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RHO archives : Topics : Family Planning Program Issues

Program Examples

The programs described below illustrate some of the strategies that have been developed to implement high-quality family planning services in low-resource settings.

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  • Bangladesh: Multi-angle approach to improving the quality of family planning services through planning, supervision, training, and referral services.
  • China: The introduction of interpersonal communication and counseling skills into a family planning training program.
  • Ecuador: Overcoming physical and cultural barriers to family planning and other reproductive health services among indigenous people in remote areas.
  • Egypt: Improving the quality of care at 4,200 Ministry of Health facilities with a clinic certification program and a mass media campaign to raise client expectations.
  • Ethiopia: Using a combination of social mobilization and community-based distribution to overcome social and geographic barriers to family planning in rural villages.
  • Jordan: Eliminating contraceptive stockouts and reducing waste with a new logistics system at the Ministry of Health.
  • Kazakhstan: Marketing OCs, condoms, and injectables through pharmacies and other retail outlets to increase consumers' knowledge of and access to contraceptives.
  • Pakistan: Franchising private-sector family planning services to make them more widely available and affordable to the urban poor.
  • Poland: Involving women in the advocacy process for reproductive health.
  • South Africa: Review of national policies and practices related to contraceptive service delivery in consideration of WHO Medical Eligibility Criteria for Contraceptive Use.
  • Turkey: Improving decision making at local, provincial, and national levels by strengthening management information systems and introducing a uniform logistics system.
  • Zambia: A national development plan focused on ensuring that all couples and individuals can exercise the right to freely and responsibly determine the number and spacing of their children.

Click here to see a list of related program examples available on other websites.

Bangladesh

With a population almost half that of the United States in an area less than 2 percent the size, Bangladesh relies heavily on family planning services to enable men and women to limit family size. Yet use of clinical contraceptives has been declining, in part because the quality of services is often inadequate.

As part of a Bangladeshi government initiative to address these problems, EngenderHealth (formerly AVSC International) implemented a project from July 1995 to March 1997 in five thanas, or counties, in the Sylhet and Jhenaidah districts. Its goal was to improve the quality of family planning services and the variety of contraceptive methods available by strengthening four components of the family planning system: planning at the local (thana) level, supervision, training, and referral services.

Approaching Quality Improvement

To get started, meetings were held with key health and family planning officials at the local, district, and national levels to orient them to local planning issues. Then AVSC engaged more than 200 providers, supervisors, and support staff at all three levels in COPE (Client-Oriented, Provider-Efficient services), AVSC's self-assessment technique used to identify and solve problems in service-delivery settings. (For a description of COPE, see www.engenderhealth.org/ia/sfq/qcope.html .)

Through COPE exercises, staff identified several factors hindering service quality.

  • Routine examinations were not being performed due to lack of laboratory facilities.
  • Sterilization services were offered in few locations and at limited times, owing to staff vacancies and insufficient numbers of staff trained in the procedures.
  • Norplant implant services were not available at all in the thanas.
  • Clients had limited access to information about clinic services, schedules, and service charges.
  • There was no regularly scheduled pre- and post-natal counseling, no counseling arranged for male clients, and often no separate room available for counseling.
  • Provider supervision and training were insufficient, as was providers' knowledge about sexually transmitted infections and infection prevention procedures.
  • Linkages between services also were lacking.

Strategies Implemented

To solve these problems, local staff developed and implemented action plans, which were reviewed monthly.

Training courses were attended by 183 service providers. Refresher courses were given on all contraceptive methods, counseling, and infection prevention, with comprehensive training given in sterilization, Norplant implants, and injectable contraception. Through facilitative supervision workshops, the supervisors learned new approaches to supporting providers in improving quality.

Results

Providers who participated in the COPE exercises and trainings indicated overwhelmingly that they were becoming more aware of and responsive to clients' needs and rights. They also paid greater attention to counseling, client screening, and infection prevention procedures, reporting that the clinics had become cleaner than before. And client referrals and coordination between sites increased substantially.

In addition, supervisors found that after participating in the workshops, they were better able to identify staff training needs, and their supervisory style became less directive and more helpful. They also gained a better understanding of what was expected of them, and since supervision became easier to perform, they provided it more systematically.

During the project period, there were no dramatic changes in the mix of contraceptive methods used. However, more clients started using clinical contraceptive services than before. Just as important, client exit interviews indicated high levels of satisfaction with the services received during the project period. Almost all clients said that the problem that had brought them to the clinic had been resolved, and all said they felt comfortable discussing the problem with the provider. The clients also believed that they had been treated well by the provider, and said they would recommend the services to friends and relatives.

Of those clients who had also received services within the past year, many noted such improvements in the clinics as the addition of partitions for client privacy, a much-needed fan, greater cleanliness, and better lighting.

Because of the project's success, the interagency evaluation team has recommended extending it for another three years. Ultimately, it is expected that these improvements in quality will result in more individuals and couples requesting clinical contraceptive services.

Adapted from Landovitz, K. Increasing access to contraception. AVSC News 35(4) 1997.

For more information contact Karen Landovitz, EngenderHealth, 440 Ninth Avenue, New York, New York 10001 USA;
Telephone 212-561-8000; Fax 212-779-9489; Email: [email protected]

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China

Studies on communication efforts have shown that mass media and educational tools such as brochures and posters are useful for transmitting information to large numbers of people, but that their influence on behavior change can be limited. Interpersonal communications and counseling provide the needed catalyst and personalized attention to needs and concerns that make a major contribution to behavior change. This country example describes the introduction of interpersonal communications and counseling (IPC/C) skills into a family planning training program for the first time.

One of the strategies the Chinese government has chosen to improve the quality of its family planning program is to strengthen services in the rural areas, where 70 percent of the population—about 870 million people—live (PRB 1998 World Population Data Sheet). In the early 1990s, the government decided to upgrade the skills and knowledge of family planning workers at the township and village level through its five-year Counseling Training Project. The Counseling Training Project was launched in 20 of China's 30 provinces and served as a pilot project for a larger program. This project addressed key aspects of quality of care in China's national family planning program—in particular the quality of information and counseling given to clients, and interpersonal relations between service providers and clients.

