This episode will provide background and basics on fragile settings and family planning programming within these contexts—including the concepts of fragility, health resilience, and the humanitarian-development nexus. Guests will also discuss the impacts of fragility on family planning and sexual and reproductive health.
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From Knowledge SUCCESS and MOMENTUM Integrated Health Resilience, this is Season 4 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season of Inside the FP Story, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I’m pleased to introduce our narrator, Charlene Mangweni-Furusa.
Narrator: Welcome to Season 4 of Inside the FP Story, where we are exploring the topic of family planning and reproductive health in fragile settings. While this topic has been mentioned briefly in previous episodes of this podcast, over the next four episodes, we will explore it in-depth.
We will begin with a look at common definitions and language, and discuss what fragility means to our guests. We’ll explore the drivers of fragility and what makes fragile settings unique for family planning, particularly when both development and humanitarian actors are present. We will also discuss gender and social norms, ensuring quality of care, and the unique needs of young people in fragile settings. For this season, we spoke with guests who are working to address family planning and reproductive health needs within fragile settings around the world. They will share examples of their programs––including what works, what does not work, and what is needed to ensure that all people in these settings receive client-centered quality family planning and reproductive health services.
Our first episode will provide background and basics on fragile settings and family planning programming within these contexts—including the concepts of fragility, health resilience, and the humanitarian-development nexus. Guests will also discuss the impacts of fragility on family planning and sexual and reproductive health.
Narrator: According to the United Nations, 274 million people are currently in need of humanitarian assistance, and tens of millions of others are living in fragile contexts. Around a quarter of these individuals are women and girls of reproductive age.
Before we go further, let’s make sure we all understand what these terms actually mean.
First of all, what are we talking about when we say “fragile settings”? Sarah Rich, the Associate Director of the Sexual and Reproductive Health Program with the Women’s Refugee Commission, offered the following definition:
Sarah Rich: I think of fragility as settings that are at a high risk—or a higher risk, relatively— of some kind of crisis occurring, particularly conflict-related crisis. So places where there's some level of political instability or you know, groups that are at odds with each other that may be armed where the risk of that turning into conflict is higher than in other settings. I think that's kind of what lends to a setting being called fragile. And then, often in many settings globally, there are always risks of disasters occurring as well, which compounds that fragility. So often in these settings, we see recurring conflict combined with floods or droughts or typhoons or whatever it is that lend a constant feeling of there being some level of instability.
Narrator: Fragile settings are places affected by some combination of conflict, disasters, weak governance and institutions, population displacements, and other acute and
chronic crises. As Sarah highlighted in her response, fragile settings are multidimensional. Measuring fragility cannot be reduced to one factor, but is defined by the interconnected, overlapping challenges affecting people in these contexts—from conflict to disasters to poverty and weak infrastructure. In fragile settings, increased illness and death result from disruptions to basic health services and systems.
We talked to Pari Chowdhary about the multidimensional nature of fragile settings. Pari works with the organization CARE, as a Senior Technical Advisor of Sexual and Reproductive Health Impact.
Pari Chowdhary: Fragile settings are never really fixed. They are constantly converging and overlapping and bringing different sets of risks and opportunities as they change. I think what creates a fragile setting is that it really can't be boiled down to a single factor. It might have been caused by one particular thing, but oftentimes once something is deemed a fragile setting, it's because there are multi-dimensions to it. And over the course of the extent of the fragility, it can also sort of fluctuate. And so the spectrum of intensity of the fragility can change as conflicts flare up or poverty levels rise or fall, or communities become adjusted to their new environments.
Narrator: While communities can adjust as fragility fluctuates, the burden and compounding effects of these multiple factors do not affect all individuals equally. Here is Dr. Henia Dakkak—Head of the Policy and Liaison Unit with the Humanitarian Office of the United Nations Population Fund (or UNFPA). She has been working in fragile settings since the 1980s, and shared her perspective on the most vulnerable groups within these contexts. You'll notice she uses both the terms "fragile" and "humanitarian"—we'll take a look at the difference in just a moment.
