Ensuring the Continuity of Sexual and Reproductive Health and Family Planning Services During the COVID-19 Pandemic: Experiences and Lessons from the Women’s Integrated Sexual Health Program

Abstract

One of the main aims of the UK aid funded Women’s Integrated Sexual Health (WISH2ACTION W2A) program is to strengthen government stewardship of sexual and reproductive health/family planning (SRH/FP) services across seven countries in South Asia and Sub-Saharan Africa. Options consultancy provides technical assistance within four work streams: 1) creation of a favorable policy and planning environment; 2) improved public sector investment; 3) national stewardship over quality improvement; and 4) establishment of accountability systems to influence and track commitments and policies. This role became even more important since the coronavirus disease (COVID-19) outbreak shifted government’s priorities to the COVID response and led to the disruption in the delivery of essential health services, threatening to undo and reverse the SRH/FP gains made to date. In this chapter, the author shares Options’ approach and experiences in engaging governments during the pandemic to ensure that access to SRH/FP remains a priority, alongside efforts to keep the routine enabling environment work on track. The author draws out wider lessons on the range of actions that can be taken at policy and systems level to protect SRH/FP during a health emergency in different country contexts, including the severity of the outbreak, socio-political environment, and health systems preparedness. The author also highlights how the pandemic can provide new policy opportunities, such as to accelerate self-care, and strengthen health systems resilience.

Introduction

One of the main aims of the UK-aid funded Women’s Integrated Sexual Health (WISH2ACTION) program is to strengthen government stewardship of sexual and reproductive health/family planning (SRH/FP) services across seven countries in South Asia and Sub-Saharan Africa. Options Consultancy provides technical assistance within four work streams or pathways of change: (1) creating a favorable policy and planning environment; (2) improving public sector investment; (3) strengthening national stewardship of quality improvement for SRH/FP services; and (4) establishing accountability systems to influence and track commitments and policies. Options’ role became even more important since the COVID-19 outbreak shifted government’s priorities to managing the pandemic response, which subsequently led to the disruption in the delivery of essential health services and threatens to reverse the SRH/FP gains that countries have made to date. In this chapter, we share Options’ approach and experiences in working with governments during the pandemic to ensure access to SRH/FP remains a priority and our efforts to keep the pre-COVID-19 enabling environment work on track. The chapter draws out wider lessons on the range of actions that can be taken at policy and systems level to protect SRH/FP during a health emergency in different country contexts, including the severity of the outbreak, sociopolitical environment, and health systems preparedness. It also highlights how the pandemic can provide new policy opportunities, such as to accelerate self-care, and strengthen health systems resilience.

The methods used for the study included document review, semi-structured interviews with the Options country teams and the technical support staff located in Kenya and London, and semi-structured questionnaires sent to the country team leads. The interviews focused on understanding the main COVID-19 interventions implemented within the four work streams and their impact. The questionnaires elicited information on the severity of the COVID-19 outbreak in each country and data on SRH/FP service uptake during the period March to November 2020. Additionally, several case studies were conducted for a more in-depth understanding of the COVID-19 adaptations and results achieved.

Following this introduction, the aims and objectives of the WISH2ACTION program are described, focusing on the creation of an enabling environment for the SRH/FP component. Next, information on the severity of the COVID-19 outbreak across the seven countries and governments’ response in the early phase of the outbreak is presented. Then, the multipronged approach adopted by Options within the four enabling environment work streams to ensure SRH/FP remained a priority of government, and the results achieved are discussed. The extent to which the pre-COVID-19 work was able to progress during the first 8 months of the pandemic is also examined. The impact the pandemic had on SRH/FP service uptake and the contribution of the WISH2ACTION program in minimizing the disruption to service access is assessed. The chapter ends by drawing out key lessons on what worked in what context, what could have been done better, and if the pandemic presented new opportunities for progressing the enabling environment work.

Background

Women’s Integrated Sexual Health Program

The Women’s Integrated Sexual Health Program (WISH2ACTION) is a UK-aid funded program which aims to support countries to achieve their national SRH/FP goals and realize their FP2020 commitments.¹ The program supports women and their partners to safely plan their pregnancies and improve their sexual and reproductive health, particularly the young, the poorest, and people with disability through:

• 1. Rights-based provision of private sector sexual and reproductive health information and services, and strengthening of public sector health information and services.

• 2. Addressing barriers to family planning uptake at individual, interpersonal, community, and institutional level.

• 3. Improving policies, government financing, stewardship for quality improvement, and accountability to create an enabling environment for family planning and sexual and reproductive health and rights.

WISH2ACTION is implemented through a consortium of organizations led by the International Planned Parenthood Federation (IPPF) with MSI Reproductive Choices, International Rescue Committee (IRC), Development Media International (DMI), Humanity and Inclusion, and Options Consultancy Services Limited. The consortium works in a coordinated manner to deliver synergistic impact, prevent unintended pregnancies, and reduce maternal mortality. All partners are using the pathway of change (PoC) tool to drive sustainable impact within their respective work components [1]. ‘The PoC responds to the need for a more practical adaptive programming tool that can be tailored to support flexibility in global health program implementation.’ The tool facilitates adaptive, contextualized planning and monitoring for multi-country programs.

