Inequities in Family Planning in Low- and Middle-Income Countries.

INTRODUCTION: Inequities in reproductive health are widespread, and periodic surveys can trace trends in inequities to guide policies and program implementation. METHODS: We examined National Composite Index for Family Planning surveys from 2017 and 2021 that assessed inequities in access to 7 contraceptive methods and traced patterns of discrimination involving 5 subgroups in low- and middle-income countries. These surveys use 10-25 informants in each country who are knowledgeable at the national level. Measures are based on questionnaire ratings on a scale of 1-10. RESULTS: Access to contraceptive methods averages about half of the maximum of 100%, with substantial variation across regions and countries for the score levels. Score profiles are similar among high-scoring and low-scoring countries, suggesting that access to each method reflects common determinants in the nature of each method and the influences acting upon national family planning programs. Access to short-term methods (pill, injectable, and condom) is much better than for long-term methods (sterilization, intrauterine device, and implant). Community-based distribution of contraceptives averages low, as it is not part of some programs. Over time the scores have improved modestly. Correlations imply that better access leads to more contraceptive use. Inequity of use across wealth groups is less where overall equity has improved. Measures of discrimination against youth, unmarried women, postabortion clients, HIV carriers, and different wealth groups indicate a need for additional policies and considerable latitude for stronger actions by providers. CONCLUSIONS: The surveys in 2017 and 2021 demonstrate both progress and deficiencies for equitable access to contraceptive methods, with highly variable results among regions and countries. Much remains to be done to alleviate discriminatory practices against particular subgroups. Equity has improved for access to contraception and contraceptive use, and it can continue to do so with greater attention to policies and practices in national programs.

How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries.

Background: At the beginning of the COVID-19 pandemic fears of severe disruptions to family planning (FP) and access to services abounded. This paper uses a unique data source, a special Supplement added to the 2021 round of the National Composite Index for Family Planning (NCIFP), to assess in depth the resilience of FP programs in the face of the COVID-19 pandemic across 70 countries spanning six regions. Methods: The 2021 NCIFP included 961 key informants who were asked questions to assess interference in the countries' ability to achieve objectives, ability to maintain commitment to FP, and availability of information and services. Open ended responses added context. Results: All programs were affected; the magnitude of effects varies by region and country. While the average resilience score, at 47 out of 100, implies middling levels of resilience, further analysis showed that despite interference in many components of programming, with some exceptions, the COVID-19 pandemic generally did not diminish government commitment to FP and programs remained resilient in providing access to services. Common themes mentioned by 178 respondents (18.5% of respondents) included: fear of infection; disruption of services / difficulty with lockdown and travel restrictions; staff / facilities diverted to COVID-19; access to reproductive health services and contraceptive methods affected; shifts in services / outreach; interference with logistics & supplies, training & supervision, and M&E; lack of attention to FP/sexual reproductive health; financing reduced or diverted; and effects on existing partnerships. A strong enabling environment for FP, which the NCIFP is designed to measure, was positively correlated with continued government commitment and access to contraceptive methods during COVID-19. Conclusion: These findings are instructive for programming: it will face challenges and 'interference' when unanticipated shocks like COVID-19 occur, with strong FP programs best prepared to exhibit resilience.

The National Composite Index for Family Planning (NCIFP): Results and Methodological Issues.

Background:  The " FP2020 Global Partnership" signaled a shift to broader, rights-based approaches to family planning programs, and the National Composite Index for Family Planning was developed as part of related measurement efforts. Methods: In each country 10-15 experts on the family planning program completed a 35-item questionnaire, first in 2014 in 89 countries, and in 2017 in 84 countries. Data were entered in Excel, with checks for consistency and data quality. The total score, and scores for each of 5 dimensions of effort are averages across the 35 indicators. Analytic techniques included cross-tabulations, graphical and correlation approaches. Results: The average total score for all countries in 2017 was 64 of the maximum of 100 of effort. Sub-regions differed: Anglophone and Francophone sub-Saharan Africa (SSA) scored highest in the total score and across all 5 dimensions. Next in order came Latin America and the Caribbean, Asia, the Middle East and North Africa, and Eastern Europe and Central Asia. Despite large differences in scores, the sub-regions followed similar profiles across the 35  indicators. The long term rise in the basic family planning effort scores continued, extending the series from surveys approximately every five years beginning in the 1980s. The highest score reached was for the strategy dimension, but the others were close. Their relative levels remained essentially the same as in the 2014 survey.                     NCIFP scores correlated positively with modern contraceptive use in both the sub-Saharan Africa (SSA) and non-sub-Saharan Africa (non-SSA) countries, but the relationships were stronger for SSA. Access to long-acting and permanent methods (LAPMs) was accompanied by greater LAPM use and modern method use. Conclusion: Repeated surveys in most developing countries show improvements in family planning effort, though unevenly, by 35 indicators and across regions.