Henia Dakkak: My aim always is to really support women who are at risk and more vulnerable in these settings. I'm not saying every woman is vulnerable, but I'm saying the vulnerability increases in such settings. We are seeing increased emergencies and plus the public health emergency of COVID-19. So, you know, we all have been seeing an increase in the population that is affected by humanitarian situations, and by crisis, by emergencies. And of course in any of these emergencies, women and children will be impacted mostly. And that's something that we recognize. We also recognize that no matter what emergency situation you are in, there will always be pregnant women. There will always be women who have been exposed to gender-based violence. There will be women who want access to contraceptives. There will be always women who will have sexually transmitted infections. There will always be women with disabilities, with HIV/AIDS. And all of them need support. Because accessing services in these situations are always going to be a problematic issue. And therefore, you know, you need to make sure that they can have the services and the access to, to services as one of the primary goals to really save lives. We know maternal mortality is higher in fragile and conflict-related countries. We have seen an increase in neonatal death also in these countries. So already the evidence, that data, is available to say why we should invest in these situations and these settings, because we know that if we don’t, maternal mortality will be on the rise.
Narrator: What is a “humanitarian crisis” and how is it related to fragile settings? According to UNICEF, the boundaries are often blurred between “fragile” and “humanitarian” contexts. However, while the terms are sometimes used interchangeably, they are not identical.
UNICEF defines fragile contexts as: “contexts where there is an accumulation and combination of risks as a result of context-specific underlying causes combined with insufficient coping capacity of the state, system and/or communities to manage, absorb or mitigate those risks.”
Meanwhile, a “humanitarian crisis” or “humanitarian emergency” is a singular event or series of events that threaten the health, safety, or well-being of a community or large group of people. In humanitarian crises, the capacity of the community to cope with the crisis is overwhelmed, and external assistance—such as national or international response—is required to help people access fundamental needs like food, shelter, and clean water. Damage from humanitarian crises can be short- or long-term. Floods, armed conflicts, and famine are all examples of humanitarian crises. And if a crisis leads to migration of communities away from their homes, a refugee crisis can result.
Fragile contexts and humanitarian contexts are interconnected and complex—yet each requires a unique response. As we mentioned previously, these terms do not mean the same thing, but they are related: When fragile settings are experiencing shocks and acute stresses—for example, a flood or an internal conflict—these settings are susceptible to humanitarian emergencies. Fragile settings may also be more susceptible to prolonged humanitarian crises, as their institutions are unable to protect the setting from these stressors. However, it is important to note that humanitarian crises can occur in non-fragile settings also—for example, when a hurricane or tsunami affects a community not deemed as “fragile.”
Sarah Rich highlighted the opportunities within fragile settings to partner and work to rebuild and improve preparedness, particularly related to family planning and reproductive health.
Sarah Rich: I really think there's an opportunity to partner with government officials, to partner with local actors who have an interest in making sure that people within their own borders have access to life saving sexual and reproductive health services, including contraception to make real strides in improving that access. And I think those strides can be made before, during and after crises alike. And we need to be looking at all three of those phases to really ensure that there's uninterrupted access for people to these services.
Narrator: The first phase is before a crisis occurs. There is a lot that can be done in this phase—for example building houses on stilts in flood-prone areas. There is also a lot to be done with regard to sexual and reproductive health.
Sarah Rich: So before a crisis, during the preparedness phase, a lot can be done in terms of ensuring access to health services and sexual and reproductive health services in the run up to crises. And there are huge opportunities to make gains on that front globally and locally within crisis-affected settings.
Then during the response phase, I think there's a lot of opportunity to continue advocating to decision makers that these services are, again, life-saving, that they have real impacts to make clear what those impacts are when services are not available. And, to continue partnering with local to global decision makers on ensuring that when a crisis occurs services are available.
And then in the aftermath of a crisis, if it's a protracted crisis or if it's a disaster that subsides over time, either way, there are really opportunities to partner again with local government, with local organizations on ensuring that as we're expanding from the minimum package of sexual and reproductive health services to more comprehensive services that it's done in a way that is sustainable, and that offers stability for women and girls and other marginalized groups, to be able to access those services, whether it's a time of crisis or not.
