Impact Magazine No. 25 by Impact Magazine

No. 25

MAGA ZINE

s d n a H r E in H CONTRIBUTIONS FROM Maverick Collective's Dr. Precious Moloi-Motsepe Women Deliver’s Katja Iversen WHO’s Ian Askew & Manjulaa Narasimhan FP2020’s Beth Schlachter AVAC’s Mitchell Warren CIFF’s Miles Kemplay PATH’s Martha Brady 10 Women Deliver Young Leaders

Cutting edge global health coverage

Psi @ WomEn dEliVEr 2019 SCHEDULE

VISIT US AT BOOTH #754

SUNDAY, JUNE 2

WEDNESDAY, JUNE 5

Making The Case For Her: Breaking Taboos Around Women and Girls’ Sexual and Reproductive Health Pre-Conference Event Hosted by The Case for Her 6-8 p.m., Vancouver Convention Centre (VCC) West, Room 110

Transforming Health Care through Self Care: Agency and Power in SRHR Side Event Sponsored by PSI, CIFF and the Hewlett Foundation 6:30-8 a.m., VCC West, Room 211

Not Without a Cervix! Advocating for an Effective Cervical Cancer Response Side Event Hosted by TogetHER for Health Co-sponsored by PSI, UICC, American Cancer Society, Jhpiego, PCI and Pathfinder PSI Presence: Moira Lindsay, PSI Caribbean 6-8 p.m., VCC West Room 217

MONDAY, JUNE 3 Youth-Powered Programming’s Next Big Thing: Going Where Young People Take Us Side Event Hosted by Adolescents 360 By Invitation Only 7:45-9:30 a.m., Fairmont Waterfront Mackenzie Ballroom Youth-Powered Investments in West and Central Africa Side Event Hosted by PSI 12-2 p.m., Fairmont Waterfront, Princess Louisa Room Power in Her Hands: Why Menstrual Health Matters for Sexual and Reproductive Health Side Event Hosted by The Case for Her PSI Presence: Maria Carmen Punzi, PSI Europe 6:30-7 p.m., The Case for Her Booth

TUESDAY, JUNE 4 The Power of Money: Driving equitable economic growth by investing in women Plenary Session PSI Presence: Dr. Precious Moloi-Motsepe, Maverick Collective 3-4 p.m., Plenary Hall, VCC West The Global Gender Digital Health Divide: A Debate Concurrent Session Sponsored by PSI, FHI360, PATH and Philips PSI Presence: Rehema Mugeta, PSI Tanzania 3-4 p.m., VCC West, 221-222 Let’s Talk About It: Period! Side Event Sponsored by CHOICE for Youth and Sexuality, UNFPA and Stars Foundation PSI Presence: Maria Carmen Punzi, PSI Europe 3-4 p.m., VCC West, Room 118 Appy Hour, presenting PSI’s HNQIS PSI Presence: Janet Patry, PSI 6:30-7 p.m., Solutions Gallery Dare to Dream: Adolescents 360’s “Sisi Nanasi” Music Video Screening WD2019 Film Festival 6:30-7 p.m., VCC West Exhibition Hall

SafeAccess to Abortion: A Cross-Sector Partnership to Eliminate Unsafe Abortion by 2030 Side Event Sponsored by MSI PSI Presence: Dr. Fatima Bunza, PSI Nigeria 6:30-8 a.m., VCC West, Room 214 Adolescent Sexual and Reproductive Health and Rights: Programming for a New Generation Concurrent Session Organized by UNFPA, CHOICE for Youth and Sexuality, Purposeful Productions and With and For Girls Collective PSI Presence: Bitania Lulu Berhanu, PSI Ethiopia 10:30-12 p.m., VCC West, Room 110 Accelerating Knowledge: Social Entrepreneurs and Family Planning Lunch Event Hosted by Bayer PSI Presence: Rosemary Nazar, PSI Tanzania 12:15-1:15 p.m., VCC West, Room 110 The Power of Stories: Making sexual and reproductive health and rights come to life Plenary Session PSI Presence: Karl Hofmann, PSI 1:30-2:30 p.m., VCC West, Plenary Hall Designing for a Better World: Can Design Thinking Improve the Lives of Girls and Women? Concurrent Session Organized by PSI, FHI360, PATH and Philips PSI Presence: Rosemary Nazar, PSI Tanzania 1:30-2:30 p.m., VCC West, Room 306 Let’s Get What We Want: Contraceptive Innovation, Access, Quality, and Choice Concurrent Session Organized by FHI360 PSI Presence: Jennifer Pope, PSI 1:30-2:30 p.m., VCC West, Room 301-305 Self-Care: The Next Frontier in Women’s Health Concurrent Session Organized by PSI, FHI360, PATH and Philips PSI Presence: Chiwawa Nkhoma, PSI Malawi 3-4 p.m., VCC West, Room 217-219

THURSDAY, JUNE 6 How Will NextGen Philanthropists Recalibrate Power? Power Talk PSI Presence: Alexandra Idol, MaverickNext Fellow 1:05-1:12 p.m., Power Stage Girls Are More Than Just Clients Power Talk PSI Presence: Bitania Lulu Berhanu, PSI Ethiopia 1:55-2:02 p.m., Power Stage FP2020 Celebration of Commitments: PSI Exceeds Pledge to Reach 10 Million Youth with Modern Contraception Sponsored by PSI 5-7 p.m., VCC West, Room 306

Editor’s Note

WHY WE’RE BREAKING UP WITH "EMPOWERMENT" I set a day’s worth of bottles by the daycare sink before kissing my 11-month-old on the head and handing him to Princess, his caregiver. Princess’ eyes glided over me, and she smiled. “You’re pregnant!” I laughed and said, “Nope. This guy is turning one next week and his brother is turning three. My hands are full and my wallet is already empty.” I walked out of the daycare center. I opened the car door and noticed a form from my last gynecologist appointment still on the dashboard. I grabbed it and started sweating. My last period had been eight weeks before. Princess was right, and I needed to do something quickly. I told my husband I wanted to protect the future for our two children: I wanted to get an abortion. My husband could have stood in my way. So, too, could society, religion or the law, but no one could “empower” me. No one could give me power to make my choice. I had to take it. I’m extremely privileged — white, Western and married to a husband who was indeed supportive — but I still feel it when someone means to empower me. It means that the power is theirs to give, and they are doing me a favor. I don’t need someone else to give me power. But I do need the obstacles removed from my path. That’s the role that the legal system, societal norms and market pressures can play, as well as organizations like ours. PSI’s strategy demands that our consumer has power in her hands and that we work to build markets so she can make the choices she desires for her life. That’s our Consumer-Powered Healthcare agenda. This Women Deliver, PSI is breaking up with the word empowerment. It’s controversial. Certainly, anyone who offers to empower women does so with the best intentions. But language matters. This word is an outdated construct, perhaps particularly in the development community; “to empower” can sound neo-colonial and condescending. It represents us, those with means, giving power to you, those with none.

In this issue of Impact magazine, created in partnership with Women Deliver, you’ll read about the self-care movement, why it’s picking up steam and how to make sure that the right supports are in place for girls and women to self-administer the care they need. It’s an exciting time as the World Health Organization and donors like the Children’s Investment Fund Foundation and the Hewlett Foundation invest in ways to enable consumers, particularly girls and women, to use drugs, diagnostics, devices and digital modalities to test themselves for HIV, inject their own contraception, administer their own medication abortions or track their cycle and its own uniqueness month over month using an app. If I had access to a form of self-care, such as medication abortion, when I discovered my own unwanted pregnancy it would have allowed me to keep my choice solely in my hands. Instead, I tried to make an appointment for an abortion with my doctor. She told me no. She referred me to Planned Parenthood, where I learned my evening appointment would be 40 miles away from my home. Of course, all of that is a very small price to pay given the threats of violence and lack of access so many other women face in countries all over the globe, developing and otherwise. Today, I tell my teenage children this story with pride, letting them know that protecting their future was the most important thing to me. It’s my goal and PSI’s to create the space for all women and girls to take hold of their power to protect their dreams. This is my second time attending Women Deliver and PSI’s fourth. Our 65-person delegation hails from nearly 15 countries and is incredibly excited to learn from all of you. We look forward to working with you to create spaces for every girl and woman to exercise the #PowerInHerHands.

K AREN SOMMER SHALETT

Editor-in-Chief, Impact Magazine

@ksommershalett

SECTION TITLE

WHAT'S INSIDE?

TABLE OF CONTENTS

Photo credit: © PSI Nepal/Davendra Lalshreesha

Photo credit: Ideo.org

Around PSI

Why the WHO is Launching Self-Care Guidelines by Ian Askew and Manjulaa Narasinhan, WHO

Girls are More than Just Clients by Bitania Lulu Berhanu, PSI Ethiopia

Girls Need to Dream by Rosemary Nazar, PSI Tanzania

by Miles Kemplay, Children's Investment Fund Foundation

by Kristy Kade, White Ribbon Alliance

by Maria Carmen Punzi, PSI Europe

by Pierre Moon, PSI Global

by Cristina Ljungberg, The Case for Her

by Sandy Garçon, PSI Global

The Self-Care Revolution is Here

The Four Dimensions of Self-Care

Photo courtesy of Women Deliver

I M PAC T M AG A Z I N E N O . 2 5

Self-Care Starts with Women

There's so Much to Gain with Menstrual Health

The Power of the Menstrual Cycle

What do Health Providers Think of Self-Care?

Photo credit: © PATH/Gabe Bienczycki

Photo credit: © PSI/Benjamin Schilling

Discreet Diagnostics by Aubrey Weber, FHI360

The Time is Now by Martha Brady, PATH

A Safe Abortion in her Hands by Maria Dieter, PSI Global

Let's Talk About Self-Care by Women Deliver Young Leaders

by Janet Patry, PSI Global

by PSI Partners

Transforming Healthcare with the Tap of a Finger

Why Invest in West and Central Africa Adolescents?

by Emma Beck, PSI Global

by Alex Idol, MaverickNext

by Jan-Willem Scheijgrond, Philips and Stephanie Dolan, PSI Global

by Rehema Mugeta, PSI Tanzania

by Katja Iversen, Women Deliver

by Dr. Precious Moloi Motsepe, Maverick Collective

by Karl Hofmann, PSI President and CEO

ECHO Reverberates Across SRH by Beth Schlachter, FP2020 and Mitchell Warren, AVAC

How to Unlock Powerful Partnerships

Maama Knows Best by Rebecca Babirye, PACE

Going Where Girls Go

Healthcare in the Palm of her Hand

Ubuntu; The Spirit of Philanthropy

A New Wave of Power

How Will You Use Your Power for Good?

Power is Ripe for Reinvention

PSI NETWORK

Impact team Editor In Chief

Art Director

Karen Sommer Shalett Director, External Relations & Communications Director kshalett@psi.org

Pol Klein Senior Manager, Creative Services pklein@psi.org

Managing Editors

Graphic Designer

Maria Dieter Associate Content Manager mdieter@psi.org

Cassie Kussy Associate Graphic Designer ckussy@psi.org

Sandy Garçon Senior Manager, Advocacy & Communications sgarcon@psi.org Emma Beck Associate Communications Manager ebeck@psi.org Editorial Assistant

Kasey Henderson Communications Assistant khenderson@psi.org

ONLINE

psi.org @psiimpact @psiimpact facebook.com/PSIHealthyLives youtube.com/HealthyBehaviors Address Population Services International 1120 19th Street NW Suite 600 Washington, DC 20036 www.psi.org

Population Services International (PSI) is a g o a non profit operating in ore than 50 countries worldwide, with programs in modern contraception and reproductive health, malaria, water and saintation, HIV, and non-communicable diseases. As PSI looks to the future, the organization will reimagine healthcare to put the consumer at the center and whenever possible bring care to the front door.

Contributors

Ian Askew James Ayers Rebecca Babirye Bitania Lulu Berhanu Rachel Braden Martha Brady Stephanie Dolan Andrea Fearneyhough ena reifinger Elisabeth Harris Lizzie Hudson Alexandra Idol Katja Iversen Gretchen Jereza Christina Julmé Kristy Kade Miles Kemplay Cristina Ljungberg Alia McKee

Dr. Precious Moloi-Motsepe Pierre Moon Rehema Mugeta Manjulaa Narasimhan Rosemary Nazar Sara Ojjeh Janet Patry Maria Carmen Punzi Malcolm Quigley John Sauer Jan-Willem Scheijgrond Beth Schlachter Annie Tourette Amy Uccello Mitchell Warren Aubrey Weber Beau Westbrook

No. 25

MAGA ZINE

In her hands CONTRIBUTIONS FROM Maverick Collective Co-Chair Dr. Precious Moloi-Motsepe Women Deliver’s Katja Iversen WHO’s Ian Askew & Manjulaa Narasimhan FP2020’s Beth Schlachter AVAC’s Mitchell Warren CIFF’s Miles Kemplay PATH’s Martha Brady 10 Women Deliver Young Leaders

Cutting edge global health coverage

Cover Credit

Pol Klein Cassie Kussy 4

I M PAC T M AG A Z I N E N O . 2 5

I S P D N U O R A PSI EXCEEDS FP2020 GOAL EARLY! PSI is catalyzing bold ways of driving health breakthroughs, with and for the young people we serve. The results? Well, the proof is in. As of Dec. 2018, PSI had reached 14 million users under the age of 25 with modern contraception—an achievement that falls two years ahead of PSI’s Family Planning (FP) 2020 pledge to reach 10 million young people with a contraceptive method. It’s an achievement that sits squarely in line with PSI’s commitment to reimagining how our youngest consumers access the health services they need, on their own terms. Meeting the FP2020 pledge comes on the heels of a youth-powered healthcare movement that has transformed PSI’s youth programming. Since the 2018 launch of PSI’s Global Strategic Plan, we’ve i e t e scri t e re or ing it an for yo ng eo e as equal partners in the health solutions that serve them. Our ags i a o escent an yo t se a an re ro ctive ea t rograms n erscore t at o r o is to in ea t o tcomes to t e o ectives yo ng eo e efine as t eir imme iate nee s i e financia sta i ity or ersona a tonomy is s ift from a

yo t centere to a yo t o ere a roac is e em ifie y our increased youth programming, our contribution to the Global Consens s Statement on eaningf o t ngagement an o r a t oring of t e Commitment to t ics in o t o ere esign But our success isn’t without its learnings. rF e ge ta g t s t at or as nee e to tr y understand who was coming through the service delivery door. As a result, we’ve devised a series of formulas to support how e trac an recor ages of o r cons mers an o e can more effective y e i o r net or mem ers to n erstan an respond to use-need in their respective countries. PSI recognizes that young people remain drastically underserved and underrepresented in the health sector. We remain unwavering in our promise that all young people—regardless of age, marital status or parity—have access to the widest range of contraceptive options, where, how and from who they want. We’ve reached upwards of 14 million young people with modern contraception and we’re energized by the opportunity to reach 14 million more. my cce o Senior o escent Health Technical Advisor, PSI

o t Se

e ro

ctive

DRONES MAP THE WAY Haitian cities are growing so fast t at organi ations i e aSS S s net or mem er in t e Cari ean nation can t trac t em effective y it a sim e ma is ra i gro t often leads to poor infrastructure, resulting in navigability issues an irections t at are iffic t to n erstan ic can e particularly challenging for girls and young women trying to access services from health facilities. This is why OHMaSS is leveraging the power of drones to provide visual directions with videos, so that girls and young women can fin t eir ay to yo t frien y services in ort a rince OHMaSS has made visual directions to 25 local clinics, detailing t e e act roa s t at ea to t e ea t c inics

ro g its socia me ia cam aign anm nfo aSS istri tes t ese vi eos via Face oo to an a ience t at as already consumed 2 million minutes of content focused on increasing no e ge an a areness of se a an re ro ctive health for girls and young women in Haiti. With these videos, Haitian girls and young women can navigate their way to the power of good health they deserve. C ristina OHMaSS

ar eting an Comm nications Coor inator

TOILETS FOR ALL Approximately 500 million people in Sub-Saharan Africa do not ave access to a asic toi et ma ing t em v nera e to avoi a e angers i e c ronic isease ma n trition an gen er ase violence. We’re not doing enough to ensure they have access to t e sanitation services t ey eserve e or an re icts t at at t e c rrent rate it i ta e severa n re years to reac universal coverage of basic sanitation. In short, business-asusual is not getting us there. n an effort to reac t e nite ations S staina e eve o ment Goal 6—availability and sustainable management of water and sanitation for a y S as artnere it fam an Social Finance to create a global movement that will push forward progress for sanitation. This initiative aims to deliver sustained access to simple and affordable sanitation for 100 mi ion eo e t ro g t e mar eting sa es an insta ation of 20 million hygienic toilets. This effort is built around three pillars of change: an approach built on inc sive mar ets sim e an affor a e ro cts an f n ing instr ments t at are fit for r ose t i first e e ivere in a small number of low-income countries, focusing on inclusive mar ets to ens re t at cons mers can access mo ern toi ets at scale and pace. is en eavor is com e re iring front f n ing across donor communities. But with investment and cooperation across the development community, we aspire to deliver toilets for all. o n Sa er an ennifer arcy Senior ec nica Water, Sanitation & Hygiene, PSI

visors for

r a a r a tan er o erator in atna ses is tan er for a it c eaning on site at a rivate ome Photo credit: Malcolm Quigley

