There are 2 ARROW logos at different positions and sizes.

The bigger logo is at middle of page which shows a part of female hand and fingers in shape of a mouthpiece for establishing women's rights. The smaller one is at below right corner.

AN ADVOCATE'S GUIDE:

Integrating Human Rights in Universal Access to Contraception

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Table of Contents

07 About this guide

09 Preface

11 Acknowledgements

13 Chapter 1
Touching base on concepts

13 Introduction

14 Key Concepts

16 Quality

19 Chapter 2
Human-rights-based provision of contraceptive information and services: Guidelines for monitoring WHO recommendations

18 Non-discrimination

22 Availability

23 Accessibility

31 Acceptability

32 Quality

34 Informed decision-making

35 Privacy and confidentiality

36 Participation

36 Accountability

41 Chapter 3
An illustrative list of indicators

41 Sample list of indicators evolved from WHO recommendations for monitoring respect for human rights in contraceptive information and services

43 Annex-1
Gathering information to answer questions in the checklist: an illustrative example.

45 Endnotes

52 Bibliography

About this Guide

This guide, as the name suggests, is meant for use by advocates for sexual and reproductive health and rights (SRHR) at the country level. The guide uses the recommendations made to national governments in the publication “Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations” published by the World Health Organization in 2014, with the aim of ensuring that “the different human rights dimensions are systematically and clearly integrated into the provision of contraceptive information and services”.

The guide takes into account recommendations made by the WHO Guidance document, elaborates on what the recommendations actually mean, and provides a checklist with series of questions that probe into the extent of which a government has implemented or complied with a specific (set of) WHO recommendation (s). There are 17 such checklists, which together constitute a ‘tool box’ for assessing whether human rights are ensured in the provision of contraceptive information and services. The guide also provides an illustrative list of indicators for tracking adherence to human rights norms by contraceptive programmes.

The guide can be used by SRHR advocates, this includes women's organisations, civil society organisations working on women, young people's health and SRHR. The tool can also be used by health professionals within the health systems at the national level, as a resource and assessment tool for provision of rights based contraceptive information and services.

This advocate's guide is meant as a generic tool. It will have to be adapted to different national and even sub-national settings, depending on its history of population control and the ethos of adherence to human rights, health system characteristics and resource levels. We hope this guide will enable SRHR advocates to use these WHO recommendations as a basis for holding governments accountable to respecting and upholding human rights in policies and strategies related to contraceptive information and services, and in the actual organisation and delivery of contraceptive services to users.

Preface

In recent years, governments, donors, UN agencies and NGOs have paid close attention to the issue of providing access to contraception as a key development strategy. Access to contraception is an essential reproductive right: enabling individuals and couples to make and follow-through on decisions around the number, timing and limiting of pregnancies. Data testifies to the fact that women and men who are unable to access contraception, in any country, come mostly from the poorer wealth quintiles, lower education quintiles, live in rural or hard-to-reach areas. The gap in accessing contraception between the rich and the poor, the better and the lesser educated, the urban and the rural and hard-to-reach, speaks of a social inequality in being able to realise this fundamental right. Women being able to plan, space and limit their families is key in reducing poverty and ensuring gender equality.

However, while being able to access contraception is a fundamental right in itself, there have been examples in the past which show that other aspects of rights have been trampled in providing contraception. These have been especially true when states have employed coercive strategies in population reduction plans. If we truly want the contraception and family-planning agenda to be sustainable and be part and parcel of everyday conversations and decisions of individuals and families we need to respect all the other different facets of reproductive rights that exist. These include, but are not limited to, the right to information and counselling, the right to choice of method and a variety of methods to choose from, the right to access all other reproductive health services (because ill-health drives families further into poverty), the right to safe sex, the right to termination of pregnancy when contraception fails. These rights should be realised by even the most marginalised people: the poor, the less educated, those living in rural and hard-to-reach areas, the young and those most often over-looked such as sex workers and transgender people.

This guide serves to help civil society advocates understand and help governments uphold the highest standards possible when implementing this critical development strategy. The tools in the guide can also be used by health professionals within the health systems at the national level, as a resource and assessment tool for provision of rights based contraceptive information and services.

ARROW and our partners are working to ensure that universal access to SRHR remains high on the development agenda in the Asia-Pacific region and the Global South and that national and international policy- and decision makers are improving SRHR policies and investments to benefit the under-served and most marginalized groups, especially women and girls. As the SRHR agenda has prominence within Agenda 2030 we feel it is critical that provision of SRH and contraception services are available, accessible, acceptable and of the highest quality. Human rights standards help ensure this.

ARROW recognises the contributions of TK Sundari Ravindran who has been working in close collaboration with ARROW to develop this guide. Her dedication to mentoring and guiding ARROW staff and partners in understanding human rights standards has enriched our ability to hold service providers to accountable to higher standards.

It is our greatest hope that this contribution helps build a strong movement of governments, donors, civil society, service providers and UN agencies who are committed to ensuring and fulfilling rights in providing universal access to contraception.

Sivananthi Thanenthiran
Executive Director

Acknowledgments

This publication, An Advocates guide: Integrating Human Rights in Universal Access to contraception, was developed by TK Sundari Ravindran. It is based on the WHO Guidance and Recommendations “Ensuring human rights in the provision of contraceptive information and services”. Sundari has been working with ARROW for a long time in fine-tuning our understanding of translating human rights standards at ground level.

We also acknowledge the contributions of ARROW staff: Sivananthi Thanenthiran and Nadia Rajaram who coordinated, gave feedback and finalised the publication; and to Saijyothirmai Racherla and Dhivya Kanagasingham for coordinating the final draft and printing the publication. The design and the layout of this book is the work of TM Ali Basir.

CHAPTER 1

TOUCHING BASE ON CONCEPTS

Introduction

Voluntary choice in marriage and family formation; determination of the number, timing and spacing of one's children; and access to the information and means needed to exercise voluntary choice are not only goals to aspire for. These “reproductive rights” are core to the protection of human rights, self-determination and equality embodied in the Universal Declaration of Human Rights.

In 1994, the International Conference on Population and Development (ICPD) in Cairo rejected demographically driven population policies and upheld respect for reproductive rights. Through the ICPD Programme of Action, 179 countries who signed on to it acknowledged that reproductive rights are human rights recognised by international and national laws. In the subsequent decades, many UN institutions and mechanisms including the Human Rights Council and Human Rights Treaty Monitoring Bodies have contributed to the recognition of sexual and reproductive health and rights as an integral part of the entitlements guaranteed to all persons by human rights.

And yet, during this second decade of the 21st century, an estimated 222 million women globally, constituting 26% of women who wish to avoid a pregnancy, are not using a modern method of contraception. This group of women with an ‘unmet need’ for contraceptive services account for 79% of all unintended pregnancies.1 Given the legal restrictions on abortion services in many countries of the world, they are forced to continue with an unwanted pregnancy or resort to illegal and often unsafe abortions putting their health and lives at jeopardy.

The London Summit on Contraceptive organised in 2012 by the Bill and Melinda Gates Foundation and the UK government brought together private foundations, governments, international NGOs to reaffirm their commitment to achieving a significant reduction in the numbers and proportions of women with an unmet need for contraceptive. Countries pledged US$ 4.6 billion over the next eight years towards realising this goal.

Even while SRHR advocates and activists have reason to laud the increased investment in contraceptive services, they also have reason to be watchful about the ways in which this will impact realities on the ground. Memories of coercive population control policies and their traumatic consequences are as yet fresh in the minds of SRHR advocates and the people in many countries of the Global South.

Who is this Guide for and what it contains

This Advocate's Guide, as the name suggests, is meant for use by advocates for sexual and reproductive health and rights at the country level. The Guide uses the recommendations made to national governments by a “Guidance document” published by the World Health Organization in 2014, with the aim of ensuring that “the different human rights dimensions are systematically and clearly integrated into the provision of contraceptive information and services”2. The aim of the Guide is to enable advocates to use these WHO recommendations as a basis for holding governments accountable to respecting and upholding human rights in policies and strategies related to contraceptive information and services, and in the actual organisation and delivery of services to users.

This introductory chapter will present concepts and definitions related to rights-based contraceptive information and services. Chapter two is the core chapter in which each section starts with a recommendation made by the WHO Guidance Document (verbatim) and an elaboration of what it means, and is followed by a checklist. Each checklist refers to and follows a given set of WHO recommendations. Each checklist consists of a series of questions which probe into the extent to which a government has implemented or complied with a specific (set of) WHO recommendation(s).

There are 17 such checklists in Chapter 2, which together constitute a ‘tool box’ for assessing whether human rights are ensured in the provision of contraceptive information and services. More details on how the checklists may be used are given in the introduction to Chapter 2.

It is important to note that some of WHO'S recommendations may be contrary to the law of the land in some countries. For example, same-sex sexual orientation is criminalized in some countries, and it may not be legal to provide contraceptives services to adolescents below 18 years of age. In such instances, advocacy may first be directed at changing laws and policies, drawing attention to the fact that WHO'S recommendations are grounded in international human rights law, and the country may have ratified Human Rights Conventions and Treaties that support these recommendations.

Chapter 3 contains an illustrative list of indicators for tracking adherence to human rights norms by contraceptive programmes, and this short list of indicators may be used for a rapid assessment.

This advocate's guide is meant as a generic tool. It will have to be adapted to different national and even sub-national settings, depending on its history of population control and the ethos of adherence to human rights, health system characteristics and resource levels.

Key Concepts

This section presents concepts and definitions related to contraceptive services and human rights that are used throughout this guide.

Comprehensive contraceptive information and services

Throughout this document ‘contraceptive services’ has been used rather than the term ‘family planning’ services, although latter term has been in use for many decades, and may be better understood in many country contexts. This is because the term ‘family planning’ is inherently biased in that it suggests that the services are only for those within the context of a family. The indirect implication is that unmarried adolescents and young people, sex-workers and others who have a need to prevent pregnancy but may not be part of a “family” are not legitimate clients of the programme.

In using the term ‘contraceptive services’ this guide explicitly considers sexually active adolescents and young people, women and men of all ages and diverse sexualities as legitimate contraceptive users and clients of contraceptive information and service programmes.

‘Comprehensive’ contraceptive information and services refers to the provision of information and services for all methods of contraception without imposing programme-based or provider-based restrictions of specific contraceptive methods.

Human Rights-Based Approach

A human-rights-based approach has two major features.

One, it takes a position that ensuring access to education and health care and other basic needs and amenities for all its citizens are not acts contingent on the good will of governments, but obligations that they are required to fulfil as a result of their ratification of international and/or regional human rights treaties.3

And two, a rights-based approach integrates international, regional and national human rights standards, principles and processes into plans, policies and programmes. The human-rights-based approach considers all persons as rights-holders, while the government and its agents are duty-bearers with specific obligations to fulfil. This will mean for example, that providing contraceptive services is an obligation of the state, not an act of charity and not left to the discretion of governments to provide or not (Box 1). High levels of unmet need for contraceptive services or poor quality of care are not inevitable but the consequence of deliberate decisions and policies, and governments are obliged to explain why they did not increase progressively their investments in contraceptive and allied health services.4

Within the context of contraceptive policies and programmes, human-rights-based approach may be understood as including the following key human rights principles and standards:

These principles and standards are further elaborated below.

Non-discrimination in the provision of contraceptive information and services

Contraceptive services information and services must be accessible and provided without discrimination (in intent or effect) based on health status, race, ethnicity, age, sex, sexuality, disability, language, religion, national origin, income, or social status. The design of programmes should take account of the fact that vulnerable groups may face special barriers.

Availability of contraceptive information and services

Adequate health care infrastructure (e.g. hospitals, community health facilities, trained health care professionals); goods (e.g. contraceptives, other drugs, equipment); basic amenities such as potable drinking water and sanitation; information and services on sexual and reproductive health including contraception; must be available in sufficient quantity within the state, and distributed equitably across geographical areas and communities.

