UNDERSTANDING RIGHTS-BASED FAMILY PLANNING May 23,

UNDERSTANDING RIGHTS-BASED FAMILY PLANNING May 23, 2017 www.familyplanning2020.org

OBJECTIVES 1. Demystify the meaning of a rights-based approach to family planning 2. Highlight what distinguishes a rights-based approach from business as usual and the difference it makes 3. Increase understanding of the benefits of taking a rights-based approach and the risks of not taking it 4. Increase awareness of concrete, rights-supportive actions that different stakeholders can take

120 million additional users CONFERENCE UNDERSTANDING OR PRESENTATION RIGHTS-BASED TITLE, FAMILY CONFERENCE PLANNING WEBINAR; LOCATION MAY 23, 2017

WHAT ARE HUMAN RIGHTS?

HUMAN RIGHTS ARE Fundamental entitlements and protections that all people, everywhere, possess by virtue of being human Based on international consensus articulated in treaties, conference documents and declarations Legal obligations with the status of international and domestic law At their core about individual human dignity

CONFERENCE UNDERSTANDING OR PRESENTATION RIGHTS-BASED TITLE, FAMILY CONFERENCE PLANNING LOCATION WEBINAR; MAY 23, 2017

HUMAN RIGHTS AND EMPOWERMENT PRINCIPLES FOR FP Rights & Rights Principles Acceptability Accessibility Availability Quality Accountability Agency and Autonomy Empowerment Equity Informed choice Informed decision-making Non-discrimination Participation Privacy and Confidentiality

DEFINITIONS Agency/Empowerment/Autonomy Individuals have the right to make and act on their own family planning decisions in consultation with whomever they choose, without pressure or obstacles. Availability Individuals have the right to a broad choice of contraceptive methods. Accessibility Individuals have the right to receive understandable information about family planning and to get the services they want which are affordable, convenient, and always available.

DEFINITIONS Acceptability Individuals have the right to choose a contraceptive method that suits their needs and preferences. Quality Individuals have the right to respectful and safe services in a clean and comfortable setting. Non-discrimination/equity Individuals have the right to be treated fairly, without discrimination based on who they are or their circumstances. Informed choice Individuals have the right to decide whether to use family planning and what method to choose, based upon accurate and complete information (including side effects).

DEFINITIONS Privacy/Confidentiality Individuals have the right to receive information and services in a setting where no one can hear or observe their interactions with the provider and to expect that their records/information will not be shared with anyone. Participation Individuals have the right to provide input into how family planning services are offered at their facility. Accountability Individuals have the right to speak up if any of their rights have not been fulfilled, and to expect that action will be taken.

RIGHTS-SIZING FP COSTED IMPLEMENTATION PLANS

SOURCE DOCUMENTS FOR THESE RIGHTS Right to the highest attainable standard of health Governments have the legal obligation to provide health services that are available, accessible, acceptable, and high quality International Covenant on Economic, Social and Cultural Rights (1966), and General Comment No. 14 on the Right to the Highest Attainable Standard of Health Right of couples and individuals to decide freely and responsibly the number and spacing of children Right to sexual and reproductive health services, information, and education Right to equality and nondiscrimination United Nations, General Comment 22 on article 12 of the International Covenant on Economic, Social and Cultural Rights) (2016) The United Nations International Conference on Population and Development (ICPD) Programme of Action (1994) The United Nations International Women s Conference Plan of Action (1995) Maputo Protocol on the Rights of Women in Africa, Article 14 (2003)

WHAT IS A RIGHTS-BASED APPROACH TO FP PROGRAMMING?

RIGHTS-BASED APPROACH TO FP Goal Focus Approach (the how ) Give people control over their fertility by ensuring that their human rights are respected, protected and fulfilled in their experience of the FP program Empower individuals to make and act on decisions about whether, when and how many children to have. Centers around the people the program is meant to serve rather than the numeric goals of the program Embraces not only health systems issues, but also their policy and cultural contexts Rights guide the way FP policy and programs are designed, implemented, monitored and evaluated Develops capacity of duty bearers the government and other institutions to meet their obligations (respect, protect, fulfill) Empowers rights holders clients and prospective clients to know and claim their rights

BEYOND BUSINESS AS USUAL Business as Usual Added Focus Availability Accessibility Acceptability Quality Voluntarism Informed choice and decision making Privacy, confidentiality Nondiscrimination Equity Agency, autonomy Empowerment Participation Accountability

PROGRESSIVE REALIZATION Do all you can to move toward the goal of everyone enjoying their rights The status of human rights varies among (and within) countries and FP programs; there are many barriers (political, cultural, and resource constraints). Stakeholders should take whatever steps possible to advance the protection and fulfillment of human rights in their FP programs over time. Lack of resources is no excuse for lack of action and progress

WHY TAKE A RIGHTS- BASED APPROACH TO FP?