AFTER THE FLUSH One in five Indian children die from diarrhea caused by unhygienic conditions. ressing t is ris e ten s e eyon access to toi ets e sanitation mar et serving n ian cons mers as ro en o n most toi ets in n ia re y on its or se tic tan s to e em tie by unregulated private service providers who dump waste in unauthorized areas. In response to the illegal dumping of waste, PSI India started a pilot program in the city of Patna, Bihar state, India. The rogram create an association of rivate tan er o erators to advocate at the local government level for access to the city’s sewerage system. The local government, in partnership with the association, licensed the operators to ensure high-quality services for consumers. The association also established a hotline and public promotion events to ensure the new services were readily accessible. This pilot, dubbed After the Flush, received seed funding from the i e in a ates Fo n ation e ne t stage i e sca e y mem ers of averic Co ective in artners i it t e For m of o ng o a ea ers at t e or conomic For m arnessing t e e ertise net or s an commitment of a g o a community of partners to adapt and scale the success of the Patna pilot, After the Flush plans to bring the power of good hygiene to 10 more cities across India. ate o erts Senior ice resi ent Co ective ate o erts S

Photo credit: ©PSI

S Co Fo n er

averic

THE ROAD TO MALARIA ELIMINATION Widely available, accurate and affordable rapid diagnostic tests ( s) ave revo tioni e ma aria case management But all suspected malaria cases must be screened, 100 percent of the time, especially if we want to reach the World Health Organization’s (WHO) ambitious 2030 goal of reducing the global malaria incidence and mortality rate by 90 percent. e aven t yet reac e f coverage an essentia ste to reaching the WHO’s goal. In countries with a high burden of ma aria t e ga is star est es ecia y ere cons mers see testing an treatment in t e rivate sector Com re ensive o icy regulation, quality assurance and supply-side strengthening a create c a enges en esta is ing services in t e private sector. Until this year, there was little global guidance provided to governments that needed assistance engaging with private rovi ers an t eir cons mers on o t ey co est or to achieve universal testing goals and effectively manage cases of malaria. Between 2013 and 2016, the WHO collaborated with PSI and a consorti m of ma aria e erts to stim ate rivate sector mar ets in five frican co ntries for a ity ass re ma aria s sing f n ing from nitai nforme y evi ence t ey found, PSI, WHO and the partners from this project created a roadmap for optimizing private sector malaria rapid diagnostic testing, published in May 2019. The roadmap describes 40 ste s t at nationa ma aria contro rograms an sta e o ers can fo o to s ort t e se of a ity ass re services in the private sector.

anessa ic

A KNOWLEDGE HUB FOR SAFEACCESS It’s time to come together to better support a woman’s right to safe abortion and to remove the barriers that restrict her access. That’s why Marie Stopes International is creating a ne on ine no e ge in co a oration it co fo n ers PSI*, International Planned Parenthood Federation, Ipas and t e Safe ortion ction F n e no e ge ca e SafeAccess, will share evidence-based guidance on safe abortion and post-abortion care programming with implementers and o icyma ers ena ing t e se a an re ro ctive ea t comm nity to or to ar an am itio s goa to e iminate nsafe abortion by 2030. SafeAccess is powering hope that one day—no woman anywhere in the world—will suffer the consequences of unsafe abortion. S

mot er an c i

in gan a a ait t e res ts of t eir ma aria a i

iagnostic est (m ) at ins

C a ters cover t e mar et f nctions critica to s in t e rivate sector i e coor ination roc rement a ity assurance, promotion and surveillance, and draw on case studies and tools from the earlier project. Content from t e roa ma i e incor orate into f t re comprehensive private sector malaria case management guidance developed by the WHO, informed by the outcomes of their recent private sector technical consultation. Ste 8

en oyer Senior C

a aria esearc

visor

oes not se

overnment f n s for its safe a ortion or

—Andrea Fearneyhough, Director, Women’s Health Project, PSI Learn more about the SafeAccess hub from PSI Nigeria’s Dr. Fatima Bunza and other safe abortion experts at “SafeAccess to Abortion: A Cross-Sector Partnership to Eliminate Unsafe Abortion by 2030,” a Women Deliver side event, on Wednesday, June 5 from 6:30-8:00 a.m. in VCC West, Room 214.

tHE ne t rontier o healtHCare

Self-care places power in the hands of consumers to understand and manage their own health. Theâ&#x20AC;&#x153;four Ds of selfcareâ&#x20AC;&#x201D;diagnostics, devices, drugs and digital technologyâ&#x20AC;&#x201D;are increasing choice and access to reproductive health services, strengthening health systems and paving the way toward universal health coverage.

W H AT I S S E L F C A R E ?

wHY tHE world healtH organization is launCHing sel -Care guidelines for Sexual and Reproductive Health and Rights Self-care interventions for health—including self-testing, selfdiagnosis, self-management, self-medication, self-monitoring and self-educating—can transform health systems and accelerate progress toward universal health coverage. Promoting autonomy and agency through a person-centered approach recognizes people’s right to make decisions and take actions to safeguard their own health. This paradigm shift in healthcare and service availability is particularly important when stigma, inequality, discrimination and violence impede a person’s ability to access health services, medicines and technologies.

The Sustainable Development Goals give the public health community the platform and the political mandate not just to improve health outcomes but to transform health systems. Increased autonomy can lead to people voicing their needs and making choices with regards to their healthcare, and not simply accepting the healthcare that providers decide they need.

Too often, policy is divorced from practice, and up to 400 million people have no access to essential health services. This includes 214 million women in developing countries who want to avoid pregnancy, but are not using contraception; an estimated 22 million women who experience unsafe abortions worldwide each year; more than 1 million people who acquire sexually transmitted infections (STIs) every day; and an estimated 29 adolescents who are infected with HIV every hour. Furthermore, gender inequality limits access to quality health services and contributes to avoidable morbidity and mortality in both women and men. Innovative and cost-effective solutions to deliver safe and quality health interventions, medicines and biomedical and digital technologies are urgently needed. Self-initiated interventions are an exciting approach to advance sexual and reproductive health and rights. © PSI/Evelyn Hockstein

WHO is committed to supporting greater autonomy to promote ea t an e eing s first conso i ate normative guidance on self-care interventions shifts its approach to healthcare from a primarily biomedical perspective to a more person-focused approach, initially in relation to sexuality and reproduction with evidence-based recommendations on interventions for maternal health, contraception, cervical cancer, fertility and STIs, including HIV and safe abortion. For countries and individuals worldwide, this shift can move the public health community from a disease prevention perspective to promoting a holistic approach to health and well-being. IAN ASKEW

Director, Department of Reproductive Health and Research, including the UNDP- UNFPA- UNICEF- WHO- World Bank Special Programme (HRP), WHO, Geneva, Switzerland

@IanAskew_HRP

MANJULAA NARASIMHAN

Scientist, World Health Organization (WHO), Geneva, Switzerland © Unitaid/Eric Gauss

I M PA C T M A G A Z I N E N O. 25

SECTION TITLE

BY MILES KEMPLAY, CHILDREN'S INVESTMENT FUND FOUNDATION

or he la five ear , the Children’s Investment Fund Foundation (CIFF) has invested in improving the sexual and reproductive health and rights (SRHR) of young people.

But these choices are now becoming increasingly popular for several reasons: •

We have always been biased toward approaches and interventions that rapidly shift power away from those that have power—the funders, politicians, policymakers, implementers and service rovi ers an ace it firm y in t e an s of cons mers see ing SRHR information, choices and services.

ere are some f n amenta a s in service e ivery norms: provider bias and stigma are well known. Stigma is ma icio s to ar t ose o co stan to enefit t e most from self-care; less overt is the over-medicalization and gating of information and tools. We know that people only spend a fraction of the time considering their healthcare in a facility, yet that is the focus of most donor investment.

•

Self-care in healthcare is one of the most powerful ways to make this power shift a reality. It creates a real opportunity for philanthropy to accelerate progress toward universal access to SRHR. It is not a new idea, and certain services already offer such options: pregnancy test kits, a daily pill to prevent pregnancy (and now HIV) or an easy self-test to know your HIV status.

The health system has weaknesses. Stock outs jeopardize our commitment to choice. Current gaps in recruitment and investment in infrastructure mean that hundreds of millions of people continue to lack access to basic healthcare, and millions more are disgruntled with the health services available.

•

SRHR is uniquely personal by nature, and demands increasingly tailored care designed around the individual, with information and tools accessible at moments that matter, often well before an individual enters a clinic or pharmacy.

During this time, we have spent over US$220 million to prevent unplanned pregnancies, unsafe abortions, HIV, sexually transmitted infections and sexual violence among adolescents and young people, often through co-funded programs with other foundations and governments.

W H AT I S S E L F C A R E ?

To date, our focus has been on the market dynamics underpinning self-care product innovations. For example, our work to dramatically reduce prices has allowed markets to procure millions of self-injectable contraceptives and HIV self-tests per year; our commitment to competition and supplier diversity is encouraging new, high-volume manufacturers to enter the market; we have supported research and development (with a five year ori on) to ring ne too s to mar et s c as eri coita choices and a new dual-product that combines pre-exposure prophylaxis with a daily contraceptive pill. This large-scale work—with impacts in dozens of countries— has been coupled with more discrete investments to better understand consumer decision-making and use human-centered design to reimagine how user-controlled contraception, medical abortion and HIV self-testing could be delivered. We are learning from hundreds of thousands of self-care users, early adopters, far-sighted policymakers, and pioneers like SH:24, iwantPrEPnow, In Their Hands and Population Services Kenya’s Be Self Sure.

My colleagues and I at the Hewlett Foundation are excited about the exploration into self-care that we are seeing among some of our partners. True innovation in service delivery, which is needed to expand access to birth control and safe abortion, may mean getting out of the service delivery mindset altogether. Ruth Levine, Director, Global Development and Population Program, William and Flora Hewlett Foundation

Moving forward we know we must do far more, in partnership with others, to realize this transformation in healthcare delivery. Our biggest shift has been to accelerate the policy and research underpinning this work, through our partnership with the World ea t rgani ation on t e first integrate g o a g i e ines for self-care in SRHR. In partnership with the William and Flora Hewlett Foundation, we co-fund the Self-Care Trailblazers Group, an advocacy initiative designed to buttress global and local ea ers from m ti e fie s o are ea ing efforts to esta is a movement, strengthen evidence and unify voices. A greater opportunity lies in using self-care to demonstrate our shift in values toward genuine people-centered care. Self-care can break through the rigidities in our sector that permit silos an sti e informe c oice e recent ritis e ica o rna series on self-care nicely outlines how to plan for unintended consequences, address risks and make self-care a critical part of informed choice. What worries us is that institutional blockages can inhibit innovation. We have deep partnerships with fantastic organizations across the SRHR landscape that we will continue to work with to embed this shift. Equally as important, self-care is an opportunity to reduce barriers to entry for new players and partners, where philanthropy and a diversity of funding tools can be particularly useful. One day it will be second nature to use an app to understand your fertility, to pick up a test for sexually transmitted infections from your local pharmacy or to order a self-injectable contraceptive online. Self-care means putting power in the hands of girls and women. It’s happening now, and it’s time to get onboard.

MILES KEMPLAY ©PSI/Benjamin Schilling

Executive Director, Adolescence, Children’s Investment Fund Foundation

@CIFFchild

I M PA C T M A G A Z I N E N O. 25

W H AT I S S E L F C A R E ?

THE FOUR DIMENSIONS OF SELF-CARE BY PIERRE MOON, PSI

For millennia, people have taken measures to care for themselves—prevent disease, promote health and cope with illness and disability—without a healthcare provider. While self-care is an old concept, new approaches have expanded the reach of self-care to health areas ranging from mental health to treatments for chronic diseases. However, it is in the sphere of sexual and reproductive health and rights (SRHR) where stigma abounds and privacy is so critical, that self-care can be especially transformative. The forces driving self-care are shaped by challenges, but also opportunities. Just last year, there were 135 million people in need of humanitarian assistance who had little or no access to the healthcare they needed. And in 2035, there will be an estimated shortage of 12.9 million healthcare workers. Meanwhile, low- and middle-income countries are home to 87 percent of the world’s youth. These young people are an opportunity for the world; the challenge is that they urgently need affordable, accessible, quality healthcare, but they live in contexts where their SRHR needs are often a low priority for the formal health system. The World Health Organization (WHO) has recently announced tri e i ion targets ens ring one i ion more eo e enefit from universal health coverage (UHC); one billion more people are better protected from health emergencies; and one billion more people enjoy better health and well-being. The need for self-care is not only borne from these global health challenges and ambitious goals; there are positive forces and opportunities that are shaping the evolution of self-care.

The 2018 “Lancet Global Health Commission on High Quality Health Services in the SDG Era” highlighted among its recommendations that services must be provided in a respectful people-centered manner: “To greatly improve healthcare, people-centered and patient-driven approaches that shift the power from the healthcare system and providers to the patients are needed.” Put simply, as a critical frontier in people-centred care, self-care is vital to the future of quality healthcare.

