Increasing Access to Family Planning Among Indigenous Groups in Guatemala

This 32-page report describes an initiative to promote equitable access to family planning (FP) and reproductive health (RH) services among indigenous women in Guatemala. The project was carried out by the United States Agency for International Development (USAID) | Health Policy Initiative, Task Order 1, which is implemented by Futures Group International in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace. From April 2006 to April 2008, in partnership with the Ministry of Public Health and Social Welfare (MSPAS), the Guatemalan Institute for Social Security (IGSS), and the Association for the Wellbeing of the Family (APROFAM), the Health Policy Initiative undertook a participatory research endeavour with the aim of reducing barriers to access and use of FP/RH services among disadvantaged groups.

As explained here, this effort was motivated by the observation that indigenous groups - such as Maya, Xinka, and Garifuna - constitute about 40% of Guatemala's total population and 75% of its economically poor. According to the 2002 National Maternal and Child Health Survey, 39% of married indigenous women ages 15-49 indicated an unmet need for FP - that is, they want to have no more children or delay the next birth by at least two years. Contraceptive use among indigenous women is roughly half that of other women; 24% of indigenous women were using contraceptives, compared with 53% of the non-indigenous women, according to the 2002 survey.

First, the project reviewed existing research and policies to identify the factors affecting access to FP/RH services. The project then conducted 108 in-depth interviews with service providers, 22 group interviews with 168 indigenous women, and 11 group interviews with 69 community educators and traditional midwives in 3 departments (Quiché, Sololá, and Totonicapán) of Guatemala. Based on the research findings, the project identified 6 major barriers that limit access to FP/RH services among indigenous groups: provider bias toward indigenous women; unsuitable conditions in facilities providing FP services; lack of appropriate information, education, and communication (IEC) materials; limited integration of community-based providers; community beliefs regarding FP; and restrictive social and familial environments. During stakeholder workshops at the national and community levels, project staff presented these findings, and participants from the MSPAS, IGSS, and APROFAM, as well as civil society organisations (CSOs), developed a set of service delivery practices that could improve access to services. These practices were then incorporated into operational guidelines that were pilot-tested in 5 districts in Quiché.

Next, the Health Policy Initiative helped the Departmental Office of Health in Quiché develop a list of 10 locally appropriate service delivery practices. These practices involved providing services and information in the local language or through a qualified interpreter, orienting providers to local conditions, and making a private area available for FP consultations. Following the collection of baseline information on the status of the 10 priority service delivery practices, the Quiché team trained service providers in the new guidelines through a series of one-day workshops. The team then monitored implementation of the guidelines in the 5 pilot districts. After one month, stakeholders reported that the guidelines were feasible and would help to improve the quality and coverage of FP services. Four of the 5 districts had implemented some part of the guidelines, such as ensuring that services were provided in indigenous languages, finding a private place for FP consultations and services, and removing signs that called attention to the facility as a source of FP services (thus discouraging potential clients who feared stigma and disapproval from family and community members). One district health team developed and broadcast television spots about family planning in indigenous languages. The project also interviewed programme implementers to capture lessons learned and best practices. They found that, for national agencies (e.g., the MSPAS) and external agencies providing technical assistance, it is important to:

• apply a systematic process to ensure that the recommended actions are applied effectively to the local context.
• think beyond enacting policy statements and consider how concrete guidelines can actually be implemented - because the positions and interests of stakeholders frequently change, continuous advocacy and targeted actions are needed to keep the issue high on the policy agenda and to influence policy decisions.
• support an evidence-based, country-driven process that fully involves service providers, the main institutions providing healthcare, and the population being addressed in identifying barriers and formulating service delivery practices to address them.
• use a comprehensive approach involving multiple stakeholders to ensure that the approach addresses local needs and conditions.
• integrate the perspective of indigenous people into development of the guidelines so that service providers may be made aware of factors that inhibit indigenous women from seeking FP services.
• conduct equity-based monitoring and evaluation - factors such as the quality of the counseling, accuracy of information provided, and the extent of community outreach need to be assessed regularly.

In developing a targeted programme, local health programme managers should - according to the researchers - consider the following practices:

• When identifying barriers: Involve the intended population in identifying barriers to service access;  interview users and non-users of health services and providers, using local language when appropriate, to understand why the intended population is not using services; and incorporate all major service providers in the study.
• When planning interventions: Involve the intended population in the design, development, and implementation of programmes; include all stakeholders, including local leaders, in programme implementation; strengthen the relationship between the area, district, and basic health units through the development of technical guidelines for FP services to ensure quality and uniformity of services throughout the system; work with community members to disseminate information that clarifies misconceptions about FP; train all health centre personnel, including non-medical staff, on FP issues; and strengthen the commitment of district health officials to FP.
• When engaging in advocacy: Involve representative non-governmental organisations (NGOs) in advocacy efforts at the local level to build support and consensus from the community and to promote early involvement of the intended population; advocate at all levels - central, district, and community - to build political will and momentum for interventions; promote a continuous process of advocacy, policy dialogue, data sharing, and information gathering and dissemination; and involve the right stakeholders - representative NGOs, major service providers, Ministry of Health officials, and district- and community-level health officials - to strengthen commitment to equitable access to FP/RH services.