Microsoft Word - National Strategy for Family Planning Services 2068, 2011.docx

National Strategy for

Family Planning Services, 2068

Government of Nepal

Ministry of Health and Population

Department of Health Services

Family Health Division

2068

Table of Contents

1. Background: .............................................................................................................................. 1

2. Current Situation ........................................................................................................................ 2

3. Problems and Challenges ............................................................................................................ 3

4. Necessity of a Strategy ................................................................................................................ 3

5. Long Term Goal and Vision ........................................................................................................ 4

6. Objectives .................................................................................................................................. 4

6.1. Specific Objectives: ............................................................................................................. 4

7. Goals of Family Planning Program .......................................................................................... 4

8. Values and beliefs .................................................................................................................... 4

9. Policies ..................................................................................................................................... 5

10. Strategies ............................................................................................................................. 5

10.1. Access and availability of services: ............................................................................... 6

10.2. Integrating family planning services: ............................................................................. 7

10.3. Capacity building: .......................................................................................................... 7

10.4. Public Private Partnership ............................................................................................. 8

10.5. Supply Management ..................................................................................................... 8

10.6. Ensuring Reproductive Rights: ...................................................................................... 9

10.7. Male Engagement: ........................................................................................................ 9

10.8. Information, Education, Communication and Behavior Change: .................................. 9

10.9. Insufficient demand: .................................................................................................... 10

11. Institutional arrangements .................................................................................................. 10

12. Economic Aspect ................................................................................................................ 11

13. Monitoring and Evaluation .................................................................................................. 11

Abbreviations:

AHW: Auxiliary Health Worker

ANM: Auxiliary Nurse Midwife

CPR: Contraceptive Prevalence Rate

CRS: Contraceptive Retail Sales

DHO: District Health Office

DOHS: Department of Health Services

DPHO: District Public Health Office

FCHV: Female Community Health Volunteers

FHD: Family Health Division

HA: Health Assistant

HIV: Human Immunodeficiency Virus

HMIS: Health Management Information System

IUCD: Intrauterine Contraceptive Device

MDG: Millennium Development Goals

MIW: Maternal Infant Workers

MOHP: Ministry of Health and Population

MSI: Mary Stopes International

NDHS: Nepal Demographic Health Survey

NFPA: Nepal Family Planning Association

NGO: Non-Governmental Organization

NPC: National Population Commission

PSI: Population Services International

TFR: Total Fertility Rate

UNFPA: United Nations Population Fund

USAID: United States Agency for International Development

VCT: Voluntary Counseling and Testing

VDC: Village Development Committee

VHW: Village Health Workers

1. Background:

Family planning has been a part of Nepal's development policy since the mid-1960s. With the aim

of planned development of Nepal, third five-year plan (1965-1970) was developed. Since its

beginning, Nepal family planning and maternal and newborn welfare plan started and this program

has been gaining considerable priority and importance since its inception. The Nepal Family

Planning Association (NFPA) was established in 1959 in Non-governmental sector and has been

serving in Nepal till date which is remarkable. Similarly, the National Population Commission

(NPC) was established in 1978 under the chairmanship of the Prime Minister. This also shows the

priority given by the nation on this program.

Own district offices and service mechanisms were established in 24 districts in 1968 to expand the

family planning program, and were eventually expanded in other districts by integrating all 75

district offices in 1988.

Previously, the family planning program was operated independently but in 1988 the Ministry of

Health and Population (MOHP) established the Public Health Division (PHD), and the family

planning program was moved under it and began to merge. The family planning program was fully

integrated in 1992, and it is now administered by Family Health Division (FHD) which is under the

Department of Health Services (DOHS).

Family planning was considered as an essential health services in the Second Long-Term Health

Plan (1997-2017). Similarly, the government of Nepal has made this program a priority in its five-

year and three-year national plans. International organizations such as USAID, UNFPA, Engender

Health, Jhpiego, MSI, PSI, and NFPA have all made significant contributions to the development

and implementation of this program. In 1978 social marketing system was introduced through the

Nepal Contraceptive Retail Sales (CRS) Company with the goal of increasing access to family

planning services, which has made a significant contribution to access to family planning services.