Accessibility of contraceptive information and services

All health care must be accessible to all without discrimination. No one shall be denied preventive, promotive or curative health care including contraceptive services and allied sexual and reproductive health services that s/he needs. Accessibility has three overlapping dimensions: Physical accessibility; economic accessibility or affordability; and access to information6.

Acceptability of contraceptive information and services

Health care institutions and providers must be respectful of medical ethics. They should respect the dignity of all clients, provide culturally appropriate care, be responsive to needs based on gender, age, culture (including religion, belief, values, norms and language), and physical abilities.9

Quality

All health care, including contraceptive information and services must be medically appropriate and guided by technical quality standards and control mechanisms. More importantly they should be characterized by positive attitudes on the part of providers, informed decisionmaking on the part of the client and provided in a timely and safe manner, and to the client's satisfaction.10

Informed decision-making

Informed decision-making is already a component of services that are acceptable and respect medical ethics. It is also a characteristic of good quality of care. However, this element is considered separately because client autonomy and informed decision-making are key characteristics of a rights-respecting contraceptive programme. Free, full and informed decision-making is an expression of autonomy, upheld by medical ethics and international human rights law.11

Privacy and confidentiality

Respect for client's privacy, confidentiality and dignity is a fundamental tenet of medical ethics. Upholding the client's privacy and maintaining confidentiality is important in all areas of health care. It is especially critical when providing contraceptive information and services, failing which several negative consequences can arise. For example, the service loses the client's trust and the client may not return for a service or follow up.

Participation

Individuals and communities must be able to play an active, free and meaningful part in the design and implementation of contraceptive services policies and programmes. Policies and programmes are therefore required to create structures and mechanisms that will allow and enable such participation by all stake-holders, especially traditionally excluded and marginalised groups.

Accountability

Governments and public agencies must be held accountable and answerable for their acts or omissions in relation to their duties related to protecting the right to health care, including right to contraceptive information and services, through enforceable standards, regulations, and independent compliance-monitoring bodies.12

Governments are also accountable for regulating the actions of private entities such as private health care providers, insurance companies and pharmaceuticals so that their actions do not violate citizens' right to health.

Why a human rights-based approach to contraceptive information and services?

What is the “value-added” of adopting a human-rights-based approach in the context of contraceptive services?

The cost of not adopting a human-rights-based approach in the provision of contraceptive information and services could be high. For example, it may result in lack of attention to less powerful or poorly resourced groups — low-income groups, young people, single women, persons with different sexualities. This would influence the programme's ability to reduce unmet need. Worse still, the consequences for the under-served group could be unwanted pregnancies ending in poor pregnancy outcomes or unsafe abortions.

When human rights are not the guiding principle for programme planning, programmes may focus exclusively on achieving fertility reduction, contributing inadvertently to inadequate importance to quality of care in service delivery settings. The consequence may be avoidable reproductive morbidity including the threat of HIV infection and a poor image and low acceptability for contraceptive services. Providers who are not aware of the need for maintaining client confidentiality may inadvertently disclose to the husband contraceptive use by his wife. In the case of women experiencing gender-based violence this could seriously threaten their safety and security.

For these and many other such reasons, ensuring human rights in the provision of contraceptive information and services is not only an added value to an efficient programme, but a moral imperative.

CHAPTER 2

HUMAN-RIGHTS-BASED PROVISION OF CONTRACEPTIVE INFORMATION AND SERVICES: GUIDELINES FOR MONITORING WHO RECOMMENDATIONS

WHO'S recommendations for human-rights standards are organised into nine sections , each section pertaining to one of the nine human rights principles and standards defined in Chapter 1 (non-discrimination; availability; accessibility; acceptability; quality; informed decisionmaking; privacy and confidentiality; participation; and accountability).14 This chapter is therefore organised into the same nine sections.

Each section is further divided into sub-sections pertaining to recommendations from the WHO Guidance document. Following each (set of) WHO recommendation(s) presented, the definition of important terms used in the recommendation and the rationale for the recommendation are presented. Where necessary, the operational implications of the recommendation are described. Following each recommendation or a set of recommendations is a box with a checklist of questions, which probe into the extent to which a government has implemented or complied with the WHO recommendation(s) in question. Not all checklists and questions may be relevant to every setting, and these will have to be suitably adapted. Some of the questions in the checklist are about policies and programme guidelines, and to find answers to these, a review of the latest policy or programme documents would be necessary. Policy documents include not only formally published policies of the government, but regulations and official orders of the government or administrative structure at different levels, and of published and unpublished studies and reports which comment on the content of these policies and programmes.

Other questions are about what the situation is ‘in practice’. To answer these, one may draw on published statistical data where relevant, or examine small-scale studies on the situation, or even undertake a limited data-collection exercise in one's own setting. It may be feasible to undertake a “fact-finding” exercise of the situation by visiting a cross-section of facilities or by speaking to key informants and community members and users of services. The collection of answers to questions in the checklist will yield a human rights ‘report-card’ for a given setting at a given time point. Not all recommendations and checklists have to be used at the same time. One may decide to focus on a particular set of rights principles at a given time and carry out a situation analysis on that. For example, an organisation may decide to carry out a situational analysis on whether or not the right of users for informed decisionmaking in matters related to contraception is being upheld.

At the end of a situation analysis, rights violations and failure to uphold rights within a given setting are likely to come to light. For example, in the situation analysis on informed decision-making, it may emerge that users are given information only on a limited range of contraceptives (or even just one); or that they receive almost no information on side-effects of contraceptives; or that the information given is not in a format that is easily understood by a large proportion of users. It will then be up to the advocates to decide which of the issues would be an immediate priority for advocacy and action.

Periodic reviews will indicate whether or not there is ‘progressive realization’ of a rights-based approach. These results may then be used to hold governments accountable. The use of WHO recommendations as basis for the checklist gives us as SRHR advocates greater leverage to demand that governments adhere to these recommendations from a multilateral technical entity.

Non-discrimination

WHO Recommendation 1.1.

Recommend that access to comprehensive contraceptive information and services be provided equally to everyone voluntarily, free of discrimination, coercion or violence (based on individual choice).15

Forced or coerced sterilizations and IUD insertions have been reported from many parts of the world. ‘Forced’ refers to sterilization or IUD insertion without a person's knowledge, while ‘coerced’ includes situations when misinformation or intimidation is used to make a person accept a method of contraception, or when other benefits/ services are made conditional on the ‘acceptance’ of contraception.16 For example, studies from India have reported that medical termination of pregnancy in government health facilities is often conditional on acceptance of sterilization or IUD.17

In Uzbekistan, a 2010 report stated that some women were required to produce sterilization certificates in order to obtain employment18. Women from low-income groups and marginalized communities such as the Roma, women with disabilities and women living with HIV are reported to be particularly vulnerable to the risk of coercive or forced sterilization.19 Coercion by health care workers to undergo sterilization has been documented in Chile, Dominican Republic, Mexico, Namibia and South Africa, and anecdotal evidence indicates that the practice may be common across the globe.20

Incentives and disincentives are a more indirect means of taking away choice from the hands of the client. Many countries have had a history of building in incentives and disincentives to ensure “acceptance” of contraception. This may take the form of cash or other benefits to clients for adopting a contraceptive method21, or denying them a benefit if they chose not to accept any method. There are also rewards offered to health-care providers for achieving specific contraceptive “targets” or penalties imposed for non-achievement of specific targets. Not only are these clearly violations of clients' right to choose.

In practice, the system of incentives and disincentives has been seen to deteriorate into coercive or unethical practices on the part of health care providers; clients have accepted contraception not because they did not want to have a child just yet or wanted to stop childbearing, but because they were in financial distress.22

WHO Recommendation 1.2

Recommend that laws and policies support programmes to ensure that comprehensive contraceptive information and services are provided to all segments of the population. Special attention should be given to disadvantaged and marginalized populations in their access to these services.

In many countries, contraceptive information and service programmes have focused exclusively on women for a number of ideological reasons. Unfortunately, this has had the effect of burdening women with the entire responsibility for contraception, while at the same time restricting access to services even for those men who want to use contraception. Less than 9% of all users of contraceptive methods in developing countries are men. Use of vasectomy among men ranged from close to 0% in Africa to 2.2% and 2.3% in Asia and Latin America respectively (2013) while condom use ranged from 2% in Africa to 7.4% in Asia and 10.1% in Latin America.23 A rights-based approach to contraception should invest in correcting this anomaly by making contraceptive information and services widely available to men and boys through service delivery mechanisms that take on board their specific needs and preferences.

For contraceptive information and services to be ‘inclusive’ and provided to all segments of the population, the very terminology of ‘family-planning’ may need to be dropped, so that those who require contraceptive services outside the context of ‘family’ — e.g. single persons, adolescents and young people, sex workers — do not feel intimidated and excluded. Combining contraceptive services with maternal health care — the classic MCH/FP programming model — is another example of discriminatory programming that sends signals to the community that single women, ‘non-mothers’ — women who have not yet begun childbearing or women who do not intend having children, as well as men -are not considered as potential clients.

An inclusive contraceptive information and services programme will not be a vertical stand-alone programme but an integral component of a comprehensive Sexual and Reproductive Health (SRH) Programme (See Box 2 for the components of a comprehensive SRH programme) that takes into account the diverse needs of specific population sub-groups.

Unmet need for contraception is much higher among adolescents (15–19 years) than among women age 20–49 years in Asia, Africa and in Latin America.25 Lack of sexuality education, legal barriers to access and lack of affordability are all factors that contribute to the high levels of unmet need for contraception among adolescents and young people. However, even in the absence of legal and policy barriers, social attitudes related to adolescents' and young people's sexuality may deter health workers from providing services. Evidence shows that adolescents and young people often face discrimination in contraceptive service provision. According to studies in Kenya, Zambia, Lao PDR and China, health providers often believed that distributing contraceptives to adolescents and young people will encourage promiscuity.26

Fear of being scolded and humiliated by the provider is an often reported reason for not use of SRH services by adolescents in many developing countries. Young women are more affected by providers' gender double-standards regarding appropriate sexual behaviour.27, 28, 29 Young or nulliparous women may be denied contraception because of provider-beliefs that contraceptive is not for women without any children. 30, 31

Sufficient evidence and know-how exists on how to set up youth-friendly sexual and reproductive health services. Because young people are not a homogenous group, contraceptive information and services for them would have to be available in multiple sites to cater to their varying needs. For example school-based services will not cater to out-of-school youth, whose numbers may be significant in some settings. Studies show that whatever the location, young people wanted assurance of privacy and confidentiality, affordable or free services, and youth-friendly Staff.32, 33, 34, 35

Discrimination by race, ethnicity and socio-economic status in the delivery of contraceptive services are prevalent in many settings36, 37, 38, 39 and usually takes the form of being pressured to limit family size and to use contraception, “for their own good”. Request for contraceptive services by women with disabilities are often met with shock and surprise and subject to interrogation by health care providers who tended to assume that persons with disabilities are asexual.40, 41

People living with HIV are often told by health providers that they should refrain from sex and childbearing, and may fear seeking contraceptive services. The risk of being coerced into sterilization would also be a barrier to accessing contraceptive services for PLHIV.42

Availability

WHO Recommendation 2.1

Recommend integration of contraceptive commodities, supplies and equipment, covering a range of methods, including emergency contraception, within the essential medicine supply chain to increase availability. Invest in strengthening the supply chain where necessary in order to ensure availability.43

This recommendation by WHO focuses on reproductive commodity security at the programme level. This would mean for example, that the full range of contraceptive commodities and supplies including emergency contraception, and the equipment necessary to provide these should be included in the National Essential Medicines List. The concept of a single first line or second line treatment, adopted for curative care, does not apply in the case of contraceptive services, where the range of contraceptives made available could make the difference between use and non-use of contraception. Also, because contraceptives are for prevention, they may be considered as not contributing to saving lives in the same way as other essential drugs for curative care. Contraceptives may be the first to be cut out of a National Essential Medicines list in case of a financial crunch. Advocacy may also be needed for adequate public funding for procuring contraceptive and reproductive commodities.44

When contraceptive supplies are stocked-out, or equipment and supplies necessary to provide a specific method are unavailable at the service delivery point, this represents a major opportunity lost to serve clients — predominantly women — who may have reached the services after negotiating many hurdles. They may never be able to return, and unintended pregnancy may be the consequence. Increasing product-availability at the service delivery point calls for good supply-chain management of all contraceptive commodities, supplies and equipment at all levels.

