Abstract
Decades of mismanagement, combined with the withdrawal of international cooperation and a protracted war, have seriously affected the health system in the Democratic Republic of Congo (DRC) and the health status of the population. As part of a Belgian development cooperation programme, we conducted a study in Kinshasa and Bukavu in April–May 2004 on how a rights-based approach could contribute to an effective and appropriate response to the sexual and reproductive health needs of Congolese adolescents. Access to condom information and supplies was studied in this context. A qualitative methodology was used, consisting of focus group discussions with adolescents and interviews with peer education programme officers. These programmes were supposed to be based on the recognition of adolescent sexual and reproductive health rights and the so-called ABC approach (abstinence, be faithful, condom use). We found, however, that sociocultural barriers and strict obedience to Vatican doctrine prevented adolescents from receiving accurate and comprehensive sexuality education and that condom supplies were blocked by peer education programme officers. The promotion of adolescent sexual and reproductive health rights is the responsibility of States, but the international community, non-governmental and faith-based organisations and donors play an essential role in assisting States in this respect and should never act in violation of adolescents’ rights.
Résumé
Des décennies de mauvaise gestion, s’ajoutant au retrait de la coopération internationale et à une guerre prolongée, ont miné le système de santé de la République démocratique du Congo et l’état sanitaire de la population. Dans le cadre d’un programme belge de coopération pour le développement, nous avons réalisé une étude à Kinshasa et Bukavu en avril-mai 2004. Il s’agissait de déterminer comment une approche fondée sur les droits pouvait répondre efficacement aux besoins de santé génésique des adolescents congolais. Dans ce contexte, nous avons évalué l’accès à l’information et aux préservatifs, avec une méthodologie qualitative utilisant des discussions par groupes avec des adolescents et des entretiens avec des responsables de programmes d’éducation par les pairs. Ces programmes étaient censés être fondés sur la reconnaissance des droits de santé génésique des adolescents et l’approche dite ABC (acronyme anglais : abstinence, fidélité et préservatifs). Nous avons néanmoins constaté que les obstacles socioculturels et la stricte obédience à la doctrine du Vatican empêchaient les adolescents de recevoir une éducation sexuelle exacte et complète et que les responsables des programmes d’éducation par les pairs bloquaient les préservatifs. Les États sont responsables de la promotion des droits de santé génésique des adolescents, mais la communauté internationale, les ONG, les organisations religieuses et les donateurs jouent un rôle essentiel pour assister les pays dans ce domaine et ne doivent jamais agir en violation des droits des adolescents.
Resumen
Décadas de mala administración, sumadas al retiro de la cooperación internacional y una guerra prolongada, han afectado marcadamente el sistema de salud de la República Democrática del Congo y el estado de salud de la población. Como parte de un programa belga de cooperación al desarrollo, realizamos un estudio en Kinshasa y Bukavu, en abril y mayo de 2004, sobre cómo un enfoque basado en derechos podría contribuir a una respuesta eficaz y apropiada a las necesidades de salud sexual y reproductiva de los adolescentes congoleses. En este contexto, se estudió el acceso a la información y los suministros de condones. Se utilizó una metodología cualitativa, que consistió en discusiones en grupos focales con adolescentes y entrevistas con funcionarios de los programas de educación entre pares. Se suponía que estos programas se basaran en el reconocimiento de los derechos de salud sexual y reproductiva de los adolescentes y en la estrategia conocida como ABC (abstinencia, fidelidad, uso del condón). No obstante, encontramos que las barreras socioculturales y la obediencia estricta a la doctrina del Vaticano impedían que los adolescentes recibieran educación sexual exacta e integral, y que los suministros de condones estaban bloqueados entre los funcionarios del programa de educación entre pares. La promoción de los derechos de salud sexual y reproductiva de los adolescentes es la responsabilidad del Estado, pero la comunidad internacional, las ONGs, las organizaciones religiosas y los donantes desempeñan un papel esencial para asistir a los Estados en esto y nunca deben violar los derechos de los adolescentes.
