6Coercion in Family Planning: past and present examples Enforced policies limiting the number of births (e.g. China but more recently contemplated in Africa)Involuntary Contraceptive Use (e.g. China, India/Emergency, Peru, US often targeted at poor and marginalized)Excessive Social Pressure (e.g. China, Indonesia, but potentially Rwanda and Ethiopia - fine line between efforts to change social norms and coercion)Targets and Performance Management Indicators linked to numbers of acceptors (e.g. China, Indonesia, Rwanda, Performance-based Financing focused on numbers)Incentives and disincentives (e.g. Bangladesh, India, payments to providers)Some of the issues that have drawn criticism towards family planning programs includePolicies limiting the number of birthsInvoluntary contraceptive useExcessive social pressureTargets and Indicators linked to numbers of acceptorsIncentives and disincentives for useThe first two issues are human rights violations, while the final three red flags that show that voluntary FP use may be at risk.Coercion and human rights violations harm people and cause lasting damage to programs and methodsHardee et al, 2014 (cite Perspectives article)
7Challenges to Rights: it’s not just about coercion SubtleOvertProvider bias for specific methodsMisinterpretation of eligibility criteriaIncentives (e.g. performance-based financing)Targets and quotasInvoluntary sterilization of ethnic minorities (Peru, Roma, U.S.) and HIV + women (Namibia, Ukraine, Kenya)PPIUD insertion w/out consent (Mexico, India)Withholding benefitsLack of :accurate informationcommunity or spousal support for FP or specific methodsaccess to new/innovative contraceptive technologiesPoor quality of servicesGender norms and status of womenNegative attitudes towards marginalized populationsLimited choice of method available (not offered); out of stockLack of equitable distribution of FP outletsLack of trained providersCost unaffordableDenial of family planning to unmarried youthCoercionCoercion is one side of the voluntarism and human rights coin. Blatant coercion gets most of the attention.There are other aspects of family planning provision that may impede fulfillment of or violate human rightsMore subtle types of coercion include (read from slide) and can create pressure to accept FP or a particular method, compromising voluntary choice about contraceptive useBarriers to access are also human rights violations.Some barriers to access are overt – such as lack of providers, supplies, or denial of services to certain populationsOthers barriers are more subtle, indirect or inadvertent, but still prevent a person’s right to family planning from being fulfilled.Subtle barriers include poor quality services, lack of information, and attitudes and norms that make FP use difficultBarriers
8A rights-based approach can address each of these challenges Challenges to Voluntarism: it’s not just about coercionSubtleOvertProvider bias for specific methodsMisinterpretation of eligibility criteriaIncentives (e.g. performance-based financing)Targets and quotasInvoluntary sterilization of ethnic minorities (Peru, Roma, U.S.) and HIV + women (Namibia, Ukraine, Kenya)PPIUD insertion w/out consent (Mexico, India)Withholding benefitsLack of :accurate informationcommunity or spousal support for FP or specific methodsaccess to new/innovative contraceptive technologiesPoor quality of servicesGender norms and status of womenAttitudes towards marginalized populationsLimited choice of method available (not offered)Lack of equitable distribution of FP outletsLack of trained providersCostDenial of family planning to unmarried youthCoercionA rights-based approach can address each of these challengesUsing a rights-based approach to family planning can address the challengesA human rights approached based on health systems strengthening can help FP programs respect, protect and fulfill human rightsBarriers
11Additional Principles Voluntary Family Planning (USAID):The opportunity to choose voluntarily whether to use FP or a specific FP methodAccess to information on a wide variety of FP choicesClients are offered, either directly or through referral, a broad range of methods and servicesVerify client’s voluntary and informed consent for sterilization in a written consent document signed by the clientPublic Health Programming:BeneficenceEquityAutonomy/AgencyHuman rights principles complement other common family planning and public health principles(Review and define principles on the slide)
14Right to Health: Governments have an obligation to provide health services that are: Rights elementsProgram implicationsAvailableBroad choice of methods offeredSufficient number and needs-based distribution of functioning service delivery pointsAccessibleInformation available in language/terms people can understand;geographic access, financial access, policy accessContinuous contraceptive security; convenient service hours; service integration increases accessAcceptableCultural acceptability of FP and specific methods;community/family supports women’s right to choose;tolerance of side effects;client satisfaction with servicesQualityClinical quality/technical competencegood client-provider interactions and counselingprivacy, dignity, respect demonstrated in service delivery Continuity of careThe right to health is not the same as the right to be healthyTo clarify governments’ obligations to fulfill the right to health, General Comment 14 was publishedThe right to health provides a set of required conditions programs are responsible for as they expand FP services including Available, Accessible, Acceptable, and Quality (AAAQ)(explain the concepts of AAAQ as indicated on the slide)For further background see the references in the facilitator’s guidanceGeneral Comment 14, Article 12 from the UN Committee on Economic, Social and Cultural Rights
19INPUTS/ACTIVITIES OUTPUTS OUTCOMES COUNTRY CONTEXT IMPACT Policy Level Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human RightsINPUTS/ACTIVITIESPolicy LevelOUTPUTSOUTCOMESIMPACTService LevelCOUNTRY CONTEXTCommunity LevelIndividual LevelThe framework was designed as a logic model linking inputs and activities to outputs, outcomes and impactThe framework provides a structure for looking at four levels of action: policy, service, community and individual, all situated within a particular contextA logic model format emphasizes results and encourages testing of assumptions about program interventionsCitation: Hardee, K., et al Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework. Washington, DC: Futures Group.August 2013
