Opinion: Achieving family planning equity starts with a power analysis

Authors: Danette Wilkins and Sara Jewett, February 14 2023 - As social and behavior change researchers and practitioners, we believe that to reduce health inequities in access to family planning programs and services globally, a critical examination of power, as a significant driver of agenda setting, decision making, and resource distribution, is necessary.

Power is directly linked to structural inequities - the systemic disadvantages one group experiences compared to other groups. Structural inequities shape how we experience the environmental conditions that affect our ability to reach our full potential for health and well-being. These conditions are referred to as social determinants of health, or SDH. For example, people in wealthier environments benefit disproportionately from global health programs and services, while socioeconomically disadvantaged groups typically remain without access to quality health information, services, and products, including family planning.

The field of social and behavior change, or SBC, has a unique role to play in deepening awareness and understanding of power and the relationship between structural inequities, SDH, and family planning access and use. Moreover, it has a responsibility to be more intentional about promoting and advancing equity in programs and services globally. This means advocating to employ SBC approaches to design and implement programs and services that address these intertwined relationships to reduce health inequities.

Multiple studies suggest SDH affects 30-55% of health outcomes. Nearly two decades ago, the World Health Organization launched its Commission on Social Determinants of Health to support governments and global health partners to address environmental conditions leading to poor health outcomes and health inequities.

Much work has been done since then, yet a significant gap remains in achieving equity in family planning. This gap is evident in the failure to reach the most socioeconomically disadvantaged groups with family planning programs and services, as most reach urban, wealthier individuals.

Just as resource-poor individuals experience reduced access to information, services, and resources necessary for good health and well-being, they also disproportionately face the lifelong effects of unintended pregnancy and childbearing. Unintended pregnancy is usually linked to both experiences of unwanted sex and lack of access to contraceptive information and services.

By failing to adequately address the relationship between structural inequities, SDH, and family planning access and use, we continue to miss opportunities to improve family planning and related health outcomes for the most disadvantaged groups. As SBC professionals we view power analysis as the key to designing and implementing family planning programs and services with more equitable impact.

Undertaking a power analysis uncovers the policies and practices that perpetuate structural inequities. The analytical framework of intersectionality is central to any power analysis as it unpacks patterns of privilege and oppression stemming from the structural inequities that give rise to disparities in health and other areas. Governments, policymakers, funders, researchers, and practitioners must jointly engage in the exercise of power analysis in order to unpack, understand, and, ultimately, act upon social and structural barriers to family planning access and use.

Conducting power analyses is only the beginning. We also need to be transparent in socializing our findings and applying them to shift power imbalances - which shape who participates in agenda setting, decision making, and resource distribution and affect who ultimately benefits the most from programs and services. As Babafunke Fagbemi, head of the Centre for Communication and Social Impact in Abuja, Nigeria, recently noted: "There is a huge gap between what we know in theory...and what we do in practice; and if we're able to bring these two domains together, we'll be able to do this right."

Tools and resources exist to bring theory and practice together and support addressing structural inequities and SDHs. For example, this programmatic tool is designed for practitioners as they consider how to identify, prioritize, and address SDH in their family planning programs, while this report provides evidence to guide strategic decision making among governments and funders in support of initiatives to reduce inequities in family planning.

We must increasingly advocate with governments, policymakers, funders, researchers, and practitioners to understand how much structural inequities and SDH fundamentally shape health and well-being. This means deepening our use of other lenses - intersectionality, equity, SDOH, and health systems - while unlearning familiar ways of doing things.

Within SBC's emphasis on participatory processes, there are opportunities to share power, unlock creative solutions, and build multisectoral movements to mobilize both individual and collective agencies. Télesphore Kaboré, from Save the Children, recently shared that "Community engagement and social accountability approaches have successfully addressed social determinants of health, including facilitating access to transportation and improving quality of health care services, but [they] are often not recognized."

To achieve equity in family planning, we need to lean into SBC approaches that promote power-sharing at scale and be intentional about addressing the relationship between structural inequities, SDH, and family planning access and use. Whether we are willing to go that far remains to be seen.

Click here to read the blog as originally posted on Devex.

Image caption/credit: A gathering in Malawi for women to receive information on family planning and contraception methods. Photo by: Lindsay Mgbor/Department for International Development (CC BY-NC-ND 2.0)

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