Policy Environment

 

Welcome to the programmatic area on policy environment within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Policy is one of the subareas found in the health systems section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. Having supportive family planning/reproductive health (FP/RH) policies is integral to the existence of successful health systems and strong FP programs. Supportive policy has been identified as one of 10 elements of successful FP programming. Policy is also one of the four components of the FP Effort Score used to measure the strength of an FP program.  The policy environment is not static, but constantly changes in response to changes in the political and economic arenas, to changes in availability and costs of RH technologies, and to emerging public health issues. Thus, any policy evaluation must address the processes by which policies are formulated and revised as well as the policies themselves. Key indicators to monitor and evaluate policy can be found in the links at left.   Full Text Having supportive family planning/reproductive health (FP/RH) policies is integral to the existence of successful health systems and strong FP programs. Supportive policy has been identified as one of 10 elements of successful FP programming. Policy is also one of the four components of the FP Effort Score used to measure the strength of an FP program. A supportive (or enabling) policy environment is defined as one in which: laws and executive orders mandate provision of products and services without imposing undue restrictions on providers or eligibility requirements on clients; government and civil society leaders openly speak in favor of RH services and healthy practices; public and private resources are adequate to ensure full population coverage; and the policy formulation process is characterized by good planning principles and broad participation.  The policy environment is not static, but constantly changes in response to changes in the political and economic arenas, to changes in availability and costs of RH technologies, and to emerging public health issues. Thus, any policy evaluation must address the processes by which policies are formulated and revised as well as the policies themselves. In order to create a politically supportive environment for FP/RH programs, several policy products/outputs can be developed, such as a law or regulation, a macro-level sectoral policy or financing mechanism, or an operational policy that includes rules, regulations, guidelines, norms, or standards. Several stakeholders can be involved in advocacy and policy dialogue to shape the law or policy. The policy is then officially drafted and voted on by policymakers. Policy Implementation Much has been described on how FP/RH policies are developed. However, there is limited evidence on how policies are implemented and what effect they ultimately have. FP/RH policies are implemented within complex political, sociocultural and economic environments. A conceptual framework developed by the Health Policy Project articulates how these complexities relate to one another and how policy development and implementation can lead to better health systems resulting in improved health outcomes. Attention to the policy implementation space implies the following: the institutions expected to implement the policy, both at the national and decentralized level,  are clearly defined; attention is paid to the institutional relationships and power dynamics among the organizations; organizations have the capacity to implement the policy; financing is sufficient and resource allocation mechanisms are in place to fund the policy; the policy is accompanied by strategic planning and an analysis of policy barriers; and strong monitoring and accountability systems are in place.  How FP/RH policies are made, who makes them, and how contentious the issues being addressed are, all have implications for its implementation.  Methodologies for Conducting Research on Policy Implementation Studies conducted to identify how policies are implemented and measure the effect of their implementation on health systems and health outcomes need to acknowledge how multifaceted the   systems are in which policies are applied and the challenges associated with measuring impact. Several methodologies have been used to conduct policy research. These include descriptive methodologies such as literature reviews and case studies which are commonly used to describe individual examples of how a particular policy was implemented in a specific context. Analytic methodologies used in policy implementation studies include stakeholder mapping and analysis, cross-sectional surveys, and system dynamics. More rigorous methodologies such as quasi-experimental and experimental studies have been used in recent times to show the impact of national