Options leads on component 3 and is tasked with creating an enabling environment for SRH/FP in seven countries—Bangladesh, Pakistan, Uganda, Zambia, Tanzania, Madagascar, and Malawi. The work comprises four interconnected streams of work or pathways of change (Fig. 6.1).

Fig. 6.1

Source Options Consultancy Services

Enabling environment goals and pathways of change.

• 1. Facilitating a favorable SRH/FP policy and planning environment: Having the right policies and legislation in place and rolled out to address critical SRH/FP gaps is a cornerstone of WISH2ACTION’s approach to strengthening national ownership. Key activities in this pathway of change include: conducting a political economy analysis to identify key policy gaps and opportunities; reviewing status of country SRH/FP plans; updating and supporting the development of new SRH/FP policies; ensuring policies are incorporated into costed annual health plans/FP2020 costed implementation plan; development of policy advocacy tools; and tracking the implementation of policies and plans at national and sub-national levels.

• 2. Improving public sector investment: Increased allocation and spend of national budget for SRH/FP commodities and services is a core indicator of strong national ownership leading to sustained SRH/FP outcomes. Options works at country level to make the case for increased domestic investments and more timely release and utilization of SRH/FP budgets. Key activities in this pathway of change include: mapping fund flows and family planning expenditure tracking; cost analyses of services and/or commodities; strengthening capacity of governments in budgeting, planning, and financial management; strengthening capacity of civil society on budget analysis and tracking; advocating for a dedicated SRH/FP budget line; and advocating for increased investments in family planning commodities.

• 3. Strengthening national stewardship over SRH/FP quality improvement: WISH2ACTION supports the creation of a sustained quality improvement (QI) process that is nationally driven, coordinated, and embedded within the institutional fabric of the health system. Key activities in this pathway of change include: conducting a situation analysis on the status of stewardship of SRH/FP quality improvement; development of national standards, policies, and guidelines for quality services; developing a QI scorecard or dashboard to track quality indicators; and strengthening capacity of government to used QI data for planning purposes.

• 4. Strengthening accountability systems to influence and track key SRH/FP commitments and policies: While governments have made commitments to improve SRH/FP, in many cases, these have not translated into increased budget allocations or improved policies. To improve government accountability, WISH2ACTION works through national and sub-national accountability mechanisms to monitor progress of plans and budgets, identify gaps, and put pressure on governments where action is needed. Key activities in this pathway of change include: helping from a representative accountability platform; developing capacity of accountability mechanisms on using evidence for advocacy and accountability; supporting collection of data to track progress; and sharing evidence with media and target audiences who are in a position to act (such as parliamentarians and ministry of health (MoH) officials at national, regional, and district levels).

The PoC tool has facilitated joined-up working across the four work streams (especially evidence and accountability working closely with policy and planning and health financing), leading to greater synergy and impact.

Options had been implementing the WISH2ACTION program in these seven countries for fifteen months, and country teams had built a strong relationship with governments and other SRH/FP stakeholders when COVID-19 struck. As a result, they were able to quickly pivot their support to minimizing the impact of COVID-19 on SRH/FP services.

COVID-19 Outbreak

All seven countries had confirmed COVID-19 cases by April 2020. The outbreak was larger in South Asia compared to Sub-Saharan Africa, with Pakistan the most heavily impacted. Pakistan registered a total of 908 cases per 100,000 population during March to November. During the same time period in Africa, Madagascar had the largest number of cases at 293/1000,000, compared to Zambia (101/100,000) and Malawi (156/100,000). Figures 6.2a, b displays the number of monthly COVID-19 cases in 6 countries by region. It displays three patterns: (1) a steady rise in cases followed by steady drop (Zambia and Bangladesh); (2) a steady rise followed by a plateauing of cases (Madagascar and Malawi); and (3) a steady rise throughout the period (Uganda and Pakistan). It is caveated that this analysis is heavily dependent on the testing capacity of countries. The number of deaths in each month followed the same trajectory as number of cases, with fatality rates ranging from 0.91% in Uganda to 2.91% in Malawi. To date, Tanzania has reported a total of 509 cases of COVID-19 and 21 deaths during March and April. The President declared the country COVID free in June, stopped reporting cases to the WHO, and has denied the presence of the pandemic since then.

Fig. 6.2

a Number of COVID-19 cases in Sub-Saharan Africa in 2020. Source Official COVID-19 data reported by the respective governments. b Number of COVID-19 cases in South Asia in 2020. Source Official COVID-19 data reported by the respective governments

Governments across the seven countries were quick to introduce lockdown measures and to turn their attention to COVID-19 prevention, management, care, and treatment. However, it took time to roll out personal protection equipment (PPE) to facilities and to implement track and test systems. While health facilities remained open in all the WISH2ACTION countries except Pakistan, SRH/FP provision was severely curtailed in the first few months of the pandemic as both health workers and clients were not able to reach facilities, due to the enforced curfews and lack of public transportation and fear of contracting the virus in health facilities. In Malawi, for example, health workers went on strike due to the lack of PPE [2]. All this led to a drop in uptake of SRH/FP services in public facilities in all countries, during the first few months of the pandemic.

Within weeks of the pandemic striking, the Options country teams used the PoC tool to adapt their work plans toward helping governments mitigate the disruption to SRH/FP services, and ensure that progress toward sustainability goals was maintained. This included efforts to deliver their original planned work to the extent possible.

