Choice: A Conversation with Dr. Fabio Castaño (Part One)
Choice: A Conversation with Dr. Fabio Castaño (Part One)
MSH spoke with Fabio Castaño, MD, MPH, global technical lead of family planning and reproductive health about MSH’s approach to family planning and what will define the future of family planning and global health. Below is part one of the conversation.
What is MSH’s approach to family planning and reproductive health?
First of all, I have to tell you that MSH has been working on family planning [FP] for over 40 years. Our first-ever international program was working with Korea! We supported their successful story of making FP an essential part of public health activities. At that time, we worked on FP from a standpoint of population control. Then, to help improve the health situation, and also contributing to reducing poverty. So, that is an interesting piece of history for MSH.
Since then our programs have evolved a lot. From 1994, with the International Conference on Population & Development [ICPD], we have entered a completely different dynamic of FP programs based more on ensuring women's rights and couple's rights to decide about their lives and the size of their families.
Now the basic, fundamental principle for FP is choice. People have the right to choose when to have a family—when is the best time and how many children they want to have.
Choice is crucial; it tells the story about how to make sure we are moving in the right direction.
How does MSH’s health system strengthening expertise support this approach to FP?
At MSH, we don't see FP programs as isolated from the health system: we approach FP as part of the whole. We come with all the resources we have—particularly leadership & management, pharmaceutical management, service delivery, capacity building—to tackle the specific problems in family planning: access, choice, service quality. Other organizations may also work from the health system perspective, but may not have the tradition and the kind of reach that we have with the projects that are big in scope, integrated, that show impact at different levels—at the national level, the district level, the community level, the household level—and, that also cross over into different health areas.
We have helped governments in many countries build and rebuild their entire health systems, including, but not only family planning programs. We bring everything together to support access to FP, and uptake of FP—especially where it is most needed.
It’s in a phrase “all together.”
How does MSH, as you say, “approach family planning as part of the whole” to support access and uptake where it is needed most?
There are many ways we do this. We bring people, services, and systems—everyone—together at multiple levels. At the policy level, we improve leadership, management, and governance--the conditions at the decision-making level—making sure that policies are conducive to FP and that governments take action on assuming the role of funding commodities and services--for instance, contraceptives.
Through our CPM [Center for Pharmaceutical Management], we have developed an integrated approach to managing medicines and commodities, with FP being a part of that.
Training and supporting human resources is also key. Over the years, MSH has combined our technical strengths with partners who have clinical expertise, making sure we build capacity at all levels: policy makers, administrators, clinicians, and community health workers [CHWs].
CHWs, for example, have been crucial for community-based distribution of FP methods. We have demonstrated expertise supporting CHWs, and through them, reaching the farthest communities with FP methods—even helping to introduce new methods and technologies, like injectables. Injectables became a game changer, as they are safe and effective and provide tremendous advantages in terms of privacy and convenience.
How does MSH support communicating FP information and delivering services?
In terms of health information, what we do best is understanding—through the use of data—where the FP needs are. We have supported countries building their information systems to manage family planning programs. Right now, for example, in Bangladesh, our SIAPS program [Systems for Improved Access to Pharmaceuticals and Services] has helped the ministry of health design and run a very interesting and sophisticated software tool to identify and quantify the needs of the different contraceptives almost daily in all the facilities in the country. So the minister of health now, can, for certain, know what are the needs and any stock outs. So they can know quickly, and make sure in a matter of hours, the health post can have the commodities people are looking for.
But that's just one aspect of managing information or data.
The other aspect, of course is how to communicate with clients and beneficiaries about FP, and how to help eliminate barriers to FP methods by providing the right information at the right time. And helping somehow demystify contraceptives. We do that in countries and through many projects—STRIDES for Family Health in Uganda is an example of how we engage with partners who work on social and behavioral change communication to use messages—most of the time in the local languages—that reach women, including women that are illiterate, in ways that they understand through mass media communication, for instance local radio, sometimes TV—but, not only that kind of communication, but also very dedicated, interpersonal–through counseling, using education, and entertaining; through involving different groups in the community to engage clients or users who have good experience with FP, as kind of positive deviants, or champions, in FP.
In the future of communications of FP, we need to expand and scale-up the use of technologies, like mHealth, that look to be promising practices.
We, the FP community, are building the evidence. MSH’s ASH project [African Strategies for Health] has done very interesting work during the past three years supporting USAID [US Agency for International Development] in putting together three compendiums of mHealth programs, a good number of them on FP implemented in many different countries across the planet. We know what works, and how, and which of those applications are promising. And we will see more people using smart devices to get the FP information right in hand.
We also work, of course, on delivery of health services, another key aspect of HSS [health systems strengthening].
One of the areas that has become increasingly important is integrating health services: FP integration with maternal and child health, with HIV, with malaria, TB, and nutrition and other non-health areas. Our programs are known for improving and strengthening health systems, with a focus on integration.
You described MSH’s whole health systems “all together” approach. What is the role of the private sector in this approach?
We have worked to help countries understand how to be more involved with the private sector to help people access FP. Besides supporting public services, we engage with private providers—such as accredited drug shop owners and dispensers—who have the ability to reach out to women and couples in very far, rural areas. We engage and promote public-private partnerships at the local level bringing tools and resources to help districts plan and support FP or integrated programs close to communities coordinating efforts among public and private facilities and accredited drug shops.
Are the accredited drug shops providing FP commodities?
Yes, of course—commodities, counseling, and, referrals. In Uganda, for instance, besides helping some 600 public and private facilities, we have expanded our drug seller initiative to involve more than 1,500 small medicine vendors. Right now most of these vendors—in Uganda, called Accredited Drug Sellers or ADS—have the capacity to provide counseling to clients on FP and provide FP methods, like oral contraceptives and condoms.
Our push is to get them to also distribute emergency contraception and female condoms and refer clients to facilities where they can get implants—the three methods considered life-saving commodities. Of course, with the case of implants, it has to be closely coordinated with public and private facilities through referral networks and getting conducive policies and regulations.
But the potential is incredible, because the small shops, as well as community health workers, can really get to the so-called “last mile”—where contraceptives are needed most.
When you say the potential is incredible, do you mean the potential for public/private partnerships to improve access to FP?
You know, the FP 2020 initiative, a partnership among major donors and countries, is the most important public/private partnership in FP nowadays and its potential is huge. It has a very concrete goal: expand family planning services to 120 million more women by 2020! The ICPD gave us a political agenda—and FP2020 [gave us] a quantifiable goal to move forward.
How to help countries reach this goal is a matter of understanding both the traditional ways, and exploring new, promising, and innovative ways—maybe ways that we haven’t paid attention to, but are already there.
One is this idea of the Accredited Drug Shops, involving “private local solutions”. Another one is to use a total market approach that ensures that everybody—the entire market of clients—is served.
The concept is to bring everyone together to serve the needs of all women and men, wherever they are. So, if there’s poor women in underserved communities, for instance: What kind of programs do we need to make sure they can access services and contraceptives? That contraceptives are available at reasonable prices, or subsidized prices, or—in the case of very poor communities—through government free services? That FP options are available through the private sector, through social marketing groups, through social insurance, or through other means? It’s bringing everyone together to serve everybody.
Another key area and discussion that would shape the provision of family planning services and contraceptives moving forward in the post-2015 development agenda is related to universal access to health and people’s right to health. MSH has been very active in this area.
We believe that to achieve the FP2020 goal of access to 120 million more women, we need to make sure that all stakeholders understand and promote the right to health point of view: Everybody has the right to access these services, have the commodities they need, and have the right to choose when and how from a variety of options. Systems need to be strengthened to support this.