42. Expanding access to family planning services to the poorest women and girls

Fiona Clark
UK Department for International Development
Erik Munroe
Marie Stopes International

The information contained in this case study is drawn from Marie Stopes International (www.mariestopes.org) lessons learned reports on poverty targeting and outreach provided to DFID for the Preventing Maternal Deaths Programme Report. This work will be published by MSI in detail in 2019.

Expanding access to sexual and reproductive health services to the poorest requires effective targeting

Empowering women and girls, particularly the most marginalised, is key to achieving the Sustainable Development Goals. Delaying first pregnancies and enabling women to choose how to plan their families means they can gain the education and skills they need to live healthy lives. This also allows families to invest more fully in their children.

The 2012 Family Planning Summit generated a global commitment to scaling up family planning services; specifically, to reach an additional 120 million girls and women across the world’s poorest countries by 2020, through the Family Planning 2020 (FP2020) partnership. Reaching the poor and young adolescents is key to achieving this goal. It is also central to increasing the prevalence of contraception, improving health outcomes and reducing maternal and child mortality.

The UK Department for International Development (DFID) has been supporting Marie Stopes International (MSI) for the past seven years through the Preventing Maternal Deaths Programme to deliver on the FP2020 targets by extending lifesaving safe abortion and family planning services to women across 19 countries. This programme is 100% financed by official development assistance and DFID has been working with MSI to ensure the programme reaches the poorest and previously most underserved women and girls, especially since 2015.

But historically, one of the factors limiting the programme’s reach to poor clients has been how to assess their poverty status. Unlike age or marital status, wealth (and thus poverty) cannot readily be assessed with a single question. Instead, various sets of questions are needed to reveal a client’s socio-economic status, and this is commonly limited to survey-based data collection.

Better targeting through analysing clients’ poverty profiles, and raising awareness to increase service demand

Marie Stopes International classifies underserved women into different categories of “High Impact Clients”: adolescents, women living in extreme poverty, adopters, and those without access to any other family planning service. In recent years, Marie Stopes International has improved its targeting by using the Poverty Probability Index tool1 to analyse the poverty profiles of its clients. Exit interviews are conducted once a year on a representative sample of clients and facilities and provide a snapshot of client profiles across different groups and countries. In 2016 these showed that clients living in extreme poverty (<USD 1.25/day) represented less than the national poverty head count and in some cases the percentage of poor clients was decreasing. In 2017, people living in extreme poverty represented 41% of clients (Figure 42.1).

Figure 42.1. Categories of high-impact clients - 2017 client exit interviews

Note: Adolescents - age 15-19; Living in extreme poverty < USD1.25/day ppp; Adopters - those who are new to accessing family planning services; No other option - those who would not otherwise have been able to access services if MSI had not provided them.

Source: Authors.

In order to reach more poor clients, Marie Stopes International has reconfigured its mobile outreach services, introduced geospatial mapping of its intervention sites against poverty data, and provided vouchers and free services to reduce cost barriers for poor clients, especially extremely poor women who lack control over family finances.

However, exit interviews provide only a limited snapshot of client profiles. To make operations more responsive to emerging trends and demands, a new approach was piloted that uses 1–2 question subsets in its routine collection of client data. This allows the programme to track its reach to poor clients month on month.

In 2016, Marie Stopes International introduced a geo-tracker system for more efficient management of its fleet of vehicles and outreach teams. This system has also proven useful in mapping service delivery and combining with geospatial poverty data to identify and close gaps in service delivery to the poorest. Making use of the fleet system for multiple purposes increases value for money, and contributes to reaching the highest possible proportion of poor women.

Complementing this work, teams have worked to increase service demand by:

  • Employing teams of male and female community-based mobilisers and engaging more MS ladies2 where appropriate.

  • Mobilising women working in the informal sector (in markets, street vendors etc.).

  • Working in collaboration with, and to complement, public sector health facilities.

  • Raising awareness in schools to ensure young adolescent women are making informed choices about their own fertility and family planning.

  • Engaging men and boys as community leaders and community-based mobilisers, and targeting them for discussion on the advantages of safe family planning.

Understanding poor clients’ needs and adapting modalities accordingly are key to success

The model piloted through the Preventing Maternal Deaths Programme has proved the following:

  • The model is very effective in increasing understanding of poor clients’ needs, and preferences and barriers in accessing family planning services. It has greatly expanded the reach to poor clients across all pilot countries covered by the Preventing Maternal Deaths Programme.

  • Family planning service providers can scientifically measure the poverty profile of their clients and document their contribution towards FP2020 goals.

  • Programmes must be designed to actively focus on service delivery to the poor.

  • Organisations must operate at scale in rural areas and need to focus on those with low levels of literacy.

  • Mobile outreach clinics reach poor clients more effectively than do static and social franchise clinics.

  • To reach those living on less than USD 1.90 per day, it is important to link service delivery to existing healthcare contacts.

What next?

DFID’s new flagship family planning programme, Women’s Integrated Sexual Health, will work across 24 African and three Asian countries to ensure women are able to safely plan their pregnancies and improve their sexual and reproductive health. In order to leave no one behind, this programme has introduced payment-based performance indicators which require service providers to at least equal the national proportion of extreme poor for their client base in each country, and to ensure at least 15% of clients are under the age of 20. The programme also supports disability inclusion and focused work with men and boys.


← 1. Previously referred to as the Progress out of Poverty https://www.povertyindex.org/about-ppi.

← 2. Community outreach women and men who serve women door to door often in remote or underserved communities, including the urban poor.

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