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

provide family plann<strong>in</strong>g services <strong>and</strong> (b) why communitiesdid not access family plann<strong>in</strong>g services.In all three groups of prov<strong>in</strong>ces, staff attitudes arementioned as a reason why health staff do not dispensecontraceptives. In <strong>the</strong> non-project <strong>and</strong> UNFPA focusprov<strong>in</strong>ces, <strong>the</strong> most important factor is <strong>the</strong> religious beliefsof staff, whereas <strong>in</strong> <strong>the</strong> PFPP prov<strong>in</strong>ces lack of supply is<strong>the</strong> primary reason.So far as <strong>the</strong> reason why communities do not accesscontraceptives is concerned, lack of supply is aga<strong>in</strong>mentioned as <strong>the</strong> ma<strong>in</strong> reason <strong>in</strong> <strong>the</strong> PFPP prov<strong>in</strong>ces,whereas community religious beliefs is <strong>the</strong> ma<strong>in</strong> reasongiven <strong>in</strong> <strong>the</strong> o<strong>the</strong>r groups of prov<strong>in</strong>ces.In Tables 2 <strong>and</strong> 3, <strong>the</strong> responses have been pooled withoutconsideration for particular prov<strong>in</strong>ces. Table 2 shows that<strong>the</strong> attitudes of health providers is perceived by healthstaff <strong>the</strong>mselves as <strong>the</strong> ma<strong>in</strong> reason why health staff do notsupply contraceptives, followed by <strong>the</strong> lack of supply <strong>and</strong>IEC materials. Table 3 <strong>in</strong>dicates that “fear” is perceived byhealth workers to be <strong>the</strong> ma<strong>in</strong> reason why <strong>the</strong> communitydoes not seek access to family plann<strong>in</strong>g services, followedby lack of awareness <strong>and</strong> religious beliefs.Although <strong>the</strong> selection of respondents <strong>in</strong> this survey wasnot based on scientific sampl<strong>in</strong>g methods, <strong>the</strong> healthworkers consulted were all well-<strong>in</strong>formed <strong>and</strong> experienced<strong>in</strong> <strong>the</strong> provision of family plann<strong>in</strong>g services. Aside fromthose com<strong>in</strong>g from prov<strong>in</strong>ces that had never participated <strong>in</strong>a major family plann<strong>in</strong>g project, most of <strong>the</strong>se respondentshad been <strong>in</strong>volved <strong>in</strong> <strong>the</strong> implementation of projectsaimed at improv<strong>in</strong>g access to family plann<strong>in</strong>g <strong>and</strong> o<strong>the</strong>rreproductive health services. It should not be concludedfrom <strong>the</strong>se data that <strong>the</strong> various family plann<strong>in</strong>g projectshad not made positive contributions towards improvedaccess. For example, <strong>the</strong> vasectomy tra<strong>in</strong><strong>in</strong>g provided under<strong>the</strong> UNFPA project provided a foundation for a muchwider vasectomy tra<strong>in</strong><strong>in</strong>g programme throughout <strong>the</strong>country <strong>and</strong> that programme has been quite successful.Similarly, <strong>the</strong> PFPP project contributed substantially to <strong>the</strong>renovation of cl<strong>in</strong>ics, provid<strong>in</strong>g a confidential, private space<strong>in</strong> which nurses were able to discuss issues <strong>and</strong> dispenseadvice. The PFPP project also changed procedures toensure that clients could access services at any time <strong>and</strong>on all suitable opportunities, ra<strong>the</strong>r than FP cl<strong>in</strong>ics be<strong>in</strong>gopen only at certa<strong>in</strong> hours.The <strong>in</strong>terpretation of <strong>the</strong> data <strong>in</strong> Tables 1-3 presents achallenge as <strong>the</strong> questions <strong>in</strong> <strong>the</strong> questionnaire were notdesigned to test a particular approach to service delivery.It is apparent, however, that <strong>the</strong> “attitudes” of healthstaff <strong>the</strong>mselves