Ensuring Continuity of Government’s Sexual and Reproductive Health/Family Planning Services

The Ebola epidemic and other similar infectious disease outbreaks have illustrated the detrimental impact such health emergencies can have on the provision of essential services if the health system is not adequately prepared. This includes health worker attention being diverted to managing the new crisis, disruption in procurement and supply chains for commodities, including contraceptives, and clients not visiting health facilities due to fear of contracting the virus. It is estimated that even a 10% decline in contraceptive use in low- and middle-income countries will result in an additional 49 million women with an unmet need, an additional 15 million unintended pregnancies, plus additional 3 million unsafe abortions would result in additional 1000 maternal deaths [3].

Recognizing this very real risk to WISH2ACTION countries, the Options country teams reached out to government counterparts as soon as the pandemic arrived, to offer support and press on the importance of maintaining SRH/FP services. In almost all cases, this was done virtually due to lockdown, using existing platforms such as SRH/FP technical working groups (TWGs) and, in some cases, newly established COVID-19 platforms. An advantage of this approach was that it enabled coordination of technical assistance (TA) with other TA providers (such as United Nations Population Fund (UNFPA) and Health Policy Plus (HP+), among others) and harmonization of messages. In the early stage of the outbreak, the main request to donors was for assistance to secure adequate PPE, put in place a test, track, and trace system, and extend treatment and care to those who tested positive. Technical partners in these forums pressed on the importance of having guidelines, protocols, and capacity in place to undertake these functions effectively, especially those related to infection control, so that essential services, including SRH/FP, could be safely provided. The WISH consortium continued to meet regularly throughout the pandemic to ensure synergy across their COVID-19 adaptations.

The next section outlines the activities undertaken within the four enabling environment pathways of change over the first six months of the pandemic, to ensure SRH/FP were considered essential services and that they continue to be accessible.

Policy and Planning Pathway

The sustainability goal of the policy and planning pathway was modified at the start of the pandemic to ‘supportive SRH/FP policies, legislation, or commitments in place and/or being implemented despite public health emergencies.’ The Options teams shifted their attention toward mitigating the disruption of COVID-19 on SRH/FP services and at the same time attempting to progress their ongoing pre-COVID work to foster an enabling policy and planning environment for SRH/FP. They engaged government through different virtual platforms to identify and agree, in coordination with other technical assistance (TA) providers, what they could do to ensure continuity of SRH/FP services. For example, the Malawi team, on realizing the COVID-19 National Response Committee did not have SRH/FP representation (and hence did not consider these essential services during the pandemic), pushed for, and was successful in establishing a sub-cluster committee on SRH/FP. This platform was effectively used to raise problems being experienced with service delivery, particularly related to family planning commodity stock out and challenges in accessing emergency contraception (EC).

Zambia, Madagascar, Uganda, and Pakistan teams produced policy briefs to advocate to governments to declare SRH/FP services essential during the pandemic and advised them on how they could practically modify service delivery approaches to ensure uninterrupted service provision. Drawing on the experience of the 2013–2016 Ebola crisis in Sierra Leone, where the number of maternal, neonatal, and stillbirth deaths related to disruption in family planning and maternal health services was equivalent to direct deaths from the virus, the briefs presented country-specific estimations of the excess unintended pregnancies, unsafe abortions, and ultimately excess maternal and newborn deaths that would result from COVID-19-related SRH/FP service disruption [4]. All the briefs called out the greater challenges faced by adolescent girls in accessing contraception during an emergency and their greater need and vulnerability due to school closures [5].

The policy briefs outlined context-specific strategies to ensure continuation of SRH/FP services during the health emergency and post-recovery period. This included:

• Ensuring provider safety and facility readiness to provide SRH/FP services through introduction of robust infection prevention and control (IPC) measures.

• Placing greater emphasis on community-based care through community health workers.

• Ensuring commodity security, through stronger forecasting and better monitoring of consumption at facility level, multi-month dispensing, and making greater use of private delivery systems.

• Greater emphasis on self-care (e.g., though self-administration of depot medroxyprogesterone acetate subcutaneous (DMPA-SC) or emergency contraception) that requires fewer or no visits to a health facility.

• Reaching out to adolescents through social media and other virtual platforms.

Some policy briefs (Uganda, Zambia, and Pakistan) outlined the need to support victims of gender-based violence, a silent pandemic within a pandemic during lockdown periods.

Options disseminated the policy briefs to decision-makers through a variety of channels, including in hard copy, and virtually to SRH/FP TWGs, National Health Taskforces, and Parliamentary Health Committee, among others. Additionally, in several countries, the advocacy messages were packaged by the civil society accountability mechanism and taken up by the media. It is hard to measure and directly attribute the impact the policy briefs had on government decisions and ultimately on the continuity of SRH/FP services. However, governments did introduce COVID-19 guidelines in Zambia, infection control guidelines and training in Pakistan, and DMPA-SC self-care in Madagascar so we can conclude the policy briefs, together with advocacy efforts from other technical partners, contributed to these decisions.

