In 2018, the UNFPA commenced analysis of available data to explore factors determining the results of the Sustainable Development Goal indicator 5.6.1 and how this indicator relates to desirable reproductive health and gender equality outcomes. The Indicator 5.6.1 looks at the proportion of married women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care.
The rationale for the current UNFPA funded hera review is to triangulate data from qualitative and quantitative sources to increase understanding on what factors impact on women’s empowerment on SRHR. The age range for the study is 15 – 49 years. The approach will include a systematic review and literature review, informant interviews, and case studies.
The specific areas of interest are summarised in the questions below:
Sustainable Development Goal number five is to achieve gender equality by 2030. SDG goal 5.6 sets out to “ensure universal access to sexual and reproductive health and reproductive rights,” and indicator 5.6.1 points to an important set of targets to measure progress. Achievement of sexual and reproductive health relies on the realization of sexual and reproductive rights, which are based on the human rights of all individuals. hera is committed to supporting human rights and the rights of all individuals to make decisions governing their bodies and to access services that support that right.
Results from hera’s review will be made available on their website when they are ready, please follow hera on twitter if you wish to receive updates and contact them if you wish to learn more.
]]>The Delivering Reproductive Health Results (DRHR) programme used social franchising (SF) and social marketing (SM) approaches to increase the supply of high quality family planning services in underserved areas of Pakistan. The authors of this paper assessed the costs, cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.
Financial and economic programme costs were calculated. Costs to individual users were captured in a pre-post survey. The cost per couple years of protection (CYP) and cost per new user were estimated as indicators of cost efficiency. For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year (DALY) averted.
Approximately £20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs. Based on programme data, the cumulative cost-efficiency of the entire DRHR programme was £4.8 per CYP. DRHR activities would avert one DALY at the cost of £20. Financial access indicators generally improved in programme areas, but the magnitude of progress varies across indicators.
The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes. This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low- and middle-income settings. Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.
The overall objective of this assignment is a focus on component one and ensuring that SAGE redesign and implementation plans are based on a thorough understanding of the evidence base on adolescent girls’ empowerment and the Sierra Leonean context.
The methodology used combined a desk review of documentation and extensive stakeholder consultations to collect information about adolescent girls’ programmes. Eliciting the views of the adolescent girls themselves was a priority.
Together with information gathered at national level, five programmes (delivered by BRAC, Concern Worldwide, Matei Empowerment Programme for Sustainable Development, IRC and Save the Children) in various areas of Sierra Leone were used as case studies, explored extensively through two field missions. Insights into smaller relevant programmes are provided through findings from a round table conversation with civil society members of the Salone Adolescent Girls Network and the results of a short follow-up questionnaire.
Some key findings of the report are:
Overall, rather than seeking to create a totally new programme, our recommendation is that SAGE build on and broaden existing programmes and structures, introducing additional or new approaches and interventions where there are gaps either in geographical coverage or approach.
Annexes, which include additional data analysis from the short questionnaire and consultations with stakeholders, can be accessed here.
Suggested citation:
Roseveare, C. M. and Lavaly, S. (2018). Support to Sierra Leone Adolescent Girls’ Empowerment (SAGE) Programme: Scoping and Design Report. London, UK: High-Quality Technical Assistance for Results (HEART).
For young girls in developing countries, not knowing how to manage their periods can hinder access to education. Research from the School of Oriental and African Studies (SOAS), University of London, demonstrates that in rural Uganda, providing free sanitary products and lessons about puberty to girls may increase their attendance at school.
Period poverty
In many poor communities, menstruation is still often seen as an embarrassing, shameful, and dirty process. Such taboos around the topic mean many adolescent girls are often unprepared for their periods and how to manage them. Less than half of girls in lower- and middle-income countries have access to basics such as sanitary towels or tampons, soap and water, or facilities to change, clean, or dispose of hygiene products.In Uganda, only 22 per cent of girls are enrolled in secondary schools, compared with 91 per cent in primary schools, with those living in rural areas being the least likely group to go to school. Researchers believe that the cost of hygiene products and the difficulties in managing periods play a key role in keeping girls out of school.
Free sanitary products and puberty lessons can improve attendance
Over 24 months, a trial was conducted in partnership with Plan International Uganda across eight schools, involving 1,008 girls, in Uganda’s Kamuli District, an area that had been observed as having low learning levels, as well as gender disparity in health and education.The research tested whether school attendance improved when girls were given (a) reusable sanitary pads, (b) adolescent reproductive health education, (c) neither, or (d) a combination of both. Girls were provided with AFRIpads, a washable, reusable cloth pad produced in Uganda, and locally-trained community health nurses held sessions that covered changes which occur during puberty, menstruation, and early pregnancy, and on the prevention of HIV.Researchers found that better sanitary care and reproductive health education for poor schoolgirls, delivered over two years, did appear to improve attendance. On average, girls increased their attendance by 17 per cent, which equates to 3.4 days out of every 20 days.