and decentralized policies on health systems and even in some cases, improved health outcomes. Because multiple factors interplay during the implementation of a policy resulting in a specific outcome, policy implementation in one environment at a given time is not replicable in a different environment. Since the study of policy is a complex process involving several stakeholders at various levels of implementation, many studies to date have relied on qualitative research rather than large quantitative surveys to document the details of the policy implementation process. Because of this and the gap in evaluations of policy implementation, more evaluation studies are needed to analyze and document the policy implementation process and highlight the effect that policy implementation has on FP/RH programs and on health outcomes. Methodological Challenges of Evaluating Policy Policy is difficult to quantify. With few exceptions (such as size of health budgets), policy indicators are inherently qualitative. That is not to say they are not objectively verifiable. Most indicators use a nominal scale (e.g., presence/ absence of a policy), and some indicators may be ordinal (e.g., higher or lower checklist ratings). Even when interval or ratio measures are theoretically possible (e.g., percentage of population in favor of a particular policy), policy and program evaluation budgets are seldom large enough to include them on an on-going basis. Policies operate at different levels. Within the same country, policies can be enacted at different levels of the program and by different processes. For example, national level FP policies may apply to all government and private health entities in a country. However, decentralized operational policies may only apply to health services in a district. Hence, decentralization adds a further layer of complexity. Policy change is usually incremental. A given policy is complete when it receives official approval at the highest level at which it was intended (e.g., a legislative action signed into law by the president, program protocols published by program director). This is often a multi-year process; adopting an all-or-none criteria (approved vs. not yet approved) may mask significant improvement in the policy environment. Those involved in field applications may find it useful to include benchmarks or progress toward approval (e.g., drafted, discussed in committee, submitted for approval, approved, revised, and updated) as part of the indicator's definition. In addition to whether a particular policy exists or has been recently adopted, evaluation of the policy environment should consider factors that improve the probability of its implementation, such as political and popular support, and sufficient resource allocations. Several factors affect implementation of policy. Supportive policies improve RH programs only to the extent that the policies are implemented. Most policy assessments include at least the content of the policy or policies. A host of other factors within the policy environment influence policy implementation including the actors involved in the policy reform, the processes used to carry out the reform, and the context within which the policy was developed. Political and popular support, participation, and the planning process itself should be included as policy indicators, because they affect both the likelihood of implementation and the process of policy formulation. It can be difficult to establish the link between policy implementation and improved health outcomes. Conducting rigorous FP/RH policy research has several unique characteristics and challenges. The position/status of the researcher can have an impact on study outcomes. There can be a lack of transparency, collaboration and communication between the government, development partners and agencies, thus preventing the researchers from gaining the necessary information to clearly identify how policies have been implemented. As controlled experiments cannot be conducted in policy studies, we cannot measure attribution and causality. Policy research includes complex variables since several components of policy research interact with each other and this interaction varies by the policy being studied and the specific context. Using facility and administrative statistics in an environment with poor monitoring can lead to inaccurate results. Further, we cannot predict the steps policymakers and other players in the field will make, thus making it challenging for researchers to conduct prospective policy research. Policy Indicators Since policy development and implementation is a complex process that can involve a varied number of players within a given context, the policy indicators in this database are only illustrative and should be modified and expanded depending on the local context within which they are applied.

