She Cares

Today, Uganda is host to the largest refugee population on the African continent and the third largest in the world. It is also dealing with multiple shocks from over the border displacement, outbreaks – including COVID-19 – and the growing impacts of climate change.

The She Cares Consortium (IRC Uganda, WORUDET, and ACORD Uganda) are working together to design, implement and generate evidence on adolescent integrated self-managed contraceptive packages in Uganda. We are employing user-centered design and behavioral research with refugee women and girls to inform the development and implementation of SRH self-care models that empower clients and leverage community networks.

The Need

Refugee women and adolescents seeking contraception in Bidi bidi and Palabek refugee settlements of Uganda face a number of demand and supply side barriers. Many of them cannot access facilities due to long geographical distances they need to traverse. Others are worried about the lack of privacy in existing facilities. And for those clients that are able to access a health facility, supply chain disruptions, health worker shortages, and stigma make it that much harder to receive these life-saving services.

Sexual and reproductive health (SRH) self-care is becoming increasingly recognized for its vital role in helping to extend the skills and knowledge, and agency to manage menstruation, pregnancy, fertility and childbirth to women and girls themselves. For the millions of people living in humanitarian and fragile settings, self-care offers an exciting opportunity to fill critical SRH gaps in disrupted health systems.

Access to contraception grows economies, creates healthy families and overall advances opportunities for women and girls. The World Health Organization recommends self-care interventions as ways to improve people’s contraceptive options and their choices of place to access these. Such self-care interventions include pregnancy testing, emergency contraception, oral contraceptives, self-injectables, and condoms. These methods are considered to be self-managed contraception (SMC).

Self-care has always been key in helping people address their health needs but new products and interventions have the potential to greatly improve health outcomes and extend health coverage.It allows for choice, agency and autonomy for individuals to manage their own healthcare while engaging health providers as needed. Self-care contributes to universal health coverage and achieving the Sustainable Development Goals (SDG) on health, gender equality, women’s empowerment and reducing inequalities.

Our Solution

We are working directly with adolescent refugee girls and women to design, test, prototype and implement new self-care solutions that reflect the needs and preferences of self-care users. These solutions focus on the particular concerns and challenges adolescents, specifically displaced people, face in accessing contraception.

The solutions include:

The Family Planning Eligibility Card

For adolescents to mitigate medical eligibility screening challenges, promote a wide range of self-managed contraceptive products, support adolescent confidentiality, and move service provision beyond the health facility: A contraceptive eligibility card issued by midwives after screening girls at the end of health education sessions. These cards show girls the suite of contraceptive methods they are eligible for, distinguishing those that may need a health worker vs. those that can be self-administered. With the card, girls can pick up self-managed contraceptives from a diverse range of distribution points (such as the out-patient facility-based pharmacy, community health workers, and drug shops) by simply pointing at any of the SMCs they are eligible for – with no further questions by providers.

The Forgiving Pill

This is a simplified attachment for combined oral contraceptive pills that accounts for the human error of missing a pill and suggests what to do in such a scenario. Clients receive this attachment along with their pills and feel more confident to recover from an error upon missing a pill instead of immediately discontinuing the method. This attachment may also be used as a health education tool by midwives when introducing the combined oral contraceptive pills, to reduce the fear of consequences of missing a pill.

Coalition Building for Self-Care

At the global level, we are part of several self-care coordination groups. IRC leads the IAWG Self-Care task team and is also a member of the SCTG Steering Committee.

Last year, we finalized the global assessment on self-care barriers and opportunities in humanitarian and fragile settings in partnership with the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) Self-Care Task Team. The report synthesizes findings and lessons-learned from interviews conducted with leading experts working on self-care and SRH and rights in humanitarian, fragile and stable settings.

We also released a subsequent Global Call to Actionaimed at advancing investments, research and implementation and an enabling environment for self-care in humanitarian settings at the end of July 2023. We are tracking global progress of self-care in these settings alongside the call to action.

What’s next?

We have just started implementing these solutions and will be evaluating their acceptability, feasibility and cost-effectiveness. We are also working with the Ministry of Health and other partners to identify ways to integrate successful solutions into national scaling pathways, including actively participating in their creation of an investment case for self-care which will be used for national and sub-national budgetary advocacy and allocation.

By building an ecosystem inclusive of both facility and non-facility health modalities we can bring products and information directly to our clients, increasing their autonomy and expanding their access to and choices for care. Self-managed contraceptive (SMC) methods such as self-injectables (Sayana Press), Emergency Contraceptive Pills, CoC (Combined Oral Contraceptive Pills) offer an opportunity to address these barriers. SMC enables women to access care during crises, allows for privacy and minimizes travel distance, and overall expands SRH access to humanitarian and hard-to-reach populations. Our vision is to reduce unintended pregnancy amongst adolescent girls and young women through a comprehensive package of SRH self-care options in Yumbe and Lamwo, Uganda.