IWG Meeting the Challenge- Gauging Awareness, Assessing Concern: Focus Group Findings on Reactions to Contraceptive Supply Shortages
Publication date: 2001
CHALLENGE M E E T I N G T H E Gauging Awareness, Assessing Concern: Focus Group Findings on Reactions to Contraceptive Supply Shortages T HE INTERIM WORKING GROUP ON REPRODUCTIVE HEALTH COMMODITY SECURITY (IWG) is a collaborative effort of John Snow, Inc. (JSI), Population Action International (PAI), the Program for Appropriate Technology in Health (PATH) and Wallace Global Fund. The IWG was formed in response to a meeting of the Working Group of the Global Initiative on Reproductive Health Commodity Management of UNFPA in January of 2000. At the meeting, UNFPA called for the participation of a wide variety of stake- holders to address the looming crisis represented by the shortfall in contraceptives around the world. The IWG’s objective is to further the goals of the 1994 Programme of Action by raising awareness about the importance of securing reproductive health supplies. The IWG seeks to identify the causes of failures and weaknesses in com- modity systems and to spur actions that will contribute to securing essential supplies for the delivery of repro- ductive health care. The IWG understands the importance of addressing the full range of reproductive health commodities. The group is focusing on contraceptives first, however, due to the widespread lack of consensus within the popula- tion and reproductive health field regarding which com- modities to include in an essential list of supplies. Moreover, there is little information on donor contribu- tions for non-contraceptive reproductive health com- modities. Through its efforts on contraceptive security, the IWG is working to bring together stakeholders to develop strategies for addressing the broader issues of reproductive health commodity supplies in the future. ACKNOWLEDGMENTS Population Action International thanks Lake Snell Perry & Associates, Inc. for conducting the focus groups sum- marized in this paper. The following individuals provid- ed invaluable assistance in the recruitment of study par- ticipants and review of the study results: Kathy Bonk, Communications Consortium Media Center; Yvette Collymore, Population Reference Bureau; Marianne Haslegrave, Commonwealth Medical Association; Susan Rich, Wallace Global Fund; Patricia M. Sears, The Centre for Development and Population Activities; and staff of UNFPA. PAI sincerely thanks the attendees of the Beijing +5: Women 2000 conference who took the time to participate in the focus groups. This material may be reproduced provided the source is acknowledged. ISBN: 1-889735-16-7 April 2001 � 1 � Gauging Awareness, Assessing Concern: Focus Group Findings on Reactions to Contraceptive Supply Shortages The focus groups revealed that almost none of the participants were aware of the impending shortage of contraceptive supplies. However, few participants were surprised to learn that the strong potential for such a shortage exists. In general, the reaction to this looming crisis was one of subdued resignation. Participants seemed to view contraceptive insecurity as just another challenge in the struggle to improve the lives of women in the developing world. The focus groups provided a number of insights into how to meet this challenge: • The first step is to raise awareness of the problem. Participants stressed that if they were unaware of a pending crisis, others are also likely to be uninformed. • Using different terminology when discussing the issue is vital to raising awareness. The phrase “commodity security” was unfamiliar, awkward, and even confus- ing to participants. The phrase “shortage of contra- ceptive supplies” is preferable. • The issue evokes passion only if it is presented in con- text; it did not motivate participants when defined as an isolated problem. Focus group results elucidate the importance of presenting the imminent contraceptive supply shortage within a broader framework of repro- ductive health, and of stressing the likely results of a shortage. • Participants emphasized the need for innovative strategies to face this challenge. They discussed the importance of motivating donors in new ways that counteract “compassion fatigue.” They also stressed the importance—and shared examples of—creative, sustainable programs to meet the demand for contra- ceptive supplies without external aid. On June 8, 2000, Population Action International (PAI) held four focus groups with 25attendees of the United Nations Special Session known as Beijing+5: Women 2000.1 PAIconducted these groups with two goals in mind: to gauge awareness of and concern about the impending shortage of donated and subsidized contraceptive supplies, and to explore ideas for addressing this shortage. The results are now being used to inform the efforts of the Interim Working Group on Reproductive Health Commodity Security (IWG) to increase contra- ceptive security around the world. This research will also inform efforts to choose appropriate terminology and shape advocacy strategies related to this process. � 2 � REACTIONS TO THE IMPENDING CONTRACEPTIVE SUPPLY SHORTAGE At Beijing+5: Women 2000, a United Nations General Assembly Special Session held in June 2000 in New York City, delegates gathered to discuss the efforts made by countries worldwide to meet the needs of women. Under discussion were actions taken and progress made since the Fourth World Conference on Women, held in Beijing, China, in 1995. Parallel to the UN Special Session, Population Action International (PAI) conduct- ed four focus groups on reproductive health and contra- ceptive commodities. The 25 participants included both members of national delegations and non-governmental organizations (NGOs) from a variety of donor and developing countries.2 Focus group participants discussed