Decades of lack of investment and maintenance of public health services, combined with a massive withdrawal of multilateral and bilateral cooperation in 1992 and a war which lasted from 1996 to 2003, resulted in the collapse of the health system of the Democratic Republic of Congo (DRC), which was left solely in the hands of non-governmental organisations (NGOs), churches and private assistance.Citation1 Although national demographic and sexual and reproductive health data are not available, there are serious indications that the sexual and reproductive health status of the population of the DRC is among the worst in sub-Saharan Africa. In 2002, the maternal mortality ratio was estimated at 990 deaths per 100,000 live births,Citation2 and ratios as high as 3,000 per 100,000 were reported in war-affected areas such as in the Kivu in eastern DRC.Citation3 The adolescent fertility rate is also among the highest in the world, with 220 births per 1,000 women aged 15–19 years.Citation4 Adult HIV prevalence rate estimates are between 4.2% and 5.1%, with estimates of the number of people living with HIV ranging from 450,000 and 2,600,000.Citation5Citation6 Whereas in urban areas the HIV prevalence rate remained stable or even decreased during the war, prevalence rates among internally displaced populations increased significantly to 7.1%.Citation7
In 2004, the World Bank identified six priorities for the social reconstruction of the DRC, all of them directly or indirectly related to health. Curbing the spread of HIV and rehabilitating the health sector were at the top of the list. Vulnerable children, including street children, child soldiers and child sex workers, have been identified as key target groups.Citation8 The Ministry of Health identified reproductive health and the fight against HIV/AIDS as two priorities in its public health strategy. The National Reproductive Health Programme and the National Programme for the Fight against HIV/AIDS specifically target youth and insist upon the coordination of all activities and interventions between the different stakeholders involved.Citation9, Citation10 The DRC is now one of the priority countries for UNAIDS and the Global Fund to Prevent HIV, TB and Malaria. The National Reproductive Health Programme explicitly refers to the recommendations made at the 1994 International Conference on Population and Development in Cairo. A national reproductive health assessment in 2004 showed that the capacity of the DRC public health system needs to be reinforced at all levels and to be supported in a sustainable way by the international community in order to achieve the agreed sexual and reproductive health objectives.Citation11
As part of a Belgian development cooperation programme, we conducted a study in Kinshasa and Bukavu in April–May 2004 on how a rights-based approach could contribute to an effective and appropriate response to the sexual and reproductive health needs of Congolese adolescents. Access to condom information, education and supplies was studied in this broader policy context. A rights-based approach is based on the recognition of the right of adolescents to full and accurate sexuality information and education as a means to ensure that they “have the ability to acquire knowledge and skills to protect themselves and others as they begin to express their sexuality.”Citation12 Accurate and comprehensive sexuality education is necessary to achieving better sexual and reproductive health of adolescents.Citation13 A rights-based approach also implies that adolescents should have access to condoms to protect themselves from sexual and reproductive health risks such as HIV and unwanted pregnancy.Citation14
The organisation of the study in the DRC was facilitated by two local non-governmental organisations (NGOs) (one in Kinshasa, one in Bukavu) involved in sexual and reproductive health peer education programmes for adolescents. The organisation in Kinshasa had originated as a Catholic programme but it gradually began to profile itself as an ecumenical organisation. The one in Bukavu was run by the Catholic diocese. Both were associated with a nationwide network providing adolescent sexual and reproductive health education, which was coordinated by the organisation in Kinshasa. The mission statement of the network was explicitly based on the recognition of the sexual and reproductive health rights of adolescents. The network had a monopoly on the organisation of life skills education in schools and the training of teachers in this respect.
The NGO in Kinshasa was selected as a partner in the implementation of a programme of “Support for Reproductive Health and Gender Needs for Displaced Populations with Special Attention to Adolescents (2001–2004)” in the DRC, which was part of a multicountry programme supported by the Belgian Development Cooperation. This NGO was in charge of the sexuality education and HIV/AIDS peer education component of the programme. Both the Kinshasa and Bukavu NGOs also received support from mainly Catholic, Belgian NGOs.
