Keneya Ciwara: Supporting Family Planning In Mali

"In Bamanankan, Mali's lingua franca, 'Keneya' means 'health' and 'Ciwara' is an antelope mask used in celebratory masked dances. The Ciwara has become Mali's symbol of national pride and identity and, above all, courage."

From the paper series Voices from the Village: Improving Lives through CARE's Sexual and Reproductive Health Programs, this 12-page report highlights a communication-centred family planning programme implemented in Mali. The case study describes Keneya Ciwara, an initiative carried out in the economically poor and remote commune of Kendie, located in the heart of Mali's Dogon country (named after the area's principal ethnic group). The goal is to increase the availability and demand for quality health services at the community level while improving essential health practices in the household.

"Taken together, the region's extreme poverty, high child mortality, low levels of education and cultural emphasis on large families make family planning a tough sell." The greatest challenge, however, is reported to be overcoming men's opposition to contraceptives - which is based on a number of misconceptions, including the myth that contraceptive use makes women sterile. It is such challenge that motivated the project's implementation by a consortium composed of Cooperative for Assistance and Relief Everywhere, Inc. (CARE), the Johns Hopkins University/Center for Communication Programs (JHU/CCP), IntraHealth International, and the Groupe Pivot/Santé Population (GP/SP) - with support from the United States Agency for International Development (USAID).

As detailed here, during its first phase (2003-2008), the Keneya Ciwara programme focused on actively involving members of the community in contraceptive distribution, and it also worked to improve immunisation, control of malaria and diarrhoeal diseases, nutrition, and reproductive health. The second phase of began in October 2008 and will last 3 years, eventually covering every health district in the country.

Keneya Ciwara revolves around a system of volunteer outreach workers ("relais") that seeks to raise awareness about family planning and other health issues among community members who lack access to local health centres. After prospective outreach workers are chosen by their village committees, they receive 7 days of training, followed by a certificate and recognition by the community ("an important step toward gaining the trust and respect of the people they aim to serve"). In the Kendie health district, there are 18 outreach workers assigned to serve 7 area villages.

Another crucial component of the programme is Musow Ka Jigiya Ton (MJTs, or Women's Savings Clubs). Because they are designed to provide women with an opportunity to improve their financial security as well as a source of funds to help ensure their reproductive health, the name given to this approach in Bamanankan is tonofla, meaning "a two-fold purpose". Each MJT selects members who are trained by the programme to be community health agents. These agents then provide basic health information and peer counselling; for example, they talk with other women about how to better communicate with their husbands about family planning. Like the outreach workers, each health agent is given an initial stock of contraceptive products that she can sell to generate income, which she then contributes to a communal fund. This money can finance the purchase of more family planning products and also fund women's visits to the community health centre, where they can procure other contraceptives, such as injectables, when needed. Members can also borrow money from the fund to start their own small enterprises. During the first phase of Keneya Ciwara, the leaders of more than 300 MJTs throughout Mali were trained; in addition, the groups received 1,000 boxes of contraceptives to sell in their respective communities. As of May 2007, there were about 560 women participating in 20 MJTs across 7 villages in the Kendie health district. In the first phase of the programme, they were able to mobilise more than US$18,000 in credit and carry out 188 awareness-raising sessions on health and family planning, which involved nearly 4,000 local women.

Results:

At the 2004 baseline survey of Keneya Ciwara, 75.9% of women of reproductive age (WRA) in Bandiagara Cercle knew a modern method of contraception. At mid-term (2006), that number had increased to 84.6%, and at the final evaluation, that percentage rose to 84.9%. Furthermore, the final evaluation showed that the contraceptive prevalence rate (CPR) was 13.5% for women in MJTs, versus 6.1% for those not in a group. MJT membership rose considerably during the first phase of the programme, from 25.6% to 45.2%.

There was a nearly threefold increase in contraceptive use in Bandiagara Cercle during the first phase of the programme; by comparison, the CPR in the entire Mopti region, which includes Bandiagara Cercle, was only 2% in 2006 (less than half that of the rate in Bandiagara Cercle). Furthermore, "the use of injectables in Kendie began to rise steadily in 2006, indicating that MJT community health agents and local outreach workers were referring increasing numbers of women to the health center for injectables. At the same time there is a decrease in the use of pills. This is likely due to the fact that women were purchasing them from the MJT community health agents and outreach workers."

CARE's Dr. Nouhoum Koita, deputy chief of party of Keneya Ciwara, commented: "If such good results can be achieved among the Dogon population of Bandiagara, who are from a very rural, conservative setting, then this reflects the efforts of the outreach workers, the women's groups and, especially, the goodwill of the villagers."

According to this document, "[t]he clear message emerging from Keneya Ciwara is that women's groups can help significantly increase rates of family planning. The groups offer women economic independence from men, allowing them to support one another in the face of opposition from their husbands. This dynamic system needs to be increasingly capitalized on through the recruitment of more female outreach workers and through the creation of more women's associations throughout the Keneya Ciwara program. Keneya Ciwara will also strive to increase the number of women trained as outreach workers....An important next step in the program is thus to emphasize, particularly to men, that there are economic advantages to using family planning. Women's groups can help open up dialogue on this subject by giving women the support and negotiating skills to improve spousal communication."