play a significant role <strong>in</strong> limit<strong>in</strong>g access.Conversely, <strong>the</strong> attitudes of <strong>the</strong> community, particularlyreligious views, constra<strong>in</strong> potential clients from seek<strong>in</strong>gservices. Male attitudes do not feature significantly among<strong>the</strong> most important reasons given for clients not seek<strong>in</strong>gaccess, but <strong>the</strong>y are mentioned. The large number of healthstaff who mentioned “fear” <strong>and</strong> “lack of awareness” as <strong>the</strong>two most important reasons for lack of community accessis consistent with <strong>the</strong> results of <strong>the</strong> two DHS that havebeen conducted (see <strong>the</strong> section below under <strong>the</strong> head<strong>in</strong>g“Current patterns of contraceptive use <strong>and</strong> unmet need”).The significance of attitudes <strong>and</strong> religious beliefs fromboth <strong>the</strong> supply <strong>and</strong> dem<strong>and</strong> side raises issues concern<strong>in</strong>g<strong>the</strong> role of Church-based health facilities <strong>in</strong> restrict<strong>in</strong>gaccess to family plann<strong>in</strong>g. The survey reported that nurses<strong>in</strong> Catholic-run health centres were frustrated <strong>and</strong> angeredby <strong>the</strong>ir <strong>in</strong>ability to offer modern family plann<strong>in</strong>g. 6 Thefact that so many village aid posts had closed or wereunable to offer services meant that more women werego<strong>in</strong>g to Church-operated health centres. The nurs<strong>in</strong>gstaff were unable to provide tubal ligation even to high-riskmultiparous mo<strong>the</strong>rs <strong>in</strong> areas where maternal mortalitywas high. They had also found that <strong>the</strong> ovulation methodthat <strong>the</strong>y were teach<strong>in</strong>g was unsuitable <strong>and</strong> unreliable forilliterate village women. Some nurses secretly distributedcontraceptives that came <strong>in</strong> <strong>the</strong> health kits <strong>and</strong> did notrecord dispens<strong>in</strong>g <strong>the</strong>m. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, supervisorsensured that no order for contraceptives was added tomedical requisitions. O<strong>the</strong>r nurses work<strong>in</strong>g <strong>in</strong> Catholichealth centres reported that <strong>the</strong>y would “get sacked” if <strong>the</strong>ysecretly distributed family plann<strong>in</strong>g methods (Burdon etal., 2002).Government policy is to encourage Church-operated healthcentres to cont<strong>in</strong>ue offer<strong>in</strong>g <strong>the</strong> ovulation method as anacceptable alternative where religious precepts prohibited<strong>the</strong> use of modern contraception. This somewhat passiveapproach is questionable when viewed from a humanrights perspective. One practical solution that has beenachieved <strong>in</strong> at least one prov<strong>in</strong>ce is for Church-run healthcentres to refer potential clients to a nearby aid post where<strong>the</strong>y know that FP services are available. This solution canwork only where <strong>the</strong> Church is at least will<strong>in</strong>g to cooperate<strong>and</strong> where aid posts are actually function<strong>in</strong>g <strong>and</strong> are be<strong>in</strong>gsupplied with commodities.A number of o<strong>the</strong>r issues to do with <strong>the</strong> barriers to accessto contraception were highlighted by <strong>the</strong> 2002 review, <strong>and</strong>still need to be addressed, <strong>in</strong>clud<strong>in</strong>g:Service providers are unaware that <strong>the</strong> family plann<strong>in</strong>gpolicy <strong>and</strong> <strong>the</strong> law allows contraceptives to be suppliedto any person above 16 years of age regardless of maritalstatus.Some family plann<strong>in</strong>g staff are still ask<strong>in</strong>g for writtenconsent from husb<strong>and</strong>s, even though this is nei<strong>the</strong>r a354