Although the family planning services have been started in Nepal with the objective of proper

population management. It has become a part of reproductive health and the rights of couples and

individuals in recent years, which has been accepted. Through the successful implementation of

family planning program MOHP is aware on managed health of individuals and family. As a result,

maternal mortality and morbidity will be reduced, which will help in improving the health of

newborns and children, as well as improve the situation and increase the access to fundamental

requirements like education and health. It also helps to promote gender equality, women's education,

and career development. It has been proven that family planning can help to minimize the risk of

HIV infection as well. If a woman becomes pregnant when she reached physical and mental

maturity, she will be able to care for herself and her baby and give birth to a healthy and appropriate

weight child. Despite these advantages, it is one of the cheapest and most effective

methods/remedies for improving human quality of life.

Considering these benefits of family planning in mind, the United Nations adopted eight Millennium

Development Goals (MDGs) in 2000 and those goals were revised and included in Family Planning

plan 2007. Therefore, family planning services in Nepal will ensure that all men and women have

the right to be informed and have access to safe, effective, choice and customized family planning

methods.

2. Current Situation

In Nepal the family planning services are being available from government, Non-government

organizations and from social marketing sectors. Because of the efforts from all these organizations

Contraceptive Prevalence Rate (CPR) has been gradually increasing and Total Fertility Rate (TFR)

is being decreasing. In 1976 the CPR was 3% and in 2006, 48% (all methods) and modern methods

CPR reached to 44%. In the meantime TFR was decreased from 6.3 to 3.1. Similarly, nearly 100%

people were known about any one methods of family planning. Unmet demand for family planning

methods are 25 %, of which 9.6% wants temporary and 15.2% wants permanent methods. According

to the preliminary results of recently published Nepal Demographic Health Survey (NDHS) 2011,

the CPR is 50% (all methods) and the TFR was found to be 2.6. But the use of modern methods of

family planning compared to 2006, it was found to be lower than normal (43.2%). In line with

Millennium Development Goals Nepal's Ministry of Health and Population has targeted to increase

the CPR to 67% and reduce the TFR to 2.5 by 2015. At present, the overall fertility target set by the

Government of Nepal is likely to be achieved by 2015, while the use of family planning is likely to

be difficult to achieve. For this, it is necessary for the organizations and individuals working in this

field to move forward in a more organized and effective manner.

3. Problems and Challenges

A. The Government of Nepal, Ministry of Health and Population has set a target of 67% CPR

by 2015 in line with the MDGs. Achieving this goal so far has been very challenging for the

program.

B. According to the preliminary results of the NDHS 2011, though CPR of all methods is nearly

50% in average but is very different between the use of family planning in urban areas (50%)

and remote areas (42%). Meeting the demands of family planning for men and women living

in rural areas has become challenging.

C. According to the NDHS 2006, the unmet need for family planning in Nepal is 25%. Despite

the decline in unmet need compared to previous years, is still high compared to other

countries. Unmet need is especially high among adolescents, those living in remote areas,

mountainous and hilly areas and those with low economic status. Meeting the unmet needs

of these groups of people has been a challenge.

D. Although long acting temporary family planning methods IUCD and Implant are more

effective but the use rate of these devices is very low. The services of these methods have

not been able to reach in rural areas sufficiently.

E. The main reason why many women and men do not use family planning methods at present

is because they believe that using family planning methods can lead to negative health

problems. It is challenging for family planning to improve the health of mothers, children

and families and to change their behavior by spreading awareness to the community about

the economic, educational, employment and other benefits of women.

4. Necessity of a Strategy

The National Family Planning Program Policy 2054 was published to all governmental, non-

governmental, social marketing, and private organizations and individuals involved in the program

to bring uniformity in its operation and improve the quality of service, as well as to provide clear

information about the policy of the then Government of Nepal. Similarly, in 2063 BS, "National

Directive on Operation of Family Planning Services 2063" was published.

Government of Nepal has prepared the Nepal Family Planning Service Strategy, 2068, in order to

implement the goals and strategies outlined in the recently published "Nepal Health Sector Program

Implementation Plan II 2010-2015", as well as to address the current need for family planning

services, its utilization rate, availability of services, lessons learned while operating the service,

internationally revised principles and commitments made by the Government of Nepal in

international fora. This revised policy is expected to be a cornerstone in meeting the MDGs of the

Government of Nepal by providing clear guidelines to individuals and organizations working in the

field of family planning and meeting the needs of family planning services, especially in remote,

backward and economically weaker couples and individuals in Nepal.

5. Long Term Goal and Vision

To improve the reproductive health and quality of life of all the males and females living in any part

of Nepal by meeting their need of family planning.