Other activities undertaken in this work stream to promote continuity of care were:

• Development of frequently asked questions and guidelines: Tanzania compiled a comprehensive set of frequently asked questions (FAQs) on COVID-19 and its implications for SRH/FP for inclusion in the government’s COVID-19 guidelines. However, this did not materialize, due to the President declaring the country free of COVID-19 in June. Bangladesh joined a technical committee setup to incorporate COVID-19 management into the existing SRH/FP guidelines. The guidelines were used to train service providers in infection prevention and control. Similar work, on development of guidelines and protocols, was undertaken in the quality improvement pathway.

• Promotion of self-care: Options country teams recognized the potential for self-care (i.e., SRH/FP products such as the injectable contraceptive DMPA-SC and emergency contraception that can be self-administered) as a way of circumventing the service delivery challenges being faced during the COVID-19 crisis. COVID-19 Policy Briefs prepared by Madagascar, Zambia, Uganda, and Pakistan all advocated for rollout of self-care, especially DMPA-SC. Governments of Zambia and Uganda had already approved self-administration of DMPA-SC prior to the arrival of the COVID-19 pandemic. Therefore, in Uganda, Options advocated for orientating district health workers on the DMPA-SC self-injection guidelines and for community health workers to be trained to support self-administration. In Zambia, they advocated for DMPA-SC distribution through community health workers and retail pharmacies for wider reach, and to use social media to inform women and girls on the availability of this method of contraception. The Madagascar team’s work to promote DMPA-SC self-injection during the pandemic is outlined in Box 1.

Box 1. Promoting Self-care in Madagascar

In Madagascar, Options and other partners had already laid much of the groundwork for introduction of self-injection, including development of operational guidelines and regional-level training, prior to the start of the pandemic. However, the program had still not been officially launched and rolled out. Recognizing that COVID-19 presented an opportunity to accelerate the national operationalization of self-injection, Options briefed the Madagascan Ministry of Health and the Director of Family Health on the advantages of promoting DMPA-SC self-injection as a part of the health emergency response. This led to the official launch of the DMPA-SC program the following week (May 28, 2020) through a webinar with all 22 regional health directors present and the rollout of the operational guidelines to service providers.

The policy change enabled women and girls to receive training on self-administration by health workers, get their first injection at a facility, and take home two further doses for self-administration. This means they will not have to return to the facility before 9 months. Since the launch in May, there has been a steady increase in the uptake of DMPA-SC. The introduction of the self-injectable during the pandemic led to a significant rise in DMPA-SC uptake from 3205 new users in May to 7536 new users in January 2021.

On the whole, countries found it challenging to progress their pre-COVID policy and planning work agendas, because health leadership was fully absorbed with the COVID-19 management response. However, Malawi still managed to make significant progress with their work aimed at updating the termination of pregnancy (ToP) legislation, as this entailed working largely with parliamentarians. In fact, the rise in teen pregnancies experienced during the pandemic helped increase support for the revised ToP legislation. The Tanzanian team was also able to continue their pre-COVID-19 work, supporting reviews of regional reproductive, maternal, neonatal, child, and adolescent health (RMNCHA) strategies. This was only possible because of the unique political context in Tanzania, with the President denying the presence of COVID-19 in the country.

Key Learnings from the Pathway

• Significant contributions were made in mitigating disruptions to SRH/FP services, especially through incorporating health emergency response within existing SRH guidelines and rollout of self-care.

• COVID-19 provided a policy window to accelerate the rollout of self-care, namely DMPA-SC self-injection in Madagascar, and progress the ToP legislation in Malawi.

• Most countries found it difficult to progress the pre-COVID-19 policy and planning work, especially related to development of new policies or work at the district level to strengthen implementation of local SRH/FP plans. However, several countries were able to continue to work with parliamentarians throughout the pandemic.

Health Financing Pathway

The sustainability goal of the health financing pathway was modified at the start of the pandemic from ‘securing improvement in public sector investment in SRH/FP’ to ‘improvement or protection of SRH/FP investments during the COVID-19 crisis.’ Country teams focused on preventing governments re-prioritizing resources during the health emergency that would have a detrimental impact on SRH/FP service provision. At the same time, they continued to pursue their ongoing work to strengthen public investment and spend in SRH/FP through virtual platforms, stressing that this was even more important in the context of the pandemic.

Bangladesh, Madagascar, and Malawi brought out investment cases to advocate to governments on the importance of continuing to fund the SRH/FP programs during the COVID-19 crisis and recovery period.

The evidence-based investment policy briefs reinforced the message that a reduction in SRH/FP funding during the crisis would lead to disruption in service provision and result in additional maternal, newborn, and child deaths. For example, Malawi estimated a disruption in services caused by a policy of moderate lockdown will contribute to additional 9550 maternal and child deaths over the next five years. The policy briefs also emphasized that investing in critical SRH/FP services and commodities at this time will save money through decreased pressure on the health system and will also help the country to get back on track to achieve its development goals. The Bangladesh investment case stressed that the government must give greater emphasis to SRH/FP services within the health budget for the country to continue to reap economic gains through the demographic dividend.

The investment briefs were disseminated to parliamentarians, ministries of finance, health directorates, regional and district councils, and civil society with some recorded success. For example, working with parliamentarians and other key stakeholders, Options in Malawi succeeded in securing commitment to increase the family planning commodity budget from MK176m to MK200 (see Box 2). In Madagascar, the WISH accountability platform (COMARESS—a civil society organization coalition) was supported to disseminate the policy brief to regional councils. Amoron’i Mania Region responded by incorporating family planning into their annual budgeted work plan. COMARESS also worked with parliamentarians and was successful in securing a commitment for the 2021 family planning commodity budget to increase by 50%. The Finance Bill was presented in November 2020. However, the executive arm removed the family planning budget even though it had been passed by parliament. After intense advocacy by COMARESS, the higher family planning budget was reinstated.