Existence of national/subnational or organizational policies or strategic plans that promote equitable and affordable access to high-quality family planning and reproductive health services and information

Definition:

"Policies and plans" include broad reproductive health (RH) and population policies, guidelines and laws. They also include programmatic and organizational documents whose objective is to regulate the kinds of services to be delivered, to whom, and under what conditions.

Most developing countries now have some national RH policies or laws in place (although few have a stand-alone family planning (FP) or RH policy). Experience has shown, however, that macro-level policies, laws, councils, and programs do not guarantee FP/RH service availability and quality. Therefore, it is strongly recommended that any policy review include operational policies such as rules, codes, regulations, guidelines, etc.

"Promote access" refers to mechanisms that encourage provision of RH services, and increase the number of service delivery points offering services and/or types of services and methods available. "Promote quality" refers to mechanisms that encourage quality FP/RH services such as technical competence of providers and responsiveness to client needs. When evaluators measure both access and quality, they should construct separate indicators for each to maintain uni-dimensionality of each.

Data Requirements:

The policy documents should be easily available to the public with details on the publishing ministry/agency and an explanation of how the policy promotes access to quality FP and RH information and services. Supporting documentation should include the policy/plan/guideline itself, where or by whom it was issued or published, and an explanation of how the policy/plan/ guideline promotes access to or quality of FP/RH services. For example: Is support given to a full range of FP/RH dimensions, or for only a single program element? Are all populations-- women, men, youth-- covered? Is accountability discussed?

At times, evaluators may wish to measure progress towards supportive policies. In this case, they can construct separate indicators for each stage of development (e.g., in draft, submitted for approval, approved), or can devise an ordinal rating scale to track progress from draft to final approval.

If targeting and/or linking to inequity, evaluators will also want to see evidence that the policies focus resources or other attention on poor and/or other underserved areas or groups.

Data Sources:

Actual policy/plan/guideline document with evidence of approval (or submission for approval). They appear in constitutional provisions; legislation; implementing rules and regulations; executive orders; ministerial level decrees, and other measures of a regulatory nature (including related regulations and enforcement mechanisms); official goals and plan programs; statements and other formally documented government directives; standards; guidelines; and decrees.

A content analysis of the documents should include level (e.g., national, provincial), topic area addressed (e.g., access, quality, FP, HIV/AIDS), and, where applicable, crosscutting issues (e.g., gender, human rights, youth).

Purpose:

The purpose of this indicator is to ensure that FP/RH policies exist that measure the degree of explicit support for access to and/or quality of FP/RH services on the part of government and other bodies, including service delivery institutions.

Gender Implications:

A gender perspective on plans and policies examines their content and their implementation strategies.

Does the policy/strategy address the society’s gender norms that may be harmful or inequitable (e.g., allowing life-saving blood transfusions for women suffering from post-partum hemorrhage without requiring the husband or woman’s father’s consent; allowing women the autonomy to obtain an FP method)?  

Evidence that policy barriers to equitable and affordable reproductive health services and information have been identified, addressed and/or removed

Definition:

This indicator focuses on identifying the barriers that prevent the implementation of family planning/reproductive health (FP/RH) policies and developing strategic plans to eliminate obstacles to accessing RH services. 

Policy barriers may affect participants in the policy process, service providers, and/or potential clients. They may affect both the public and private FP/RH sectors (such as restrictions on particular contraceptive methods or eligibility requirements for RH services) or may affect primarily the private sector. There are five categories of regulatory barriers:

Added to these are restrictions on access to training and exclusions from policy formulation meetings and other arenas in which policies are made.  To read more about operational policies in RH and how to address them, see Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs.

Data Requirements:

Evidence of a new/updated policy document such as a policy, strategy, operational plan, etc. that has addressed restrictions in the old policy.  If the policies are addressing inequity, there should also be evidence that the new/revised policies focus resources or other attention on addressing the inequities identified.

This indicator can be quantified in several ways. As a baseline measure, it may be expressed as the number and type of policy barriers that significantly hinder provision of RH services. To measure change over time in a country application, the evaluator should count and qualify the policy barriers identified at baseline, which were subsequently removed. Evaluators can measure change through naming and counting those identified policy barriers that do not appear in the new policy. Evaluators should link clearly the barriers identified at baseline, the policy interventions carried out, and the barriers identified at follow-up.

Because policy barriers by their nature tend to be very specific, evaluators can readily assess whether the new policy removes them. For example, if the barrier removed is import duties on contraceptives, evaluators can interview commercial distributors to determine if they no longer pay duties.

Data Sources:

Legal and regulatory reviews; actual policy documents with evidence of government approval or submissions for approval of changes. Key informant interviews can be conducted to identify other ways in which policy barriers were addressed, such as the creation of new operational policies, involvement of civil society and other stakeholders in addressing the policy barriers, and any strategic plans that have been developed to address those barriers.

