Men have been sidelined from sexual and reproductive health services for decades. Is it time for them to take a more active role?
Shah Jalal moved to the capital from the southern coastal district of Jhalakati after completing his primary schooling. He now sells vegetables at Malibagh Bazaar in Dhaka. Jalal who is 33, and his wife Farzana, 28, are typical of many Bangladeshi families in which contraception is left largely to women.
"I once used condom bought by my wife from a health NGO visitor but – um – didn't feel comfortable, and I left contraception to her," he says, "She asked me to go with her to the clinic only when it was a major matter of implanting the stick-like object."
The 'stick-like object', is the Norplant birth control device, devised in Finland, which is inserted under a woman's skin, typically in the arm, to provide long-term though not permanent contraception. Women have been the deliberate targets of four decades of attempts to cut the population of the world's most crowded country. While contraception has been a key element, sterilising the woman in the couple was the main thrust.
Lately the country has broadened its focus on reproductive health, away from an emphasis on cutting family size to an emphasis on sexual and reproductive health, including raising awareness of sexually transmitted infections like HIV and AIDS. A significant slot on the state-run radio and television is devoted to reproductive health advice through expert lectures and dramatic presentations.
Bangladesh has already adopted the strategy of involving more men in reproductive healthcare in line with worldwide recommendations established at UN health and population conferences, "but failed to achieve the desired results", said Jalaluddin Ahmed, who works on reproductive health issues as director of the South-South campaign.
The almost exclusive focus on women's fertility has meant that men have continued to be sidelined by sexual and reproductive health services. Statistics show that only 5.4 per cent of males in Bangladesh adopt even the traditional methods of contraception under the old-model family planning programme, such as the use of condoms and vasectomy.
Akhter Ali, a rickshaw driver on Dhaka's jammed streets, gives his blunt view of family planning. "I've never taken my wife to a doctor or family planning centre. Why should I? Allah gives the mouths and Allah feeds them," says Akhter who comes from the north-eastern district of Sherpur. In good health at 35, Akhter, who has one son, does not see the need to adopt family planning methods.
Targeting women to cut population numbers has proven effective. But stopping the spread of sexually transmitted infections needs the participation of both sexes, men's involvement being key. In Bangladesh, the majority of men do not know about the symptoms, transmission and prevention of reproductory tract infections and sexually transmitted diseases.
Extensive research by government agencies and non-governmental organisations has diagnosed the reasons why men are reluctant to engage with reproductive health services. These include social stigma, religious taboos, and economic worries in the male-dominated society. "Vasectomy was equated with castration by the common folk, and feared," said Shamsul Hoque, Advocacy Programme Officer at the reproductive health charity Marie Stopes. He put the vasectomy rate at just 0.6 per cent.
According to the 2004 demographic and health survey, around 80 per cent of men could not name sexually transmitted infections, while 50 per cent of married men had not heard of HIV or AIDS. Bangladesh has an estimated 13,000 cases according to UNAIDS and is considered to have the virus under control, but health providers would agree there is little room for complacency.
Many men in Bangladesh associate condoms with promiscuity, and believe they will be judged as irresponsible for buying them. Professor M Golam Rahman of Dhaka University, who has researched the effectiveness of communication campaigns, says most young men are reluctant to get condoms from female health and family planning assistants. "Especially the young and adolescents won't buy one from an elderly seller, lest he should think ill of him or her, suspecting adultery", says the Professor.
In rural areas, reproductive services do not cater to the needs of most men and they lack access to decent quality health care. One project which attempted to improve the quality of services for men and to increase the number of men going for sexual health check-ups showed promising initial results.
The Frontiers Project, collaboration between the government and donors, undertook a pilot scheme in 2003 to integrate men into family planning centres. The project, funded by the US Agency for International Development (USAID), first carried out test studies at eight rural Health and Family Welfare Centres (HFWCs) in Dhaka district.
All the centres had originally been conceived as woman-focused services, staffed by one paramedic and two female health assistants. The pilot study involved publicising the services in the community, and training health providers to recognise the symptoms of sexually transmitted infections. They also carried out group discussions with men, as well as community and religious leaders.
At the end of the project, researchers discovered that not only did the numbers of men attending and being examined for STIs increase, but so did the number of women. Furthermore, more than 90 per cent of the female clients said they would not mind receiving services under the same roof as a man.
Encouraged by the success of the pilot project the Ministry of Health and Family Welfare had planned to scale up activities from eight HWFCs to 40, but these plans failed to take off because there was difficulty in getting medicine to all the centres.
Dr Ubaidur Rob, Country Director of the International Population Council, says initial work is still being undertaken in the 40 selected centres, but he adds, "The funding allocation is not adequate for going forward." He believes it might be possible to pool enough funds from donors to introduce integrated health services for both men and women, provided the right policy decisions are in place. Given that there are 3,477 Health and Family Welfare Centres countrywide, there is still a long way to go.