Voluntary, Rights-based Family Planning: Why, What and How? Voluntary, Rights-based Family Planning Framework Orientation Doc id

Agenda Opening Remarks – name, title Ice breaker Presentation: Introduce the VRBFP Framework Discussion Case Studies Facilitator: name, title - Add detail (time, names) from the workshop agenda © 2010 Bill & Melinda Gates Foundation

Objectives Explain why it is important for family planning programs to take a voluntary, rights-based approach Introduce what a rights-based approach in FP is using the Voluntary, Rights-based FP framework Describe how the framework and approach can be used in programs (Optional) Provide a hands-on opportunity to apply the framework using case studies Review orientation objectives If using the case study activity, remove (Optional) from objective 4 © 2010 Bill & Melinda Gates Foundation

WHY? The importance of taking a voluntary, rights-based approach to family planning - This section introduces the challenges and issues that FP programs face and how a rights-based approach can benefit programs, providing a rationale for taking this approach. © 2010 Bill & Melinda Gates Foundation

History of Rights and Family Planning History of associating human rights with FP and SRHR Tehran 1968 – Human Rights Conference – voluntarism in FP Cairo 1994 – ICPD – reproductive health and rights Issues in FP/population programs Examples of coercion and forced sterilization (India, China, Peru, etc) Civil society participation Attention to accountability mechanisms Effective use of human rights treaty bodies to address issues of coercion and human rights violations There is a human rights basis for providing family planning information, services, and education. The right of couples to decide, freely and responsibly, the number, timing and spacing of their children was included as part of human rights as early as 1968. This includes an emphasis on voluntary use of family planning. The Programme of Action from the U.N. International Conference on Population and Development in Cairo reiterated this right and expanded the focus to include related sexual and reproductive health issues. Human rights violations have, at times, tainted FP programs. Civil society has actively engaged with FP to improve the quality of programs, raise awareness about issues, and increase the accountability of programs and address problems. Civil society has also been antagonistic towards FP programs and has at times detracted investment in FP Human rights accountability mechanisms have been and can be called upon to help redress rights violations © 2010 Bill & Melinda Gates Foundation

Coercion 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 include Policies limiting the number of births Involuntary contraceptive use Excessive social pressure Targets and Indicators linked to numbers of acceptors Incentives and disincentives for use The 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 methods Hardee et al, 2014 (cite Perspectives article)

Challenges to Rights: it’s not just about coercion Subtle Overt Provider bias for specific methods Misinterpretation of eligibility criteria Incentives (e.g. performance-based financing) Targets and quotas Involuntary sterilization of ethnic minorities (Peru, Roma, U.S.) and HIV + women (Namibia, Ukraine, Kenya) PPIUD insertion w/out consent (Mexico, India) Withholding benefits Lack of : accurate information community or spousal support for FP or specific methods access to new/innovative contraceptive technologies Poor quality of services Gender norms and status of women Negative attitudes towards marginalized populations Limited choice of method available (not offered); out of stock Lack of equitable distribution of FP outlets Lack of trained providers Cost unaffordable Denial of family planning to unmarried youth Coercion Coercion 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 rights More subtle types of coercion include (read from slide) and can create pressure to accept FP or a particular method, compromising voluntary choice about contraceptive use Barriers 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 populations Others 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 difficult Barriers

A rights-based approach can address each of these challenges Challenges to Voluntarism: it’s not just about coercion Subtle Overt Provider bias for specific methods Misinterpretation of eligibility criteria Incentives (e.g. performance-based financing) Targets and quotas Involuntary sterilization of ethnic minorities (Peru, Roma, U.S.) and HIV + women (Namibia, Ukraine, Kenya) PPIUD insertion w/out consent (Mexico, India) Withholding benefits Lack of : accurate information community or spousal support for FP or specific methods access to new/innovative contraceptive technologies Poor quality of services Gender norms and status of women Attitudes towards marginalized populations Limited choice of method available (not offered) Lack of equitable distribution of FP outlets Lack of trained providers Cost Denial of family planning to unmarried youth Coercion A rights-based approach can address each of these challenges Using a rights-based approach to family planning can address the challenges A human rights approached based on health systems strengthening can help FP programs respect, protect and fulfill human rights Barriers

WHAT IS A RIGHTS- BASED APPROACH? - This session describes the underlying concepts and principles used to develop the VRBFP framework. © 2010 Bill & Melinda Gates Foundation

