Care International provided the following updates on progress in achieving its FP2020 commitments:
Validating tools to measure the impact of key approaches on health outcomes: CARE has developed three tools to support measurement of women’s empowerment, governance and health outcomes.
- WEMEASR (Women’s Empowerment- Multidimensional Evaluation of Agency, Social Capital and Relations). WEMEASR is a quantitative survey tool designed to use with women and consists of 20 short scales that measure women’s empowerment in domains critical to sexual, reproductive and maternal health. CARE is using various adaptations of WE‐MEASR in program evaluations in several countries to assess how well the scales work in other contexts and to explore associations between programming, empowerment and health behavior outcomes.
- Health Worker VOICES (Voices in Open, Inclusive Communities and Effective Spaces): A Tool to Measure Governance in Sexual, Reproductive and Maternal Health Programs (under review)
- Women’s VOICES : A Tool to Measure Governance in Sexual, Reproductive and Maternal Health Programs (under review)
The growing popularity and promise of social accountability approaches within the health sector makes it particularly important to foster good evaluation research to ensure that these approaches are effective. To this end, we developed and tested a set of measures evaluate a social accountability approach—CARE’s Community Score Card (CSC)—on reproductive and maternal health. We developed two survey tools—one for women (Women’s VOICES) and one for health workers (Health Workers’ VOICES). These tools include scales to measure constructs within CARE’s key governance outcomes domains: empowerment of women and community members; empowerment of health workers; and expanded, inclusive, and effective negotiated spaces in which the two groups can effectively interact to improve health service delivery and outcomes.
Reaching the most vulnerable and marginalized populations to reduce inequality: CARE focuses on reducing global poverty and inequality, and increasing social justice through the empowerment of women, girls and other vulnerable and marginalized populations. CARE has worked in several countries to implement programs and activities that work to reduce inequality:
- In Bangladesh, CARE is working with GlaxoSmithKline and the Government of Bangladesh to ensure mothers and children in remote areas of the country receive appropriate and necessary maternal and child health services, including family planning information and methods. CARE has worked with these partners on the Community Health Worker Initiative, to develop a skilled cadre of private MNCH providers that can complement government services in remote areas where the public health system is not adequately functioning. These private, skilled providers are women who come from the communities themselves, receive government training on skilled birth attendance and receive payment for their services, either through government entitlement schemes or fee for service from clients (these providers meet with communities and local government to establish fees that everyone can pay). The next phase of the project will include training specifically on family planning information, methods and services. This cadre of private, skilled providers is reducing a reliance on unskilled providers and ultimately, reducing geographic and wealth inequities in access to critical healthcare services.
- Through the Supporting Access to Family Planning and Post Abortion Care (SAFPAC) Initiative, CARE supports the delivery of family planning and other essential SRH services within CARE’s emergency response in Nepal and Syria, to those most affected and left vulnerable by emergency and conflict. In Nepal, CARE has been providing clean delivery kits and dignity kits to women living in the hardest-hit rural areas and is working with partners, such as UNFPA and local NGOs, to ensure access to life-saving SRH services (family planning, safe delivery, rape treatment, and STI treatment). In Syria, CARE is providing financial, technical and material support to a local NGO to deliver comprehensive family planning services to Syrian women served by 6 health centers in Idleb and Aleppo governorates.
- In Ethiopia, the TESFA project had targeted married adolescent girls who are hard to reach, most vulnerable, socially isolated groups in their community. The primary goal of the project was to improve their sexual reproductive health, with a particularly focus on increasing access to family planning and improving their economic empowerment. The initiative helped to draw lessons on how to reach an isolated subgroup of girls, recruit them into program and facilitate their empowerment process including their access to FP information and services. At the end of the project, access to FP services had significantly increased, with current use of modern contraception increased from 51% to 78%.
Ensuring women and girls’ family planning and reproductive health needs are addressed in both development, emergency and post-conflict response activities: CARE’s sexual, reproductive and maternal health programming works throughout the emergency to development continuum to reach the needs of the most vulnerable, especially women and girls. CARE works with partners such as UNFPA and UNHCR to reach the most vulnerable in emergency and crisis-affected settings.
