"...dialogue and reflection can lead to positive outcomes..."
In advance of the 2017 Family Planning Summit, this report provides a snapshot of CARE's efforts to ensure provision of quality sexual and reproductive health (SRH) services - including family planning - in some of the most challenging contexts around the world. Strategies explored include shifting social and gender norms to increase women's voice and empowerment, promoting mechanisms for accountability between community members and health providers, and reaching vulnerable and marginalised people in humanitarian and conflict-affected settings with family planning information and services. The Path to 2020 also shares the key actions the organisation is calling governments, donors, and other civil society actors to mobilise around, in order to catalyse progress and re-ignite the commitment (made by CARE and other organisations in July 2012) to reach 120 million women and girls by 2020 ("FP2020").
The report groups examples of CARE's programmes according to 4 components of the 2020 commitments:
- Develop approaches for addressing gender and social barriers to family planning use and validating tools to measure the impact of these approaches on health outcomes. CARE's key strategy is fostering the empowerment of women and girls. To that end, CARE's Social Analysis and Action (SAA) model is designed to facilitate dialogue and reflection on norms and behaviours that may undermine reproductive health and help catalyse a community-led change process to create an environment that supports women's and girls' choices. Since 2012, CARE has used SAA with couples to improve communication and reproductive decision-making - with communities to build a more supportive environment for SRH, and with health providers to improve SRH service delivery to adolescents. (Figures 1 and 2 on page 4 highlight positive results from evaluations of two projects that used the SAA approach.) Examples of addressing gender and social barriers:
- The Young Men's Initiative, implemented by CARE in the Western Balkans (see Related Summaries, below, invited young men (ages 13-19) to deconstruct masculinity in their cultures and to recognise how gender norms and male socialisation can lead to inequitable attitudes. The program also made a deliberate effort to identify the spaces to reach youth with information on SRH, ultimately deciding to leverage the power of the internet. The Pazisex website (with corresponding Facebook page) is an educational, youth-friendly outlet that uses cartoon images to deliver information on contraceptives, safe sex, sexuality and reproductive health. Pazisex, which literally means "watch out-sex" but can be interpreted as "be careful-ex", receives 2,000 new visitors each month. Promundo partnered with CARE Balkans to develop the Pazisex website as well as a SRH curriculum for schools and other campaigns to challenge young men's notions of manhood while discouraging violence and discrimination.
- CARE is working in the garment sector in Cambodia and Bangladesh to respond to the gaps in knowledge, awareness, and self-efficacy regarding SRH among female factory workers. For instance, CARE Cambodia developed Chat! Contraception, which consists of: short, targeted activity-based sessions that provide key information on communication and consent, contraception, sexually transmitted infections (STIs), and safe abortion; video dramas featuring characters in a fictional garment factory that engage workers' emotions as they relate to the everyday challenges of characters; and an interactive mobile app that challenges workers to prove and improve their understanding of reproductive health topics.
- Strengthen local governance mechanisms and build capacity of women and communities. CARE's key strategy is to expand spaces for meaningful participation of women and girls in shaping how reproductive health services are provided in their communities. The vision is that this can ultimately lead to improved responsiveness of the health system to the community's needs, thereby changing the relationship between the community and the health delivery system and ensuring that they work together as a complete system to accelerate SRH progress. CARE's Community Score Card© (CSC) brings together community members, health providers, and local government officials to identify obstacles to access and delivery of health services, to generate local solutions, and to work together to implement and monitor the effectiveness of these solutions. This approach gets community members and frontline service providers involved and invested in governance of local health services. This report shares the results of a cluster-randomised control trial (RCT) in Malawi testing the effectiveness of the CSC approach. This and other studies cited show that improving patient-provider relationships, as well as identifying and addressing local level bottlenecks, may be important factors in enabling increased uptake of family planning services. CARE believes that "social accountability approaches are gaining more visibility as comprehensive community engagement and governance mechanisms." Selected examples of governance and building capacity include:
- CARE is working to promote the empowerment, motivation, and retention of frontline health workers while increasing the resilience of health systems. Working closely with the state government of India, CARE introduced comprehensive and whole-site training, quality assurance, and clinical monitoring and coaching within Bihar health centres. The intervention also includes training on clinical skills needed for female and male sterilisation, performing integrated family planning counseling, and infection prevention. CARE India has been using mobile technology to aid frontline health workers in registering and tracking patients, managing care, and counseling pregnant women and mothers with newborns. As part of the consortium working on the Urban Health Initiative (2010-2015), CARE worked with 25 local non-governmental organisations (NGOs) to capacitate and deploy urban Accredited Social Health Activists (ASHAs), who have provided outreach to over 1,800 slums and 900,000 women in Uttar Pradesh; they have now been incorporated into the state government health system.