Narrator: To ensure that communities are able to defend themselves against the fluctuation and uncertainty that accompanies all phases of crisis response, many programs aim to increase “health resilience” in fragile settings. This is a concept that we will explore throughout this season of the podcast. Strengthening health resilience in fragile settings allows individuals, communities, and systems to better absorb, adapt, and transform in order to rebuild and reduce the risk from future shocks and stresses. In this context, the term “shock” refers to sudden events that impact vulnerability—for example, a disaster like a tsunami. The term “stresses” refers to long-term trends that impact vulnerability—for example, pollution or deforestation.
Erica Mills works for Pathfinder International as a Family Planning and Reproductive Health Technical Advisor for the MOMENTUM Integrated Health Resilience project—or MIHR. Here is her explanation of resilience:
Erica Mills: MIHR uses the USAID Global Health Bureau definition of resilience, which is the ability of people, households, communities, systems, and countries to mitigate and adapt to shocks and stresses in a manner that reduces acute and chronic vulnerabilities and facilitates equitable health outcomes.
So I think really what that boils down to is kind of building the capacity of all of these different levels, from the individual to the system, to either mitigate or adapt to different shocks, emergencies, et cetera. And then also just over time, reducing their vulnerabilities to these scenarios. As a project, we look at health resilience as almost a subset of overall resilience. So it's building the resilience of people to manage their own health, ensure better health outcomes, same at the household community and systems level. But then not totally separating it from larger resilience that takes into account economic activities, education, broader life planning, those types of things.
Narrator: When measuring health resilience, we examine what are known as “resilience capacities”—absorptive, adaptive, and transformative.
Absorptive capacity encompasses the prevention and coping measures taken by individuals and communities to avoid permanent negative health impacts of shocks and stresses. Adaptive capacity is the ability to make choices and to respond to longer-term changes, including socioeconomic and environmental changes, that affect one’s health. Transformative capacity is the enabling environment for systemic change—it describes the ability of the system overall to respond and make long-term changes that can positively improve the health system—this includes governance mechanisms, policies, community networks, cultural norms, etc.
We asked Male Herbert, Gender and Youth Lead at MOMENTUM Integrated Health Resilience in South Sudan, to describe these “resilience capacities” in the context of family planning.
Male Herbert: We have the absorptive resilience capacities. We measure this, particularly in family planning, through interest from individuals and communities. We also measure through the desire of individuals and communities to prevent pregnancy and the desire to use family planning methods.
The adaptive resilience capacities in family planning are measured through couples’ access to family planning services, especially when couples are able to come together as wives and husbands to access family planning information and services. We also measure through the use of family planning services by couples and the sustainability of the use of family planning services. We also measure availability of different family planning commodities in the health facilities and the same time the ability of the health facilities to correctly use family planning guidelines without bias and discrimination.
And then the transformative capacities are measured through the equitable policies and nationally driven processes to support family planning. The national driven processes to support appropriate provider behavioral interventions for provision of family planning services and availability and implementation of costed implementation plans for family planning. So those are the ways how we do measure resilience capacities in our supported facilities.
Narrator: As Male detailed in his answer, resilience is measured at different levels, and there are individual, community, and structural approaches that can improve all three of these resilience capacities. We will discuss some of these approaches more in other episodes this season, and offer examples of how programs can increase resilience and improve the quality of health services.
For now, let’s explore this concept of response before, during, and after a crisis—moving from preparedness to response to development. Moving through these three phases isn’t linear, and often the lines intersect or are blurred.
A concept that can help us understand this further is the “Humanitarian-Development Nexus.” The Humanitarian-Development Nexus marks an important turning point in the understanding of humanitarian and development settings. It recognizes that previous models—which were linear in nature—are obsolete, and that a region or country does not transition from humanitarian to development aid in one direction.
Here is Erica Mills’s description:
Erica Mills: I think of the humanitarian development nexus as both the intersection of—and the collaboration between—the humanitarian sector, which focuses on short-term response to acute emergencies and the development sector, which focuses on more long-term change and development, and is currently in more stable settings.