Meanwhile, as digital technologies evolve to inform growing numbers of consumers about healthcare, and as incomes rise in many low- and middle-income countries, so greater numbers of people demand better healthcare. Health consumers are increasingly aware of their rights and asking to receive quality, affordable healthcare. As consumer expectations have evolved over the past decade, t ey ave in ence t e ra i eve o ment of fo r imensions of healthcare that have brought self-care to the forefront. Examples of these four dimensions are highlighted on the following pages. Pronta, PSI’s global brand of emergency contraceptive pills. © OHMaSS/Maxence Bradley

SECTION TITLE

Drugs – Emergency Contraceptive Pill Emergency contraceptive pills (ECPs) are not new, but important new variations of this drug and new insights into how women use ECPs bring new understandings of how it can be safely used. Many pregnancies are mistimed or unplanned, even in settings where highly effective contraception is available, putting women and girls at risk. ECPs are the only contraceptive method that can prevent a pregnancy after intercourse. Despite its unique role, ECPs too often remain underutilized, stigmatized and, in many places, inaccessible.

However, the newest generation of ECPs contains 30 milligrams of the selective progesterone receptor modulator ulipristal acetate ( ) ic remains effective for five ays after interco rse Despite its role as a more effective ECP product, the UPA ECP regimen remains unaffordable for the majority of low-income users, as the product is still on patent and sold at a prohibitively high price.

Diagnostics– Human Papilloma Virus (HPV) DNA Self-Sampling

Women choose ECPs, or “on demand” contraception as their primary contraceptive method for a variety of reasons—from having sporadic intercourse to the desire not to use a daily method it ormones s criteria s ecifies t at t e met o can be used in any circumstance. Many studies have shown that some women prefer to use ECPs multiple times within a cycle, preferring this option over other methods.

Each year, 500,000 women are diagnosed with cervical cancer; more than half of these cases are fatal. Ninety percent now occur in low resource contexts, where cervical cancer is a much greater burden because most cases are detected at a very late stage, when treatment is no longer possible. Screening programs that detect treatable, precancerous cervical lesions are often inaccessible due to cost, equipment and provider shortages and lack of knowledge about these services.

In African markets and in the US, the most commonly and cheaply available ECP product is made of 1.5 milligrams (mg) of the hormone levonorgestrel, which protects sperm from fertilizing an egg for o rs after interco rse fter o rs its efficiency decreases—a critical factor given that sperm can potentially ferti i e an egg to five ays after interco rse

Several strains of HPV are known to cause cervical cancer. Over the past decade, the evidence has expanded dramatically for use of mo ec ar testing ne of t e i e y recogni e enefits of HPV testing is that it can be performed using self-collected vagina s a s e rimary enefit of t is a roac is t at the majority of women screened do not have to undergo a

I M PA C T M A G A Z I N E N O. 25

SECTION TITLE

Zambia has a relatively low modern contraceptive prevalence rate pelvic examination as part of the initial screening process. HPV se f sam ing offers e i i ity for o an ere omen co ect their samples, offering new avenues for expansion of cervical screening coverage. Acceptability of HPV self-sampling among women is high, coupled with the potential to facilitate greater levels of screening, treatment and health impact in all settings. es ite se f sam ing a vantages one si e oes not fit a Not all women are comfortable with a self-sampling approach. Common concerns include physical discomfort or worry that they will not perform the sampling correctly. Others prefer a clinic setting because they can receive immediate treatment there, if required. PSI is piloting multiple service delivery models to identify t e most efficient an im actf ays to offer testing an self-sampling to provide women with a range of options that suit t eir s ecific nee s references an circ mstances

(mCPR) and a high unmet need for family planning. In response, Society for Family Health, PSI’s affiliate in Zambia, launched the Sexual and Reproductive Health for All Initiative (SARAI) in 2015. SARAI is a five-year USAID-funded project that aims to increase the mCPR by two percent each year through increased access to quality voluntary family planning and reproductive health services.

Due to its robust community-based network for family planning service provision, in 2017 the project was selected to initiate Zambia’s roll-out of DMPA-SC in collaboration with the Government of the Republic of Zambia.

Devices – Subcutaneous DMPA (DMPA-SC) The FP2020 goal is that 120 million more women and adolescent girls will use contraception by 2020. DMPA-SC, also known by its brand name Sayana® Press, is an injectable contraceptive that can dramatically expand access and choice for women. DMPA-SC has been available for over two decades; it is the challenges and opportunities of the goals set in the past decade that have led to renewed interest in the scale up of this device. As opposed to the more complex intramuscular (IM) injection, such as Depo-Provera-IM, DMPA-SC requires a simpler injection just beneath skin. It is uniquely suited for self-injection or delivery by community-based distribution agents, pharmacists or drug shop workers. Evidence indicates that DMPA-SC can reach new users of contraception, including young women and adolescent girls, and has the potential to promote continued contraceptive use. Launched in 2017, the DMPA-SC Access Collaborative, led by PATH and John Snow, Inc. in partnership with a broad group of stakeholders, is a three-year initiative working in up to 12 countries to increase use of DMPA-SC. There are already millions of girls and women using DMPA-SC and 25 countries have approved DMPA-SC for self-injection. 15

SECTION TITLE

ÂŠ PASMO/Victor Grigas

Digital Health New technology in telemedicine, mobile phones, wearables and tablets are creating opportunities for consumers to take a more active role in their health and well-being. This is particularly true when it comes to sexual and reproductive health. Digital health, the convergence of information and communication technologies for health information and services, is enabling the optimization and personalization of health information and resources. Sometimes digital health tools are the intervention, as with fertility monitoring apps. Alternatively, digital health tools can sometimes support an intervention, such as tablets and apps that convey information via videos.

is year mar s a significant mi estone for it the anticipated release of normative guidelines addressing both digital health and self-care. Examining the evidence base for digital health, and providing recommendations for future research and practice, the guidelines highlight ways digital health can s ort se f care an increase se f efficacy an se f confi ence in healthcare. And yet these guidelines provide a timely reminder that digital health interventions are not enough on their own, but rather should add value to the health system and to the individuals using these technologies.

PIERRE MOON

Project Director, Family Planning & Reproductive Health Department, PSI

@psiimpact

I M PA C T M A G A Z I N E N O. 25

SIâ&#x20AC;&#x2122;s new P s in p r e d n u consumerg Design thinking in r e v li e d o t pproach a ÂŠ at the e n r o e t s s u y e K e h t s t are. PSI pu c h lt a e h d type, e o r t e o r p pow , e t a e id process to e h t f o r n and e t ig n s e ce d o t e r u il from fa and learn fast t produce functional, tha tone ÂŠ s y e refine solutions K . s t e k r a lthcare m a e h le b a in a t s su blic good. u p l a b lo g , le b aila is a freely av

DESIGN THINKING

GIRLS ARE MORE THAN JUST CLIENTS

In my home country of Ethiopia, a young woman’s success is measured by how soon she settles down and starts a family of her own. That, however, is not unique to Ethiopia. Girls across developing countries often face cultural pressures to marry young, with the expectation that they prove their worth by having a baby shortly after they wed. It means that girls don’t always have a say in how many children they and their partner ant at er t at ecision is in ence y t eir s an an his family. It’s a complex situation. Through PSI’s youth-powered programming, we’re driving toward a future in which girls know that they can choose the lives they want to live. That’s why we’re working in partnership with young people to understand what matters for girls today, so we can deliver solutions that reframe how young people think about planning for their futures, including the decision to start a family, en t ey are rea y S s ags i se a an re ro ctive health (SRH) project Adolescents 360 (A360) in Ethiopia is a case study into how we, alongside the young people we serve, are changing the conversation around contraception by giving girls and their husbands a new way to plan for the children they desire, on their own terms. © PSI/Benjamin Schilling

I M PA C T M A G A Z I N E N O. 25

A young couple engage in Smart Start counseling © PSI/Benjamin Schilling

DESIGN THINKING

Launched in 2016, A360 brings together young designers like myself alongside a range of experts—from cultural anthropology and adolescent developmental science, to public health, Human Centered Design (HCD) and meaningful youth engagement— committed to changing how we reach adolescent girls with modern contraception. It’s a mix of perspectives that’s created Smart Start, a contraceptive counseling tool that introduces financia messaging to e co es an for t e fami ies an lives, they want.

contraception—and we’re doing it by leading with what matters most to young people, today. PSI’s youth-powered approach has opened new ways of seeing and understanding how we, in partnership with health systems, can work with girls, for girls to reimagine the future of youth-powered SRH solutions.

I joined PSI in 2017 when I was 22. Growing up, I was fortunate to have learned about contraception in school. But not every girl has the same opportunity. That’s been my motivation to pursue this work. As a young designer, I am a youth voice that represents the needs and desires expressed by young girls. In Ethiopia, for example, girls and their husbands told us that they desired economic security amidst changing times. A smaller family, they said, could e ac ieve t at goa e eve o e Smart Start as a financia planning platform that supports rural couples to understand the cost enefit of e aying regnancy e a roac vie s gir s an t eir in encers as more t an st c ients it S nee s t rather as humans with many immediate desires. In the 13 months since implementation, more than 17,000 girls have voluntarily taken up a contraceptive method through Smart Start. We’re continually gaining momentum. The local Women’s Development Army—a group of volunteers who support health service outreach—works hand-in-hand with Smart Start to elevate the importance of the program among communities, all while supporting the health system to identify girls and mobilize them to services. At the same, we’re driving toward government integration with pilot sites in Northern Ethiopia. PSI’s youth-powered approach has deepened my understanding of the physical, psychological and emotional changes that are a part of adolescence and, by extension, the value of a human centered approach to creating solutions that serve young people with the tools most relevant to their lives. s a yo ng esigner am tr y gratifie to e a art of a S program that is impacting actual lives by transforming how we reach, inspire and serve young people with modern contraceptive programming. Together, we’re shifting how we talk about

A young couple engage in Smart Start counseling © PSI/Benjamin Schilling

Hear more from Bitania at the Women Deliver concurrent session, “Adolescent Sexual & Reproductive Health & Rights: Programming for a New Generation” on Wednesday, June 5 at 10:30am and again at her Power Talk on Thursday, June 6, at 1:55pm on the Women Deliver Power Stage.

BITANIA LULU BERHANU

Adolescents 360 Young Designer PSI Ethiopia

DESIGN THINKING

Self-care is not new t it s recent y ecome more firm y embedded within the larger global health and development agenda. Now, the task before health advocates is to institutionalize self-care as part of health policy across systems, programs and practice. The task seems daunting at times, due in part to a lack of shared vision about what constitutes self-care. There is general agreement that self-care is a critical component of any comprehensive health program. We at White Ribbon Alliance (WRA) are fond of saying that self-care “is the root of all healthcare.” Beyond that, perspectives diverge. Does self-care include new diagnostics, products and devices to support self-testing or self-treatment? Does it provide the resources and resilience to keep yourself mentally and physically strong? Does it let you know when to take yourself to a provider? Depending on who you ask within global health and development, the answer is all, some or none of the suggestions above—therein lies the dilemma. What’s the advocacy ask for self-care? Where do we start? I can tell you the answer to the second question. It is both maddeningly complex and simple: start with women. If self-care is about putting power in her hands, that must apply to self-care advocacy, too. Effectively institutionalizing self-care necessitates a bottom-up approach to advocacy. Without directly engaging women and girls in self-care design and development, the approaches being developed risk missing their intended mark. While universal in some regard, self-care is also startlingly personal. In 2017, WRA embarked on an effort to engage women, along with their families and providers, in self-care activities in Bangladesh, Bolivia, Indonesia and Zimbabwe. The project was unique in its relative lack of parameters. Local women’s groups were asked to support communities with poor maternal and newborn health outcomes, where women had fairly limited interactions with the healthcare system and where there were few development projects. The only other stipulation was that self-care goals, messages and activities would be designed by the women themselves.

I M PAC T M AG A Z I N E N O . 2 5

As expected, projects varied in topic and activity. For example, in Bangladesh, the focus was on birth preparedness. Women organized book clubs to discuss “Babu Barta,” akin to What to Expect When You’re Expecting. In Bolivia, the subject was maternal and newborn nutrition, cooking classes and recipe books, among many other topics. The surprising element was what these projects all had in common. The women involved independently identified two key components of self-care largely missing from current discourse. A recently published framework in the British Medical Journal ( ) i entifie as ects of se f care organi e n er t e headings of self-testing, self-management and self-awareness. What BMJ’s framework left out, and what these women explicitly

SECTION TITLE

Asma Begum (center) and family implement her birth preparedness plan as part of a WRA-supported self-care project in Bangladesh. © White Ribbon Alliance, Photo by WRA Bangladesh.

included, were the ideas of self-advocacy and self-organizing. We all know that self-care is individualistic in practice, but it is rarely practiced in isolation. Women recognized the need for both a i ity an confi ence to negotiate for t eir o n ea t it in households, health centers and halls of parliament. They also recognized their power in coming together to make joint asks and to overcome geographic, structural, social and political barriers to effectively practice self-care. This brings me to an additional element all our endeavors had in common: astounding and rapid results. Women, health providers and local leaders attributed dramatic increases in healthy behaviors and service utilization to the projects. They also achieved rapid changes in policy and programs. In Zimbabwe, artici ants s ccessf y a vocate for istrict officia s to ti i e their own funds to continue and expand activities. Their advocacy continues to pay forward: half of Zimbabwe’s community clinics are now supporting self-care initiatives and the country is working toward the inclusion of self-care in national guidelines. In Indonesia, the Ministries of Health, Education and Maritime ffairs an Fis eries are eve o ing t e first ever oint initiative to promote self-care activities for maternal and newborn nutrition in t e ro ect s r ra fis ing comm nities

For these women, self-care was about using their own power to lift themselves up. It spurred activism and political movement; they were proud of what they accomplished for themselves and their communities. These new self-care activists wanted to talk about it with others and when they did, people not only listened, they invested. Indispensable to the institutionalization of self-care is the idea that women know best for themselves—as much as any decision-maker or health expert—and as a collective there is no more powerful force for change. For professional advocates, it means truly believing in and trusting women. It means pushing for a paradigm shift away from top-down policy-making and toward one of community-driven policy change. It means amplifying, listening and responding to women’s voices as the centerpiece of self-care efforts.

KRISTY K ADE

Deputy Executive Director, White Ribbon Alliance Global Secretariat & Co-Chair, What Women Want

@WRAglobal

DESIGN THINKING

there s so uC H to gain With mEnstrual HEa lth Menstruation programming is a strategic stepping stone for gender equality. But projects that fund the integration of menstrual health into sexual and reproductive health and rights (SRHR) and water, sanitation and hygiene programming (WASH) are sparsely funded. Menstrual health plays a critical role for Sustainable Development Goal (SDG) 5 (Gender Equality), 3 (Education), 4 (Healthcare) and 6 (Water and Sanitation), which should make menstrual health a strategic funding priority. enarc e t e first erio is a vita sign of health that marks the transition from childhood to adolescence. But many pre-adolescent girls lack information and support before or during this transition, leaving them unprepared to manage their period safe y comforta y an confi ent y is ac of preparation can have a profound impact on a girl’s health and reproductive life. Girls’ perception of the onset of puberty is seldom the positive experience it could be. Across the world, menstruation is met with silence and discrimination, causing restricted mobility, infection, loss of economic participation and in some extreme cases, even death. Menstruation is surrounded by shame, anxiety, embarrassment,

I M PAC T M AG A Z I N E N O . 2 5

ain an sometimes even am ifie that reinforce harmful practices.

y socia norms

In September 2018, the UN Human Rights Council adopted a resolution on the human right to safe drinking water and sanitation that called upon states to “address the widespread stigma and shame surrounding menstruation and menstrual hygiene by ensuring access to factual information thereon, addressing the negative social norms around the issue and ensuring universal access to hygienic products and gender-sensitive facilities, including disposal options for menstrual products.” However, the SDGs and the Global Strategy for Women’s, Children’s and Adolescent Health developed by the World Health Organization lack s ecific goa s an in icators for menstr a ea t in t eir or ma ing it critica for f n ers to fi t is gap through investments in evidence and metrics. t e Case for er e ave earne t at a ressing menstrual health effectively requires a multi-tiered strategy that combines cross-sectoral programming, research and advocacy. Menstrual health is about informing women and girls about their bodies and teaching them to understand family planning, reproductive health and giving them the space to ask questions.