- In Nepal, CARE is working with health facility staff, trained in provision of youth-friendly services, to visit schools and youth clubs to deliver SRH information and conduct pop-up clinics for counseling and service referral. This programme aims to reach 15,000 adolescent girls and boys from marginalised castes and Muslim communities in Rupandehi and Kapilbastu districts as part of a six-country adolescent empowerment initiative.
- Reach the most vulnerable and marginalised populations to reduce inequality and ensure women and girls' SRH needs are addressed in development, emergency, and post-conflict response activities. For example, in the Democratic Republic of the Congo (DRC), CARE is working to ensure that the SRH needs of adolescents who have grown up amidst crisis are not neglected and that opportunities are available for them to create change for themselves and their communities. CARE, along with representatives from the Ministry of Health's National Program for Adolescent Health, worked with youth from surrounding communities to design a programme to meet their SRH needs in two internally displaced persons camps on the outskirts of Goma. The objective is to expand access to youth-friendly services by sensitising providers to the needs of youth and conducting values clarification activities with providers. The project also used the CSC to bring together youth and providers to define common indicators of quality SRH services and put in place a system for monitoring progress.
- Build political will and mobilise action at all levels to ensure implementation of policies and programmes that address the needs of communities and are rights-based, effective, and culturally appropriate. The report outlines several strategies and examples; to cite only a few:
- CARE Australia hosts the Secretariat of the Australian Parliamentary Group on Population and Development, a cross-party group of parliamentarians who champion women's rights and advocate for investments in comprehensive SRH services. From 2015-2017, representatives from this group led 16 round-table briefings in the Australian Parliament and supported these representatives to champion SRH and rights through delegations led by the Asian Forum of Parliamentarians on Population and Development in 7 international conferences.
- CARE played a role in the reform of Chad's national family planning policy, which authorises midwives and nurses – the primary service providers for the most economically poor and rural women in Chad – to provide a wide range of contraceptive methods. This policy change resulted in an 8-fold increase in the number of healthcare workers authorised to provide family planning.
- CARE Burundi led a coalition of partners in advocating for the development and institutionalisation of a national comprehensive sexuality curriculum, The World Starts With Me (see Related Summaries, below).
- In Myanmar, where civil society participation is very nascent, CARE is working at the local level to create space for citizen engagement on village health committees and at the national level to ensure that the government's 2018 national reproductive health strategy includes mechanisms that enable meaningful citizen participation.
- As part of its efforts to elevate family planning as a core, life-saving intervention in all humanitarian responses, CARE is an active member of the Inter-agency Working Group for Reproductive Health in Crises (IAWG) and Every Woman, Every Child, Everywhere.
CARE concludes the report by pledging to partner with others in the global family planning community and calling on governments, partners, and civil society to: (i) ensure access to comprehensive family planning services in all crisis-affected and fragile settings; (ii) invest in participatory governance and social accountability processes to transform health systems and drive FP2020 progress; (iii) ensure programming for adolescents is designed and co-created with adolescents themselves; and (iv) strengthen health systems by ensuring adequate capacities, compensation, and support to frontline health workers providing family planning and reproductive health services.
Posting from Mariela A. Rodríguez to the IBP Consortium community, July 7 2017; and email from Mariela A. Rodríguez to The Communication Initiative on July 12 2017. Image credit: © 2011 Yogesh Aditya/CARE