20Assess to inform interventions Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human RightsINPUTS & ACTIVITIESOUTPUTSOUTCOMESIMPACTPOLICY LEVELIllustrativeFamily planning services areAvailable (adequate number of service delivery points, equitably distributed)Accessible (affordable and equitable; free from discrimination; no missed opportunities for service provision)Acceptable (respectful of medical ethics, culturally appropriate, and clients’ views are valued)Highest quality (scientifically and medically appropriate and of good quality (e.g., full, free, and informed decisions; a broad choice of methods continuously available; accurate, unbiased, and comprehensive information; technical competence; high-quality client-provider interactions; follow-up and continuity mechanisms; and appropriate constellation of services)Accountability systems are in place, which effectively expose any vulnerabilities, and alleged or confirmed rights violations and issues are dealt with in a significant, timely, and respectful mannerCommunities actively participate in program design, monitoring, accountability, and quality improvementCommunity norms support the health and rights of married and unmarried women, men, and young people and their use of family planningAgency of individuals is increased to enable them to make and act on reproductive health decisionsIllustrativeWomen, men, and young people decide for themselves— free from discrimination, coercion, and violence— whether, when, and how many children to have and have access to the means to do soTrust in FP programs is increasedUniversal access to FP is achievedEquity in service provision and use is increasedAvailability of a broad range of contraceptive methods is sustainableWomen get methods they want without barriers or coercionFP needs are met; demand is satisfiedDecreasedUnintended pregnanciesMaternal/infant deathsUnsafe abortionsAdolescent fertility rateTotal fertility rateIncreasedAgency to achieve reproductive intentions throughout the lifecycleWell-being of individuals, families, communities, and countriesDevelop/revise/implement policies to respect/protect/fulfill rights and eliminate policies that create unnecessary barriers to access (All Rs)*Develop/revise/implement policies to ensure contraceptive security, including access to a range of methods and service modalities, including public, private, and NGO (R2)Create processes and an environment that supports the participation of diverse stakeholders (e.g. policymakers, advocacy groups, community members) (R2/R3)Support and actively participate in monitoring and accountability processes, including commitments to international treaties (All Rs)Guarantee financing options to maximize access, equity, nondiscrimination, and quality in all settings (R2/R3)SERVICE LEVELInform and counsel all clients in high-quality interactions that ensure accurate, unbiased, and comprehensible information and protect clients’ dignity, confidentiality, and privacy and refer to other SRH services (All Rs)Ensure high-quality care through effective training and supervision and performance improvement and recognize providers for respecting clients and their rights (All Rs)Ensure equitable service access for all, including disadvantaged, marginalized, discriminated against, and hard-to-reach populations, through various service models (including integrated, mobile, and/or youth-friendly services) and effective referral to other SRH services (All Rs)Routinely provide a wide choice of methods and ensure proper removal services, supported by sufficient supply, necessary equipment, and infrastructure (R2)Establish and maintain effective monitoring and accountability systems with community input; strengthen HMIS and QA/QI processes (All Rs)Assess to inform interventionsCOUNTRY CONTEXTCOMMUNITY LEVELEngage diverse groups in participatory program development and implementation processes (R2/R3)Build/strengthen community capacity in monitoring and accountability and ensure robust means of redress for violations of rights (R2/R3)Empower and mobilize the community to advocate for reproductive health funding and an improved country context and enabling environment for FP access and use (All Rs)Transform gender norms and power imbalances and reduce community-, family-, and partner-level barriers that prevent access to and use of FP (R3)Support healthy transitions from adolescence to adulthood (All Rs)* Reproductive rights:R1: reproductive self- determinationR2: access to sexual and reproductive health services, commodities, information, and educationR3: equality and non- discrimination(“All Rs” indicates that all rights are encompassed)NOTE: This slide is animatedThe framework has been vetted and received input from dozens of people. With each review the inputs and activities were made more comprehensive, and the font got smaller. **Ask participants to refer to their framework handout so they can read the content of the frameworkFirst click:The framework is a logic modelSecond click:The activities are linked to the three reproductive rights categories described by Erdman and CookThird click:The model takes into account the country (or local) context in which programs operate.The context needs to be assessed to inform FP interventions and ensure they are appropriateFourth Click:There are four levels of action in the health system, and therefore in FP programs: policy, service, community and individual.Fifth – Eighth clicks (content of the level boxes are filled in)Each of the levels has actions that contribute to quality family planning programs and fulfilling human rights(Provide an example from each level as the content appears and say which reproductive right is associated with it)- The framework includes additional detail for the country context and all levels of actionNinth click:The outputs include availability, accessibility, acceptability and quality, as well other human rights related outcomesTenth and eleventh clicks:There are many outcomes and impacts of family planning programs.The outcomes and impact that programs monitor may vary from project to project (Note that FP2020 is developing core, global indicators)The framework provides some examples, but not a comprehensive list.INDIVIDUAL LEVELIncrease access to information on reproductive rights, contraceptive choices (All Rs)Empower, through education and training about reproductive health, self-esteem, rights, life-skills, and interpersonal communication (R1/R2)Foster demand for high-quality services and supplies through IEC/BCC and empower individuals to demand their rights be respected, protected, and fulfilled (R2)August 2013Citation: Hardee, K., et al Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework. Washington, DC: Futures Group.
30CASE STUDIES (45 minutes) 1) In your small group, discuss what factors supported or challenged contraceptive choice and human rights in this case study. Write each individual factor on a note card or Post-It and determine the level in the health system at which it exists.2) For each challenge identified, consider what should be done to promote respect for, protection and fulfillment of human rights in the program described. Use one note card or Post-It for each suggested intervention or change.3) Select someone at your table to post and explain your cards during the report back