The recommendation also talks about an effective contraceptive supply chain. The aim of an effective contraceptive supply chain would be to get the “right quantities of the right contraceptives to the right places at the right time in the right condition at the right cost”.45 Procurement of contraceptives must be based not only on estimates developed by tracking past use.

A needs assessment should be undertaken among under-served groups or hitherto un-served groups in the community so that supplies are adequate to cater to all those who need them. Such estimates must be periodically reassessed to account for changes in patterns of demand. They should also account for all methods including emergency contraceptive pills and condoms and for all distribution points e.g. facility level, community level and self-dispensing points like for condoms.

Another aspect of an effective supply chain is planning for storage of contraceptive devices. Such storage areas should be clean, well ventilated, dry, well lit, out of direct sunlight and pest free. A system of First — in First — out (FIFO) should be put in place and expired stock should be regularly removed. Quality of contraceptive devices should be routinely checked and staff must be trained to check for quality and warning signs that a device is of poor quality or damaged. Planning for quality control and storage of contraceptive commodities, supplies and equipment is an essential component of good supply-chain-management.46

Accessibility

WHO Recommendation 3.1

Recommend the provision of scientifically accurate and comprehensive sexuality education programmes within and outside of schools that include information on contraceptive use and acquisition.

Sexuality education is defined as “an age-appropriate, culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgmental information. Sexuality Education provides opportunities to explore one's own values and attitudes and to build decision-making, communication and risk reduction skills about many aspects of sexuality'.48

The term ‘comprehensive’ in relation to sexuality education indicates that this approach will encompass the full range of information, skills and values to enable young people to exercise their sexual and reproductive rights and to make decisions about their health and sexuality. For example, they will not be narrowly focused on abstinence-only or on HIV/AIDS prevention.

According to the International Planned Parenthood Federation (IPPF), comprehensive sexuality education should be rights-based and gender-sensitive. It should also be citizenship-oriented, fostering responsible behaviour and action skills that promote enabling social conditions for sexual and reproductive health and well-being. Most importantly, comprehensive sexuality education should be sex-positive. This means that the curriculum should demonstrate a positive attitude towards sexuality and sexual pleasure as important for personal well-being and happiness.49

In terms of major themes to be covered by the curriculum, UNESCO guidelines on comprehensive sexuality education emphasize educating children and young people on six key concepts:

The right of adolescents and young people to have access to comprehensive sexuality education is upheld by a number of international conventions and documents. For example, the UN Convention on the Rights of the Child (1989) states that children and young people have the right to have access to information which will allow them to make decisions about their health (Article 17) including contraceptive (Article 24). The United Nations Committee on the Rights of the Child (2003) has required State Parties to provide adolescents with access to accurate sexual and reproductive health information, “including on contraceptive and contraceptives, the dangers of early pregnancy, the prevention of HIV/AIDS and the prevention and treatment of sexually transmitted diseases (STDs)”, regardless of marital status and parental consent.51

There is also considerable research evidence, which shows that well-planned and executed sexuality education programmes for adolescents and young people, implemented in schools and communities have resulted in increased knowledge of human sexuality. Many of the interventions have helped to delay the onset of sexual activity among adolescents and young people, reduce the frequency of unprotected sex and the number of sexual partners and increase condom use and contraceptive use. 52, 53, 54, 55, 56

And yet, comprehensive sexuality education may not receive explicit policy or legal support in many countries.

For example, a UNESCO review of comprehensive sexuality education in 28 countries of the Asia-Pacific region reported that in only about half the countries was comprehensive sexuality education mentioned in the national HIV, reproductive health, population or youth policies. The review also found that coverage of schools and out-of-school youth through comprehensive sexuality education was limited, and the content of the education was often narrowly focused on safe sex and prevention of HIV.57 Even where governments have been committed to implementing Comprehensive Sexuality Education, there may be resistance from religious leaders and from a section of the parents58 or from within the education sector itself.59 Advocacy to change community attitudes to Comprehensive Sexuality Education is a challenge that SRHR advocates will have to take on.

WHO Recommendation 3.2

Recommend eliminating financial barriers to contraceptive use by marginalized populations including adolescents and the poor, and make contraceptives affordable to all.

It is now well established that charging user fees for services or requiring the client to purchase medicines and supplies — leading to out-of-pocket expenditure for the client — reduces access especially for preventive and promotive services. Studies have also shown that households are unwilling to spend money for contraceptive services.60

Thus, in order to ensure maximum access especially for low-income women and young people without a source of income, contraceptive services have to be made free at the point of delivery at the least, for such population subgroups.

Contraceptive services are often not covered by many insurance schemes. Since almost all women need contraceptive services, they are non-random and/or high probability events, and therefore considered “uninsurable” as stand-alone benefits. As a result, contraceptive services may be unaffordable not only for the poor but also for from non-poor groups without a regular income or access to cash. It is important to ensure that contraceptive services are a part of the Benefits packages of insurance schemes.

Even where affordability has been addressed at the Programme level through suitable measures, there may be financial barriers to overcome at the service-delivery level. One example is the demand by various levels of personnel and health providers, for payments for services or supplies that are supposed to be free. ‘Informal payments’ are fairly widespread in many developing and transition countries and constitute a significant proportion of out-of-pocket expenses incurred.61, 62

Informal payments may be hiked up in the case of particularly vulnerable individuals such as undocumented individuals and single women who may fear being stigmatised for seeking contraceptive services.

WHO Recommendation 3.3

Recommend interventions to improve access to comprehensive contraceptive information and services, for users and potential users with difficulties in accessing services (e.g. rural residents, urban poor, adolescents). Safe abortion information and services should be provided according to existing WHO guidelines (Safe abortion: technical and policy guidance for health systems, 2 edition)

WHO Recommendation 3.8

Recommend that mobile outreach services be used to improve access to contraceptive services for populations who face geographical barriers to access

In 2011, 215 million women in low and middle income countries were estimated to have an unmet need for modern contraception: of these, 140 million were not using any method of contraceptive while 75 million were using less effective, traditional methods.63 While the recommendation focuses on especially marginalised and disadvantaged groups, it may be important to acknowledge that being a woman in a patriarchal society in and of itself imposes many barriers to women's access to contraceptive information and services (See Box 3). Unmet need for contraception is on average 2–4 times higher among low-income women than women from higher income groups. Women living in rural areas and with lower levels of education are similarly disadvantaged.64 A recent analysis of Demographic and Health Surveys spanning 20 years from over 100 countries found that although average levels of contraceptive use had risen in all countries, the gap between the poorest and the average had also steadily risen, and was wider in richer countries.65 The low coverage of rural and less developed areas including urban slums by contraceptive services, and the cost of services are major factors contributing to this disparity.

As noted earlier, contraceptive services provided free-of-cost or at subsidised cost to the client would help removing financial barriers. Community-based distribution of contraceptives is another strategy to increase access to contraceptive services, and addresses both cultural/ gender-based barriers and time/cost related barriers to reaching functional contraceptive services. Several studies from Africa and Asia have shown that trained community-based providers are able to provide information as well as services effectively to those located in rural, remote and difficult to reach areas. Community-based services are also cost-effective.66, 67, 68 However, they do not provide access to long-acting contraceptive methods including intrauterine contraceptive devices and surgical sterilization.

Mobile outreach services have been identified as a strategy to fill this gap. Mobile outreach service delivery is defined as “FP services provided by a mobile team of trained providers, from a higher-level health facility to a lower-level facility, in an area with limited or no FP or health services.69 In some cases, services are actually provided in the mobile unit, while in other instances, services are provided in a fixed location within communities.

Access to safe abortion information and services

With increasing access to contraceptive information and services during the past decades, the rates of induced abortion have tended to decline. For example, globally the rates of induced abortion declined from 35 per 1000 women age 15–44 years in 1995, to 29 in 2003.70 However, women will always need access to safe abortion services even if they were contraceptive users. According to the WHO, in 2008 globally 33 million women were estimated to become accidentally pregnant while using a method of contraception.71

Restricting the availability of safe abortion services pushes women to seek unsafe abortion at considerable cost to their health. Nearly 47,000 women were estimated to have died from complications of unsafe abortion in 2008, while million women suffered disability from the same cause.72

Support for women's right to accessing safe abortion services may be found in a number of international human rights treaties. Drawing on these, the 2012 WHO Technical and Policy Guidance Document on Safe Abortion calls on governments to remove regulatory, policy and programme barriers to safe abortion services, and to abide by the principle that the laws of the land should protect women's health and human rights. The Guidance Document recommends that safe abortion services be made available starting from primary health care level, with referrals to higher level facilities as appropriate; and that services be affordable to all sections of women including young women and adolescents.73

WHO Recommendation 3.4:

Special efforts should be made to provide contraceptive information and services to displaced populations and those in crisis settings, and to survivors of sexual violence who particularly need access to emergency contraception.

In 2012, two-thirds of the world population or 4.4 billion people were living in a country affected by a major disaster or conflict. Of these, 144 million were directly affected by disaster or displaced by conflict.74 A significant proportion of those displaced is sexually active persons who are likely to be in need of sexual and reproductive health services including contraceptive services. Many would desire to prevent a pregnancy and childbirth during a time of displacement and emergency, and especially to prevent exposing a newborn to the risks posed by such a situation. Many of them may have been unable to bring with them the contraceptive method they used or run out of supplies. And yet, contraceptive services are not often prioritised in the Minimum Initial Services package (MISP) provided in humanitarian settings.

The Inter-Agency Working Group on Reproductive Health in Crisis has, in a 2010 statement, recommended that contraceptives should be available to meet demand from the onset of an emergency; and that comprehensive contraceptive services should be available as soon as the situation stabilizes.75 Implementation of contraceptive services in humanitarian settings involves staff training, community education, logistics and supply chain management and developing a system of client follow-up. The Inter-Agency field manual on reproductive health in humanitarian settings (2010) provides detailed guidelines on implementing contraceptive services in humanitarian settings.76

A number of recent studies have reported that women and girls in humanitarian situations are also at a higher risk of experiencing sexual violence because of the use of rape as a weapon of war, or exposed to coercive sex.77 Emergency Contraception is therefore a critical need for women and girls displaced by disasters and conflict.78

Sexual violence is not unique to humanitarian situations but prevalent also in everyday life across diverse cultures and social and economic settings. An estimated 7.2% of adult women experience sexual violence from a non-partner at some time in their lives, and 30% experience physical and/or sexual violence from an intimate partner.79 WHO recommends the inclusion of emergency contraception as a part of the protocol for medico-legal services for survivors of sexual violence to prevent unwanted pregnancy resulting from the sexual violence.80

WHO Recommendation 3.5:

Recommend that contraceptive information and services, as a part of sexual and reproductive health services, be offered within HIV testing, treatment and care provided in the health care setting.

About 80% of all women and men living with HIV are in their reproductive years. As ART becomes more widely available with a concomitant increase in life expectancy among Persons Living with HIV (PLHIV), many of them will want to have the option of choosing whether and when to have children. They may wish to avoid pregnancy for a number of reasons, including fear that the child will be infected with HIV, or because they want to preserve their resources on maintaining their own health and the health of their families.