Purpose:

The purpose of this indicator is to measure the extent to which policy barriers have been identified through the development of new policies, operational policies, and/or strategic plans and addressed through the implementation of these policies, strategies and guidelines. It highlights how policy reform can increase access to RH services for all sectors of the population. For example, removing client eligibility requirements-- such as marital status, minimum age, or parity for receiving FP methods or RH care-- empowers women and youth to demand the services and products they want. In another example, private sector participation in policy development may ensure that RH programs address the needs of all different groups in a population (e.g., women, men, commercial sex workers, men who have sex with men). The private sector can also be an important provider of RH services, especially in countries where government programs are either overburdened by demand or are unable to reach certain population groups.

Issue(s):

Although a policy barrier may have legally been removed, the change may not be effectively practiced as attitudes and behaviors of the policy implementers can lag behind. For example, if a barrier constraining contraceptive options is eliminated-- such as requiring parental consent to provide services to unmarried youth under age 18 -- in addition to conducting a legal and regulatory review, evaluators should also interview providers to assess their awareness of the barrier removal as well as interview youth to assess their ability to obtain services.

If those interviewed are not forthright, the evaluators may not be aware of policy barriers those implementing the policy may face in the field. Evaluators also need to identify and interview those with institutional knowledge to document how policy barriers were identified and addressed. In some instances, a policy barrier may have legally been removed. However, it may be much harder to change attitudes and behaviors of those implementing policies.

Identifying and addressing policy barriers in an iterative process. Addressing one set of barriers will lead to the recognition of another set of barriers which will require further interventions. Hence, it is challenging to measure this process.

Poverty and Equity Considerations:

Fear of discrimination, or a breach of confidentiality, discourages many marginalized people from approaching health care providers. This is compounded by a lack of information tailored towards sexual minorities and a lack of capacity to provide specialized health services (IPPF, 2011). Because access to health interventions is inequitable for sexual minorities, the result is a disproportionately heavy burden of ill health among the socially disadvantage, which is positively associated with poverty.

Gender Implications:

A gender perspective on policy barriers examines the question, do the plans recognize the common and different barriers women and men face in access to health care.  It also ensures that strategic plans made to address these barriers are gender sensitive.

Percent of government health budget allocated to family planning and reproductive health

Definition:

Budget allocated to family planning (FP) and reproductive health (RH) programs include the following resources: financial, human, physical infrastructure, and material support. Resources may be expressed in monetary forms, such as local currency budgets or US dollar conversions; other units, such as number of staff or staff time assigned to RH, are also possible. If used within a single country, the indicator can be expressed in terms of total resources. If cross-country comparisons are intended, the indicator should be expressed over a common denominator, such as resources per capita or RH resources as a percentage of the total budget.

This indicator builds on the next indicator which looks at Types of financing mechanisms for delivery of family planning/reproductive health goods and/or services Identified, tested and/or officially adopted.

Data Requirements:

Evidence of allocations to or expenditures on FP and RH, by the government.

Data Sources:

National and sub-national expenditure budget documents with evidence of approval; national and sub-national accounts; invoices, and other evidence of expenditures; personnel or staff assignment rosters. 

Other sources of information on national and sub-national funding include the surveys commissioned by UNFPA and the Netherlands Interdisciplinary Demographic Institute (NIDI), the UNAIDS/ Harvard University study on national expenditures on HIV/AIDS, and individual country studies of national expenditures and efforts to develop national health accounts.

Purpose:

This indicator measures the commitment of resources by either a government at the national or decentralized sub-national level to the FP and RH program. Evaluators must carefully define this indicator before they apply it to a country.

First, they must define the realm of expenditures by determining which government services are being tracked.

Second, evaluators must decide how to treat the source of public funds. For example, they may exclude donor grants but may include loan funds.

Third, evaluators may track separately capital expenditures (for new or renovated facilities, equipment) and recurrent expenditures for program operations (salaries, supplies, maintenance). Capital budgets may fluctuate widely from year to year, rising to cover construction of new facilities and falling when construction is complete. Thus, a decreased capital budget may not demonstrate or indicate a worsened policy environment. On the other hand, recurrent budgets should show at least maintenance or preferably steady increases over time, to cover growing populations and expanded and/or higher quality services.

