FORCE Mali: Starting the conversation on sexual health

“What I often see now, after a teenager comes for an appointment, I really see their eyes shining. It’s satisfying for me because I can really give them advice, whether they are couples or teenagers or young women.” – Aminata Niangaly, a midwife in Mopti, Mali.

Just like in many countries, sex remains a taboo in Mali. There is little room in public to talk about the teen pregnancies, early marriages, and female genital mutilation that mar many young people’s lives. Mothers may discuss sex with their daughters, and fathers with their sons, but their knowledge is incomplete. Therefore, so is many young people’s understanding of their sexuality.

But change is underway. The Dutch government’s Orange Knowledge Programme, managed by Nuffic, created the materials for an educational programme to train Malian medical technicians, midwives and nurses in a new sexual and reproductive health curriculum. The project, known as FORCE, was initiated by organisations within Mali’s healthcare system and developed in collaboration with the Royal Tropical Institute (KIT). So far implemented in five health schools (two public, three private) in the cities of Mopti, Koutiala and Sikasso, it will eventually be used by all eighty-five health schools in Mali. It is the first such update to the curriculum since 1998, and the first time Mali’s public and private health schools have collaborated in this way.

The FORCE institutional collaboration project has so far been implemented in public and private health schools in Mopti, Koutiala and Sikasso, with more to follow.

In the beginning, it was a shock,” says Professor Bokary Landoure, director of the Amadou Gar-ba Koita health school in Mopti. “It was disturbing, speaking about was really a shock.” Like anyone who has grown up in Mali, the students at Professor Landoure’s school felt the weight of the taboo around sex and sexual health. But quickly, he says, they got used to it, and the atmosphere in the room began to change.

This is the power of the FORCE project. The practical information it provides on issues like early pregnancy or female genital mutilation is much-needed, but the real change comes from the fact that clinicians are being made to confront and discuss sex and reproduction. Gaps are being opened in the wall of silence. Before, a 17-year-old girl who came to a health technician, nurse or midwife pregnant but unmarried would be questioned, judged. “Today,” says Professor Landoure, “these are no longer the questions we ask, because we say to ourselves, ‘she has the right to conceive’. We are not there to judge them. Our mission is rather to accompany them with useful information.”

Armed with new attitudes, the clinicians who have so far benefitted from the new FORCE curriculum are creating a new dynamic in Malian healthcare, one where young patients who ask for help are made to feel accepted, safe. For the first time, they are having truly positive experiences discussing their sexuality with their nurse or midwife, which makes it far more likely that they’ll come back again.

It’s a timely development. A deeply religious country, Mali’s powerful Muslim and Christian leaders are ideologically driven to suppress public conversations around sex and reproductive rights. And where the truth is kept out, rumour rushes in. Dr. Sidi Yaya Ba, ophthalmologist and president of the Association of Private Health Schools, points out the ease with which young people, with no formal sexual health education, turn to the internet and social media to answer the questions they inevitably have. “Many young men believe a woman cannot get pregnant or they cannot get a sexually transmitted disease after having intercourse just once. This is because they don’t have the right information.” But when they do have the right information, thinks Dr. Ba, “that can change everything.” Fewer early pregnancies lead to fewer problems at birth. Fewer STDs leads to a healthier population. Women will be empowered, socially and economically. People will be happier. Nor are these benefits only for the young. “As parents, if our children have fewer problems, we will have a better life.”

What then will it take to make this vision of Mali’s future a reality? The progress made by FORCE is significant, but reaches only as far as Mali’s fractured healthcare system; the impact so far is limited to wherever the newly trained clinicians work, and many Malians live far beyond their reach. But even with investment in the healthcare system, in supplies and infrastructure and the training of more personnel, the aversion of Mali’s religious leaders remains an obstacle. If the conversation around sexual health is to extend nationwide, it is they, Mali’s cultural gatekeepers, who must be convinced.

But perhaps Mali’s religious leaders are not as averse to dialogue as some perceive. In February 2020, during the last regional meeting of the Orange Knowledge Programme for the Sahel region, Nuffic’s Joseph Junior Seh witnessed a coming together of religious leaders and medical doctors: “seeing the willingness of a male religious and traditional chief to have a conversation with a female doctor was a sign of hope.”

A religious leader and medical doctors meet - February 2020.

Nor is responsiveness amongst the religious leadership to issues around sexual health unprecedented, having previously allowed their opinions to evolve in response to the emergence of AIDS. Why couldn’t other problems related to sexual health compel them in the same way? And if it’s abstinence that religious leaders want to preach, Dr. Ba would argue that “the best way for a girl or a boy to abstain is to know the consequences of their acts.”

Whatever the opening argument from advocates for change, all agree that care must be taken. Dr. Ousmane Sylla, a public health doctor specialising in sexual and reproductive health, sizes up the challenge: “It is not on the first try that we will change habits that have existed for millennia. The evolution of habits and customs is progressive on some issues. We must be careful on other questions, and go slowly.”

Dr. Sylla’s caution is understandable. Feedback from those who have overseen and benefitted from the FORCE project – administrators, teachers, students, patients – has been positive, and there is optimism. But changing deep-lying social norms requires patience and skill. It is a long battle, and continued collaboration with Dutch institutions and the Orange Knowledge Programme are vital for success. For now, Dr. Sylla is preparing for the conversations Mali is yet to have: “We should not fool ourselves. We must have as allies the religious, the traditionalists, which means we should prepare ourselves so that we won’t be surprised by any question [they might have], and so that we know everything there is to know related to sexual and reproductive health.” For Dr. Sylla, as for his colleagues, a respect for knowledge is the key to progress, but a respect for culture is the key to success.

For now, everyone involved in the FORCE project can be proud to have contributed to a fundamental shift in the way the Malian health system works. Public and private health schools have built a template for cooperation that will last long after the programme officially ends; indeed, on 9th December, the Minister for Education is set to validate the FORCE sexual and reproductive health curriculum for use in all of Mali’s public and private health schools. And whilst the pro-gramme is driving change in Mali, it has also been of great benefit to the Dutch partners: “We have learnt a lot about how to develop partnerships with private and public health schools,” says Prisca Zwanikken, Senior Advisor at KIT. The lessons learnt in Mali will resonate far beyond, informing the teaching on sexual and reproductive health and rights that KIT works to deliver all around the world.