gh prh priorities 2014-2020.pdf

GH/PRH Priorities for

2014-2020

Draft for Discussion January 2015 2

GH/PRH Priorities for 2014-2020

Introduction

International family planning is an impressive story of global evolution in political will, policy change, appreciation for human rights, social norms and behavior change. Modern contraceptive prevalence has more than quadrupled to 46% (55% including China) since the 1960s, and actual family size has declined from more than six children per woman to three (2.6, including China), on average. Change that took centuries in Western Europe and the US has transpired in just one or two generations in Asia and Latin America and is unfolding increasingly rapidly in much of Africa. For five decades, USAID has played an intellectual and technical leadership role in this transformation.

Even so, challenges remain. Family planning receded from the global radar screen in the years following the 1994 Cairo Conference on Population and Development as the broader concept of reproductive health took center stage and attention and resources shifted to fighting the HIV/AIDS epidemic. Millennium Development Goal (MDG) 5b, universal access to reproductive health (which includes access to voluntary family planning), has seen the least progress over the 15-year MDG timeframe. More than 220 million women in developing countries want to postpone or stop childbearing but are not using a modern method of contraception and actual family size still exceeds desired family size in many countries. Key subpopulations —adolescent girls and boys, the poor, newly married couples, post-partum women, and men—do not have equitable access to the FP/RH services they want and deserve. Unequal gender norms continue to disadvantage women and girls in multiple health and non-health arenas. Public sector supply systems are struggling to meet the needs of their populations for high-quality information, services, and products. Long acting and permanent methods of contraception (LAPM) are not as available, affordable, accessible, or acceptable as short acting methods despite the fact that desire to limit childbearing exceeds desire for spacing everywhere except West and Central Africa.

Various partnerships in recent years have helped to revitalize attention to FP/RH. The Ouagadougou Partnership, established by USAID, Government of France, the Bill & Melinda Gates Foundation (BMGF), and Hewlett Foundation in 2011, focuses on jump-starting FP/RH in Francophone West Africa. The Alliance for Reproductive, Maternal, and Newborn Health, founded in 2012 by USAID, the U.K. Department for International Development, BMGF, and Australian Department of Foreign Affairs and Trade, created a forum for these four donors to jointly prioritize accelerated action towards achievement of MDG 5. The 2012 London Summit on Family Planning brought welcome global visibility to family planning, setting a goal of enabling 120 million additional women and girls in the world’s 69 poorest countries to access and use contraception by 2020 and launching the global movement known as Family Planning 2020 (FP2020). More than 30 of the 69 countries have made commitments to address the policy, financing, delivery and socio-cultural barriers to women accessing contraceptive information, services and supplies; and donors, foundations, and private entities have pledged an additional US$2.6 billion in funding. USAID remains the largest bilateral donor of international FP/RH assistance, has a

Draft for Discussion January 2015 3 leadership role in the FP2020 governance structure, and is a key implementing partner of the FP2020 agenda.

With this history and renewed momentum as background, USAID’s Office of Population and Reproductive Health held an Office-wide retreat in September 2013. Our primary purpose was to identify priorities for the use of core FP/RH funds over the 2014-2020 period. This an opportune time to look forward and position the Office for continued leadership:

The 2015-2030 Sustainable Development Goals (SDG) are taking shape, providing a unique opportunity for the Office to demonstrate global leadership in influencing how FP/RH is included and progress is measured.

Rights and equity are key themes in the SDGs and have particular salience for FP/RH.

The Office can contribute its experience in promoting voluntarism, informed consent, and program quality, as well as its pioneering work on gender equity to the global dialogue and to country-level programming.

A majority of the countries that have made pledges to FP2020 are USAID FP/RH priority or Ouagadougou Partnership countries yet progress towards the FP2020 goals has been slower than expected. A clearer focus by the Office on method choice, supply chains, family planning workforce, behavior change communication, a total market approach, and country support by Office staff can help accelerate progress.

The Lancet Commission on Investing in Health identified three key components of a road map to achieving a convergence in health status between developing and developed countries: mobilizing financing, targeting financing towards the most cost-effective interventions, and increasing investment in research and development.

Building on its history of strong support for improving the policy environment, the Office can help foster commitment for increased domestic resource allocation to family planning (a Lancet Commission best buy) in partner countries; and the Office will continue its leadership in contraceptive research, development, and introduction.

Our thinking since the retreat has benefitted from input at a PRH Partners’ Meeting in early 2014 and additional elaboration of five focus areas by small working groups. This document identifies priorities, and how and where we will work. These parameters will guide decisions about the allocation of GH/PRH core funds and the core-funded activities of our implementing partners. We hope the document will be useful to USAID field missions and AID/W offices, donors, foundations, and other public and private sector entities that may be interested in partnering and/or investing with us to advance this work.