The research project has significantly strengthened awareness that sanitary pad provision and puberty education are both vital in improving attendance. Even in the absence of resources to provide sanitary pads, the research recommends that inclusion of adequate and gender-sensitive puberty education in the school curriculum can improve attendance.
Organisations such as UNICEF and CARE have used the evidence to identify solutions to barriers to girls’ schooling associated with puberty. The project collaborated with Save the Children, UNESCO, WaterAid, and AFRIpads to lobby for menstrual hygiene management to be included as an indicator in post-2015 sustainability goals.
Further collaborations building on the evidence have included working with Save the Children on how to link the distribution of sanitary care to their West African programmes, and with UNESCO on effective programming in puberty education and menstrual hygiene management.
Ghana’s Deputy Minister of Education referenced the research when defending the decision to allocate part of the country’s 2014 World Bank loan to providing sanitary pads for female students in need. Samuel Okudzeto Ablakwa stated that when adolescent girls are unable to take proper care of themselves during the menstruation period, it affects their confidence, which eventually keeps them out of school.
Female hygiene on the global agenda
The research team continues to use the results as part of a push to promote female hygiene onto the global development agenda. The findings featured in preparatory documents for the WHO/ UNICEF Joint Monitoring Programme indicators for menstrual hygiene management, and have been cited in the UNESCO Puberty Education & Menstrual Hygiene Management report, which aims to promote sexuality education as part of skills-based health education for young people.
The impact of the research has the potential for addressing psychosocial wellbeing, dignity, comfort, and ability to manage menstruation without shame, which are all essential for girls responding to the challenges presented by menstruation in low-income contexts.
The project, ‘Menstruation and the Cycle of Poverty: Does the provision of sanitary pads improve the attendance and educational outcomes of girls in school?’ was funded by ESRC-DFID’s Joint Fund for Poverty Alleviation Research. It was led by Catherine Dolan, SOAS, University of London; Paul Montgomery, University of Birmingham; and Linda Scott, Chatham House. The research was carried out in partnership with Plan International Uganda, with the assistance of Julie Hennegan, Johns Hopkins University; Maryalice Wu, University of Illinois; and Laurel Steinfield, Bentley University.
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This blog was originally posted on UKFIET on 4 April 2018. Reposted with permission.
]]>Cleland et al (2006) explains that the promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and prevent 32% of all maternal deaths and nearly 10% of childhood deaths. It would also substantially contribute to the empowerment of women, achievement of universal primary schooling, and long-term environmental sustainability. Over the last 40 years, family planning programmes have played a key part in raising the prevalence of contraceptive practice from less than 10% to 60% and reducing fertility in developing countries from six to about three births per woman. However, in half of the 75 larger
low-income and lower-middle income countries (mainly in Africa), contraceptive practice remains low and fertility, population growth, and unmet need for family planning are high (Cleland et al 2006).
Frontline workers are key, as are home visits to promote contraception in the 4th, 6th and 7th months after delivery when women are most exposed to unwanted pregnancies. Interpersonal communication supported by mass media could play a key role in adoption of birth spacing by increasing correct knowledge on contraception, addressing misconceptions and triggering spousal communication (Khan et al 2013). This research could be useful when planning behaviour change communication for women who have previously given birth. This report is based on a brief search of the literature over a four day period and the following sections outline different methods of behaviour change communication.
]]>The evidence suggests that mobile phones are extremely useful for increasing access to SRHR, both through educating the public directly or providing information to health professionals. Information can be provided directly or referrals made to clinics or other centres for accessing SRHR. Key challenges include a low proportion of the population owning mobile phones in some areas or lack of funds to charge them, and certain groups, including women, those over 45 and socio-economically disadvantaged groups being less likely to have access to a phone. Web-based approaches are also very useful in increasing access to SRHR. This includes online health education programmes, websites and social media platforms. These services are very popular for accessing information and are often described by users as non-judgmental and authoritative. Many clients are then referred on to other services. Challenges include lack of access to computers and embarrassment at visiting sites referring to SRHR in public. Mixed approaches were also common among programmes to increase access to SRHR and were found to be largely very successful in achieving their goals.
]]>Evidence suggests that pills and injectable contraceptives can be safely provided at the community level by community health workers (CHWs) and through the retail sector. Provision of injectables by CHWs has been delivered to as high a standard as provision by nurses and midwives in Uganda according to one study. Technical experts have endorsed safety of the practice also. Research on the provision of injections in pharmacies suggests practices are often unsafe.
Evidence on increasing access to safe abortion includes: