Improving the evidence for integrated family planning and economic growth programming : a synthesis of the evidence

Integrated family planning and economic growth Background: programming has the potential to be more equitable and cost-effective, to garner high levels of support from communities, and to support countries on their journey to self-reliance. The available evidence is limited, but demonstrates that such integrated programming can catalyze improved outcomes in both sectors. We reviewed available program evidence to explore what information is available to implementers regarding potential best practices. Economic growth is a broad sector; we focused specifically on Methods: the need for evidence related to integration of family planning with microfinance and livelihood programs. We conducted an extensive literature search and reviewed both published and gray literature according to two criteria: whether the papers explicitly focused on FP/EG integration and whether they included program descriptions, including discussions of what specific interventions were implemented. We find that only limited information exists regarding how best to Results: design and implement such programs for FP/RH and economic growth. We provide ideas drawn from the identified program evidence about potential best practices for FP/RH and economic growth integrated programs, and find an increasing need for tools and resources on related best practices. Both family planning and economic growth programs should Conclusions: consider strengthening linkages between the two sectors, to accelerate the achievement of global family planning goals as well as to improve economic growth outcomes. We call for additional research and improved documentation to clarify the apparent contributions and effectiveness of FP/EG integration, as well as to confirm promising practices. The integration of family planning and economic growth sectors is particularly important as the global community works toward achieving broader global and country-level development goals.


Introduction
Why integrate family planning and economic growth programming? With the advent of the Sustainable Development Goals (SDGs) and an increased focus on self-reliance, there is renewed attention to the potential, and indeed the need, for effective integrated programming across sectors to help countries reach their development goals. Specifically, there is increased interest in integrated family planning and economic growth programming, and a felt need for research and evaluation in this area. However, to date, governments and donors have not significantly invested in such programs. In this Open Letter, we argue that the family planning and economic growth communities should increase resources for developing and strengthening capacity for and commitment to the integration of FP/EG programming, for the benefit of both sectors and to improve sustainable development outcomes overall. We also identify some potential best practices or key components of FP/EG-specific integrated programs, focusing specifically on microfinance, microenterprise groups, savings groups, and vocational or livelihood programs. Further research and practice is necessary to validate these key components and identify additional implementation considerations.
Integrated development has been defined as "an intentional approach that links the design, delivery and evaluation of programs across disciplines and sectors to produce an amplified, lasting impact on people's lives" i . Here, integration means either the intentional linkages between family planning programs and the types of economic growth programs described above, or the implementation of joint programs aiming to influence both family planning and economic growth outcomes.
Why should the economic growth community integrate family planning programming? Family planning is a key determinant across multiple development sectors and can hasten the achievement of development goals ranging from peace and democracy to food security and climate change to economic growth ii . Family planning is critical for the achievement of the goals of economic growth programs, including closing the economic gender gap and improving inclusive development iii , for reasons which include: • Many reports have established that women's economic empowerment is key to growth and prosperity, and have identified contraceptive access as critical to ensuring women can contribute productively to the economy iv,v . Contraceptive access and use can increase women's decision-making power in the household vi , as well as attainment of education and participation in the labor force: increasing maternal age at first birth and reducing childbearing during adolescence "increases the likelihood of school completion and participation in the formal labor market. Longer birth intervals [also] increase labor market participation, as does having fewer children" vii . These impacts are seen in countries across the world. According to one study, achieving gender parity in economic participation could add $12 trillion (26%) to the global economy by 2025 viii .
• Family planning and reproductive health issues -including lack of access to reproductive care, limited or no access to affordable contraceptives, early marriage, lack of timing and spacing of births, and lack of or stigma related to male engagement in family planning -serve as barriers to achieving economic program goals. A review of programs and activities supporting women's economic empowerment and economic equality identified key themes for these programs include women's increased access to, control over, and ownership of resources; women's increased agency, voice, and choice; and improved well-being and dignity ix . High-quality family planning programming can serve as a catalyst for all of these themes ii .
• Family planning, by reducing fertility and changing demographic structures, can reduce future unemployment and underemployment, and create large working age populations with fewer dependents, propelling economic growth and supporting achievement of the demographic dividend x . Inclusive family planning programs can also help reduce economic inequities and ensure economic opportunities can be accessed by all. As described in a recent report on family planning, economic growth, and equity, the influence of family planning on the labor market through improved health and education and changing population structures is now well-documented x .
Why should the family planning community integrate economic growth programming? In 2012, Family Planning 2020 (FP2020) called international attention to the importance of family planning for health and development, and highlighted unmet need for family planning globally. Unmet need is defined as the percentage of women who do not want to become pregnant but are not using contraception. FP2020 aims to enable 120 million more women to use modern contraceptive methods by 2020; xi however, global goals will not be met based on current trajectories xii . A review of 52 countries found that, depending on the country, between 8 and 38 percent of married women between the ages of 15-49 continue to have an unmet need for contraception xiii . "Never-users" of family planning and discontinued past users contribute significantly to the continuing high unmet need and to unintended pregnancies: recent analyses show that never-users make up about 62% of global unmet need xiv and 65% of unintended pregnancies, and past users who discontinued use of contraception contribute approximately 33% of unintended births xv . These "non-users" often do not receive family planning information and services by existing health systems. An analysis of Demographic and Health Survey data across eight countries showed that large majorities of non-users of family planning had not discussed family planning with either a fieldworker or at a health facility at the time of the survey ( Figure 1). Moreover, data show that many nonusers are not interacting with the health system at all. In Angola, for example, only 32% of women not using family planning had visited a health center at all xvi .
To accelerate achievement of country and global family planning goals, the family planning community must continue to develop innovative solutions for reaching non-users, including utilizing pathways outside of traditional health services. One such pathway is strengthened linkages between family planning and economic growth programs. For example, the microfinance sector, one area of focus in this paper, offers program platforms for reaching additional populations with integrated family planning information, counseling, and services xvii .
Mostly positive evidence has been documented regarding the bi-directional connections between health and economic growth programs xviii . Evidence specific to family planning and economic growth programming, however, is extremely limited.

Identification of papers
We reviewed papers on the integration of family planning and economic growth (FP/EG) programs, focusing specifically on microfinance, micro-enterprise groups, savings groups, and vocational or livelihood program elements. Other elements of economic growth programming such as trade reform or unlocking private capital were not included. USAID's Knowledge Services Center carried out a literature search in January-February 2017 on Medline, PubMed, Popline and Cochrane online databases. Running both limited and full search terms ( Table 1) in each of the databases yielded over 1,680 articles between 2000-2016, which we reviewed according to three criteria in sequential order. First, we reviewed whether the papers explicitly focused on health and EG integration, and found that 47 unique papers addressed integrated economic growth and health programs. We then reviewed these papers to determine whether they 1) focused on family planning explicitly and 2) included program descriptions, specific discussions of what specific interventions were implemented (details of the practice, program, or policy, per the World Health Organization's implementation research recommendations) xix . Data was synthesized in Endnote.
Only seven results from the initial 47 papers included program information, and only three of these discussed the integration of economic growth and family planning specifically. Given this limited number, we also reviewed program literature available via USAID's Development Experience Clearinghouse (DEC) and the Microenterprise Results Reporting Dashboard. This search included the portion of our initial search terms that focused on family planning, reproductive health and economics (notated in Table 1), and papers were reviewed according to the same criteria as above. We identified five additional relevant papers and program reports. In sum, we thus identified eight total papers and reports that met our criteria across the published and gray literature. We did not intend to disaggregate by source of programming (e.g., whether the programs were designed by the FP or EG sectors, or both), but we note that the majority of these papers and reports are FP projects that contain EG elements. These limited numbers emphasize our call for more research and documentation in this area.

Results
We describe results from these programs below, to help practitioners envision what this type of work might look like.

Program summaries
Rwanda. In Rwanda, the USAID-funded SPREAD's health program leveraged relationships with local governments and rural, income-generating populations to integrate FP services, information, and communication into the existing cooperative system of coffee activities. Results included increased understanding of FP's benefits; the development of new FP champions, including among men; improved couples communication related to FP; and an increase in FP use among women and couples. Agribusiness capacity was built among farmers as well xx .
Integrated sectors: Family planning, health, and economic growth/agribusiness Integration approach: Population, Health, and Environment (PHE) approach to development, with multi-sector collaboration to create synergies at the community level.
India. In India, FP information and services were provided to 800 women through the microfinance program of which they were members through the USAID-funded PROGRESS project. Family planning use dramatically increased from 40% to 69% and unmet need decreased from 42% to 12%. Additional economic growth outcomes were not reported xxi .
Integrated sectors: Family planning and microfinance.
Integration approach: Information and referrals on family planning were integrated into an existing microfinance program.
Also in India, a quasi-experimental impact evaluation was conducted of an integrated family planning and livelihood development intervention for adolescent girls, implemented through the International Youth Foundation's Samriddhi Project, which provided reproductive health information, vocational counseling and training, and savings account assistance. The evaluation found a significant increase in reproductive health knowledge in the experimental group despite little change in other components of the study xxii .
Integrated sectors: Family planning/reproductive health and livelihoods.
Integration approach: Experimental intervention that provided reproductive health information, vocational counseling and training, and savings assistance in an integrated program.
Kenya. In Kenya, in a USAID-funded integrated health and dairy cooperative intervention, 83% of women surveyed reported that they preferred receiving health services, including short-term contraceptive methods and referrals for long-term and permanent methods, at an agricultural cooperative field day rather than at health facilities. In total, 87% of women identified as having contraceptive need discussed family planning with a provider at the field day, and of the women already using a modern contraceptive method, 42 of them (25%) received additional supplies of a modern method at the field day. Respondents also noted an increase in dairy cooperative memberships xxiii .
Integrated sectors: Family planning and agriculture/livelihoods.
Integration approach: Integrated family planning provision and referrals into existing agriculture/livelihood cooperative events.

Indonesia.
In Indonesia, a government-sponsored program developed to improve the health of women workers provided reproductive health services for female workers. Medium to large companies with successful implementation showed a decrease in pregnancies and "an increase in both economic productivity and quality of work." xxiv Integrated sectors: Family planning/reproductive health and livelihoods.
Integration approach: Engaged public and private sector employers to integrate family planning/reproductive health into the workplace. Economics terms* Economic strengthening, economic empowerment, microcredit, savings, microfinance, financial incentive, cash transfer, social-grant, savings group, savings village, subsidies, voucher, community insurance, social insurance, self-help-groups, cooperative, livelihood, business-training, socio-economic-support, financial literacy, demographic-dividend, poverty reduction, income generation.

Reproductive health terms*
Reproductive health, reproductive medicine, sexual health.
Bangladesh. In Bangladesh, a family planning outreach and credit program conducted through Grameen Bank found that women living in Grameen Bank villages were 16% more likely to use contraception than women in villages without a program. This same program found that home visits had strong effects on raising contraceptive use rates by 21% among the comparison group and 30% among the nonmember credit-village group xxv .
Integrated sectors: Family planning and microcredit.
Integration approach: Combined home visits by family planning workers to women who were members of the Grameen Bank or Bangladesh Rural Advancement Committee groups, linking family planning to self-employment support.
Ethiopia. In Ethiopia, the Guraghe People's Self-Help Development Organization (GPSDO)'s program integrated livelihood and FP/RH activities, in addition to conservation activities, and compared results with a site with only an FP/RH program. Results supported both FP and EG outcomes. GPSDO found that "57.7 percent of women in the PHE program area earned income through alternative livelihoods," which help them earn more income, "compared to only 15.2 percent of women in communities which only received reproductive health interventions" and also found "a significant difference in the percentage of men who supported use of contraception in PHE sites compared to reproductive health only sites (30.2 percent vs.
Integration approach: Population, Health, and Environment (PHE) approach to development, with multi-sector collaboration across conservation, livelihood, and family planning/ reproductive health sectors at the community level.
Mali. In Mali, the USAID-funded Keneya Ciwara program sought to increase demand and use of family planning and develop community FP advocates, while utilizing women's microfinance and credit groups to help women improve both their financial security and their reproductive health outcomes. The financial groups were given initial stocks of commodities that they could sell to purchase more commodities and pay for clinic visits for additional FP services; members also used the income to start their own small businesses. The endline evaluation found that the contraceptive prevalence rate was 13.5 for women in the savings groups compared to 6.1 for women not in the groups, and community surveys showed changes in attitudes towards FP among both women and men. Microfinance group members mobilized more than $18,000 in credit in phase one of the intervention, and participation in the groups grew to 45.2% of women in the target districts, with plans to scale up across Mali xxvii .
Integrated sectors: Family planning and microfinance/microcredit.
Integration approach: Provided women in microfinance groups with family planning commodities for their own use and for business purposes; generated demand for family planning and improved financial access options for family planning as well as improved financial security overall.

