International Planned Parenthood Federation, or IPPF (Boydell); PATH (Keeley); Population Council India (Aruldas); Population Council (Hardee)
Civil society organisations (CSOs) are often involved in expanding services, raising awareness, generating demand, and advocating for an improved enabling environment to ensure women and men have full, free, and informed choice to determine whether and when they have children. This review summarises the evidence on civil society's engagement in improving family planning (FP) programmes around the world and highlights the possible opportunities to further strengthen civil society engagement in those programmes.
Researchers from the Evidence Project, which is supported by the United States Agency for International Development (USAID), conducted a literature review to document the range of ways in which CSOs have been involved in FP/reproductive health (RH) and to assess the strength of the evidence related to interventions that included CSO participation. The literature review identified 63 FP/RH interventions described in 60 publications that involved civil society, either as a prime implementer or collaborator, and that had been evaluated. The interventions were spread across 27 countries spanning Africa, Asia, Latin America and the Caribbean, and Europe. Outcomes identified related to contraceptive use included increased uptake, changes in knowledge and information about modern contraceptives, other sexual or RH behaviour changes, and changes in intention to use contraception.
The interventions identified generally fell under the following 10 technical strategy areas: service delivery (facility-based, community-based, and mobile outreach), financing, social franchising, mHealth, human rights and quality of care, introducing and scaling-up fertility awareness methods, social and behaviour change (SBC) (community and individual), youth (community-based, school-based, facility-based, and combination community/school/facility), programming for men, and advocacy/accountability (capacity building, and community-led assessment and monitoring). The report provides an explanation of each of the 10 areas as well as a summary of the evidence, with specific programming examples.
The review found that the strategies with the highest strength of evidence were CSO provision of facility-based FP and SBC interventions.
- CSO provision of facility-based FP had relatively strong evidence, with increases shown in the modern contraceptive prevalence rate (mCPR) in both rural and urban settings.
- SBC approaches identified in this review included: life skills and peer education; adult health education (group and one-on-one); school-based education; couple communication; community mobilisation; working through gatekeepers; and mass media interventions designed to reach a general public audience. CSO-led SBC interventions were fairly strong and included the creation of local committees and self-help groups and work with local gatekeepers. Reported changes were seen in knowledge, attitudes, and awareness about birth spacing and FP, changes in behaviour resulting in increased uptake of contraception, and/or changes in sexual behaviour or contraceptive behaviour, and increased capacity of service providers and of CSOs to undertake or support SBC communication.
Moderate evidence was seen in strategies including community-based service delivery, mobile outreach, financing, introducing or increasing access to fertility awareness methods, and programming for men.
- Community-based service delivery interventions had modest evidence, with much of it drawn from feasibility and operations research.
- CSO involvement in mobile outreach has the potential to be an effective way to deliver FP methods to increase client satisfaction and deliver a wider range of methods, particularly increasing access to intrauterine devices (IUDs) and implants.
- With regard to CSO involvement in financing interventions, the most notable results were a modest increase in knowledge and awareness of contraception.
- The findings related to CSO involvement in social franchising are mixed, with general increases in awareness and knowledge of contraception, but inconsistent data on the impact on contraceptive uptake and use. There were also mixed findings on the effect of CSO social franchising on equitable access, though demand-side vouchers appeared to be affordable and acceptable for FP users.
- The strength of the findings about CSOs introducing or increasing access to fertility awareness contraceptive methods suggests these interventions increased knowledge about the methods, increased use of the methods, and increased acceptability among clinic-based and community-based providers.
- CSO programming for increased male participation in FP/RH was mainly focused on increasing men's sense of responsibility for and access to contraception, and promoted positive changes in men's attitudes and support for FP.
The findings for CSO interventions that employed mHealth are drawn from operational research rather than rigorous evaluations. Nevertheless, findings suggest that mHealth services designed to respond to queries about contraceptive methods were popular and may have helped users find the best method for them. For example, in the Philippines, The Social Acceptance Project - Family Planning introduced the FamPlan Hotline to increase FP knowledge and provide referrals via text, voice, or email, with the goal of increasing access to FP nationwide. The hotline was implemented by a local non-governmental organisation (NGO), and, between August 2004 and August 2006, 60,916 text messages and 4,131 phone calls were received, with most of the questions related to FP (e.g., what is the safest method, how to detect one's fertile period, how to use the pill or injectable). Questions to the hotline increased significantly during media promotional activities.
The strength of evidence about CSOs implementing FP using rights-based approaches is low, although with generally positive reporting from clients related to better treatment, greater confidence asking questions, and better counselling.
Adolescent-friendly contraceptive programmes provided at the community, school, and facility levels, and as part of larger interventions, saw mixed results. Better results were seen for interventions that focused on reaching individuals and for interventions that combined service provision and education.
Most of the advocacy and accountability interventions identified focused on building the capacity of CSOs and facilitating interventions related to community engagement and participation. The evidence to support these types of interventions was generally weaker and tended to focus on process outcomes such as capacity building and positive statements made in favour of FP.
Looking broadly at the findings, the researchers observe that "civil society plays a diverse role in the provision of FP programmes, with interventions that promote both supply and demand, as well promoting enabling environments in communities and the health service and policy worlds. This diversity of roles places CSOs between the health system and the communities they serve, where they can expand service provision and link the community to the health system. CSOs are accountable to the state as a functioning part of health care delivery, but also to the communities they represent and serve. Underlying this unique position is the assumption that civil society is able to work independently, without impairment. Supporting a strong and free civil society is essential to enabling them to play their dual function."
The researchers conclude that "results from this literature review indicate that CSOs have a unique and significant role to play in family planning programs and have a great potential to aid in piloting innovations and scaling up proven programs." However, because many of the interventions that included a strong contribution from civil society were multi-stakeholder initiatives with limited description of the specific inputs of each stakeholder, it is challenging to determine the exact role and contribution of individual stakeholders, including civil society.
Evidence Project website, December 19 2017. Image credit: Images of Empowerment