issues surrounding women’s reproductive health and health care in general, and reproductive health commodities specifically. The focus groups were designed to gather information on participants’ awareness of and concern about the impending shortage of donated and subsidized contra- ceptive supplies and to solicit their ideas for addressing this problem. The first section of this report describes the focus group methodology and participants’ reactions to evi- dence of the impending contraceptive shortage. The sec- ond section summarizes participants’ suggestions on how to raise awareness of the problem and develop solutions. The third section presents information on general attitudes about women’s reproductive health and how this issue fits into broader political and social contexts in the developing and developed world. RESPONSES TO IMPENDING CONTRACEPTIVE SUPPLY SHORTAGE Limited Awareness Participants in each focus group were shown the graph below, which illustrates the imminent shortage of donat- ed and subsidized contraceptive supplies.3 Reactions were the same in all four groups. It is worth noting that the graph used with the groups was not self-explanatory and required further discussion. Once they were shown the graph, many participants had questions. Some want- ed to know about factors that contribute to the increased demand for contraceptives or receive clarifica- tion on why donation levels are declining. Others were curious about the role of non-donated supplies. In short, while the graph was a vital tool for explaining this issue, it alone was not sufficient. Very few participants from either donor or recipient countries were aware of the impending contraceptive supply shortage. Moreover, participants believe others in their countries also remain unaware. Evidently, the looming shortage is not yet on the radar screen of many of the NGOs and activists that focus on women’s issues. < PART I > Evidently, the looming shortage is not yet on the radar screen of many of the NGOs and activists that focus on women’s issues. � 3 � Little Surprise, Distress, or Passion Although most participants had not heard of a contra- ceptive supply shortage, few were surprised to learn of it. They were concerned about the shortage but seemed to take it in stride. Neither donors nor recipients exhib- ited strong emotion about this issue, but rather an atti- tude of resignation. In developing countries, contracep- tive shortages are just one of many challenges faced by women and NGOs. According to the responses of several donor country participants, supplying contraceptive commodities is simply not “fashionable.” As one donor participant explained, her colleagues would rather be “developing programs and position papers and actions statements” than simply supplying a commodity. Other donors explained that even those committed to reproductive health issues might not support simply supplying com- modities, preferring instead to invest in more intricate programs. Even in those circles where reproductive health issues are important, there is a feeling that simply supplying contraceptives is not worthwhile, and that other strategies may be more beneficial and politically popular. Finally, some donors emphasized that certain government leaders fear getting into a situation in which they are obligated to endlessly supply contracep- tives to a growing and more demanding population. The relative lack of concern expressed might stem in part from participants’ perceptions that current supply shortages, where they do exist, are intermittent and not very serious. Moreover, participants explained that since health services delivery systems in developing countries are inefficient across the board, it is not surprising or alarming that problems exist with regard to the supply and distribution of contraceptives. 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2005 2010 2015 Actual Level of Donor SupportTrend Line for Donor Support Projected Need for Subsidized Contraceptives < FOCUS GROUP HANDOUT > GAP BETWEEN SUPPORT AND NEED � 4 � RECOMMENDATIONS FOR ACTION The focus group findings suggest nine important steps needed to trigger sustained action on the impending shortage of donated/subsidized contraceptive supplies. Participants themselves directly recommended some of these; others were gleaned from focus group discussions of the issue. 1. Raise Awareness The first step is to raise awareness of the impending supply shortage. Participants from both donor and developing countries stressed that if they were unaware of a looming shortfall, others in their countries are most certainly uninformed. Many participants requested that they be given copies of the graph to show to others in their countries. They also requested to have a more detailed discussion on the imminent shortage so that they could better explain it to others. 2. Change the Terminology A significant obstacle to raising awareness about the impending shortage of contraceptives is the terminology currently used when discussing the issue. Many partici- pants were unfamiliar with the phrase “commodity security” and a few were confused by it. Some said that when they hear the word “security,” they think of defense issues, not supplies of such things as contracep- tives. In addition, participants seemed more comfortable with the word “supplies” than “commodities.” Focus group results suggest the need to use a phrase such as “impending shortage of contraceptive supplies.” < PART II > 3. Define the Issue Broadly Participants made clear that they prefer to define repro- ductive health and reproductive health care broadly and inclusively. They object to definitions that focus solely, or even primarily, on preventing unintended pregnan- cies. They emphasized that the prevention and treatment of STDs, as well as other concerns, such as infertility, breast health, and safe motherhood, should not be over- looked. Some participants also objected to limiting the scope of the problem to women and stressed the impor- tance of recognizing men’s roles in both causing and solving problems. Finally, participants underscored that reproductive health cuts across many core issues that affect conditions in their countries such as economic progress, development, and national security. 4. Highlight Ramifications Participants suggested that understanding of the impli- cations of a shortage might motivate people to take action. Educational efforts should therefore emphasize negative ramifications, such as increased rates of unin- tended pregnancies and births, the more rapid spread of HIV/AIDS and other STDs, declining maternal health, and the unraveling of critical family planning policies and programs. “Bring in the element of how family planning impacts on quality of life for these women. We should look at the women and how we are going to reduce maternal mortality. This is a very important thing to be done if we care for these women.” — African Participant � 5 � 5. Target the Message Participants expressed the opinion that those actors who seek to put the shortage of contraceptive supplies on the agenda of women’s organizations, activists, and govern- ments should develop distinct messages for each target- ed audience. Human rights groups are motivated by human rights arguments, such as a women’s right to choose whether and when to have children. Government and business may be best reached by stressing the eco- nomic consequences of not dealing with the imminent shortage of donated/subsidized contraceptives. Some participants felt that it is vital to address repro- ductive health issues in general, and the supply of con- traceptives in particular, in a “roundabout” way in order to avoid controversy. In other words, ready access to contraceptives should be presented as a way to attain other social or economic goals or solve widespread problems such as child spacing, disease control, and maternal and child health. 6. Engage Donors Creatively Participants from both donor and developing countries suggested that sympathy-based approaches are not as effective as they once were because of “compassion fatigue” and a growing feeling that the problems in the developing world are insurmountable. New, creative strategies are therefore needed to motivate both govern- ments and donors to increase their efforts to mitigate contraceptive supply shortages. Participants stressed the importance of appealing to donors’ self-interest. Specifically, some suggested that the need for financial aid should be re-phrased and pre- sented to potential donors as an “opportunity for investment.” Participants also felt that it is important for donors to see how their actions—or lack thereof—in the developing world can affect other countries, includ- ing their own. Some participants therefore advocated a re-framing of the issue in a distinctly “global” context. Still others suggested that donor funds should be chan- neled into research on methods of birth control designed to be more effective and efficient in the devel- oping world. Whatever approach is taken, participants agreed that it is vital for donors and grantees to work together. They were fully aware that this is easier said than done. Participants from developing countries complained that donors frequently offer aid with “strings attached” and are more concerned about furthering certain ideologies or achieving particular outcomes than actually helping individuals in the recipient country. Participants also said donors must learn to not force solutions on recipi- ents, but to instead work with them to develop effective, culturally relevant programs. For their part, representa- tives of donor countries emphasized that recipients must be held accountable for the success of their programs and be open to adopting alternative approaches. 7. Work Together, Forge Alliances, Share Information Participants underscored the many ways that NGOs can play an important role in meeting the challenges posed by contraceptive supply shortages. For example, they can publicize the issue, facilitate partnerships between NGOs and government representatives, and serve as a connection between donor organizations and recipients. Participants also put forward the possibility of develop- ing regional solutions, such as the establishment of pur- chasing cooperatives and other joint endeavors. Some participants were more optimistic about the possibilities of collaboration than others. Several felt that NGOs will have to take the lead in fostering col- laboration because the majority of governments in the developing world are simply not ready, willing, or able to address the issue of contraceptive supply. “Ask them to invest. They must look at it as an investment, rather than just feeling sorry for women and maternal mortality and things like that. They do look at it as a problem but they don’t really care. It should be presented as a positive thing like it is going to be a gain.” — Eastern European Participant � 6 � 8. Self-Sufficiency and Sustainability No matter what strategies are pursued to engage donor countries in meeting the contraceptive supply challenge, most participants from developing countries said they feel they must ultimately turn inward to find long-term solutions. In fact, some felt this is the only viable option because donor assistance will inevitably cease. Others stressed that they would prefer to meet their own needs, even if donors are still willing to help. Most participants agreed that collaboration among NGOs, the private sector, and the governments of developing countries is essential to successfully tackle the contra- ceptive supply problem without outside aid. Another factor driving the desire for an inward-look- ing strategy is that recipient countries