What does program documentation show about the "how"?
Limited implementation research exists to identify core components of successful FP/EG integrated programming, though researchers and implementers have called for implementation science studies to address this gap xxviii . The eight programs demonstrated some similarities across these interventions. These commonalities, listed below, may become potential best practices, and would benefit from further research and validation.
Intentional integration. Rather than simply implementing vertical programs with the same populations in the same time period, the programs demonstrated intentional integration. All of these programs planned from the beginning to integrate or link their FP and economic growth programs in different ways. Some stand-alone microfinance programs (without intentional integration of family planning information, services, or linkages) have been found to increase contraceptive use and improve reproductive health outcomes ix . In Bangladesh, for example, participants of microfinance programs were 1.69 times more likely to use contraceptives and women with control over resources are 4.28 times more likely to use contraceptives xxix . However, other studies have found that simply participating in microcredit initiatives is not associated with improved family planning practices or increased contraceptive use xxx,xxxi . Stand-alone programs cannot be assumed to successfully influence other areas of programming; the possible value-add to both sectors is in intentionally integrated programming.

High-quality providers of FP information and services.
In many of the examples, provider quality is identified as a core element of the program. Programs selected trained providers from the public and private sectors to participate in the program or brought separate FP programs to provide technical assistance, capacity building, and oversight; programs also ensured appropriate counseling materials and guidelines were available and used and provided ongoing supportive supervision and refresher training.
Accurate referral networks. Accurate, feasible referral networks are critical since many of the integrated programs relied on referrals for some, or all, service provision. These referral networks usually existed prior to the beginning of the program, but were developed if missing, and integrated programs incorporated efforts to ensure referral resources were updated frequently and made available to each activity site.
Community engagement. Stakeholder buy-in and trust are critical, particularly when working with audiences not traditionally engaged in health programming. Engagement with project communities before and during the activity increased participation in and trust of the programs. Stakeholders and key community leaders should be identified in partnership with the community prior to beginning an integrated activity. This also ensures integrated activities will complement existing community structures and support priority community needs.

High-quality social and behavior change programming.
Integrated SBC programming designed to cohesively address more than one health or development issue can strengthen, unify, and promote integrated programs xxxii . Integrating SBC along the service delivery continuum can improve service outcomes xxxiii , and is especially relevant in integrated programming. Further, a behavior-centered approach can serve as a unifying feature of successful cross-sectoral programs.

Discussion and conclusion
Our review of program evidence was more challenging than we expected because thus far, family planning has not been a primary focus of integrated micro-enterprise and livelihood development programming, nor has economic growth integration been a focus of family planning programs with strong evaluative components. As noted above, the majority of the projects reviewed here are primarily FP projects that contain EG elements. Most existing evidence is limited to small-scale or pilot activities. Other existing evidence is secondary, such as interventions showing livelihood and financial benefits resulting from programs focused on health and the environment xxxiv .
The available evidence demonstrates that integrated FP/EG programming has positive FP/RH outcomes as well as benefits for economic growth outcomes, catalyzing the effects of both. However, additional research and improved documentation is needed to clarify the apparent contributions and effectiveness of FP/EG integration, and to confirm promising practices. We identified five critical components shared by successful programs; these provide a starting point for future program designs and evaluations. Confirming these potential best practices will be critical to moving the field forward and supporting future policymakers, program designers, and implementers. Funders and program managers should plan and budget for data collection before interventions begin, and support the incorporation of rigorous, high-quality monitoring, evaluation, and implementation research approaches that can be used to understand the contributions and effectiveness of FP/EG integration to improving economic and health outcomes xxvi . Rigorous context and process documentation is especially important to inform future implementation. The findings thus far, however, can serve to advocate for the value of these integrated activities.
Further research questions include: Under what conditions is FP/EG integration more efficient and/or more equitable than siloed programming? Would FP/RH and/or EG outcomes realized among participants otherwise have been missed? Do integrated programs receive more support from communities, or more funding from policymakers? What is preventing successful programs from being scaled up? Which countries have relatively extensive national or sub-national microfinance or entrepreneurial programs or networks in which FP/EG programming might be tested at a larger scale? What makes an FP/EG program sustainable? What approaches contribute to increased country capacity to implement this type of integration?
In sum, though more research is critical, we know that integrated programming has the potential to be efficient, costeffective and garner high levels of support from communities and partners. Many governments and donors are increasingly interested in multi-sectoral programming as a critical approach for improving integrated, inclusive development outcomes, and are looking for tools, resources, and guidance on best practices. The integration of family planning and economic growth sectors is particularly important as the global community works toward achieving broader global and country-level development goals.