SECTION TITLE

Funding is needed not only to support and scale programming t a so to so i ify t e researc an evi ence ase e Case for Her has made this a priority through a diverse portfolio of grants, investments and research including close collaboration with PSI through the Maverick Collective. PSI’s menstrual health focal point, Maria Carmen Punzi, has been documenting where and how menstruation pops up in PSI’s regional and national work. In her research, she has spoken to a large number of PSI offices an er fin ings over e ming y s ort t e evi ence gat ere y e Case For er gir s ant to ta a o t t eir periods, are eager to know more, and more importantly, an n erstan ing of menstr ation eavi y in ences ot t e start and continuation of long-acting reversible contraceptive use (LARCs). Evidence suggests that irregular bleeding coupled with the lack of education and understanding of menstruation is one of t e most significant ca ses of iscontin ation of Cs n addition, tackling menstruation-related pain and other symptoms can be a primary reason for a girl to start using contraception. Additional funding needs to be focused on developing a clear business case. Qualitative and small-scale studies conducted in Uganda and India demonstrate a link between poor menstrual hygiene management and school absenteeism. According to World Bank estimates, a 1 percent increase in girls’ completion of secondary education increases gross domestic product by 0.3 percent and contributes to annual growth rates by 0.2 percent. We need to solidify the evidence that correlates to menstrual health and the research must look further than missed days of school and consider, for example, a student’s ability to concentrate in class, safe and sanitary WASH infrastructure in schools and impact on sexual and reproductive health of women and girls. Social enterprises need access to investment capital and funding to scale up projects. Examples include AFRIpads in Uganda, which produces cloth for reusable pads for millions of women in multiple countries. Small enterprises and movements are © PSI/Jake Lyell

maturing into sustainable companies, and there’s still a need for significant investments n i e ot er siness sectors menstrual companies are saddled with the need to provide education, awareness and advocacy, creating an additional financia r en More investment in advocacy is necessary to change attitudes and global taboos tied to menstrual health. WASH United, which launched Menstrual Hygeine Day in 2015, is a fabulous example. In 2018, there were over 500 registered Menstrual Health Day events in 71 countries, and more than 650 articles and 45,000 contributions on social media were generated. Examples like this prove that a relatively small investment in a vocacy can ave a si a e an significant im act is or is in encing t e ay eo e t in a o t erio s an it becomes clear that when we talk about menstruation we’re ta ing a o t m c more t an a s an tam ons e re ta ing about women’s rights, access to education and healthcare. it so m c at sta e an so m c to gain f n ing menstrual health is one of the most strategic, cross-cutting and impactful investments that a funder can make.

CRISTINA LJUNGBERG

Philanthropist, Maverick Collective Founding Member & The Case for Her Co-Founder

@cjljungberg

DESIGN THINKING

GIRLS NEED TO

DREAM Photo credit: River Finlay

Young people are the heart of development’s future.

That’s because their voices were never a part of the solutions.

But despite our footprint, my generation faces real challenges that too often block us from achieving our dreams.

ro g e are ringing gir s into t e mi n an ania that’s led to A360’s Kuwa Mjanja, a girl-powered movement that dares girls to dream.

As a 25-year-old PSI designer, my job is to step into the shoes of our youngest consumers—to understand what forces shape their lives, and work together to deliver the tools for young people to drive forward their goals. Access to contraception is a part of that package. I am one of PSI’s more than 630 young designers working to reimagine how young people access modern contraception. ro g S s ags i a o escent an yo t se a an reproductive health (AYSRH) project Adolescents 360 (A360) in Tanzania, I, alongside my team, have spoken to thousands of yo ng eo e an t eir in encers to ret in o e reac girls aged 15-19 with AYSRH services. We used design-thinking to get human-centered. Through this approach, we’ve learned that by addressing a girl’s desire for power and control over her often unpredictable life, we can transform how we position contraception as relevant and valuable. We shouldn’t tell girls what they should be doing, what their life goals should be and why they should be using contraceptives. We let them tell us.

Her Goals, Her Priority Kuwa Mjanja hosts events (think less service delivery and more girl-powered parties!) that inspire girls to consider their life dreams, teach them real-world entrepreneurial skills and create safe spaces for girls to ask questions about their bodies and their lives. Girls then engage in private counseling with youth-friendly providers who introduce contraception as a tool in service of girls’ life goals. I now see providers taking the time to get to know girls as more than just clients. Girls should walk away feeling like they just s o e to a confi ante o gets t em Bringing consumers into the center of design breaks down the power dynamics between who is designing and who is being designed for. It brings us together to listen to each other and to lead with empathy and curiosity as we dig into what matters in our consumers’ lives.

Learning from Girls

at is t e va e of ringing gir s se f efine reams into the conversation. It’s a powerful way to create an emotional connection between girls and the health system. And it gives girls the space to feel comfortable to choose contraception, on their own terms.

ir s e resse concerns a o t going to c inics for S services eca se of t e overt y c inica e erience ey go in e ect re a o t res onsi e se a e avior an if t ey fo n a friendly provider, possibly get counseling and contraception.

Hear more from Rosemary at the Women Deliver 2019 concurrent session, “Designing for a Better World: How can we better integrate design thinking to improve the lives of women and girls?” on Wednesday, June 5 at 1:30pm in VCC West, Room 306.

Girls felt powerless in an unsupportive system. The health system, designed to clear thousands of clients a day, did not prioritize adolescent girls. No one took the time to get to know them or ask them what they needed.

I M PA C T M A G A Z I N E N O. 25

ROSEMARY NAZAR

Adolescents 360 Young Designer, PSI Tanzania

nyone a s w o ll a ) ting (HIVST s e t the T e r p lf r e e t S in d HIV n test a IV H n a lished m r b u p O H to perfo W . private in , lf e s r e h for HIVST s n io t results a d n e l recomm a b lo g t s ir ries have f t n u o the c 9 5 currently PSIâ&#x20AC;&#x2122;s d n a m o r 6 f 1 0 e 2 c n e in id licies. Ev o p T S IV H d ) Project R adopte A T S ( a ic r in Af costSelf-Testing ST is a stigma-free, HIV rol shows that or people to take cont yf effective wa HIV status. eir and learn th

HIV

st e T Self-

D I AG N O S T I C S

r e w o P l a u E r t s n tH E m the oF cYcle What do a new mother, a pre-teen girl and an adolecent taking a hormonal contraceptive have in common? They are all most likely experiencing heavier, lighter or less predictable bleeding than what is considered “average menstruation.” The reproductive cycle is a continuum, unique for every woman, and while the bleeding experience starts with menarche, it continues when she becomes sexually active and changes throughout the course of her life.

Understanding contraception, fertility and pregnancy can be a challenge in itself, but it becomes even more so when girls and entire communities believe myths about menstruation and restrict their daily activities because of them. When global health NGOs implement sexual and reproductive health and rights (SRHR) programs, we often work with girls and women who have already started menstruating. However, it is im ortant not to ass me t ey ossess s fficient if any knowledge of the menstrual cycle. Typically, girls know how to manage their period, often limited to correct use of pads and hygiene practices. This is far from comprehensive. Understanding contraception, fertility and pregnancy can be a challenge in itself,

but it becomes even more so when girls and entire communities believe myths about menstruation and restrict their daily activities because of them. Considering all of the above, how can menstrual health help strengthen and provide new insights for our SRHR programs? 1. Improving counseling for contraceptive continuation. Recent work conducted by PSI Europe, in partnership with the funding collaborative The Case for Her, has confirme at revio s st ies1 have found: a common reason women discontinue hormonal contraceptives is their impact on menstruation. Hormonal and intrauterine device (IUD) contraceptives can cause bleeding to stop a toget er ( ormona ) rovo e eavier o (co er IUD) or lead to spotting (Depo-Provera shot). Health workers must be aware of how concerning it is for women to see their bleeding patterns change as a result of contraception, and how important it is for women to feel normal and healthy. Counselors should use informative tools like the job aid NORMAL 2 to inform and reassure their clients. 2. Validating women’s individual experiences of menstruation. Some women view contraceptiveinduced amenorrhea (absence of menstruation) as positive, convenient and liberating from problems associated with menstruation, like painful periods. Others view regular menstruation as a marker of health

1. Rademacher, K. H., Sergison, J., Glish, L., Maldonado, L. Y., Mackenzie, A., Nanda, G., & Yacobson, I. (2018). Menstrual bleeding changes are NORMAL: Proposed counseling tool to address common reasons for non-use and discontinuation of contraception. Global Health: Science and Practice, 6(3), 603-610. o ai

etreive from

tt s

f i

org sites efa t fi es me ia oc ments reso rce norma co nse ing o ai

3. Polis, C., Hussain, R., & Berry, A. (2018). There might be blood: A scoping review on women’s responses to contraceptive-induced menstrual bleeding changes. Contraception, 98(4), 348. 4. Danna, K., Jackson, A., Mann C., & Harris, D. (2019). Lessons learned from the introduction of the levonorgestrel intrauterine system in Zambia and Madagascar. Retrieved from http://www.wcgcares.org/wp-content/uploads/2019/04/EECO-LNG-IUS-Case-Study.pdf 5. Findings from PSI’s Adolescents 360 Project. Retreived from https://www.psi.org/2018/09/in-tanzania-long-acting-methods-are-for-girls-with-a-plan/ 6. Menstruation as a Diagnostic Tool for Women’s Health https://www.nichd.nih.gov/newsroom/news/121218-menstruation-podcast 7. NextGenJane https://www.nextgenjane.com/ 8. QuraSense https://qurasense.com/#site/home

I M PAC T M AG A Z I N E N O . 2 5

SECTION TITLE

an ferti ity an fin it reass res t em t at t ey re not pregnant, and so they don’t feel comfortable with not having a period3. Each woman has a unique menstrual experience, and to truly serve her, we need to listen to her concerns, understand her preferences and dispel myths. Since women’s decisions about contraception are determined by their perceptions of the method’s impacts on fertility and cycle irregularity,4 and their beliefs and desires about motherhood,5 all of these elements must be taken into account, when providing comprehensive information about the menstrual cycle, what changes are normal and when it’s important to speak to a doctor.

When girls and women learn to track their cycle, they gain important insights about their health, like getting to know what a “normal” period is for them in terms of cycle length, bleeding, as well as cramps and other symptoms. 3. Menstrual health as self-care. Menstruation is a valuable indicator and predictor of health. When girls and women learn to track their cycle, they gain important insights about their health, like getting to know what a “normal” period is for them in terms of cycle length, bleeding, as well as cramps and other symptoms. The introduction of period tracking apps to help record this data is an opportunity for women and girls all around the world to get more in touch with their cycle, spot anomalies early and become their own best health advocates.

4. Menstruation and the future of diagnostics. The iagnostic fie is ing it innovations to ring care closer to consumers and to help communities and individuals take control of their health. Research from the United States’ National Institutes of Health (NIH),6 as well as projects like QuraSense7 and NextGenJane, 8 are showing that menstrual blood contains a vast range of unique health data that permits early diagnoses and disease management without the need of an invasive blood test. Menstrual blood samples will also soon be used to test for HIV, and cervical cancer and other sexually transmitted diseases and infections, and even potentially diagnose menstrual morbidities like endometriosis, which can affect fertility. Menstrual health has the power to revolutionize the way we deliver SRHR interventions. It is essential that the global health community of practice acknowledges this and works to integrate menstrual health into existing interventions, further enabling women and girls to become powerful experts for their own bodies and health. Hear more from Maria Carmen about menstrual health at the Women Deliver 2019 concurrent sessions, “Power in Her Hands: Why Menstrual Health Matters for Sexual and Reproductive Health” on Monday, June 3, 6:30pm at The Case for Her booth and “Let’s Talk About It-Period!” on Tuesday, June 4, at 3:00pm (VCC West, room 118).

MARIA CARMEN PUNZI

Menstrual Health Focal Point, PSI Europe

@mcarmenpunzi

DIAGNOSTICS

WHAT DO HEALTH WORKERS THINK OF SELF-CARE? Interventions that were previously available in the developing world only through health clinics are increasingly being found in the Global South on the shelves of pharmacies, at health kiosks or through community health workers bringing product and services to consumers’ front doors. Self-care, as it’s been deemed, is shifting the center of gravity for many diagnostics, drugs and devices from a clinical setting to individuals selfadministering at home or in their workplaces. This takes the notion of task-shifting in health to a whole new level. Since 2016, PSI has been leading the implementation of the Unitaid-funded HIV Self-Testing Africa (STAR) initiative to catalyze and shape the global market for HIV self-testing (HIVST). The aim is to help reach the goal of 95 percent of HIV positive individuals knowing their status by improving the uptake and frequency of testing among those who are reluctant or have limited access. This often includes men, adolescents and key populations. Nearly 5 million HIVST kits will be distributed across Eswatini, Malawi, Lesotho, South Africa, Zambia and Zimbabwe by 2020, enabling an unprecedented number of individuals to learn their status in a stigma-free private space. We wanted to know what the health workers on the frontline of t e fig t against S t in a o t acing t is in of o er in consumers’ hands. So, we asked them. Nurses Genevieve Weimers and Sharon Murundi-Manganye (both working at public sector healthcare facilities in South Africa), Manqosa Khang (HIV Testing Services Coordinator in Lesotho’s Leribe District) and Lungowe Musonda (sister in-charge at Mapalo Health Facility in Lesotho’s Copperbelt Province) answered a series of interview questions to help us understand how HIVST self-care turned skeptics into advocates.

What was your initial view on HIVST before it came to your area? Genevieve Weimers: My initial view was that it may disrupt the normal HIV testing services (HTS) program, which is already implemented in the facility. My concern was that a lot of programs are introduced in a very short space of time. Sharon Murundi-Manganye: Initially, I didn’t understand the program and was very skeptical regarding how the community would receive new test types and how it would affect HTS and traditional testing. Manqosa Khang: Initially, I thought HIVST was a strategy to retrench counselors because I thought conventional testing was not going to be used anymore. Lungowe Musonda: I had a negative opinion because I thought people would not be able to test themselves at home.

I M PA C T M A G A Z I N E N O. 25

How has HIVST been received by the people and populations that you serve? GW: Since the introduction of HIVST in the facility where I am working, I have noticed that a lot of clients are interested in using a new method of HIV testing. More clients are reached daily. Those who were never interested in the facility are now testing. LM: Most people are accessing the tests, are able to test and to share the results with the health practitioners.

How have you integrated HIVST into the services you offer at your healthcare center? How has HIVST impacted HIV service delivery?

DIAGNOSTICS

How has HIVST impacted patient behaviors? SMM: Those that opted for [a self-test] have returned with their partners, as well as family members, advocating for the test. They are also sticking to the window period notice. MK: Basotho males have changed attitudes and behavior toward health services, which they previously considered as services for females and children.