GH/PRH Priorities for 2014-2020

1. Continued Commitment to Fundamental Principles and Guiding Rationales Our commitment to long-standing fundamental principles and guiding rationales remains unchanged.

Our work will continue to be guided by the principles of voluntarism and informed choice that have been the foundation of USAID’s population (now family planning and

Draft for Discussion January 2015 4 reproductive health) program since its inception in 1965. Decisions about whether, when, and how many children to have are personal and private. Individuals and couples have the right to make and act on those decisions freely and for themselves, without coercion and with accurate and full information about the benefits and side effects of available contraceptive methods, as well as all legal pregnancy options. Additional principles of equity and rights are also fundamental to the Agency’s FP/RH program. The principle of equity requires that the ability to make and act on these fertility decisions be available to all, regardless of circumstances such as geography, income, or HIV status, among others.

The rights principle extends beyond the right of individuals and couples to choose the number, timing, and spacing of their children to the responsibility of duty bearers to protect, respect, and fulfill that right. Over the 2104-2020 period, the Office will continue to fund and support activities that ensure voluntarism and informed consent in FP/RH programming and promote equity in access to FP/RH services. We will also seek opportunities to demonstrate the value-added of a rights-based framework for family planning, helping to refine the framework as needed.

USAID’s FP/RH program is guided by three inter-related rationales: 1) Individuals and couples have a right to choose the number, timing, and spacing of their children (discussed above); 2) FP/RH programs improve women’s and children’s health; and 3) FP/RH programs benefit economic development, natural resource sustainability, and state stability through their effects on population size and age structure. Although each of these rationales has enjoyed support at different times or among particular stakeholder groups, all are relevant to both FP/RH and the broader development agenda. For example, FP/RH programming as an economic development intervention makes recognized contributions to achieving USAID’s mission of “partnering to end extreme poverty and to promote resilient, democratic societies while advancing our security and prosperity.” As a health intervention, it contributes to the Agency’s health goals of ending preventable child and maternal deaths and achieving an AIDS-free generation. Over the 2014-2020 period, the Office will categorize its work according to the Agency mission and health goals. The Office will continue to fund and support activities that promote achievement of the demographic dividend, with attention to equity; link family planning and population dynamics to resilience, environmental sustainability, and state stability; further demonstrate through research and implementation the linkages between healthy timing and spacing of pregnancy and improved maternal and child health; and improve access to high-quality information, services, and appropriate contraceptive methods for people living with HIV and AIDS.

2. Provide Global Leadership on a FP Indicator and Benchmark for the SDGs Over the 2014-2020 period, GH/PRH’s efforts will contribute to the FP2020 goal of enabling 120 million additional women and girls to use contraceptive information, services, and supplies, without coercion or discrimination, by 2020. At the same time, we seek to ensure that FP/RH continues to be recognized as an indispensible component of development programming well into the future. To that end, GH/PRH supports the inclusion of universal access to reproductive health as a target for the SDGs. We define access as encompassing availability, affordability, accessibility, acceptability, and quality of information, services, and products, as well as agency to seek and use the FP/RH services of one’s choice. GH/PRH also believes the concept of voluntarism must be central to a family

Draft for Discussion January 2015 5 planning indicator under this broader reproductive health target. To this end, GH/PRH has proposed “met demand for family planning” as the indicator and “75% of the demand for family planning met by modern contraceptive use in every country” as the 2030 SDG benchmark. Over the 2014-2020 period, the Office will support additional analysis of the implications of this benchmark for country programs, including expansion of the denominator to include all women, disaggregation of the benchmark by age groups and wealth quintile, and implications for programming strategies and investments. GH/PRH will also undertake further analysis of the relationship between the FP2020 goal and the 2030 FP benchmark.

3. Advance Five Focus Areas A significant outcome of the retreat was the decision to identify five focus areas1 for the Office’s work for the 2014-2020 period. These five areas represent both a focus on ensuring that the fundamentals of strong FP/RH programming are solid and advancing new approaches. The five focus areas are:

1. Method Choice: Method choice exists when client-centered information, counseling, and services enable women, youth, men, and couples to decide and freely choose a contraceptive method that best meets their reproductive desires and lifestyle, while balancing other considerations important to method adoption, use, and change.

2. Social and Behavior Change Communication: Social and behavior change communication is most effective when it is theory-driven, interactive, and uses a range of communication channels and approaches to shape not only demand and FP use, but also client-provider communication, couples’ communication, and engagement of community leaders and other influencers.

3. Supply Chains: Supply chains are functioning well when contraceptives and related FP/RH supplies are available to clients, when and where they need them, in good quality and at affordable cost.

4. Family Planning Workforce: A well-performing FP workforce is one that works in ways that are responsive, fair and efficient to achieve the best FP outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed;

they are competent, responsive and productive).