- Since 2011, CARE’s Supporting Access to Family Planning and Post-Abortion Care in Emergencies (SAFPAC)Initiative has been reducing unintended pregnancies and deaths from unsafe abortion by delivering FP and PAC services to crisis-affected populations in 5 countries with large SRH needs: Chad, Djibouti, DR Congo, Mali, and Pakistan. Core interventions include: 1) providing competency-based training with follow-up clinical assessment and coaching to health providers; 2) ensuring a continuous supply of reproductive health commodities to all health facilities and strengthening inventory management practices; 3) making supportive supervision visits to health facilities on a regular basis; and 4) mobilizing communities to raise awareness about family planning and to shift norms that block women’s access to family planning services. At the same time, the initiative has been strengthening CARE’s institutional capacity to support SRH programming across its emergency response. Currently, the initiative supports the delivery of family planning and other essential SRH services within CARE’s emergency response in Nepal and Syria (see above). Between July 2011 and May 2015, the SAFPAC project reached 98,658 new users of modern contraceptive methods across the 5 countries (with a catchment population exceeding a half million women of reproductive age), 57% of whom chose long-acting methods of implants or intrauterine devices
- CARE is also committed to reaching the FP and RH needs in emergency and post-conflict responses though our leadership in and engagement with the Interagency Working Group on Reproductive Health in Crises (IAWG). CARE serves on the IAWG steering committee where it has successfully advocated for the inclusion of family planning as part of the Minimum Initial Service Package for Reproductive Health in Crisis Situations (MISP).
Building political will and mobilizing action at all levels ensure accountability to commitments: At the global level, CARE has actively contributed to key processes to shape standards and commitments to delivering universal access to high-quality, rights-based family planning, and to strengthen systems for ensuring meaningful accountability of all actors to deliver on these commitments. Highlights of this work include:
- CARE served as one of four civil representatives on the Accountability Work stream for the UN Global Strategy for Women’s Children’s and Adolescents Health, which shaped guiding principles and structures for monitoring and accountability of the Global Strategy at global, national and sub-national levels.
- CARE provided significant staff time to support FP2020; specifically, supporting membership on the FP2020 Rights and Empowerment Working Group. This group contributed to the development of FP2020 Rights and Empowerment Principles, and the development of rights indicators to measure progress in achieving FP2020 goals. CARE continues to advocate for the inclusion of citizen-generated feedback on FP services in FP2020 monitoring and accountability systems.
- CARE contributed to a multi-stakeholder consultation convened by the Guttmacher Institute to develop a set of relevant and measurable SRHR indicators for the post-2015 SDG framework.
Ensure implementation of policies and programs that are rights-based, effective, and culturally appropriate and address the needs of communities: Since 2011, CARE has been working in southern Chad to increase access to high-quality family planning services for host and internally displaced (IDP) populations served by the government’s primary health care system.
- This initiative emphasizes long-acting reversible contraceptive (LARC) methods and comprehensive counseling in order to ensure that women obtain the method that best meets their needs and preferences. When CARE began this work, national guidelines for SRH service delivery restricted LARC services to hospitals. Furthermore, these guidelines required nurses and midwives to be supervised by a doctor whenever providing LARC services. These conditions effectively prevented many women in Chad from accessing LARC services. CARE helped change these guidelines by working hand-in-hand with local government and communities to demonstrate that nurses and midwives can safely and effectively deliver these services in health centers if they receive competency-based training and regular supportive supervision. Based in large part on this joint effort, the Ministry of Health convened a series of workshops with key partners (e.g. CARE, UNFPA and an IPPF affiliate) to produce the 2013 National Family Planning Policy, which, among other things, permits LARC service delivery in any primary health center by any trained nurse or midwife regardless of a doctor’s presence.
