How resilient were family planning programs during the COVID-19 pandemic?  Evidence from 70 countries

The National Composite Index of Family Planning

Building on the Family Planning Program Effort Score measured since the 1970s (Kuang & Brodsky, 2016; Lapham & Mauldin, 1984; Mauldin & Ross, 1991; Ross & Stover, 2001), the NCIFP was developed after 2012 to support FP2020’s efforts to improve the enabling policy and program environment for family planning, by examining the levels and types of effort for a range of family planning policy and programmatic indicators, including indicators to measure rights-based programming.

The NCIFP includes 41 items related to five dimensions of family planning programs, namely, Strategy, Data, Quality, Equity and Accountability, with scores summing to a total possible score of 100¹ (Box 1). For more information about development of the NCIFP, see Weinberger & Ross (2016). Three rounds of the NCIFP have been completed: 2014, 2017 and 2021. To see scores from the first three rounds of the NCIFP, or to compare country scores over time, see Rosenberg (2020) or visit the Track20 website at Track20.org.

A ‘COVID-19 Supplement’ was added to the 2021 round, which includes results from 70 countries in six regions (Rosenberg et al., 2022). The regional representativeness of the sample for 2021 is 64 percent of countries for both Anglophone and Francophone sub-Saharan Africa regions (SSAF-A and SSAF-F), 52 percent of countries for Asia, 18 percent of countries for Latin America and the Caribbean (LAC), 21 percent of countries for the Middle East and North Africa (MENA), and 53 percent of countries for Eastern Europe and Central Asia (EECA). The total number of respondents in 2021 was 961.

The NCIFP is administered through a key informant approach, with the key informants comprising 10–15 respondents in each country who know the family planning program, from the public sector and private sectors; from civil society and nongovernmental organizations; from academic/research organizations; and from development and implementation partners. Country-level NCIFP data collection was managed by either Track20 monitoring and evaluation officers (MEO) assigned to work with the MOH or by a consultant selected based on familiarity with the FP/RH policy and program environment. The MEO or consultant selected respondents who are known to have at least 5 years’ experience with the family planning program, ensuring at least two respondents from each of the categories listed above. While the same respondents were identified for the 2021 round that had participated in the 2017 round, their inclusion was not always possible given turnover in relevant positions.

The approach uses a rating system based on opinion of “the extent to which” with 1–10 as responses (1 = non-existent; 10 = extremely strong effort) for each item in the NCIFP. The 2021 round was administered in eight languages online using Google Form, with an offline option available. The questionnaire included informed consent for respondents.

While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country.

COVID-19-specific questions added to the 2021 NCIFP as a Supplement

The Supplemental questions on COVID-19 came at the end of the regular NCIFP questionnaire and respondents were told that this final set of questions was unique to the 2021 NCIFP and was meant to capture the resiliency of the health system. The questions on COVID-19, shown in Box 2, covered four main aspects of family planning program resiliency: 1) the extent to which COVID-19 interfered with the country’s ability to achieve its objectives related to seven issues (shown in Box 2), with space to add additional issues; 2) the extent to which the government maintained commitment to family planning; 3) the extent to which the family planning program was able to maintain availability of contraceptive information and services; and 4) extent to which clients were able to access contraceptive counseling and methods during lockdowns associated with COVID-19. Taken together, these results give an indication of the resiliency of family planning programs in the face of the COVID-19 pandemic from the perspective of stakeholders who know the programs well.

Analysis of the NCIFP

Data from the google forms questionnaires were exported to Excel for analysis. The authors, led by RR, calculated scores for each item by averaging across individual items in each dimension of the NCIFP and across the COVID-19 Supplement questions. Total scores are an average across all 41 items in the NCIFP. Dimension scores are an average of the individual items in each dimension. Country scores were generated by taking the average for all respondents within that country and converting to a score from 1-100. Regional scores are the average of all country scores within that region. Scoring on responses to COVID-19 questions about ‘interference’ was reversed for analysis for consistency with scoring of the five dimensions of the NCIFP. Thus, a high score indicates little interference to the program from COVID-19 and thus higher resilience of the program and a low score indicates a great deal of interference and lower resilience.

Analysis also included correlations between the NCIFP total score (an average of the five dimensions (excluding the COVID-19 Supplement) and three COVID-19 Supplement indicators: 1) the total Supplement score; 2) the Supplement item on whether government commitment was maintained; and 3) the Supplement item on whether access to contraception was maintained.

Respondents had the opportunity to provide a short answer to ‘COVID Other’ following the questions about COVID-19 interference. The authors, led by KH, analyzed the responses to this open-ended question to highlight common and unique themes across the regions. We started with a list of all of the open-ended responses, grouped by country and region. Starting with the themes represented by the items in the COVID-19 Supplement, we let the comments ‘speak for themselves’ and represent the voices of the respondents in terms of themes that emerged.

Ethical approval and consent

Since the first round in 2014, the NCIFP has been conducted within a monitoring and evaluation framework focused on family planning programs, rather than under a research protocol. Still, written informed consent was obtained to take part in the NCIFP and all data has been anonymized.

Regional variation in family planning program resilience during COVID-19

Regions show variations in the resilience of their family planning programs during the COVID-19 pandemic (Figure 1). Keeping in mind that a high score indicates higher resilience and a low score indicates lower reliance, the average score across all 70 countries was 47 out of 100. SSAF-F had the highest score (55), indicating that that region’s family planning programs were affected by COVID-19, but still may have been most resilient during the pandemic. LAC has the lowest overall score (35), meaning that COVID-19 was considered to affect family planning programs to a greater extent in that region. Figure 1 also shows that respondents gave higher scores overall for the five standard dimensions of the NCIFP in 2021 (described in Box 1) compared to their assessments of the resilience of the program in the face of COVID-19.

Figure 1. Resilience of the FP Program during COVID-19 and NCIFP Score, by Region.

Turning to the components of resilience of the family planning program to COVID-19 (Box 2 and Figure 2), respondents in four of the six regions were positive about their governments’ continued commitment to family planning and ability to maintain access to contraceptives in the face of COVID-19. LAC (yellow line) and EECA (green line) were the exceptions, with less positive views on government commitment and access to contraceptives during COVID-19 (Figure 2). Regarding interference, across the regions, COVID-19 was considered to have the most effect on advocacy and community mobilization efforts and on supply and logistics. Restrictions to movement and/or transport were considered to have had more effect on access to long acting and permanent methods (LAPM) than on access to short term methods (STM) across all regions except SSAF-F (orange line). SSAF-F had equal levels of interference to access to both types of methods related to restrictions to movement and/or transport.

Figure 2. Components of resilience, by Region.

Note: The wording for each component of resilience in Figure 2 is found in Box 2.

Country variation in family planning program resilience during COVID-19

Country scores for resilience vary widely, with Turkmenistan reporting the highest resilience (78) and Bolivia the lowest (22) (Figure 3). Within regions, there is considerable variation in the country scores for resilience. The largest difference is 52 points in EECA, from the high of 78 for Turkmenistan and a low of 26 for Armenia. The smallest difference is 19 points in MENA (from a high of 54 in Djibouti to a low of 35 in Palestine. Table 1 provides the component scores for the items in the COVID-19 Supplement for each country, grouped within regions. The scores across countries reinforce that for most countries, with some exceptions, while the government maintained commitment to family planning, the programs faced interference. Among the 70 countries, around half (36) had similar scores related to the government maintaining commitment to family planning and the country maintaining availability of contraceptives (scores for those two items were within 5 points of each other in those 36 countries). In eight countries, the scores for those items differed by 10 or more points.

Figure 3. Resilience of the FP Program During COVID-19, for Countries Grouped Within Regions.

Correlations between Total NCIFP Scores and COVID-19 Supplement Scores

To assess links between the strength of the overall enabling environment for family planning in programs and resilience to COVID-19, we measured correlations between total scores on the five dimensions of the NCIFP (Strategy, Data, Quality, Accountability and Equity) and the Total COVID-19 Supplement score. The connection was positive with a correlation coefficient (R²) of 0.26 (Figure 4). The correlation between the total NCIFP Score and the Supplement item on whether government commitment was maintained was R²= 0.59 (Figure 5) compared to R²= 0.50 for the Supplement item on whether access was maintained (Figure 6). The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning.

Figure 4. Correlation: Total NCIFP and Total COVID-19 Supplement.

Figure 5. Correlation: Total NCIFP and Maintained Government Commitment During COVID-19.

Figure 6. Correlation: Total NCIFP and Maintained Access During COVID-19

Self-reported challenges related to the effects of COVID-19

Respondents were given the opportunity to provide open-ended responses about the effects of COVID-19 on family planning programming. Comments from 178 respondents from 63 of the 70 countries, representing around 18.5% of all respondents, provide a narrative snapshot and reinforcement of the challenges that family planning programs faced in the context of COVID-19 across the regions (Table 2). Comments can be grouped into seven themes. Fear of infection was mentioned in 5 of 6 regions, disruption of services / difficulty with lockdown and travel restrictions was mentioned in all six regions and staff / facilities diverted to COVID-19 was mentioned in 4 of 6 regions. Five of six regions mentioned: access to reproductive health services and contraceptive methods affected; shifts in services / outreach affected; interfered with logistics & supplies, training & supervision, and M&E; and lack of attention to FP/SRH, financing reduced or diverted, and partnerships affected.

A respondent from Morocco reaffirmed the diversion of providers, saying,

A respondent from Bangladesh explained,

Also in Asia, a respondent from Pakistan reflected,

In line with findings shown in Table 1, the comments mostly indicated more issues with long acting and permanent methods than with short term methods. A respondent in Eswatini noted that,

Another respondent from Eswatini added that the shortages especially affected rural areas.

The comments showed varying views, even within regions and countries, on how severe and how long-lasting the effects of COVID-19 were and the interactions of COVID-19 with other underlying issues affecting the family planning program. For example, one respondent from Uganda said,

In contrast, another respondent from Uganda described the situation differently, saying,

A respondent from Burkina Faso noted the effect of COVID-19 on partnerships that were implementing programming, explaining that the pandemic interacted with other stressors to affect family planning:

A respondent from El Salvador explained that family planning got lost with COVID-19, saying,

A respondent from Vietnam reflected on issues of equity, noting that,

Not all respondents thought COVID-19 had adversely affected contraceptive use, although they did say that the family planning program had adapted to the pandemic conditions. A respondent from Tajikistan said,

Likewise, a respondent from Guinea explained that the effect was short-lived, saying,

Limitations

This paper has limitations in that the findings from the countries are based on self-reports from respondents on their perceptions of the effects of COVID-19 on the family planning program. Still, the findings represent expert opinion from respondents in each country who were familiar with the family planning program and were in a unique position to observe program features and effects. The questions on COVID-19 were added as a Supplement to take advantage of the timing of the 2021 NCIFP, which limited the number of questions that could be added. That is, the respondents answered the questions on COVID-19 in the context of earlier items on the enabling environment for family planning. While a strength of the data is that they were collected in late 2021 and thus provide a broad perspective over the period of the pandemic from 70 countries across six regions, they do not capture any periodicity of the effects (e.g., effects of lockdowns with easing over time). The qualitative findings do indicate a gradation of effect, with the most intensive effects early in the pandemic.

Furthermore, characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.