5. Total Market Approach: A total market approach is implemented when the comparative advantages and complementary roles of all sectors of the FP/RH market are considered and supported in order to foster long-term, sustainable delivery of FP/RH information, products and services to all market segments or population groups who want to use them.

Each of the five areas is further elaborated in the appendix to this document. Each focus area brief provides a definition of the focus area, a vision for 2020 and 2030, priorities for programming with PRH core funds, and linkages to the other focus areas. GH/PRH

1 For the past decade, the Office has had six technical priorities—FP/HIV integration, FP/MCH integration, contraceptive security, long-acting and permanent methods, community-based access, poverty/equity—and four cross-cutting priorities—youth, gender, population-environment, and repositioning family planning. As a result of the 2013 retreat, some of these areas are being folded into one of the five focus areas (e.g., Method Choice encompasses LARC/PMs; Total Market Approach and FP workforce encompass different aspects of community-based access) while others will be pursued as components of the principles (e.g., attention to gender and poverty/equity as component of rights) or as integral to the Agency mission (poverty/equity, population-environment) or health goals (FP/MCH, FP/HIV), or centered within our geographic focus (repositioning family planning).

Draft for Discussion January 2015 6 recognizes that these five focus areas do not encompass the full range of FP/RH programming needed at the country level nor the full range supported by USAID missions.

However, we believe that prioritizing them will greatly further the Office’s strategic objective of “advancing and supporting voluntary family planning and reproductive health programs worldwide” and assist Missions in achieving their specific FP/RH program objectives. Over the 2014-2020 period, GH/PRH will support these focus areas with additional attention, technical underpinning, and resources.

4. Maintain Attention to Evidence and a Supportive Environment These focus areas do not define the totality of the Office’s portfolio. Success in the five focus areas will require attention to FP/RH program components that are traditional strengths in the GH/PRH portfolio. These strengths include improving the enabling policy environment, attention to gender norms, biomedical and implementation science research, and strong data collection, monitoring and evaluation. Over the 2014-2020 period, the Office portfolio will continue to include activities that advance and support these components, while also ensuring that they evolve to meet new needs (e.g., mobilizing domestic resources for

FP/RH).

5. Focus on Underserved Populations, Particularly Youth Youth ages 10-24 account for more than 30% of the population in many developing countries, and their reproductive health knowledge and access to information and services is generally worse than that of married women of reproductive age. Their access to education, health services, and jobs, and the decisions they make in these areas, will affect the world’s progress for decades to come. It is impossible to think about future FP/RH programming without considering the needs of youth.

However, youth are not a homogenous population. Nor are they the only key population.

Married youth are often underserved by FP programs, as social norms to prove their fecundity are strong. Keeping girls in school is a proven intervention to delay age at marriage but often exposes them to gender-based violence and unintended pregnancy.

Post-partum mothers and post-abortion clients are key audiences for messages about healthy birth spacing. Rural and peri-urban populations often have to travel long distances to access FP/RH services or find them too expensive. The Office will prioritize youth and other underserved populations over the 2014-2020 period. Effectively reaching underserved populations will require both demand-side interventions (e.g., tailored messaging for youth, awareness-raising among key influencers) as well as supply-side programming (e.g., training for service providers in LAPM, expanding provision of fertility-awareness based methods and vasectomy, changes in policies, effective market segmentation).

How GH/PRH Will Work The Office will continue to organize its work according to the three intermediate results of our strategic framework: 1) global leadership demonstrated in FP/RH policy, advocacy, and services; 2) knowledge generated, organized, and disseminated in response to program needs; and 3) support provided to the field to implement effective and sustainable FP/RH programs. Over the 2014-2020 period, the Office will increase our emphasis on, and capacity to undertake and successfully nurture, donor and public-private partnerships.

Draft for Discussion January 2015 7

Where GH/PRH Will Work The 24 priority countries for USAID’s FP/RH program are identical to those for EPCMD activities, with the exception of the exclusion of Indonesia (which has graduated from USAID FP/RH assistance), and the inclusion of the Philippines (which has strong MCH indicators and poor FP/RH indicators). In addition, as a founding partner in the Ouagadougou Partnership, USAID is increasing attention to FP/RH programming in Francophone West Africa (Benin, Burkina Faso, Cote d’Ivoire, Guinea, Mali, Mauritania, Niger, Senegal, and Togo). Over the 2014-2020 period, the Office will continue to prioritize these 31 countries2 in its allocation of core resources and its program design, as well as advocate for additional bilateral resource allocation to West African countries.

Beginning in the early 2000s, USAID has pursued a strategic approach to graduating countries that have developed strong and sustainable FP/RH programs. This approach has permitted the allocation of additional resources to priority high-need countries, largely in sub-Saharan Africa and South Asia, even in the face of relatively stagnant budgets. Budget increases that came with President Obama’s Global Health Initiative have enabled additional increases in country allocations. Over the 2014-2020 period, the Office will revisit the graduation strategy and identify the next set of countries that is approaching graduation thresholds.