Issue(s):

Particularly in countries that provide FP/RH services along with other maternal child health or primary health care services, evaluators may have trouble identifying and linking the line item in the budget of the appropriate ministry/organization to FP/RH. Moreover, when personnel provide other health services in addition to FP/RH, evaluators may have difficulty determining the proportion of time devoted to FP/RH.

In such cases, evaluators have the following options. First, the most commonly used, though least reliable approach, is to interview supervisors and health workers, asking them to estimate the percentage of their time spent providing FP/RH services. This percentage can then serve as a basis for allocating labor and other joint costs.

Second, evaluators can conduct a time-use survey of a sample of facilities, using either the technique of patient flow analysis or direct observation of health workers at specified intervals (i.e., work sampling). Bratt et al. (1999) showed that, compared to direct observation, neither self-reports nor patient-flow analysis reliably estimates allocation of staff time.

Third, another commonly used indicator of government resource commitment to RH is the share of the national budget allocated to FP/RH. The main problem with this alternative is that RH programs are often financed by several levels of government (e.g., national, state, local). Another problem is that such an indicator is sensitive to variations in the size of the national budget due to political, ideological, or national security considerations.

Fourth, some evaluators convert total expenditures to a per capita measure. This conversion permits cross country comparisons and at the country level may complement, rather than replace, the total resources indicator.

Fifth, as a precursor to this indicator, evaluators may track, on an interim basis, newly enacted plans or policies (either at the government, organizational, or programmatic level) that attempt to increase resources for RH services. Examples include new, separate budget line items for RH services in national and local MOH budgets, or a directive that insurance plans must cover RH services. Planning to increase resources for RH services may signal an increased recognition of the importance of such services.

Finally, government can enhance resource adequacy by spending existing resources more efficiently.  An important question regarding implementation is whether funds or other resources allocated are actually expended to provide RH services. Many governments fall short of implementing their published budgets. When assessing implementation, evaluators must confirm that the resources allocated to RH programs actually flow to the operational units in the field providing the services. In practice, most evaluations will not be able to follow the money trail down to the operational level.

Types of financing mechanisms for the delivery of family planning/reproductive health goods and/or services identified, tested, and/or officially adopted

Definition:

This indicator complements the indicator, Percent of government health budget allocated to family planning and reproductive health.

This indicator measures the "financing mechanism"-- any process that raises funds for family planning (FP) or reproductive health (RH) service provision. Examples of these mechanisms may include: fee for services, sliding fee scales, subsidized services through donor financing, and third-party payment mechanisms such as health insurance.

"Identified and tested" refers to actions that assess the feasibility and appropriateness of certain funding mechanisms for providing FP/RH services. To meet this indicator, a country or program must both identify and test a new financing mechanism as well as officially endorse the mechanism.

Program administrators mobilize resources through four main sources: direct government (central or local) financing, donor financing (including bilateral, multilateral, and private foundations), user fees, and third-party payment mechanisms such as health insurance. In the face of declining government and donor funding for RH, new (alternative) financing mechanisms such as user fees and health insurance take on added importance.

Data Requirements:

Information on type of financing mechanisms identified and/or tested and verification that it/they have been officially adopted. 

Data Sources:

Documents and meeting minutes; pilot tests; study results; policies; strategies.  Budgets and actual expenditure reports should be accessible to the public and evaluators. In addition, a line item for FP and RH funding in expenditure budget documents should exist at all levels of health expenditure reports.  Evidence of expenditures should also be available with invoices, staff rosters, etc. This indicator may involve a budget tracking exercise of FP and RH funds. Data sources can also include reports of donor funds that are allocated to FP and RH activities through implementing partners other than the government. Expenses incurred by the public in accessing FP and RH services through the private sector should also be measured.