What challenges do you see with HIVST service delivery and distribution? MK: The main challenge is that, due to the fact that it is new in Lesotho, most people get tempted to re-test for HIV to see if it can reveal the results they already know. The challenge can be overcome by capacitating counselors more and more to be able to probe further and dig for necessary information before giving out HIVST [kits]. LM Some o t to test at ome eca se t ere is ins fficient room to test at the health facility.

Where does more work need to be done? GW: Making sure all stakeholders are on the same page with regard to newly approved guidelines. LM: More work needs to be done in maternal and child health for secondary distribution, where male involvement is poor. nitai

ric a ss

SMM: We included patient navigators and case managers to assist clients t at screene ositive to e navigate for confirmation MK: I had to introduce it to the district authorities and create awareness at work placesâ&#x20AC;&#x201D;mostly at construction sites, government ministries and banks. It has doubled counselorsâ&#x20AC;&#x2122; efforts to convince the client for testing, hence, my sites always meet their target.

As a provider, what challenges has HIVST helped you surpass? MK: I have been able to surpass zero-positive reporting and the challenge of testing many people unnecessarily with a conventional test because HIVST is a screening tool before a conventional test can be done. LM: Congestion in HIV counseling and testing rooms has reduced and more patients are testing, thereby increasing the number of people knowing their status.

Do you think that HIVST should replace conventional testing? GW: Both HIVST and traditional [testing] can be implemented simultaneously. Clients should be allowed to choose which method they prefer SMM: It is important that both HTS and HIVST are offered to the client as options. Test kits should be made freely available to all interested or opting to test. Those returning with a positive result should be linked to care immediately.

SANDY GARĂ&#x2021;ON

Senior Advocacy Manager, PSI

@SanGarcon

DIAGNOSTICS

DISCREET

DIAGNOSTICS Mylène Nibizi* is a female sex worker (FSW) living in Ngozi province, Burundi. She’s always known that she might have HIV, but FSWs like Mylène face substantial barriers to accessing existing testing services,including fear of stigma and discrimination from healthcare providers. “I never had an HIV test before,” explains Mylène. “I was afraid that my neighbors or clients could know my status if I tested in a nearby health center.” Burundi’s HIV prevalence among key populations—including FSWs like Mylène, men who have sex with men and transgender people—is very high. For female sex workers, the prevalence rate is estimated to be extremely high at 21.3 percent. So the USAID- and PEPFAR-supported LINKAGES project, implemented by FHI360, has been working in Burundi since 2016 to reach key populations to link them to HIV self-testing (HIVST) services. n S r n i se f n ing from t e ffice of t e U.S. Global AIDS Coordinator and Health Diplomacy to introduce peer-mediated HIVST using OraQuick HIVST devices in three provinces, including Ngozi. Peer-mediated HIVST is when a peer educator explains to someone in their key population how to use the kit, provides post-test counseling and refers or accompanies the peer to other needed services. Mylène describes her experience with a peer educator. “One day, I was approached by a peer educator providing HIV self-test kits in our area,” she recalls. “[The peer educator] found me at home and told me about a new test that I could use myself. I agreed to use the test and she showed me how to do it."

HIVST has many advantages, especially for marginalized key populations. Not nly is it nfi ential an easy t se, but results can also be read directly by the individual taking the test.

HIVST has many advantages, especially for marginalized key o ations ot on y is it confi entia an easy to se t results can also be read directly by the individual taking the test. Mylène remembers when she read her self-test results. “The result of the test was positive. In the beginning, I felt afraid, even if it was not a big surprise to me. But my friend comforted me, and I accepted it.” “The following day I went to [the] clinic, accompanied by [my peer e cator to ave a confirmatory test it a frien y er si e y ne fe t confi ent a ing into t e c inic to confirm er test and get connected to care she needed. “Since then, I am regularly taking my medicine and my health is well. Nobody in my neighborhood knows anything about my HIV status, apart from my peer educator. I now make sure to use condoms with my clients.”

I M PA C T M A G A Z I N E N O. 25

*Name changed to protect the client’s identity.

AUBREY WEBER

Technical Officer, FHI360

@awebermph

Subcutaneous DMPA (DMPA-SC) is a new, easy-to -use injectable contraceptive unique ly suited to self-administration, which is rapidly expanding in FP202 0 countries. Evidence suggests s elf-injection is safe, effective, high ly acceptable, can increase contracepti ve continuation and expands the m ethod mix. PSI is developing markets for DMPA-SC in 14 countries.

ered t is in m d a lf e S contraceptive injectable

DE VICES

THE TIME IS BUILDING THE EVIDENCE FOR SELF-CARE

NOW

A woman in Senegal self-injects the contraceptive, DMPA-SC. © PATH/Gabe Bienczycki

We stand at the opportune moment for supporting women’s rights and capabilities by moving the self-care agenda forward with both enthusiasm and evidence. Self-care has been highlighted as among the most promising approaches to advancing the Sustainable Development Goals. It has an important—yet largely untapped—potential to transform the global ea t fie y tting ecision ma ing o er into t e an s of women. Essential components of our agenda are designing and testing self-care products and practices and evaluating their impact on health outcomes. An expanded array of products, procedures and practices is already being introduced and scaled, enabling women and girls to more actively participate in their own healthcare. Among the many tools in sexual and reproductive health are contraceptive self-injection, medication abortion, HIV self-testing, human papillomavirus self-sampling, phone-based applications for re icting menstr a cyc es ov ation re iction its ericoita “on-demand” contraception, contraceptive vaginal rings,

I M PAC T M AG A Z I N E N O . 2 5

diaphragms, and newly emerging multi-purpose prevention products. Digital and diagnostic tools that help individuals manage chronic conditions such as diabetes and hypertension can also be considered part of self-care.

We see self-care as the ultimate form of task-shifting—where women receive information and training and then administer interventions themselves.

PATH has not only developed many products for the global ea t fie t as a so intro ce t em as art of task-shifting efforts within the context of primary healthcare. We see self-care as t e timate form of tas s ifting ere omen receive information and training and then administer interventions t emse ves as s ifting c ts across many areas of ea t an i ecome increasing y im ortant as o icyma ers an managers see o ort nities for cost an rogram efficiencies within primary healthcare.

DE VICES

Acceptability, Feasibility, Effectiveness: What does the evidence tell us? Overall, we have good evidence of acceptability and feasibility for products and practices that promote self-care, among both omen c ients an ea t care or ers Evidence is growing that women not only can safely and effectively use these tools, but t at t ey i e oing so esearc as emonstrate t at en people are active participants in their own health, they can better adhere to instructions, medication, and treatment. Two recent examples of mounting evidence for women’s ownership of practices are HPV DNA self-sampling for cervical cancer screening and contraceptive self-injection. PATH’s e erience or ing it testing in Centra merica s o e that self-sampling was highly acceptable to women and reached never efore screene omen o are at t e greatest ris of developing cervical cancer. In Nicaragua and Guatemala, self-sampling was chosen by 96 percent and 72 percent of women, respectively, when they were offered this opportunity. In Nicaragua, 47 percent of these women had never been screened, in spite of the existence of a long-standing Pap-based public screening program. A woman in Senegal holds DMPA-SC in both hands. © PATH/Gabe Bienczycki

a ing Se f care a rea ity Self-care has come a long way and will continue to evolve. If embedded within the primary healthcare continuum of care, this practice can have a dramatic impact on health and well-being. Se f care as t e otentia to ma e ro cts more accessi e it a so e s omen ma e an enact ecisions a o t t eir health, reinforcing the internationally agreed upon human right to good health and self-determination. Further research will etermine ic se f care interventions or est for ic populations and for what outcomes. Now is the time to provide cr cia evi ence t at i ma e se f care a rea ity an contri te to broad health and development goals. A woman in Guatemala holds her HPV self-sampling kit at her stall in the market, where Ministry of Health workers offered women the opportunity to be screened in their workplace. © PATH/Xiomara Celeste Gonzalez

For contraceptive use, a growing body of evidence suggests that self-injection of subcutaneous depot medroxyprogesterone acetate ( SC) ea s to e a or im rove contin ation rates com are it rovi er in ection is enefit comes it o t notable increases in unintended pregnancy or safety concerns. Thus, self-injection of DMPA-SC is a promising approach to increasing contraceptive use.

Learn about the growing evidence for self-care from Martha and PSI Malawi’s Chiwawa Nkhoma at the “Self-Care: The Next Frontier in Women’s Health” concurrent session at 3:00pm in VCC West, Room 217-219.

MARTHA BRADY

Director of Sexual and Reproductive Health, PATH

@PATHtweets

DEVICES

ECHO REVERBERATES ACROSS SRH

In July 2019, the HIV and Family Planning (FP) communities will convene around the results of the ECHO (Evidence for Contraceptive Options & HIV Outcomes) trial, which assesses three reversible contraceptives and whether they affect the user’s risk of HIV. Beth Schlachter, Executive Director of FP2020 joins Mitchell Warren, Executive Director of AVAC, to discuss the trial and the coming together of the HIV and FP communities to work together for women to understand their options.

Q: What is the ECHO trial? Beth Schlachter: ECHO looks at three highly effective, reversible methods of contraception—the progestogen-only injectable depot medroxyprogesterone acetate (DMPA), a levonorgestrel implant called Jadelle and the copper intrauterine device—to evaluate whether there is any difference in the risk of HIV acquisition among women and girls using these methods. The more evidence and information women and girls have, the better able they are to determine which methods work best for them. Our goal is to ensure they have the information they need to make informed decisions about their healthcare and the study will advance that objective.

Q. Are you worried that one of the contraceptive methods is going to show it increases the risk of acquiring HIV? Mitchell Warren: No matter the result, the ECHO trial will not provide an answer about what countries, programs or individuals should do; it will provide information that should prompt, inform and guide action by all stakeholders. And as that evidence is used to inform policies and programs, the perspectives and experiences of women and girls who will be affected must be at the center of decisions and messages.

Q. How did FP2020 and AVAC come together to work on ECHO and why? BS: It was a natural partnership that grew organically. AVAC had been involved with the ECHO trial team for years and FP2020 had been monitoring it. When Mitchell approached us over a

I M PA C T M A G A Z I N E N O. 25

year ago to discuss the need for alignment between the FP and HIV communities, it made so much sense. Working together has enabled us to amplify our individual concerns and bring in many more organizations and advocates to ensure that we use the ECHO trial results as an opportunity to place women and girls at the center of the discussion. MW: The ECHO trial is a perfect example of what integration and comprehensive sexual and reproductive health really means. This is not about HIV or contraception; this is about putting these pieces together, and no one organization or community can do it alone. Our collaboration with FP2020 shouldn’t be a surprise or an exception. If we want women and girls to have truly informed choice about sexual and reproductive health and rights, contraception and HIV, this has to be the new normal.

DEVICES

Q. Will the HIV and FP communities continue to work together for the foreseeable future? MW: Even if we collectively and easily navigate the ECHO trial results in the months ahead, I will judge this collaboration—not just between FP2020 and AVAC but comprehensively across o r fie s as on y artia y s ccessf if it sto s t ere r great hope is that we are actually building a new infrastructure for a vocacy rograms an o icies t at re ect a ne s irit and passion for “integration” that puts women and girls at the center for the long haul.

Q. Why is the ECHO trial so important to those who care about FP and HIV prevention? What can we learn from it? MW: Results from the ECHO trial will allow for clearer messages on HIV risk and the three contraceptives studied, and should prompt action. Current data on progestogen-only injectable contraceptives mostly comes from observational studies and are almost entirely focused on injectable DMPA-intramuscular (IM). Some of these studies suggest that DMPA-IM increases their risk of acquiring HIV while others do not. The ECHO trial was designed to address this uncertainty, and is the most rigorously designed and conducted study of contraception and HIV risk in history. Whatever the results are in mid-July, this evidence can and should be used to improve programs that meet the needs of women and girls and support their choices.

BS: I couldn’t agree more. Throughout this year, FP2020’s leadership is conducting a global consultation to learn from stakeholders and partners how our current partnership has supported advances for reproductive health services and contraceptive use so the next iteration of this partnership can build on what works for 2030 and beyond. Our collaboration with AVAC shows that the HIV and FP sectors can work effectively together, and the expectation of “integration” must be written into our partnerships going forward. We’re committed to this because women and girls are counting on us to serve their perspectives and needs above our own. We’ve learned so much from AVAC, and it’s been an absolute pleasure to get to know and work in partnership with Mitchell and his dedicated and inspiring team.

BETH SCHLACHTER

Executive Director, FP2020

@BethFP2020

MITCHELL WARREN

Executive Director, AVAC

@HIVpxresearch

DE VICES

how to unloc

POWERFUL PARTNERSHIPS Public-private partnerships are often key to unlocking innovative healthcare solutions in the developing world, putting the power of good health directly in the hands of those who need it most. Philips, a corporate leader in healthcare technology, is working with national governments to create partnerships that work hard for the private sector, the public sector, and most importantly, the people they serve. PSI’s Deputy Director for Corporate Partnerships, Stephanie Dolan, chatted with Jan-Willem Scheijgrond of Philips’ Government Affairs office to learn more about the innovative partnerships they’re building. Stephanie Dolan: What platforms exist that bring together public and private partners early on to co-create processes that effectively mitigate risk, especially in fragile markets?

Jan-Willem Scheijgrond: At Philips, we believe in the need to build platforms where partners from the public sector, private sector and civil society can convene and co-create health solutions. A neutral convener is essential to this process. In Kenya, the UN Resident Coordinator and the Minister of Health are convening these partners to unlock US$1 billion in investments for primary care i i s as one of t e first artners to oin t is initiative SD: In low- and middle-income countries, the private sector delivers as much as 60 percent of health services. Often, these ventures are undercapitalized and fragmented. What prevents investors from entering these markets?

I M PAC T M AG A Z I N E N O . 2 5

JWS: This is due to a mix of things. There is often no pooling of eman for ea t care services i e ins rance t s iffic t to re ict eman ic re ces t e financing a etite of e capitalized investors. Another challenge is that governments often don’t see private providers as part of the healthcare system and don’t include them in reimbursement schemes. If these governments provided public healthcare services and offered reimbursed healthcare services, they could invest in private providers. However, due to these uncertainties, private providers rely heavily on out-of-pocket expenditures—in some countries, clients pay as much as 75 percent of costs out-of-pocket. For private providers, this is often an unreliable and unpredictable source of funding. SD: What incentives does the private sector offer to those making long-term investments in the digital health space? JWS: At the moment there is no clear market, since most countries haven’t developed a coherent digital health strategy. Governments must create demand for a supply that simply isn’t there. I’ll give you an example. With our innovations, Philips will be able to reach pregnant women and nurses in remote locations with ultrasound technology, while a radiographer coaches and supports the nurse remotely via telephone. The images collected can also be sent electronically to central diagnostic centers, where ar tificial technology and exper ts can identify at-risk pregnancies. This service will be 50 percent cheaper than services offered at urban hospitals. So it’s a win-win—quality antenatal care in local communities at a fraction of the cost, without having to travel to a hospital. But without a comprehensive “digital and connected care” strategy, governments can’t consider these kinds of innovations. Digital health has the power to completely transform healthcare, especially in developing countries.