2 Senegal and Mali are included in both the 24 priority countries and the Ouagadougou Partnership countries.

Draft for Discussion January 2015 8

Appendix

1) Method Choice

VISION: In support of the goals for reaching 120 million additional family planning users by 2020, meeting 75 percent of demand for family planning by 2030, ending preventable child and maternal deaths, and achieving an AIDS-free generation:

By 2020 more women, youth, men and couples in USAID’s 24 priority countries and the Ouagadougou Partnership countries who wish to prevent pregnancy are using their preferred method of family planning (FP).

By 2030, a broad range of contraceptive methods is available to meet the varying needs of women, youth, men and couples who wish to prevent pregnancy.

DEFINITION: Client-centered information, counseling and services enables more women, youth, men, and couples to decide and freely choose a contraceptive method that best meets their reproductive desires and lifestyle, while balancing other considerations important to choice, correct use, or switching methods, PRIORITIES for 2014 - 2020:

1. Connect specific population groups with appropriate methods by expanding the range of existing methods available. Some contraceptive methods may be specific to certain populations, such as permanent methods (PMs) for limiters and the Lactational Amenorrhea Method (LAM) for postpartum women, while other methods remain underutilized by or inaccessible to certain populations, such as long-acting reversible contraceptives (LARCs) for youth and postabortion women, and vasectomy for men.

Thus, specific sub-populations to reach include:

● Youth: expand access to methods beyond pills and injectables, including LARCs, emergency contraception (EC), male and female condoms, LAM for young breastfeeding mothers, and the Standard days Method (SDM) to raise awareness about reproductive health (RH), menstrual cycles and pregnancy risk.

● Limiters: ensure that LARCs and PMs are available and affordable; remove access barriers.

● Postpartum: Promote LAM; offer IUD, tubal ligation and vasectomy for immediate PP use; for breastfeeding women offer progestin-only methods after six weeks (MEC review may change the timing for immediate postpartum use) and combined hormonal methods after six months. Counsel non-breastfeeding women to begin use of ANY method within 30-45 days after birth.

● Postabortion: expand access to all FP methods, including EC, LARCs and PMs.

● Men: encourage participation with partner in FP counseling and use of SDM, condoms, and vasectomy.

● Lowest quintiles: remove cost barriers to all FP methods and services.

2. Introduce or scale up access to under-utilized methods (e.g., implants, IUDs, tubal ligation, vasectomy, emergency contraception, injectables, LAM, SDM) to expand

Draft for Discussion January 2015 9 method choice for poor and underserved communities and sub-population groups (e.g., youth, poor, peri-urban, postpartum, postabortion, limiters, men, PLHIV)

● Implement evidence-based and effective service delivery approaches that include both supply and demand components and reach underserved communities and population groups, such as:

o mobile outreach, community-based distribution (CBD) of injectables, social marketing, social franchising, postpartum and postabortion FP integrated with MNCH/N services, FP integration with HIV services, task shifting, youth-friendly services, male clinics, event days, vouchers, mobile technology, etc.

● Identify and implement activities for key points of intersection with the other four focus areas and policies to enhance method choice, such as:

o Social and Behavior Change Communication (SBCC): Promote “Positive

Positioning” of FP that addresses the beneficial aspects of FP and of each contraceptive method. Refocus counseling to be rights-based and client-centered, starting with clients’ needs, desires, knowledge, and requests, and helping her/him decide on a method that can be correctly and consistently used, or to switch to another method in order to achieve their reproductive desires and fit with their lifestyle.

o Product Availability (PA): Strengthen the role of service providers and pharmacy managers in logistics management information system (LMIS), stock management and forecasting; strengthen last-mile distribution and first-mile LMIS reporting to avert stockouts.

o Family Planning Workforce (FPW): Address provider bias regarding specific methods or client characteristics; ensure skill base to provide quality counseling to male and female clients as well as couples to enable all clients to make free and informed decisions about whether and when to have children, what method to use, and how to correctly use it. Ensure provider competence to provide quality clinical services for methods requiring injection, insertion, removal, or surgery.

o Total Market Approach (TMA): Offer a range of quality information, counseling and services to obtain methods through public, NGO, commercial, and lay and private (not for profit) providers/ outlets, as appropriate to the population and the method.

o Policies: Promote operational policies that enhance access to method choice (e.g., to support task shifting, reduce price to consumers, enable service integration, improve quality and informed choice, remove age, parity and other medical barriers, expand private sector sales and provision, etc.)

