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In-Depth Reading Time: 6 minutes

How Are Governments Ensuring that Voluntary Family Planning Remains an “Essential Service” During COVID-19?

A Focus on East and Southern Africa

In a variety of ways that suit their contexts, countries around the world have adapted international guidance on providing voluntary family planning and related reproductive health care during the COVID-19 pandemic. Tracking the extent to which these new policies are successful in maintaining women’s access to safe, high-quality care will provide valuable lessons for responses to future public health emergencies.

In late January 2020, the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern, a formal declaration that triggered governments to mandate that only “essential” health care be provided during the pandemic. Though well-intentioned, this directive is also ambiguous. While health care workers scramble to manage waves of highly infectious and often critically ill patients, who decides what type of health care is essential?

Amid an inconsistent designation of “essential” services, overburdened health facilities, lockdowns, supply chain interruptions, and travel restrictions, without decisive action, provision of voluntary family planning will inevitably decline, with potentially devastating effects. The Guttmacher Institute estimated the impact of a 10% proportional decline in the use of short- and long-acting reversible contraceptive methods in 132 low- and middle-income countries. By their calculations, this would result in an additional 49 million women with an unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year.

Fortunately, governments have taken steps to help ensure that voluntary family planning care remains essential and accessible. Below, we highlight actions taken by five countries in East and Southern Africa and compare their guidance to the following WHO recommendations:

  • Substitution: Make other contraceptive options (including barrier methods, fertility awareness-based methods, and emergency contraceptives) more readily available in case a woman’s regular contraceptive method is unavailable.
  • Relaxing requirements for a prescription: Provide uninterrupted access and multi-month supplies for oral or self-injectable contraception and emergency contraception, along with clear information about the method and how to access referral care for adverse reactions.
  • Task sharing: Enable pharmacies and drugstores to increase the range of contraceptive options they can provide and allow for multi-month prescriptions and self-administration of subcutaneous injectable contraceptives if available.
Country Substitution Relaxing Prescription Requirements Task Sharing
Kenya X 3-month refills for pills Community-based distribution (CBD) of pills and condoms
Offered guidance for continued provision of injectables and other methods allowable in private-sector pharmacies and drug shops
Uganda X 3-month refills for pills Allowed for community health workers (CHWs), but no clear emphasis on the private sector
Tanzania Emergency contraceptive pills (ECPs) recommended 3-month refills for pills Recommend ECPs be provided at all pharmacies and drug shops
Zambia X 3-month refills for pills X
(Did not disallow, but offered no clear guidance)
Zimbabwe Fertility awareness methods (FAMs) 3-month refills for pills X
(Did not disallow, but offered no clear guidance)

Kenya

Kenya released a guidance document, Practical Guide for the Provision of Maternal, Newborn and Family Planning Care and Services during the Context of COVID-19, that officially designated voluntary family planning as an essential service. Recommendations include:

  • Providing methods that require less client/health worker interaction (for example, oral contraceptive pills [OCPs] versus new intrauterine device [IUD] insertions), if acceptable to clients
  • Offering extended refills (three-month supply) of pills
  • Offering injectables at public- and private-sector health facilities
  • Minimizing crowding at health facilities by offering family planning care 24 hours a day, but staggering client access
  • Counseling women on normal side effects of contraception to discourage premature method discontinuation
  • Encouraging task sharing through community-based distribution and private-sector facilities, such as drug shops and pharmacies, to alleviate the burden on health care facilities (only for pills and condoms)
  • Working with trusted motorcycle taxi operators to deliver pills and condoms to women in their communities

Kenya’s openness to task sharing sets it apart from some neighboring countries. In general, the government’s guidance encourages a balance between innovation and fidelity to established recommendations in order to maintain women’s access to safe, high-quality family planning care.