Zambia and Bangladesh were also successful in progressing their health financing work during the COVID-19 outbreak by working virtually with key stakeholders. In Zambia, Options had identified low disbursement of funds against SRH/FP budget allocations as the main financing challenge. Building on their budget monitoring and tracking work, the team made the case to the Parliamentary Committee for Health that timely release and utilization of SRH/FP funds were even more important during the COVID-19 crisis to prevent family planning commodity stock outs at health facilities. This led to parliamentarians querying the underspend with the Ministry of Finance, which in turn followed up with the Ministry of Health. The collective advocacy resulted in increased disbursements being made to districts. Upto quarter 3 of FY2020, 67% of the SRH/FP budget had been spent compared to only 41% during the same period in the previous year.

The Bangladesh team was able to continue their work on digitizing the SRH/FP financial management system (FMS). The digital FMS will support better tracking of allocations, disbursements, and spend on SRH/FP activities, and ultimately lead to more effective and transparent budget utilization. The Options team took the opportunity to add a financial indicator in the FMS specifically for infection control during a health crisis. This will support tracking of allocations to PPE in this crisis as well as future infectious disease outbreaks, thus contributing to stronger health systems resilience.

In most of the countries, the COVID-19 outbreak slowed progress on strengthening SRH/FP financing. However, in Malawi and Zambia, and to some extent in Madagascar, the COVID-19 emergency strengthened the case for increased funding to SRH/FP and timely fund disbursements and utilization. Several factors appear to have influenced the scope for action and progress, including the strength of the relationships that had been built with government prior to COVID-19, and the ability to interact with policy-makers virtually. However, the main driver of the ability to act and influence public financing is a country’s political economy, and this holds both within and outside of a health emergency.

Box 2. Using the Investment Case as an Advocacy Tool in Malawi

On learning that the family planning commodity budget line for FY 2020/21 had been reduced from MK186m in FY 2019/20 to MK176 million in FY 2020/21, Options in collaboration with MANASO, the WISH accountability partner, organized a meeting with the Ministry of Health to strategize how the family planning commodity budget could not only be reinstated but be increased. It was agreed that Options would convene a Health Financing Advocacy Coalition of key SRH/FP stakeholders and make a presentation to Members of Parliament during the National Assembly Budget Hearing (in October 2020), laying out the case to increase the family planning commodity budget. At this hearing, Options drew on the analysis presented in the investment brief and made the case that an increase in the family planning commodity budget was even more important in the context of the pandemic to ensure uninterrupted provision of family planning services.

The Members of Parliament welcomed the presentation and recommendations that were put forward and agreed to push for an increase in the family planning commodity line allocation in the budget to MKW 250 million. During subsequent deliberations on the 2020/2021 budget, this was decreased to MK200m. Though a lower amount than advocated, it still represents a 14% increase over the original proposed allocation.

Key Learnings from the Pathway

• It is possible during a health crisis to strengthen public investment for SRH/FP and, at a minimum, maintain key relationships, continue generating evidence, and advocate for change.

• Experiences in Malawi and Zambia show that presenting evidence of the impact the pandemic is having on SRH/FP services to key decision-makers can strengthen the case for more and better public investment in SRH/FP.

• Building resilience into ongoing systems and strengthening work is feasible, as demonstrated in Bangladesh.

Quality Improvement Pathway

As in the other pathways, the quality improvement (QI) pathway was adjusted to respond to government needs during the COVID-19 pandemic, while also developing strategies to ensure a continued focus on the WISH2ACTION program goals. To inform this process, the Pakistan and Malawi teams used a tool designed by Options, to assess the level of disruption to QI stewardship work during the COVID-19 pandemic and guide needed adaptations. It can also help identify support needs of government to address QI for SRH/FP during the pandemic. The tool scores countries against several criteria, including disruption in government capacity to act as steward over SRH/FP, government prioritization of SRH/FP during COVID-19, and level of disruption and adaptation to SRH/FP services.

In Pakistan, following the assessment, Options offered to support the Population Welfare Department (PWD) in trickle-down trainings for infection prevention and control (IPC) guidelines and COVID-19-related information education and communication (IEC) aides for health workers and service users, in the four WISH districts of Punjab. The PWD had closed all their facilities as soon as the pandemic arrived in the country due to lack of IPC measures and PPE, and as a result of the support provided by Options, they were able to reopen facilities in these districts by the end of July. In Malawi, the assessment showed a significant drop in number of clients accessing family planning, due in large part to health workers having gone on strike due to a shortage of IPC supplies. The technical partners (such as Options, UNFPA, and HP+, among others) responded in a coordinated manner to help maintain SRH/FP services during the pandemic. Options took responsibility for adding a chapter in the national family planning reference manual on ‘Provision of family planning services during emergency situations.’ Once the new chapter is approved by the government, the team will use the manual to roll out training. Both Malawi and Pakistan teams planned to repeat the QI assessment after a 3-month period, to track progress being made with mitigating SRH/FP service disruption, as well as mitigating disruptions to QI stewardship work and inform ongoing support needs. The second assessment in Pakistan showed that shortages of PPE and contraceptive commodities continued to be a challenge in PWD-run facilities. In response, Options agreed to train health providers in provision of the DMPA-SC injectable as a way of mitigating commodity shortages.

