Family Planning Ecosystem

This framework describes the key elements in the family planning (FP) ecosystem that support individuals to make and act on their family planning choices.  As the graphic suggests, this framework embraces the idea of an interconnected system that, when all parts are functioning, drives increased access, quality and equity. It shows the dynamic relationship between supply and demand, and how assets, capabilities, expectations and conducive conditions operate on both sides of the equation to produce outcomes. Although no single program will address all these elements, it is important to consider the whole FP ecosystem when designing programs, including both individual and broader system elements.  Failing to do so risks looking for answers in the wrong places, diagnosing and solving the wrong problems, and perhaps even missing the biggest, most transformative opportunities.   The creation of the framework was guided by three principles that are at the heart of efforts to unlock FP demand, though these may look different in different contexts.  These principles are people, power and connection .  People: Health systems are more than commodities and infrastructure, “health systems are also human systems”[1]. Many different people make up health systems—policy makers, service providers, service users—and have various roles, stakes, and power within them.  As public health crises such as Ebola illustrate, over reliance on technical solutions without the engagement and support of actors in the system, including affected populations and communities, are doomed to fail[2]. Focusing solely on the hardware of the health system, underestimates the dynamic human dimensions that drive behavior, trust, motivation, quality, positive user experience, and, ultimately, desired program outcomes.  This principle suggests we build our programs around people and relationships, always keeping women and girls at the center of our FP efforts. Power: The FP ecosystem is complex and encompasses the continually negotiated relationships and power dynamics within the household, the community, and between users and the health system.  As program designers and researchers, rather than trying to identify and “solve for” every possible barrier or challenge a person might face, this principle suggests we place greater emphasis on “solving with”. In other words, work should focus on building and supporting women’s capacity to identify and overcome the obstacles—interpersonal, social, structural--they face across their reproductive life journey, so they can exercise their power to navigate their own path[3].  Further, the health system and the actors within it need to be empowered and equipped to respond and adapt to user’s needs and preferences and to ever-changing conditions[4] ,[5] .  This approach has the potential to create a virtuous cycle, as women are more able to negotiate services and demand quality—whether at a clinic, a pharmacy, or on-line—and health providers and the delivery system are more able to adapt and respond effectively to that demand.  Connection:  Related to shifting power dynamics, the third principle underpinning the framework is about connection, participation and engagement.  Although the theory of supply and demand is based on the idea of interdependence, the global family planning community has largely approached supply and demand as two vertical systems.  There is a growing realization, however, that these two components need to be in conversation, and that social participation in health care is not only a human right, but also holds value in improving health care and keeping systems accountable[6].  Community members are experts in their context and experience and can deploy this knowledge to help solve health care problems[7] ,[8] . Mechanisms that bring community members and health providers together to mutually identify service provision and utilization problems and then jointly generate, negotiate, and monitor solutions have been successful in increasing uptake, quality and sustainability of services.[9] , [10].  To achieve the goal of helping individuals make and act on their FP choices, this principle suggests we pay more attention to these connections and the mechanisms that enable and support participation, engagement, user and community voice, system responsiveness, adaptative capacity and quality. [1] Sheikh K, Ranson MK, Gilson L. Explorations on people-centeredness in health systems. Health Policy & Planning , 2014;29: ii1-ii5. https://www.ncbi.nlm.nih.gov/pubmed/25274634 [2] Final report of the Ebola Interim Assessment Panel, July 2015.Geneva: World Health Organization; 2015. Available from:  http://www.who.int/csr/resources/publications/ebola/ebola-panel-report/en/ .  [3] Asian Communities for Reproductive Justice. A new vision for advancing our movement for reproductive health, reproductive rights and reproductive justice. 2005. https://forwardtogether.org/wp-content/uploads/2017/12/ACRJ-A-New-Vision.pdf [4] Framework on integrated, people-centred health services. Geneva: World Health Organization; 2016. Available from:  http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1&ua=1%0Ahttp://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1 [5] Agyepong IA, Sewankambo N, Binagwaho A, Coll-Seck AM, Corrah T, Ezeh A, et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet. 2017 Dec;390(10114):2803–59. Available from: https://linkinghub.elsevier.com/retrieve/pii/S014067361731509X [6] Potts H. Participation and the right to the highest attainable standard of health: University of Essex: Human Rights Centre, 2008. http://repository.essex.ac.uk/9714/1/participation-right-highest-attainable-standard-health.pdf [7] Howard-Grabman L, Miltenburg AS, Marston C, Portela A. Factors affecting effective community participation in maternal and newborn health programme planning, implementation and quality of care interventions. BMC Pregnancy Childbirth 2017; 17: 268. [8] Wallerstein N. What is the evidence on effectiveness of empowerment to improve health? Copenhagen: WHO Regional Office for Europe, 2006. http://www.euro.who.int/Document/E88086.pdf [9]  Monga T, Shanklin D. Two promising social accountability approaches to improve health in Malawi: Community score cards and national health budget consultation, analysis and advocacy. Maternal & Child Survival Project (MSCP), August 2018.  https://coregroup.org/wp-content/uploads/2019/03/TwoPromisingSocialAccountabilityApproachestoImproveHealthinMalawi.pdf [10] Fox JA. Social accountability: What does the evidence really say? World Development, 2015; 72:346-361. https://www.sciencedirect.com/science/article/pii/S0305750X15000704?via%3Dihub