What is a Human Rights Approach? Principle Action Participation/ Empowerment Communities and individuals are empowered to know and demand fulfillment of their rights Recognize people as key actors in their own development, rather than passive recipients of commodities and services. Accountability Governments that have signed human rights treaties have obligations to Put monitoring mechanisms in place, and Demonstrate efforts towards progressive realization of rights. M&E of both processes and outcomes of programs Non-discrimination & Equity Increases focus on structural barriers that lead to inequities in access and quality of FP services. Linked to treaty bodies Align programs with governments’ legal obligations to uphold rights Participation, Accountability, Non-discrimination, Empowerment, and Linked to treat bodies (PANEL) are commonly accepted HR based programming principles Note: define each of the principles using the slide as prompts For additional background on HRBA please see references in facilitators guidance Human rights-based approaches hold the dignity of individuals at the center © 2010 Bill & Melinda Gates Foundation

Additional Principles Voluntary Family Planning (USAID): The opportunity to choose voluntarily whether to use FP or a specific FP method Access to information on a wide variety of FP choices Clients are offered, either directly or through referral, a broad range of methods and services Verify client’s voluntary and informed consent for sterilization in a written consent document signed by the client Public Health Programming: Beneficence Equity Autonomy/Agency Human rights principles complement other common family planning and public health principles (Review and define principles on the slide)

Legally Defined Human Rights Related to Reproductive health Summarized from Global Treaties and Conventions Legally defined human rights have been translated into reproductive rights, such as in the IPPF Charter on Sexual and Reproductive Rights This list of rights supports many elements of sexual and reproductive health including access to family planning services For further background see the references in the facilitator’s guidance © 2010 Bill & Melinda Gates Foundation

3 Broad Categories of Reproductive Rights Rights to reproductive self-determination Right to bodily integrity and security of person Rights of couples and individuals to decide freely and responsibly the number and spacing of their children Right to make decisions concerning reproduction free of discrimination, coercion and violence Rights to sexual and reproductive health services, information, and supplies Including right to the highest attainable standard of health Rights to equality and nondiscrimination The longer list of rights can be grouped into three categories, as done by Erdman and Cook These three rights support voluntary family planning For further background see the references in the facilitator’s guidance Erdman and Cook (2008) © 2010 Bill & Melinda Gates Foundation

Right to Health: Governments have an obligation to provide health services that are: Rights elements Program implications Available Broad choice of methods offered Sufficient number and needs-based distribution of functioning service delivery points Accessible Information available in language/terms people can understand; geographic access, financial access, policy access Continuous contraceptive security; convenient service hours; service integration increases access Acceptable Cultural acceptability of FP and specific methods; community/family supports women’s right to choose; tolerance of side effects; client satisfaction with services Quality Clinical quality/technical competence good client-provider interactions and counseling privacy, dignity, respect demonstrated in service delivery  Continuity of care The right to health is not the same as the right to be healthy To clarify governments’ obligations to fulfill the right to health, General Comment 14 was published The 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 guidance General Comment 14, Article 12 from the UN Committee on Economic, Social and Cultural Rights. 2000.

Other related concepts CREATE A WORD CLOUD: Rights-based approach Voluntary FP Full, free and informed choice Contraceptive choice Quality of Care Quality assurance/ improvement Many aspects and elements of quality family planning programs are related to human rights based programming. These are some related terms and concepts that are familiar to the FP community. November 12, 2013 © 2013 Bill & Melinda Gates Foundation | © 2010 Bill & Melinda Gates Foundation

A Rights-based Approach… Improves the availability, accessibility, acceptability and quality of family planning information, services and supplies Ensures voluntarism by protecting the right of the individual to decide freely and responsibly, whether and/or when to have children and promotes programmatic attention to full, free and informed choice Expands access to family planning without discrimination or coercion Demands that accountability systems are in place to effectively expose vulnerabilities, and requires that alleged or confirmed rights violations and issues are dealt with in a significant, timely, and respectful manner Considers how programs are designed to respect dignity and promote individual agency A rights based approach builds on what family planning programs already do FP programs already strive in increase the availability, accessibility, acceptability and quality of programs and generally work to ensure voluntarism The rights approach increases emphasis on equity and non-discrimination so that all people gain access to services It also demands that accountability systems are put in place The rights approach keeps the dignity and agency of individuals at the center of program design © 2010 Bill & Melinda Gates Foundation

