Reaching the Unreachedfor Family Planning in Nepal:

Achievements, Issues, Challenges and Way Forward

Deepak Karki

DFID Nepal

National Conference on Family Planning: Reaching the Unreached

18-19 March 2019, Kathmandu, Nepal

@dkarki

Outline

• Reaching the Unreached

• What is achieved so far?

• What are the key issues and challenges?

• What is the way forward?

Reaching the Unreached in Family Planning: What are we talking about and why?

• Who are the unreached? And where are they from?

• Why do we need to reach the unreached in family planning?

• What is the framework for reaching the unreached?

Who are the unreached? And where are they from?• Adolescents (married and unmarried)

• Young people

• Poor, ultra poor

• Urban poor

• Women at post partum and post abortion period

• Ethnic minorities. e.g. Muslims

• People living in heard to reach areas (geography)

• (Young) Migrants and their spouses

• People living with HIV (PLHIV) and other STIs

• Female sex workers

• Sexual and gender minorities e.g. LGBTI

• Differently challenged people

Why do we need to reach the unreached in family planning?• Family planning is human rights (constitutional mandate)

• Family planning is development opportunity for individuals, families and society

• Family planning is a proven investment case for health and development

• Family planning matters the most to those who are left behind

• Family planning can be an entry point for integrated development approach in the changed context of Nepal

Benefits for Poor Women• Poorer women stand to gain more than wealthier women from improved

coverage of modern contraceptive services.

• If unmet need for modern contraception were fully satisfied while maintaining current levels of maternal and newborn care, there would be an 89% decline in unintended pregnancies among women from poor households, compared with an 81% decline among women from wealthy households.

• Reduction in maternal mortality would be most pronounced among the poorest women: Fulfilling all unmet need would lead to a 20% decline in maternal deaths among the poorest women, compared with 15% among the wealthiest women.

• Combined investments would be cost-effective: For every additional dollar spent on expanding modern contraceptive use, the country would save $2 on maternal and newborn care.

Source: Sundaram A et al., Adding It Up: Costs and Benefits of Meeting the Contraceptive and Maternal and Newborn Health Needs of Women in Nepal, New York: Guttmacher Institute, 2019. DOI: https://doi.org/10.1363/2019.30352

What is the framework for reaching the unreached?

Human Rights

Advancing the Leaving No One Behind (LNOB)

Primary Health Care (PHC)

Universal Health Coverage (UHC)

Sustainable Development Goals (SDG)

Achievements, so far?

0

1

2

3

4

5

6

7

0

20

40

60

80

100

NFS1976

NCPS1981

NFFS1986

NFHS1991

NFHS1996

NDHS2001

NDHS2006

NDHS2011

NMICS2014

NDHS2016

NHSS2020

Fertility and contraceptive use trends*

mCPRUnmet need

Decreasing TFR while stagnant CPRCurrent concerns:

❖↑ safe abortion

❖↑ traditional method

❖↑male migration ❖ high method

discontinuation

DFID Nepal Family Planning Project (NFPP)’s approach to reach the unreached

Address the Unmet Need for Family Planning among Excluded and Vulnerable Women in Nepal

Increasing access to family planning services to women,

including remote and excluded women and increasing demand

where use is low

Expanding the range of contraceptive methods

available to excluded and vulnerable women

Evidence to understand determinants of non-use, market and supply chains,

and to demonstrate impact

FA, TA and Policy dialogue

Over last 12 months, DFID/NFPP contributes • Through UNPFA Nepal and

Marie Stopes International, the UK has helped over 24,000 women access LARC and almost 9,000 to access permanent methods.

• Visiting Service Providers have reached over 50% public health facilities in programme districts in 2018 Janajati

27%

Brahmin/Chhetri

22%

Madhesi

21%

Dalit20%

Muslim7%

Others3%

What are the shifts in FP movement in?

Family planning

camps

Community based

programming, engaging

communities/orientations

Satellite clinics

FP integration into other

programmes & Innovations

FP as a broader

development agenda

Learning and Adopting …… to reach the most unreached

• What we learned from FP programming; and what we have adopted?

• Are do doing the right things (to reach the unreached)?

• Have we stopped doing the things that we know – “does not work”?

• Are we continuing (and intensifying) the efforts that we know – “works”?

What are the key issues and challenges?• RH and FP commodity security? Procurement and supply of

quality FP methods and related medical equipment? - even more complex and uncertain in the changed context?

• Adequate trained human resource for FP services? Expanding and strengthening FP training sites; clinical mentoring and coaching?

• All health facilities (public and private) offer (five and more) methods of family planning? Really?

What are the key issues and challenges?• Health and FP information management systems?

• Data for decision making and expressing the full accountability including social and political accountability?

• Financing the FP services ? Who is financing, what are key interventions financed and where, how much is financed and who are covered?

• Qualify FP service delivery in health facilities – public and private? FP counselling, privacy & confidentiality often challenged

Other questions?

• Do we know the family planning choices of Nepalese women and girls?

• Do we know the real stories of interface between the supply and demand for family planning services?

• Do we know what (interventions, strategies and framework) works for reaching the most unreached in Nepal? Are they tailored to the 3Cs- clients, context and contents?

Possible way forwards• Federalism is an opportunity - for reform (policy, structure and

functions) FP governance including broader political and social accountability – advocacy, coordination, collaboration

• Human resource is key service

• Social mapping – Who are the most marginalized and vulnerable (unreached) and where are they? Adolescents, poor, urban poor, ethnic minorities, differently challenged people, people living in hard to reach areas

• Women and girls (adolescents) at the centre – change the mind set, respect the social norms

Possible way forwards

• Tailored approaches in demand generation, service delivery and (community and health) system strengthening efforts -BCC/SBC, PBCC, policy advocacy and social mobilization, integration of FP with other programmes, digital in health

• Always focus on most cost-effective interventions and approaches. Examples, methods mix (LARC)

• Quality matters – it is often not automatic (and it costs?)- for everything, everywhere and by everyone

• Young people migration and family – we need new language/agile social norms for family planning

Possible way forwards

• Identify/adopt the game changers – technical and strategic solutions. For examples, Sayana Press, task shifting, digitals in FP

• Advancing the LNOB across the bridge – PHC, UHC and SDGs

• Knowledge and learning – evidence informed policy making, programming and review; learning and adopting is key

• Operational research – effectiveness, quality and coverage; Health policy and system research – efficient and responsive systems

• Engage all, including private sector in actions for FP

It is Possible … Reaching the Unreached

Together We will achieve the family planning

related SDGs 3 & 5 and contribute to achieve the

other 15 SDGs