Family Planning in Asia and the Pacific - International Council on ...

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As far as <strong>the</strong> supply of contraceptive commodities isconcerned, <strong>the</strong> general arrangement <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> is thatUNFPA purchases <strong>and</strong> pays for contraceptives <strong>and</strong> o<strong>the</strong>rsupplies <strong>and</strong> equipment on behalf of governments fordistribution by government-operated health facilities,usually public health centres or cl<strong>in</strong>ics or, <strong>in</strong> larger centres,a dedicated reproductive health cl<strong>in</strong>ic attached to a hospitalor o<strong>the</strong>r health facility. In one or two countries, UNFPApurchases commodities on behalf of <strong>the</strong> government ona “third party” procurement arrangement, with <strong>the</strong> costscovered <strong>in</strong> <strong>the</strong> government budget. Ano<strong>the</strong>r modalityof purchase <strong>and</strong> supply is through NGOs, often <strong>Family</strong>Health Associations (FHA) affiliated with IPPF. FHAsobta<strong>in</strong> supplies through IPPF, generally at low or no cost.F<strong>in</strong>ally, <strong>in</strong> some countries, contraceptives are available <strong>in</strong>pharmacies which purchase <strong>the</strong>ir supplies from normalwholesale suppliers based overseas. Because of its highHIV prevalence rate, Papua New Gu<strong>in</strong>ea is a somewhatspecial case with several <strong>in</strong>ternational donors provid<strong>in</strong>gcondoms. O<strong>the</strong>r contraceptives <strong>and</strong> commodities areprovided through <strong>the</strong> health budget <strong>and</strong> <strong>the</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Association.In general, <strong>the</strong> distribution <strong>and</strong> dispens<strong>in</strong>g of contraceptives<strong>in</strong> <strong>the</strong> develop<strong>in</strong>g <strong>Pacific</strong> countries is based upon a threetiersystem:(a) Government-operated public health facilities associatedwith maternal <strong>and</strong> child health services or reproductivehealth cl<strong>in</strong>ics. Services are generally free <strong>and</strong> suppliesare provided by UNFPA.(b) <strong>Family</strong> Health Associations (<strong>Family</strong> WelfareAssociations <strong>in</strong> some countries) affiliated with IPPF<strong>and</strong> with supplies <strong>and</strong> commodities furnished by IPPF.O<strong>the</strong>r NGOs (such as YWCA or generic youth clubs)also distribute contraceptives <strong>and</strong> provide reproductivehealth services. In some countries NGOs are suppliedby <strong>the</strong> government, with UNFPA be<strong>in</strong>g <strong>the</strong> ultimatesupplier.(c) Private pharmacies <strong>and</strong>/or doctors <strong>in</strong> private practicewho dispense contraceptives ei<strong>the</strong>r on an over-<strong>the</strong>counterbasis or by means of prescription. Theseoutlets tend to be concentrated <strong>in</strong> urban areas.Although <strong>the</strong>re are shortcom<strong>in</strong>gs <strong>in</strong> <strong>the</strong> reliability ofcontraceptive supplies <strong>and</strong> <strong>the</strong>re is room for improv<strong>in</strong>glogistical arrangements, commodity security has greatlyimproved <strong>in</strong> recent years <strong>and</strong> <strong>the</strong> prospects for fur<strong>the</strong>rimprovement rema<strong>in</strong> quite good. As <strong>in</strong> so many o<strong>the</strong>rareas to do with <strong>the</strong> delivery of health services, PapuaNew Gu<strong>in</strong>ea is a special case. This arises from <strong>the</strong> fact thatPapua New Gu<strong>in</strong>ea rema<strong>in</strong>s a predom<strong>in</strong>antly rural, villagesociety. A significant proportion of village-based healthfacilities (aid posts) have closed <strong>in</strong> recent years due to <strong>the</strong>difficulty of ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g staff, law-<strong>and</strong>-order problems<strong>and</strong> <strong>the</strong> shortages of supplies. The extreme remotenessof so many rural villages makes commodity security verydifficult to achieve.Supply cha<strong>in</strong> <strong>and</strong> logisticsmanagementEnsur<strong>in</strong>g a secure, timely <strong>and</strong> reliable supply of contraceptivesfor all persons who wish to use <strong>the</strong>m is a strategy thathas received substantial technical <strong>and</strong> f<strong>in</strong>ancial supportover <strong>the</strong> past several years <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> countries. Thekey organizations provid<strong>in</strong>g it are: UNFPA, AustralianAgency for <strong>International</strong> Development (AusAID), NewZeal<strong>and</strong> Agency for <strong>International</strong> Development (NZAid)<strong>and</strong> IPPF.As a result of this support, contraceptive choice hasbroadened from oral contraceptives, condoms <strong>and</strong><strong>in</strong>jectables to <strong>in</strong>clude emergency contraceptive