Although other WISH2ACTION countries did not conduct a systematic assessment to guide their response to helping government address QI for SRH/FP during the pandemic, they acted in a similar manner. Several helped incorporate IPC into existing SRH/FP guidelines. Tanzania and Uganda undertook assessments to determine how ready facilities were to provide essential services, including SRH/FP. Tanzania was not able to follow through on their findings due to the subsequent political denial of the COVID-19 pandemic.

Uganda shared its findings with the Parliamentary Portfolio Committee, highlighting that most health facilities were ill-prepared and not ready to sustain routine service delivery during the lockdown. Bangladesh, Madagascar, and Zambia were able to progress their pre-COVID-19 QI stewardship work by working virtually with senior officials:

• Madagascar was able to progress the development of a quality improvement (QI) guide and agree to rolling out an implementation plan for QI guidelines during the pandemic by moving all meetings online. It organized a Zoom meeting for the Sub-Committee for Quality Improvement of Family Planning in June 2020 and agreed to the timetable and approach for implementing the QI guide. Due to lockdown conditions, the plan includes conducting training using Zoom and making greater use of training videos, both examples of new adapted ways of working during the pandemic.

• Bangladesh continued working on the development of a digital family planning clinical supervision quality improvement monitoring tool. It seized the opportunity to incorporate new indicators related to COVID-19 infection prevention and control into this system, enabling better tracking of health staff and client safety in health facilities including hand-washing and social distancing.

• Zambia continued its discussions on which key indicators to include in the QI scorecard.² It populated the scorecard to capture the situation pre-COVID-19 and during the health emergency. Although Zambia did not adopt the scorecard for COVID-19 specifically, the assessments showed that the pandemic had an impact on quality of care.

Key Learnings from the Pathway

• By leveraging existing QI networks, the Options teams were able to respond and contribute to addressing the more direct QI needs for SRH/FP arising from the pandemic. This work helped ensure that continued progress was made toward WISH sustainability goals.

• By incorporating COVID-19 preparedness into existing SRH/FP guidelines and QI stewardship work, it was possible to contribute to development of more resilient health systems. This work will endure and ensure SRH/FP systems are more prepared for the next health emergency.

• The facility readiness and disruption to QI stewardship tools that have been developed by Options represent global public goods that can be used by other countries in the current health emergency and in the future emergencies. For example, the facility readiness tool has already been adapted for use in psychiatric hospitals in Ghana.

Evidence and Accountability Pathway

In Madagascar, Zambia, Uganda, Malawi, and Bangladesh, where Options was helping to strengthen civil society accountability mechanisms for SRH/FP, they were supported to pivot their attention toward holding government to account for the continuation of SRH/FP services during the pandemic. By working in a complimentary manner with the other pathways of change, especially policy and planning and health financing, the accountability work was able to deliver synergistic impact. Actions included: generating information on the impact COVID-19 was having on SRH/FP service delivery and uptake by women and girls, packaging the evidence into compelling formats, and using it to advocate to key decision-makers to continue providing SRH/FP information, counseling, and services. In Madagascar and Malawi, the accountability mechanism disseminated advocacy messages that had been generated by the policy and planning and health financing pathways, namely the policy briefs and investment case briefs.

Advocacy messages were targeted at decision-makers in central government (e.g., in Malawi) as well as at sub-national level (e.g., in Madagascar), using a range of platforms, such as parliamentary committees, budget committees, SRH/FP technical working groups, district forums, and one-on-one meetings with key decision-makers. Several of the accountability structures (Uganda, Madagascar, and Zambia) worked with the print and digital media to draw attention to the impact COVID-19 was having on SRH/FP services, as a way to build pressure on government to act. The media was supported and encouraged to publish human interest stories highlighting the impact the neglect of SRH/FP services was having on vulnerable groups such as adolescents and people with disabilities.

The Options teams in Madagascar and Uganda were successful in advocating and bringing about change at regional levels. In Madagascar, they supported COMARESS, their civil society accountability partner, who has a presence in all 22 regions of the country, to develop regional advocacy strategies. In Vatovavy-Fitovinany Region, the COMARESS affiliate met with the regional RH/FP manager and requested access to data on family planning uptake prior to and after the COVID-19 outbreak. Noticing a sharp drop in family planning uptake, they then shared the analysis with the Regional Director of Health who agreed to sensitize health workers in the region on the importance of continuing to provide quality family planning services and ensure availability of family planning commodities. Following the meeting, the Regional Director of Health also took the initiative of using a local radio program that was broadcasting daily on the COVID-19 situation, to inform the population that they should continue to visit government health facilities for SRH/FP services and that it was safe to do so.

In Uganda, the lead civil society organizations under the sub-national accountability mechanism in Bugiri and Kaliro districts conducted a rapid assessment to gather evidence on the detrimental impact COVID-19 was having on SRH/FP service access. The organizations shared this information with the District Task Force on COVID-19 (rather than the District Family Planning Coordinator). This resulted in an easing of restrictions on the provision of community outreach family planning services.