The field study took place in April–May 2004 and was followed by a seminar to report the findings and discuss the results with the international agencies, NGOs and local authorities that had been involved in the study or were interested in it. The seminar was organised in Bukavu in November 2005 and was also actively attended by young peer educators.
This paper reports on the access of adolescents to condom information and supplies.
Methodology
Programmes run by local NGOs and supported by Belgian Development Cooperation in the area of sexual and reproductive health and child protection were selected for the assessment. The study was conducted in Kinshasa, the national capital, and Bukavu, the capital of the war-affected province of Sud-Kivu.
The methodology used consisted of 11 semi-structured focus group discussions with adolescents (four in Kinshasa, seven in Bukavu), and semi-structured interviews with programme officers of one sexual and reproductive health peer education programme in Kinshasa and one in Bukavu. We also made site visits to areas where street children gathered (three in Kinshasa, one in Bukavu) and had an exchange with a group of 34 adolescent peer educators in Bukavu. With both the street children and the peer educators the questionnaire used for the focus group discussions was also used, though not in a structured way.
The adolescents were selected for the focus groups by a person considered trustworthy by youth, either a teacher, the director of the training centre they were attending or one of the employees who visited them in their living or working environment. We asked these mentors to choose participants who were aged 13–16 and include both in-school and out-of-school adolescents. We aimed to have eight groups of 6–8 adolescents each, four with exclusively boys and four with exclusively girls. In the end, 11 focus group discussions were organised with a total of 117 adolescents (70 girls and 47 boys). Three of these groups were mixed boys and girls. All groups were either exclusively in-school or out-of-school adolescents. The number of participants per group was 6–12; one group had 26 participants. Four focus groups consisted of adolescents who were attending the peer education programmes. The composition of the focus groups, however, did not affect the sorts of responses reported. The focus group discussions were organised at a venue that also guaranteed privacy. The directors of the institutions where the focus group discussions took place had given their consent to the questionnaire that was used. Because the issue was considered to be sensitive, however, all focus group discussions were attended by one or more observers appointed by the respective institutions.
The focus group discussions and the interviews were conducted according to pre-established, semi-structured questionnaires. The questionnaire for the focus group discussions was an adaptation of the questionnaire used for the Health Assessment Mission commissioned by the UN High Commission for Refugees and the World Health Organization in the Bhutanese refugee camps in Nepal in 2003. This questionnaire was based on a set of tools developed by the US Centers for Disease Control for the Reproductive Health for Refugees Consortium, the Centre for Research on the Epidemiology of Disasters at the Catholic University of Louvain, Belgium, and a guide developed by the International Centre for Reproductive Health at Ghent University.Citation15 Citation16 Citation17 Citation18 The questionnaire was reviewed by the facilitating NGOs in Kinshasa and Bukavu, with particular attention to the cultural acceptability of the questions. The questionnaire was tested in a focus group discussion organised by the Ministry of Women and Family Affairs in Kinshasa. The focus group discussions were facilitated by experienced local peer educators. They were conducted in the local language (Lingala in Kinshasa and Swahili in Bukavu) and simultaneously translated into French to researcher/co-author Marleen Bosmans, who attended as an observer.
For the interviews with the programme officers a semi-structured questionnaire was developed on sexual and reproductive health policies and services for children and adolescents. The interviews were conducted in French by Bosmans. All focus group discussions and interviews were recorded. Notes were taken in French by local peer educators (one in Kinshasa and two in Bukavu) and by Bosmans. Afterwards the notes were compared and reconciled with the recordings.
All respondents gave their consent to participate. The adolescents in the focus group discussions were told they could choose not to answer or to leave the discussion whenever they felt like it, but everybody stayed.
The analysis of the focus group discussions and the interviews focused on the responsiveness of the programmes to adolescents’ sexual and reproductive health needs and their right to information, education and care.
