September 2002, Vol. 8, No. 2

Case Studies
New Book Documents Transformations in
Reproductive Health Programs Worldwide

Participants at the 1994 International Conference on Population and Development (ICPD) in Cairo recognized reproductive health as a basic human right and a prerequisite to hastening socioeconomic progress and slowing population growth. This recognition led to the Programme of Action, which called for population programs—previously focused on demographic targets and contraceptive service delivery—to take a client-centered approach to reproductive health and attend to issues of gender, sexuality, and empowerment.

In the eight years since the Programme of Action was issued, how well have reproductive health and population programs addressed its mandates? The Population Council recently published Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning, a book of 22 case studies documenting this global response. The book, coedited by Population Council researcher Nicole Haberland and consultant Diana Measham, adds a critical new dimension of analysis to the body of material evaluating efforts to promote ICPD goals. 

“Policies pronounced on the world stage are only as good as their implementation in the field,” says Haberland. “These case studies show that strides have been made in expanding the scope of reproductive health care. While much remains to be done to realize the Cairo vision, these case studies demonstrate that there are concrete, field-level experiments grappling with how to best do so.” 

Moving big systems toward a client center 
Some of the most widely condemned violations of women’s reproductive rights have taken place in China and India. China instituted its harshly enforced policy of one child per couple in 1979, including strict rules about the type of contraceptive method women must adopt at different stages of their reproductive lives. Economic growth, social change, and international outcry since that time, however, prompted the minister of the State Family Planning Commission to call for a reorientation of the program in 1995. Deqing County was chosen to be the first to experiment with improving quality of care. The county family planning program now focuses on improving client satisfaction and permitting informed choice. Although women are not given a choice about family size, they are informed about a range of contraceptive methods and allowed to select the product they prefer—an explicit departure from the system’s past approach. 

For decades, field workers in India’s national family planning program strove to meet government-mandated, stringently enforced quotas for recruiting users of various contraceptive methods—particularly sterilization. They paid little attention to the quality of the care patients received, or to patients’ needs for other reproductive health services. In 1996, official policy in India became more client centered, focusing on the delivery of comprehensive, high-quality services. Importantly, health workers—rather than government bureaucrats—were asked to determine the health care and family planning goals of the communities in which they worked. 

Case studies in three districts in southern India showed that experiences implementing the new approach have varied. Nevertheless, a number of common lessons can be drawn. For example, while health workers show greater commitment to goals that they set for themselves, the policy changes have greatly increased their workload. While they have taken their new responsibility seriously, in some settings their new service delivery goals have been supplanted by mandates from mid-level supervisors. And although many women are receiving higher quality care, in some cases health workers still assign contraceptive methods without taking women’s preferences into account. 

“Changes take time; they don’t happen overnight. But these improvements bode well for the future of family planning programs in China and India,” state the editors. 

Targeting gender violence
Gender-based violence is endemic in many countries. In addition to its direct physical and emotional consequences, it influences women’s reproductive health, for example, by impinging on their ability to use contraceptives and avoid sexually transmitted infections. The casebook describes programs in two countries, Tanzania and Venezuela, that took different approaches toward addressing this issue. 

In Venezuela, a family planning organization, the Asociación Civil de Planificación Familiar (PLAFAM), began to screen for gender violence among its clients with the goal of supporting women who had experienced abuse. PLAFAM began its program by increasing staff awareness, training clinicians, hiring psychologists, developing educational materials, and obtaining information about supportive agencies. PLAFAM also collaborated with other community groups to lobby successfully for Venezuela’s first legislation, passed in 1999, outlawing both violence against women and violence within families. 

The book also documents community-level strategies to reduce gender-based violence. In Tanzania, the organization Jijenge! attempted to change how an entire community regards women and to replace norms that perpetuate violence against them. 

Jijenge! began by working with male and female community leaders to form a volunteer community-interest group to guide the antiviolence intervention. Jijenge! also conducted in-depth interviews and focus-group discussions to determine community attitudes about domestic violence. On the basis of evidence gleaned from this research, group members developed several community-awareness activities, including community theater, story booklets, murals, and radio programs. In addition, neighborhood watch groups were formed to intervene more actively in the cycle of violence. 

Although it is difficult to measure change in gender-based violence, anecdotal evidence points toward the success of Jijenge! According to community leaders, there has been an observable shift in people’s willingness to intervene when they witness violence. “Women’s health advocates, armed with compelling data, have called attention to the deleterious effects of gender violence on reproductive health,” says Measham. “Cairo helped to cement its place on the agenda’s challenges. These are two excellent examples of how this concern is now being addressed at the project level.” 

Strength in numbers
In addition to documenting the field-level effects of policy reform and efforts to reorient service provision, the casebook profiles efforts to address the social and economic underpinnings of women’s reproductive ill health. Organizations in Nepal and Peru, for example, sought to empower women through group formation. Women were given the opportunity to identify the reproductive health and gender concerns most important to themselves and their communities and to begin to address these concerns in ways that clinic-based services cannot. 

In Peru, women participated in weeklong diagnostic exercises arranged by the Movimiento Manuela Ramos's USAID-financed ReproSalud project. They identified reproductive tract infections (RTIs) as their reproductive health priority. Program managers had expected unplanned pregnancy, maternal mortality, and other issues to top the list. In response, an RTI prevalence survey was undertaken to facilitate advocacy efforts with local authorities. The project also provided the women with intensive training. Given their difficulty in negotiating safe sex and seeking reproductive health care, partner communication and negotiation skills were emphasized. 

In Nepal, the Boudha-Bahunipati Family Welfare project addressed reproductive health concerns both by enhancing clinic-based reproductive health care and by forming and supporting women's savings and credit groups. Trained staff helped group members explore and prioritize their reproductive health concerns. Two years after the project began, measurable effects were found in the use of a range of reproductive health services. 

The programs and interventions detailed this volume represent a rich body of experience that can help to provide direction, fresh ideas, and cautions as the field moves forward. "Many of these efforts are at the vanguard of change. Replicating and scaling up the approaches they embody is the key to meeting Cairo's goals," the editors conclude. 

For more information or to order the book, click: 
http:// www.popcouncil.org/cairocasestudies/index. 

Source
Haberland, Nicole and Diana Measham (eds.). 2002. Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York: Population Council.

Outside funding
The Ford Foundation and the Pew Charitable Trusts

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