Box 3 outlines the work undertaken by the evidence and accountability mechanisms in Zambia to hold the government accountable for SRH/FP service continuity during the COVID-19 crisis and describes some of the results achieved.

Box 3. Strategies for Holding Government to Account During COVID-19 in Zambia

In Zambia, Options and the accountability partner initially focused their efforts on securing health facility safety and a transparent and robust COVID-19 response. They developed a media brief advocating for transparent and prudent use of COVID-19 resources and for adequate supply and distribution of PPE. It highlighted that 30% of health workers would become infected with COVID-19 in the absence of prompt action. This effort, alongside efforts from other technical partners, led to the Government of Zambia launching the National Strategy for Reducing New Infections of COVID-19, issuing standard operating procedures for community engagement, and publishing a list of all COVID-19 funding received and spent.

The accountability mechanism was then supported to undertake a review of how the pandemic was affecting SRH/FP services delivery and advocate for more specific actions to be taken to ensure the continuation of services. Finding a sharp drop in new family planning users in the period March to May 2020 compared to the same period in the previous year (see Fig. 6.3), a reduction in budget allocations, and commodity stock out in facilities, they re-engaged the media to support publication of stories on the impact the pandemic was having on SRH/FP service provision. They also encouraged the media to highlight what government needed to do to improve service access, for example, through promotion of self-care and prioritizing the needs of adolescent girls.

Options was not able to leverage a civil society-driven accountability mechanism in Pakistan and Tanzania for the continuation of SRH/FP services, as the political environment in the two countries was not conducive. In Pakistan, the security environment did not permit the concept of government being held accountable by civil society. As a result, the team advocated directly to the Population Welfare Board. In Tanzania, Options initiated a rapid political economy analysis (PEA) early on in the outbreak to understand how SRH/FP services were being prioritized within the COVID-19 context. The rapid PEA also aimed to understand the scope to influence through the accountability mechanism (the Global Financing Facility (GFF), Civil Society Coordinating Group). However, it was not possible to take this effort forward because of the denial of the presence of the pandemic in the country. Efforts then shifted back to progressing the pre-COVID-19 work agenda.

Key Learnings from the Pathway

• Civil society coalitions can be effective in holding governments to account for providing SRH/FP services during a health emergency if the political context is conducive. Additionally, the media, when briefed well, can be a key ally in holding governments accountable.

• It is important that accountability initiatives are directed at both national and sub-national levels for maximum impact.

• In countries like Zambia with a favorable political environment and a strong civil society culture, the capacity of the accountability mechanism to hold government to account in a future health emergency is likely to be sustained.

Program Contribution to Mitigating the Disruption of COVID-19 on Sexual and Reproductive Health and Family Planning Service Uptake

Due to the lack of preparedness for the health emergency, including securing infection control in health facilities quickly and not considering SRH/FP an essential component of the emergency response, all the countries except Tanzania experienced a decline in SRH/FP uptake (as indicated by the modern contraceptive prevalence rate (mCPR) of new family planning users, family planning discontinuation, and number of injectable users), when compared to family planning uptake in the previous year. Most countries experienced the biggest fall during March to May 2020, followed by a gradual improvement from June/July onward. As of November 2020, the majority had reached or almost reached pre-COVID-19 performance levels, with the exception of Pakistan. Tanzania is an outlier in that there is no discernable impact of COVID-19 on family planning uptake levels. Figures 6.3a, b outline the impact of COVID-19 by comparing family planning uptake in 2019 and 2020 in Pakistan and Zambia. In Pakistan, the mCPR completely collapsed in April 2020 (to 0.06% compared to 31.9% in April 2019), as the Population Welfare Department closed all facilities at the onset of the pandemic. mCPR gradually increased from July onward when facilities reopened. However, as of November, it has still to reach pre-COVID-19 levels (mCPR was 23.2% in November 2020 compared to 34.1% in the same month of the previous year). In Zambia, there were 19.2 new users in April 2020 compared to 25.9 in the same month in 2019. New users started to increase gradually thereafter and by November had reached pre-COVID-19 levels (22.8 new users in November 2020, compared to 22 in the same month the previous year). Data on family planning performance in 2019 and 2020 for each country can be found at the end of the chapter.

Fig. 6.3

a Pakistan: modern contraceptive prevalence rate (mCPR) in 2019 and 2021 (%). Source Contraceptive Logistics Management Information System (cLMIS). b Zambia: New family planning users in 2019 and 2020. Source DHIS2

Although data is not yet available to show the direct impact of the actions taken by Options on family planning performance, we can conclude that our interventions, together with those by other technical partners, contributed to minimizing the disruption to SRH/FP services caused by the pandemic. For example, work undertaken in Pakistan’s QI pathway on supporting IPC training, printing and sharing of communication materials through virtual platforms directly supported the reopening of facilities in July. Similarly, in Zambia, advocacy undertaken through the policy and planning, and accountability pathways led to stronger COVID-19 safety in health facilities, transparency in the government COVID-19 funding and response, and SRH/FP service adaptations (such as self-care) that helped regain some of the initial COVID-19-related SRH/FP service losses.