Unfortunately, contraceptive information and services are often inaccessible or unavailable to persons living with HIV. One of the reasons is the providers do not often have the knowledge and skills to counsel persons living with HIV on their contraceptive options. For example, a study from Ghana among health care providers found that many of the providers violated client's rights to contraceptive counselling. Providers also expressed their inability to provide qualified guidance on reproductive options to HIV positive women because of lack of training and the absence of clear guidelines.81 Also, provider bias and stigma results in many of them pressuring women to undergo sterilization, rather than present them with all reproductive options.82

Universal access to contraceptive services implies planning to address the specific needs of PLHIV in the planning and implementation of services. Most contraceptive methods are safe and effective for persons living with HIV. However, a number of factors will have to be considered when offering them contraceptive advice (See Box 4). For example the choices will be different for persons whose partners are uninfected as compared to those whose partners are infected. Dual protection from infections as well as pregnancy should be an important part of contraceptive options offered to HIV positive persons. Integrating contraceptive services with VCT, treatment and care services makes it possible to reach not only persons living with HIV but also sections of the population who are unlikely clients of contraceptive services. For example, whether HIV positive or not, contraceptive information and services may be offered to groups often underserved by contraceptive programmes, such as adolescents and young people, men who have sex with men (but also have female partners), transgender persons and sex workers. Programmes to prevent parent-to-child transmission of HIV should logically include contraception as a key element.84

WHO Recommendation 3.6:

Recommend that comprehensive contraceptive information, counselling and services be provided during antenatal and postpartum care

WHO Recommendation 3.7:

Recommend that comprehensive contraceptive information, counselling and services be routinely integrated with abortion and post-abortion care

Integration of contraceptive information and services with prenatal and postpartum care

According to WHO, after a live birth the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce risk of adverse maternal, perinatal and infant outcomes.85 It is also known that a large proportion of women throughout the world (92–97%) do not want another child within two years of the previous delivery. But globally, 65% of women in the first year postpartum do not use a method of contraception although they express an intention to use contraceptive.86

Interventions integrating contraceptive and prenatal and postpartum services have been implemented in many low and middle income countries,87 and robust evaluations exist of the effectiveness of these in increasing contraceptive use among postpartum women and in achieving healthy birth spacing as recommended by WHO.88, 89, 90 The unmet need for contraception among women in the first year postpartum indicates the need for integrating contraceptive services with prenatal and postpartum care as an essential component of a human rights-based and gender-responsive contraceptive programme.

A word of caution is in order here. Integration of contraceptive counselling and services with postpartum care should not be misinterpreted to justify actions such as compelling women to accept a method of contraception when they are feeling vulnerable, during labour and immediately after childbirth. Nor does it mean providing without the woman's knowledge and clearly expressed consent a method such as an IUCD immediately after placental delivery or sterilisation alongside a c-section.

Integration implies providing women with comprehensive counselling regarding sexual and reproductive health issues of concern, including contraception, at various points of contact with the health services during pregnancy, childbirth and the immediate postpartum period, allowing the woman and her spouse ample time to consider the matter and make an informed choice. They may then avail of the services in the postpartum period before sexual activity is resumed, at a time that is most convenient to her/him.91

Integration of contraceptive services with postabortion care

The WHO guidelines of birth spacing specify that after an abortion or miscarriage there should be at least a six month interval before attempting the next pregnancy in order to avoid adverse maternal, perinatal and infant incomes.92 Women who have had an abortion are at high risk of pregnancy soon after the abortion (could be as soon as one week after), and are in need of contraceptive information, counselling and services almost immediately. Studies of women receiving post-abortion care indicate that they have a high unmet need for contraception. A review of 10 studies of women receiving post-abortion care reported that more than half of all women expressed an interest in using contraception after post-abortion care. A subset of 6 studies which had relevant data showed that only about a quarter (27%) of the women left the facility with a method.93 As in the case of integrating contraceptive services with prenatal and postpartum services, there exist a number of effective models of integrating contraceptive services with abortion and postabortion services. Essential points to bear in mind include providing contraceptive services at the same time and location where women receive abortion or post abortion services; and offering a wide range of contraceptive methods including condoms, spermicides, oral contraceptives, emergency contraceptive pills, injectables, implants, lUDs and sterilization.94

Here again, it needs to be clarified that integration of contraceptive information and services with post abortion care is meant for the convenience of the woman seeking safe abortion services. Making abortion services conditional on acceptance of contraception — a practice reported from some countries — constitutes a violation of women's reproductive rights.

WHO Recommendation 3.9:

Recommend elimination of third-party authorization requirements, including spousal authorization for individuals/women accessing contraceptive and related information and services

WHO Recommendation 3.10:

Recommend provision of sexual and reproductive health services, including contraceptive services, for adolescents without mandatory parental and guardian authorization/ notification, in order to meet the educational and service needs of adolescents

In many countries, service providers ask for authorization from the spouse, usually the husband, for providing family planning services. This requirement may be found in the laws, or regulations of Ministries of Health/Family Planning or in the health facility guidelines.95 At times, even after the laws and regulations have changed, health providers may continue the practice because of their own beliefs that a woman's reproductive choices have to be approved by her husband.

The practice of requiring women to obtain their husbands' authorisation in order to obtain contraceptive methods would be especially damaging to women experiencing forms of intimate partner violence that include “birth control sabotage” and/or “pregnancy coercion” which include not allowing a woman to use contraception or actively sabotaging her use of contraception.96

Spousal authorisation requirements are usually applied exclusively to women and as such, represent a violation of women's right to equality and non-discrimination. International Human Rights Treaty Bodies such as the CEDAW (Convention on the Elimination of All forms of Discrimination Against Women) have expressed concern over laws that mandate authorisation by the husband for the wife to obtain contraceptive methods such as sterilization, and recommended the removal of such restrictions.97

Third-party authorization is often mandatory for adolescents below 18 years who seek contraceptive services. Research studies show that making parental consent mandatory for providing contraceptive services to adolescents discourages contraceptive use, without necessarily altering adolescents' sexual behaviour. The consequence is an increase in the number of unwanted pregnancies.98

Contraceptive services, while encouraging adolescents to inform their parents, should not make parental involvement a precondition. For example in the UK, any ‘competent’ young person can consent to medical treatment. Young people over 16 years of age are presumed to be competent to give consent to medical treatment unless otherwise demonstrated. For young people under the age of 16 years, however, competence to consent is assessed. In addition, for contraceptive advice and provision, health providers are advised to use checklists such as Fraser Guidelines (Box 5). 99, 100

The Convention on the Rights of the Child (CRC) explicitly recommends that states parties make available and accessible appropriate SRH services keeping in mind adolescents' best interests and taking into account the ‘evolving capacities’102 of adolescents to exercise autonomy and participate in decisions.103, 104, 105, 106

Acceptability

WHO Recommendation 4.1:

Recommend gender-sensitive counselling and educational interventions on family planning and contraceptives that are based on accurate information, that includes skill building (i.e. communications and negotiations) and that are tailored to meet communities' and individuals' specific needs.

There are two dimensions of acceptability at the service delivery level: medical and socio/cultural. Services should respect medical ethics; and they should be organized and delivered in a gender-sensitive manner and be tailored to the specific needs of the communities being served. The recommendations on informed decision-making and privacy and confidentiality address aspects of medical ethics and the focus here is on gender-sensitivity and meeting community-specific needs.

Acceptability implies that all sexual and reproductive health facilities, goods and services should be respectful of the needs of different population subgroups. Some examples include: having a staff member who is from the same language-speaking or ethnic group as minority or immigrant communities; using suitable media for disseminating information to a low-literacy population; providing sexual and reproductive health services to indigenous populations where and how they would feel comfortable; tailoring services to meet the specific needs of men.

The recommendation talks of “gender-sensitive” counselling, educational interventions and ‘skill-building’ for communication and negotiation. Gender-sensitivity implies acknowledging differences in needs between women and men because of biology as well as socially constructed gender-norms; and being aware of the ways in which gender-based inequalities between women and men constrain women's autonomy and choices.

In particular, gender-based norms about appropriate sexual and reproductive behaviour restrict women's knowledge about their bodies and their sense of entitlement to make reproductive decisions. Patriarchal society restricts women's sexuality and controls their reproduction, making reproductive autonomy beyond the reach of a majority of the world's women.

Women facing intimate partner violence may have several concerns that affect contraceptive use. Partner support for certain methods like condoms or vaginal diaphragm may not be available. They may not have adequate financial resources to pay for a particular service. Women may fear further violence for using or talking about contraception. Or intimate partner violence may cause disruptions in every-day life, which make it difficult to use methods such as oral contraceptive pills.

Gender-sensitive counseling will try to understand the underlying, often gendered, reasons why women are hesitant to make contraceptive decisions and encourage them to express their constraints and fears.107 During counselling sessions, the specific needs of clients experiencing intimate partner violence, e.g. visibility of the method used, side effects or need for partner support — must be considered and providers must be able to offer contraceptive choices accordingly.108

Beyond gender-sensitive counselling, specific gender-responsive interventions may be needed such as workshops to help women develop skills for negotiating contraceptive use with their husbands, or interventions with men to encourage them to be better informed and to take responsibility for contraception.109

WHO Recommendation 4.2:

Recommend that follow-up services for management of contraceptive side-effects be prioritised as an essential component of all contraceptive service delivery.

Recommend that appropriate referrals for methods not available on site be offered and available.

Concern about side-effects is an important reason why women do not use a contraceptive method despite intending to postpone or stop childbearing. According to an analysis of Demographic and Health Survey data of all surveys carried out during 2000–2008 in South Asia and Sub-Saharan Africa, health concerns and fear of side effects was responsible for unmet need for contraception among 37% and 39% of women in South Asia and sub-Saharan Africa respectively.110

This shows the critical importance of follow-up services in contraceptive service delivery, for reviewing the client's health, for counseling to address any concerns, for managing any side effects and for removal of the method and switching to an appropriate alternative contraceptive method when the user so desires.

At the Programmatic level, a full range of appropriate methods for a particular facility is decided based on the level of facility, the skills of providers and legal requirements. The Programme has to plan for providing clients with easy access to methods that cannot be made available at lower levels of care. However, a rights- based contraceptive service should be able to provide a range of contraceptive methods that meet the varying needs of different clients, and this may be done through a number of ways. For example, specialist providers may be brought in on specific fixed days. Organizing mobile services to provide long-acting reversible methods on site is another option and has been discussed in an earlier section. If these are not feasible, the facility should make provisions for referral, and also transportation to reach the referral facility at no extra cost to the client and with minimum delay.111

Quality

WHO Recommendation 5.1:

Recommend that quality assurance processes, including medical standards of care and client feedback, be incorporated routinely into contraceptive programmes

WHO Recommendation 5.2:

Recommend that provision of long-acting reversible contraception (LARC) methods should include insertion and removal services, counselling on side-effects, in the same locality

WHO Recommendation 5.3:

Recommend ongoing competency-based training and supervision of health-care personnel on the delivery of contraceptive education, information and services. Competency-based training should be provided according to existing WHO guidelines.

Quality of care is a major determinant of contraceptive use in many developing country settings.112 Within the context of contraceptive services, six elements of quality of care put forth by Judith Bruce (1990), has been in use for many decades: choice of methods; information given to clients; technical competence of providers; interpersonal relations; follow-up and continuity mechanisms; and appropriate constellation of services.113 More recently, Germain (2013) outlined the following six action elements that are necessary to ensure that quality standards meet human rights norms, some of which are addressed by the WHO recommendations related to quality:

Quality assurance is “an organisation's guarantee that the product or service it offers meets the accepted quality standards. It is achieved by identifying what “quality” means in context; specifying methods by which its presence can be ensured; and specifying ways in which it can be measured to ensure conformance”.115 Quality assurance is a component of quality management, which involves putting in places processes and mechanisms that guarantee that products and services meet the defined quality standard.