seek long-term sustainability. In short, most participants agreed that it is essential to develop independent, sustainable systems. Some participants noted that self-sufficiency and sus- tainability are desirable goals not just for countries, but also for individuals. Ideally, as women become more educated and empowered, they will be able to afford contraceptives themselves and will not need ongoing assistance. Some participants noted that although complete self- sufficiency and sustainability are worthy goals, they may not be realistic ones. They emphasized that some women and couples will never be able to afford the con- traceptives they need and will always depend on assis- tance. Likewise, some argued that sustainability is a worthy goal for programs to adopt, but that some will inevitably have clientele who need contraceptives. Some entity must therefore always exist to fill supply and service gaps. It is therefore important to engage donors in efforts to supply contraceptives to those who need them, at least for the foreseeable future. A further concern expressed by some participants (pri- marily donors from countries with socialized medical systems) was the potential for uneasiness with what was termed the “American model” of paying for medical care. In many developing countries, as well as in many donor countries, the notion of being forced to pay for health care (as is done by the vast majority of the U.S. population) is strange. Thus, reproductive health pro- grams that charge even modest fees for services or com- modities may in fact discourage potential customers. 9. Innovative Solutions Many developing countries already employ innovative strategies as they work to achieve sustainability and independence in their reproductive health programs. The following examples illustrate this trend. • An Asian participant spoke of an innovative program in her country through which a group of NGOs mar- kets their own brand of condoms. The brand and dis- tribution of these condoms are strategically linked to the NGO’s overall public education and outreach campaign. • Another Asian participant explained that her country has the ability to produce condoms themselves and is working to develop that industry. • Some participants mentioned groundbreaking pro- grams in their countries in which volunteers are given condoms to sell and then allowed to keep a portion of profits from sales. The programs thereby provide an incentive to market condoms. • Some participants mentioned the need to form coop- eratives that could buy contraceptive commodities in bulk. This would allow members to both meet their own needs and negotiate lower prices. • In the name of individual self-sufficiency, some partic- ipants advocated charging a nominal fee for contra- ceptives to individuals who can afford it. According to proponents, the advantage of this approach is that women become accustomed to paying for supplies and are thereby better prepared for the day when sup- plies may no longer be subsidized. In addition, some participants said that women feel that products must be better if they have to pay something for them, and are therefore more appreciative of the contraceptives and more likely to use them. This perspective con- trasts directly with others’ concern that charging fees for services or commodities (no matter how small) could inadvertently discourage potential customers. Although complete self-sufficiency and sustainability are worthy goals, some women and couples will never be able to afford the contraceptives they need and will always depend on assistance. � 7 � GENERAL ATTITUDES TOWARD WOMEN’S REPRODUCTIVE HEALTH Participants believe that women’s reproductive health and health care are critical global issues that are as important as any of the “Twelve Areas of Concern” identified in the Beijing platform.4 They emphasized that issues of reproductive health are inextricably linked with the other 11 issue areas and that none of these problems can be seen, or solved, in a vacuum. Participants felt strongly that reproductive health is vital to the empowerment and advancement of women and girls in the developing world. Despite overwhelming agreement about the importance of reproductive health, participants know their views are not widely shared. In developing countries, reproductive health issues are still largely the bailiwick of NGOs. Governments and other influential groups have not put women’s reproductive health care high on their policy and budgetary agendas, and the human rights communi- ty does not usually view reproductive health as a human rights issue. Indeed, participants from developing coun- tries reported that women themselves do not always consider reproductive health to be a core issue in their daily lives. Even participants from donor countries, where the issue is more widely viewed as critical, said that many officials and individuals do not consider the reproductive health of women in the developing world to be a priority. < PART III > Participants reported that access to reproductive health care in the developing world is inadequate, especially for socioeconomically disadvantaged and rural groups. Women in developing countries face multiple barriers to accessing reproductive health care in general and con- traceptives in particular, including the following: • Structural Barriers—e.g., inefficient distribution, limited contraceptive choices, and inadequate service delivery. • Economic Barriers—poverty on both an individual and societal level. • Cultural Barriers—such as rigid gender roles, societal norms of women’s behavior, and the acceptance or rejection of family planning. • Educational Barriers—including a lack of education and information about the benefits of family planning and various family planning methods. • Political Barriers—for example, the perception that improving reproductive