As a first step, national project staff learned about local realities by conducting knowledge, attitudes, and practice (KAP) surveys with villagers and family planning workers at the grassroots level. The information from this study was used to develop training programs and materials, and was used as baseline data for project evaluation. A "pyramid" training program was designed in which a small group of core trainers from the provincial and prefecture training stations received training, who then trained a larger group of master trainers from their province. The master trainers then trained an even larger number of staff at the county and township levels, who in turn trained village-level workers. Ultimately, more than 80,000 rural family planning providers were trained.

Trainers acquired skills in IPC/C, adult learning principles, participatory training methods (such as group discussion and skill practice), and development of training materials based on the needs of the audience. Later, trainers learned IPC/C-training skills specifically tailored to rural Chinese situations and counseling skills related to help clients select appropriate family planning methods and prevent STI/ HIV.

Post-workshop evaluations showed that family planning workers understood the concept of informed choice and that counseling is important in a family planning program to achieve client satisfaction and effective use of methods. Family planning workers also liked the participatory learning techniques used in the trainings and reported that they learned far more than they had previously through the usual lectures. Feedback also showed that family planning managers and local government officials who had been trained in IPC/C or oriented to the goals of the project were more likely to support the local workers in their efforts to improve the quality of services for clients.

A PATH report, Face to Face: Training Family Planning Counselors in China (1995), provides additional information about this program.

For more information, please contact:
Margaret Britton, PATH, 1455 N.W. Leary Way, Seattle, Washington 98107 USA;
Telephone 206-285-3500; Fax 206-285-6619; Email: [email protected]

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Ecuador

Indigenous communities in Ecuador have little access to health services of all kinds, including family planning. As a result, indigenous communities have markedly higher rates of fertility, maternal mortality, and infant mortality than the rest of Ecuador, and they have lower contraceptive prevalence as well. According to a 1999 survey, for example, women living in the high sierra average 5.6 children each, compared with 4.3 in rural areas and 2.8 in urban areas.

Barriers to modern health care include:

  • Physical accessibility, because indigenous people live in remote rural areas of the high sierra.
  • Affordability, because poverty is endemic.
  • Language, because local people speak Quechua rather then Spanish.
  • Discrimination, based both on culture and gender.
  • Friction between modern medicine and traditional health beliefs.

Jambi Hausi (which means “House of Health” in Quechua) is one response to the clear need for culturally appropriate reproductive health information and services in indigenous communities. This clinic was established in 1994 in Otavolo by the Federación Indígena Campesina de Imbabura, an indigenous organization that works to strengthen the political position and cultural identity of the Quechua people. Jambi Hausi also has received assistance from UNFPA, which supports initiatives to address the special needs of indigenous people throughout Latin America.

Jambi Hausi offers a full range of medical treatment and takes a comprehensive approach to reproductive health care. The clinic has an examination room, delivery room, laboratory for blood work, dentist’s office, and pharmacy. It also sponsors educational activities, including talks on reproductive health issues in Quechua communities and, more recently, discussions of sexual health with adolescents. With the help of community volunteers and a van, the clinic’s outreach program carries both medical and educational services to remote mountain communities.

From the start, services at Jambi Hausi were designed to respect and respond to the special needs and concerns of indigenous people. The doctors and midwives are indigenous women who speak the local language, understand the community’s culture and traditional health beliefs, and can attend to female clients without raising concerns about modesty. Jambi Hausi also provides traditional as well as modern medical treatments. A local healer or yachag is on the staff; the clinic has medicinal plant gardens; and the pharmacy dispenses traditional as well as modern medicines.

The combination of modern and traditional treatment has been popular with local people. While the clinic was designed to serve about 4,000 people in ten nearby communities, by 1998 it was drawing almost 10,000 clients a year over a much larger area. User fees are recovering an increasing percentage of the clinic’s costs, and Jambi Hausi hopes to achieve self-sustainability soon.

Openly addressing sexual and reproductive health has proved challenging. Obstacles include religious beliefs, the community’s feeling that such issues are a purely private matter, and sensitivity regarding the issue of infidelity and male migration. Yet the clinic’s services have had a positive impact on local health practices and outcomes. In the areas served by the clinic, people have begun to space their children for health reasons, contraceptive prevalence has risen from 10 percent to 40 percent, and infant and maternal mortality rates have fallen markedly. The success of Jambi Hausi makes it a model for culturally appropriate services in other indigenous communities.

For more information, please contact:
Myriam Conejo, Coordinator, Centro de Salud Jambi Huasi, Federación Indígena y Campesina de Imbabura (FICI), Modesto Jaramillo 608 y Morales Esquina, P.O. Box 65, Otavalo, Ecuador
Telephone: (593-6) 921 712; Email: [email protected]

This program example is based, in part, on:
Hinrichson D. Taking health to the High Sierra. People & the Planet. 1999;8(4):21-22. Available at: www.peopleandplanet.net/pdoc.php?id=298.
Hughes J. Gender, Equity, and Indigenous Women’s Health in the Americas. Washington, D.C.: Pan American Health Organization; 2004. Available at: http://newweb.www.paho.org/English/DPM/GPP/GH/IndigenousWomen-Hughes0904.pdf.

Egypt

Since 1988, the Egyptian Ministry of Health and Population has been working actively to improve public-sector family planning services. Initial efforts upgraded management systems, decentralized administration, trained providers in family planning, and expanded access to services by increasing the number of government health facilities offering family planning, deploying mobile clinics, and adding rural outreach workers. Despite these efforts, however, many potential clients stayed away because of the low quality of services.

In response, the Ministry launched a Quality Improvement Program (QIP) employing an innovative two-part strategy. Clinical standards and protocols, training courses, a three-level supervision system, and a clinic certification plan were introduced to "push" quality into every level of the service delivery system. At the same time, public media campaigns were designed to "pull" quality into health facilities by raising community expectations about the quality of family planning services and prompting clients to demand good-quality care. Over a three-year period, beginning in 1995, the intervention was extended to all 4,200 government family planning service outlets in Egypt.

The heart of the initiative is a monitoring and certification system based on clinic standards and protocols. District supervision teams visit every facility four times a year and rate them on a list of 101 minimum essential service requirements. Each indicator is clear-cut, understandable, and can be readily scored on a yes-no basis, so there is no confusion and no room for negotiation. When a facility scores 100 during two consecutive quarters, it is certified as a Gold Star clinic. When it scores less than 100, supervisors work with the clinic staff to analyze the reasons for each problem and develop solutions. QIP scores are entered into a computerized management information system (MIS) and monitored at the facility, district, and governorate levels to help managers assess strengths and weaknesses, identify dysfunctional facilities and districts that need more attention, and identify common problems that require action at higher levels.

The Gold Star communication campaign was designed to build demand for high-quality care by raising client expectations and improving the image of public-sector providers and clinics. A first wave of television and radio advertising educated the public about what constitutes good care, showing them what to expect in counseling, cleanliness, treatment, and clinic management. The second phase of the campaign encouraged consumers to locate good-quality clinics by looking for the Gold Star symbol.

QIP faced many challenges during its implementation:

  • Planners underestimated the magnitude of the resources needed and the changes to be made so every step in the roll-out took longer than anticipated.
  • Because health personnel were used to referring all issues to top management, it was difficult to motivate middle- and lower-level staff to take responsibility themselves.
  • Extensive training for providers, supervisors, and managers was needed to strengthen technical skills and to change entrenched attitudes toward clients and their jobs.
  • Service providers initially resisted the new service standards and monitoring system.
  • The push-pull strategy required an unprecedented partnership between two independent government ministries: the Ministry of Health and Population, which was responsible for service delivery, and the Ministry of Information, which was responsible for mounting the communication campaign.

A thorough evaluation of the project has documented its many accomplishments:

  • The quality of care has improved steadily: the proportion of facilities meeting all minimum service standards rose from 29 percent to 46 percent over a 21-month period after all facilities became eligible for Gold Star status.
  • Because the greatest gains have been made by facilities with the lowest baseline levels of quality, the program has narrowed disparities in the quality of care between regions and between primary and secondary care facilities.
  • The media campaign has succeeded in teaching clients to expect better care at public clinics, so much so that client satisfaction has declined even as the quality of care has improved.
  • Improved quality has increased the proportion of Egyptian family planning users who seek services at government facilities, with client flow highest at Gold Star clinics.
  • Organizational culture has changed profoundly so that leaders, managers, supervisors, providers, and support staff are now committed to providing good quality services.
  • QIP has established a sustainable framework for continuous quality improvement by building the ongoing costs of certification and monitoring into the ministry's regular budget.

Lessons Learned

Experience in Egypt has identified several elements critical to achieving large-scale and sustainable quality improvement in family planning and other health services.

  • Clinical and service standards must be clearly stated, realistic, and achievable, so that front-line staff understand what is expected and receive the support needed to meet the standards.
  • Regular, ongoing monitoring is needed to maintain as well as to achieve standards.
  • Leadership commitment and advocacy at every level is required before workers will embrace quality improvement and make real changes in how they deliver services.
  • Raising client expectations and creating a demand for high-quality services heightens the impact of quality improvement programs.

The QIP Gold Star system has proven so successful that Egyptians are expanding the service standards to cover reproductive and family health, piloting a similar program under MOHP health insurance reform, and developing comparable standards for the nongovernmental and commercial sectors.

For more information, please contact:
Dr. Yehiya El Hadidi, Director, Population Sector, Ministry of Health and Population, Egypt
Telephone: 202-795-4937; Fax: 202-795-8097

or

Ron Hess or Michelle Heerey, Johns Hopkins University Center for Communication Programs (JHU/CCP), 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA,
Telephone: 410-659-6300; Email: [email protected] or [email protected]

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Ethiopia

In 1996, with funding from the government of the Netherlands, CARE launched a five-year Population and AIDS Prevention Project (POP/AIDS) to improve the health status of women and children living in Ethiopia. Rural areas of the country, where most of the population lives, tend to have highly traditional cultures and limited access to health services. In the project area, less than half of adults were aware of family planning when the project began, and the contraceptive prevalence rate was less than 5 percent.

The family planning component of the POP/AIDS project launched community-based family planning services in rural villages with a “Phase-In/Phase-Out” strategy. To start the process, a CARE extension agent moved into a local village for six months and worked intensively with a targeted Peasant Association and the cluster of 4-9 villages belonging to it. The extension agent assessed local practices and social networks, identified the natural opinion leaders in each village, built support for family planning, and began distributing pills and condoms and making referrals to the local health clinic. After about three months, the extension agent asked each village to help select a volunteer Community-Based Reproductive Health Agent (CBRHA). The extension agent worked with the CBRHAs during an orientation period before sending them for formal training conducted by the Ministry of Health (MOH).

After they returned from training, the CBRHAs gradually took over the duties of the extension agent, including counseling, group education, and the distribution of contraceptives. The extension agent then moved on to another village but provided follow-up support and supervision during a three-month phase-out period. The CBRHAs continued their work with support from the staff at the local health clinic and community leaders. Each CBRHA visits the local health clinic monthly to pick up more supplies, review their records and reports, and receive supervision.

  • By the end of the five-year project, CARE extension workers had successfully launched and transferred community outreach activities to 344 CBRHAs serving a population of 260,000.
  • In the project area, the contraceptive prevalence rate rose from 5 percent to 24 percent.
  • The proportion of adults aware of at least two modern contraceptive methods increased from 48 percent to 73 percent.
  • The proportion of married couples who, within the past year, had discussed the number of children they wanted rose from 7 percent to 34 percent.

Outside of the project area, family planning awareness and use remained extremely low.

Lessons Learned

The community-based distribution program has become more successful and more active in some villages than others. A comparison of more and less active villages found that the following factors contribute to success at the local level:

  • Emphasizing the economic benefits of family planning helps overcome the community’s suspicions and persuade opinion leaders to advocate family planning.
  • Identifying and enlisting the support of natural leaders, who genuinely influence public opinion, is essential to establish a culture of family planning; relying on formal leaders is ineffective.
  • Recruiting men as CBRHAs is an effective strategy in rural Ethiopia, where men are primarily responsible for reproductive health decisions and where only men have the education needed to master the training curriculum.
  • Raising the awareness and acceptability of family planning in the community through intensive social mobilization is a necessary first step.
  • Only by systematically assessing local practices, eligible couples, natural leaders, and social networks can extension agents understand the community and effectively implement this kind of intervention.
  • Collaborating with the MOH contributes to the sustainability of the project by providing a continuing source of supervision and resupply for CBRHAs as well as a referral network.
  • Making pills available in the village and ensuring a consistent supply of contraceptives at local clinics encourages women to try family planning and sustains their continued use.

With the support of the MOH, the CBRHAs have expanded into other health services, helping with immunization and polio campaigns and the distribution of Vitamin A. Broadening the role of the CBRHAs may help dispel lingering suspicions about family planning and has the potential to strengthen links with other community-level agents in development and agriculture.

For more information about this project, please contact:
CARE Ethiopia, P.O. Box 4710, Addis Ababa, Ethiopia

This program example is based on: Rubardt, M. CARE International’s community-based distribution program in eastern Ethiopia increases contraceptive use. At A Glance Issue 8. NGO Networks for Health (December 2002).

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Jordan

Logistics became a priority for Jordan's Ministry of Health (MOH) in 1996 because disruptions in contraceptive supplies were threatening to undermine family planning services. There were no written logistics manuals or procedures, no formal inventory control system, and no logistics training for staff. Staff members were left to devise their own methods to handle logistic issues, and many reordered contraceptives only when supplies ran out. A situation analysis found that family planning clients could not always get their choice of contraceptive because stockouts were common. At the same time, widespread overstocking led to wastage: in 1997 the MOH had to destroy 7,000 IUDs that were beyond their expiration date.

With strong backing from MOH policy makers and technical assistance from the Family Planning Logistics Management Project (FPLM), a workshop was held to design a new contraceptive logistics system for all major providers of family planning services in Jordan, including MOH facilities, the Royal Medical Services, and NGO programs. Representatives from every level of the MOH participated. Based on their recommendations, detailed manuals and training curricula were developed for directorate and health center personnel, and a cadre of logistics trainers was established.

Over a two-year period, more than 550 service delivery and supervisory staff received training in logistics, including midwives, nurses, doctors, and their supervisors as well as warehouse managers. More than 99 percent of these trainees passed the final competency-based exams. The training effort not only familiarized health personnel with the new logistics system, it also made them appreciate the importance of logistics in their work. A year after training, interviews found that the job procedures manual remained a valuable resource and that most midwives had informally trained other personnel to take over their logistics responsibilities if needed.

A new computerized management information system at the central level aggregates essential data and produces regular, accurate reports for all management levels. Data come from order forms and other written reports completed at lower levels of the system. The information system collects data on the quantities of contraceptives dispensed to users, stock on hand at every level of the supply chain, losses, and adjustments. It also calculates the percentage of contraceptives dispensed by each directorate. Under the old system, it took more than five months to compile annual data for the Minister of Health. In contrast, the new computerized system can generate reports about every directorate and service delivery site in the country in only two weeks.

These timely reports promote communication and problem-solving. In monthly discussions with each directorate, the MOH's senior logistics officer examines stock-outs, overstocking, unusual losses, and adjustments, and helps resolve problems before they become crises. The senior logistics officer also makes an annual visit to each directorate, during which she visits one-fourth of service delivery points, reviews how the logistics system is functioning, offers refresher and on-the-job training, and completes a supervisory checklist. At a follow-up meeting with all of the midwives in the directorate, the senior logistics officer motivates staff with public praise for good work and discusses needed improvements. Regular monitoring and supervision demonstrates the ministry's commitment to logistics and increases the status and visibility of logistic activities.

An outside evaluation documented the achievements of Jordan's logistics improvements program from 1997 to 1999:

  • The proportion of facilities experiencing a stockout during the preceding six months fell from 85 percent to 10 percent of health centers and from 72 percent to 5 percent of directorates.
  • Widespread overstocking of IUDs, condoms, and other methods has been eliminated.
  • Improvements in storage conditions and inventory control systems have sharply reduced losses from expiration and damage.
  • The proportion of facilities with accurate records of their contraceptive inventories has doubled from 30 percent to 63 percent of health centers and from 25 percent to 52 percent of directorates.
  • The logistics system has become institutionalized within the MOH, with data reported in timely fashion and used to manage contraceptive supplies at all levels.
  • More reliable contraceptive supplies have contributed to rising contraceptive use in Jordan. From 1997 to 1999, couple-years of protection (CYP) from condoms and pills doubled.

Lessons Learned

  • Advocacy directed to top officials pays off: their strong and consistent commitment enabled dramatic improvements in a relatively short time.
  • Hiring a full-time, professional logistics manager within the MOH to champion the program created a sense of ownership, expedited the transfer of needed skills, and helped institutionalize the new logistics system.
  • Participation by middle- and lower-level MOH personnel during the needs assessment and design phases built local ownership in the logistics system, ensured that it reflected local requirements and limitations, and contributed to its sustainability.
  • By collecting routine and research data, planners gathered the evidence needed to legitimize their recommendations and build a broad consensus for decisions.
  • Investing in local trainers is cost-effective and has increased sustainability.
  • Because systems development cannot exceed the skills development of local managers, logistics capacity was built in stages and the information system was not automated at lower levels.

For more information about Jordan's logistics improvement project, please contact:
Shyam Lama, John Snow, Inc., 1616 N. Fort Myer Drive, 11th floor, Arlington, VA 22209 USA
Telephone: 703-528-7474; Fax: 703-528-7480; Email: [email protected]

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Kazakhstan

The breakup of the Soviet Union exacerbated contraceptive shortages in Kazakhstan and increased women's dependence on abortions. To help address this problem, the Red Apple social marketing program was launched by SOMARC in 1994 to sell contraceptives in pharmacies, kiosks, and other retail outlets to couples who can afford them. Red Apple guaranteed retailers a consistent supply of contraceptives at an affordable price and created an easily recognized logo (a man and a women holding hands in the center of an apple) to promote them. The program currently promotes 14 products under the Red Apple label, including oral contraceptives, condoms, and an injectable.

Launching a social marketing program faced special challenges in the former Soviet Union. On a philosophical level, the very concept contradicts the Soviet belief in universal entitlement to social services. On a practical level, there was no experience with and little understanding of basic western marketing principles in Kazakhstan. To create a supportive environment for the program and ensure its public acceptance, SOMARC established a Reproductive Health Advisory Board. The board recruited respected representatives from a wide variety of constituencies, including the Ministry of Health, physicians, pharmaceutical companies, women's organizations, religious leaders, and private business. Board members provided political support, reviewed all materials and activities for cultural sensitivity, identified potential problems, and acted as spokespersons to the media.

Another challenge for the program was the dearth of family planning knowledge among pharmacists and physicians as well as potential clients. Red Apple attacked this information gap with a variety of activities. A public education campaign disseminated contraceptive information directly to men and women via the radio, television, and newspapers. Advertising also directed clients to clinics and pharmacies displaying the Red Apple logo for high-quality, affordable, and readily available contraceptive services and supplies. Pharmacies were transformed into information centers by distributing posters and brochures and by training pharmacists about contraceptive use, benefits, and side effects so they could answer customer questions.

In March 1997, the program expanded its educational activities with the Red Apple Information Services, a hotline staffed by trained medical personnel who respond to queries from consumers, pharmacists, and medical professionals. This increasingly popular service currently serves callers from 11 cities. Hotline operators offer accurate information about a wide range of reproductive health issues and refer callers to local pharmacies and clinics. Red Apple also participates in health fairs and educational campaigns that promote family planning and STI prevention. Hotline operators conduct educational outreach programs with clinic providers and consumers, including students, factory workers, and the military. The operators use a variety of communication channels, including the mass media, to promote the Red Apple hotline and contraceptive products.

The success of the Red Apple program depends in part on the close relationships established with pharmaceutical manufacturers, distributors, and retailers. The manufacturers cooperate by printing the Red Apple logo on the products, providing new information about products to hotline operators during weekly meetings, and collaborating on promotional activities. Distributors supply the contraceptives at a reasonable price. Pharmacists receive regular visits from hotline operators, who spend half their time as pharmacy detailers. They update and motivate pharmacists, check supply levels, collect price and sales data, and recruit new pharmacies to participate in the program. These highly trained operator-detailers create a crucial link between consumers and suppliers of quality reproductive health products. In addition to providing accurate health information, Red Apple operator-detailers can refer hotline callers to a nearby pharmacy or clinic that can provide the product or services they want at a price they can afford.

From April 1999 to September 2000, the Red Apple program was implemented by the Commercial Market Strategies (CMS) Project. During this time, Red Apple continued to expand its activities and achieved the following:

  • Detailed an increasing number of service delivery points so that more than 1,600 sites now sell Red Apple products around the country.
  • Added three new products to the Red Apple family of contraceptives.
  • Expanded the Red Apple hot line to another city and trained hotline operators on additional reproductive health issues, including STIs, emergency contraception, menopause and HRT, abortions, pregnancy, breastfeeding, and gynecological problems.
  • Responded to increasing numbers of hot line callers: from January to September 2000, Red Apple operators talked to more than 23,000 callers and answered 28,800 questions on reproductive health issues. The hotline currently receives an average of 2,500 calls per month.
  • Made over 1,000 referrals per month to hotline callers, sending them to trained pharmacies and clinics where they can obtain the information, products, or services they need.
  • Tracked a dramatic increase in sales of Red Apple products through pharmacies in Almaty: monthly sales of oral contraceptives and condoms have more than tripled since April 1999.

Additional information about the Red Apple social marketing program is available from:

SOMARC: Social marketing history is made in Kazakhstan. SOMARC Highlights, No. 1. Available online at http://198.93.224.40/hl_1_95.asp.

Thompson, R. et al. Building support for CSM through advocacy: SOMARC in Kazakstan and Uzbekistan. SOMARC Occasional Paper 23 (1997). Available online at http://198.93.224.40/SOMOP23.asp.

For further information about Red Apple, please contact:
Raushan Sarsembaeva, Director of the Business Women's Association of Kazakhstan (BWAK), 129 Maulenov Street, Almaty, Kazakhstan 480047;
Telephone: 7-3272 62-74-51; Fax: 7-3272 62-74-51; Email: [email protected]

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Pakistan

When the social marketing program in Pakistan expanded from condoms to clinical methods in the mid-1990s, it became essential to expand the pool of skilled family planning providers serving poor communities. The solution was social franchising—that is, recruiting physicians from Pakistans highly developed private health sector to add family planning to their existing medical practices and marketing those services under an easily recognized brand name. Population Services International (PSI) and its local affiliate, Social Marketing Pakistan (SMP), designed and launched the Green Star franchise network in 1995. After one year of pilot testing, the franchise system was evaluated, refined, and expanded to cities nationwide.

Like commercial franchises, Green Star is governed by a contract between the franchiser, SMP, and the health care providers who join the network as franchisees. Providers agree to integrate family planning services into their practices and to deliver those services according to protocols and quality standards set by SMP. In return, SMP supplies the providers with training, support, and materials, including a Green Star sign for display outside the clinic. SMP also markets the Green Star brand name to attract clients to franchise locations. The incentive for providers is economic: they hope to attract more clients because of their Green Star affiliation and also to make a profit on sales of Green Star brand contraceptives.

Because of cultural restrictions on who can give pelvic exams in Pakistan, the Green Star network initially recruited licensed female physicians who could offer a full range of family planning services, including the insertion of IUDs. Later, male physicians were added to the network because of their ability to talk with men about supporting contraceptive use. The next step was recruiting pharmacists, who play an important role in disseminating accurate family planning information and in shaping customers decisions to use family planning. Eventually, Green Star also added lady health visitors who deliver health care to the poorest and most underserved urban neighborhoods.

Recruiting providers into the network has become easier since the Green Star brand has achieved recognition and respect. The network can now use more stringent criteria to select and admit new providers. Experience has shown that the most successful Green Star providers own and operate their own clinics, which makes their employment more stable and follow-up easier. Younger physicians just entering the medical profession also make strong champions of the network: they are more open to training, hold more positive attitudes toward family planning, and have the most to gain from the Green Star franchise.

Training is key to the franchises success, since it ensures that providers understand Green Star service delivery protocols and can meet advertised standards of quality. The network has developed different training curricula and reference materials for each type of provider. Training courses range in length from half a day for pharmacists to 40 hours for women physicians learning how to insert IUDs. Providers who pass the examination are given a certificate and invited to join the Green Star network.

