voluntary, rights-based family planning framework: what, why, and how? module 1: orientation
TRANSCRIPT
Voluntary, Rights-based Family Planning Framework:
What, Why, and How?
Module 1: Orientation
Agenda
Opening Remarks—[name, title]
Ice breaker
Presentation: Introduce the VRBFP Framework
Discussion
Case Studies
Discussion
Facilitator: [name, title]
Objectives
1. Explain what a rights-based approach in FP means
2. Explain why it is important for FP programs to take a voluntary, rights-based approach
3. Introduce the VRBFP framework and describe how it can be used in programs
4. Provide a hands-on opportunity to apply the framework using case studies
WHAT is a rights-based approach?
What Are Human Rights?
Human rights are internationally agreed-on entitlements that all people have by virtue of being human.
They are articulated in international treaties, conventions, protocols, and other instruments that have the status of international law (i.e., they are legal obligations).
Individual human dignity is at the core.
Right to HealthGovernments have an obligation to provide health services with the following elements:
General Comment 14, Article 12 from the UN Committee on Economic, Social and Cultural Rights. 2000.
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
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)
Reproductive and Human Rights re: FP
The rights of individuals and couples:
“These (reproductive) rights rest on the recognition of the basic rights of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children, and to have the information and means to do so…” “ The principle of informed free choice is essential to the long-term success of family planning programmes.”
ICPD, 1994
"The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence.”
Beijing Women’s Conference, 1995
Rights-based Programs…
Respect (refrain from interfering with or curtailing the enjoyment of human rights)
Protect (guard against human rights abuses)
Fulfill (take action to facilitate the enjoyment of…)
…human rights for both clients and potential clients in the way the program is designed, implemented, monitored, and evaluated
Progressive Realization The status of human rights varies among countries and
FP programs.
Political, cultural, and resource constraints may hinder some elements of a rights-based approach.
Governments and implementers should take whatever steps possible to advance the protection and fulfillment of human rights in their FP programs over time.
Incremental steps continue to leave many people vulnerable to human rights violations; sustain advances to gradually realize rights for all.
Checkpoints for Choice, EngenderHealth, 2014
Human Rights Principles (PANEL)
Principle Action
Participation Engage communities and individuals in planning and monitoring programs.
AccountabilityFulfill (governments) obligations to respect, protect, and fulfill rights enshrined in treaties they have signed.
Nondiscrimination and Equality
Increase focus on barriers that lead to inequities in access and quality, particularly for marginalized, disadvantaged, and vulnerable groups.
EmpowermentInform people of their human rights and to increase their capability to demand and exercise those rights.
Linked to standards
Align programs with standards set by international human rights bodies and mechanisms.
(UNESCO, 2008)
Public Health Programming
Beneficence
Equity
Autonomy/Agency
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
Additional Principles
WHY?The importance of taking a voluntary,
rights-based approach to family planning
Why Take a Rights Approach?
Governments have a legal obligation to protect and fulfill the human rights of their citizens.
There are practical benefits: both health and rights outcomes benefit both individuals and programs. (HRA contributes to improved health outcomes for women and children, WHO 2013)
Rights violations persist in some programs and a human rights-based approach to FP can prevent violations in the future.
Practical Benefits of a Rights-based Approach
Improves 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
Expands access to family planning without discrimination or coercion; removes barriers to reach groups not currently being served
Demands effective monitoring and accountability mechanisms to identify and address violations
Informs program design or strengthening to ensure respect for individual dignity and promotion of individual agency
Violations Persist
Coercion in family planning = actions or factors that compromise individual autonomy, agency, or liberty in relation to contraceptive use or reproductive decision making through force, violence, intimidation, or manipulation.
Access barriers prevent many people—particularly the underserved, hard to reach, unmarried youth—from getting the contraception they want.