pills,implants <strong>and</strong> female condoms. Tubal ligations are performed<strong>in</strong> many countries <strong>in</strong> urban areas, <strong>and</strong> vasectomies <strong>in</strong> a fewcountries, although dem<strong>and</strong> for <strong>the</strong> latter is low.Reproductive health policies <strong>and</strong>strategiesThe <strong>in</strong>corporation of reproductive health, <strong>in</strong>clud<strong>in</strong>g familyplann<strong>in</strong>g, <strong>in</strong>to national <strong>and</strong> subnational developmentplans <strong>and</strong> sector plans is well advanced <strong>in</strong> most <strong>Pacific</strong>isl<strong>and</strong> countries, but sexual health <strong>and</strong> family plann<strong>in</strong>g<strong>in</strong>itiatives target<strong>in</strong>g specific groups are less evident. Nearlyall develop<strong>in</strong>g <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territories(<strong>the</strong> Cook Isl<strong>and</strong>s, <strong>the</strong> Federated States of Micronesia,Fiji, Kiribati, Marshall Isl<strong>and</strong>s, Nauru, Samoa, SolomonIsl<strong>and</strong>s, Tonga, Tuvalu <strong>and</strong> Vanuatu) have developed or are<strong>in</strong> <strong>the</strong> process of develop<strong>in</strong>g national reproductive healthpolicies <strong>and</strong> strategies <strong>in</strong> which voluntary <strong>and</strong> rights-basedfamily plann<strong>in</strong>g is a core component. As DHS surveys arerecent <strong>and</strong> as yet not fully analysed, it has not been possibleto target specific groups, o<strong>the</strong>r than adolescents, whoseneeds are addressed largely by <strong>Family</strong> Health Associationsor o<strong>the</strong>r NGOs.Fund<strong>in</strong>g sourcesUNFPA is <strong>the</strong> primary fund<strong>in</strong>g source for contraceptivecommodities <strong>and</strong> o<strong>the</strong>r reproductive health supplies <strong>in</strong><strong>the</strong> smaller <strong>Pacific</strong> isl<strong>and</strong> countries. UNFPA has beenadvocat<strong>in</strong>g, with very limited success, for many yearsamong m<strong>in</strong>isters of health to <strong>in</strong>clude funds <strong>in</strong> <strong>the</strong>ir ownhealth budgets for <strong>the</strong> purchase of contraceptives. Largerisl<strong>and</strong> countries, such as Fiji <strong>and</strong> Papua New Gu<strong>in</strong>ea,purchase <strong>the</strong> bulk of <strong>the</strong>ir supplies through <strong>the</strong>ir own94
udgets, supplemented by donor fund<strong>in</strong>g – particularly <strong>in</strong>Papua New Gu<strong>in</strong>ea where <strong>the</strong> HIV epidemic has reacheda serious level (Hayes, 2007).L<strong>in</strong>kages to o<strong>the</strong>r reproductivehealth issuesHIV <strong>and</strong> o<strong>the</strong>r sexually transmitted<strong>in</strong>fectionsAs <strong>in</strong> many o<strong>the</strong>r parts of <strong>the</strong> world, a large proportionof <strong>the</strong> population <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> will never come <strong>in</strong>tocontact with HIV or o<strong>the</strong>r STI health services, despitesignificant numbers of people be<strong>in</strong>g at risk of STIs due to<strong>the</strong>ir practice of unsafe sex. Self-referral for STIs or HIVrema<strong>in</strong>s relatively uncommon <strong>and</strong> is usually restricted tosymptomatic <strong>in</strong>dividuals – however many cases of STI <strong>and</strong><strong>in</strong>deed <strong>the</strong> early stages of HIV rema<strong>in</strong> asymptomatic. Thispoor uptake of HIV/STI services rema<strong>in</strong>s problematic,facilitat<strong>in</strong>g fur<strong>the</strong>r transmission <strong>and</strong> caus<strong>in</strong>g significantimpacts on reproductive health – such as via neonataltransmission, reproductive system symptoms, <strong>in</strong>fertility<strong>and</strong> o<strong>the</strong>r STI-related morbidities. As such, l<strong>in</strong>kagesbetween HIV, family plann<strong>in</strong>g <strong>and</strong> broader sexual <strong>and</strong>reproductive health services provide multiple benefits ofexp<strong>and</strong>ed coverage of HIV/STI care, reduced HIV/STIrelatedmorbidity <strong>and</strong> mortality <strong>and</strong> improved reproductivehealth outcomes.It is thus relevant <strong>and</strong> advantageous to offer HIV- <strong>and</strong>o<strong>the</strong>r STI-related care <strong>in</strong> reproductive health sett<strong>in</strong>gs,such as family plann<strong>in</strong>g services. Specific promotion ofcondoms with<strong>in</strong> family plann<strong>in</strong>g, as <strong>the</strong> only currentlyeffective barrier contraceptive, also gives fur<strong>the</strong>r uniqueadvantages – dual protection (aga<strong>in</strong>st both unplannedpregnancy <strong>and</strong> HIV/STIs), <strong>and</strong> <strong>the</strong> reduced side effects ofa s<strong>in</strong>gle-use contraceptive that is required only dur<strong>in</strong>g <strong>the</strong>sex act itself. Long-act<strong>in</strong>g contraceptives have undesirableside