6. Objectives

To improve the health of mothers and babies as well as the living standards of the whole family by

increasing the access, availability and use of quality family planning services required for

individuals and couples.

6.1. Specific Objectives:

6.1.1. To increase the access and use of family planning services in a way that has quality,

safe, effective and acceptable to the general public. Increase access to services,

especially for those living in remote, tribal, Dalit, poor and backward classes and in

high unmet need areas.

6.1.2. To improve women's and men's access to family planning services by creating a

supportive environment.

6.1.3. To increase the demand for services through behavior change and communication

related programs.

7. Goals of Family Planning Program

The main goals of the family planning program will be as follows:

• To reduce total fertility rate to 2.5 by 2015.

• To increase contraceptive prevalence rate to 67% by 2015.

8. Values and beliefs

In order to achieve the set goals, family planning services will be based on the following values and

beliefs:

• Equal access to services for men and women of different castes, religions, cultures and

geographical areas.

• Quality service with informed choice based on true and complete information.

• Culturally appropriate service.

• Inclusive service without gender and social discrimination.

9. Policies

Policies related to family planning services will be as follows:

A. Emphasis will be placed on providing quality services to women and men living in any part

of Nepal with informed choice based on true and complete information about family

planning.

B. To make family planning service accessible to all, services will be provided in partnership

with government, private, non-government and social marketing sectors. The role of private

sector in providing family planning services will be encouraged.

C. Family planning will be established as a reproductive right of men and women.

D. Access and availability of family planning services will be increased.

E. Family planning services will be effectively integrated with other aspects of health care.

F. Various programs will be implemented to increase the capacity of service providers and

managers.

G. Supply management will be made effective to ensure the availability of family planning

commodities.

H. Various creative programs will be conducted to increase the engagement of men in family

planning services.

I. Various programs of effective information, communication, education and behavior change

communication will be conducted to increase the truth/fact knowledge required by the

general public for making necessary decisions to adopt family planning services.

J. Special programs will be conducted to meet the needs of family planning methods in high

unmet need groups and areas.

10. Strategies

The following strategies will be adopted to implement family planning policy:

10.1. Access and availability of services:

1. In order to increase the access and availability of family planning services, IUCD has been

set up through all primary health centers and health posts under the Ministry of Health and

Population. And other temporary instruments including implant services will be provided

regularly. In addition, male sterilization services will be provided regularly in the primary

health centers.

2. Voluntary sterilization services will be provided regularly throughout the year through

district based hospitals and stable clinics. This service will also be made available through

mobile camps in remote places as required. However, emphasis will be given to provide

regular services from static clinics by gradually reducing the number of mobile camps.

3. All types of clinical and non-clinical family planning services will be provided by the

following health agencies.

Level

Condom

Pills

Dipo

IUCD

Implant

Male

sterilization

Minilap

FCHV

ü*

Village/rural

Clinic

Sub-Health Post

ü**

Health Post

Primary Health

Center

District Family

Planning Clinic

Hospital

Note: * Only to repeat clients, ** Limited only

4. Effective monitoring and supervision of family planning program will be ensured. In

addition, the referral system will be made effective.

5. By mobilizing Female Community Health Volunteers (FCHV) at the local level, information

and referral services related to family planning, distribution of condoms and distribution of

additional pills to women using pills will be encouraged.

6. Family planning services will be made available at the community level by increasing and

expanding the number of mobile camps, static clinics and rural clinics in coordination with

non-governmental and private organizations.

7. Condoms will be made widely available so that they will prevent both family planning and

HIV/sexually transmitted diseases (Dual Protection). Their benefits will be widely

publicized.

8. In the Village Development Committees (VDCs) where Implant and IUCD services are not

available, these service will be provided on regular basis through Satellite Clinics.

9. Necessary training will be conducted for Village Health Workers (VHW) and Maternal

Infant Workers (MIF) and 3 months contraceptive injection will be provided in rural areas

through them.

10. Feasibility studies will be encouraged in order to make quality, effective, and affordable

family planning methods available in addition to those now available in Nepal.

11. All consumers will have access to free family planning services and methods provided by

health facilities under the Ministry of Health and Population of the Government of Nepal.

10.2. Integrating family planning services:

1. Family planning services will be provided integrating with other programs such as

HIV/STIs, safe abortion services, abortion complication treatment services, maternity

services or emergency maternity services, postpartum services, youth and adolescent health.