Purpose:

This indicator measures the commitment of resources being allocated to FP and RH activities by the government, donors and the private sector. Funds for FP/RH services can be mobilized through four main sources: direct government (central or local) financing, donor financing, user fees, and third party payment mechanisms such as health insurance. This indicator highlights the importance of financial resource mobilization as an essential component of a national plan or policy.

Issue(s):

Not all new financing mechanisms are necessarily good. Adding a new mechanism like fee for service can be good if it increases available resources for FP/RH, or bad if it suppresses demand. Often economic barriers, such as high fees for services or high transportation costs, restrict access to health services. On the other hand, charging nominal fees for certain FP/RH services may increase demand for such services, because people may associate better quality of services or a greater need for those services with having to pay for them. National health budgets can demonstrate intentions, but expenditures may not be consistent with the budget. Expenditure data are, by definition, retrospective and there may be time lags of several years before accounts are reported and reconciled. Infrequent.

If there is no line item for FP and RH services, then that poses a challenge for the evaluators. Even in the presence of a line item, getting the true expenditure on FP/RH services can be a challenge. For example, if FP/RH services are integrated with other maternal and child health services or if the same providers provide multiple services or if the FP/RH budget is not itemized to clearly note where and how the money was spent. Evaluators should also analyze if there is a discrepancy between the allocated budget and the actual amount spent on FP and RH activities. In a decentralized health system, funds for health services can come from national and decentralized ministries, such as state, local, etc. Hence, the budget tracking exercise should take the various decentralized budgets into account. In societies where a huge proportion of health expenses are covered out-of-pocket, the evaluators will also need to include out-of-pocket and private sector expenditures when calculating the full cost of healthcare.

In terms of implementation, evaluators will need to distinguish between the testing of a new mechanism and the mechanism's success at increasing revenues without unduly depressing demand. Organizational willingness to test a variety of financing mechanisms signals a positive policy environment, even if the organization ultimately adopts only one or two of the mechanisms.

Existence of official policy incentives to stimulate and/or increase private sector financing and/or delivery of family planning/reproductive health services and/or commodities

Definition:

This indicator constitutes a subset of the indicator, Existence of national/subnational or organizational policies or strategic plans adopted that promote equitable and affordable access to high-quality family planning/reproductive health (FP/RH) services and information. It focuses attention on the private sector.

Policy incentives refer to any course of action that facilitates private sector participation in providing RH services. Such incentives may include tax breaks for private sector organizations that provide RH services or for individuals who contribute to NGOs or mission hospitals providing RH, tariff relief, and public vouchers.

Data Requirements:

Evidence of policies developed that provide incentives

Data Sources:

Actual policy documents with evidence of government approval, or submission for approval.

Purpose:

Governments can hinder private sector participation through several policy barriers. On the other hand, governments cannot mandate private providers to offer FP/RH services. The purpose of this indicator is to measure the extent to which governments facilitate the private sector's involvement in providing RH services.

Issue(s):

Evaluators have limited experience in applying this indicator in developing countries. Tariff relief that
exempts contraceptives from import duties is the most widely-practiced policy incentive to private sector service delivery. In South Korea, the family planning program at one time provided vouchers to reimburse private sector physicians for performing voluntary sterilizations and IUD insertions. Indonesia tested a similar voucher system with private midwives, and Nicaragua has tested special vouchers for sex workers. Tax codes may offer deductions for charitable contributions to NGOs. Hence, more data are needed in the application of this indicator.

Institution has the technical capacity and inter-institutional relationships to implement family planning/reproductive health policies

Definition:

Technical capacity” refers to staff knowledge, training and experience along with the systems in place required to operationalize a policy.  “Inter-institutional relationships” refers to the working relationships the institution or organization has with other players it is expected to interact with in order to implement the policy (e.g., policymakers at the national and decentralized level, universities, faith-based organizations, non-governmental organizations, government stakeholders, donors, civil society, community leaders, healthcare institutions and healthcare providers, etc.).  It is about the networks and leverage institutions have with others that can facilitate or impede policy implementation. 