3. Support missions and bilateral projects to expand method choice

● Support missions and their bilateral projects to implement and document High

Impact Practices (HIPs) and other evidence-based/effective practices (EB/EPs) for introduction and scale up of methods and choice, and to evaluate the impact of expanding method choice and access, including to specific populations.

● Support missions to build method choice, access, and specific sub-populations into new designs as well as their PMP and reporting.

Draft for Discussion January 2015 10

● Provide periodic data-based updates (e.g., met/unmet need among specific sub-populations, procurement orders); coordinate on mission needs (e.g., policy, service delivery capacity, BCC, etc.) to respond to shifts in fertility intentions, method choice and access, etc.

4. Introduce new methods/technologies

● Introduce and document the effectiveness of information, counseling, service delivery, demand creation and system strengthening approaches for expanding access to new methods/technologies and/or population groups, including introduction of:

o new technologies (e.g., Sayana Press, Implanon NXT) o women-initiated methods (e.g., SILCS diaphragm, vaginal rings, women’s condom)

● Understand and support women’s agency related to female-initiated and controlled methods.

5. Demonstrate global Leadership Communicate the vision, definition and priorities of method choice to internal and external stakeholders [coordinate w/ Knowledge Sharing, Country Support, Partnerships, and SBCC].

o Provide direction to PRH projects and communities of practice (CoP) to: expand method choice for specific methods and population groups; improve the quality of counseling for method choice; ensure norms support clients’ decision making.

o Implement staff updates in PRH, (and with HIDN, OHA, OCS, HSS, regional bureaus and Missions) including technical information and programming considerations for each method.

Collaborate with global partners, manufacturers, Missions and projects on:

o Specific methods and technologies, such as the Implants Access Program, Sayana

Press, LNG-IUS, expanding access to permanent methods, PPIUD inserter, etc.

o Advocacy for financial resources to scale up information, counseling, quality, service delivery, and the development of new contraceptives and technologies.

Collaborate with WHO on key issues of global impact, such as Medical Eligibility

Criteria (MEC); Task Shifting; HC/HIV safety and drug interactions; materials for program managers, providers, clients, trainers; prequalification of contraceptives and technologies, research priorities, etc.

6. Strengthen Measurement, Monitoring, Research and Data Utilization

● Conduct research to better understand method choice as it relates to patterns of use, switching; client interest, concerns and preferences by age, wealth, parity, residence, lifestyle. Develop, test and implement indicators to measure method choice. Incorporate into DHS analyses, special studies, Mission PMPs/PPRs.

● Commission HIP Briefs, DHS secondary analyses, journal articles and papers around issues related to method mix, method choice, fertility intentions, method switching, etc.

Draft for Discussion January 2015 11

● Test alternative approaches to facilitating client’s decision making and method choice that are client-centered, based on reproductive desires, fit with the client’s lifestyle, provide comparative information on effectiveness and side effects, and enable the client to use the method correctly and consistently, or switch to another method if desired.

● Monitor, analyze, and support advocacy and policy formulation based on results of studies in emerging areas, such as ARV/HC interactions.

● Monitor DMPA and implants orders and pipelines as sentinel indicators, and engage countries to assess / align with their service delivery capacity for scale up.

● Continue biomedical research to:

o develop multipurpose prevention technologies (MPTs) that provide simultaneous protection from unintended pregnancy and STIs, including

HIV;

o fill gaps in the existing method mix (e.g., highly effective methods that last for one-to-two-years);

o refine existing methods to make them more acceptable, affordable and easier to provide and to use (e.g., biodegradable implants, non-surgical sterilization).

Draft for Discussion January 2015 12

Social and Behavior Change Communication (SBCC)

Vision:

PRH envisions a future in which women and girls, as well as men and boys, possess the knowledge, skills and motivation to practice positive reproductive health-related behaviors, including:

● Open discussion of sexual health and reproductive health, desired fertility, and contraception,

● Healthy timing and spacing of pregnancies,

● Voluntary adoption of family planning, with attention to changing needs across the lifespan, and

● Correct and consistent use of contraception.

By 2020, USAID-supported behavior change activities in priority countries will consistently reflect proven practices in coordination, design, implementation, and evaluation for SBCC,3 and will measurably contribute to increased contraceptive utilization among priority populations.

By 2030, partner governments and local organizations will possess the technical and operational capacity to coordinate, design, implement, monitor, and evaluate effective SBCC programs. Locally-led behavior change programs will employ proven practices, including close alignment with health services and attention to social and normative factors, to increase and sustain correct utilization of contraception. Finally, there will exist sustainable country-level or regional mechanisms for SBCC training and professional development, including academic programs, specialized training organizations, and communities of practice, as well as fora for knowledge management and learning, such as online platforms, databases, or materials libraries.