Hardee et al., publication pending 2014*
Coercion in Family Planning
Excessive social pressure
Targets and performance management indicators linked to numbers of acceptors
Incentives and disincentives
Enforced policies limiting the number of births
Involuntary contraceptive use
Hardee et al., publication pending 2014*
Challenges to Rights—It’s about more than blatant coercion
Subtle Overt
Co
erc
ion
Ba
rrie
rs
Provider bias for specific methods
Incentives to providers or clients
Targets and quotas
Community/family pressure
Lack of capacity of the health system to ensure the availability of all methods at all levels of the health system
Involuntary sterilization of ethnic minorities, the poor, and HIV-positive persons
Postpartum IUD insertion without consent
Provider incentive payments
Withholding of benefits for non-acceptance
Refusal to remove IUD and/or implants
Provider bias against specific methods or population groups
Misinterpretation of eligibility criteria
Lack of
o Accurate information
o Community or spousal support for FP or specific methods
o Access to new/innovative contraceptive technologies
Poor quality of services
Gender norms and low status of women
Limited choice of methods available (e.g., specific methods not offered, stock-outs)
Lack of equitable distribution of FP outlets
Lack of trained providers
Costly, unaffordable services
Denial of FP to unmarried
Challenges to rights—It’s about more than blatant coercion
Subtle Overt
Co
erc
ion
Ba
rrie
rs
• Provider bias for specific methods
• Incentives to providers or clients
• Targets and quotas
• Community/family pressure
• Lack of capacity of the health system to ensure the availability of all methods at all levels of the health system
• Involuntary sterilization of ethnic minorities, the poor, and HIV-positive persons
• Postpartum IUD insertion without consent
• Provider incentive payments
• Withholding of benefits for non-acceptance
• Refusal to remove IUD and/or implants
• Provider bias against specific methods or population groups
• Misinterpretation of eligibility criteria
• Lack of :
o Accurate information
o Community or spousal support for FP or specific methods
o Access to new/innovative contraceptive technologies
• Poor quality of services
• Gender norms and low status of women
• Limited choice of methods available (e.g., specific methods not offered, stock-outs)
• Lack of equitable distribution of FP outlets
• Lack of trained providers
• Costly, unaffordable services
• Denial of FP to unmarried
A rights-based approach can address each of these challenges
A human rights–based approach can enhance both health
and human rights outcomes.
Public health
promotes and protects health and prevents
premature mortality, seeking the greatest good for the greatest
number of people.
Human rights
promote and protect the well-
being of individuals by
ensuring respect for individual
entitlements and dignity.
Checkpoints for Choice, EngenderHealth, 2014
Finding Common Ground
HOW to operationalize rights in family planning programs
Operationalizing Human Rights inFamily Planning Programs
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?
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.
Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfil Human Rights
CO
UN
TR
Y
CO
NTEX
T
OUTPUTS
OUTCOMES
IMPACT
INPUTS/ACTIVITIES
Policy Level
Service Level
Community Level
Individual Level
OUTCOMES
INPUTS & ACTIVITIES
CO
UN
TR
Y C
ON
TEX
TA
sses
s to
info
rm in
terv
enti
ons
OUTPUTS
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
* 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)
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
IMPACT
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
Last Updated March 2014
Framework for Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights
POLICY LEVEL A. Develop/revise/implement policies to respect/protect/fulfill rights and eliminate policies that create
unjustifiable medical 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)
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 for implants/IUDs, 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)
Citation: Hardee, K., et al. 2013. Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework. Washington, DC: Futures Group.
25
A Detailed Framework
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 a wide range of stakeholders more deliberately Systematically think through interventions’ impact on rights
Implement
Make rights and responsibilities explicit Offer a full, free, and informed contraceptive choice Expand concept of demand to include rights
Monitor and evaluate
Incorporate indicators specific to human rights Monitor human rights outcomes as well as FP outcomes Engage, empower communities and clients in monitoring Routinely track for and manage program vulnerabilities and risk
factors Promote accountability throughout the system
Sustain Engage communities to improve services and outcomes and
achieve lasting behavior change
Using the Framework in FP Programming
RIGHTS
HEALTH
EDUCATION
Need to partner across sectors, service modes, and disciplines
Facility-based services
Private commercial
sectorNGOs
Social marketing
Community-based services
Public sector
Checkpoints for Choice, EngenderHealth, 2014
Systematic reviews of tools and interventions are summarized in additional publications
Publications
Questions?
Observations?
What challenges do you envision
Related to what you are already doing—it may not be as difficult as you think.
Discussion
Youth-friendly services
Gen
der
eq
uit
y
Access
Build on the good work you are already doing
Pledge of political will and resources with FP2020
Opportunities offered by the costed implementation plan development process that is underway
Availability of new tools to apply abstract human rights concepts in actual practice
An Extraordinary Opportunity for Voluntary Family Planning
Applying the Framework to Case
Studies
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.
Case Studies (45 minutes)
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?
Next Steps
**Tailor this slide to the context of the presentation**