When Everything Must Go Right So Nothing Goes Wrong

By Pamela Barnes, President & CEO, EngenderHealth

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.

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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.

Uganda Prioritizes Voluntary Family Planning and Charts Course for a Rights-Based Approach

Blog post by Jan Kumar, EngenderHealth/RESPOND Project

The planets have aligned in Uganda over the past few weeks for a significant shift in the country’s national family planning (FP) program that sets it on a new and ground-breaking course. From July 28-30, 2014, the Ugandan Ministry of Health (MOH)—with support from the United Nations Population Fund (UNFPA)—hosted an event titled “Accelerating social and economic transformation through universal access to voluntary family planning.” President Museveni used this opportunity to accelerate the government’s commitment to FP2020 and to voice his endorsement for FP as a means to improve maternal health, reduce poverty, and support social and economic development. The meeting paved the way for the promotion of equitable access to a wide range of quality FP services that ensure full, free, and informed choice, as well as the protection and fulfillment of human rights for all Ugandan women and couples who wish to space or limit their childbearing.

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The Leaking Bucket Phenomenon in Family Planning

Guest post by Anrudh K. Jain, Ph.D., Distinguished Scholar, The Population Council

Family planning (FP) programs in developing countries have been experiencing a phenomenon that I like to call “the leaking bucket.” Let’s say that you place a bucket under an open tap and watch the water level rise, until you discover a hole in the bottom of the bucket. Water is now leaking out of the bucket. Filling the bucket will be easier once the hole is plugged. In the same way, meeting women’s desire to reduce unwanted fertility will become easier once FP programs pay more attention to contraceptive discontinuation.

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Can 223 million women be wrong? A reflection on the status of voluntary sterilization programs

Guest post by Lynn Bakamjian

Tanzanian couple receiving family planning counselling (Photo credit: Sala Lewis)

Tanzanian couple receiving family planning counselling (Photo credit: Sala Lewis)

Today, as family planning (FP) programs are receiving renewed attention and resources as a result of FP2020, several important issues have risen to the top of the investment agenda. These include increasing access to quality long-acting reversible contraceptive (LARC) methods; task-shifting FP information and services to lower level health workers to address provider shortages; and scaling- up approaches that extend services, such as postpartum FP , mobile services, and increased engagement of the private sector. As programs strive to make more contraceptive choices available to reach more than 200 million women with an unmet need for FP, there is one topic that receives little attention—how to expand access, availability, acceptability and quality of permanent methods (PMs) (voluntary female sterilization and vasectomy). Continue reading

Meeting the Reproductive Needs and Rights of Women and Girls: The Legacy of ICPD is in the Details

Guest post by Mary Beth Hastings, Vice President of Center for Health and Gender Equity (CHANGE)

The task of translating the International Conference on Population and Development’s (ICPD) Programme of Action (PoA) into meaningful change for women and girls globally includes some important detail work. Several years ago, my organization – the Center for Health and Gender Equity (CHANGE) – set out to better define the meaning of key PoA terms. Our guiding question was: “What constitutes comprehensive, rights-based sexual and reproductive health (SRH) care?” We found some useful literature and human rights documents to point us in the right direction, but most importantly, we wanted to make sure our answer was grounded in the lived experiences of women and girls.

Field research in Bahir Dar, Ethiopia. Photo by M.B. Hastings/CHANGE

Community-based health workers in Bahir Dar, Ethiopia met with CHANGE to share their comprehensive approach to sexual and reproductive health and rights. Photo by S. Sippel/CHANGE

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Getting Real on Rights: Experience from Two Country Consultations on Applying a Rights-Based Approach to Family Planning Programming

Guest post by Shannon Harris

Given the many challenges that countries face in providing family planning (FP) services, how can a client-centered, rights-based approach to programming help governments meet their obligations to respect, protect, and fulfill clients’ rights to meet their reproductive needs and desires? This question framed two recent country consultations in India and Kenya to explore the feasibility and desirability of applying the voluntary, rights-based FP (VRBFP) conceptual framework. Were country-level FP stakeholders—program managers, policymakers, and providers—even interested in such an approach?

With funding from the Bill & Melinda Gates Foundation, the Futures Group and EngenderHealth partnered with the Population Foundation of India and the National Council for Population and Development in Kenya to host national and regional stakeholder consultations, as well as conduct FP site visits to explore these questions. Despite diverse cultural, policy and program environments, stakeholders in both countries expressed tremendous interest in using a rights-based approach. Stakeholders found the program vision described in the VRBFP framework appealing and relevant to their programs because of its emphasis on the individuals and communities served by the FP program, while simultaneously acknowledging the importance of the policy environment and supply-side factors.

