Nurses at Aberdeen Women’s Centre with a fistula patient © UNFPA

In practice

Eradicating obstetric fistula in Sierra Leone: Iceland’s transformative partnership with UNFPA

Key messages

Obstetric fistula, a neglected health condition, is heavily affecting women’s and girls’ health, rights and empowerment in Sierra Leone. Iceland’s support to a transformative intervention by the UNFPA and the Ministry of Health and Sanitation aims to eradicate fistula by 2030. The comprehensive approach covers prevention and surgical treatment, whilst promoting social reintegration and addressing gender and social norms.

KeywordsGender equality, Poverty and inequality, Partnerships

Key partnersIceland, Multilateral institution

Last updated13 March 2023

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Sierra Leone has one of the highest lifetime risks of pregnancy-related mortality and morbidity, including obstetric fistula. Affecting the most vulnerable women and girls, the condition leaves them incontinent, often leading to chronic medical problems, depression, social isolation and poverty. As fistula is almost entirely preventable, eradicating it in Sierra Leone requires a comprehensive and transformative approach that addresses and eliminates its root causes. As a small donor, Iceland was seeking ways to strengthen its impact on gender equality and women’s empowerment and to target some structural causes of gender inequality in Sierra Leone.


Iceland has been a long-standing supporter of both the Government of Sierra Leone and the United Nations Population Fund’s (UNFPA) Global Campaign to End Fistula, which aims to improve access to quality maternal health services to prevent and manage obstetric fistula. Building on its successful co-operation with the UNFPA, and recommendation from a 2021 evaluation to strengthen cross-sectoral linkages across education, health, and gender at the country level, Iceland signed a five-year, USD 7 million project agreement in 2022 to scale up its support for the elimination of fistula in Sierra Leone – a country where Iceland is expanding its bilateral co-operation. The integrated fistula elimination project, in partnership with UNFPA and the Ministry of Health and Sanitation, was officially launched in May 2022. The six pillars of the project are:

  1. 1.

    Informing adolescent girls and women, and key community actors, on sexual and reproductive health and rights (SRHR) for preventing obstetric fistula.

  2. 2.

    Identifying obstetric fistula survivors and linking them to care.

  3. 3.

    Providing rehabilitation and social reintegration services to survivors before and after surgery.

  4. 4.

    Strengthening the capacity of targeted referral hospitals to provide fistula and other gynecological surgeries as part of their routine reproductive, maternal, newborn, child and adolescent health (RMNCAH) services package.

  5. 5.

    Strengthening targeted health facilities to provide quality preventative RMNCAH services.

  6. 6.

    Setting up a knowledge management system to bolster the obstetric fistula programme in the country.

The project involves:

  • A national taskforce to provide leadership, technical guidance, and programme co-ordination.

  • Reliance on multiple partners, both within the government and civil society organisations (CSOs), such as the Haikal Foundation and Aberdeen Women’s Centre, which support the project by conducting community mobilisation and providing medical care.

  • A results-based approach to use evidence from the programme to inform the modelling and development of tools with the aim to maximise efficiency.


During the first year of the project, an initial resource mapping identified support-structures within communities. Outreach efforts involve a variety of approaches, including radio jingles in local languages, radio discussion sessions and public events.

Initial results in 2022 include:

  • Policy engagement. A National Fistula Strategy is being drafted. Strategic activities have been integrated into the work plans of key ministries and CSOs, and obstetric fistula is now a key focus area in the revised National Reproductive, Maternal, New-born, Child, and Adolescent Health and Nutrition strategy. A multi-stakeholder Fistula Taskforce was established to oversee the national fistula programme, consisting of the Ministry of Health and Sanitation and other key line ministries, CSOs, academia, and professional associations.

  • Prevention. Awareness information has reached 360 women and girls, and 120 fistula ambassadors and champions from all 16 districts have been trained in prevention, identifying fistula and referring those affected for care.

  • Medical care and social reintegration. 104 women and girls have been screened for obstetric fistula, 42 women living with obstetric fistula have undergone fistula repair surgery with a 100% success rate, and 54 obstetric fistula survivors have undergone rehabilitation and social reintegration.

  • Capacity building. Training efforts reached 78 health care providers and 38 providers of emergency obstetrics and new-born care.

Lessons learnt

  • Starting with a small grant in 2020 gave Iceland the confidence to substantially scale-up support to end fistula. Iceland was already working in Sierra Leone and looking to establish bilateral co-operation in district-level fishing communities. Investing in a national programme through a multilateral partner was a logical step for a small bilateral donor like Iceland.

  • Tackling some structural causes of gender inequality through a transformative approach can achieve systematic and long-lasting impact on the status of gender equality.

  • Comprehensively addressing health system challenges while promoting social reintegration and economic empowerment of women and girls through training can remove social and cultural barriers to gender equality and help to change power relations and economic, gender and other social norms.

  • Prevention and increasing access to treatment are important for tackling obstetric fistula. As part of its prevention measures the project focuses strongly on addressing gaps in knowledge among adolescent girls, women and men on the causes and consequences of obstetric fistula. It also seeks to improve patient identification and referral mechanisms to enable more women and girls to access quality fistula management services, including by identifying support structures within communities.

  • Government leadership and multi-stakeholder collaboration are key to the success of the programme. Collaborating with government officials across ministries and at the district level, as well as with healthcare providers, district officials and multilateral partners, strengthens the programme’s capacity to reach different communities, and to integrate measures to eradicate fistula into national strategies and plans.

Further information

UNFPA (2023), Obstetric Fistula in Sierra Leone,

UNFPA (2022), UNFPA News, “Fistula survivors recognized in a ceremony to celebrate their reintegration into communities”, 9 December 2022,

UNFPA (2021), Annual Report 2021 – Delivering on the transformative agenda,

UNFPA Sierra Leone (2020), “Addressing obstetric fistula in Sierra Leone” (video),

OECD resources

OECD (2023), OECD Development Co-operation Peer Reviews: Iceland 2023, OECD Development Co-operation Peer Reviews, OECD Publishing, Paris,

OECD, “Guidance on gender equality and the empowerment of women and girls”, Development Co-operation Fundamentals

To learn more about Iceland’s development co-operation see:

OECD, "Iceland", in Development Co-operation Profiles,

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