Transcript Foundation PowerPoint Template

Voluntary, Rights-based Family
Planning: Why, What and How?
Voluntary, Rights-based Family Planning Framework
Orientation
Agenda
 Opening Remarks – name, title
 Ice breaker
 Presentation: Introduce the VRBFP Framework
 Discussion
 Case Studies
 Discussion
Facilitator: name, title
Objectives
1. Explain why it is important for family planning
programs to take a voluntary, rights-based
approach
2. Introduce what a rights-based approach in FP is
using the Voluntary, Rights-based FP framework
3. Describe how the framework and approach can be
used in programs
4. (Optional) Provide a hands-on opportunity to
apply the framework using case studies
WHY?
The importance of taking a voluntary, rights-based
approach to family planning
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
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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)
Challenges to Rights: it’s not just about coercion
Overt
Coercion
Subtle
•
•
•
•
•
•
Barriers
Provider bias for specific methods
•
Misinterpretation of eligibility criteria
Incentives (e.g. performance-based
financing)
Targets and quotas
•
•
•
•
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
•
•
•
•
•
Involuntary sterilization of ethnic
minorities (Peru, Roma, U.S.) and
HIV + women (Namibia, Ukraine,
Kenya)
PPIUD insertion w/out consent
(Mexico, India)
Withholding benefits
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
Challenges to Voluntarism: it’s not just about coercion
Overt
Coercion
Subtle
•
•
•
•
•
•
Barriers
Provider bias for specific methods
•
Misinterpretation of eligibility criteria
Incentives (e.g. performance-based
financing)
Targets and quotas
•
•
•
•
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
•
•
•
•
•
Involuntary sterilization of ethnic
minorities (Peru, Roma, U.S.) and
HIV + women (Namibia, Ukraine,
Kenya)
PPIUD insertion w/out consent
(Mexico, India)
Withholding benefits
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
WHAT IS A RIGHTSBASED APPROACH?
What is a Human Rights Approach?
Principle
Action
Participation/
• 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.
Empowerment
Accountability
Governments that have signed human rights treaties have
obligations to
1) Put monitoring mechanisms in place, and
2) Demonstrate efforts towards progressive realization of rights.
M&E of both processes and outcomes of programs
Non-
Increases focus on structural barriers that lead to inequities
discrimination & in access and quality of FP services.
Equity
Linked to treaty
bodies
Align programs with governments’ legal obligations to uphold
rights
Human rights-based approaches hold the dignity of individuals at the center
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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
Public Health Programming:
• Beneficence
• Equity
• Autonomy/Agency
• Verify client’s voluntary and informed
consent for sterilization in a written
consent document signed by the client
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Legally Defined Human Rights Related
to Reproductive health
Summarized from
Global Treaties and
Conventions
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
Erdman and Cook (2008)
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
•
•
•
Acceptable
•
•
•
•
•
•
•
•
Information available in language/terms people can understand;
geographic access, financial access, policy access
Continuous contraceptive security; convenient service hours;
service integration increases access
Cultural acceptability of FP and specific methods;
community/family supports women’s right to choose;
tolerance of side effects;
client satisfaction with services
Clinical quality/technical competence
good client-provider interactions and counseling
privacy, dignity, respect demonstrated in service delivery
Continuity of care
Quality
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
November 12, 2013
© 2013 Bill & Melinda Gates Foundation
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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
HOW TO
OPERATIONALIZE
RIGHTS IN FAMILY
PLANNING
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?
Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights
INPUTS/ACTIVITIES
COUNTRY
CONTEXT
Policy Level
Service Level
OUTPUTS
OUTCOMES
IMPACT
Community
Level
Individual
Level
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
Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights
INPUTS & ACTIVITIES
POLICY LEVEL
A. Develop/revise/implement policies to respect/protect/fulfill rights and eliminate policies
that create unnecessary barriers to access (All Rs)*
B. Develop/revise/implement policies to ensure contraceptive security, including access to
a range of methods and service modalities, including public, private, and NGO (R2)
C. Create processes and an environment that supports the participation of diverse
stakeholders (e.g. policymakers, advocacy groups, community members) (R2/R3)
D. Support and actively participate in monitoring and accountability processes, including
commitments to international treaties (All Rs)
E. Guarantee financing options to maximize access, equity, nondiscrimination, and quality
in all settings (R2/R3)
OUTPUTS
Illustrative
•
 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; highquality client-provider
interactions; follow-up and
continuity mechanisms; and
appropriate constellation of
services)
COUNTRY CONTEXT
Assess to inform interventions
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)
•
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)
INDIVIDUAL LEVEL
A. Increase access to information on reproductive rights, contraceptive choices (All Rs)
B. Empower, through education and training about reproductive health, self-esteem, rights,
life-skills, and interpersonal communication (R1/R2)
C. Foster demand for high-quality services and supplies through IEC/BCC and empower
individuals to demand their rights be respected, protected, and fulfilled (R2)
Family planning services are
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
OUTCOMES
IMPACT
Illustrative
Decreased
• 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
• 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
* Reproductive rights:
R1: reproductive selfdetermination
R2: access to sexual and
reproductive health
services, commodities,
information, and
education
R3: equality and nondiscrimination
(“All Rs” indicates that all
rights are encompassed)
• Agency of individuals is increased
to enable them to make and act on
reproductive health decisions
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
Country Context
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
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Policy Level
A. Develop/revise/implement policies to respect/protect/fulfill rights
and eliminate policies that create unnecessary barriers to access
(All Rs)
B. Develop/revise/implement policies to ensure contraceptive security,
including access to a range of methods and service modalities,
including public, private, and NGO (R2)
C. Create processes and an environment that supports the
participation of diverse stakeholders (e.g. policymakers, advocacy
groups, community members) (R2/R3)
D. Support and actively participate in monitoring and accountability
processes, including commitments to international treaties (All Rs)
E. Guarantee financing options to maximize access, equity,
nondiscrimination, and quality in all settings (R2/R3)
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POLICY LEVEL
A. 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
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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 youthfriendly 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)
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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 communityfamily-, and partner-level barriers that prevent access to and use of FP
(R3)
E. Support healthy transitions from adolescence to adulthood (All Rs)
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Individual Level
A. Increase access to information on reproductive rights,
contraceptive choices (All Rs)
B. Empower, through education and training about reproductive
health, self-esteem, rights, life-skills, and interpersonal
communication (R1/R2)
C. Foster demand for high-quality services and supplies through
IEC/BCC and empower individuals to demand their rights be
respected, protected, and fulfilled (R2)
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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
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 ?
Applying the
Framework to Case
Studies
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
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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?
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Next steps
**Tailor this slide to the context of the presentation**
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