FP IS UNIQUE AS A HEALTHCARE ISSUE FP is an elective, preventative healthcare service It is related to sexuality and fertility, which involve religious and cultural sensitivities, gender and power dynamics Because it has population implications, governments set goals for FP use

ADDRESSING RIGHTS IN FP IS PARTICULARLY IMPORTANT Access Barriers prevent many people particularly the underserved, hard to reach, unmarried youth from getting the contraception they want Coercive pressures, some subtle and some overt, push people to accept FP, or specific methods, they don t want Poor quality, including lack of respect for client s dignity, privacy or confidentiality; inadequate counseling that undermines informed and voluntary choice; substandard clinical care

Barriers Coercion LOOK BEYOND THE OBVIOUS There are many challenges to human rights. Preventing blatant coercion isn t enough. Subtle Provider bias for specific methods Incentives to providers or clients Targets and quotas Lack of capacity of the health system to ensure the availability of all methods at all levels of the health system Overt Involuntary sterilization of HIV+ women PPIUD insertion without prior consent Refusal to remove implants Provider bias against specific methods or population groups Misinterpretation of eligibility criteria 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 individuals Source: Checkpoints for Choice, EngenderHealth, 2014

BENEFITS OF TAKING AND RISKS OF NOT TAKING A RIGHTS-BASED APPROACH TO FP Benefits Advances progress toward universal access to FP Improves outcomes and effectiveness Improves accountability to clients and communities Protects programs reputation Risks of not fulfilling rights Marginalized and vulnerable groups not served Inability to foresee the unintended consequence of method- or number-driven initiatives Lack of trust and support from community Poor reputation among donors leads to funding decreases

WHAT S IN IT FOR ME? Individual Service Provider Government or donor Implementing agency No matter who you are, you get Information and services you want to achieve your reproductive intentions, are treated with respect, and are empowered to make and act on your decisions, free from coercion, discrimination and violence You enjoy the trust of your clients and the support of your community You get enhanced and accelerated program outcomes, increased sustainability and protection against negative, unintended consequences that can undermine the program You get an approach that unifies and guides all elements of a holistic, quality family planning program

A RIGHTS-BASED APPROACH COVERS ALL PROGRAM ELEMENTS Youth-friendly services Quality of Care Expanding method choice Monitoring, supervision and accountability Informed choice Gender equality/reproductive empowerment Integrated service delivery Social and behavior change Community engagement

HOW TO APPLY A RIGHTS-BASED APPROACH IN FP

CONSIDER THE WHOLE PROGRAM AND FACTORS AT ALL LEVELS OF THE HEALTH SYSTEM Policy: laws, policies, regulations, standards and guidelines and project priorities that govern what FP methods are offered, how they are to be provided (quality), where they are available, who can provide them and who can use them; also engagement of sectors beyond health (e.g., education, gender, women s affairs, etc.) Service delivery: all factors related to the capacity and performance of staff and their facilities, including range of methods offered, referral mechanism, clinical practice, client-provider interactions (nondiscrimination. information provided, counseling, privacy, confidentiality, dignity and respect) and rights literacy; as well as monitoring and supervision, quality assurance and quality improvement Community: includes social and gender norms that affect women s empowerment and acceptability of FP, constructive involvement of men as partners and as FP users; support for healthy transitions from adolescence to adulthood, supportive attitudes toward vulnerable and marginalized groups, and engagement in program development, implementation and monitoring processes; rights awareness Individual: all characteristics and circumstances that apply to the individual that affect knowledge of, desire for and ability to make and carry out FP decisions, including awareness of one s human rights and of redress mechanisms for rights violations; expectations of quality of care and interpersonal communication and negotiation skills Source: Hardee et al. 2014. Voluntary, Human Rights-based Family Planning: A Conceptual Framework. Studies in Family Planning. 45(1): 1-18.

VIGNETTE 1: AMBITIOUS NATIONAL GOALS The Government of Andoria has made family planning a national priority. Current CPR is 23% with 75% of the current method mix attributed to pills and injectables. Andoria has committed to a CPR goal of 50% by 2020, in effect doubling current prevalence and requiring an annual increase of 5%. This goal is supported at the highest levels of government, with visible calls to action from the President and Minister of Health to all districts. The major activity to support this goal is the training of providers in IUD and implant insertion, although there hasn t been sufficient caseload to support practical training in implant removals. In Andorita District, the supervisor focuses mainly on reviewing the clinic register and encouraging facility staff to increase FP uptake, especially of LARCs. The supervisor spends little time discussing other issues, such as the lack of equipment, supplies and educational materials; delays in salary payment; low caseload and demand for FP; and requests for removals. As a result, providers are talking up the benefits of LARC with FP clients, especially among poor women as they are considered not as likely to effectively use short-acting methods. The clinic charges for removals, although insertion services are free.

