More than 200 million women and girls in developing countries who would like to avoid becoming pregnant are unable to access modern contraception methods. Urgent action is needed to address this huge unmet need. Next week the UK Government will host a high-level Summit to consider the options.
The barriers which prevent women and girls from accessing sexual and reproductive health services are multiple and complex. Even when services are technically available, social barriers can mean that women and girls do not feel they can use them – whether its partners and husbands restricting women’s choice or negative attitudes of health workers that push women away. Women and girls may also be denied access to family planning because they are too poor to pay.
On 11 July the UK Department for International Development will be hosting the London Family Planning Summit: a high level meeting which aims to galvanise political commitment and generate the resources needed to scale up access to family planning. There is no doubt that a focus on sexual and reproductive health is long overdue, so the initiative is welcome. However, some of the approaches being considered appear not to be based on evidence of what works. It seems likely that there may be a strong emphasis on the role of the for-profit private sector in service delivery, including a focus on social marketing and social franchising. There is little evidence that these approaches are able to deliver results for poor women and girls.
Social marketing and franchising have been enthusiastically embraced by governments, donors and some NGOs to deliver health programmes, especially for contraceptives. Put simply, social marketing uses the basic principles of commercial marketing to “sell” behaviour change. Social marketing organisations promote goods and services that are considered to have a social value and in return they receive public subsidies to expand their enterprises. Social franchising involves a network of for-profit private providers contracted to provide services under a common brand. In both cases, consumers are required to pay for products.
In 2010 DFID commissioned a review of the evidence on private sector engagement in sexual and reproductive health. The review identified significant risks with the private sector including problems with accreditation and regulation, and found little evidence on the question of equity. With regards to social franchising, while there was an increased uptake of family planning services overall, there is only moderate evidence of increased uptake by the poor. Similarly, social marketing schemes may be effective at widening access, the review notes that, “obviously it does not reach the very poor who cannot afford to pay for the product or service”. The review did not compare the effectiveness of the private sector with that of the public sector.
A more recent 2011 study assessed the contribution of social franchises to universal access to reproductive health services in 27 countries in Africa, Asia and Latin America. Not only did the authors find that the franchises had not widened the range of reproductive health services available, “in almost two-thirds of the franchises the full cost of the services was paid out of pocket, which was largely unaffordable for low-income women”. In many cases prices crept up over time which effectively priced out the poor. They concluded that continued investment in social franchises in the provision of reproductive health services could not be justified unless further evidence is forthcoming.
The trend of increased investment in unproven and risky private sector solutions is concerning given the lack of robust and convincing evidence that these can improve equitable access and quality of care for women. These studies clearly show that more evidence is needed before governments and donors promote social marketing and social franchising as the ‘magic bullet’ that will meet the unmet need for family planning.
Instead, investment should be used to strengthen the country health systems that are best placed to deliver comprehensive sexual and reproductive health services. To have the greatest impact an integrated approach based on rights and choice should be promoted and the social and financial barriers to access must be addressed. In a report published last week, ActionAid stress the importance of ensuring women are fully informed about the options and a have a range of contraception methods to choose from.
The London Family Planning Summit promises change on an unprecedented scale. Business as usual is clearly not an option, but to achieve the vision of universal access to family planning, solutions must be based on evidence of what works.
Ceri Averill is a Health Policy Advisor at Oxfam-GB