Definition: SBCC is the use of communication strategies—mass media, “new” and social media, community-level activities, and interpersonal communication (IPC)— to influence individual and collective behaviors pertaining to health. High-quality SBCC is an essential element of health programming, as it shapes not only demand, but also client-provider communication, couples’ communication, and engagement of community leaders and other influencers. SBCC is closely related to advocacy (which seeks to influence the behavior of leaders) and social marketing (which includes demand creation for socially marketed products and services), and should ideally be aligned with both at the country level through partner coordination and shared planning processes.

Many implementers situate SBCC in a socio-ecological framework, which recognizes that determinants of health and health behavior exist on multiple levels and extend beyond the individual. Specifically, socio-ecological models acknowledge the influence of interpersonal

3 As defined in High Impact Practices in Family Planning: Health Communication, available at https://www.fphighimpactpractices.org/resources/health-communication-enabling-voluntary-and-informed-decision-making.

Draft for Discussion January 2015 13 relationships, community structures, and cultural norms and values on individual choices and behaviors.

Research shows that theory-driven, interactive communication that follows a proven design and implementation process 4 can increase knowledge, shift attitudes and norms, and produce changes in a wide range of behaviors. In the context of family planning programs, well-designed and -implemented SBCC can increase acceptability, quality of care, and agency by:

● Creating informed and voluntary demand for family planning products and services.

● Ensuring individuals can use contraceptives correctly and appropriately.

● Helping healthcare providers and clients interact with each other in a respectful and non-judgmental manner.

● Changing non-clinical behaviors that contribute to sexual health, such as age of sexual debut, number of sexual partners, alcohol/substance abuse, and gender-based violence.

● Shifting norms that influence individual and collective behavior, including those pertaining to desired family size and birth spacing; women’s decision-making, couples’ communication; men’s roles and responsibilities in family planning; and young people’s sexuality and sexual health.

Priority Audiences:

SBCC has been shown to influence uptake of family planning services among women with unmet need. It is also unique in its ability to address norms and behaviors that exist outside the health system, and to reach those who may not access clinic-based health services. For this reason, priority audiences for reproductive health SBCC include young people (including very young adolescents; unmarried and married adolescents; and young parents); men (as both users and supporters of family planning); and socially marginalized groups.

In addition to these primary, or “direct,” audiences, SBCC should be leveraged to improve knowledge, attitudes, and behaviors among influencing audiences, including healthcare providers, parents, and community leaders.

4 Proven approaches for design and implementation of SBCC programming include JHU-CCP’s P-Process, FHI360’s C-Cycle, PSI’s DELTA, and other processes that encompass systematic review of data; identification of audiences, messages, and channels; pretesting of creative outputs; implementation; and evaluation.

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Cultivating Global Leadership in Social and Behavior Change To achieve its goals in FP/RH behavior change, USAID must support its staff and partners in developing, evaluating, and refining targeted, innovative approaches to behavior change.

PRH will continue to emphasize innovation in the behavior change work it supports, through:

● Review of trends across the behavior change and communication fields;

● Evaluation of emerging practices; and

● Support for activities that encourage engagement of new partners and ways of thinking.

GH/PRH and Missions will cultivate a culture of learning and collaboration that emphasizes exchange between USAID and other donors active in development communication (including UNICEF, UNFPA, the Bill and Melinda Gates Foundation, and the World Bank);

and among SBCC implementers and other behavior change professionals. Engaging private sector communication and behavior change professionals such as commercial marketers, journalists, and social media specialists in the US and abroad will remain a priority.

PRH Priorities SBCC has long been an area of investment for PRH. Practices supported by the Office have been documented through a High Impact Practices (HIP) Brief on Health Communication, and mainstreamed via trainings and courses targeting USAID staff and partners.

Despite this longstanding commitment, USAID-supported SBCC – like family planning communication more broadly - continues to face serious challenges. SBCC for family planning is often overly clinical in both messaging and mode of delivery, and ineffective in reaching the populations most in need of information and motivation. It can also lack the visibility or quality of design to effectively and sustainably change behaviors. There is an urgent need for large-scale, high-quality social and behavior change campaigns that promote dialogue around reproductive health, women’s empowerment, desired fertility, and male engagement, in the interest of increasing voluntary and correct use of contraception.

PRH’s SBCC team has identified four priority areas in behavior change programming for health: 1) expansion of the evidence base; 2) consistent application of proven practices; 3) in-country capacity strengthening; and 4) continued innovation in research, design, and production. Within these broad categories, there are a number of important needs that should be addressed.

Expansion of the evidence base through research and measurement:

The literature around SBCC for family planning, while extensive, is dated, with few major studies conducted in the last decade. As a result, much of the existing research does not accurately reflect the current state of SBCC practice, including use of multi-channel interventions or information communication technology (ICTs) and social media. There is an urgent need to update this evidence base with new research, particularly rigorous studies that approximate randomization or allow for longitudinal analysis. Studies measuring social and normative change are particularly scant, as are evaluations of

Draft for Discussion January 2015 15 community-level SBCC programming and interpersonal communication (IPC) delivered at scale. USAID should prioritize research and evaluation in these areas.