VIGNETTE 1: RIGHTS CHALLENGES & PROPOSED ACTIONS Human Rights/Rights Principles Availability/Accessibility financial & other barriers to implant removals Quality rapid & incomplete LARC rollout, inadequate supervision and focus on improvement Agency/Autonomy/Informed Choicemethod-specific promotion, program and supervisor focus on uptake results in provider pressure and bias Discrimination- poor women receive more directive counseling Illustrative Program Actions Advocate to policymakers for promotion of free, informed choice Support training for forecasting FP services to ensure realistic goals and adequate financing for roll-out Review fee structures to ensure affordable access to removals Strengthen counseling to make it unbiased and client-centered Make human rights explicit in training, service guidelines, provider job descriptions and supervisory tools

VIGNETTE 2: REENA, A 15-YEAR OLD YOUTH Reena is fifteen years old and lives in a farming community. Her parents are arranging for her to marry a merchant s son. Reena has other plans she wants to be a teacher. She has a boyfriend, Kazim, who is pressuring her to become intimate. Reena is conflicted about opposing her parents and is afraid of becoming pregnant, although she doesn t understand how pregnancy happens or how to prevent it. She has had no sex education in school. Reena notices a poster on the street for a new teen hotline and calls the number. She is referred to the local primary healthcare clinic, which is crowded with mothers and babies. She is led into a small area which is open to the waiting room. Reena is embarrassed, so complains of an imaginary headache. While the nurse takes her blood pressure, she tells the nurse that a friend of hers has a question about how to prevent pregnancy. The nurse looks disapproving and asks, How old is your friend and is she married? Reena replies, Sixteen and not yet married. Then she shouldn t be having relations and doesn t need prevention, says the nurse. With this, the conversation ends; Reena leaves, disappointed and confused.

VIGNETTE 2: RIGHTS CHALLENGES & PROPOSED ACTIONS Human Rights/Rights Principles Illustrative Program Actions Availability/Accessibility/Acceptability lack of services geared to the needs of unmarried youth Privacy/Confidentiality counseling offered in public area Non-discrimination- judgmental provider discriminates against unmarried youth Equity- unmarried youth not treated like other clients Autonomy/agency/empowerment: cultural norms do not support female empowerment Review/revise policies & plans and advocate for resources to support sex education & youth-friendly FP services Support SBCC campaigns to influence social and gender norms and promote awareness of women s and girls rights to RH info and services Re/train providers in counseling, including rights literacy and values clarification Revise job descriptions and supervision protocols to ensure providers are accountable for upholding human rights, including nondiscrimination and equitable access to quality information and services for all

THINK DIFFERENT Typical intervention Develop policies to support FP access and quality; remove unnecessary medical barriers to contraceptive use Train providers in FP clinical and counseling skills Strengthen supervision to support quality management and improvement Support demand creation activities, including community engagement/mobilization Strengthen monitoring and evaluation systems to support stewardship, management and accountability Rights-supportive intervention Ensure policies explicitly reference human rights and align with service guidelines and protocols; review who is/is not accessing services to support equity Integrate rights literacy in FP clinical and counseling training Ensure provider performance expectations and supervisory protocols include human rights; strengthen client and community feedback mechanisms Include the promotion of women s and girls rights in SBCC activities; implement interventions to address gender and sociocultural barriers Ensure FP strategies and plans include accountability and redress mechanisms; establish and ensure use of protocols for investigating allegations of rights violations

PROGRAMMING RESOURCES

WHAT DOES A RIGHTS-BASED APPROACH LOOK LIKE IN PRACTICE?

COMMUNITY ENGAGEMENT IN KADUNA, NIGERIA Training Facility Health Committees on FP, Rights, and their Roles and Responsibilities Ignited commitment to action on FP and human rights I am going to ensure clients are treated with courtesy and respect, receive good clinical care, [and experience] non-discrimination/equity. I will also ensure that the FHC puts in practice all that they have learned. FHC Member I will ensure that the PHC does not stock out on drugs and commodities needed. I will ensure that patients are treated in the right manner at all times. I will sensitize clients on their rights and how to utilize them. FHC Member I will ensure that client privacy and confidentiality is adhered to in the PHC's at all times. And to let them know that it is their right. FHC Member I will make myself accountable for sufficient drugs and family planning services in my community facility. FHC Member

COMMUNITY ENGAGEMENT IN KADUNA, NIGERIA Ignited follow-through Sensitization of community leaders and influencers (e.g. District Heads, Imams etc.) Community visits/dialogues held Successful resource raising for un- and under-funded facility needs Follow-up on individual commitments She sensitized her family members and women in Islamiya School on the benefits of FP. Two of these women from the Islamiya school became interested and were referred by her to the facility. They have visited the facility and accessed the services. Mentor, FHC Kabala He visited a family in the neighborhood and shared the benefits of family planning with them. The wife wants to take a rest but husband is resisting. He re-scheduled a visit to discuss with the husband. Mentor, FHC Romi

ACKNOWLEDGMENTS This presentation is based on work conducted on rights and family planning over a number of years and with support and input from a number of donors, organizations and projects. The Bill & Melinda Gates Foundation USAID The Hewlett Foundation FP2020 Futures Group/Palladium EngenderHealth Evidence Project/Population Council, IPPF and PRB Sustainable Networks Project: IPPF and RHU The following individuals were instrumental in developing the presentation: Lynn Bakamjian, Jan Kumar, Karen Hardee, Kaja Jurczynska, and Sandra Jordan

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