HOW TO OPERATIONALIZE RIGHTS IN FAMILY PLANNING - This section takes the concepts we just reviewed and shows how they have been integrated into the VRBFP framework so they can be operationalized in FP programs © 2010 Bill & Melinda Gates Foundation

Operationalizing Human Rights in Family Planning How can we ensure public health programs oriented toward increasing voluntary family planning access and use respect, protect and fulfill human rights in the way they are designed, implemented and evaluated? Using both human rights and public health principles, the framework was developed to answer the question: How can we ensure public health programs oriented toward increasing voluntary family planning access and use respect, protect and fulfill human rights in the way they are designed, implemented and evaluated? © 2010 Bill & Melinda Gates Foundation

INPUTS/ACTIVITIES OUTPUTS OUTCOMES COUNTRY CONTEXT IMPACT Policy Level Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights INPUTS/ACTIVITIES Policy Level   OUTPUTS OUTCOMES IMPACT Service Level   COUNTRY CONTEXT Community Level   Individual Level   The framework was designed as a logic model linking inputs and activities to outputs, outcomes and impact The framework provides a structure for looking at four levels of action: policy, service, community and individual, all situated within a particular context A logic model format emphasizes results and encourages testing of assumptions about program interventions Citation: Hardee, K., et al. 2013. Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework. Washington, DC: Futures Group. August 2013

Assess to inform interventions Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights INPUTS & ACTIVITIES OUTPUTS OUTCOMES IMPACT POLICY LEVEL   Illustrative Family planning services are Available (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 manner Communities actively participate in program design, monitoring, accountability, and quality improvement Community norms support the health and rights of married and unmarried women, men, and young people and their use of family planning Agency of individuals is increased to enable them to make and act on reproductive health decisions Illustrative Women, 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 so Trust in FP programs is increased Universal access to FP is achieved Equity in service provision and use is increased Availability of a broad range of contraceptive methods is sustainable Women get methods they want without barriers or coercion FP needs are met; demand is satisfied Decreased Unintended pregnancies Maternal/infant deaths Unsafe abortions Adolescent fertility rate Total fertility rate Increased Agency to achieve reproductive intentions throughout the lifecycle Well-being of individuals, families, communities, and countries Develop/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 LEVEL Inform 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 interventions COUNTRY CONTEXT COMMUNITY LEVEL Engage 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- determination R2: access to sexual and reproductive health services, commodities, information, and education R3: equality and non- discrimination (“All Rs” indicates that all rights are encompassed) NOTE: This slide is animated The 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 framework First click: The framework is a logic model Second click: The activities are linked to the three reproductive rights categories described by Erdman and Cook Third 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 appropriate Fourth 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 action Ninth click: The outputs include availability, accessibility, acceptability and quality, as well other human rights related outcomes Tenth 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 LEVEL Increase 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 2013 Citation: Hardee, K., et al. 2013. Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework. Washington, DC: Futures Group.

Country Context Country Governance Health Governance Funding/Resources Assess the overall country and global context—within which voluntary, human rights-based family planning is situated—and use the findings to inform interventions at all levels, including interventions related to marginalized and vulnerable populations: Country Governance Health Governance Funding/Resources Health Policy Environment Sociocultural context and gender norms Diverse stakeholder participation Adherence to global human rights agreements Global accountability of actors National accountability mechanisms FP programs are situated within a country context, which needs to be assessed prior to designing and implementing interventions Areas to assess include (read the list and provide detail for 1 or 2 areas of interest): Overall country governance, including the World Bank’s six dimensions of overall governance— accountability and voice, political stability and support, rule of law/regulatory quality, government effectiveness, power relationships and dynamics, and control of corruption Health governance, including government stewardship for health (e.g., health systems strengthening through the establishment of health systems building blocks) and family planning/reproductive health Financing/resources, including the availability of funding at national and local levels for health, reproductive health, and family planning Health policy environment, including those policies related to family planning (e.g., safe motherhood policy, youth policy) and health status (e.g., maternal morbidity and mortality, infant mortality, child health status) Sociocultural context and gender norms, including those affecting marginalized populations Diverse stakeholder participation, including the engagement of civil society, communities, and public and private sector actors Adherence to global human rights agreements, including in national laws and policies Global accountability of donors and other global actors, including to country-level work National accountability mechanisms in place, including the means of redress for violations of rights for government as duty-bearer to respect, protect, and fulfill human rights (e.g., treaty monitoring bodies, human rights tribunals, national courts), including accountability for private actors and for international assistance © 2010 Bill & Melinda Gates Foundation