To ensure that Green Star providers meet the franchises standards of quality, training staff also have a monitoring function. They make regular site visits, especially to providers who are new to the network, to answer technical questions, assist with procedures, and solve problems. In addition, SMP field staff visit Green Star sites quarterly to assess providers performance, and mystery client surveys are conducted periodically. If a providers services do not meet Green Star standards, she or he is required to undergo remedial training.

Multimedia advertising campaigns, promotions, and public relations activities have created awareness of the Green Star brand and continue to generate demand for its services and products. By 1997, 93 percent of respondents in low-income urban areas recognized the Green Star logo and identified it as a symbol of high-quality family planning at affordable prices.

In recent years, the Green Star network has launched additional reproductive health products and services and is trying to reposition itself as a health franchise, rather than just a family planning provider. In addition to the four reversible contraceptive methods offered at the start of the project (condoms, oral contraceptives, a 2-month injectable, and the IUD), Green Star franchisees now deliver postabortion care services, STI services for men and women, emergency contraception, voluntary surgical contraception, multivitamins and nutrition counseling, a 3-month injectable, and HIV/AIDS-prevention information and services.

Achievements

The Green Star franchise network has succeeded in tapping underutilized capacity in the private sector to make family planning more accessible and affordable for the poor. Family planning services have been added to more than 11,000 private sector outlets in 40 urban areas in Pakistan. Together they serve an estimated 7.5 million family planning clients annually, 74 percent of whom are from low-income groups. The introduction of multiple low-cost Green Star contraceptive products also has given these clients a wider choice of methods. The Green Star network delivered nearly 500,000 couple-years-of protection (CYPs) in 2001, and will deliver more than 600,000 CYPs in 2002, at an overall cost per CYP of less than US$3.00. Green Stars efforts have contributed to an increase in contraceptive prevalence in Pakistan from 17 percent in 1997 to 23 percent in 2000.

As for providers, Green Star training has improved providers interpersonal and technical skills, which, in turn, has raised the quality of care. A large majority of Green Star providers offer clients respectful and cordial treatment, information about multiple methods, detailed explanations of the method they choose, and information about follow-up.

However, several challenges remain:

  • Remedial training and encouragement has not proven sufficient to ensure that providers meet Green Star standards, so quality of care varies widely between providers.
  • Some Green Star outlets charge higher prices than recommended for Green Star products and services in order to increase profits.
  • Providers do not always receive enough of an increase in family planning clients to keep them motivated and give them adequate practice providing family planning services.
  • Because of the rapid growth of the network, trainers are overextended and cannot make monthly monitoring visits to all outlets.

Lessons Learned

The Green Star experience has generated many lessons for social franchising programs:

  • Before expanding a network, the franchises business model should be thoroughly field tested and refined.
  • Establishing a fully functional and reliable MIS at the start allows the franchiser to monitor providers and keep control over the network.
  • By establishing a franchise dues system at the outset, managers can screen out applicants who are not serious, increase franchisees commitment to the network, and contribute to cost recovery
  • A contract that clearly spells out the roles and responsibilities of franchisees and that outlines enforcement mechanisms is necessary, but not sufficient, to maintain control over the quality of services offered by franchisees.
  • The quality of providers recruited into the network is more important than their number. Selection criteria should incorporate the traits of successful franchisees.
  • To ensure the quality of services, the support and monitoring team must be large enough to make frequent site visits to all providers.
  • Developing an in-house training program gives the franchiser direct control over the quality and scheduling of training.
  • Community-based activities involving franchisees can help reach potential clients and create demand for services; mass media advertising is not enough.
  • Noneconomic incentives, such as recognition ceremonies, can help keep providers motivated when they do not receive immediate economic rewards from the network.
  • Market the franchise network as a source of "trustworthy family health" rather than just family planning.
  • The incremental cost of integrating additional reproductive health products and services to a franchise network is small once the network has been built and minimum standards of quality of care are ensured.

The Green Star network is working to expand its services and to raise the standard of care. Recent initiatives include:

  • establishing district-level referral and training hubs;
  • partnering with community-based organizations and introducing mobile reproductive health clinics to reach underserved slums and peri-urban areas;
  • developing more stringent selection criteria and more detailed operations manuals;
  • creating refresher training courses, incentives for quality of care, and more rigorous monitoring; and
  • adding a business management module to the training curricula.

For additional information about the Green Star franchise network, please contact:

Dr. Rehana Ahmed, Chief Executive, Social Marketing Pakistan (Ltd), D-29, Block 2, KDA Scheme #5, Clifton, Karachi, Pakistan; t
Telephone: 92-21-583-8841; Fax: 92-21-586-7891; Email: [email protected]

or

Dana Hovig, Senior Vice President, Population Services International, 1120 19th St. NW, Washington, DC 20036, USA
T telephone: 202-785-0072; Fax: 202-785-0120; Email: [email protected]

This program example is based on: Julie McBride and Dr. Rehana Ahmed, Social Franchising as a Strategy for Expanding Access to Reproductive Health Services: A Case Study of the Green Star Service Delivery Network in Pakistan, CMS Technical Paper Series. Washington, DC : Commercial Market Strategies (September 2001). Available at: www.cmsproject.com/resources/PDF/CMS_GreenStar.pdf.

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Poland

A combination of political, religious, cultural, and financial barriers has discouraged the use of modern contraceptives in Poland. Less than 10 percent of women use modern contraceptives, and women frequently resort to illegal and unsafe abortions. Reproductive health is not a priority for the government; family planning services are not readily available in either the public or private health systems; misinformation about contraception is widespread; and sex education in schools is limited. The situation grew worse in 1998 when the government eliminated its subsidies for contraceptives and parliament voted to remove sex education from public schools (although the president ultimately vetoed the latter measure). The government office responsible for womens equality was replaced with one promoting a traditional approach toward womens roles in the family.

In response to this hostile environment, the Federation for Women and Family Planning, a coalition of nine NGOs, launched an initiative to involve women in the advocacy process in 1997. After preparing and circulating a report on the status of reproductive health in Poland, the federation formed a ten-member advisory council of scientists, politicians, and health policy makers to develop messages and advocacy strategies to reach key audiences. The federations advocacy activities have multiple objectives, including the reintroduction of safe and legal abortion, legalization of voluntary sterilization as a contraceptive method, improved access to family planning information and services, sex education in the schools, the promotion of patients' rights, and contraceptives subsidies for poor women. A wide audience was targeted, including health practitioners, teachers, journalists, politicians, and policy makers.