A rights-based approach to quality of contraceptive services has at least two major components: one, the assurance of quality of medical standards of care, and two, responsiveness to client's expectations from contraceptive services. Assurance of the quality of medical care is usually done through supervision, clinical reviews and audits and through accreditation by quality assurance bodies such as the ISO. Some ways in which client feedback may be sought are suggestion boxes, formal review committees in which clients participate, and periodic client-exit interviews and studies on client perspectives. Box 6 provides clients' expectations from contraceptive services ascertained through a study.

A key component of good quality contraceptive services, especially in the case of long-acting reversible methods, is the assurance to clients that should they decide on discontinuation of the method because of side-effects or for any other reason, the decision will be respected; and that removal services will be provided, if not in the same facility, then, within a reasonable distance at affordable costs without undue delay. For example, if clients want to discontinue using a medication or contraceptive method, staff would be required to discuss with them their reasons for wanting to discontinue; offer appropriate alternatives or provide support and information if they wish to become pregnant.

Technical competence of the provider is an important aspect of quality of care. Development and use of standard protocols for provision of contraceptive services constitutes an important component of high technical quality. Towards this, investment must be made to train providers of contraceptive services on the latest clinical guidelines which the World Health Organization publishes at regular intervals.118

Informed decision-making

WHO Recommendation 6.1:

Recommend the offer of evidence-based, comprehensive contraceptive information, education and counselling to ensure informed choice.

WHO Recommendation 6.2:

Recommend every individual is ensured an opportunity to make an informed choice for their own use of modern contraception (including a range of emergency, short-acting, long-acting and permanent methods) without discrimination

Client autonomy and informed decision-making are key characteristics components of a rights respecting contraceptive service. ‘Informed decision-making’ in contraception means that the client makes a decision considering all the circumstances of his/her life, after hearing all the information related to a wide range of contraceptive options. It also means that if the client receives all relevant information and decides not to use any contraceptive method, this is still a successful outcome.119, 120

For “informed” decision-making, clients should receive at least the following information on each available method of contraception:

Some ways in which informed decision-making may be facilitated within contraceptive information and services are mentioned in Box 7 below:

Privacy and confidentiality

WHO recommendation 7.1:

Recommend that privacy of individuals is respected throughout the provision of contraceptive information and services, including confidentiality of medical and other personal information

Privacy is “the right and power to control the information (about oneself) that others possess”.124 Privacy also commonly refers to respecting the rights of individuals not to be physically exposed against their will. Confidentiality is “the duty of those who receive private information not to disclose it without the patient's consent”.125

Confidentiality is the mechanism through which the provider protects the client's right to privacy.126

Upholding the client's privacy and maintaining confidentiality is important in all areas of health care. It is especially critical when providing sexual and reproductive health services. Failure to do so may result in loss of client trust on the services. While in many settings extended families and spouses may be considered to have the ‘right’ to know about a client's contraceptive decisions, providers must always make efforts to uphold an individual client's privacy unless the client specifically indicates a desire to include others in the decision making (in which case it must be respected and provided for). Likewise, irrespective of the cultural context, young people have a right to privacy and confidentiality when seeking sexual and reproductive health services. Box 8 below summarises some ways in which client privacy and confidentiality may be upheld in a health facility:127

Participation

WHO recommendation 8.1.

Recommend that communities, particularly people directly affected, have an opportunity to be meaningfully engaged in all aspects of contraceptive programme and policy design, implementation and monitoring

Participation by different stakeholders, especially those who are less powerful and have scarce resources, is an important tenet of a human rights-based programme. One of the most common mechanisms for community or users' participation in health programmes is committees: health centre or clinic committees, facility health committees; village health committees.

A systematic review of studies evaluating the role of such committees reports some measure of success in enhancing service accountability. Key factors that influenced the success of health committees were: how committee and group members were selected and their motivation for involvement; whether they received adequate support in terms of financial and technical resources for effective participation; and the extent to which they received cooperation from health workers and health managers.130

The extent to which community-participation mechanisms address contraception-related concerns and give voice to gender-specific needs and needs of marginalized groups is not clear from the literature. Because of power hierarchies and social stratification within communities, community-based structures may exclude women and those from less powerful groups, and as representatives of patriarchal values, oppose contraception and SRH services.131 Another challenge would be that duty-bearers such as policy makers, health managers and health care providers may not always see the need for or value of consulting with users of services.

Measures such as fixing specific quotas for the inclusion of women and those from marginalized groups and building their skills for meaningful participation through capacity-building initiatives; as well as enhancing duty-bearers' knowledge and skills to encourage and engage with community-participation mechanisms may be useful in ensuring that participation actually happens in practice.132

Stronger Voices for Reproductive Health’ is a Project in Geita District of Tanzania that aimed to build capacity of women to be informed and empowered users of sexual and reproductive health services. The project implemented a series of seven capacity-building workshops for women on sexual and reproductive health and rights. The Project worked not only with women rights-holders, but also with duty-bearers, consisting of local government representatives and health care providers. This was considered to be important for ensuring an informed response to the rights claimants by duty-bearers. During the project period of about five years, the proportion of service providers who were aware of clients' rights to privacy increased from 22% to 80%. Proportion of women engaging in discussions with health care providers to improve quality of care increased from 3% to 20% during the project period.133

Accountability

WHO Recommendation 9.1:

Recommend that effective accountability mechanisms are in place and are accessible in the delivery of contraceptive information and services, including monitoring and evaluation, and remedies and redress, at the individual and systems levels.

WHO Recommendation 9.2:

Recommend that evaluation and monitoring of all programmes to ensure the highest quality of services and respect for human rights must occur.

Recommend that, in settings where performance-based financing (PBF occurs), a system of checks and balances should be in place, including assurance of non-coercion and protection of human rights. If PBF occurs, research should be conducted to evaluate its effectiveness and its impact on clients in terms of increasing contraceptive availability.

Accountability may be defined as the “obligation of power-holders to take responsibility for their actions... towards citizens who have the right to demand”.134The concept of accountability combines three elements: keeping track of what is happening where and to whom, and what is not happening; reviewing progress against objectives, targets and bench-marks, noting differentials in progress across population groups and reflecting on barriers and facilitators for progress; and action to improve performance and provide redress to those who have been ill-served by a programme. Accountability mechanisms exist at various levels, from the international to local.

At the international level, Governments that have ratified various treaties135 supporting reproductive rights including the right to information and services related to contraception are obligated to submit regular, periodic reports to the committee which monitors compliance of states with the treaty's obligations. This is an accountability mechanism at the international level. The committees use these reports to engage in a constructive dialogue with representatives of the State party and then issue concluding observations, which commend the positive aspects but also raise concerns and make recommendations for further action. NGOs may hold their governments accountable by preparing and submitting a “shadow report” to the same treaty monitoring body which addresses omissions, deficiencies, or inaccuracies in the official government reports.

Accountability mechanisms at the national and sub-national levels may include Human Rights Commissions, professional disciplinary proceedings, Annual Health or Health-Condition Specific Reviews produced by the government, and so on. In China, for example, provincial governors regularly report progress on maternal mortality; and funding is dependent on progress.136

Civil society actors have participated in holding governments accountable through ‘social accountability’ mechanisms. Budget tracking is one such activity. The amount that a government allocated in its budget for a particular programme may be seen as an indicator of its real priorities, no matter what its policy documents proclaim. Another example is the publication of ‘Report Cards’ of government performance. For example in Bogotá, Colombia, the annual Report Card entitled “How are we doing in Health?’ measures yearly changes in coverage, quality and public perceptions of health services. Two types of data are collected. The first is statistical data on health systems coverage and health status indicators such as maternal mortality ratio. The second is a survey among citizens which measures citizens' satisfaction with the quality of health services on a scale of 1 (worst) to 5 (best). The survey has been implemented since 1998137. lt would be important to produce such Report Cards on sexual and reproductive health and rights, including contraceptive information and services. No matter what the manner of tracking progress is, one important consideration is that the indicators used are “human-rights-based”. This would mean, for example, that we track not only end-results such as contraceptive prevalence rates, but also processes that ascertain that human rights were upheld or at the least, not violated, in the course of achieving these results.138

In a human rights framework, accountability combines elements of responsiveness, answerability and redress. Formal redress procedures in the health sector are intended to rectify something that has gone wrong, and consist of “official venues in which individuals can present their understanding of their entitlements, receive an attentive hearing, and be given an explanation or compensation.”139 National Human Rights Commissions and Offices of Ombudsmen are some examples of remedial and redress mechanisms at the country level. Where “Right to Health’ as elaborated in international human rights treaties has been incorporated into domestic laws, courts of law within a country would be an effective mechanism of remedy and redress. At the international level, the CEDAW Committee oversees complaints procedures including for the violation of reproductive rights of a woman. Any woman who is not satisfied with redress provided within her own country may approach the CEDAW Committee with her complaint. The CEDAW Committee has a good track record of redress for the violation of reproductive rights.140

The emergence of Performance-Based-Financing (PBF) raises some concern from a human rights perspective. PBF is a national tool for improving utilization and provision of health care services “based on financial or in-kind rewards made to providers, payers or consumers after measurable actions have been taken”.141 Examples include Conditional-Cash Transfers (CCTs) to clients; and incentives paid to providers for meeting targets. Evidence on the effects of PBF suggests that there are many down-sides to the approach, including a focus on quantity rather than quality of services; and increase in inequity by rewarding users, providers and facilities that are better able to meet conditionality or targets set by the programme.142 Both these are in conflict with a human-rights-based approach.

Beyond WHO recommendations: Protecting and upholding the rights of service providers

Rights-based contraceptive information and services depend on the extent to which providers and the service delivery team as a whole are equipped and supported by the health system to do so. We therefore outline some essential dimensions of upholding the rights of contraceptive service providers, although recommendations contained in the WHO Guidance document do not address this issue explicitly.

Non-discrimination and affirmative action

If health care providers are to imbibe rights-based and gender-sensitive responsive values, then these same values must be reflected in various domains of health providers' work-environment including in recruitment, working conditions, work-place safety and security. For example, recruitment of health providers must be such that the work force represents the diversity of the community it serves in terms of gender, race, religion, caste etc. This may require specific affirmative action policies and long term investment in education and training of persons from marginalized groups.

Health workers must be protected from discrimination based on caste, race, religion, gender or sexual orientation. There should be a clear policy on zero-tolerance for discriminatory behaviour, and redress mechanisms for violation of such a policy. The management should signal its commitment to equality and non-discrimination in word as well as in deed.

Workplace safety and security

Health care workers are exposed to a number of health and safety hazards in their workplace on an everyday basis. A worker health and safety policy is essential for the health sector, which addresses hazards faced by all levels of health workers, especially those working in outreach and community services.

Violence in the workplace is an important concern. It is estimated that about 25% of all work place violence takes place in the health sector. Since a large majority of the health work force consists of women, a large number of victims of violence are women.143 Studies show that this violence may be gender based too.144 Hate crimes based on homophobia, racism and other prejudices also pose risks.

Capacity-building for human-rights based and gender-responsive approaches to service delivery

Pre-service training of health professionals does not equip health care providers adequately in human rights, culturally sensitive or gender responsive approaches. A survey in Nicaragua and El Salvador among 183 medical and nursing students found that only 37% felt confidence in their ability to identify human rights violations in the delivery of health care services; 40% said they would be able to take action if rights violations occurred and 33% reported that they would be able to advocate for their rights as health care providers to supervisors.145

Early innovations offer some potential models for in-service training of reproductive health care/family planning service providers on human rights. For example, experiences from pilot interventions in Nicaragua and El Salvador to build capacity of doctors and nurses on human rights issues in sexual and reproductive health care suggest that human rights training should focus on developing problem-solving skills which build provider-capacity to identify and act on human rights and ethical dilemmas in real-world settings, e.g. through services audit or critiquing video-taped service delivery scenarios.146

Enabling Community Health Workers (CHW)

In many developing countries, a large cadre of women community workers are recruited to provide community-based SRH services, especially contraceptive information and distribution. Enabling them to adopt a human-rights-based approach poses some specific challenges.