USAID Missions are increasingly approaching social and behavior change through integrated platforms that address a range of health areas, and/or sectors beyond health.

Evaluating the impact of such integrated programs – and the effect of integration upon reproductive health-related behavior change specifically, will be essential in the coming years in order to define and apply best practices.

Application of best practices:

Better practices in SBCC for family planning are well understood, but not consistently applied. SBCC is most likely to produce behavioral impact when it:

● Uses research to segment and profile audiences;

● Uses research to identify key drivers of behavior among specific audiences, and addresses these drivers through messaging and activity design;

● Addresses the social context, including gender norms and dynamics;

● Communicates harmonized messages across a variety of channels;

● Promotes audience engagement and participation;

● Is closely aligned with supply-side interventions, including service delivery and social marketing. 5

USAID Missions should ensure that SBCC, social marketing, and service delivery partners clearly reflect these practices (and others outlined in the Health Communication HIP brief) in their communication activities. PRH will provide technical assistance to Missions and their bilateral partners to ensure that best practices are mainstreamed in country activities, with attention to scale and sustainability.

Capacity strengthening:

To ensure the long-term sustainability of current social and behavior change efforts, developing the capacity of both partner governments and local implementers is critical.

Over the last decade, many bilateral and central SBCC projects have begun to incorporate capacity strengthening as well as direct design and implementation in their work. These experiences have demonstrated that SBCC capacity strengthening must utilize a range of learning approaches to enhance the ability of individuals, institutions, and systems, with attention to both technical and operational functions. Despite increasing USAID emphasis on capacity strengthening, there are few robust studies exploring the process or impact of capacity strengthening interventions for SBCC; additional research in this area will help ensure that implementers use the most effective approaches and interventions for their needs and context.

5 Noar SM, Palmgreen P, Chabot M, Dobransky N, Zimmerman RS. A 10-Year Systematic Review of HIV/AIDS Mass Communication

Campaigns: Have We Made Progress? Journal of Health Communication 2009; 14(1):15-43.

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Innovation:

SBCC has not systematically incorporated or addressed advances in other behavioral disciplines, including commercial marketing and advertising, behavioral economics, social psychology, applied anthropology, and human-centered design. Integrating practices from these fields into SBCC research, implementation, and evaluation has the potential to improve the impact of SBCC interventions, particularly around intractable social and behavior change challenges and hard-to-reach audiences. Innovative behavior change approaches offer an opportunity to revitalize plateauing family planning programs and stimulate latent demand.

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Supply Chains

I. 2020 Vision

PRH priority countries possess the capacities to design, implement, and sustain high-performing supply chain systems for family planning and reproductive health services.

II. 2030 Vision

The long-term availability of affordable and quality family planning and reproductive health supplies to clients is ensured.

III. Definition

This c area is dedicated to improving the long-term availability of affordable, quality-assured contraceptives and related family planning/reproductive health (FP/RH) supplies for clients -- when products are available to clients, when and where they need them, in good quality and at affordable cost. PRH provides commodity procurement and technical leadership to improve product availability through improved supply chain systems from manufacturers to service delivery points, specifically improving global supply, country supply chain systems, and enabling environments.

The supply chains focus area works in concert with other focus areas to support PRH’s principles by:

making available through PRH’s global supply operation the full range of products needed for informed choice;

strengthening both public and private sector country supply chain systems, with a focus on last mile distribution to ensure that contraceptives are available to even the most marginalized, hard-to-reach, or disadvantaged clients; and supporting policy and regulatory environments that ensure the availability of a full range of products through healthy markets, including the introduction of new products that expand contraceptive options for clients.

IV. Priorities to 2020

While other priorities are described below, data visibility and monitoring and evaluation are the single largest area of PRH investment under this focus area. For example:

having a management information system and the business intelligence capabilities to support day-to-day transactions and to monitor performance and support higher-level strategic decision-making for PRH’s global supply operation;

strengthening in-country logistics management information systems, particularly to improve last mile visibility;

Draft for Discussion January 2015 18 working with global partners for data standardization and interoperability across donor and country systems;

improving data collection and analytical methods to support the design and assessment of supply chain alternatives; and monitoring enabling environments through the Contraceptive Security Indicators and Contraceptive Security Index.