Acceptability of the questionnaire
It was observed that the programme officers and trainers in the sexual and reproductive health peer education programmes did not always feel comfortable talking about adolescent sexuality. Those who reviewed the questionnaire for the focus group discussions in Kinshasa considered the questions too direct and suggested removing certain questions, particularly those about men/boys having sex with men/boys. Their argument was that in Congolese culture people are not used to talking about sexuality and that practices such as men/boys having sex with men/boys “did not exist in the DRC”. However, an exchange with a group of street boys in Kinshasa found that out of a group of 20 boys at least five had had sexual experiences with other boys, often forced. The existence of men/boys having sex with men/boys was also confirmed in the focus group discussions. Moreover, the reviewers in Bukavu fully approved the questionnaire which had also been pre-tested and positively approved by the adolescents as well as by those who attended the focus group discussion as observers.
The consensus was therefore to continue using the original questionnaire. None of the questions was removed, although the facilitators of the focus group discussions in Kinshasa sometimes tried to rephrase things and were at times asked by the researcher to respect the directness of the questions.
Throughout the study it was observed that on the whole, adults, including programme officers and trainers of trainers, felt uncomfortable talking about sex and sexuality. They never did talk about “sexual relationships” but always about “genital intercourse”. Sexuality education was taught as a “value”, “a vital force that impregnates each and every cell of our body”. They never used the words “sex” or “sexuality” and did not talk about “making love” either.
That sexuality was not talked about in a straightforward way with youth was confirmed in the evaluation of the focus group discussions, when many adolescents and peer educators said it was the first time that they had been able to talk openly and directly about sexuality. At the seminar organised to report the research results, most participants showed great curiosity and wanted to know more about sexuality and sexual behaviour. Questions regarding sexuality were never asked from the floor, however, but only in confidence during the breaks.
Adolescent focus group discussions and exchanges: key findings
In the focus groups discussions, we aimed to ascertain the extent of adolescents’ knowledge of and access to condoms in the context of being able to prevent unwanted pregnancy and sexually transmitted infections (STIs), including HIV.
When asked whether they knew boys and girls of their own age who had already had sexual relations without being married, the common answer was that there were many adolescents, including friends, who did not wait till marriage to have their first sexual experience and did not necessarily protect themselves.
“I know three girls who have had sexual relations very young and who already have little children… One of them died during childbirth.”
“For a soldier, there is no minimum age for having sexual relations. It does not matter whether he is big or little, he is a soldier and goes after the girls, that’s him… He can have a girlfriend at the age of 12, 13 or 14, it does not matter.”
“Out of ten boys or girls, at least seven or eight have had sexual relationships.”
The lack of protection affected girls in particular. If they got pregnant, they were supposed to stay home and raise the child. Although abortion is illegal in the DRC, it was often raised as a possibility to end unwanted pregnancy. To the question of what they would do if their girlfriend got pregnant, in most focus groups the response was that the girl would try to abort or would be urged to do so.
“If we don’t love her, we would ask her to get an abortion.”
“If one of our girlfriends gets pregnant, we always ask her to get an abortion.”
“If the means allow, the boy’s family can take the girl. If not, there is the possibility of running away, abortion or (the boy) denying the pregnancy [i.e. saying he is not the father].”
Adolescents’ knowledge about how to prevent unwanted pregnancy appeared to be poor and sometimes even completely wrong, as the answers of those who were keen to explain their understanding about the calendar method to the others, revealed:
“Yes, when a girl has her period, one should abstain from sexual relations.”
“Yes, I have two children, it is an experience, I know how you can get pregnant, particularly when you have sexual relations during ‘the bad periods’.”
In all focus group discussions, abstinence and fidelity were put forward as the main methods for preventing unwanted pregnancy. Fidelity was only understood within the context of marriage, however, and not considered to apply in relationships between boyfriends and girlfriends.
Many of the adolescents doubted the reliability of condoms and girls who would use a condom were considered to be “easy”.
“One should abstain from sexual relations, but easy girls they can use a condom.”
“Sexual abstinence or condom use [for protection], although the condom does not protect for 100% as it can tear.”
“Abstinence, condoms and if the girl does not want to have sexual relations, in any case, she cannot get pregnant.”