So the nexus is kind of where those two things meet, which often you think about as kind of a cutoff, but there's a lot of times where you're somewhere in the middle or there's a back and forth between the two. And so how do we bridge that gap and how do we build upon humanitarian response and then transition that into longer term development.
Narrator: Keeping the Humanitarian-Development Nexus in mind, we asked Pari to describe the differences between programs that work in fragile and humanitarian settings, and those that work in a development context.
Pari Chowdhary: In a humanitarian context, because there are competing needs that are existing as a result of whatever the emergency is—whether it's a war or conflict or a disaster—family planning often comes in as a secondary element or a secondary piece of programming.
And we see this a lot, even in our funding mechanisms for this kind of work. It's rare for us to experience a donor or funding mechanism that is solely dedicated towards improving sexual and reproductive health and family planning of a population that is undergoing some sort of humanitarian crisis or conflict. In those situations, the funding mechanisms are designed to address other needs that take precedence, like perhaps shelter, or governance, or safety, or protection, things like that. And then sexual and reproductive health and family planning are part of that program as one element, rather than the key focus of the program.
In development, because we have a slightly more stable society, we are able to create programs and also receive funding mechanisms that are more solely focused on sexual reproductive health programming, and are recognizing that sexual and reproductive health or family planning is the next most important frontier in elevating that community's ability to access healthcare or fully actualize their potential.
So I think that's one major key difference. Another difference is that humanitarian contexts automatically elevate the level of vulnerability and risk that people are experiencing, especially certain subgroups. And so, as a result of that, most of the times, the folks who are experiencing that additional level of risk are also the same folks who would be the ones who are needing family planning or sexual reproductive health services.
And so it's harder to reach those populations. There are sometimes social, religious, and cultural norms that are creating an additional layer of complexity in delivering sexual and reproductive health programming, or discussing topics like family planning in societies that are not so used to talking about that openly and things like that. So that difference is maybe still present in development contexts, but the additional layer of vulnerability and risk that comes with a conflict is unique to a crisis setting. And you have to be slightly more thoughtful in how you're approaching that topic or how you are including it in your programming.
So there are a lot more pieces to an equation in a humanitarian context that need to be [accounted] for versus in a development context, you are better, I mean, you're more easily able to come in and sort of assume that other parts of the system will work as intended and therefore support your existing programming.
Narrator: Pari highlighted two key differences between humanitarian and development contexts: first, because funding in humanitarian settings is dispersed to cover everything from basic shelter to governance, it can be difficult to carve out funding and give priority to sexual and reproductive health service delivery. Second, those more vulnerable to the effects of humanitarian contexts are often those with the greatest needs for sexual and reproductive health services, as opposed to development settings where programs are working within more stable surroundings.
Now that we have defined some key terms and concepts that we’ll use throughout this season of the podcast, let’s dig in a bit more on what the ramifications are for family planning and reproductive health within fragile settings.
Narrator: We asked our guests what the biggest challenges are when working on family planning and reproductive health in fragile settings. In their answers, they highlighted some important characteristics of fragile settings.
Henia mentioned a key underlying challenge of prioritizing family planning within a range of other needs.
Henia Dakkak: So in many places, the more you are exposed to these types of changes continuously, the last thing you are going to think is about contraceptives. I mean, you need to survive. You need to eat. You need to drink. You need to be warm. You need to find clothing. You need to find shelter. I think the last thing on a woman's mind at that moment would be contraceptives. It's not like some women don't ask for it. Absolutely, they do ask, when somebody asks them, if they need contraceptives, then they will tell you, “Yes, we need contraceptives.”
Narrator: As Henia pointed out, women need contraception, but they are also concerned about food, shelter, and other basic needs for themselves and their families.
Pari talked about this challenge as well.
