Like so many around the globe, I have spent recent weeks cheering on athletes at the 2016 Olympics in Rio de Janeiro. These athletes are real-life superheroes. Take Simone Biles, who has won the most Olympic and world championship medals ever won by an American gymnast—simply amazing. Watching the Olympics, I am inspired by and in awe of the dedication and effort needed to succeed—not just by the athlete but also all the people who helped make that success happen, including family, coaches, doctors and therapists, fans, and so many more. It is that same collective commitment by many working toward a shared goal that achieves results, no matter what the industry or field.
It is in this spirit of collective effort by a village of actors that I am very pleased to share key results from the Expand Family Planning (ExpandFP) project in Tanzania. Led by EngenderHealth, the ExpandFP project ensures clients’ full, free, and informed choice of contraceptive method while expanding the availability and use of long-acting reversible contraceptives (LARCs)—i.e., hormonal implants and intrauterine devices (IUDs). Funded by the Bill & Melinda Gates Foundation, ExpandFP is part of the global FP2020 effort to provide contraception to an additional 120 million women and girls in the world’s poorest countries by 2020. The project focused on:
In addition to strengthening local capacity to expand the basket of choices/method mix (LARCs and permanent methods), ExpandFP also reached clients in diverse settings, including routine services at core facilities, mobile outreach services, and special days dedicated to FP.
Based on this comprehensive approach, ExpandFP significantly increased contraceptive uptake in its six participating districts during the project. Specifically, 160,378 clients voluntarily chose a contraceptive method between January 2014 and September 2015 (on average, approximately 23,000 clients per quarter), compared with 25,138 clients in the preintervention baseline period between January and December 2013 (on average, approximately 6,300 clients per quarter).
In terms of location, ExpandFP learned that mobile outreach services reached 57% of total clients, with the remaining 39% served via routine daily services and 4% during special FP days, which shows the value of offering diverse settings for women to access contraception.
Although a majority of clients received contraception at mobile outreach events, ExpandFP also worked to sustainably upgrade routine FP services at the static health care sites. Client loads for routine services at the 21 supported facilities increased from around 6,200 clients per quarter during the baseline period to just about 9,000 clients during the intervention, representing a 44% increase in clients served per quarter.
Improvements in method mix were also striking: The proportion of FP clients choosing LARCs increased more than six-fold, from 10% (implant, 8.4%; IUD, 1.6%) during the baseline period to 62% (implant, 49.5%; IUD, 12.9%) in the intervention period. A sizable increase in adoption of female sterilization was also seen, from fewer than 1% of clients to 12%.
In summary, ExpandFP dramatically improved the contraceptive options available and the ways in which they could be accessed, thereby increasing contraceptive uptake. The results in Tanzania demonstrate that there are many facets to ensuring that FP services are designed, implemented, and monitored in a way that protects women’s rights and puts their needs, desires, and preferences at the center. It truly does take a village to achieve success, and it is vital to ensure that these positive gains continue and expand across the country.
To download the full ExpandFP Tanzania brief please click here:
For more information on the ExpandFP Project, visit:
When I think about how far the global family planning (FP) community has come since the first International Conference on Family Planning (ICFP) in 2009, I am amazed by the progress to date. Like many of my colleagues in the field, we have seen significant momentum since FP2020 and increased resources toward improving women’s access to FP.
Equally critical to achieving the FP2020 goal of reaching 120 million new FP users, however, is how efforts are undertaken. That is why EngenderHealth, along with its partners, has taken deliberate steps toward ensuring that FP services are designed, implemented, and monitored in a way that protects women’s rights and puts their needs, desires, and preferences at the center.