effects for many people. Such contraceptives have tocont<strong>in</strong>ue to be taken by <strong>the</strong> user even dur<strong>in</strong>g periods ofsexual <strong>in</strong>activity.A converse benefit occurs where people liv<strong>in</strong>g with HIVor o<strong>the</strong>r STIs are provided with effective family plann<strong>in</strong>gadvice. As part of comprehensive prevention of parent–tochildtransmission (PPTCT), it is imperative that peopleliv<strong>in</strong>g with HIV are provided with contraception to ensurethat any result<strong>in</strong>g pregnancy is planned <strong>and</strong> preparedfor <strong>in</strong> consultation with <strong>the</strong>ir health-care providers.Contraceptive advice is thus a core part of comprehensiveHIV care (prong 2 of PPTCT). The presentation ofpersons to family plann<strong>in</strong>g cl<strong>in</strong>ics is also a good opportunityto promote HIV test<strong>in</strong>g, referr<strong>in</strong>g persons diagnosed withHIV for follow-up <strong>and</strong> management, <strong>and</strong> counsell<strong>in</strong>gpersons found to be free of HIV on how to stay HIVnegative <strong>and</strong> reduce risks of future <strong>in</strong>fection (prong 1 ofPPTCT).Barriers to l<strong>in</strong>kages of HIV with family plann<strong>in</strong>g <strong>and</strong>o<strong>the</strong>r sexual <strong>and</strong> reproductive health services do exist,however. Often <strong>the</strong>se services are set up <strong>in</strong> a very verticalmanner with separate fund<strong>in</strong>g streams <strong>and</strong> health-carestaff – sometimes <strong>in</strong> different localities. Time constra<strong>in</strong>ts<strong>and</strong> cl<strong>in</strong>ic layouts that are not user-friendly can alsoh<strong>in</strong>der delivery of HIV/STI counsell<strong>in</strong>g <strong>in</strong> familyplann<strong>in</strong>g sett<strong>in</strong>gs. There can be (spurious) ownershipissues between staff over which cl<strong>in</strong>ic is go<strong>in</strong>g to providewhich services – <strong>in</strong> reality <strong>the</strong>re is noth<strong>in</strong>g stopp<strong>in</strong>g bothHIV <strong>and</strong> family plann<strong>in</strong>g services from provid<strong>in</strong>g carefor both needs. Sometimes, family plann<strong>in</strong>g cl<strong>in</strong>ic staffare not completely familiar or comfortable with rais<strong>in</strong>gHIV <strong>and</strong> STI issues, preferr<strong>in</strong>g to limit <strong>the</strong>ir guidance topurely contraceptive matters. This is a missed opportunity.At <strong>the</strong> community level, <strong>the</strong> paucity of sex education <strong>and</strong>stigmatiz<strong>in</strong>g attitudes towards HIV <strong>and</strong> o<strong>the</strong>r STIs createan unsupportive environment which fur<strong>the</strong>r reduces <strong>the</strong>chance of HIV <strong>and</strong> STI care be<strong>in</strong>g ei<strong>the</strong>r sought out oreffectively delivered.Some good examples of fully <strong>in</strong>tegrated adolescent sexual<strong>and</strong> reproductive health services exist, where <strong>the</strong>se “onestopshops” furnish a comprehensive range of sexual <strong>and</strong>reproductive health, HIV/STI, drug <strong>and</strong> adolescentcounsell<strong>in</strong>g <strong>and</strong> awareness, toge<strong>the</strong>r with HIV/STIdiagnosis <strong>and</strong> treatment (or at least referral for treatmentif required). These adolescent sexual <strong>and</strong> reproductivehealth services take full advantage of <strong>the</strong> opportunityaris<strong>in</strong>g from a young person attend<strong>in</strong>g <strong>in</strong> order to ensurea holistic approach to sexual <strong>and</strong> reproductive health care,<strong>in</strong>clud<strong>in</strong>g both pregnancy <strong>and</strong> disease-prevention advice<strong>and</strong> services. Broader reproductive health services, such as<strong>the</strong> ma<strong>in</strong>stream family plann<strong>in</strong>g cl<strong>in</strong>ics with<strong>in</strong> outpatientcl<strong>in</strong>ics, would significantly benefit from a similar one-stopshopapproach. When develop<strong>in</strong>g primary health-careservices, <strong>the</strong>re is a need to tra<strong>in</strong> <strong>and</strong> promote delivery ofcomprehensive sexual <strong>and</strong> reproductive health care by publichealth centre staff, <strong>in</strong>clud<strong>in</strong>g comb<strong>in</strong>ed family plann<strong>in</strong>g<strong>and</strong> HIV/STI advice <strong>and</strong> treatment for patients.Strategies for streng<strong>the</strong>n<strong>in</strong>g national capacity to identify<strong>and</strong> implement l<strong>in</strong>kages for sexual <strong>and</strong> reproductive health<strong>and</strong> HIV are currently be<strong>in</strong>g developed <strong>in</strong> <strong>the</strong> FederatedStates of Micronesia <strong>and</strong> Vanuatu. These <strong>in</strong>clude pre- <strong>and</strong><strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g <strong>and</strong> HIV counsell<strong>in</strong>g<strong>and</strong> test<strong>in</strong>g.95