JAN-WILLEM SCHEIJGROND

Vice President, Global & Public Affairs, Royal Philips

@Philips

STEPHANIE DOLAN

Deputy Director, Corporate Partnerships & Philanthropy

@PSIImpact

More than 25 million unsafe abortions occ ur every year, 97% of which take place in develop ing countries. Drug-induc ed abortion, or medic ation abortion (MA), is a safe abortion method particularly suited fo r low-resource sett ings as it can be taken at home with limited m edical supervision. PSI is w orking in abortion in 25 countries throughout Latin America, Africa and Asia.

Medication Abortion

DRUGS

MAAMA

KNOWS BEST Postpartum hemorrhage (PPH), or excessive bleeding after childbirth, is the leading cause of maternal mortality in Uganda, and pregnant women in Uganda learn to recognize its signs. To decrease the risk of PPH and ensure a safe delivery, most expecting Ugandan mothers use Maama Kits, which include every World Health Organization (WHO)-recommended tool a mother needs for a safe delivery—sterilized and neatly packed to the size of a sleeping bag—for deliveries at clinics and in homes. And soon, every one of these convenient kits will include two additional medications, recognized by the United Nations as essential life-saving commodities: chlorhexidine to sterilize the baby’s umbilical stump, and misoprostol, which the mother can take herself to prevent or treat heavy bleeding, as it contracts er ter s to sto t e o of oo In 2016, Sara Ojjeh, a founding member of Maverick Collective, PSI’s philanthropy and innovation lab, invested in a pilot program led by PACE, PSI’s network member in Uganda. The investment aimed to reduce the high rates of maternal and neonatal mortality in Uganda.

Thirty-four percent of maternal deaths in Uganda are due to PPH, according to estimates from the Uganda Demographic Health Survey.

Thirty-four percent of maternal deaths in Uganda are due to PPH, according to estimates from the Uganda Demographic Health Survey. These unnecessary deaths can be reduced with misoprostol. Most Ugandan health facilities use oxytocin to control postpartum bleeding, but it requires refrigeration. In low-resource areas where oxytocin is not readily available, misoprostol—which can be stored at room temperature—is a valuable alternative. Although the drug has been registered in Uganda for over nine years, it has not been accessible to expecting mothers for deliveries at clinics, or for the 27 percent of Ugandan mothers who give birth at home. The project aimed to change the Ministry of Health (MOH) guidelines to include chlorhexidine and misoprostol in Maama Kits and make them available for distribution at the community level. PACE’s project, with Ojjeh’s investment, was piloted in five istricts it ig materna morta ity to test if comm nity distribution of misoprostol could contribute to a reduction in maternal mortality. PACE distributed 25,000 kits, which included misoprostol and chlorhexidine. All of the women who received the kits were

I M PA C T M A G A Z I N E N O. 25

DRUGS

A ProFam ambassador (left) shows a Maama Kit to an expecting mother (right) outside her home in the town of Lweza, Uganda. © PACE/Kalungi Kabuye

monitored through delivery and postnatal care to track maternal outcomes. In the targeted districts, about nine of every 1,000 women reported experiencing bleeding before or after birth. During the course of the project, bleeding declined to almost half its revio s rate on y five o t of omen re orte ee ing With the investment in the pilot project, PACE was not only able to test community distribution of misoprostol, but with the positive results, they were also able to successfully advocate for changes to government guidelines including: 1. Uganda’s MOH added the inclusion of chlorhexidine and misoprostol to the list of safe delivery guidelines. 2. The MOH approved the inclusion of misoprostol in community distribution guidelines. 3. The current manufacturer of misoprostol only packages the drug in blister packs of 10 tablets, though the prescribed dosage to prevent PPH is only three tablets. The National Drug Authority approved three tablet blister packs of misoprostol to be made in Uganda. Despite these wins, there’s still more work to be done for mothers in Uganda.

ore f n ing is nee e to fin a man fact rer for t e t ree ta et blister packs of misoprostol. And where the pilot project found s ccess in five istricts f rt er investment co ens re t at t e new, more powerful Maama Kits are available nationwide. Every Ugandan woman deserves access to a Maama Kit complete with chlorhexidine and the correct dose of misoprostol so that more mothers will be there for their children, and more children will thrive into adulthood. Ugandan mothers know when something is wrong, and they no at it ta es to fi it aama it ts t e o er of a safe delivery right in their hands. —With contribution from Maria Dieter, Associate Content Manager, PSI, @mariadeets

REBECCA BABIRYE

Malaria and Child Survival Program Manager, Programme for Accessible Health Communication and Education (PACE)

@paceUganda

DRUGS

A SAFE ABORTION IN HER HANDS Ritika Yadav* sat facing her husband, Pradip. They were midconversation, speaking quietly as they sat in their home in the ancient, bustling city of Patna, India. “I’m ...” Ritika was interrupted by her children playing a game in the next room, screaming with glee. She waited until they were finis e regnant s e finis e They just couldn’t afford another child. “Your sister told me that she took some medicine once so that she didn’t have a baby,” Ritika explained. “Can you go to the pharmacy and buy it for me?” Pradip set off for the pharmacy. The pills Ritika asked for are known as medical abortion (MA), a combination of the drugs mifepristone and misoprostol. This is the most common method of abortion in India. The Guttmacher Institute and others estimated that in 2015, 81 percent of the 15.6 million abortions in India were MAs. Although a doctor’s prescription is required for MA, pharmacists often sell it over the counter.

S n ia rivate imite ( ) a for rofit socia enter rise founded by PSI, has been selling MA kits like Ritika’s since 2016 using the brand Safe Abort. As of April 2019, PSI IPL had sold almost 1.8 million Safe Abort kits, which it estimates has saved the lives of 2,300 Indian women. In 2018, with funding from the David & Lucile Packard Foundation, PSI IPL interviewed 57 clients about their experiences with selfa ministering ey recogni e more efficient an accessi e systems were needed for informing clients about effective selfadministration, so PSI IPL created an interactive system using Safe Abort’s packaging that instructs the client to scan the pack and play a video on her smartphone.

Pradip returned an hour later with a small box of pills. “The pharmacist explained how you should take the pills. I wrote it all down,” Pradip showed her a small yellow piece of paper with a few scribbles on it. Ritika scrutinized his notes, her brow furrowed in concern. “I don’t understand,” she frowned. “These directions are different from what your sister said.” Ritika wasn’t sure what to do. She turned over the package of pills. On the front was a bright pink and purple label that read “Safe Abort.” She carefully opened its contents an reac e insi e to fin t e me ication enc ose with a small piece of paper. Next to a set of written instructions on using the medication was an option directing her to download an app on her phone for more information. Photo courtesy of PSI/IPL

This image from the Safe Abort video demonstrates how to take a mifeprostone tablet. Image courtesy of PSI/IPL.

Ritika was curious about the app, so she used the phone she and Pradip shared to download it and was connected to the Safe ort interactive information system rig t images as e on her smartphone as she watched a short video demonstrating how to take the pills correctly. Pradip watched over Ritika’s shoulder. “Yeah, that’s exactly what the pharmacist told me,” he said. Ritika smiled. That night, Ritika easily followed the video’s instructions, which put her mind to rest as she safely self-managed her MA. It had een a iffic t ecision an t is tiny scanna e co e a ma e all the difference. Relief washed over her. * To respect privacy, the characters in this piece are composites of several men and women interviewed during the 2018 qualitative survey funded by the David and Lucile Packard Foundation.

—With contribution from Rachel Braden, Associate Program Manager, PSI IPL

Do you have an Android phone? Learn how to use the Safe Abort kit like Ritika did! Download and open the Safe Abort app from the Google Play Store and point your phone at the logo above to watch a video about how to safely selfadminister a medical abortion.

I M PA C T M A G A Z I N E N O. 25

MARIA DIETER

Associate Content Manager, PSI

@MariaDeets

er half of the ov e, on al a ric Af n ra ha Sa In Suba phone by 2025. n ow to ed ct pe ex is n tio popula at puts healthcare th gy lo no ch te in s st ve in I PS e Connecting Th . nd ha â&#x20AC;&#x2122;s nt ie cl e th of in the palm ovide convenient, pr to s m ai p ap ile ob m ra with Sa to health information, ss ce ac d an m de on d, te trus ients through cl t or pp su d an s ice rv se th links to heal the continuum of care.

Connecting with Sara Mobile App

D I G I TA L

G N I M R O F TRANS E R A C H HEALT

R E G N I F A F O P WITH TH E TA

session, the QAO listens closely as the ProFam provider speaks it eac atient an fo o s t e a estionnaire on t e evice so that feedback can be given to the provider after the session. e a is S an a reviation for ea t et or a ity m rovement System m emente in co ntries inc ing Cameroon S is se to assess t e a ity of care at over 8,000 health facilities. A community health worker manages intake for a client at a roFam franc ise c inic in ao n Cameroon S a e ye

Just outside the center of YaoundĂŠ, Cameroon, sits a small clinic overlooking a hilly landscape. Two providers, employed by the ProFam franchised network of clinics, are busy managing intake for a small group of clients gathered on the terrace as they await their turn for a family planning counseling session. Also among this group are several supervisors known as Quality ss rance fficers ( s) t s t eir o to assess t e a ity of service each patient receives from his or her provider. But instead of the usual clipboard and paper checklist, the QAOs ean over an a on a an e ta et scr tini ing t e estions t at a ear on t e screen it eac ta of a finger ring eac

I M PAC T M AG A Z I N E N O . 2 5

And because QAOs can access the app on their smartphones or tablets in any envir n ent, in l in f ine, feedback and information uptake has i r ve the effi ien y an a ra y of care offered to clients.

e too com rises fo r mo es ( an ssess m rove an onitor) ic a o s to se t eir time an reso rces more efficient y to go e act y ere c ients an rovi ers are i e roFam c inics to rovi e m c nee e care an services These modules work together to help QAOs conduct consistent supervision visits, immediately share targeted technical feedback with providers and monitor trends in provider performance an a ity

D I G I TA L

The Plan Module schedules future assessments based on where support is most needed (e.g., clinics with low-qualit y scores) and where it will have the greatest impact (e.g., clinics with high patient volume).

The Assess Module allows QAOs to assess clinical skills using customized checklists, currently available in 14 health areas.

n an office at t e roFam C inic a arge aging a er c ec ist is ta e to t e a cata oging estions i e t e ones fo n in t e Sa e se to fi one of t ese o t every time e a a s ervision visit a rovi er e aine as e gest re to ar t e ist e receive a co y an t e s ccess score as ca c ate y an t too a ong time

With HNQIS, healthcare providers in centers like the YaoundĂŠ ProFam Clinic donâ&#x20AC;&#x2122;t need to rely on these paper checklists anymore. Instead, they work ith A s sin H IS t enefit fr tailored, adaptive and quick support.

t t e same time ecision ma ers at S s net or mem er in Cameroon and partner organizations can make programmatic ecisions it ata co ecte y S an in e to t e S ea t management information atform ere S oo s its client service data on a global scale.

The Improve Module displays an instant qualit y of care score and is designed to promote performance improvement through standardized feedback and a shareable action plan.

The Monitor Module displays a dashboard of graphs and tables that highlight trends and overall performance by facilit y and health area.

S system e an ing it as a igita too to fit t e nee s of decision makers like ministries of health and implementing artners et er it s eing se at c inics in t e ro ing i s of Cameroon, or in the hands of health ministers in capitals across t e g o e t e g o a im act of S on a ity c ient care is st getting starte Hear more about HNQIS from Janet at the Women Deliver 2019 Appy Hour on Tuesday, June 4, at 6:00pm in the WD2019 Solutions Gallery at VCC West. â&#x20AC;&#x201D;With contribution from Elisabeth Harris, Global Business Systems Program Assistant, PSI

JANET PATRY

Training Facilitator Global Business Systems, PSI

@right2thrive

s S contin es to see s ccess S is t in ing ig a o t a a ting it for se at a g o a eve it t e niversity of s o (t e eve o ers of S ) an ot er ey sta e o ers S can or to ar integrating S as a ermanent too it in t e

D I G I TA L

Digital Technologies to Youth-Powered Reproductive Health Breakthroughs emeni i lo hover her fin er over her cli on the address of the next door to knock on.

oard, landing

She smiles. It’s been a good week. “In Tanzania, talking to young people about contraception has never been easy work,” says Likulo. “It requires good techniques to engage young people and understand how they perceive and interact with the world around them.” Likulo is one of 150 healthcare educators supporting PSI’s youth-powered sexual and reproductive health (SRH) project, deployed to reach girls aged 15-19 with contraceptive precounseling. It’s a tall task: in an environment in which young Tanzanian girls o ee mis erce tions a o t contrace tion i o m st fin ways to meet consumers where they are—and with what they need—to make contraception relevant, accessible and valuable for young girls. “Girls worry about what impact contraception may have on their bodies and their fertilities,” Likulo pauses. “We see the implications of those beliefs in practice: at times, we’ve gone a whole month without referring a single girl to the clinic.” But that’s now changing. By working in partnership with young people, PSI, across its global network, is driving new ways of designing and delivering reproductive health solutions—and with it, tapping into digital technologies like Mjanja Connect to power frontline educators like Likulo with targeted tools they need to reach the girls they serve.

Flipping the Script n an ania one of t e co ntries in ic S s ags i youth-powered SRH project Adolescents 360 (A360) operates, there are 2.3 million girls aged 15-19. More than half of the girls in this age group are sexually active, but one in four does not use modern contraception. That same number is already pregnant. To resolve these gaps, PSI is doing things differently. Through A360, co-funded by the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation, PSI fuses a diverse team of disciplines—cultural anthropology, social marketing, adolescent developmental science, adolescent and youth SRH and human-centered design—all in partnership with young people. The approach allows the team to step deep into consumers’ lives to understand what young people need, today.

I M PA C T M A G A Z I N E N O. 25

And as Likulo says: it works. From implementation launch in January 2018 through March 2019, A360 Tanzania’s combined mobilization, outreach and service delivery activities have served more than 70,000 girls with modern contraception. Nine in 10 girls who engage with A360 Tanzania voluntarily take up a method. Six in 10 girls choose a long-acting reversible contraceptive.

D I G I TA L

ig t

ea to ir s

“If you don’t address girls’ fears, you won’t see them coming in for services,” says Edwin Mtei, PSI Tanzania’s A360 Project Director. Indeed, girls in Tanzania told PSI’s A360 team that they dreamt of starting sinesses of finis ing sc oo an of ecoming

There needed to be a focus on the client experience. And it needed to be streamlined so health workers could effectively engage clients, and then track their pathway to care.

Bringing Girls’ Dreams into the Conversation A young woman opens the door. “Karibu,” Likulo says warmly. “My name is Semeni.” She points to an Android tablet. “I’m here to talk about your health.” The girl shakes Likulo’s hand with a boldness. She grabs a beaded purse from the ledge by her front door, before stepping outside of her house. “I’m Amina.” Likulo adjusts her grip as she turns the tablet around to give Amina a full view of the screen. Likulo presses play. A ringing c or s of gir s voices fi s t e s ace a coming from t e a in Likulo’s hands. This is Mjanja Connect, an interactive tablet-based technology driven by girls’ insights gleaned from A360 and delivered by educators at the helm of mobilizing girls to care. Developed with support from the Vodafone Foundation, Mjanja Connect delivers PSI Tanzania a new way of reaching girls with SRH information, and then tracking how and when they engage with the health clinic for contraceptive services. Mjanja Connect changes the conversation around contraception—leading with what matters to girls now and into the future.