To achieve a vision of client-centered care, FP programs must offer contraceptive choice, which still remains elusive in many settings. This is especially the case in poor contexts with limited and/or no access to long-acting reversible contraceptives (LARCs) and/or permanent methods. Fortunately, as a result of FP2020, donors and pharmaceutical companies launched the Implant Access Program (IAP), which guarantees a 50% reduction in the prices of Jadelle®, Implanon®, and Implanon NXT® through 2018.*
The reduction in cost for contraceptive implants—a previously less-accessible yet highly effective FP option—was a major step toward making this method more available and affordable in low-resource settings. It helped paved the way to initiate a new project—Expand Family Planning, or ExpandFP—which aims to increase access to and use of FP, with a focus on hormonal implants and in a context of voluntarism and informed choice. Led by EngenderHealth with support from the Bill & Melinda Gates Foundation, the project is building the capacity of public-sector FP systems to offer hormonal implants in Tanzania, Uganda, and the Democratic Republic of the Congo (DRC)—countries with high unmet need for FP.
Since 2013, ExpandFP, in partnership with ministries of health, has made measurable contributions toward supporting FP2020 goals, benefiting from the IAP price reductions, and expanding FP options. For example, the project has seen an extraordinary shift in method mix in project-supported services, most notably for implants.
In addition to providing technical assistance, EngenderHealth undertook a study to assess client perceptions of quality and choice in FP service delivery as part of ExpandFP. Study highlights show:
The experiences in Tanzania, Uganda, and the DRC demonstrate that global commitments coupled with local actions can achieve positive results. There is much to build on in terms of progress—and there must be continued investment by governments and donors to achieve sustainability, for the health and well-being of women and families today and for generations to come.
If you are attending ICFP, visit us on Tuesday, January 26, 10 am–1:20 pm, for the poster presentation “Putting choice and rights at the center: Results from a family planning client survey in the Democratic Republic of the Congo, Tanzania, and Uganda.” If you cannot join us at ICFP, visit https://www.engenderhealth.org/our-work/major-projects/EXPAND-FP_Brief_3-countries.pdf for more information about interim results from the ExpandFP project.
*Bayer and RHSC (Reproductive Health Supplies Coalition) recently announced an extension of the low prices for implants until 2023.
How can stakeholders ensure that family planning programs are designed, implemented, and monitored in a way that respects, protects, and fulfills human rights and puts clients’ needs and preferences at the forefront?
With a renewed global commitment to family planning (FP) among donors and governments worldwide, momentum is growing to support practical ways to infuse a human rights approach into voluntary FP programs. In support of these efforts, EngenderHealth recently published Checkpoints for Choice: An Orientation and Resource Package, a new publication (also available in French) that offers practical guidance on how program planners and managers, policymakers, donors, service providers, community leaders, to strengthen clients’ ability to make full, free, and informed contraceptive choices within a rights-based context.
The package provides a detailed plan for a one-day workshop (including all supporting materials) to help FP stakeholders:
This tool builds upon, complements, and advances the groundbreaking work undertaken by EngenderHealth and the Futures Group on the Voluntary Rights-Based Family Planning Conceptual Framework and its accompanying User’s Guide—a planning tool organized around the holistic framework. Checkpoints for Choice serves as an introduction to the rights and choice-related concepts that undergird the framework which are critical to understanding the framework itself and applying the User’s Guide.
“Our intention with Checkpoints was to make human rights concepts—often viewed as abstract and difficult to operationalize—more readily accessible and applicable to actual program implementers,” explained Holly Connor, Asia Program Portfolio Specialist with EngenderHealth and one of the publication’s authors. “Especially those working at the country level to plan and manage projects and provide family planning services.”
“Since the 2012 London Summit on Family Planning, considerable progress has been made, especially under the FP2020 initiative, to advance a human rights-based, client-centered approach to family planning programs worldwide,” affirmed Dr. Yetnayet Demissie Asfaw, Vice President of Strategy and Impact for EngenderHealth during a rights-based FP workshop organized in partnership with the Population Council. “While more certainly remains to be done, Checkpoints for Choice fills a critical gap in making rights a reality for women and couples in countries with some of the highest unmet need for family planning.”
To read more EngenderHealth publications on rights-based FP, informed and voluntary decision-making, and quality of care, click here.
