With the arrival of COVID-19, countries are experiencing disruptions of health services of all kinds— health workers have been redeployed, supplies already in short stock are even more difficult to find, scarce financial resources for health are being reallocated, and routine health services are less, if at all, available. COVID-19 is causing facilities to lockdown in some settings, in part because many providers lack sufficient personal protective equipment (PPE) to safely provide services. At the same time, many clients—particularly those seeking family planning and reproductive health (FP/RH) services—cannot access services at all. This is due to a confluence of factors: police action is preventing movement; facilities are shutting their doors; many people are fearful of contracting the virus; in some cases, women are forbidden from leaving their homes by a partner.
Without a clear end to the pandemic in sight, predictions about the negative impacts on FP/RH are grim. If the situation continues for even six months, UNFPA estimates that as many as 47 million women in low- and middle-income countries could be unable to use modern contraceptive methods, resulting in potentially 7 million additional unintended pregnancies. Equally devastating is an estimated 31 million additional cases of gender-based violence. Based on evidence from Ebola, more women and girls may die due to lack of service access than from the coronavirus itself.
The FP/RH community has responded quickly to the pandemic to endeavor to maintain gains in family planning use and improvements in health systems. Normative bodies have issued guidance on the essential nature of FP/RH services and recommendations on alternative channels to delivering them have been issued. It is absolutely critical to understand that “sexual and reproductive health cannot be viewed as a luxury.”
Thinking systematically is essential to creating an environment to ensure that services remain available during crises. To achieve a more sustainable path, the focus should be on developing and implementing relevant policies that provide a legal and regulatory platform to allow stakeholders to hold decision-makers accountable for commitments.
What does a favorable policy environment for FP/RH program look like? The policies need to be grounded in the premise that all citizens have a right to experience the highest attainable standard of health. They need to ensure that FP/RH policies translate into meaningful actions that support acceptable, accessible, available, and quality FP/RH services, and that the policies include benchmarks to ensure accountability. Such policies can be introduced and/or strengthened now to prepare for the future, to ensure FP/RH programs continue to serve clients during crises.
Since family planning and reproductive health services are essential, policies need to enable continuity of services and facilitate access for women and girls. Important system-wide policies to pursue now include solidifying task sharing among and between health worker cadres, being careful to pay attention to the important role that pharmacies and drug shops play for increasing access to services. Burkina Faso, Cote d’Ivoire, Kenya, Mali, and others have incorporated this approach in their policies. Expanding the range of tasks that can be performed by health care cadres like community health workers, midwives, and pharmacy workers, has been promoted by the World Health Organization (WHO) since 2012 with an additional update to their guidance in 2017.
WHO also recently released guidelines for self-care—the ability of individuals and communities to promote and maintain health without the support of a health care provider. Modifying policies along the lifecycle continuum of care for women and girls and including self-care across the spectrum of services offered, can increase access to care during calm times and crises. Along with this policy change, countries can incorporate advanced provision of pills (including for emergency contraception), self-injection for DMPA-SC, and guidance on the possibility of extended life of long-acting reversiblecontraceptives to prepare for the future.
Accompanying these service provision policies, facility structure and cost policy revisions are needed. Revising national guidelines to modify facility flow to maximize physical distancing in waiting areas, screening processes, and ensuring privacy for exams, and allowing for the establishment of greater infection prevention stations and protocols can reduce possibilities of transmission, protect health workers, and rebuild clients’ confidence in the safety of facilities. These changes can be complemented by formalizing access to adolescent-responsive contraceptive services to address the specific needs of this substantial segment of the population. And, to enable clients to receive services when they can’t physically visit facilities, it is critical to include provisions for cost-recoverable telemedicine in service delivery protocols and insurance schemes.
Furthermore, to prepare countries to deliver services in future crises, and strengthen the nexus between humanitarian and development communities, it is important to include provisions for crisis scenarios in policies to ensure that access, availability, acceptability, and quality of FP/RH services and supplies are not compromised.
Without supplies—i.e., contraceptives, PPE, maternity kits—family planning and reproductive health services are not possible. This crisis has compromised the availability of essential supplies. To mitigate such situations in the future, policies related to supplies need to allow for streamlined and fast-tracked approval for, and registration of, new contraceptives and essential medicines. This can help get supplies into countries more quickly, as could establishing regional partnerships and agreements to procure supplies regionally, based on agreed-upon standardized quality criteria, timeframes, and transportation methods. Another strategy to strengthen supplies policies is to devise contracting mechanisms that entice greater private sector involvement in a range of integrated services, ensuring that FP/RH is included.
Chronic shortages of health workers have plagued many countries for decades. This gap widens now during the pandemic through staff illness, redeployment, or refusal to provide care without PPE. To lessen the potential negative impact in the future and strengthen the health system now, human resources policies need to address the needs of health workers, most of whom are women, including issues of pay gap, gender-based violence in the workplace, and placement in locations away from their families. This is an opportune time to establish payment policies and practices that include mobile money, and to formally integrate community health workers into the health system and pay them accordingly. Increasing health worker safety can be achieved by linking the importance of infection prevention control with service provision (through training and supply planning) and licensure and continuing medical education. And to make such education more attainable for widely dispersed health workers, policies can allow and encourage online continuing medical education.
No one knows how long the COVID-19 pandemic will last. What is known is that, without making long-lasting modifications to how we live, work, and play, it will be extended further into the future. In the FP/RH arena, having a strong and favorable policy framework, learning from the pandemic, and adapting anticipatory policies now for the future are critical to better positioning the global community to overcome this and future health-sector crises.
Sara Stratton is a director for health at Palladium and is a senior technical advisor for family planning on the USAID-funded Health Policy Project.
Sources: Deutsche Welle, Global Health: Science and Practice, High Impact Practices, Inter-Agency Working Group on Reproductive Health in Crises, International Conference on Family Planning, International Federation of Gynecology and Obstetrics, IntraHealth, Marie Stopes International, The Atlantic, The Lancet, United Nations Population Fund, US Agency for International Development, World Health Organization.
Lead Photo Credit: Mobina Khatun (45-year-old) is one of the 40 Rohingya Women Volunteers working with UN Women to mobilize their communities on crucial issues within different camps in Ukhiya. Photo Courtesy of Pappu Mia/UN Women.
Written by Sara Stratton
Published on 10-06-2020 in NewSecurityBeat