The adolescents not only doubted the effectiveness of condoms as a contraceptive method, but also as a means of protection against HIV. These doubts were widespread, including among the peer educators and adolescents who had received sexuality education. All groups of adolescents were asked if they knew how to prevent HIV infection. In six of the 11 groups, one of them with young peer educators, condom use was not mentioned as a method of protection against HIV. The respondents who mentioned condoms as a means of protection also warned that condoms did not fully protect.
“Some talk about condoms… but they do not protect 100%.”
“Use a condom but even when you use a condom you may get AIDS.”
“AIDS can pass through the condom and enter.”
“It can have little holes.”
Overall, these adolescents had no idea where condoms could be obtained for free. Only in one focus group was it mentioned that in some bars they had free condoms. Some considered that condoms were too expensive and that this was the reason “why they made their girlfriends pregnant”. Some felt too ashamed to buy condoms and others explained that “she is your girlfriend, so you trust her and you don’t use a condom.”
At a centre that received a free condom supply from international organisations, neither the boys nor the girls knew about the existence of free condoms at the centre. Why? The centre had decided not to distribute the condoms because “they did not want to encourage them to have sex”.
An exchange with street boys revealed that they knew perfectly well they should use a condom when having sex with a girl to prevent HIV, but they had not considered the use of a condom when engaging in sex with other boys.
“AIDS and (sexually transmitted) diseases, this is only between men and women. If it is between man and man there are no diseases.”
Interviews with programme officers: key findings
In the interviews with programme officers we tried to assess how the recognition of adolescents’ rights contributed to facilitating their access to condom information, education and supply. In both Kinshasa and Bukavu, the programme officers insisted that all adolescents were given information about condoms in their programmes. Both programmes also claimed that they used the so-called ABC approach (abstinence, be faithful, condom use).
In Kinshasa, the programme officers said this information was given “according to the doctrine of the Catholic Church”. What this actually meant was unclear, as their answers were rhetorical and evasive. We were also told that the adolescents were given information about modern contraceptives, but in fact family planning counselling for unmarried, non-pregnant girls was not provided. Information about condoms was mainly offered as a means of preventing HIV, rather than for contraceptive use. The programme officers in Kinshasa also avoided giving clear answers as to whether the programme provided free condom supplies.
In Bukavu, the programme officers explained that they emphasised the risks of condom use when they promoted abstinence and fidelity, which were the only methods to prevent HIV allowed by the Catholic Church. They pointed out that they could not promote the use of modern contraceptives either, for the same reason.
“As we are a structure of the Church, we insist on abstinence and fidelity in our strategies to combat AIDS but when we sensitise, we say that there is also the use of the condom and the risks of using condoms.”
“We promote the natural method for doing family planning… Moreover, this method is the one proposed by the Catholic Church because the artificial methods do not conform with the will of God.”
Support meeting for women who have been raped, South Kivu, DRC
It appeared that in Bukavu the “C” of “condom use” had been changed into the “C” of confiance (self-confidence) in the songs composed to raise awareness about AIDS. In the calendars used as material for the HIV prevention campaigns, the “C” was omitted altogether and only the “A” and “B” were there. People in town said that the T-shirts worn by the peer educators and the adolescents during HIV/AIDS awareness-raising activities only mentioned abstinence. One of the consequences of this approach was that the training of peer educators in Bukavu also emphasised the risks of using modern contraceptives. Nor were adolescents given full information even about the menstrual cycle on the ground that it might encourage sexual liberties.
“As we take abstinence as a basic value, we do not give unmarried girls clear information in order to avoid that they start behaving like married women… The information we give the children on this subject is correct but not complete, in order not to liberalise sexual relations… We cannot give them all the information, the whole truth concerning the [menstrual] cycle… We inform them about the whole cycle but not about how to determine [the safe period].”
In Bukavu, the decision not to supply condoms was said to be in line with the policy of the diocese. A discussion with the general director of the Health Department of the diocese, a Catholic sister who had senior responsibility for the peer education programme, revealed that she fiercely rejected the idea of supplying condoms, even to girls living on the street and surviving as sex workers. She did not consider condoms as a means of protecting them from unwanted pregnancies, HIV or other sexually transmitted infections, but rather as an encouragement to continue their way of life.