The federation uses a combination of print materials and interpersonal advocacy to disseminate its messages. Products and activities include:

  • monitoring the observance of women's reproductive rights;
  • widely publicized reports on women's reproductive rights and health, including a September 2000 report on Anti-Abortion Law in Poland: Functioning, Social Effects, Attitudes and Behavior;
  • fact sheets, leaflets, guides, and other publications to disseminate accurate information and counter rumors;
  • media campaigns, including press conferences, press releases, and open letters;
  • a quarterly bulletin and workshops for reproductive health and rights advocates;
  • meetings, seminars, and conferences for target audiences such as politicians and doctors;
  • cultivating relationships with journalists to encourage media coverage of important issues; and
  • publicizing international standards on women's reproductive health and rights and the commitments of the Polish government to international agreements.

The federation has established a nationwide network of 220 advocates and nine local support groups that vigorously promote family planning and sex education at the local and regional levels. As a result of their efforts, more than 50 schools have begun offering sex education courses, with the help of sex educators trained by the federation. Ten local womens organizations have organized seminars on improving health services for women and launched information campaigns on patients rights, contraception, and family planning. Reproductive health services have improved in some clinics after doctors attended federation-sponsored events; they have started doing breast exams, informing patients about family planning and modern contraception, and showing respect for patients rights. University lecturers in sex education and gender studies have also begun using the federations guide on Reproductive and Sexual Health and Rights.

Lessons Learned

Lessons learned from the federations experience include:

  • In a hostile political environment, advocacy is most influential when it is flexible and broad-based. The federations advocacy efforts have benefited from using multiple channels of communication, both print and interpersonal, and from targeting multiple audiences, including practitioners, NGOs, community members, and the media, as well as policy makers.

  • Disseminating accurate data and information to policy makers is essential for legislative change. The federation has found that well-researched and objective fact sheets and reports can counter myths and misinformation, demonstrate the need for change, and even enlighten politicians about the governments international commitments.

  • Representation on elective bodies is an effective advocacy strategy. Lack of experience with legislative and policy procedures posed a major obstacle to the federations initial advocacy efforts. The election of a federation official to the local parliament not only increased the organizations influence, it also provided valuable knowledge about dealing with the bureaucracy.

For more information about the federations advocacy activities, please contact:
Wanda Nowicka, Executive Director, Federation for Women and Family Planning, Nowolipie 13/15 Street, 00-150 Warsaw, Poland;
Telephone/fax: 022-635-93-95; Email: [email protected]

Additional information in English and Polish is also available at the federations website: www.federa.org.pl

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South Africa

The WHO eligibility criteria are intended to be adapted by country programs to reflect the diversity of settings in which contraceptives are provided. Many local factors affect how the guidelines can best be adapted. For example,

  • the level of clinical knowledge and experience of various types of providers in the program,
  • the type of service delivery system through which contraceptives are provided,
  • local policies regarding contraceptive service provision the family planning needs and perspectives of clients,
  • resources available at various levels of service delivery,
  • the types of contraceptive products registered for use and or available in the country, and
  • the prevalence of STI or other chronic diseases (such as current liver disease, breast cancer, heart diseases) that limit use of certain contraceptive methods.

South Africa is one of the first countries to undertake a systematic review of the WHO Medical Eligibility Criteria for Contraceptive Use and make recommendations for adapting the criteria for local use in their service delivery guidelines. The review and adaptation process has been coordinated by the South Africa Directorate of Maternal, Child and Women's Health and has involved representatives from numerous women's groups, medical experts, as well as researchers and reproductive health program personnel. Although the adaptation effort is still ongoing, the process has resulted in recommendations for changes in service delivery, training, and research.

The directorate began its national policy review by asking for feedback from the field. Provincial health departments held workshops involving local stakeholders to review current policies and practices in light of the WHO recommendations. Based on these workshops, local groups developed a list of critical policy questions and identified areas where current practices differed from the WHO recommendations. The same stakeholders will review the revised national family planning policy plan once it has been drafted.

Using locally generated information, the directorate's task force convened to review national policies and practices related to contraceptive service delivery. The group carried out a method by method review and also considered broader issues, such as the need for quality counseling and the individual client's right to choose a method.

In addition to making method-specific recommendations, the task force identified areas for further research as well as a number of technical questions that need to be addressed. For example, the task force recommended South Africa-specific reviews of the following issues:

  • the relationship between hormonal contraceptive use and bone density,
  • the acceptability of the diaphragm,
  • the effect of repeated use of emergency contraception,
  • the recommended dose of emergency contraception among women using liver enzyme inducing agents,
  • the feasibility of introducing decentralized female sterilization services, and
  • the relative advantages of triphasic, monophasic, and third-generation oral contraceptive products.

During the initial review, the task force recognized but did not attempt to address the program implications of their recommendations. Transforming the group's recommendations into action through changes in policy, training, and IEC efforts will be considered as the next step in the adaptation process.

For more information, please contact:
Ms. Meena Cabral, Family Planning and Population Unit, World Health Organization, 20 Avenue Appia, CH 1211 Geneva 27, Switzerland;
Telephone: 41-22-791-3360; Fax: 41-22-791-4189; Email: [email protected]

Turkey

The Maternal-Child Health/Family Planning (MCH/FP) General Directorate of Turkey's Ministry of Health (MOH) has been working to strengthen its management information systems and to introduce a standardized logistics management system with technical assistance from the Family Planning Management Development (FPMD) project of Management Sciences for Health. The goal is more rational decision making, which, in turn, will increase the cost-efficiency, management, and quality of family planning and maternal and child health services in the public sector.

Field surveys in 12 provinces in 1996-1997 identified multiple weaknesses in MOH decision making. Provincial and health facility managers viewed the collection of service statistics as a bureaucratic obligation with no relevance to their own jobs: they had no incentives to collect good data and did not know how to use the data to monitor services in their own facilities. The absence of a uniform logistics management system led to frequent stockouts of contraceptives, poor storage conditions, and the presence of expired commodities on the shelves. Demonstration activities to solve these problems were piloted in five provinces before being scaled up.