Guest post by Banchiamlack Dessalegn, Ph.D., Senior Technical Advisor for Monitoring, Evaluation and Research, Family Health International 360 (FHI 360), Addis Ababa Ethiopia
Knowledge and awareness of available family planning (FP) methods, as well as of their benefits and side effects, is a prerequisite for informed decision making (Bongaarts et al., 2012). Behavior change communication (BCC) is a tool for increasing knowledge and awareness. In this way, BCC can be seen as critical to facilitating successful voluntary, choice-based FP.
The Government of Ethiopia aims to increase the modern contraceptive prevalence rate (mCPR) to 55% by 2020, as stated in Ethiopia’s new Health Sector Transformation Plan. To achieve this, the Federal Ministry of Health (FMOH) is putting emphasis on improving the FP method mix, including by increasing demand for and access to long-acting and permanent methods of FP (LA/PMs) without compromising informed and free choice. While target-setting at the national and subnational levels might lead to the erosion of choice-based FP services, the FMOH has given clear direction that services must be based on proper counseling and free choice. As a result of the concerted efforts and results-oriented policies of the FMOH, impressive achievements have been made in recent years, with the mCPR increasing from 28.6% in 2011 to 41.8% in 2014 and the total fertility rate dropping from 4.8 to 4.1 lifetime births per woman during the same period (CSA [Ethiopia] & ICF International, 2012; CSA [Ethiopia], 2014).
Guest post by Heather Barclay, International Planned Parenthood Federation
Comprehensive sexuality education (CSE) has been the focus of much discussion and political debate over the years. It has been lauded as the way for young people to be empowered and realize their rights, as well as a means through which to create demand for family planning and sexual health services. But as with many highly politicized debates, the truth lies somewhere in the middle.
A hallmark of CSE is its rights-based approach to education about sexuality, gender, sexual and reproductive health, and sexual behavior. It equips young people with life skills and empowers them to make autonomous, informed decisions about their bodies and futures. That means teaching young people comprehensively both about the biology of sex and about the personal, emotional, societal, and cultural forces that shape the way in which they choose to conduct their lives, including their sexual and reproductive lives. In particular, CSE imparts information, promotes responsibility, and equips youth to question why they act in certain ways, so that they can make informed and considered decisions that allow them to have healthy and empowered lives.
by Sara Malakoff, Senior Program Associate, EngenderHealth
Female sterilization is the world’s most popular contraceptive method with more than 220 million users. Sterilization is convenient for women who desire to limit childbearing, as it requires no further visits to a health care provider. In addition, it does not have the side effects that contribute to the discontinuation of user dependent methods, such as hormonal contraception. However, access to both male and female sterilization varies significantly geographically, is limited in many parts of the world (particularly in rural areas), and has not increased at a pace comparable to that of the unmet need to limit childbearing.
In an attempt to address issues of full contraceptive choice and to ensure the availability of and access to a wide range of contraceptives, including permanent methods, Marie Stopes International (MSI) and EngenderHealth under the auspices of the Support for International Family Planning Organizations (SIFPO) project funded by USAID, convened a two-day technical symposium in Nairobi in March 2014 entitled Provision of Permanent Methods of Contraception in Low-Resource Settings. A dynamic group of over 40 participants from 27 organizations and 13 countries attended the event.
Guest post by Christina Wegs, Senior Advisor for Global Policy and Advocacy, CARE
December 10th was International Human Rights Day. This day commemorates the adoption of the Universal Declaration of Human Rights (UDHR) by the UN General Assembly in 1948, which affirmed the rights of all people, everywhere and all the time. The Declaration, as well as similar international treaties and agreements, confirm the centrality and importance of protecting and fulfilling sexual and reproductive rights (SRR). Embraced within the concept of SRR is the right to reproductive self-determination; the right to sexual and reproductive health (SRH) information, education, and services; the right to the highest attainable standard of health; and the right to equality and non-discrimination.