Pari Chowdhary: The biggest challenges that we face in this work are actually different depending on the context. If we were to talk about fragile and humanitarian contexts, you know, the nature of a humanitarian or emergency dictates sometimes that there are other needs that also take precedence over things like family planning or sexual reproductive health, needs like food security and shelter, and physical safety, and things like that. So, when I work in our humanitarian programs, a lot of the time we are building our family planning and reproductive health programs as additions to larger programs that are addressing these more immediate needs. And I, of course, personally see reproductive health and family planning as an immediate need, but I recognize that in times of emergency, there are other things that can take precedence.
And so that can be a challenge that happens sometimes. Continuing with this example of humanitarian settings, oftentimes rights-based care can be suspended when there's a destruction of infrastructure and facilities and just the general norms that would exist in a society. Talking about things like family planning and especially family planning of vulnerable populations, it requires work to rebuild the culture, or even just start a culture of getting communities to think about family planning as a rights-based issue. Ensuring that everyone has access and care, oftentimes can be a challenge because people see it more as like, “Well, if I need more immediate care in other health areas then why is this what's being prioritized?”
In fragile settings, we always have disruption of routine health, service organization, and delivery systems, limitation of commodity supply. There's increased health needs across the board, not just for reproductive and sexual health, but other things as well. But at the same time, there's also, you know, these unpredictable and complex resourcing issues with commodities and also human resources. And of course, when you are in a fragile context, people are experiencing a vulnerability to multiple public health crises. Like there's increased rates of violence, increased displacement, food insecurity. And so the challenge is being able to deliver and provide an effective and ethical family planning program in such a setting when there are so many competing priorities.
Narrator: Sarah Rich further talked about the reasons why sexual and reproductive health is often not prioritized in fragile settings, and what the consequences are.
Sarah Rich: Decision makers don't always prioritize sexual and reproductive health services for a lot of reasons. We see that globally in the US and elsewhere. And we see those ramifications. Even more so in crisis affected settings where resources become even scarcer and where decision makers really have the capacity to impact what services are or are not available. As well as in terms of funding decisions too. If donors don't see sexual and reproductive health and rights as essential and life saving, then it's less likely to be available. So I think that's one huge challenge. Another major challenge that we see is that the humanitarian architecture is structured such that often we have international organizations and international groups going in when there's a crisis playing a specific role and then oftentimes kind of heading out. And so what we really need to do is to be partnering with local organizations who are the folks who are there when a crisis occurs and who will be there even after a crisis subsides or ends to make sure that those organizations are leading the way, paving the path to ensure that sexual and reproductive health services are available before during and after crises alike.
Narrator: Sarah mentioned a really important challenge of working in fragile settings—often, implementing organizations are not consistent, and leave settings after a crisis subsides. We will address this topic in later episodes as we discuss preparedness and partnerships in fragile settings before, during, and after crisis situations.
Moses Okwii, a Research and Innovations Associate with Dev Con consulting, lives and works in South Sudan. He talked about some of the challenges he faces working on family planning and reproductive health research.
Moses Okwii: South Sudan is a very fragile state, I must say, given its history in terms of conflicts, as well as disasters that keep on reoccurring every now and then. So there are several issues always that we face—starting with issues of access to most of these locations. Sometimes locations are actually cut off. South Sudan is a unique country whereby if you want to move from one state to another, you have to take a flight. But also when you move to some of these locations, some of them are not secure. Some of them are very poor road infrastructure, and yet you have to reach deep up to the lowest person within that particular community. So sometimes it's really very challenging.
Secondly, the community social norms and social cultural issues are still quite rigid. Even if you are actually interviewing adult females the males usually want to have a bit of control and be able to understand what is going on, even upon giving them explanations.
The other issue is because of the fragility of the country, in terms of security, there's a lot of clearances always required from the local authorities, right from the national level before you go to the lowest level, of the village where the interview [takes place]. So those are some of the issues that we actually face operating in this kind of environment. We also have limited infrastructure. When you go to most of these field locations, access to the internet is challenging, access to accommodation sometimes is also a problem. So it is just a wide spectrum of issues that we have to navigate every now and then.
Narrator: Henia also talked about the impact on family planning and reproductive health for those in fragile settings.
Henia Dakkak: I have been in many, many humanitarian settings, and that's the focus of my work. Currently, I am in Moldova supporting the country office in responding to humanitarian needs.