At the reportback seminar in November 2005, several programme officers pointed out that if the Catholic Church should decide to change its policy concerning condom use and modern contraceptives, they would certainly apply those changes in the peer education programme.
Discussion
Access of adolescents and children at risk, such as street children, to sexuality education and condom information and supplies should be looked at within the broader context of their sexual and reproductive health needs and rights. The promotion of condoms cannot be seen in isolation from the prevailing norms and values concerning adolescent sexuality, however. Taboos on adolescent sexuality were shown in this study to impede peer educators from addressing this issue in an open and non-judgmental way. Condom use was associated with promiscuity rather than seen as an act of responsible behaviour based on respect for the adolescent’s own well-being and that of his or her girlfriend or boyfriend. Sociocultural barriers to discussing sexuality and the promotion of condom use were reinforced by strict obedience to Vatican doctrine. Religion was used as the justification for reducing the “ABC” approach to an approach whereby abstinence was promoted among adolescents as the only responsible way of behaving.
In a context where the health system has collapsed, adolescent fertility is high, HIV prevalence is rising and adolescent sexual and reproductive health knowledge is poor, comprehensive sexuality education, accurate information about condoms and a free condom supply are essential to enable adolescents to make informed choices regarding their sexuality. Deliberately denying them this information is a violation of their right to protection and their right to health and life.
Under international law, States have the legal obligation to ensure a progressive realisation of the right to health, including sexual and reproductive health, and to remove all barriers that interfere with access to sexual and reproductive health services, education and information.Citation19 They also have the obligation “to take other measures ensuring equal access to health care and health-related services provided by third parties” and to ensure that “third parties do not limit people’s access to health-related information and services”.Citation20 International treaty bodies, however, also refer to the essential role of international development assistance in assisting States to take up these responsibilities.Citation21 NGOs, including faith-based organisations, have an equally vital role to play.Citation22
In a post-conflict setting like the DRC, where the government has been so weakened and where the implementation of the National Sexual and Reproductive Health Programme is highly dependent upon the active involvement of third parties, the role of NGOs and donors is crucial. However, the question is whether stakeholders who deliberately violate adolescents’ sexual and reproductive health rights can be permitted to have control of adolescent programmes precisely because they do not fully respect those rights.
Our findings might lead to the conclusion that Catholic organisations should not be allowed to be in charge of adolescent sexual and reproductive health programmes – and certainly not to have the monopoly on sexuality education in schools. However, because of what happened in the seminar in Bukavu, where we reported on our findings, we would argue differently. We found that it was strategically important to include Catholic organisations and thus encourage the internal debate on the approach taken. At the seminar, we were personally approached by several people, including Catholic sisters, trainers of trainers, medical doctors peer educators and the authorities, who testified that the study in Bukavu had been an eye-opener. They had started questioning the bans of the Catholic church on modern contraceptives and condom use and showed a genuine interest in the implications of a rights-based approach to issues such as abortion, sexual relationships before marriage, men having sex with men, masturbation and so on.
Whether or not condoms are promoted and provided to adolescents who need them, and the effectiveness of such condom promotion, depends in the DRC on bridging the gap between sociocultural and religious values regarding adolescent sexuality and adolescents’ own rights and needs. Donors, such as the Belgian government, who have recognised a rights-based approach to adolescent sexual and reproductive health and HIV/AIDS prevention as a priority in their development cooperation policy, have a particular responsibility, as the DRC is extremely dependent on external support for improving adolescent sexual and reproductive health. Providing complete and accurate information on sensitive matters such as sexual and reproductive health, free from religious norms and values, should be a minimum requirement and conditio sine qua non for receiving such support. Moreover, donors must actively engage in monitoring, supervision and evaluation of the programmes they fund in the field.
Acknowledgements
To all the women, men, girls and boys who kindly gave us their time and were actively involved in the organisation of the study, interviews and focus group discussions.
References
- M Van Herp, V Parqué, E Rackley. Mortality, violence and lack of access to health care in the Democratic Republic of Congo. Disasters. 27(2): 2003; 141–153.