Data availability Disclaimer
The views expressed in this article are those of the author(s

Fariyal Fatma Fikree
Evidence to Action, PATH, Washington, DC, USA This is a well-researched letter that seeks to draw attention to the linkages between economic growth and family planning when economic growth and family planning interventions are integrated. The authors have conducted a thorough literature review that, in fact, demonstrated the paucity of rigorous evaluation research and program documentation on integration of FP interventions with economic growth incentives. Notwithstanding that only eight papers and program reports met the search terms criteria, the authors have attempted to distil the key FP/EG influencers that contribute to improvement in contraceptive knowledge and/or uptake.
I have a few suggestions that, in my opinion, will substantially improve the paper.
Rationale: The rationale is well articulated and with excellent references; though limited to family planning uptake, unmet need and unintended pregnancy. However, the downstream effects, particularly of unintended pregnancy in the context of maternal and perinatal morbidity and mortality, keeping girls in school and DALYs will strengthen the argument for FP/EG integration as well as the rationale for external funding of rigorous evaluation research and program documentation.
Results: The authors have adequately summarized the FP/EG integration interventions elicited from their literature review. However, in the country summaries where pre and post statistics are mentioned, the authors do not report whether the increase in contraceptive uptake for example, was statistically significant.
The second half of the results section describes the key influencers/contributors that facilitated the effectiveness of the FP/EG integration. This is the most interesting aspect of the open letter as it sheds light, based on the literature review, on specific programmatic action steps for achieving effective FP/EG integration. However, this section would significantly benefit from a deeper dive into the country summaries and the recommended programmatic actions. For example, "Accurate Referral Networks" is proposed as a contributor for effective FP/EG integration but the authors do not provide evidence gleaned from the country summaries to substantiate inclusion of "accurate referral networks". Which country program referral networks existed prior to the beginning of the program or were developed as part of the intervention and what was the effect on change in contraceptive knowledge and/or uptake as a consequence of the "accurate referral network". That is the evidence/data that needs to be included in this para. Similarly for each of the other recommended programmatic actions. In other words, what is missing from this section is the substantive evidence from the country summaries that validate/corroborate the programmatic recommendations.
Is the rationale for the Open Letter provided in sufficient detail? Partly

Does the article adequately reference differing views and opinions? Yes
Are all factual statements correct, and are statements and arguments made adequately supported by citations? Partly

Is the Open Letter written in accessible language? Yes
Where applicable, are recommendations and next steps explained clearly for others to follow? Yes to increase participation and efficacy. The authors conducted a thorough literature review and summarize their findings which demonstrate that although the limited research they found is very promising, much more needs to be done.
The piece would be much stronger if the authors addressed some of the reasons why there isn't more integration of FP initiatives with other programs. The positive impact of being able to manage female fertility on many desired outcomes such as individual and community health, participatory government, and education, among others, is well-documented. However societal and cultural stigmas related to sexuality, fertility, and educating males and females about the basics of human sexual reproduction so that they can understand how to use family planning obstruct such progress. The omission of a discussion of how this impacts both the successes and failures of this kind of program integration is perplexing. The authors make a solid case for the benefits to women that result from more FP/EG initiatives and participation. Looking at how to better include males, and how to educate males about the society-wide benefits that result from families being able to plan births and integrate economic growth opportunities with better outcomes for fewer children should be included among the suggestions for future research and development.
One possibility suggested, though not articulated, by this research is that if we do a much better job of emphasizing the importance of FP in achieving other economic goals it might be possible to circumvent societal and cultural constraints which currently limit the efficacy of family planning programs. Additionally, making it clear that such programs do not benefit only women, but families and society as a whole might help engender more support both within communities and from external funding sources.

follow?
Yes