Uganda

The Global Financing Facility estimated that due to current COVID-related disruptions, the percentage of married women using modern and traditional family planning methods could drop from the current level of 44% to 26% in a year, without intervention. To help ward off the damaging results of an estimated 941,800 fewer women receiving family planning care, the Government of Uganda released an interim guidance document, Sustained Delivery of Essential Health Services in the Context of COVID-19 in Uganda, prioritizing voluntary family planning as an essential service. Subsequently, the Ministry of Health (MOH) prepared specific guidelines on reproductive health care in the context of the pandemic. The approach focuses on:

  • Emphasizing community-based distribution through village health teams (with limits on the number of people attending community events) and motorcycle taxi operators to connect with clients who require refills
  • Continuing clinical outreach for long-term and permanent methods
  • Providing three-month supplies of short-acting methods, rather than requiring women to return to a clinic monthly
  • Supporting contraception continuance among women who wish to limit or space births (for example, health care workers review records to identify clients in need of refills and contact them through village health teams or trained motorcycle taxi operators)
  • Advising district health authorities to consider maintaining higher levels of stock than usual, if possible

It is interesting to note that despite some successful pilot programs, Uganda’s COVID guidance does not recommend task sharing via provision of injectables in private-sector clinics or by drug shops. However, Uganda’s plan to review medical records to identify women in need of refills and engage trusted motorcycle taxi drivers to contact these clients is a novel approach that could be easily replicated if successful.

Tanzania

During a webinar in June, Dr. Alfred Mukuwani, Tanzania’s Assistant Director for Reproductive and Child Health, explained that Tanzania’s approach to COVID-19 differs from that of some neighboring countries. The country never fully locked down, but rather emphasized infection prevention, mainly through handwashing. Tanzania’s New Practical Guidelines for Maternal Nutrition and Child Health and Family Planning Services during COVID-19 focuses on the following measures:

  • Carefully tracking inventory and accurately ordering commodities to minimize stockouts
  • Deferring elective invasive surgical procedures, such as bilateral tubal ligation
  • Continuing to offer facility-based family planning care, and exercising infection prevention control to protect both clients and service providers
  • Deferring removal of long-acting methods to reduce physical contact between clients and health care providers
  • Suspending community outreach until widespread restrictions on movement are lifted
  • Ensuring that ECPs—deemed especially important while people are advised to stay home—are readily available in all facilities and drug outlets and from CHWs
  • Providing OCPs with up to three-month refills

Provision of ECPs is unique to Tanzania among the countries discussed here, and their ready accessibility is especially important.

Zambia

The Government of Zambia developed General Guidelines for Continuation of Essential Public Health Services, which notes that the likelihood of increased unintended pregnancies during the pandemic necessitates women’s continued access to voluntary family planning information and care. Zambia’s strategy for maintaining continuity of voluntary family planning relies on:

  • Providing short-term methods, because they are easy to administer, safe for most women, and require relatively little interaction between clients and providers
  • Relaxing requirements related to refills on OCPs, allowing three-month refills

However, injectable contraceptives are the most popular method among Zambian women, and the guidelines do not emphasize task sharing (such as provision by drug shops) to increase access or reduce the burden on facilities. Also, outreach services were suspended, and the guidelines defer the removal of long-term methods, provision of IUDs, and elective surgeries like vasectomy and tubal ligations. As a result, practically speaking, many women will have few options beyond condoms and OCPs, which may result in decreased use of voluntary family planning.

Zimbabwe

Some family planning clinics in Zimbabwe have closed because of COVID-19, and others have suspended outreach services. Even where clinics remain open and provide a full range of contraceptive care, attendance has dropped precipitously; one nongovernmental organization (NGO) reported that the number of clients fell by 70% in April 2020. Zimbabwe’s MOH developed guidance which, similar to those of the other countries, asserts that voluntary family planning is an essential service and its provision will continue during the pandemic. However, unlike Zambia and Kenya—whose main strategy is provision of short-acting methods—Zimbabwe is promoting fertility awareness methods (FAMs), such as lactational amenorrhea and the Standard Days Method. This emphasis on FAMs is unique; they are a viable option, especially given that access to facilities is limited. However, the effectiveness of FAMs varies widely, and intensive counseling will be required to successfully shift clients currently using other methods.

