Access to care services

Introduction

The international community has emphasised the importance of a multisectoral approach to tackle female genital mutilation (FGM/C). Female genital mutilation/cutting (FGM/C) is a global health issue. More than 200 million girls and women in 30 countries in Africa, Asia and the Middle East have undergone the practice, and more than 3.6 million girls are annually at risk. The impact of FGM/C is spreading further through migration to other parts of the world including Europe, the USA, Australia and Canada. Hence policies are needed to address this issue in both countries of origin and countries of migration.

FGM/C encompasses all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons, and is most commonly performed on minors. Type IV includes all other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterization.

Methods

A mixed methods approach was employed to map the involvement of the health sector in the management of FGM/C both in countries where FGM/C is a traditional practice, and countries where FGM/C is practiced mainly by migrant populations.

Data was collected in 2016 using a pilot-tested questionnaire from 30 countries (11 countries of origin and 19 countries of migration). The key elements identified were: Training of Health Care Proffessionals (HCP), involving HCP in the preventive work, legal regulations on HCP duties to avert and report as well as to perform FGM/C, and the availability of healthcare services.

These elements were grouped in three categories: 1) training and duties of HCP, 2) performing FGM/C by HCP, and 3) availability of health services. Eleven respondents representing 11 countries of origin returned filled questionnaires. Supportive documents were provided for only two countries (Iran and the Gambia).

Results

A total of 24 countries had a policy on FGM/C, of which had assigned coordination bodies and had partially or fully implemented the plans. Systematic training of healthcare providers (HCP) was more prevalent in countries of origin, whereas involvement of HCP in the prevention of FGM/C was more prevalent in countries of migration.

National health policies and their implementation 24 out of 30 countries had a policy on FGM/C in the form of a national plan of action or national or professional guidelines. These policies were fully or partially implemented in 20 countries and not implemented in four (Gambia, Somaliland, Spain and Sweden).

Discussion

National policies on FGM/C can signify governmental commitment to the prevention and provision of care for those at risk of FGM/C and those who have been subjected to FGM/C, and might be triggered by the ratification of certain legally binding policy documents, such as the Maputo Protocol or the Istanbul Convention.

In particular, provide a platform and structure for long-term and systematic work on FGM/C whereby different sectors can collaborate effectively. To enable monitoring and evaluation, and accountability, distribution of responsibilities, targets and outcome indicators should be clearly stated.

Significant efforts have been made in securing that both countries of origin and countries of migration have such policies in place. Twenty-four of the participating countries in this study reported to have a national policy on FGM/C, of which 19 countries had clear distribution of responsibilities (See the table below).

13 countries did not allocate funding for their plans and only few established systems for monitoring and evaluation. The extent of involvement of the health sector in these plans varied considerably across the participating countries

Conclusion

The authors’ study findings indicate that substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. There is a need for countries of origin and countries of migration to incorporate systems for monitoring and evaluation into their plans of action.

The authors have identified five areas for improvement in the involvement of the health sector in the management of FGM/C: First there is a need to strengthen systematic training of HCP, particularly in countries of migration. Secondly, the role of HCP in averting and reporting FGM/C is unclear and inconsistent. There is therefore a need for studies that can evaluate and compare the different practices in different countries. It is also an ethical dilemma that HCP have a duty to avert and report in 19 and 16 countries respectively, but have a duty to provide relevant health education in only eight of these countries of which none are countries of origin. Thirdly, a stronger emphasis on the role of HCP in the provision of health education is needed everywhere but mainly in countries of origin. Further, provision of psychological and sexual counselling services with competency on FGM/C is lacking in 82% of the countries of origin and 42% of the countries of migration, and should be prioritized. Finally, routines and guidelines should be put in place to ensure the availability of FGM/C codes, particularly in countries of origin, and their systematic use in medical records in all countries.