Photo by H. Connor/EngenderHealth

Members of the Futures Group/EngenderHealth rights framework team visit a community motivator in India’s Bihar State to identify the realities and challenges related to protecting and fulfilling human rights in FP at the community level—specifically to identify the conditions and practices that either uphold or violate human rights. (Photo by H. Connor/EngenderHealth)

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Keeping Complexity in a Human Rights–Based Approach to Family Planning: Is It Worth It?

Submitted by Shannon Harris, on behalf of the team led by Futures Group and EngenderHealth that developed the Voluntary, Rights-Based Family Planning Framework

Human rights–based family planning (FP) programming—what does it mean? Where do you start to translate it into practice? How comprehensive do you need to be? It is easy to become daunted by a long list of inputs and activities, such as those listed in the voluntary, rights-based family planning framework developed by a team led by Futures Group and EngenderHealth. The recent 2020 Vision newsletter refers to the overwhelming nature of existing guidance documents for ensuring that FP programs are rights-based and offers a simplified starting point. But will simplification of a complex set of challenges lead to the transformation in FP programming that our field needs?

We welcome the dialogue started by Population Action International (PAI) about how to move forward to protect and fulfill human rights within FP programs. This conversation is needed; multiple voices and views add richness to the discussion. PAI suggests starting with three priorities: voluntarism, informed choice, and achieving a diverse method mix. Certainly, we have to start somewhere, and these three elements are essential to rights-based FP— programs must be vigilant in preventing instances of coercion and in ensuring full, free, and informed contraceptive choice.

However, these program elements are not sufficient to ensure equitable access to services for all nor to ensure that the services are of high quality. They also do not address community factors that impede access to and use of FP. And they do not address the issue of accountability. These are critical considerations for reaching and fulfilling the human rights of the 220 million women with an unmet need for FP.

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Walking Together: Strengthening Health Facility and Community Links to Improve Access and Choice

Guest post by Molly Tumusiime, Program Associate (Community Engagement), EngenderHealth/Uganda

The Right to Health asserts that people are entitled to access reproductive health services, including family planning (FP), that are acceptable to them and of the highest possible quality. However, there are many barriers to individuals’ realizing this right at many levels. While policy change and provider training can support increased FP access and use and better ensure contraceptive choice, interventions at the policy and service delivery levels alone are insufficient. Community-level barriers also impede service utilization and should be addressed in participatory and cooperative ways.

In 2010, EngenderHealth began piloting site walk-throughs (SWTs) in Bangladesh, Ethiopia, Ghana, Tanzania, and Uganda. This promising approach—rooted in the core human rights principles of participation, empowerment, and accountability—catalyzes community participation in health and strengthens the accountability of service providers to communities. In addition, SWTs foster linkages and collaborative partnerships between health providers and community members in addressing barriers to informed choice and service access and in improving the quality and acceptability of services.

Photos by E. Brazier/EngenderHealth

Photos by E. Brazier/EngenderHealth

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Hot Topic: Rights and Choice at the International Conference on Family Planning

From November 12–15, an estimated 4,000 government officials, policymakers, program managers, researchers, academics, and youth advocates will gather in Addis Ababa, Ethiopia for the 3rd Annual International Conference on Family Planning (ICFP).

The theme of this year’s conference—cohosted by The Bill and Melinda Gates Institute for Population and Reproductive Health and Ethiopia’s Ministry of Health—is “Full Access, Full Choice,” echoing the Family Planning 2020 (FP2020) initiative’s call to ensure that rights and contraceptive choice are central to meeting the commitment made at the London Summit on Family Planning to reach an additional 120 million women with access to contraception by 2020.

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World Contraception Day and the UN General Assembly Millennium Development Goal Review

Celebrating World Contraception Day

Today, the international community celebrates World Contraception Day. This global campaign strives to increase awareness of contraception and encourage its use to enable people to make informed decisions about their sexual and reproductive health and to prevent unplanned pregnancy and sexually transmitted infection. This year’s motto, “Your Future, Your Choice, Your Contraception,” targets young people.

Bwaila Hospital, Lilongwe, Malawi (Photo by Holly Connor/EngenderHealth

A woman enjoys her new granddaughter at Bwaila Hospital in Lilongwe, Malawi. She is there in support of her daughter, who has requested counseling from a family planning nurse on obtaining a female sterilization. (Photo by Holly Connor/EngenderHealth)

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