Photo courtesy of TBWA/Khanga Rue

mothers—when they are ready. But with fears that contraception could lead to serious side effects, and with entrenched misconceptions about any changes to menstruation, adolescent gir s a ong c assifie contrace tion as not re evant for me That’s in part because the conversation around contraception as fo o ing a one si e fits a a roac “Frontline workers were using tools for women to reach girls with services,” says Rosemary Nazar, an A360 Young Designer involved in Mjanja Connect’s creation. “But you can’t use the same engagement tool for mothers that you use for girls.” Before A360, health educators like Likulo engaged consumers it re co nse ing sing a i c art inten ing to g i e t e conversation around contraception. But the chart featured photos of adults with babies that didn’t resonate for girls who didn’t have children. It also presented contraceptive methods by length of effectiveness, an inclusion that often turned off young girls who fear that a long-lasting method could harm their dreams of motherhood.

Amina leans into the tablet as she bounces her head in sync with Mjanja Connect’s opening music video, known by the team as Sisi Nanasi, or “I am a Pineapple” in Kiswahili. The video’s inclusion emerged during a design sprint focused on what it would take to make girls feel that this tool was something for them. A360 young designers shared that opening with a music vi eo co an ania s gir efine ran ing vis a s of pineapples to symbolize sweetness and crowns to celebrate strength—that young girls could relate to folded into girl-powered music they could connect with. Sisi Nanasi makes no mention of contraception, but rather spotlights bold young girls who prompt viewers to consider what it means to be young and achieve dreams. A digital quiz appears after the music video closes. ere o yo

ant to e in five years

Amina lifts her beaded purse. “I make and sell these bags to girls in my community. I dream of making my business huge,” Amina smiles widely. “I want to contribute to my family. Likulo nods encouragingly. “That is good, Amina. The steps you take today to plan for the future you want will enable you to achieve your goal of setting up that business.

D I G I TA L

Courtesy of TBWA/Khanga Rue

i o i s to t e screen s ne t s i e the body getting rid of toxic blood.”

r e or Fa se

erio is

“Go ahead,” Likulo says. It’s a nod to encourage Amina to dig into, and then debunk the myths surrounding contraceptive side effects, like changes to menstruation. The quiz helps segment girls into categories: younger girls with less knowledge about their bodies, and older girls who may already be sexually active. Understanding the audience ensures the right message—and the right options—are then delivered.

I M PA C T M A G A Z I N E N O. 25

Based on quiz answers, the app presents two method recommendations for girls to compare side-by-side, and they can watch video testimonials delivered by “girls like me” to hear first an from eers a o t y t ey se ecte t e met o at they can expect when they receive it at the clinic and what side effects may come from the contraceptive chosen. All messaging leads with a return to fertility, speaking directly to girls’ primary, expressed concern.

D I G I TA L

Courtesy of Adolescents 360

Courtesy of TBWA/Khanga Rue

Courtesy of Adolescents 360

D I G I TA L

If a girl opts for a method, the app provides a referral which girls can redeem at a PSI Tanzania clinic. The process ensures no information is lost nor duplicated between clinic visits, while allowing healthcare educators like Likulo to follow-up with their clients, like Amina. “Mjanja Connect shows that technology can be a powerful tool to increase the reach and impact of SRH education among young people today,” says Lee Wells, Head of Health Programs for the Vodafone Foundation. “Mjanja Connect gathers and shares complex contraceptive information for each user to offer guidance that is engaging, personalized and relevant to their needs.” Courtesy of Adolescents 360

As Wells says, technology is key in delivering this level of service at scale. “We hope Mjanja Connect will encourage young people to take action with their SRH, by putting reliable information and the ability to make informed choices about their future in their hands,” Wells adds.

Reaching Girls. Supporting Health Systems. “Mjanja Connect is a game changer,” Likulo says. “It makes the narrative consistent, it builds trust among girls and has lightened t e ten o s a er or t at e se to fi o t to trac gir s pathway to care.” Likulo eyes her clipboard. She’s got another house to visit. Courtesy of Adolescents 360

no onger ave to carry a i c art met o ags note oo and pens. I now just need to carry my tablet. It makes me more effective.” Since integrating Mjanja Connect, Likulo now refers about six girls to the clinic per week. That’s up from the average of one she was referring before. —With contribution from Gaston Shayo, Marketing and Communications Specialist, PSI Tanzania.

EMMA BECK

Associate Communications Manager, PSI

@emmashoshanna

I M PA C T M A G A Z I N E N O. 25

D I G I TA L

dare to drEa This past International Women’s Day, PSI went global with the #DareToDream challenge—a PSI and Vodafone Foundation-partnered social media campaign to get us all thinking about what it takes to lead with young people’s insights in our mission to reframe the narrative around contraception. To do that, partners joined us in sharing the Mjanja Connect “Sisi Nanasi” music video, posting social media videos dancing to Sisi Nanasi’s chorus and highlighting how access to contraception helped them #DareToDream.

#DareToDream has encouraged us to consider how contraception can bring us all closer to reaching our life goals. It’s an entry point to igniting—and then maintaining—a global dialogue around what it takes to work with and for young people to make contraception relevant for the next generation of consumers. This is a movement, and we’re thrilled to be driving this forward, together. Join in online! Visit http://bit.ly/daretodreampsi to learn how. Don’t forget to check out posts from our partners below..

Don’t miss your chance to come dance with us! Join PSI at the Sisi Nanasi video screening during the Women Deliver Film Festival on Tuesday, June 4 at 6:30pm at the VCC West Exhibition Hall.

D I G I TA L

HEALTHCARE IN THE PALM OF HER HAND At age 17, I longed to have my own mobile phone. A Tanzanian mobile service provider had just introduced a promotion to make free night time phone calls. I deeply wanted my own phone to talk to friends and relatives all night. But my parents wouldn’t buy one. For them, a mobile phone wasn’t a priority. So I got creative: I asked my sister, who had a job, to get one for me. at first one as a ry t no mo i e tec no ogy is an essential part of my day-to-day life. I use it to pay bills and to s o on ine en ave a estion t am too afrai to as anyone, I just Google it. The smartphone revolution is drastically changing the lives of young African women like me. But in Tanzania, it hasn’t yet reached a group that also has questions they’re afraid to ask: adolescent girls. There are over 43 million mobile phone owners in Tanzania—72 ercent of t e o ation S s yo t o ere se a an reproductive health project, Adolescents 360 (A360), found that while 77 percent of girls ages 15-19 use a phone, only 25 percent own their own phone. And despite the continuous growth of mobile technology in Tanzania, a large gender gap in internet use remains: 35 percent of Tanzanian men use mobile internet compared to only 17 percent of Tanzanian women, according to a 2019 Global System for Mobile Association report. A360’s study found similar results: 84 percent of Tanzanian girls reported using the internet less than once monthly. In Tanzania, where many girls and women share a device with friends and family, discreet access to health education and information is essentia at s y S an ania ses SS ( nstr ct re S ementary Service ata) to rovi e gir s it information a o t t eir o ies SS is free an a o s sers to navigate through information using a menu and leaves no trace on t e mo i e evice n i e ca s or te ts it a re o ate ist of information a o t se a an re ro ctive ea t (S ) SS gives girls and women a discreet way to access information about their chosen contraceptive method on a shared smartphone. PSI also uses the Connecting with Sara (CwS) platform, named for PSI’s archetypal user, to power healthcare for women by tracking and engaging with them through their mobile phones sing ca s te ts an socia me ia it er consent t e atform

I M PA C T M A G A Z I N E N O. 25

tracks her throughout her continuum of care— not just when she visits the clinic — sending referrals and using client satisfaction surveys. CwS isn’t just used in Tanzania; it integrates with apps in Zimbabwe, Mozambique, Kenya, Nepal and Honduras, too. I’m 31 now. The world has changed a lot in the 15 years since got my first mo i e one e m st contin e to e ore t e possibilities of digital technology as more women gain access to mo i e tec no ogy it rograms i e SS e can overcome gender and age barriers to ensure that girls, no matter where they are, have access to the health information they need—right in the palm of their hands. For me t at s not a

ry t s a riority

Hear more from Rehema about using technology to advance adolescents’ access to SRH at the Women Deliver 2019 concurrent session, “The Global Digital Health Divide: A Debate” on Tuesday, June 4 at 3:00pm in VCC West 221-222.

Rehema Mugeta IPC Coordinator, PSI Tanzania

In partnership with young people, PSI’s Adolescents 360 (A360) digs deep into consum ers’ lives to redefine how girls aged 15-19 pe rceive and access modern contraception in Ethiopia, Ta nzania and Nigeria. Fusing exciting girl-defined brandin g with aspirational messaging, A360 repositions contra ception as a tool in service of girls’ visions for their lives.

SMART ST ART Card

DELIGHT

UBUNTU

THE SPIRIT OF PHILANTHROPY There is a word in the Nguni language called “Ubuntu,” which means, “I am because we are.” It is a spiritual concept that brings meaning to the burning sense of belonging each person feels and compels us to connect to our inner personal power for the enefit of ot ers The Motsepe Foundation was established with this spirit, which we aim to instill amongst stakeholders locally, regionally and internationally. Poverty, discrimination and inequality erode this innate sense of togetherness. They may disparage the sense of belonging women and girls have in society, limiting their agency to improve their welfare and that of their communities.

The prosperity of a society is intertwined with the prosperity of its women, and for as long as they are left behind the wealth and happiness of their countries will be lacking.

A 2018 report by the World Bank Group found that an estimated $160 trillion of wealth is lost globally in lifetime earnings due to gen er ga s n s Sa aran frica t is fig re is tri ion n res onse to t is financia ine a ity t e otse e Fo n ation advocates for gender-responsive budgeting initiatives which ensure that national budgets align to the needs of whole populations. The Motsepe Foundation measures its impact through the strengthening of social cohesion and the liberation of women and girls. These both contribute to the creation of a truly prosperous society. With a focus on youth, the Foundation unlocks girls’ potential to achieve social, economic and political agency. Our programs ensure that there are more women in the fie s of science tec no ogy engineering mat (S ) socia entrepreneurship and sports; we also work hard to make their voices heard in social and economic discourse.

I M PAC T M AG A Z I N E N O . 2 5

The Motsepe Foundation has committed to the Giving Pledge, as well as the UN Sustainable Development Goals. Through local and global partnerships with the Department of cation of So t frica arvar enne y Sc oo t e Sc a Fo n ation for Socia ntre rene rs i t e i en nstit te averic Co ective an ot ers e aim to fin creative solutions for societal change. This change happens when the needs of women and girls are addressed. Their needs are not unique, only overlooked. ac year t e otse e Fo n ation osts a S mmit to nite the voices of women and girls. Their diversity ignites valuable discussions around new challenges and solutions which we co ective y commit to s orting financia y an ot er ise To invest in women and girls is to invest in their access to choice and to uplift their individual power. In every community, and for each individual whose lives were touched by the Foundation, we see a circular motion of Ubuntu inspiring the empowerment of thousands of other people. To be a humanitarian is to consider our individual power through the lens of humanness, and aim for the achievement of oneness. Through philanthropy, as in Ubuntu, we reimagine the world as a place of peace, compassion, respect and justice. But to birth this new world requires systemic transformation that facilitates women into spaces where they are misrepresented, and rallies for the adoption of a bold vision where no one is left behind. Hear more from Dr. Moloi-Motsepe at the Women Deliver 2019 concurrent session, “The Power of Money: Investing in Girls & Women” on Tuesday, June 4 at 3:00pm at the VCC West Plenary Hall.

DR. PRECIOUS MOLOI-MOTSEPE

Co-Chair, Maverick Collective Co-Founder & CEO, Motsepe Foundation

@MotsepeFoundtn

DELIGHT

Photo credit: JLwarehouse / Shutterstock.com

Dr. Precious Moloi-Motsepe speaks at the 2018 Global Citizen Festival in Johannesburg, South Africa. Photo by Jemal Countess/Getty Images.

DELIGHT

let's talk a out sel Care

ng Leaders, youth advocates You r ive Del n me Wo 10 se the et Me the programs and policies that from around the globe active in that self- car e is about more e iev bel o wh s, live ly dai ir the ect aff owerI nH erH an ds. We asked than health— it’s about taking #P e cou ld transform sexual and car f— sel of er pow the how m the their commu nities. reproductive health and rights in

”. . .[ Self- care] pr od bodil y autonom y an ucts, when readily accessible, engend fr aming your own d respect. They render you capable er futu re with your ow of n hands. ”

— Su maira W aseem, 21 Global Peac e Ambassad or Global Peac e Chain Pakistan

”I see self- care as a lifesaver. In intense situatio ns , an unprotec ted relationship ca n cause sudden panic that lead s to bad results for yourself and fo r society. But an abor tion pill ca n work as a mira cle to save lives.” — Umair Asif, 28 Founder, Kafka Welfare Organization Pakistan

I M PAC T M AG A Z I N E N O . 2 5

lity in " If [self-care] becomes a rea be ld wou it n the , nity my commu , pen hap to gs thin t bes one of the , ple peo ng you for especially because of all the bias and vice judgmental attitudes at ser ." ters deliver y cen — Mar y Adeoye, 24 Health Sexual and Reproductive ocate Adv hts Rig and Nigeria

DELIGHT

right] to take "When a female is granted [her this a triu mph for lth, com plete ownership of her hea the most intimate in self her commu nit y. Car e of one healthcare system Our d. ways promotes peace of min mind." of ce pea should be rooted in creating ck, 27 — Ashley Foster-Estwi George The r, ato rdin Coo ch Qualitative Resear e Research Centre Alleyne Chronic Diseas Barbados

of ten afraid to "My peers are tive and reproduc access sexual n ca s since law health services e the m g rrents. Givin serve as dete es ic rv ss these se option to acce y m no ves me auto on my own gi ht rig an m and my hu over my body d an th services to access heal ” information. gow, 21 — Dennis Glas Youth re pi As Director, na Network Guya Guyana

”Accessibility and proper, basic knowledge about selfadministered sexual and reproductive health products play a key role in maintaining the physical, mental, emotional health of the individual and entire society, by offering a sense of personal freedom, choice and bodily autonomy.” — Tatiana Biciuc, 28 Young Leader, Women Deliver Republic of Moldova

tion (MA) is a ”Medical Abor women to take revolution for al over their sexu sole decision RH). tive health (S and reproduc legal, re abor tion is In Nepal, whe for ill stigmatized women are st red te Self- adminis accessing [it]. tion pills have medical abor cess g women to ac allowed youn ma.” ig re without st service and ca 31 Bajrachar ya, — Shreejana p hi rs ne rt or tion Pa Asia Safe Ab Nepal

"My ability to obtain reproductive health products will give me the power to own my body in a healthy way [because] these products will come with instructions on how to use them correctly and I’ll be certain that I have privacy.” — Aurelia Naa Adjeley Sowah-Mensah, 24 Youth Advocate, Women Deliver Ghana

s increase "Self-care intervention ty an iali ent the riva y, nfi d people ize nal autonomy of margi that gs tin in humanitarian set lth hea ine la s ffi iently tra e uat deq workers, [have] ina [lack] health infrastructure and and ual evidence- based sex licies or reproductive health po practices.” — Hamza Meghari, 25 iver Fel Young low, Women Del Palestine

"By bringing reproduct ive health products like HIV and hepatitis C tests, condoms , lub e, [and the] ability to schedule appo intments for PrEP directly [to] the community, I am able to educate and equip our commu nities with the resources that we all deserve!” — Helena Likaj, 27 Program Manager, Od yssey House USA

DELIGHT

WHY INVEST IN WEST AND CENTRAL AFRICAN ADOLESCENTS AND YOUTH? Across Francophone West and Central Africa (FWCA), young people too often face socio-cultural obstacles to accessing comprehensive sexual and reproductive health (SRH) services, where and how they need. For young people in FWCA to have the adolescent and youth SRH choices they want and deserve, we must reimagine how we strengthen the market to reach and serve our youngest consumers, on their own terms.