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
Page 54 and 55: TableTable1EventNational policyYear
Page 56 and 57: A third observation is that reporte
Page 58 and 59: TableTable2Current Contraceptive Pr
Page 60 and 61: Figure(-1.2), Cook Island</
Page 62: FigureTableTable3Trends in<
Page 65 and 66: Nam. Nearly all economies i
Page 67: 2008 2009% Bilateral % Multilateral
Page 70 and 71: family planning wi
Page 73 and 74: IntroductionFamily
Page 75 and 76: The advent of the
Page 77 and 78: FigureFigure1Oceania and</s
Page 79 and 80: next 25 years, however, TFR fluctua
Page 81 and 82: FigureFigureFigure2Total fertility
Page 83 and 84: family planning pr
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Page 87 and 88: that estimates of CPR for earlier p
Page 90 and 91: Figuremarried at an older age compa
Page 92 and 93: As previously mentioned most <stron
Page 94 and 95: FigureFigure945Relationship between
Page 96 and 97: The concept of “unmet need” has
Page 98 and 99: TableTable8Percentage of th
Page 100 and 101: TableTable9Percentage of reasons fo
Page 102 and 103: family planning pr
Page 106 and 107: Socio-cultural challenges tofamily
Page 108 and 109: likely to use contraception than yo
Page 110 and 111: 15 Tests of statistical significanc
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Page 116: Figurewill exceed the</stro
Page 119 and 120: in urban (67%) tha
Page 121 and 122: ased service delivery poin<
Page 123 and 124: Most FWAs who were recruited two to
Page 125 and 126: are considered, unmet need for effe
Page 127 and 128: Households pay the
Page 129 and 130: Effective public-private partnershi
Page 131 and 132: ConclusionThe Bangladesh Fa
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Page 135 and 136: National Institute for Population R
Page 137 and 138: IndiaIndiaFamily <
Page 139: IntroductionThe use of contraceptiv
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Page 144 and 145: FigureFigureFigure1Contraceptive pr
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Page 150 and 151: FigureFigure3Contraceptive prevalen
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the north
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TableTable10Differences between nor
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TableTable11 Total fertility rate <
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End Note1The first camp was success
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152
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154
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Figure1980s and ex
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health care and ed
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assistance from UNFPA and</
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in CPR. Likewise,
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International supp
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in development has
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__________ (2007). Population <stro
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170
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TableTable2What has the</st
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174
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per cent of women reported us<stron
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is provider bias that such methods
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TableTable7skewed distribution of h
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TableTable8TableTable9182
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that of the nation
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TableTable12 7some policies that ex
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The system guides the</stro
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FigureFigure4Total donor expenditur
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FigureFigureagain
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Impact of family plannin</s
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marketing of contr
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United States Agency for In
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200
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acceptable. From an NGO perspective
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FigureThis trend of limited donor f
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Figureto have the
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FigureFigure5Percentage change <str
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FigureFigure6Desire to limit childb
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coordination betwe
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the 1980s
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Policy Management.__________ (n.d.,
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218
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Population Activities (UNFPA) for a
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where family plannin</stron
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Thus an objective assessment of <st
