(October 2010) Policies are the foundation for building high-quality, sustainable family planning programs. However, while countries aspire to enhance equity and alleviate poverty, they all too often fail to articulate clear equity-based goals for family planning policies and strategies. Family planning policies must be informed by an understanding of the nature of inequalities in the country: identifying the poor and most vulnerable groups, quantifying inequalities in family planning service access and health status, and understanding the barriers to equitable access. Family planning policies can demonstrate a government’s priorities and commitment to improving the lives of its people. A family planning policy, plan, or strategy should outline clear, time-bound equity goals.

The poor and other vulnerable, underserved, and most-at-risk populations should be engaged throughout the family planning policy-to-action continuum. These groups are the most capable of voicing the challenges and barriers they face, and the appropriate interventions. Family planning policies and strategies must include equity-based monitoring mechanisms and indicators that assess the reach of programs and impact on health.

During a PRB Discuss Online, Suneeta Sharma, deputy director of family planning and reproductive health under the USAID Health Policy Initiative, answered questions from participants about incorporating equity goals into family planning policies and development agendas, and the challenges associated with this process. This global dissemination effort is the first of a series supported by PRB’s IDEA project, funded by USAID’s Bureau for Global Health.

Oct. 18, 2010 1 PM EST

Transcript of Questions and Answers 

Usman Al-Rashid: How do ensure equity in FP when there is short fall in commodities worldwide? In ensuring equity especially in FP, the less empowered and vulnerable groups need to be taken into consideration for free products and services. FP/RH is all about women, how do you ensure equity when the end users are more tilted to one side? FP equity should be seen in the broader picture of social development and empowerment. What is your take on all these?
Suneeta Sharma: Yes, this session focuses on reaching the poor. The poor have higher unmet need for family planning services, they are less likely to use modern methods, and in most of the countries highly subsidized public sector services do not reach the poor. It is important to engage and empower the poor; quantify the level of inequities; understand the barriers to access; integrate equity into policies, plans, and agendas; target efforts and resources to reach the poor; and yield public private partnerships for equity.

Boatemaa Sandra: For family planning policies to be effective, I suggest an awareness creation of the benefits of family planning to individuals, policy makers and communities and an in-depth explanation of family planning components.
Suneeta Sharma: Yes, awareness raising is an important strategy to keep FP high on policy agenda and facilitate better implementation of the family planning policies. Family planning saves lives. It is important from public health, human rights, and development angles.

Susana Toye: As part of this how do we access the hard to access – I am thinking specifically of child brides for example…
Suneeta Sharma: We need to target our efforts and resources to reach the underserved populations. For example, programs that bring services closer to the community can be effective in this case. Countries have initiated voucher and fee exemption mechanisms to make services affordable and accessible to the poor. Community based programs can be effective in reaching the married adolescents.

Sanjay Mishra: Family planning and population concerns are inextricably linked with development but development plans frequently do not be able to involve floating populations/pariah and other out-bands who live in camps near railway stations and in drainpipes. About 15% (as of my estimation) live unrolled/unregistered with a high fertility rate. I would like to put this concern with special reference to India where North East Bihar is full with such population living in temporary camps, who is responsible for this population as they have infiltrated now in Indian territory. Even this is common now in African continent – many southern African countries are receiving the population from the north. Is there any special policy/plans underway to make governments responsible and to mainstreamof those population groups? Secondly, how to cover them in family planning policies and development?
Suneeta Sharma: Population growth affects socio-economic development of a country. Reducing total fertility rate to the replacement level is an important goal in the 11th five Year Plan. A number of countries including Jordan and Thailand have strong health and family planning programs for refugee populations. Bihar needs targeted efforts to reach the underserved population and meet their unmet need for family planning services.

Issa Almasarweh: How can the most-at-risk populations be engaged and served if in many countries like Jordan, policy making is central and FP services are facility based?
Suneeta Sharma: Hi Issa! A number of countries organize consultative meetings at regional, district, and community levels to engage the policy implementors and clients. It is very important to understand demand side barriers to FP use and develop policies and strategies to address those barriers. We can conduct focus group discussions with users and non-users of FP, organize community level meetings, engage poor women in planning committees, and engage them as community mobilizers. We can also engage NGOs representing these poor women in problem identification, policy formulation, policy implmenetation, and policy monitoring. If you are interested, I can send you a report on engaging the poor. It has a number of good examples.

Sizarina Hamisi: The teenage and youth are most at risk for early pregnancies in Africa. How can a health/women issues journalist incorporate teenage/youth issues, family planning and development in a society where contraceptives are viewed as immoral?
Suneeta Sharma: • In Sub-Saharan Africa youth who are at risk for early pregnancy are also at risk for HIV transmission – must consider comprehensive approach to reproductive health care.
• Must take into account socio-cultural norms – early pregnancy is often tied to early marriage. in countries where early marriage is common practice, younger women are at greater risk for early pregnancy, and thus more likely to experience pregnancy-related complications. The approach in these countries should focus on delay of early marriage by promoting higher education for girls/women, and delaying sexual debut.
• Where contraceptive/condom use among youth is stigmatized, focus should be on abstinence but also ensuring high-quality youth friendly services (YFS) for sexually active youth. YFS, which offer activities beyond RH services and that involve parents and the community, have proven to be successful in many parts of sub-Saharan Africa.