- At the other end of the spectrum, CARE has been working with local government officials, law enforcers, and community leaders to raise their awareness of existing national policies and laws protecting women’s right to SRH services. The national 2002 SRH law (2002) protects women’s right to receive family planning, without consent from a father or husband and without regard to her marital status. However, when CARE began its work, many people, including police officers, were unaware of this law and believed that it was illegal to provide family planning to young or unmarried women and to women without their partners’ knowledge or permission. After several men registered official complaints with the police concerning their wives’ use of family planning services without their consent, CARE met with local police officers to discuss the national SRH law and the right of women to SRH services. Not only did the officers end up supporting the law, but also they requested more information about various family planning methods and their benefits. In response, CARE held two workshops for police on the national SRH law, SRH rights, family planning and birth spacing. Since then, police have facilitated similar workshops for men’s groups and both health care providers and women have reported referring husbands to the police to verify and explain the legality of contraceptive use. Consequently, CARE has made it a best practice to ensure that all stakeholders know about and understand the provisions of the national SRH law.
Developing approaches for addressing gender and social barriers to increased family planning use: Since the London Summit, CARE has continued to strengthen our knowledge and evidence base for catalyzing meaningful change in the social and gender norms that restrict health and rights. A core approach used by CARE is Social Analysis and Action (SAA), a participatory dialogue process that enables men, women and youth to explore and challenge the social norms, beliefs and practices that shape their lives and health.
- The SAA approach was used in the Results Initiative, (RI) a four year project carried out in Kenya, Ethiopia and Rwanda with the goal of increasing and sustaining the use of family planning by addressing the underlying social and cultural barriers to family planning, including gender norms. The project catalyzed ongoing dialogue with men, women and youth about how gender roles restrict family planning and provided role models for equitable communication and use of family planning. In Kenya, results from the project revealed significant increases in the current use of modern family planning between baseline and endline: use of modern family planning increased among women by 17.2% (from 34% to 51.2% of women) and among men increased by 24.3% (from 27.9% to 52.2%). Women who participated in SAA dialogues were significantly more likely to use modern family planning methods. Women’s reported use of modern FP was significantly associated with higher spousal communication, control over their own cash earnings and self-efficacy to use FP. Men were significantly more likely to use modern FP if they reported high approval of FP and more equitable gender beliefs. In qualitative interviews, men and women described how community dialogues addressed myths and misconceptions, normalized discussion about FP, and increased its acceptability. Public examples of couples making joint FP decisions and using FP provided models appeared to legitimize communication and joint decision-making with spouses about FP especially for men. Women described partner support as a key enabler of FP use, offering practical and emotional benefits; however, women emphasized the importance of their ability to access FP without their partners’ knowledge and support when facing partner opposition. Couples reported that increased communication contributed to increased couple-level ha
- Similarly in Ethiopia, the project evaluation reported significant change in the use of family planning, where women’s FP current use changed from 32%-61% and men’s from 38%-82%. Inter spousal communication is found to be positively and significantly correlated with levels of exposure to the RI project and is positively associated with FP use for both men and women in the household survey. CARE continues to address gender and social norms in our SRMH programming.
- The SAA approach has also been used to improve family planning use among married adolescent girls in Ethiopia by the TESFA Working with key ‘gatekeepers’ of married adolescent girls to critically reflect on the barriers to FP use and the negative consequences of the restrictions to access services, it was possible to create support for the most marginalized and invisible groups of adolescent girls to access FP information and services. By the end of the project, use of modern family planning methods showed a 27 percentage point increase among the targeted adolescent girls.
- CARE has conducted a recent mapping that revealed that the SAA approach has been adapted and used for sexual and reproductive health projects including family planning in more than 10 CARE country offices. The lessons and experiences of using the approach and some of the results have been shared with partners at key international conferences including the International Conference on Family Planning (2013) and Women Deliver (2013).
- The success of SAA hinges on creating an effective cadre of change agents: CARE staff/SAA facilitators build awareness about how their own assumptions, beliefs, and attitudes about gender, power and sexuality shapes their work, and build concrete skills for facilitating productive dialogues about gender, sexuality and power. CARE is developing training materials for SAA facilitators to build key facilitation skills and provide tools and guidance for catalyzing community dialogues for social change.