Join these women and others at the side event, “Youth-Powered Investments in West and Central Africa” as they discuss what it means to invest in the future of adolescents in FWCA on Monday, June 3 from 12:00-2:00pm in the Fairmont Waterfront Hotel’s Princess Louisa Room.

e invite ea ers from across t e re ro ctive ea t fie donors, implementers and young people themselves—to share their perspective on the importance of investing in FWCA adolescents and youth, and what each visionary is doing to change the landscape for the next generation. As they share: it’s time to combine our energy and voices to serve the FWCA adolescents and youth who need it the most.

Aissata Segolene Kodio, Activist and Young Leader, Women Deliver "I am starting a campaign where young girls like me who usually have to work or get married can access quality education and Sexual Reproductive Health (SRH) resources so we can build our own wealth and be able to make our voices heard.”

anet o t rogram fficer Global Development and Population Program, Hewlett Foundation “FWCA’s youth are ready to take the lead in determining their futures. Comprehensive SRH information and services are a critical component to ensuring that is possible. It is the funding community’s role to support innovative SRH programs that put youth at the center from the start. Through our support for the Ouagadougou Partnership (OP) and the nine Francophone West African countries in it, we fund the OP Youth Think Tank, the OP Youth Ambassador program for civil society, several youth advocacy efforts and human-centered design program innovations to better reach young people with services they want and need.”

I M PA C T M A G A Z I N E N O. 25

Jess Jacobs, Philanthropist, Maverick Collective “The importance of supporting SRH efforts lies squarely in the fact that access to contraception for adolescent girls—as well as their adult counterparts—helps countries catalyze economic growth and community development. This is the same whether you’re in West or Central Africa, the U.S., or any other region around the world. Investing in that access in FWCA, and truly investing in the girls and women themselves, means that each person is supported to build the future she dreams of and to see it through, exactly as she planned.”

DELIGHT

Hope Neighbor, Partner Camber Collective “Girls in FWCA pay an especially high price for lack of choice. West and Central Africa has one of the largest youth populations in the world—77 million 15 to 24-year-olds live in the region. Girls have limited choice due to a combination of systemic factors, social norms and challenged service delivery. And girls pay the highest price in the world for their lack of choice, with a maternal mortality ratio of three times the world average.”

Kristely Bastien, Youth Technical Advisor, PSI Côte d'Ivoire

Nicolette Van Duursen, Francophone Africa Director, Ipas “There are more than 1.8 million unsafe abortions in West Africa each year. Unsafe abortion is the most neglected and easily addressable health crisis for young people. Ipas Francophone Africa uses user-centered design to not only understand what women and young girls want out of self-use interventions, but to also support community health workers and providers in providing high-quality safe abortion services to young women. ro g as a es C arification an ttit e ransformation interventions, we work toward ensuring that every young women and girl is able to access comprehensive abortion and contractive care without fear or stigma.”

“If we are going to invest in youth, we need to be in it for the long haul and we need to be consistent. A youth focused meeting? Great. Youth on staff? Great. Inviting youth to work on program design, implementation and monitoring? Great. But not enough. Let’s ask: How frequently are we doing this? And are we being consistent?"

Nomi Fuchs-Montgomery, Deputy Director for Family Planning, Bill & Melinda Gates Foundation Nicole Cheetham, Director International Youth Health and Rights Division, Advocates for Youth

“By listening to what matters most to young people, we can test holistic models that include expanding method choice, addressing provider bias and supporting gender transformative interventions. Based on insights, we are building evidence to scale in the region so the connection between their reproductive health and personal ambitions go hand in hand.”

“In FWCA, adolescents experience some of the highest levels of child marriage, adolescent pregnancy and maternal mortality in the world—yet resources to support their vulnerabilities fall short. It’s time to invest in youth leadership, strengthen and expand promising and effective models and support innovation to advance SRH and rights.” 57

POWER

A NEW WAVE OF POWER

Abena Fikru* has been married for one month. Just 15 years old, she lives in a rural Ethiopian village outside of Addis Ababa and dropped out of school to support her husband, Tamrat,* at home. She has deep brown eyes that shine as she speaks of him. “[Tamrat] is more beautiful than me,” she gushes unabashedly, describing him as caring and hardworking. Tamrat is still in school and sells sand to earn income. At home, Abena cooks, cleans and sews. Abena and I are both newlyweds. We share the same values: ove ar or an financia sta i ity met my s an in business school. After graduating, we moved to New York City to continue building our careers and relationship. “I fell in love with my husband the moment we met,” I revealed to Abena as if we had been friends for years.

MaverickNext is a unique program which, through deep partnership with PSI, galvanizes young philanthropists to reimagine the way in which sexual and reproductive healthcare is designed and delivered for girls and young women. MaverickNext has the dual purpose of catalyzing innovative health impact while building a movement of women leaders who are bold, informed and strategic in the ways they invest their resources. By partnering with MaverickNext and PSI—and connecting it gir s i e ena am i ing my no e ge ase fi ing critica information ga s an re efining at it means to e a philanthropist. I am no longer just a donor allocating my funds to a cause. I am an experienced and insightful leader. That is power.

When I sat with Abena, I did not think about all of the important articles and exhibits cataloging the inequities facing girls in Ethiopia. I didn’t think about the statistics regarding sexual and reproductive health or child marriage. This data was not top of mind in that moment because it didn’t provide the full picture. It didn’t illustrate Abena’s anxiety over a challenging conversation she will soon have with her in-laws. “I am avoiding,” she said. To them, immediately getting pregnant would prove her fertility. Data doesn’t illustrate Abena’s plans and dreams. With her husband’s support, coupled with PSI’s Smart Start program, Abena will be taking up a contraceptive implant to prevent an unintended pregnancy for up to three years while she and Tamrat earn the money they need to provide for their future family. Data lacks empathy.

" "

We do not gain empathy through textbooks and newspaper articles. We gain empathy by connecting with e le firsthan .

We do not gain empathy through textbooks and newspaper artic es e gain em at y y connecting it eo e first an Rarely do women like Abena and I—women from opposite sides of the world—have the ability to connect as deeply as we did. MaverickNext made it possible.

MaverickNext has the dual purpose of catalyzing innovative health impact while building a movement of women leaders who are bold, informed and strategic in the ways they invest their resources.

I M PA C T M A G A Z I N E N O. 25

Before Alexandra Idol leaves Abena Fikru’s* home outside of Addis Ababa, Ethiopia, they pose for a picture, showing off their wedding bands. Photo courtesy of Emilee Kaufman.

As I left Abena’s home, she lifted her left hand, signaled me to do the same and—instead of a traditional goodbye—touched her wedding band to mine. Hear more from Alexandra at her Power Talk on Thursday, June 6 at 1:05pm on the Women Deliver Power Stage. * Names changed to protect clients’ identities.

ALEXANDRA IDOL

MaverickNext Fellow

@ MaverickNext

P OW E R

HOW WILL YOU USE YOUR POWER FOR GOOD?

Every three years, delegates from around the world gather at the Women Deliver Conference to drive forward progress for girls and women. Over three and a half days, thousands of ecision ma ers an in encers from civi society governments the private sector and international agencies join advocates, activists and journalists to identify solutions to bring us closer to a gender equal world. And in 2019, at a time when conservative winds are blowing around the world and threatening to set back gender equality, we’re putting a special emphasis on power. To keep action top-of-mind for every participant, we’ll ask: “How will you use your power?” So it’s only fair to hold ourselves accountable and ask ourselves the same question: how has Women Deliver used its power as the host of the largest conference in the world on gender equality?

From the plenary stage to concurrent sessions, to the fueling station (what we term our exhibition hall) and beyond, Women Deliver 2019 (WD2019) will showcase how to shift power dynamics and demonstrate meaningful youth engagement, intersectionality, working across silos and bringing people together across generations, geographies and sectors. A nd of c ourse , to demonstrate the power of gender equality, every facet of WD2019 will spotlight new research, data, case studies, solutions and testimonials that underscore how everybody wins in a gender equal world. When girls and women have true equality, there’s a ripple effect that extends way Courtesy of Women Deliver beyond the individual and enefits fami ies comm nities economies an o e societies This undeniable cascade will be center stage throughout the conference. To make it truly inclusive and global, Women Deliver is supporting travel and/or registration for more than 1,000 people from across the globe to join us in Vancouver. WD2019 will connect these delegates to the people, resources, ideas and inspiration that will fuel their future work, and their participation will fuel and enrich the global dialogue. With the focus of more than 8,000 participants from over 165 countries and 2,700 organizations on site and more than 100,000 people engaging in a global dialogue on gender equality around the world, this is a key opportunity - one of many - to move the needle for girls and women. .

Courtesy of Women Deliver

First, we didn’t keep that power to ourselves. We started with a global listening tour, where we spoke to and heard from more than 1,500 individuals to better understand the global landscape—trends, opportunities and challenges—facing girls and women today. And we asked what people would like to see happen at the conference and who they wanted to hear from. Based on our listening tour, we worked hand-in-hand with more than 150 organizations to co-create a platform and programming that would spotlight the work of hundreds of individuals and organizations tackling these issues.

If we all continue to use our individual power, our power over systems and our power as part of a movement, we can make real change. I hope we all look back at WD2019 and see how, together, we inspired the world to harness power for good, demonstrated the power of gender equality and catalyzed investment where it counts the most for girls and women. I, for one, can’t wait to see the change that can happen when all of us answer the critical question: How will you use your power?

K ATJA IVERSEN

President & CEO, Women Deliver

@Katja_Iversen

P OW E R

E p i r s i PoweForr rein ention Power, its abuses and its character are all around us in 2019. We see it in our politics, in our struggles over economic systems and business models. We see it playing out in the dispossession of millions of people of their homes and safe places to live, as the world grapples with more refugees and displaced people than ever. And, as always, we see it playing out in the bedroom. “No one gives you power; you just have to take it,” is attributed recently to Speaker Nancy Pelosi, but also to comedian Roseanne Barr. It doesn’t matter where you stand on the US political spectrum: the truth of this statement transcends politics. A more apt quote might be the 18th century wisdom of author and pioneer of Western women’s rights, Mary Wollstonecraft, “I do not wish women to have power over men; but over themselves.” What about power in healthcare? Our moment is ripe for reinvention.

Primary healthcare, more in the hands of health consumers and patients themselves, can unlock faster progress toward universal health coverage. New diagnostic tools and self-administered therapies are creating the possibility for radically reducing the middle man, so to speak. The barriers of old—too few doctors and trained me ica ersonne in t e o a So t inefficient or over e me health facilities; and a mismatch between where the people are and where the healthcare is—are now potentially surmountable, with the help of digital healthcare tools, connectivity and referral networks that allow for a system leapfrog. Primary healthcare, more in the hands of health consumers and patients themselves, can unlock faster progress toward universal health coverage. Where our healthcare moment of today connects with Wollstonecraft’s 225-year-old wish is in the most prized and most contested realm of control of them all: fertility. First radical, then seemingly banal to the 21st century audience, but now considered radical again, is the idea that women need to e a e to e ercise contro over t eir o n ferti ity e enefits accruing to women, to their families and communities, and to the planet as a whole are now clearer than ever. And yet, today we see ever more indications of just how threatening this control must be to men around the world, as leaders in the North and South disparage and undermine family planning, contraception, women’s agency and, ultimately, control of fertility.

I M PAC T M AG A Z I N E N O . 2 5

Power isn’t mine to give, though as a white American male in his 50s leading an international NGO, I am perceived to have lots of it. But there is power to seize, and it is hers to take. My job is to ensure that my role and my organization help remove the barriers to women’s ability to take their power and use it for themselves. Our job is to make it easier for Sara, PSI’s archetypical health consumer, to lead a healthier life and plan the family she desires. I wouldn’t condescend to “empower” Sara. I can, however, get out of her way. Hear more from Karl at “The Power of Stories: Making sexual and reproductive health and rights come to life” Plenary Session on Wednesday, June 5 from 1:30-2:30pm.

K ARL HOFMANN

President & CEO, PSI

@KarlHofmannPSI

AC T I O N

CHANGE

The Case For Her

PROGRESS

POWER

COMMUNICATION

Menstrual health and rights can be accessed by all when LUTIONS we workS O together. INNOVATION

AGE N CY

The Case For Her funds programmes, research, and

initiatives focused on female health. At Women Deliver, we will bring together diverse partners addressing

EQUALITY

menstrual education, access, and stigma to S U S T Aawareness, INABLE normalize menstruation A D V O C Aand C Yreach the global goals.

COLLABORATION

SUSTAINABLE DEVELOPMENT GOALS Lack of knowledge about menstruation constrains menstruators' ability to manage their overall reproductive health. Make menstrual health a critical component of comprehensive sexual and reproductive health.

Lack of access to WASH facilities, pain management tools, products and knowledge affects quality of education. Include menstrual health in national curriculum to ensure that all students understand the menstrual cycle.

Menstrual taboos and myths lead to a culture of silence, discrimination and harmful practices. Break down menstrual taboos and myths through education and conversation to help build positive norms.

2.4 billion people lack access to proper sanitation, which disproportionally impacts girls and women. Include women and girls when designing safe and culturally acceptable facilities and solutions.

Inadequate menstrual health and education hold menstruators back from participating fully at work and in society. Economic equality starts in school. A 1 % increase in secondary education completion raises GDP by 0.3%.

Disposal of menstrual products remains unsolved in many places across the globe. A comprehensive approach to menstruation includes disposal systems and access to sustainable solutions.

Visit us at booth 160 during Women Deliver

r e w o P Eco s d n a H r u o Y in irls and tten with g ri w t s ju ’t asn in, too. d they live e holding w rl ’r o u o w y e e th in t z c T h e mag a d it to prote cure the ; we printe d in m in it ting to se n m m o c wome in t n governme t. Canadian e th nvironmen in e jo r u e o W health of

By using 100% p

Impact magazin

ost-consumer re cycled paper, e saved the follo wing resources:

23.9

fully grown trees

10.8

million British Th ermal Units of energy

You’rE reading this on cocoon silk rEcYcled papEr Impact No. 25 was printed using 100% recycled, chlorine-free Cocoon Silk paper.

5,300

gallons of water

100

pounds of solid waste

You’rE holding a 100% carbonnEutral magazinE The paper lifecycle, transport and printing of every paper product creates greenhouse gas emissions. But through investments in energy efficiency and non-fossil fuel technology, the carbon emissions created by the printing of Impact No. 25 have been fully offset.

13,610

pounds of greenhouse gass

tHis papEr is FsC-cErtiFiEd The Forest Stewardship Council (FSC) is a certification system that ensures environmentally appropriate paper options. The FSC helps society at large by providing incentives to sustain forest resources and help manage forests in the long-term. 100%