health services and contracep- tive supplies with external assistance could threaten national autonomy and security. Reproductive health is connected to many basic, con- tentious societal issues, including the role of women, fam- ily structure, and human sexuality. Debating women’s reproductive health problems therefore engenders a great deal of controversy. Reproductive health and health care are still taking shape as issues. Indeed, in many countries, the term “reproductive health” is imprecisely defined, and in a few countries the term does not even exist. In develop- ing countries in particular, reproductive health implies a loosely delineated, variable set of issues even among women activists. Even in more developed nations the concept is still evolving. “We developed a list of 13 barriers [to getting reproductive health care] last year and we revised it and came up with more. We have a growing list of barriers.” — Eastern European Participant PAI and its partners are now better informed about the level of awareness and concern among NGOs and gov- ernment representatives with regard to the impending shortage of donated and subsidized contraceptive sup- plies. These new perspectives will help us move forward with the development of new, effective, country-specific strategies. A great deal of effort will be required to overcome the lack of awareness and passion expressed in the focus groups with regard to the issue. NGOs, donors, and advocates in developing and developed countries all have important roles to play in addressing the contraceptive supply crisis. The primary goal of new strategies should be to talk widely about the impending shortage and its potential consequences in language that is familiar and comfortable to target audiences. The second step is to explore and implement innovative strategies to engage NGOs, donors, and gov- ernments in advancing contraceptive supply sustainabili- ty and self-sufficiency throughout the developing world. As a result of the focus groups, we are now convinced that issues surrounding contraceptive supply cannot effectively be approached in a vacuum, but must be placed in a broad context of reproductive health and health care issues. In ongoing efforts, all parties involved in reproductive health commodity security must be sensitive to the controversy surrounding repro- ductive health and sexuality and the needs of the partic- ular populations it seeks to assist. NOTES 1 This UN session concluded the five-year review of progress made since the Fourth World Conference on Women. 2 The donor countries represented were Canada, Japan, Sweden, the United Kingdom, and Italy. The developing country participants were from Colombia, Gabon, India, Indonesia, Kenya, Malaysia, Mexico, Nepal, Nigeria, Peru, Romania, Russia, Uganda, Zambia, and Zimbabwe. 3 Please note that the graph used in the groups was merely illustra- tive. There were no values on the Y-axis and the X-axis was not scaled accurately. These simplifications did not affect comprehen- sion of the graph. 4 The “Areas of Concern” identified in the Beijing Platform for Action can be summarized as the inequitable burdens placed on and discrimination against women with regard to poverty; education and training; health; violence; armed conflict; the economy; power and decision-making; institutional mechanisms; human rights; media; environment; and the rights of the girl child. < CONCLUSION >Amorphous definitions of “reproductive health” and “reproductive health care” are further complicated by widely differing attitudes about health and health care. For example, in many countries preventive health care is an unfamiliar concept; one sees a doctor only when ill enough to be bedridden. Thus, visits to a doctor for routine, regular reproductive health care that is preven- tive in nature goes against the health care practices to which people are accustomed. HIV/AIDS is a fundamental, unavoidable issue that must be integrated into any discussion of reproductive health. Participants agreed that the HIV/AIDS epidemic has changed how countries confront and address issues related to public health and sexuality. On the one hand, it has raised awareness and spurred debate and action on topics once considered taboo. On the other hand, it tends to limit the public and policy-related focus to preventing the transmission of HIV/AIDS (and, to a lesser extent, other STDs), subsequently relegating other aspects of reproductive health (including the prevention of unin- tended pregnancy) to low positions on the list of priori- ties. In addition, the need to address HIV/AIDS con- tributes to the emphasis in some reproductive health pro- grams on the use of condoms alone, rather than on the simultaneous use of other forms of birth control as well. � 8 � Issues surrounding contraceptive supply cannot effectively be approached in a vacuum, but must be placed in a broad context of reproductive health and health care issues. M E E T I N G T H E CHALLENGE Securing Contraceptive Supplies T he Interim Working Group on Reproductive Health Commodity Security (IWG) is a collaborative effort of John Snow, Inc. (JSI), Population Action International (PAI), the Program for Appropriate Technology in Health (PATH) and Wallace Global Fund. Recognizing the important leadership role of the UN Population Fund (UNFPA) in meeting the goals of the 1994 Programme of Action, the IWG’s objective is to further these goals by raising awareness about the importance of securing reproductive health supplies. The IWG seeks to identify the causes of failures and weaknesses in commodity systems and to spur actions that will contribute to securing essential supplies for the delivery of reproductive health care. S E C U R I N G S U P P L I E S F O R R E P R O D U C T I V E H E A L T H Printed on Recycled Paper
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