Reproductive health commodity security, once an area dominated by a few players, is now a global movement joined by many actors. PRH’s leadership for product availability is increasingly exercised through partnerships, both formal and informal. Key global partnerships with product availability as their primary raison d’être are the Reproductive Health Supplies Coalition, People that Deliver, and U.N. Commission on Life-Saving Commodities. Within USAID, PRH is expanding its coordination and collaboration with other health programs (HIV/AIDS, malaria, maternal and child health) as they too increase their support for product availability through the same supply chain systems. And, there are an expanding number of inter-agency partnerships focused on specific tasks, such as with UNFPA, World Bank, and Gates Foundation.

a) Global supply

Availability to the client begins with quality-assured, affordable products entering supply chain systems. PRH supports a “best in class” global supply operation that provides a consistent supply of contraceptives and other FP/RH products for USAID-supported programs. PRH collaborates with partners to ensure uninterrupted supply to country programs, and provides technical leadership to secure full product pipelines for the future by developing and implementing tools and approaches to reduce unpredictability/volatility and vulnerability in the global market. To support healthier global markets for FP/RH products, PRH focuses on improved global demand forecasting and coordinated supply planning;

enabling existing and new quality-assured suppliers to enter markets;

harmonization of country regulatory environments (e.g., product registration);

better use of data and multi-agency fora to engage industry and align supply and demand;

improved visibility into country markets and understanding of future trends; and support for new product introduction.

b) Country supply chain systems

Improving country supply chain systems to ensure that FP/RH products are then available to clients requires attention to myriad supply chain functions, from product registration, forecasting, and procurement, to last mile distribution. Three strategic routes to strengthening these functions are:

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Strategic design of supply chain systems: supporting supply chain systems to use industry best practices for improved performance, risk management, efficiency, and sustainability. Network optimization, segmentation, integration, outsourcing, supply chain costing.

Data visibility: enabling end-to-end, real time data visibility that drives supply chain system decision-making. Automation of information systems, data standardization, systems interoperability, improving the “first mile” of data from service delivery points.

Human resources: supporting cost-effective human resource strategies for supply chain systems. Professionalization of the supply chain work force, recruitment and retention, incentives and supervision.

c) Enabling environments

Whether for global supply or country supply chain systems, improvements in supply chain systems require more than technical solutions. They also require commitment, leadership, and engaged stakeholders in the public and private sectors; adequate, predictable, and sustainable financing for products and supply systems; and good governance and supportive policies. Illustrative areas of attention are:

Commitment, leadership & engaged stakeholders: providing and using quality data for advocacy and decision making; strengthening organizational leadership and supporting champions; engaging civil society as stakeholders.

Financing: building capacities to gather, analyze and interpret financing requirements and revenue sources across the public and private sectors, and to coordinate stakeholders to implement strategies that ensure effective allocation and utilization of resources so that products are available to all.

Governance & supportive policies: promoting supportive policy and regulatory environments (product selection and registration, essential medicines lists, etc.);

improving transparency in decision-making and financial and supply chain systems;

strengthening government-led coordination with active participation of relevant actors.

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Family Planning Workforce

VISION: In support of the goals for reaching 120 million new family planning users by 2020, meeting 75 percent of contraceptive need by 2030, ending preventable child and maternal deaths, and achieving an AIDS-free generation:

By 2020 the public and private sector FP workforce in PRH priority countries will be strengthened, expanded and in place to support and implement the priority interventions of the other PRH focus areas in order to increase access to high quality FP products, information and services that are gender sensitive and age and developmentally appropriate.

By 2030 there will be adequate numbers of well-prepared family planning providers positioned within both the public and private sectors, so as to ensure access to high quality FP products, information and services by women and men of all ages who want them. As part of the larger health workforce, they will be supported by human resource systems that embody strong human resource management (HRM) practices, thereby enhancing the sustainability of the strengthened FP workforce.

Definition In large part, the workforce for family planning is the same workforce that provides maternal and child, HIV, malaria, tuberculosis, and other health services. The WHO has defined a “well-performing health workforce” as “one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).”6 For family planning, this means:

adequate numbers of the appropriate mix of workers necessary to ensure access to and the delivery of services (e.g., doctors, nurses, midwives, pharmacists, CHWs, etc.; public and private sector; lay and professional cadres; paid and unpaid workers; male and female workers; managers; supply chain workers; pharmacists, drug shop keepers, non-formal providers), with up-to-date knowledge and skills across the full spectrum of FP methods and services (as appropriate), and interpersonal communications skills to reach a wide range of clients, positioned within communities and facilities to ensure full access to a variety of FP methods, in a well-equipped, supportive and equitable work environment that promotes productivity, respects the dignity of all clients, and encourages retention in the workforce.

6 2007, World Health Organization, Everybody’s Business: Strengthening health systems to improve health outcomes: WHO’s framework for action.

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Workforce Priorities 2014-2020

1. Increase access to high quality FP services by expanding the number of FP workers/providers available With an estimated shortage of 7.2 million healthcare workers worldwide, including the priority countries for EPCMD, FP2020 and AFG, increasing the number of…