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

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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.

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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**