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226
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Figureeconomic growth durin
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TableTable1TableTable2For spac<stro
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eflect a provider bias (e.g., <stro
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The Indonesian delegation was very
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than in ensur<stro
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in-country <strong
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(Ministry of Healt
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242
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244
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FigureTrends and p
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TableTable3Unmet need for contracep
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TableTable5TableTable6TableTable725
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TableTable8TableTable9Malaysia, abo
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previously mentioned is based on fo
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TableTable16births and</str
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FigureFigure3TRF54.5Scatter plots o
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ReferencesAng, Eng Suan (2007). Stu
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Demographic data sheet: population
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population size, with just 336,000
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NuptialityIn Myanmar nuptiality is
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FigureIn Myanmar, birth-spac<strong
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Scope of coverage and</stro
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FigureIn Myanmar, out of six select
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equirements. The Min</stron
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according to <stro
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Adolescent sexual and</stro
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FigureHIV/AIDS. An HIV-positive wom
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National Population PolicyMyanmar i
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Linkages with o<st
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TableTable4Achievements of Myanmar
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monitoring <strong
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Nay Pyi Taw, 26 October 2010.53 Sit
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292
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294
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TableTableA296
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dispense and adm<s
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(1) I am against a
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FigureFigureFigure3Use of modern co
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FigureFigure7Traditional method use
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Figureprojection, and</stro
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Figure 11 summarizes the</s
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correlating <stron
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Figurethe use of c
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FigureFigure15Sexual behaviour <str
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track the distribu
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Figureservices, which should <stron
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FigureFigureFigure18 Population <st
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National Statistics Office, <strong
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TableTable11326
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TableTable19Laws and</stron
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worker and hours w
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334
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336
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includin</
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TableTable1Contraceptive prevalence
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These results suggest that about 70
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2 The (period) TFR is the</
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346
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FigureThe existence of traditional
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Guinea case by <st
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The establishment of provin
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provide family plannin</str
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Figurelegal requirement nor a condi
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FigureTableTable5TableTable6Figure4
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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