- WHO. Reproductive Health Indicator Base. At: <www9.who.int/familyhealth/RHR/RHR_NavigateScreen.htm. >. Accessed 7 July 2005.
- WHO. DRC Country Emergency Profile. 09/08/2002. At: <www.who.int/disasters/repo/7942.doc. >. Accessed 30 August 2004.
- Population Reference Bureau Data Finder. At: <www.prb.org/datafind/prjprbdata/wcprbdata6.asp?DW=DR&SL=&SA=1. >. Accessed 7 July 2005.
- Ministère de la santé. Programme national de lutte contre le VIH/sida et les IST (PNLS). At: <www.minisanterdc/leministere/pnls.htm. >. Accessed 6 September 2005.
- UNAIDS/WHO. Epidemiological Fact Sheet on HIV/AIDS and Transmitted Infections. 2004 Update. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, Geneva, 2004. At: <www.unaids.org. >. Accessed 7 July 2005.
- C Mulanga, SE Bazepeo, JK Mwamba. Political and socioeconomic instability: how does it affect HIV? A case study in the Democratic Republic of Congo. AIDS. 18(5): 2004; 832–834.
- World Bank. Transitional support strategy for the DRC. Report No.2775. World Bank, 2004. At: <http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/03/09/000012009_20050309120753/Rendered/PDF/27751.pdf. >. Accessed 7 July 2005.
- Ministère de la santé. Programme national de santé de la reproduction (PNSR). At: <www.minisanterdc.cd/leministere/pnsr.htm. >. Accessed 7 July 2005.
- Ministère de la santé. Programme national de lutte contre le VIH/sida et les IST (PNLS). At: <www.minisanterdc/leministere/pnls.htm. >. Accessed 6 September 2005.
- JSI Research and Training Institute, Assessment of reproductive health in the DRC. Arlington, USA, 2002.
- United Nations. General Comment No.3 (2003). HIV/AIDS and the rights of the child. Thirty-second session 13–31 January 2003. CRC/GC/2003/3. 17 March 2003.
- S Susheela, A Bankole, V Woog. Evaluating the need for sex education in developing countries: sexual behaviour, knowledge of preventing sexually transmitted infections/HIV and unplanned pregnancy. Sex Education. 5(4): 2005; 307–331.
- OHCHR/UNAIDS. HIV/AIDS and Human Rights. International Guidelines. Second International Consultation on HIV/AIDS and Human Rights. Geneva, 23–25 September 1996. 1998; United Nations: Geneva.
- M Brennan, O Bilukha, M Bosmans. Refugee health in Nepal: Joint UNHCR-WHO evaluation of health and health programmes in Bhutanese refugee camps in Nepal. EPAU/2005/04. April. 2005; United Nations High Commissioner for Refugees-Evaluation and Policy Analysis Unit: Geneva.
- Reproductive Health for Refugees Consortium. Monitoring and Evaluation Tool Kit. Draft for Field Testing. RHR Consortium, February 2003 (CD-rom).
- Needs Assessment of Reproductive Health among Refugee Women. Preliminary Report. Centre for Research on the Epidemiology of Disasters, Department of Public Health, Catholic University of Louvain (Annex 1).
- Bosmans M, Temmerman M. Towards a Comprehensive Approach of Sexual and Reproductive Health Rights and Needs of Women Displaced by War and Armed Conflict. A Practical Guide for Programme Officers. De Consulterij – ICRH, Ghent, July 2003.
- CESCR. General Comment No. 14 (2000). The right to the highest attainable standard of health. E/C.12/2000/4. Twenty-second session. Geneva, 25 April – 12 May 2000 (Article 21;30).
- CESCR. General Comment No. 14 (2000). Op. cit. (Article 35).
- CESCR. General Comment 3. The nature of States parties obligations. Fifth session, 1990 (Article 13).
- United Nations. General Comment No. 3 (2003). HIV/AIDS and the rights of the child. Thirty-second session 13-31 January 2003. CRC/GC/2003/3. 17 March 2003 (Article 42).