Data Requirements:

Information is needed on the technical proficiencies of the institution responsible for policy implementation. Evidence is also needed on how the implementing institution interacts and collaborates with other institutions in implementing family planning/reproductive health (FP/RH) policies.

Data Sources:

Implementation plans can outline the specific activities the institution will undertake to implement the policy. Quarterly and annual reports of implementing institutions will provide an overview of the technical capacities of the institution. They can also state how each institution is performing in comparison to its expected outcomes. Qualitative interviews will provide insight into the relationships between institutions as well as any attempts that have been made to build relationships with other organizations. Organizational capacity assessments can provide information on technical capacity. Action items of meeting minutes to see who is involved in various activities and initiatives can supplement qualitative interviews).

Purpose:

Policy implementation includes both technical and organizational aspects—not only must an institution have the knowledge and technical skills for implementation but it must also have the appropriate organizational structure, network, and relationship with other institutions to  foster collaboration. Power structures and inter-institutional dynamics involved in implementing the policy should not be underestimated. Complex policies will involve multiple institutions, at national and decentralized levels, in its implementation. This indicator highlights the implicit need for institutions to carry out expected activities as well as work together to implement FP/RH policies. 

Issue(s):

In identifying if an institution has the technical capacity and institutional relationships to implement policy, evaluators will have to use multiple data sources and rely heavily on qualitative data which can be subjective and difficult to interpret.  Assessing inter-institutional relationships can be challenging and time-consuming, particularly for an “outsider”, as intangible qualities such as reputation and clout often influence how institutions relate to one another. 

Clear, concise, and standardized definitions for measuring capacity of institutions to uptake policy do not exist.  Furthermore, the technical and organizational resources and networks required for implementation vary by policy and context, so what is appropriate for an organization in one case may not be deemed sufficient in another case.    

Evidence that systems exist for monitoring the progress made in implementing family planning/reproductive health policies

Definition:

This indicator determines the mechanisms that are in place to monitor a family planning (FP) or reproductive health (RH) policy and how it is being implemented. It measures if all stakeholders and institutions responsible for implementing the policy have the technical capacity to do so and how capacity is being built. It notes the relationships among implementing institutions, and power dynamics within and among organizations and stakeholders. The presence of adequate financing mechanisms and resource allocations are acknowledged. The capacity of institutions to identify policy barriers and strategically address them is also measured.

Data Requirements:

Depending on the policies being monitored, specific indicators need to be identified that reflect changes in the policy implementation process as well as health programs and systems. The indicators should be able to show changes over the past two to three years, be comprehensible and actionable.

Data Sources:

Project records; quarterly reports; action plans; interviews with key informants; newspaper articles; published statements; speeches; meeting minutes of various institutions, stakeholders and civil society groups.

Purpose:

This indicator uses data to inform better policy implementation. It can measure incremental changes in the intent, processes, and impacts of reforming FP/RH policy. The objectives for the indicator and the selected questions and measures will provide comprehensible information that will allow government officials to interpret which policies are driving their score and are actionable in the sense that concrete policy initiatives can improve their progress. National health policies and the indicators used to measure progress with these policies should be consistent with existing international efforts and priority targets, such as the Millennium Development Goals. In this way, it also ensures that all stakeholders are held accountable for implementing the policy. Measuring this indicator will strengthen accountability mechanisms and ensure more transparent monitoring.

Issue(s):

Policy implementation is a complex process that can span several years. Having the funds and capacity to monitor the process over a long period of time can be a challenge. Since several stakeholders may be responsible for implementing a policy, it requires a lot of resources to monitor progress. Implementing stakeholders may not always share information freely thus making it challenging for monitoring to take place. Infrequent data collection or complex validation processes can lead to long lag times between policy implementation and the measurement of progress indicators.