Usha Natampalli: Don’t women with special needs need to be a part of equity policies?
Suneeta Sharma: Yes, inequities are defined as inequality of health status and use that is unjust, avoidable, and unnecessary. We definitely need to think about women with special needs. Also in poor/low income households, generally women have the least access to household resources. We have been involved in designing and implementing policy interventions for indigenous women, rural and urban poor women, and refugees. Understanding specific barriers to access among the poor and underserves groups and designing appropriate solutions in an essential part of the policy development process.

Rahat Bari Tooheen: Integration of equity goals will require a tremendous social investment into changing attitudes and norms that may hamper family planning goals. What would be the most socially acceptable strategy in this regard?
Suneeta Sharma: By equity goals, we mean specific goals for poor and underserved population who have higher unmet needs and lower contraceptive prevalence rates. For example, national reproductive health strategy of Kenya has spciific timbound CPR goals for the poor. This is perfectly aligned with the overall goal of FP. For achieving our overall goals for the FP, we need to target efforts and resources to meet unmet need for FP among the poor.

Jay Gribble: Hi Suneeta—Addressing equity into family planning policies and programs is critical to helping women and men achieve their desired family size. When we look at ideal family size, the poor tend to want to have more children than the wealthy, which poses challenges to health and development. How can programs address these types of social norms of large families without being paternalistic? Are you familiar with success stories in which these social norms among the poor have led to smaller actual or ideal family sizes? Thanks!
Suneeta Sharma: Hi Jay, we are emphasizing the need to fully understand both demand and supply side barriers to access among the poor and engage the poor in designing policy soltions and monitoring. Good understanding of demand side barriers help design more effective interventions: for example in Peru and Guatemala, indigenous women mentioned about non availablity of culturally appropriate information is one of the key barriers. In both these countries, policy efforts then focused on making culturally appropriate counseling available to these women. By engaging poor women as community mobilizers, the states of Uttarakhand UP in India were able to increease use of FP, MH, and ANC services among the poor. Kenya national strategy call for community based distribution and communication interventions to address the issues of higher desired fertility among the poor. I have not seen any documented evidence of changing social norms. But a number of countries have been effective in addressing demand side barriers.

Alain Yehouessi: 1- How could African countries reach family planning policies when those who are supposed to educate people (deputy in parliament, religious and political leaders, teachers and others) are not really convinced of the goodness of such policies? 2- Here in France and others developped countries many Africans researchers(senior and junior) are abble to help NGO and other association for family planning policies and development agendas. But most of the time those Africans are not contacted or associated. How could those NGO help African countries for instance without using those researchers? It’s difficult to be integrated in programs. Most of them in France are underused. But they could be used efficiently in Africa in various programs. Does USAID have a special approach to solve this problem?
Suneeta Sharma: There is a lot of emphasis on country ownership and sustainability. Donor-funded programs are mainly implemented by local NGOs and experts in the countries. Regional and global level forums and meetings provide a platform for experts in developed countries to contribute in these discussions. Also, international organizations are trying to engage experts through online panels and e-chats.

Joanna Hoffman: What can we be doing (or be doing better) to engage and involve youth in the development of FP policies and programs?
Suneeta Sharma: Countries have tried a number of strategies to engage youth in policy development and implementation. For example, Egypt and Jordan trained youth champions, organized youth forums, and engaged the ministry of youth in planning committees.

Joanna Hoffman: Access to family planning is often tied to issues of power and control within families and relationships. How can we address gender-based violence within the context of FP policies and programs?
Suneeta Sharma: In Kenya, the output based financing (voucher scheme) covers maternal health, FP, and GBV. They provide voucher that women can access free counceling and services related to GBV. In Bolivia, municipality level action plans have sections on GBV. Health Policy Initiative Project implemented a participatory methodology to understand the relationship between FP and GBV, identify reasons for GBV, organize community and policy level dialogue to inform the development of policies and programs to reduce GBV. Various municipalities also allocated funds for impllementing interventions to reduce GBV.

Usha Natampalli: Don’t you think Socio-Psychological Issues and gender planning need to be considered before planning for equity policies across nations?
Suneeta Sharma: We are trying to meet the unmet need for family planning, so that women and men can make informed decisions regarding their family size and spacing. The policies, efforts and resources need to focus on meeting needs of the poor and underserved population. In operational terms, I am suggesting strategies which are in the direct control of the health system. We need to take into account both the demand and supply side barriers to increased use of FP services.