true with regard to its leadership and advocacy activities for the application of SRHR principles in the country. While it made continuous efforts in terms of the former, and it achieved evident success, such as in advocating for introduction of a free-of charge HIV testing service, as well as setting this service on a voluntary and confidential basis throughout the country or its achievements resulting from the First Meeting with Members of the National Assembly entitled Lobbying in Parliament to Influence National HIV/AIDS Policy, the HERA lacked an organized approach towards recording and developing its strategies. Therefore it has reached a decision in its future activities, to pay significant attention to advocating since it is a key instrument to influence or change national policy and strategy in favor of achieving SRHR and thus, along with this section summarizing its advocacy action, it developed a separate document entitled HERA 2009 – 2011 Strategic Guidelines on Advocating for Achieving Better Sexual and Reproductive Health and Rights. If just a few years ago advocating for SRHR meant introducing and implementing new approaches through direct advocating for SRHR with state institutions, as well as influencing and making an ongoing effort to deal with state bureaucracy, today the situation is quite different. Namely the political situation in the country has changed. The ongoing turmoil of the country’s transition dictates introduction of values driven by the capital. At the same time the country is hit by a wave of imposed religious values originating from Eastern Europe influencing the secularity of society, as well as rightwing political parties which have an authoritarian approach. SRHR opposition groups are already organized and active for quite some time, using unconventional methods for changing public opinion. Such SRHR opposition groups are launching intimidating awareness campaigns, however never identifying themselves in public, using scaring approaches which should justify choosing life over abortion. Such points of view were briefly supported by official Government representatives and the church, triggering a procedure for amending the existing abortion legislation, as well as triggering an ensuing government awareness raising campaign promoting points of view which should eventually ban or limit the right of choice with regard to SRH. In addition to such shortcomings on the part of the Government, the HERA will have to pay significant attention to building its internal capacities in terms of advocating. Thus it must develop its own structure ready to respond to the increasing challenges in view of protection of the basic SRHR principles. In terms of this, the HERA will work on establishing a separate approach in connection with its relations with the public, as well as on establishing partnerships with the more liberal media outlets. Furthermore, HERA’s Executive Board and its volunteers must work on establishing contact with likeminded organizations or people in decision-making positions, i.e. HERA’s role in establishing a lobby group consisting of Members of Parliament or independent lobbyists or journalists is becoming more and more inevitable.

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With regard to abortion, the HERA will commit itself to maintaining the current legislation providing women with the right of making a choice on their termination of pregnancy, as well as with the opportunity of having access to safe abortion and modern contraceptives. With regard to HIV/AIDS, the HERA will advocate for the enhancement of preventive programs particularly for those aimed at the youth, along with access to quality health care and therapy administration services for people living with HIV/AIDS, as well as building capacities for such people to become independent actors to fight stigma and discrimination and enhance enjoyment of human rights. With regard to youth and adolescents issues, the HERA will advocate for the introduction of sexual education and access to quality SRH services, as well as build capacities for the youth and promote youth participation. The HERA will advocate for the provision of access to information, education and services related to SRH for all, especially for the young, women and marginalized groups.

Challenges • Decreased access to information, education and SRH services • Introduction of initiatives for limiting sexual and reproductive rights • Avoidance, i.e. no mention of sexual and reproductive health in national legislation, strategies and programs • Existence of weak and short-term civil society partnerships • Insufficient advocating capacity in civil society organizations • Strong SRH opposition and indifferent and adjustable public opinion • A few media outlets which are really aware of and promote a pro-choice approach related to SRHR General Objective: Commitment of all relevant factors in the country for achieving strong political, financial and public support for sexual and reproductive health and such proper rights Strategic objectives Strategic Objective 1

Main Strategic Interventions •

Strengthen identification and representation of SRHR and HIV/AIDS in national policy and legislation and provide enforcement of such

Improve SRHR information access by implementing national surveys and comparative analyses with such surveys conducted in neighboring countries Evidence-based advocating during the course of introduction of any amendments or development of national programs or laws by taking active participation in multi-sectoral bodies or commissions, public debates or media debates and directly advocate with the state

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SRHR and HIV/AIDS provisions

• • • •

administration Initiate and organize lobby groups staffed with Members of Parliament, intellectuals and media representatives Build capacities in media outlets Strengthen media activities and HERA’s visibility by the use of an ongoing campaign for promoting and protecting SRHR principles. Strengthen internal advocating capacities of the organization and develop a public relations strategy to achieve preparedness for possible response to activities by the SRHR opposition

Strategic Objective 2 • Strengthen the role of civil society organizations in terms of promotion and protection of human rights thus building their credibility

• •

Building capacities in civil society organizations throughout the country in terms of advocating for SRH as part of their human rights programs Extending partnerships by creating alliances including civil society organizations from different fields of activism, above all youth organizations, as well as women’s and human rights organizations Strengthening the already established partnerships by defining clear positions for activism Signing joint civil declarations in favor of protecting the right of making a free choice in relation to people’s SRHR and their distribution to responsible institutions During drafting of new legislation or programs, advocate for inclusion of rights of marginalized groups and their sexual and reproductive rights

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Strategic framework