Gender Implications:

Policy goals and objectives may affect sub-populations differently. Hence, special measures need to be built into the policies and resulting initiatives and programs to address gender inequalities. The value of this and related indicators is dependent on analysis with attention to achieving gender equality and identifying gender differences in policy implementation and outcomes.

Evidence of civil society involvement in developing family planning/reproductive health policies

Definition:

Evidence exists in demonstrating the involvement at national and subnational levels of individuals and groups from civil society in developing family planning (FP)/reproductive health (RH) policies.  

Data Requirements:

Individuals and groups should be identified in advance and key informants interviewed using a standardized questionnaire or assessment tool that measures level of involvement as assisting or actively engaging in policy dialogue, planning, and/or advocacy. A third party review of project records, reports, action plans, newspaper articles and published statements and speeches is recommended.

Data Sources:

Project records; quarterly reports; action plans; interviews with key informants; newspaper articles; published statements; speeches; meeting minutes.

Purpose:

This indicator can be used to identify the existence, types, and levels of civil society participation and advocacy in FP/RH policy development. A number of factors influence the planning and implementation of policy including the nature of the policy process, the actors involved in the process, and the context in which the policy is designed and must be implemented. The motivation, flow of information, and balance of power among civil society and public stakeholders influences policy development. In addition, involvement of civil society early in the process improves the likelihood of success. For example, civil society groups are well-suited to participate in much needed advocacy for policy issues, adapt policy strategies to reach under-served populations, and monitor program accountability.  

Issue(s):

While policy formulation is being increasingly recognized as requiring a multisectoral approach, involvement of civil society groups may not continue during implementation.  This indicator does not extend beyond the policy development stage and additional indicators are needed to measure continued levels of civil society participation during the implementation phase.  Thus, an important follow-up indicator would be Evidence of civil society participation in monitoring the implementation of family planning/reproductive health policies.

Gender Implications:

National RH policies may affect subpopulations differently and women and girls constitute an especially vulnerable population if gender equality measures are not built into the policies and resulting initiatives and programs. Women and girls can face barriers to RH services and information that are intensified by cultural gender norms. Government and policy leaders need to include women and women’s groups as stakeholders in the policy development process, while making gender equality central to policy decisions, program design and implementation.   

Evidence of civil society participation in monitoring the implementation of family planning/reproductive health policies

Definition:

Evidence exists in demonstrating the involvement at national and subnational levels of individuals and groups from civil society in monitoring established family planning (FP)/reproductive health (RH) policies. Participation in monitoring the implementation of policies can include:

Data Requirements:

Individuals and groups should be identified in advance and key informants interviewed using a standardized questionnaire or assessment tool that measures level of involvement as assisting or actively engaging in policy monitoring. A third party review of project records, reports, action plans, newspaper articles and published statements and speeches is recommended.

Data Sources:

Project records; quarterly reports; action plans; interviews with key informants; newspaper articles; published statements; speeches; meeting minutes.

Purpose:

This indicator can be used to identify the existence, types, and levels of civil society participation and advocacy in FP/RH implementation. Civil society can play an important role in monitoring how FP/RH policies are being implemented.  Civil society can represent various voices and groups of sub-populations and thus are able to advocate for the just and complete implementation of the process. They can bring to light barriers and challenges in the implementation process thus prompting action to address those barriers.

Issue(s):

Policy implementation is a complex process that can span several years. Having the funds and capacity to monitor the process over such a long period of time can be a challenge. Since several stakeholders may be responsible for implementing a policy, civil society groups require a lot of resources to advocate for sound implementation and monitor progress. Implementing stakeholders may not always share information freely with civil society groups and the general public making it challenging for monitoring to take place.

Gender Implications:

Civil society groups can advocate for special vulnerable and minority populations and ensure that the FP/RH policies are being implemented equitably within the targeted population. Government and policy leaders need to include women and women’s groups as stakeholders in the policy implementation process, while making gender equality central to policy decisions, program design and implementation.