There are no standard guidelines for how CHWs may be identified and recruited. Experience from several countries across the world has demonstrated that in order to be effective, CHWs must be recruited from the communities that they will be serving.147 In hierarchical societies, ‘community-selection’ may not be a good option and caste/ethnic/race based biases in the community may play out in CHW selection, and a member of a dominant social group may be recruited.

Once CHWs are recruited, their training is an essential element and has to be more than cursory. In addition to knowledge inputs, training should include a focus on human rights and the value of social justice and gender equity.148, 149 This is because many of them would have internalised the dominant cultural values and norms in the community that are not supportive of equity (e.g. caste or ethnicity based discrimination, elitism) and will need to unlearn these.

CHWs encounter high safety and security risks. When they take-up human rights issues, CHWs face backlash both from vested interests and from within the community150, 151 Often, cultural norms work at cross purposes with values of human rights and equity. Community Health Workers who belong to the local community face the additional burden of maintaining their place within the community when they go against culture and traditions to uphold human rights values.

Community based health workers, like any other staff of the health system, need support in the form of supportive personnel policies, training, supportive supervision, and access to supplies and equipment. But they do not always receive these because there is no clarity on whether she is a representative of the community or is a worker of the health system. The lack of clarity on the CHW's role also results in poor and unfair compensation of the CHW's time and efforts. She is often recruited as a ‘volunteer’ and if paid at all, only given ad hoc payments for specific tasks done. This situation needs to be reviewed and reconsidered as a matter of workers' rights.

CHAPTER 3
AN ILLUSTRATIVE LIST OF INDICATORS

The previous sections gave detailed checklists to review compliance with or implementation of WHO'S recommendations for ensuring human rights in the provision of contraceptive information and services. In this section we have short-listed a sample of indicators evolved from the checklist that may be used for monitoring or tracking a government's performance in this regard. This is merely an illustrative list. The development of an agreed set of indicators for monitoring is a consensus-building process involving all stakeholders, and has to be undertaken in different settings taking into account the specificities of the setting.

Sample list of indicators evolved from WHO recommendations for monitoring respect for human rights in contraceptive information and services

Non-discrimination

  1. Gender equality and women's empowerment are explicit objectives of the SRH programme. Yes/No
  2. Proportion of users who report using a contraceptive method of their choice
  3. Number of reports in the media in the past year of any coercion in the provision of contraceptive services, and numbers of persons affected (if available)
  4. Data on contraceptive prevalence rates are available, disaggregated
    a) By sex Yes/No
    b) By age, including adolescence Yes/No
    c) By rural-urban location Yes/No
    d) By income/wealth Yes/No
    e) By any other axes of vulnerability (specify) Yes/No

Availability

  1. National Essential Drugs List includes the full range of contraceptive methods including emergency contraception. Yes/No
  2. Proportion of ever-users (women age 15–44 years) reporting discontinuation of contraception because of disruption in supply
  3. Proportion of never-users (women age 15–44 years) reporting non-use because of non-availability of contraceptives

Accessibility

  1. A comprehensive sexuality-education programme is in place. Yes/No
    If yes,
    a) Does it address rights, stigma and/or discrimination? Yes/No
    b) Is it sex-positive? Yes/No
    c) Does it talk about diverse sexual and gender identities? Yes/No
  2. Proportion of young people (10–24 years) covered by a comprehensive sexuality education programme.
  3. Contraceptive services are available free at the point of delivery to all sexually active individuals including adolescents and young people, irrespective of marital status. Yes/No
  4. Proportion of women age 15–44 years covered by contraceptive information and services within their communities.
  5. The country (or province/state)'s laws/regulations related to safe abortion services adhere to international Human Rights Law. Yes/No
  6. Unsafe abortion ratio152
  7. The protocol for medico-legal services to survivors of sexual violence includes the provision of emergency contraception. Yes/No
  8. Proportion of medico-legal cases of sexual violence in women which were administered emergency contraception.
  9. Guidelines for HIV services include the provision of contraceptive services as part of the counselling and service delivery protocol. Yes/No
  10. Proportion of women living with HIV of reproductive age who are users of contraception.
  11. Proportion of women living with HIV reporting an unwanted pregnancy (or seeking termination of pregnancy).
  12. Women are required to obtain their husbands' authorisation for use of one or more methods of contraception. Yes/No
  13. Adolescents require parental or guardian's authorisation for accessing any SRH service, including contraceptive information and/or services. Yes/No

Acceptability

  1. Protocols for service provision explicitly require providers to
    1. a) Give complete information of a comprehensive range of contraceptive methods including on benefits and risks including protection offered for STIs/HIV; contra-indications and common (affecting 10% or more of users) side effects. Yes/No
    2. b) Refer clients for obtaining contraceptive methods not available in a given facility. Yes/No
    3. c) Manage side-effects of contraception at no additional costs to the client. Yes/No d) Act on clients' demand for removal of a long-acting reversible method of contraception such as the IUCD or the implant. Yes/No
  2. Proportion of clients satisfied with the privacy and confidentiality offered in contraceptive information and service delivery settings.

Informed decision-making

  1. Contraceptive programme guidelines specifically highlight that clients have the final say in whether, when and which method of contraception to use. Yes/No
  2. Proportion of current users of contraceptive users reporting that they were
    1. a) informed about
    2. b) the side effects of the method used
    3. c) what to do if side effects were experienced
    4. d) other methods that could be used for contraception
  3. Proportion of women currently sterilised who were informed that they would not be able to have any more children

Participation

  1. SRH policy or programme guidelines outline the creation of mechanisms for users' participation in contraceptive programmes. Yes/No. If yes,

    Mention is made of specific quotas for the membership of women and for other marginalised groups in the mechanisms of participation. Yes/No

Accountability

  1. Sexual and reproductive rights supported by international human rights treaties are incorporated into domestic laws. Yes/No(lf yes, specify which treaties and which laws)
  2. There are domestic laws and/or regulations that violate sexual and reproductive rights supported by treaties that the government has ratified. Yes/No(lf yes, specify which treaties and which laws)
  3. There is a national or sub-national Accountability Mechanism with legal backing for protection of sexual and reproductive rights (e.g. Human Rights Commission, Ombudsman's Office etc). Yes/No
    1. a) If yes, proportion of complaints related to the provision of contraceptive information and services received.
    2. b) Proportion of these complaints that have been resolved.

ANNEX-1 GATHERING INFORMATION TO ANSWER QUESTIONS IN THE CHECKLIST: AN ILLUSTRATIVE EXAMPLE.

Answering the questions included in the checklists, in order to assess whether or not a WHO recommendation has been implemented may require gathering information from multiple and diverse sources. This would include looking at policy documents and data sources, talking to key informants or even gathering primary data on a limited scale. The following table containing illustrates potential ways in which questions in Checklist 2 may be answered.

Question Data sources
2.1. Is the contraceptive information and services programme labelled as a “family planning” or a “family welfare” programme? The name of the programme should give the answer. To call it family planning or family welfare would indicate exclusion, for example, of young unmarried people, others who are currently single, sex workers and so on.
2.2. Is the programme a part of the maternal and child health programme? This is also usually indicated in the name (MCH/FP). If not, document describing the maternal and child health programme will be able to give the details. The main concern is that MCH programmes do not generally include services for men and hence a combined MCH/FP programme would tend to exclude men.
2.3. Are gender-equality and women's empowerment explicit objectives of the programme? Information would be available from the official document about the programme, usually found on the website of the Ministry of Health. If the objectives do not mention these, it may be useful to check whether the targets or goals include gender equality or women's empowerment.
2.4. Do programme objectives explicitly mention attention to the needs of adolescents and young people? To men? Information would be available from the official document about the programme, usually found on the website of the Ministry of Health. If the objectives do not mention these, it may be useful to check whether the targets or goals include adolescents, young people or men.
2.6. Are data available on who the excluded and marginalised groups are; their sexual and reproductive health needs; and barriers encountered by them in accessing contraceptive information and services? How large or small are the gaps in information? Which groups have been left out?

Obtaining information on this will be a complex task requiring a review of available information on contraceptive use, from official sources such as annual reports of government; from large scale surveys such as national, provincial and district health surveys and the Demographic and Health Survey data for national and provincial levels; and smaller studies.

What we want to know is whether data are available by ethnicity/ race/caste; other minority groups and vulnerable groups such as migrants, people with disabilities, sex workers, PLHIV and so on, both on coverage by services and barriers to access.

2.7. Have resources been invested in data collection and research to obtain such data (as specified in 2.6?) This again, will require looking for information on whether there are any specific projects that address data gaps in sexual and reproductive health including contraception about the situation of vulnerable groups; if yes, which groups are being addressed by the project and so on. For example, has there been an attempt to include persons with disabilities as a category for disaggregation of data on contraceptive prevalence? Or has there a special survey on the reproductive health needs — including contraception — of sex workers or persons living with HIV?
2.8. In practice, are contraceptive information and services available to all sexually active persons irrespective of age, marital status or sexual orientation (e.g. single women; all men; adolescents and young people; sex workers, PLHIV)? There are two ways in which one may be able to gather information on this. One is to review all data and research which address one or more parts of this question. The second is to engage in a primary data collection process in one's own district or sub-district. Data may be gathered through qualitative interviews with health service providers working at different levels about who their clientele for contraception is, specifically probing for whether they have ever provided services to single women; PLHIV etc. and specifically probing as to what they think should be the policy towards providing services to all groups; and why.

Endnotes

1.   Singh S and Darroch JE. Adding it up: costs and benefits of contraceptive services — estimates for 2012. New York, Guttmacher institute and United Nations Population Fund (UNFPA), 2012. Accessed at <http:www.guttmacher.org/pubs/AIU-2012-estimates.pdf>.

2.   World Health Organization. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations. Geneva, WHO, 2014.

3.   Paragraph 12 b of General comment No. 14 (Committee on Economic, Social and Cultural Rights, 22nd session): The right to the highest attainable standard of health — article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR). Geneva: United Nations Economic and Social Council; 2000 (E/C.12/2000/4, http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En, accessed 3 December 2013).

4.   UNFPA and Harvard School of Public Health. A Human Rights-Based Approach to Programming. Practical implementation manual and training materials. New York, United Nations Population Fund, 2010. p. 18

5.   WHO-EURO. Checklist for assessing the gender responsiveness of sexual and reproductive health policies. Pilot document for adaptation to national contexts. Copenhagen, World Health Organization Regional Office for Europe, 2010

6.   European Anti-Poverty Network Ireland. A handbook on using a Human Rights-Based Approach to social exclusion and equality. At: <http://www.eapn.ie/eapn/wp-content/uploads/2009/10/handbook-on-using-a-human-rightsapproach-to-achieve-social-inclusion-and-equality.pdf>. Accessed on 20 October 2013. Page 9.

7.   UNFPA and Harvard School of Public Health. A Human Rights-Based Approach to Programming. Practical implementation manual and training materials. New York, United Nations Population Fund, 2010. p. 18

8.   UNFPA and Harvard School of Public Health. A Human Rights-Based Approach to Programming. Practical implementation manual and training materials. New York, United Nations Population Fund, 2010. p. 18

9.   Paragraph 12 b of General comment No. 14 (Committee on Economic, Social and Cultural Rights, 22nd session): The right to the highest attainable standard of health — article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR). Geneva: United Nations Economic and Social Council; 2000 (E/C.12/2000/4, http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En, accessed 3 December 2013).