However, COVID-19 has impacted the pace of progress of the enabling environment work agenda. Early in the pandemic, it was difficult to engage senior health leadership at national and sub-national levels, as their attention had shifted to managing the COVID-19 response. Additionally, Options teams in all instances turned their attention to helping to minimize the disruption in SRH/FP services. Most countries were able to pick up on their routine work 2–3 months into the pandemic, when government had more bandwidth to engage with technical partners, still mostly doing this through virtual platforms. In some instances, like in Malawi, to make the case for an increased budget for commodities, COVID-19 actually served to strengthen the case for more funding, thereby facilitating the routine health financing work. More broadly, we can conclude that without the COVID-19 adaptations to the enabling environment work plan, the WISH2ACTION sustainability goals would have been impacted even more negatively than they were.

Key Conclusions and Lessons

This final section draws out wider lessons and conclusions on what worked in different contexts and what could have been done better to inform actions to minimize disruption in SRH/FP services in a future pandemic.

• The enabling environment work provided a crucial platform to help mitigate the disruptive impact of COVID-19 on SRH/FP services: The Options country teams were able to provide rapid TA that was aligned to the enabling environment work and make a substantial contribution to reducing the disruption to SRH/FP services. This points to the importance of the enabling environment work as a way to build resilient and more sustainable SRH/FP policies and systems both within and outside of a pandemic. Some notable achievements include:

  • Emergency-ready SRH/FP guidelines, manuals, and tools.

  • Expanded contraceptive choice, with introduction of self-injection with DMPA-SC.

  • Higher allocation and utilization of the contraceptive commodity budget.

  • Strengthened infection prevention and control in health facilities.

  • Greater access to SRH/FP services at community level.

• The political economy is the most important factor determining the ability to influence policies and practices both during and outside a health emergency: The accountability work in Pakistan was severely constrained before the arrival of the pandemic and continued to be so after its arrival. Due to the political and security environment, it is very difficult for civil society to hold government to account. As a result, the Pakistan team was unable to engage civil society as a way of mitigating the impact of COVID-19. In contrast, Zambia and Madagascar have vibrant civil society, and so were able to leverage it effectively to hold government to account and minimize the disruption to SRH/FP services. In Tanzania, the President’s denial of the pandemic meant that the Options team was not able to implement any activities to limit disruption to SRH/FP. The ability to influence health budgets and spend is also heavily dictated by a country’s political economy. For example, Zambia, Malawi, and Madagascar successfully leveraged the pandemic to strengthen the case for more and better SRH/FP spend.

• Civil society accountability mechanisms played an important role in mitigating disruption to SRH/FP services: Countries that had developed a strong accountability mechanism were able to leverage it to target advocacy messages generated by the policy and planning, and health financing pathways, to influence government decision-makers at national and sub-national levels. They were also able to successfully harness the media to hold government to account for the continuation of SRH/FP. Using evidence gathered by the civil society organization, the print and digital media were able to show the impact the pandemic was having on SRH/FP service access, especially on adolescent girls. Media stories also made recommendations on how the government could improve service access, for example, through stronger community outreach, use of digital platforms to reach adolescents, and self-care. Another key lesson is the importance of focusing advocacy efforts at both national and sub-national levels. Both Madagascar and Uganda advocacy efforts at regional and district levels resulted in improvements in SRH/FP service access.

• COVID-19 served to strengthen the case for enabling SRH/FP policies: Several countries used the pandemic to make a stronger case for their pre-COVID-19 enabling environment work. Both Zambia and Malawi generated evidence on family planning commodity stock out in facilities to advocate for better utilization of the commodity budget and a larger commodity budget. Malawi provided evidence to the Parliamentary Health Committee on the increase in teen pregnancies during the early stages of the pandemic. This served to strengthen parliamentarian support for reforming the Termination of Pregnancy Bill which Options had been working on prior to the pandemic. In Madagascar, the COVID-19 outbreak hastened the launch of self-care, namely the self-administration of DMPA-SC. This helped the country add a significant number of new family planning users during the period June to July 2020, thus helping to slowly regain family planning uptake to pre-COVID-19 levels.

• SRH/FP systems are more resilient and better prepared for the next health emergency: The IPC guidelines, standard operating procedures (SOPs), tools, and manuals that Options helped develop or modify are ready for use in a future health emergency. In Bangladesh, health emergency indicators were added to the digital quality of care dashboard as well as the digital financial management system. This work led to the development of two new tools: the first to assess facility readiness to provide SRH/FP services during a pandemic and the second to measure the disruption to stewardship of SRH/FP quality improvement and identify quality gaps. The modified guidelines, new tools, and more resilient systems will enable governments to respond more quickly during the next major infectious disease outbreak, resulting in less disruption to SRH/FP services.

• The pathway of change is a useful management tool during a health emergency: The pathways of change tool guided Options teams to identify country-specific support needs during the pandemic. They were able to rapidly pivot their technical assistance toward mitigating the impact of COVID-19 on SRH/FP, while still retaining focus on strengthening government stewardship for SRH/FP and creating resilient and sustainable policies and systems to achieve the sustainability goals. This required only minor modifications to be made to the milestones, indicators, and goals in the four pathways of change, demonstrating the flexibility of this management tool.

The next section contains more detailed information for each country on: the severity of the COVID-19 outbreak; the COVID-19 intervention and impact, trends in family planning uptake during the outbreak compared to the previous year; and the key takeaway lesson for that country.