Implications For Continued Contraceptive Access

Country Implications of guidelines for continued contraceptive access
Kenya The guidelines generally have positive implications for continued access to short-term methods. Task sharing through CBD (pills and condoms) and the private sector is highlighted, including through innovative means such as motorcycle taxi operators. Long-term methods are available for women to start and/or continue if they are able to visit a facility.
Uganda The guidelines generally have positive implications for contraceptive access for people who are comfortable receiving care through CBD and health facilities. Women who are far from facilities have less access, because the guidelines do not emphasize provision through private-sector clinics or drug shops. Access is even more limited for clients who are not able or willing to leave their homes. No emphasis on FAMs, which could be a substitute method for clients stuck at home.
Tanzania The guidelines offer some continuity for people who are willing and able to visit a facility or drug shop (of the countries reviewed here, only Tanzania did not lock down). Otherwise, access is limited because clinical community outreach and CBD are suspended. The guidelines do recommend that drug shops and pharmacies stock ECPs.
Zambia The guidelines offer some continuity of family planning, particularly for clients who prefer pills or condoms, but offer very few options for women who prefer long-acting methods.
Zimbabwe With clinical outreach care suspended and CHWs advised to stay home, contraceptive options are limited for women who are unable or unwilling to visit a facility. The guidelines recommend substituting with FAMs, but the effectiveness of these methods is limited if women and couples are not properly counseled on their use and the importance of adherence.

What Can We Learn from These Varied Responses to COVID-19?

While WHO guidance provided a generic platform for responses to COVID-19, the countries discussed here customized according to their own goals, policies, and political contexts. The most commonly adopted WHO recommendation is to relax requirements to allow easier access to short-acting methods for up to three months. However, as for the recommendation that substitutions be made when the preferred method is not available, countries’ guidance varies quite a bit. For instance, Zimbabwe prioritizes FAMs, while Tanzania prioritizes emergency contraception. There is also significant variation in the level of flexibility: While Uganda and Kenya have more open approaches that encourage innovation, Tanzania and Zambia seem to be more restrictive.

The pandemic has caused countries to rapidly adjust their policies and adopt measures that, under normal circumstances, could take years to implement. When the emergency lifts, there will be rich opportunities to study what worked, what did not, and what measures might be applied not only to future pandemics but also to everyday family planning guidance. Illustrative programmatic and research questions include:

  • Did women who were provided three-month refills of pills continue taking them as prescribed, or did they forget without the usual monthly check-ins with providers? Did they have issues with storing three months of pills?
  • In the absence of other choices, how many couples used FAMs and how were pregnancy rates affected? Where FAMs were effective, what kind of counseling did women and couples receive?
  • How successful were the innovations, such as the use of motorcycle taxi operators to deliver contraception during lockdowns? Could women afford the costs in poor urban settlements or rural areas?
  • How were countries able to change their policies so swiftly? What can family planning advocates and policy researchers learn from the process
  • How satisfied were women and couples who had to change from their usual methods to something more readily available during the pandemic? Did they switch back after regulations eased?
  • How were birth rates affected in each country?

It remains to be seen whether any country’s response will be more successful than others. Going forward, it will be important to track all the key metrics of reproductive health/family planning to learn valuable lessons from the experiences of women and couples using voluntary family planning during these extraordinary times.

Document COVID’s Impact on FP With This Tool

The USAID-funded Research for Scalable Solutions (R4S) Project, with technical assistance from the USAID-funded EnvisionFP Project, developed a series of survey questions that can be added to ongoing studies and activities to systematically capture the effects of the COVID-19 pandemic and recovery process on voluntary family planning access and use.

Photo Credit: World Bank / Ousmane Traore
Frederick Mubiru

Technical Officer II

Frederick Mubiru, MSC is a Technical Officer II in FHI 360’s Research Utilization Department and works as the Family Planning Advisor for the Knowledge SUCCESS project. In his role, he provides technical and scientific leadership to the designing of Knowledge Management strategies and priorities for the project’s FP/RH audiences, content products development and supporting strategic partnerships for the project. Frederick’s background as Project Director and Manager included overseeing operations of large-scale Family Planning and Gender projects with both FHI 360 and the Institute for Reproductive Health at Georgetown University, providing technical support to the Ministry of Health on FP and Advocacy for Task Sharing policies, and others. He previously coordinated the research, monitoring, and evaluation departments at MSH and MSI in Uganda. He holds a Master of Science in Population and Reproductive Health Studies from Makerere University, Kampala.

Suzanne Fischer

Suzanne Fischer, MS, joined FHI 360 in 2002 and is now an Associate Director of Knowledge Management in the Research Utilization division, where she supervises a team of writers, editors, and graphic designers. In addition, she conceptualizes, writes, revises, and edits curricula, provider tools, reports, briefs, and social media content. She also trains international researchers on writing scientific journal articles and has co-facilitated writing workshops in eight countries. Her technical areas of interest include youth sexual and reproductive health and HIV programs for key populations. She is the co-author of Positive Connections: Leading Information and Support Groups for Adolescents Living with HIV.

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