10.  Paragraph 12 b of General comment No. 14 (Committee on Economic, Social and Cultural Rights, 22nd session): The right to the highest attainable standard of health — article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR). Geneva: United Nations Economic and Social Council; 2000 (E/C.12/2000/4, http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En, accessed 3 December 2013).

11.  Faden RR, Beauchamp TL. A history and theory of informed consent. New York, Oxford University Press, 1986.

12.  Paragraph 12 b of General comment No. 14 (Committee on Economic, Social and Cultural Rights, 22nd session): The right to the highest attainable standard of health — article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR). Geneva: United Nations Economic and Social Council; 2000 (E/C.12/2000/4, http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En, accessed 3 December 2013).

13.  European Anti-Poverty Network Ireland. A handbook on using a Human Rights-Based Approach to social exclusion and equality. At: <http://www.eapn.ie/eapn/wp-content/uploads/2009/10/handbook-on-using-a-human-rightsapproach-to-achieve-social-inclusion-and-equality.pdf>. Accessed on 20 October 2013. Page 9.

14.  The nine human rights principles and standards contain many overlapping dimensions. To avoid repetition, each dimension is dealt with under only one of the principles/ standards and cross-referenced.

15.  Both this recommendation and the next address nondiscrimination. To avoid repetitions, the discussion on non-discrimination, and the corresponding checklist, have been taken up in the next sub-section, while this sub-section focuses on involuntary and coerced contraception.

16.  Open Society Foundation. Against her will: Forced and coerced sterilization of women worldwide. New York, Open Society Foundations, 2011. At: <http://www.opensocietyfoundations.org/sites/default/files/againsther-will-20111003.pdf>, Accessed on 4 December 2013.

17.  Khan ME, Barge S and Kumar N. Availability and access to abortion services in India: Myth and realities. Paper presented at the IUSSP Conference, Brazil, 2001, pages 11–12. At: <http://www.archive-iussp.org/Brazil2001/s20/S21_P10_Barge.pdf>, Accessed on 8 July 2014

18.  Mansur Mirovalev. “Uzbek Women Accuse State of Mass Sterilizations,” The Independent, July 17, 2010.

19.  Open Society Foundation. Against her will: Forced and coerced sterilization of women worldwide. New York, Open Society Foundations, 2011. At: <http://www.opensocietyfoundations.org/sites/default/files/againsther-will-20111003.pdf>, Accessed on 4 December 2013.

20.  Open Society Foundation. Against her will: Forced and coerced sterilization of women worldwide. New York, Open Society Foundations, 2011. At: <http://www.opensocietyfoundations.org/sites/default/files/againsther-will-20111003.pdf>, Accessed on 4 December 2013.

21.  For further reference see “UNFPA. Eliminating forced, coercive and otherwise involuntary sterilization: An interagency statement. New York, United Nations Population Fund, 2014. Available at: www.unfpa.org/rights/Eliminating_forced_sterilization.pdf,

22.  Hartmann B. Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice. New York: Harper & Row, 1987.

23.  World Contraceptive Use

24.  Reerink IH and Campbell BB. Improving reproductive health care within the context of district health services: A Hands-on Manual for Planners and Managers. New York, UNFPA, 2004.

25.  IPPF. Unmet need of adolescents. Available at: https://www.ippfwhr.org/en/news-room/the-unmet-need-ofadolescents. Accessed on 17 July 2014.

26.  Tavrow P. Promote or discourage: how providers can influence service use. In Malarcher S (ed). Social determinants of sexual and reproductive health: informing future research and programme implementation. Geneva, WHO, 2010. Pp 17–36.

27.  Zhang LY, Jejeebhoy S, Shah IH, Zhang LH, Hisa J, Imem W. Access to contraceptive services among married young people in the northeast China. European Journal of Contraception and Reproductive Health Care 2004; 9:147–154.

28.  Langhaug LF, Cowan FM, Nyamurera T, Power R, RegaiDziveShiri Study Group. Improving young people's access to reproductive health care in rural Zimbabwe. AIDS Care 2003; 15: 47–57.

29.  Tangmunkongvorakul A, Kane R, Wellings K. Gender double standards in young people attending sexual health services in Northern Thailand. Culture, Health & Sexuality 2005; 7: 361–373-

30.  Speizer IS, Hotchkiss DR, Magnani RJ, Hubbard B, Nelson K. Do service providers in Tanzania unnecessarily restrict clients' access to contraceptive methods? International Family Planning Perspectives 2000; 26:13–42.

31.  Kaler A, Watkins SC. Disobedient distributors: street-level bureaucrats and would-be patrons in community-based family planning programs in rural Kenya. Studies in family Planning 2001; 32: 254–269.

32.  Youth-friendly' staff may be described as staff members who have a sex-positive attitude and consider sexuality an integral part of human existence; understand that young people are not a homogenous group; understand diversity in sexual orientation and gender identity; and are able to strike a balance between protecting the young person and respecting and enabling their autonomy — Adapted from IPPF. Keys to Youth Friendly Services website. At: www.ippf.org/resources/publications/keysyouth-friendly-services, Accessed 28 october2013.

33.  Erulkar, A S, Onoka, C J and Phiri, A. What is youth-friendly? Adolescents'preferences for reproductive health services in Kenya and Zimbabwe. African Journal of Reproductive Health 200559(3): 51–58.

34.  IPPF. Provide: Strengthening youth friendly services. Inspire pack. London, International Planned Parenthood Federation, 2008.

35.  Biddlecom, A, Munthali, A, Singh, S and Woog, V. Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda. African Journal of Reproductive Health 2007; 11(3).

36.  Downing RA, LaVeist TA, Bullock HE. Intersections of ethnicity and social class in provider advice regarding reproductive health. American Journal of Public Health. 2007; 97:1803–1807

37.  Becker D, Tsui AO. Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences. Perspectives in Sexual and Reproductive Health. 2008; 40:202–211.

38.  Reerink IH and Campbell BB. Improving reproductive health care within the context of district health services: A Hands-on Manual for Planners and Managers. New York, UNFPA, 2004.

39.  Bird ST, Bogart LM. Birth Control Conspiracy Beliefs, Perceived Discrimination, and Contraception among African Americans: An Exploratory Study. Journal of Health Psychology. 2003; 8:263–276.

40.  Mulindwa IN. Study on reproductive health and HIV/ AIDS among persons with disabilities in Kampala, Katakwi and Rafai Districts. Commissioned by Disabled Women's Network and Resource Organisation in Uganda. May 2003. At: http://v1.dpi.org/files/uploads/publications/study%20in%20kampala.pdf. Accessed 2 November 2013.

41.  Kallianes V, Ruberfeld P. Disabled women and reproductive rights. Disability and Society 1997; 12: 203–221.

42.  Open Society Foundation. Against her will: Forced and coerced sterilization of women worldwide. New York, Open Society Foundations, 2011. At: <http://www.opensocietyfoundations.org/sites/default/files/againsther-will-20111003.pdf>, Accessed on 4 December 2013.

43.  Ensuring availability of contraceptive information and services requires action on many fronts beyond those mentioned in the WHO recommendation. We have therefore added questions in the checklist that speak to other dimensions of availability such as adequate allocation of public resources for health; increasing the number of health service delivery points and of service providers; and service providers' willingness to provide the complete range of SRH services to all.

44.  US Agency for International Development. Working within an integrated supply chain. Contraceptive security: Ready lesson II. Bethedsa, USAID, n.d

45.  Centre for Diseases Control and Prevention (CDC). The pocket guide to monoging controceptive supplies, Available at:http://www.hawaii.edu/hivandaids/Pocket%20Guide%20to%20Managing%20Contraceptive%20Supplies.pdf.

46.  Centre for Diseases Control and Prevention (CDC). The pocket guide to monoging controceptive supplies, Available at:http://www.hawaii.edu/hivandaids/Pocket%20Guide%20to%20Managing%20Contraceptive%20Supplies.pdf.

47.  In a recent case before the European Court of Human Rights relating to conscientious objection to provide abortion services, the Court decreed that providers may not “give priority to their personal beliefs over their professional obligations”- O'Rourke A, De Crespigny L and Pyman A. Abortion and conscientious objection: the new battleground. Monash Law Review 2012; 38(3): 87–119.

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83.  Adapted from Mitchell HS, Stephen E. Contraceptive choice for HIV positive women. Sexually transmitted Infections 2004; 80:167–173, Table 2

84.  For information on details of how to integrate contraceptive services with ART, see Farrell BL. Controceptive-integroted HIV services: a framework for integrating contraceptive and antiretroviral therapy services. New York: EngenderHealth/The ACQUIRE Project, 2007 [57] .Available at: http://www.engenderhealth.org/files/pubs/acquire-digitalarchive/6.0_integrate_fp-lapms/6.2_resources/6.2.4_tools/fp-hiv-integration_framework_final.pdf

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87.  Some examples include the Healthy Timing and Spacing of Pregnancy’ (HTSP) program [60], the “Optimal Birth Spacing Intervention” (OBSI) [59] and the more recent ACCESS-FP programs- CATALYST Consortium. End-of-Project Report [Internet]. USAID/CATALYST Consortium, 2005. [accessed Jan 16 2013]. Available from: pdf.usaid. gov/pdf_docs/PDACG357.pdf],

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90.  MCHIP (Maternal and Child Health Integrated Program). Access to health program website. At: www.accesstohealth.org.

91.  For a comprehensive guide to postpartum sexual and reproductive health counselling, see “Postpartum counselling: A quick reference guide for physicians by the Association of Reproductive Health Professionals”. Available at: http://www.arhp.org/uploadDocs/QRGpostpartum.pdf- Kidder E, Sonneveldt E, Hardee K. Who receives PAC services? Evidence from 14 countries. Washington, D.C The Futures Group, 2004.

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98.Minors and the Right to Consent to Health Care. The Guttmacher Report on Public Policy, 3(4)» New York, Alan Guttmacher Institute, 2002.

99.For guidance, refer to “Clinical Effectiveness Unit. Contraceptive choice for young people. London, Royal College of Obstetricians and Gynaecologists, 2010. Available at: http://www.fsrh.org/pdfs/ceuGuidanceYoungPeople2010.pdf — General comment No. 15 (Committee on the Rights of the Child, 62nd session): The right of the child to the enjoyment of the highest attainable standard of health (article 24). New York, United Nations Convention on the Rights of the Child, 2013. (CREC/C/GC/15, www2.ohchr.org/english/bodies/crc/docs/GC/CRC-C-GC-15_en.doc, accessed 8 October 2013.

100.  RCOG. Contraceptive choice for young people.London, Clincial Effectiveness Unit, Faculty of sexual and reproductive healthcare clinical guidance, Royal College of Obstetricians and Gynaecologists, 2010.

101.  RCOG. Contraceptive choice for young people.London, Clincial Effectiveness Unit, Faculty of sexual and reproductive healthcare clinical guidance, Royal College of Obstetricians and Gynaecologists, 2010.

102.  The concept of ‘evolving capacities’ in the Child Rights Convention seeks to strike a balance-based on capacity-between parental responsibility for protecting the child and the rights of the child to autonomy and decisionmaking.

103.  For further information on international human rights treaties that oblige the State to reform laws that restrict adolescents' access to contraceptive information and services, see “Chapter X. Adolescents' reproductive rights ‘, in Centre for Reproductive Rights. Goining ground: A tool for odvoncing reproductive rights low reform. New York, Centre for Reproductive Rights, 2006. Available at: http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_bo_GG_adolescents.pdf

104.  General comment No. 15 (Committee on the Rights of the Child, 62nd session): The right of the child to the enjoyment of the highest attainable standard of health (article 24). New York, United Nations Convention on the Rights of the Child, 2013. (CREC/C/GC/15, www2.ohchr.org/english/bodies/crc/docs/GC/CRC-C-GC-15_en.doc, accessed 8 October 2013.