One priority for the MOH is building information-based management skills at national, provincial, and local levels. After developing a Turkish training curriculum on "Using Information for Monitoring and Evaluation," three-day workshops were held for central and provincial family planning program managers, supervisors, and data administrators. Trainees learned the importance of information for health decision making, basic concepts of monitoring and evaluation, and how to analyze, present, and use data to make decisions. Following the workshops, provincial managers designed their own local training sessions and conducted "echo training" in basic monitoring and evaluation skills for health facility personnel. One of the key tools used to improve the use of information at the local level is a laminated poster on which health facilities can track and graph family planning use by method, method mix, and over time. This "Monitoring and Evaluation Wall Chart for Family Planning Services" leads managers through the process of collecting, analyzing and evaluating data and helps them monitor the method mix, logistics system, and other services at their facility.

Two other newly developed tools have played an important role in strengthening the use of information. Provincial managers have responded enthusiastically to an annual feedback report on family planning performance by province: it is the first time that the central directorate has acknowledged the receipt of monthly service statistics or commented on provincial performance. Newly developed situation analysis tools are used to assess the management information capabilities of provinces joining the project. With knowledge of local conditions, trainers can tailor training workshops and follow-up technical assistance to the specific needs and circumstances of a province.

Improving the contraceptive logistics system is also a top priority for the MOH, which is using the Top-Up Commodities Management System for its clinics, designed by FPMD in collaboration with central and provincial managers. Top-Up is a flexible system that can be adapted to local geography, infrastructure, and levels of demand for contraceptive commodities. Indeed, several Provincial Health Directorates have used the system to manage the distribution of all commodities to health facilities, not just contraceptives. Developing a curriculum and reference guide in Turkish and training essential personnel were the initial steps in introducing Top-Up. These materials were designed to make managers aware of the need for information throughout the logistics cycle, to introduce the commodities distribution system, to train participants in general rules for warehousing and storage conditions, and to help managers plan for the implementation of the Top-Up system.

Activities to improve management and logistics systems have been expanded to 22 of Turkey's 80 provinces, covering 54 percent of the population and almost 2,500 public-sector health facilities. More than 3,600 staff have been trained to use the data they routinely collect to make decisions about improving staff performance and the quality of family planning services. By rationally distributing contraceptive supplies, the Top-Up system has significantly reduced stockouts, oversupply, and waste. Perhaps most important, new management and logistics systems are being institutionalized in the MOH, assuring the sustainability of the improvements already made and fueling their further expansion. Staff at central and provincial levels are now capable of conducting MIS situation analyses and analyzing the results, leading workshops and refresher training on contraceptive logistics and on information-based decision making, and providing follow-up technical assistance.

Improving management information and logistics systems in Turkey has faced several challenges, however:

  • Turnover of MOH employees at both the central and provincial levels has required periodic re-orientation and re-training.
  • Delays in the procurement of contraceptives by the MOH led to temporary, shortages of condoms, IUDs, and oral contraceptives in some provinces during late 1999 and early 2000 which undermined the logistics system.
  • There are insufficient technical personnel in the MCH/FP General Directorate to staff and manage the numerous projects of international donors and manage the competing priorities of donors and international agencies.

Lessons Learned

  • A "coaching" approach to technical assistance can gradually build the capability of local managers to undertake training and technical assistance without external support.
  • Training workshops offer a rapid and cost-effective way to change the attitudes of large numbers of health managers toward data collection, and they help ensure sustainability by giving managers the skills they need to use their own data for local decision making.
  • Training should be followed up within a few months to see if skills and tools are being applied. In the absence of a routine supervision system and funding for supervision visits at the provincial level, an alternative system to assure training follow-up must be designed and supported.
  • Simple management tools are essential to enhance the impact of skills training and to allow managers at every level of the health system to monitor, evaluate, and improve family planning services.
  • The effectiveness of a logistics management system depends on the availability of commodities: shortages may cause managers to abandon established protocols on the timing and amount of commodities delivered.

Although USAID funding for Turkey ended in March 2002, technical assistance to the MOH is continuing under the Management and Leadership Development (MLD) Project of Management Sciences for Health.

For further information, please contact:
Dr. Ersin Topcuoglu, MSH Senior Technical Officer & Country Representative 19 sokak 26/2 Bahcelievler, Ankara 06490, Turkey;
Telephone: 90-312-235-1221; Fax: 90-312-235-6329; Email: [email protected]

Alison Ellis, Leader, Performance Improvement & Systems Team and Country Team Manager—Turkey, MLD Project, Management Sciences for Health (MSH), 891 Centre Street, Boston, MA 02130, USA;
Telephone: 617-524-7766, ext. 361; Fax: 617-524-1363; Email: [email protected]

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Zambia

The Government of the Republic of Zambia adopted a National Population Policy in 1989 as part of its fourth National Development Plan. This policy recognized the effects of rapid population growth on Zambia's socioeconomic development and the need to incorporate population concerns into the national development and planning process.

The main objective is to ensure that all couples and individuals can exercise the basic right to decide freely and responsibly the number and spacing of their children and have the information, education, and means to do so. Other specific objectives include slowing the nation's high population growth rate, enhancing the health and welfare of all, and preventing premature death and illness, especially among high-risk groups of mothers and children.

To help the national and district levels in the planning and implementation of the family planning component of their reproductive health programs, a policy framework was developed. The first section of the document describes the framework for family planning supported by the Ministry of Health. The second section, "Strategies for Providing Family Planning within Reproductive Health" addresses the challenges of providing family planning within the context of the broader context of reproductive health as defined at the International Conference on Population and Development (ICPD) in 1994. It looks at the status of various aspects of reproductive health in Zambia, especially family planning and proposes specific strategies for improving access to and quality of family planning care. For example, the importance of addressing the reproductive health needs of couples throughout their reproductive lives is emphasized. The third section, "Family Planning Methods," contains a technical description of all family planning methods available in Zambia and includes guidelines for service provision based on the revised WHO medical eligibility criteria.

Some specific recommendations include:

  • ensuring that providers are trained in all available modern methods;
  • making barrier methods, particularly condoms and spermicides, available through a range of channels;
  • making combined oral contraceptives available through community-based providers who will use checklists based on the eligibility criteria; and
  • making family planning methods available to women seeking postabortion care.

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