Marie Stopes International

Submission to the International Development Committee - Humanitarian Crises Monitoring: Coronavirus in Developing Countries: Secondary Impacts, October 2020

Introduction

Marie Stopes International (MSI) is one of the world’s largest providers, and advocates of sexual and reproductive health and rights (SRHR), delivering women centred information and services across 37, mostly middle- and low-income, countries. By the end of 2019, over 32 million people globally were using a form of contraception supplied by MSI. As a key partner to ministries of health, the services we delivered in 2019 averted an estimated 6.5 million unsafe abortions, 14 million unintended pregnancies and 34,600 maternal deaths.

We welcome the opportunity to contribute to this critical inquiry. This submission will focus on the first and third topics of interest as laid out by the International Development Committee:

-          Non-coronavirus health care; the communities trust and engagement in healthcare provision (especially in relation to other infectious diseases and immunisation), and,

-          Treatment of women and children; levels of domestic abuse, gender-based violence and exploitation of women and children, including child marriage

Adapted ODA-funded initiatives aimed at mitigating the secondary impacts of COVID-19

MSI would like to acknowledge the flexibility of the Foreign, Commonwealth and Development Office (FCDO) with current contracts and awards, which has allowed our programmes to adapt and respond to the specific SRHR needs of communities. Timely and supportive financial and programmatic flexibility at the beginning of the crisis gave us the flexibility needed to find new and innovative ways of reaching our clients with services, and therefore mitigating some of the secondary impacts of COVID-19. We were able to use project funds to procure crucial infection prevention and control equipment so we could continue to deliver services. FCDO also allowed us flexibility around milestones that were no longer achievable under COVID-19, giving front-line teams the time and headspace to innovate and adapt.

Through FCDO’s support, we have implemented practical, timely adaptions as well as transformational innovations that have the potential to change the way health care is delivered longer-term. For example, in Nigeria, to ensure that clients could continue to access services in the height of lockdown, MSI Nigeria offered a collection service using MSI vehicles for women who wanted to access essential SRHR services but could not reach our centres due to travel restrictions. MSI Nigeria has also been able to provide some services, such as long acting and reversible contraception and occasionally taking blood samples for lab testing, in clients homes.

In Niger and Sierra Leone, myths and misconceptions surrounding COVID-19 and health providers were risking decreased community trust and engagement in healthcare provision. We were able to mitigate these risks by forging new community partnerships. In Niger, for example MSI mobilisers built on their relationships with other community mobilisers to share accurate information about COVID-19. In Sierra Leone, service providers identified new ways of working with key community stakeholders such as chiefs, chair ladies, and peripheral health unit staff to strengthen their partnerships and messaging. The effective collaboration with these trusted stakeholders has helped in reducing fears about accessing health services during COVID-19.

Technological innovations have been key to adapting to COVID-19. With more clients depending on digital technologies for information and access to services, investing in our contact centres has been crucial. In Ghana, the contact centre took a record-breaking 422 calls in one day following the outbreak of COVID-19, and in Sierra Leone, they are handling a 25% increase as women and girls seek alternative ways to access information and services. In Ghana, with re-purposed FCDO funding, MSI invested in a multi-channel IMIchat platform, to improve client experience and continuity of care, while making it easier for contact team members to work from home. Additionally, with increased sexual and gender-based violence (SGBV) as a result of COVID-19 restrictions, MSI is looking into how it can upskill contact centre staff with SGBV training to offer improved safeguarding to clients.

The challenges COVID-19 has presented to client engagement has also pushed us to explore new direct ways of reaching women and girls with information. The biggest telecommunication provider in Ghana, MTN, partnered with our programme in Ghana to send direct SRH video, picture and text messages to their subscribers who consented to receiving these. The new campaign kicked off this month and is aiming to reach 150,000 people.

Impacts of COVID-19 on access to SRH care and other secondary impacts

Thanks to the flexibility of donors, including the FCDO, and the actions from many governments to declare SRH services as essential, the impacts of COVID-19 on our ability to deliver SRH services has not been as severe as originally expected.

However, there remain COVID-related barriers to SRH services and other secondary impacts, which have been particularly felt by women and girls across the globe.