105.  Hodgkin R, Newell P. Implementation handbook for the Convention on the Rights of the Child, 3rd edition. Geneva, United Nations Children's Fund (UNICEF); 2007. At: <http://www.unicef.org/publications/files/Implementation_Handbook_for_the_Convention_on_the_Rights_of_the_Child_Part_1_of_3.pdf>. Accessed on 3 December 2013.

106.  Center for Reproductive Rights. Gaining ground: A tool for advancing reproductive rights law reform. New York, Center for Reproductive Rights, 2006. Chapter 10: Adolescent reproductive rights.

107.  For a good training resource for gender-sensitive contraceptive counselling,see “Ministry of Health (MOH) and IntraHealth International. Preservice Educotion FomilyPlonningReference Guide. Lilongwe, Malawi: MOH, 2010: Unit 5. Available at: http://www.intrahealth.org/files/media/preservice-education-family-planningreference-guide/MPsFPRG_unit5.pdf.

108.  For an example of guidance (needs to be adapted to developing country settings) on addressing the contraceptive needs of women experiencing intimate partner violence and/or reproductive coercion, see “Chamberlain, L, & Levenson, R. Addressing Intimote Portner Violence Reproductive ond Sexual Coercion: A Guide for Obstetric, Gynecologicond Reproductive Health Core Settings.2012, 2nd Edition. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Health_Care_for_%20Underserved_Women/~/media/Departments/Violence%20Against%20Women/Reproguidelines.pdf

109.  For a comprehensiveresource that provides guidance on enhancing client skills for making contraceptive choices, see “ Comprehensive counselling for reproductive heolth: An integrated curriculum. Trainers' Manual. New York, Engenderhealth, 2003. Available at: www.engenderhealth.org/files/pubs/counseling-informed–choice/ccrh_tm.pdf

110.  World Bank. Unmet need for contraception. Wasington, DC, The World Bank.At:<http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:22546157~pagePK:64229817~piPK:64229743~theSitePK:672263,00.html>. Accessed on 26 December 2013.

111.  For further guidance on follow-up services, management of side-effects and referrals, see COPEvfor Reproductive Health Services: A Toolbook to Accompany the COPE Handbook. New York, Engenderhealth, 2003. Available at: http://www.engenderhealth.org/files/pubs/qi/toolbook/cope_toolbook-a.pdf

112.  RamaRao S, Lacuesta M, Costello M et al. The link between quality of care and contraceptive use. International Family Planning Perspectives. 2003; 29(2)76–83.

113.  Bruce J. Fundamental elements of the Quality of Care: a simple framework. Studies in Family Planning 1990; 21(2): 61–91).

114.  Germain A. Meeting human rights norms for the quality of sexual and reproductive health information and services. Discussion paper presented at the “International Human Rights Conference: ICPD Beyond 2014”, June 26 2013].

115.  ESS Quality Glossary 2010, Developed by Unit B1 “Quality; Classifications”, Eurostat, 2010. At: <http://epp.eurostat.ec.europa.eu/portal/pls/portal/!PORTAL.wwpob_page.show?_docname=2344300.PDF>. Accessed on 20 July 2014..

116.  Creel LC, Sass )V, Yinger NV. Client-centred quality: clients' perspectives and barriers to receiving care. New Perspectives on QOC. No. 2. New York, Population Council and Population Reference Bureau, 2002. At: <http://www.prb.org/pdf/NewPerspQoC-Clients.pdf>. Accessed on 19 November 2013.

117.  Creel LC, Sass JV, Yinger NV. Client-centred quality: clients' perspectives and barriers to receiving care. New Perspectives on QOC. No. 2. New York, Population Council and Population Reference Bureau, 2002. At: <http://www.prb.org/pdf/NewPerspQoC-Clients.pdf>. Accessed on 19 November 2013.

118.  For guidance on competency-based training of service providers, see “WHO. Sexual and reproductive health: core competencies in primary care. Geneva, WHO, 2011. Available at:http://whqlibdoc.who.int/publications/2011/9789241501002_eng.pdf

119.  For further guidance on informed decision-making, see “Choices in Family Planning: Informed and voluntary decision making. New York, EngenderHealth, 2003.” Available at: http://www.engenderhealth.org/files/pubs/counseling-informed-choice/choices.pdf. For guidance specific to facilitating informed decision-making among young people, see “IPPF. Keys to youth-friendly services: Obtaining informed consent”, London, IPPF, 2012. Available at: www.ippf.org/sites/default/files/informed_consent.pdf

120.  Queensland Health. Guide to informed decisionmaking in health care. Brisbane, Centre for Health Care Improvement (CHI), Queensland Health, 2012.

121.  Engenderhealth. Choices in Family Planning: Informed and voluntary decision making. New York, EngenderHealth, 2003.” Available at: http://www.engenderhealth.org/files/pubs/counseling-informed-choice/choices.pdf.

122.  Kim YM, Putjuk F, Basuki E and Kols A. Increasing client participation in family planning consultations: “Smart Patient” coaching in Indonesia. Baltimore johns Hopkins University Center for Communications Programs, 2003.

123.  Creel LC, Sass JV, Yinger NV. Client-centred quality: clients' perspectives and barriers to receiving care. New Perspectives on QOC. No. 2. New York, Population Council and Population Reference Bureau, 2002. At: <http://www.prb.org/pdf/NewPerspQoC-Clients.pdf>. Accessed on 19 November 2013.

124.  WHO. Considerations for formulating reproductive health laws. WHO/RHR/00.1. Geneva, World Health Organization, 2000.

125.  WHO. Considerations for formulating reproductive health laws. WHO/RHR/00.1. Geneva, World Health Organization, 2000.

126.  PATH. Ensuring privacy and confidentiality in Reproductive Health Services: A Training Module and Guide. Washington, D.C, PATH, 2003.

127.  PATH. Ensuring privacy and confidentiality in Reproductive Health Services: A Training Module and Guide. Washington, D.C, PATH, 2003.

128.  IPPF. Keys to youth-friendly services: Obtaining informed consent”, London, International Planned Parenthood Federation, 2012. Available at: www.ippf.org/sites/default/files/informed_consent.pdf

129.  PATH. Ensuring privacy and confidentiality in Reproductive Health Services: A Training Module and Guide. Washington, D.C, PATH, 2003.

130.  Molyneux S, Atela M, Angweny V and Goodman C. Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy and Planning 2012; 1–14, doi:10.1093/heapol/ezro83.

131.  Murthy RK and Klugman B. Service accountability and community participation in the context of health sector reforms in Asia: Implications for sexual and reproductive health services. Health Policy and Planning 2004; (suppl 1): i78-i86 65].

132.  For further reference, see: A Guide to Action for Community Mobilization and Empowerment Focused on Postabortion Complications: Facilitator's Manual. The RESPOND Project/EngenderHealth, 2010. Available at: http://www.respond-project.org/pages/files/6_pubs/curricula-manuals/COMMPAC-Facilitator-Manual-May2010.pdf. Another useful resource is Community based family planning best practices manual. Wellshare International 2011. Available at: http://www.k4health.org/sites/default/files/CBFP%20Best%20Practice%20Manual_FinalWeb.pdf.

133.  UNFPA and Harvard School of Public Health. A Human Rights-Based Approach to Programming. Practical implementation manual and training materials. New York, United Nations Population Fund, 2010.

134.  Cornwall A., Lucas H., Pasteur K. Accountability through participation: developing workable partnership models in the health sector. Institute of Development Studies Bulletin 2003; N0.1 (1).

135.  Some of the international human rights treaties on which reproductive rights are grounded include the International Covenant on Economic, Social and Cultural Rights; the Convention of Elimination of All forms of Racial Discrimination; Convention on the Rights of the Child; Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW); and Convention on the Rights of Persons with Disabilities.

136.  George A. Using accountability to improve reproductive health care. Reproductive Health Matters2003; 11 (21): 161–170.

137.  Chacón F. G. ELLA Policy Brief: Citizen Participation in Evaluating Health Services: The Latin American Experience.ELLA (Evidence and lessons from Latin America) Practical Action Consulting, Lima, Peru, 2012. At: <http://ella.practicalaction.org/sites/default/files/120516_GOV_CitPar_BRIEF1.pdf>. Accessed on 19 November 2013.

138.  For further guidance on rights-based SRH indicators, see: “Strategic indicators for universal access to sexual and reproductive health and rights. An advocate's guide.” Kuala Lumpur, Asian-Pacific Resource and Research Centre for Women (ARROW), 2013. Available at: http://www.arrow.org.my/publications/AdvocateGuide_Final_RN_Web.20131127.pdf

139.  Gauri V. Redressing grievances and complaints regarding basic service delivery.Washington DC, The World bank, 2011.

140.  PMNCH. National advocacy mechanisms for women and children's health.Geneva, PMNCH, 2012.

141.  World Bank. Results-Based Financing for Health. Cure, curse or mixed blessing? Washington DC, The World Bank, Technical Brief, 2009. At: <https://www.rbfhealth.org/system/files/RBF_Tech_MixedBless_R1.pdf>. Accessed on 26 December 2013.

142.  Oxman AD, Fretheim A. An overview of research on the effects of Results-Based-Financing. Report no.16–2008. Oslo, Norwegian Knowledge Centre for the Health Services, 2008.

143.  International Labour Office/International Council of Nurses/ World Health Organization /Public Services International. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva, International Labour Office, 2002.

144.  Newman CJ, de Vries DH, Kanakuze JA and Ngendahimana G. Workplace violence and gender discrimination in Rwanda's health workforce. Increasing safety and gender equality. Human Resources for Health 2011; 9:19. At: <http://www.human-resources-health.com/content/9/1/19>. Accessed on 28 October 2013.

145.  Reyes HLM, Padilla-Zuniga K, Billings DL and Blandon MM. Incorporating human rights into reproductive health care provider education programs in Nicaragua and El Salvador. RevisitaPanamericanaSaludPublica 34(1): 54–59.

146.  Reyes HLM, Padilla-Zuniga K, Billings DL and Blandon MM. Incorporating human rights into reproductive health care provider education programs in Nicaragua and El Salvador. RevisitaPanamericanaSaludPublica 34(1): 54–59.

147.  Prasad BM, Muraleedharan VR. Community health workers: a review of concept, practice and policy concerns. Consortium for Research on Equitable Health Systems (CREHS), Working paper, 2008

148.  Sundararaman T, Ved R, Gupta G, Samatha M. Determinants of functionality and effectiveness of Community Health Workers- results from evaluation of ASHA program in 8 Indian states. BMC Proceedings 2012; 6 (Suppl 5): O30. Available at:

149.http://www.biomedcentral.com/1753-6561/6/S5/O30.Accessed 2 November 2013.

149   For a comprehensiveresource that provides guidance on enhancing client skills for making contraceptive choices, see “Comprehensive counselling for reproductive heolth: An integrated curriculum. Trainers' Manual. New York, Engenderhealth, 2003. Available at: www.engenderhealth.org/files/pubs/counseling-informed–choice/ccrh_tm.pdf

150.  Nandi S. The role of community health workers (CHWs) in addressing the social determinants of health in Chattisgarh, India. Mini-thesis submitted in partial fulfillment for the degree of Master of Public Health. University of Western Cape (South Africa), 2012.

151.  Van Ginneken N, Lewin S, Berridge V. The emergence of community health worker programmes in late apartheid era in South Africa: A historical analysis. Social Science and Medicine 2010; 71:1110–1118.

152.  These may be obtained from WHO'S most recent estimates on unsafe abortion ratio. The latest estimates are available from WHO. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortalityin 2008. — 6th edition. Geneva, World health Organization, 2008.

Bibliography

ARROW receives institutional support and core funding from the Ford Foundation, FJS and SIDA

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