2. Family planning information and services will also be provided from immunization clinics,

Ayurveda dispensaries, nutrition clinics and from VCT centers.

10.3. Capacity building:

1. Permission will be given to conduct family planning training by evaluating non-

governmental organizations and private sector training institutes other than the existing

approved training facilities in order to provide skill-based training to the manpower

providing family planning services.

2. Opportunities for capacity building of program managers will be provided in order to

improve the effectiveness of family planning services.

3. All types of clinical family planning services such as IUCD, Implant and voluntary

sterilization services will be provided by certified physicians who have successfully

completed training based on expertise. In addition, Implant and IUCD services will be

provided by certified nurses (ANM, staff nurses and above) who have successfully

completed skills-based training and health workers such as HA, A HW.

4. In order to extend the permanent and temporary family planning services to the rural areas,

the services will be expanded by conducting a task shifting study based on the qualifications

and experience criteria of the currently designated service providers as per the findings of

research conducted in other countries.

10.4. Public Private Partnership

1. In order to mobilize and manage the required financial resources to provide family planning

services in an effective manner, and to increase the quality and availability of services,

partnerships will be made with private, non-governmental and social marketing

organizations for family planning methods. Family planning services and methods operated

under the private sector and social marketing will be charged as prescribed.

2. Institutions providing family planning services from the non-governmental and private

sectors will be encouraged to provide permanent and temporary methods/services of family

planning within the framework of the policies, strategies, directives and protocols of the

Government of Nepal.

3. The private and non-profit sectors will be encouraged to extend services in geographically

remote locations and areas where family planning services are scarce. The concerned District

Public Health Office will supply family planning commodities to those organizations that

provide free family planning services.

4. Arrangements will be made for information of family planning methods and services

provided from any region and source to be included in the quarterly report of the concerned

district.

5. Quality, effective and low cost family planning methods will be encouraged to be produced

within the country.

6. Family planning services run by NGOs will have to pay the prescribed fees, but the resources

received from the Government of Nepal will have to be distributed free of cost.

10.5. Supply Management

1. An annual audit will be conducted in the presence of nationally concerned stakeholders to

ensure the availability of family planning methods and resources available for the program

from the partners and Government of Nepal.

2. The procurement process will be done according to the one-stop system by auditing the

equipment distributed by the government health facilities across the country.

3. To ensure the supply of family planning methods, the practice of purchasing the required

methods for two or more financial years at a time (Multi-Year Procurement) will be

followed.

4. Each district will receive necessary family planning commodities on an annual basis, based

on annual usage. The District Public Health Office (DPHO) will distribute family planning

commodities to the health facilities on a quarterly basis based on their usage.

10.6. Ensuring Reproductive Rights:

1. Family planning services will be recognized as the reproductive rights of men and women

and quality services will be provided accordingly.

2. In order to make family planning services quality, it is mandatory to provide counseling

services to the clients before providing the services.

3. In order to ensure counseling services, the availability of trained service providers related to

counseling in health institutions will be ensured.

4. If all the children die after male sterilization, the service of reconnecting the sperm tube

(Recanalization) will be provided free of cost to such couples.

5. Nondiscriminatory services will be provided to men and women seeking family planning

services (in terms of religion, politics, gender, economics, and social status).

6. In order to ensure the reproductive rights of couples and individuals, infertility treatment

services will be provided in the regional and central hospitals of the Government of Nepal

and at the same level of hospitals and health institutions run by the private sector.

7. Abortion will be denied to be used as a method of family planning.

10.7. Male Engagement:

1. In order to increase the male engagement in family planning programs/services, male

friendly reproductive health programs will be conducted by identifying the needs of men

while providing family planning services.

2. In places where the number of male sterilization is low, special emphasis will be given to

male sterilization by helping male clients to make voluntary choices through counseling.

3. In order to promote male engagement in family planning programs, males will be

encouraged to act as propagandists and facilitators, as well as to use family planning

methods.

10.8. Information, Education, Communication and Behavior

Change:

1. Demand for family planning services will be increased by promoting the concept of birth

control and healthy and organized family through the medium of behavior change

communication approaches (mass communication, group communication, interpersonal,

various educational materials, etc.).

2. Geographical diversity, social and cultural values and beliefs will also be taken into account

while conducting behavioral change communication programs and service delivery

programs.