MSI’s service delivery data shows that due to COVID-related disruptions, 1.9 million fewer women have been served by MSI’s programmes than originally forecast for January - June 2020. We estimate that this will lead to:

-          1.5 million additional unsafe abortions

-          900,000 additional unintended pregnancies

-          3,100 additional maternal deaths.[1]

The impact has varied hugely by country, with MSI’s programmes in Asia facing the greatest impact. Our programmes in India have faced a particularly strict lockdown, resulting in 1.3 million fewer women served than forecast, with 920,000 fewer safe abortion and post-abortion care services being delivered. Due to this drop in MSI’s services, it is estimated that there will be an additional 1 million unsafe abortions, an additional 650,000 unintended pregnancies and 2,600 maternal deaths in India alone.

Increased risk of SGBV

MSI has witnessed increasing rates of safeguarding concerns around SGBV and domestic abuse during the COVID-19 pandemic. Our Ipsos MORI survey[2] found that 1 in 10 women (9%) surveyed in India reported needing domestic abuse services during the pandemic. A fifth of respondents (21%) seeking an abortion service reported not being able to attend a face to face appointment for fear of leaving their home due to domestic abuse, with 18% of women reporting the same when seeking contraceptive services or products.

Fear of accessing health services

In our Ipsos MORI survey of women in India, we found that almost a third of women (31%) who were seeking a contraceptive service or product during the pandemic were unable to leave home to attend the service due to fear of COVID-19 infection. These same restrictions were reported for those seeking abortion services, at slightly higher rates.

Lack of information on safe abortion availability

In South Africa, only 43% of women surveyed thought that people could access an abortion service from a private abortion clinic during the pandemic, compared to 76% before the pandemic. Likewise, in India, perceived availability of abortion services from a clinic decreased from 61% to 44%.

Strained health systems

A shortage of health care providers and increased waiting times for procedures not related to COVID-19 has also made it harder for people to access care, particularly in public facilities. In tandem, emergency reproductive and maternal health services are affected by over-stretched facilities and staff. A third (30%) of our respondents in India who sought a safe abortion service during the pandemic reported that the wait time for an appointment was 1–2 weeks and 9% reported a wait-time of more than 5 weeks.

What can the FCDO do to support developing countries during the COVID-19 crisis?

1. Take a flexible approach to current contracts

FCDO flexibility on current contracts and awards has been crucial for implementers during the current crisis as we aim to continue service delivery, sustain and retain teams and infrastructure, and ensure we are ready to scale back up when restrictions end. We ask that the FCDO continues with its flexible approach as we continue to respond to the challenges of COVID-19.

2. Maintain support and leadership on SRHR

Despite the competing priorities posed by the current crisis, it is vital to maintain investment and momentum to increase access to SRHR, particularly in the most vulnerable countries in sub-Saharan Africa and Asia, both to save lives and because these interventions are crucial to developing strong and resilient health systems. If SRHR services are not protected in times of crisis, subsequent health outcomes and strains on the health system through secondary impacts will be severe.

3. Encourage governments and partners to deliver services in innovative ways. For example, through advocating for the removal of regulations to allow remote access, and the provision of technical support and funding to support:

• Telemedicine services: A recent review by colleagues at the WHO found that across 13 studies, 94-6% of abortions carried out via telemedicine were complete, in line with completion rates expected from clinic-based care.[3]
• Provision from pharmacists: WHO evidence shows that pharmacists can safely and effectively provide short term contraceptive methods and injectables[4] and a growing body of evidence has highlighted that pharmacy workers can safely and effectively provide medical abortion.[5]
• Task-sharing: Where a client is not able to travel to a facility or see a doctor, women should not be denied access to services by unnecessary restrictions on the services that community health workers, nurses or midwives be trained to safely provide.

4. Encourage international partners and governments to classify SRHR, including contraceptive, and safe abortion as essential health services, as outlined in the Universal Health Coverage Political Declaration and as recommended by the WHO. Include comprehensive SRH in basic packages of health services within FCDO-funded programmes and support their inclusion in national government responses to COVID-19.

5. Continue to support and work with UNFPA Supplies so that the programme can support supply chains and contraceptive security. Co-ordinate with existing RH supply co-ordination mechanisms and national governments to identify potential supply gaps and strategies to fill them. At country level advocate with UNFPA and partners for a total market approach to enhance co-ordination between public, non-profit, and for-profit providers to optimise the use of existing products and services.