Despite international recognition of the importance of SRR, sixty years on and twenty years after the International Conference on Population and Development, women and girls in every part of the world continue to face considerable barriers to realizing their SRR. In many places, unmarried women and adolescents are denied access to reproductive health information and services, many women are not able to exercise full, free, and informed contraceptive choice, and women continue to die from preventable complications of pregnancy and childbirth. Pervasive gender inequality limits women’s decision-making autonomy and undermines their health and well-being throughout their lives. Finally, many women—especially poor and socially marginalized women—continue to experience systemic discrimination in health care, which not only results in poor quality of care and poor health outcomes, but also acts as a powerful disincentive to women seeking care.
In global health, nobody has an easy job, but ensuring voluntary and safe permanent contraception is among the toughest. Everything has to go right so that nothing goes wrong.
The latest disturbing news coming from Chhattisgarh, India, reminds us that despite being 20 years post-ICPD, we global health professionals have more to do to ensure reproductive rights, choice, and quality of care. And as the story goes—as it has too many times before—the devastating consequences are borne by mostly poor, rural women. It’s unconscionable.
Although the Chhattisgarh situation is under investigation by the Government of India, we know that quality of care was compromised at all levels. This includes the conditions under which the surgical sterilizations were performed, the high number of surgeries in a given period, the questionable quality of the medications, the implicit targets set by local authorities, and financial incentives. In many ways, there isn’t a simple answer to what happened–there were a series of systemic, programmatic and clinical failures. Many organizations, including EngenderHealth, have called for a greater need to ensure and protect human rights, reproductive rights and clients’ rights; and to address informed and voluntary decision making, counseling, client safety and service quality.
But how does this translate into action? What must go right so that nothing goes wrong?
EngenderHealth’s commitment to getting everything right, beginning with our work in voluntary permanent methods decades ago, has led to the development of standards used throughout the field for informed consent, clinical safety, infection prevention, and other aspects of quality service delivery. These have also been applied to broader family planning and reproductive health issues. What we’ve learned is that investments must take place at all levels – beginning with a fundamental recognition that individuals have a basic right to full and appropriate information about their reproductive health choices and that they are able to make decisions without coercion, pressure, or inducements. For EngenderHealth, it’s about achieving a vision of client-centered care and all that is meant by this term.
For example, in India it would mean expanding the contraceptive method mix in the public sector, ensuring quality, and working to advocate for a focus to be on client’s choices rather than achieving targets. Right now, it’s mostly sterilization services, intrauterine devices (IUDs), condoms and pills—a situation which limits choice for women and others, including unmarried adolescents. We also see a greater need for training so that service providers are equipped with skills to provide voluntary, safe and quality services and can monitor quality, rights and choice for continuous quality improvement. These are examples of the kinds of concrete actions that must be undertaken as part of a broader comprehensive strategy rooted in a rights-based approach.
The incident in Chhattisgarh is a sobering reminder of what can happen when family planning services are not designed, implemented, or monitored in a way that protects and fulfills individual's human rights. We urge the Ministry of Health and state governments to take decisive action to develop practical approaches for infusing a rights-based approach, with quality of care as one of the top priorities and with women’s needs, desires, and preferences at the center. To do otherwise would simply maintain the status quo.
EngenderHealth and its partners have developed two new publications to assist diverse audiences, including donors, policymakers, program planners and managers, service providers, rights advocates, and community members, in their efforts to achieve rights-based family planning programs.
The first publication is the Voluntary Rights-based Family Planning Conceptual Framework User’s Guide, a practical resource to help stakeholders design, implement, and monitor family planning programs that respect, protect, and fulfill human rights. Coauthored with the Futures Group, with support from the Bill & Melinda Gates Foundation, the guide is a companion to the recent publication of Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework, which took long-standing family planning concepts, such as quality of care, voluntarism, and service access and linked them with human rights principles, such as empowerment, equity, nondiscrimination, and accountability. The Framework provides a holistic vision of what a rights-based family planning program looks like; the User’s Guide provides a pathway to applying the framework in actual practice.