From my side, what I have seen is, in many of these places, women lose a lot of their support system that they have. And that also makes them more vulnerable and makes it more difficult for them to access services that they utilized before.
Let me give you an example. Let's say a woman had Depo Provera before. But she had to move. She has to flee from where she is. She's going to another place. She doesn't know where to get the service. She doesn't speak the language. All of that plays into why, for example, maybe at some point the woman might discontinue having her service. Because it is a difficult situation for most women. They have to assume new roles. Some of these new roles would be maybe taking care of another elderly person, taking care of a disabled child. Maybe, you know, she has to exchange, let us say, food for sex. There are many, many elements that go into the vulnerability. You know, we are talking about women who most probably lost everything that they have. They are not in a stable home. They don't even have their belongings. They don't have access to finances. All of this plays a big role in whether this woman will be able to get access to family planning.
Narrator: Henia also shared a specific example from her work in Indonesia, after the tsunami in 2004. This example highlights some of the reasons why fragile settings are different from development contexts, and why family planning needs to be prioritized.
Henia Dakkak: I was in Banda Aceh in 2004 after the tsunami. And we are talking about Indonesia that has a good level of contraceptive use. Contraceptive use is very high among women and adolescent girls. It's around 68 percent, which is very high. All the contraceptives that were in the clinics were destroyed, totally destroyed. Totally. There was no way you could salvage anything. And that gives you an understanding. If the woman survives the tsunami, contraceptives most likely will not be available until maybe two months down the road or one month down the road, because we are talking about a place that was totally destroyed, and you need to bring everything. And usually people will prioritize food, water, things that are mostly needed. Contraceptives will not be in the first delivery of goods that will happen in this situation.
And I can tell you one thing that afterwards, every single organization came to me and asked me, can we get the interagency reproductive health kit? Can we get access to contraceptives? Because a lot of the women were utilizing contraceptives before that, it's a high contraceptive prevalence country, but then everything was destroyed.
So it was good that UNFPA was able to bring the contraceptives immediately, but it took most probably two weeks to three weeks before the contraceptives were available in Banda Aceh. It was a very difficult situation.
We cannot predict what every situation will be. But most of the places I have been, it's the same situation. Look at Ukraine now. Things have been destroyed and certain people are fleeing. They are not taking anything with them. They're going to another place.
So I think until contraceptives become a universal commodity, we will not see that much improvement. Of course we are working on it and we will continue working on it, but unless it becomes universal, it becomes part of the primary healthcare, it is something that is provided immediately in an emergency, we will still see lack of of prioritization among all the different needs that are happening in these type of of emergencies.
Narrator: As Henia explained, contraception is often not prioritized in these settings, and it is not considered an essential commodity—but it is greatly needed by women who are displaced and do not have access to contraception. This speaks to the need for including family planning within universal health coverage and primary health care and identifying it as an essential, lifesaving commodity to be provided following a humanitarian crisis—so that it is immediately available for all who need it.
Narrator: The first episode of the season introduced the concepts of fragility, health resilience, and the humanitarian-development nexus. We introduced the key challenges of delivering sustained family planning and reproductive health services in fragile settings. We have highlighted experiences from a range of contexts, which can offer important lessons for those working in other fragile settings.
As Henia and our other guests have mentioned, social norms can often prevent individuals from accessing family planning and reproductive health care in fragile contexts. Join us next episode as we discuss these norms, the specific challenges presented in such contexts where family planning is discouraged, and some entry points for family planning programs.
Season 4 of Inside the FP Story is produced by Knowledge SUCCESS and MOMENTUM Integrated Health Resilience. This episode was written by Sarah Harlan and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Brittany Goetsch, Natalie Apcar, Christopher Lindahl, Terry Redding, Lorelei Goodyear, Christine Lasway, and Isabelle Bremaud.
Special thanks to our guests Sarah Rich, Pari Chowdhary, Male Herbert, Henia Dakkak, Erica Mills, and Moses Okwii.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher; and visit knowledgesuccess.org for additional links and materials.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
Thank you for listening.
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