Policy Level Develop/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) - Within each level of action are the main bullets included on the framework and then detailed action for each bullet. © 2010 Bill & Melinda Gates Foundation

POLICY LEVEL Develop/revise/implement policies to respect/protect/fulfill rights and eliminate policies that create unnecessary barriers to access (All Rs) Develop laws and policies that ensure that family planning services are sufficiently available; physically and economically accessible to all people without discrimination; acceptable—respectful of culture and confidentiality; and of the highest possible quality Support the promotion of gender equity and women’s autonomy in realizing their reproductive rights Support prevention of harmful practices (e.g., child marriage, gender-based violence, female genital cutting) and knowledge of the rights violations and harms caused by such practices Ensure equitable access to services for all groups (e.g., without discrimination in respect of ethnicity, age, income level) Eliminate unjustifiable access barriers (e.g., client eligibility criteria) or policies that contain method-specific or performance-based targets or incentives that have the effect of being coercive in practice Set service standards and enable task shifting and task sharing and facilitate access to a wide range of safe and effective contraceptive methods Protect privacy in service delivery settings Example: Bullet A from the policy level (read the bullet and provide a few examples of the detail bullets **Refer participants to printed copy of framework and walk them through looking at each level using the next three slides as prompts © 2010 Bill & Melinda Gates Foundation

Service Level A. Inform 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) B. Ensure high-quality care through effective training and supervision and performance improvement and recognize providers for respecting clients and their rights (All Rs) C. 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) D. Routinely provide a wide choice of methods and ensure proper removal services, supported by sufficient supply, necessary equipment, and infrastructure (R2) E. Establish and maintain effective monitoring and accountability systems with community input; strengthen HMIS and QA/QI processes (All Rs) Refer participants to printed copy of framework © 2010 Bill & Melinda Gates Foundation

Community Level A. Engage diverse groups in participatory program development and implementation processes (R2/R3) B. Build/strengthen community capacity in monitoring and accountability and ensure robust means of redress for violations of rights (R2/R3) C. 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) D. Transform gender norms and power imbalances and reduce community- family-, and partner-level barriers that prevent access to and use of FP (R3) E. Support healthy transitions from adolescence to adulthood (All Rs) Refer participants to printed copy of framework © 2010 Bill & Melinda Gates Foundation

Individual Level Increase 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) Refer participants to printed copy of framework © 2010 Bill & Melinda Gates Foundation

Using the framework in FP programming Phase of the Program Cycle Illustrative Actions that Incorporate Rights Principles Assess needs Ask new questions i.e. who are we not reaching and why? Design Engage stakeholders more deliberately Systematically think through interventions impact on rights Implement Make rights and responsibilities explicit (clients’ rights, providers’ needs) Offer a full, free & informed contraceptive choice Expand concept of demand Monitor and Evaluate Promote accountability throughout the system Do facilities have mechanisms to protect privacy? Collect and use client feedback/means of redress Do service data indicate equitable service delivery Sustain Engage communities to improve outcomes and achieve lasting behavior change - The framework can be used throughout all phases of the program cycle © 2010 Bill & Melinda Gates Foundation

Discussion Questions? Observations? Does the framework help you see your work differently? If so, in what ways? What activities are you already involved in that you could build on to take a rights-based approach? What might you do differently? What challenges to this approach do you envision ? Invite participants to ask questions and give general observations about the framework © 2010 Bill & Melinda Gates Foundation

Applying the Framework to Case Studies © 2010 Bill & Melinda Gates Foundation

CASE 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

Discussion Did anything surprise you? If so, what and why? Is there anything familiar about the circumstances described in the case studies? Which of the suggested interventions or changes would be relatively easy to implement? Which might be harder? How might you be able to begin? What more would it take? Invite observations from the group about the activity and the collective outcome using the questions on the slide If these points are not raised by the group, the facilitator can raise them as part of the reflection: Observe that there are factors at all 4 levels that support and that hinder rights; addressing these complex barriers requires taking a holistic approach. What level(s) appear to require the most urgent attention? Acknowledge the supporting factors that should be valued, strengthened, and built upon. © 2010 Bill & Melinda Gates Foundation

Next steps **Tailor this slide to the context of the presentation** Provide next steps if an assessment/planning process in planned If no formal next steps have been planned, highlight ideas that were generated through the workshop discussions © 2010 Bill & Melinda Gates Foundation