EngenderHealth also developed Checkpoints for Choice: An Orientation and Resource Package, which takes a closer look at the concept of voluntarism—one component of a rights-based approach—and helps stakeholders understand the clients’ experience and their ability to make full, free, and informed choices about family planning.The tool, developed with support from the William and Flora Hewlett Foundation and the United States Agency for International Development, consists of a detailed plan with all support materials for a one-day workshop to enable family planning program planners and managers to strengthen the focus of family planning programs on clients’ ability to make full, free, and informed contraceptive choices in the context of a rights-based program. In addition to the workshop guidance and materials, the package includes links to recommended references, tools, and additional reading.
Worldwide, women choose injectable contraceptives because they are safe, reliable, and discreet. In many rural or remote areas, however, travelling to a clinic to receive an injection is costly and burdensome. PATH, an international nonprofit health organization, is collaborating with global partners to address this challenge. We began with a basic question: What would it take to deliver more injectable options to women, particularly outside the clinic setting?
One answer is Sayana® Press: a small, easy-to-use injectable contraceptive that has the potential to increase access and choice for millions of women worldwide.
“You’ve done remarkably well!” Those were the admiring words of an incredulous high-level United Nations (UN) official, when a colleague and I met him a few weeks ago to discuss the outcome of the Open Working Group (OWG) of the General Assembly on the Sustainable Development Goals (SDGs). “We,” of course, are the women’s groups (organized as the Women’s Major Group) who've fought long and hard to ensure that a standalone goal on gender equality would feature in the SDGs proposed by the OWG. The inclusion of gender equity was not a given, but it was achieved.
We had also pressed governments to ensure that sexual and reproductive health and rights (SRHR) would be included as targets under both the gender goal (SDG 5) and the goal on health (SDG 3). We came away with a significant, if partial result: Under SDG 3, governments agreed, by 2030, to “ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes” (target 3.7). Under SDG 5, they also agreed to “ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the ICPD and the Beijing Platform for Action and the outcome documents of their review conferences” (target 5.6).
Governments also agreed to “eliminate all harmful practices, such as child, early and forced marriage and female genital mutilations” (target 5.3). Other important targets included to eliminate all forms of violence against all women and girls (target 5.2), reduce the global maternal mortality ratio to less than 70 per 100,000 live births (3.1), end the epidemics of AIDS, tuberculosis, and malaria (3.3) and achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines (3.8). Compared to the Millennium Development Goals, the proposed SDGs represent significant progress, addressing critical areas for action that, if implemented, will transform the lives of women and girls globally. They also put the lie to claims that “we could never get today the agreements we obtained in the 1990s.” We have in fact gone beyond them.
What now? The General Assembly will begin its final negotiations on the final post-2015 development agenda early next year, for adoption in September 2015. Governments from the global South have clearly indicated that they expect the outcome of the OWG to be the basis for negotiation, and would not tolerate attempts by the Secretary General’s staff to “streamline” its 17 goals and 169 targets. That is good news for SRHR, because these targets were the most thoroughly debated and negotiated in the OWG. What emerged on SRHR from the OWG certainly represents global consensus, despite objections from a handful of opponents led by the Holy See and Saudi Arabia.
The OWG document can and should be improved upon. Human rights, the rule of law, and access to justice were not sufficiently established as key aspects of development. As noted by several governments last month at the UN General Assembly’s first ever panel discussion on child marriage, preventing child, early, and forced marriage should be its own target since it has multiple, far-reaching causes and consequences. “Sexual rights” (i.e., the right of everyone to have control over matters related to their sexuality, free of coercion, discrimination, and violence) were omitted from the SDGs, despite having been agreed to by governments at Rio+20 and recent ICPD Beyond 2014 reviews in Africa, Asia-Pacific, and Latin America and the Caribbean. Non-discrimination on the basis of sexual orientation and gender identity, which the UN Human Rights Council has just again denounced, should be included. Finally, adolescents and their right to sexual and reproductive health services and information, including comprehensive sexuality education, must be addressed if the post-2015 agenda is to be relevant for the 2.4 billion children under the age of 19 alive today.
The freedom to determine what happens to our own bodies and to make decisions about sexuality, relationships, and childbearing are fundamental facets of our lives. By investing in and promoting these rights, governments can unleash the power of women and girls and transform societies.