3. Interpersonal communication will be strengthened even more because this method has been

demonstrated to be more successful in modifying family planning behavior.

4. Programs will be carried out in collaboration with other governmental and non-

governmental organizations besides health facilities working in community, to raise public

awareness about the importance and methods of family planning services.

5. In order to increase public awareness about the importance and methods of family planning

services, programs will be conducted in coordination with other governmental and other

non-governmental organizations besides the health facilities working in the community.

10.9. Insufficient demand:

1. In order to fulfill the need of family planning services for the Dalit, poor and backward

groups, special services will be provided through mobile family planning camps, static

clinics, rural clinics, satellite clinics in the places where they live.

2. At the district level through micro planning, special emphasis will be given to increase the

information and services in the places resided by the ethnic, Dalit, poor and backward

classes. Priority will be given to micro planning in districts where the use rate of family

planning is low.

3. Unmet need of family planning is high in groups such as adolescents, industrial workers,

postnatal mothers, couples who are living separately due to employment and other reasons,

people/couples living in slum settlements in urban areas, economically disadvantaged, and

those living in rural areas. Special programs will be conducted for them to meet the demand

of family planning services.

4. New thoughts and ideas will be encouraged to increase the access of family planning services

to the areas and classes where there is less use of family planning services.

11. Institutional arrangements

This policy will be implemented through the following institutional structures:

A. Central level

The Ministry of Health and Population, Department of Health Services, Family Health Division will

be the main responsible bodies for the implementation of this policy. This division will formulate

and issue guidelines, monitor the services provided by government and other organizations and

individuals, make arrangements to list the organizations and individuals providing family planning

services and take necessary actions for the implementation of the policy.

B. Regional Level

The Regional Health Directorate will coordinate for the operation of the program at the regional

level and ensure the quality of the program through inspection and monitoring.

C. District Level

The main responsibility for the effective implementation of the program within the district will be

with the concerned DPHO. The DPHO will identify areas and groups with low service utilization

rates within its district and formulate plans with the participation of stakeholders. It will ensure

availability of quality services and resources. In addition, district will coordinate with private and

non-government sector service providers, monitor services. The data associated with district family

planning services of the entire area will be sent to the regional and central system regularly.

D. Community and Health Facility Level

Health facilities, community level service centers and health workers will provide the services

and methods as specified in the guidelines and protocols and submit the report regularly to the

concerned district public health office.

There will be a Reproductive Health Steering Committee at the central level to make policy

decisions on the overall issue of reproductive health. There will be a Reproductive Health

Coordination Committee for mutual cooperation and coordination between the program and the

concerned stakeholders and the division. There will also be a Family Planning Sub-Committee under

this committee.

For the coordination of programs at the district level there will be the District Level Reproductive

Health Coordinating Committee.

12. Economic Aspect

When managing financial resources, the following resources will be mobilized and managed by the

following bodies and institutions:

• Annual budget from the Government of Nepal for conducting family planning programs

• Resources from NGOs

• Resources received from partner organizations for development

• Resources from local bodies, individuals and institutional donors

13. Monitoring and Evaluation

The monitoring and evaluation mechanism of the family planning program will be as follows:

A. Central Level

The Ministry of Health and Population, Department of Health Services, Family Health Division will

be the main bodies implementing, monitoring and evaluating the family planning program. The

Family Health Division will formulate and issue an annual action plan and monitor the services

provided by governmental and other non-governmental organizations. In addition, the indicators of

family planning services will be monitored regularly in coordination with the Health Management

Information Systems (HMIS) section under the Management Division. The Family Health Division

will also conduct special evaluation of family planning programs as per the need in coordination

and cooperation with its own resources and from other partner organizations.

B. Regional Level

The Regional Health Directorate will monitor the family planning services regularly at the regional

level by making necessary coordination with the center and the district.

C. District Level

The main responsibility of monitoring and evaluating the family planning program within district

will be with the concerned district public health office. The District Health Office (DHO) will

coordinate with private and non-government sector service providers in planning, ensuring the

availability of quality services and methods. In addition, DHO will monitor the services and send

all the progress related to family planning services in the district to the regional and central system

on a regular basis.

D. Community and Health Facility Level

Family planning programs will be monitored by providing services and tools as specified in the

guidelines and protocols by health institutions, community level service centers and health workers.

In addition, these organizations will regularly send the statistics of the services provided by them to

the concerned office.