FANTA III FOOD AND NUTRITION TECHNICAL A SSISTANCE Family Planning Integration with Food Security and Nutrition Reena Borwankar and Shelly Amieva Recognizing the urgent need to address both the direct planning (Borwankar and Amieva 2015). As a companion and underlying causes of malnutrition, the U.S Agency for to this review, the Health Policy Project conducted two International Development (USAID) Multi-Sectoral Nutrition literature reviews summarizing the empirical evidence on Strategy 2014–2025 calls for the increased availability why it is important to integrate these services (Smith and of family planning and reproductive health services Smith 2015; Naik and Smith 2015). This brief summarizes (USAID 2014). To escalate the U.S. Government’s global the findings from the FANTA desk review. commitments in this area and to optimize the effectiveness of food security and nutrition programs, there is a need to understand how best to integrate family planning with food security and nutrition programming and a need to raise This brief summarizes the findings of a FANTA report, awareness about the importance of family planning for Desk Review of Programs Integrating Family Planning improved food security and nutrition outcomes. However, to with Food Security and Nutrition. It provides a date there has been limited peer reviewed literature and a snapshot of the various ways development programs dearth of documentation on programmatic experiences of are integrating family planning with nutrition and food integrating family planning with food security and nutrition security interventions. The brief offers lessons learned (Brickley et al. 2011; Maternal and Child Health Integrated and promising practices for programming, provides Program [MCHIP] 2010; Ringheim 2012; USAID 2011; recommendations for USAID, and sheds light on gaps Yourkavitch 2012). in the evidence base. The full report (available at www. fantaproject.org/fp-integration) synthesizes learnings To address this evidence gap, the Food and Nutrition from 102 programs and provides a rich set of program Technical Assistance III Project (FANTA) conducted a desk examples, including three case studies. review to take stock of and better understand how food security and nutrition programs are integrating family Producer group members in Zambia use the Better Life Book to learn about the links between conservation, food security, and family planning. (Photo provided by COMACO program staff) Family Planning Integration with Food Security and Nutrition METHODS development food assistance programs, about a third were The focus of the desk review was primarily grey and population, health, and environment programs and the published literature from USAID-funded programs rest were other global or Mission-funded USAID programs, implemented over a 10-year period (2003–2013). including one non-USAID program. While nutrition and Several funding streams supporting the implementation family planning integration occurred in both health and of food security, nutrition, and family planning programs multisectoral programs, family planning and food security across USAID Bureaus and Offices were targeted for the integration occurred only within multisectoral programs. review. The 102 programs of focus in the review included Although over half of the programs were multisectoral, child survival; maternal, newborn, and child health; food family planning was integrated only within health activities assistance; population, health, and environment; and food in 43% of programs, suggesting more room for integration security and agriculture programs. Data sources included across non-health interventions. program documents such as evaluation and annual reports, technical briefs, and implementation plans. A program was Of the programs reviewed, family planning and nutrition considered integrated if food security and/or nutrition and or food security interventions were mostly built into family planning interventions were delivered either at the program design from the outset as part of larger integrated same service delivery point or by the same provider. health (maternal, newborn, and child health or integrated management of childhood illnesses) or multisectoral HOW PROGRAMS ARE INTEGRATING FAMILY agriculture, conservation, livelihoods, and health packages. PLANNING WITH FOOD SECURITY AND Only 10% of programs added family planning after program NUTRITION implementationEducation +began, Counseling usually + Commodity as a result Services of receiving additional funds. Types of Integrated Programs by Sector. Within the 102 Education + Counseling + Commodity Services programs reviewed, family planning integration was found in Integration Models. Programs reviewed were categorized health sector programs implementing only health activities as offering one of three types of integration models based Education + Counseling + Commodity Services (45% of programs), as well as in multisectoral programs that on the type of family planning intervention(s) delivered included agriculture, environment, fisheries, or livelihood across all the nutrition and/orEducation food + Counselingsecurity points of activities in addition to health activities (55% of programs). contact within the program: (1) family planning education, Over half of the health sector programs were Child Survival (2) family planningEducation education + Counseling and counseling, or (3) family and Health Grants Programs and the rest included other planning education, counseling, and commodity provision. USAID global and Mission-funded health sector programs, EducationAll three + Counseling models could include referrals to family planning including two non-USAID health programs. Close to half of services. The third model was most common across both Education the multisectoral programs were Office of Food for Peace health and multisectoral programs (see Figure 1). Education 0% 20% 40% 60% 80% 100% Figure 1. Family Planning Integration Models Education 0% 20% 40% 60% 80% 100% Education + CounselingEducation + Counseling + Commodity + Commodity Services Services 0% 20% 40% 60% 80% 100% Multisectoral Health Sector All Multisectoral Health Sector All EducationEducation + Counseling + Counseling Multisectoral Health Sector All Note: All three family planning EducaEducationtion intervention categories may include referral to family planning services. 0% 20% 40% 60% 80% 100% 1 The ENA framework is an integrated package of priority nutrition actions intended to be promoted at six contact points across the lifecycle (antenatal care, delivery and immediately postpartum, postnatal and family planning, immunization, growth monitoring/well child, and sick child visits). Multisectoral Health Sector All 2 Family Planning Integration with Food Security and Nutrition Integrated Service Delivery Strategies. Across the were critical to most program integration strategies and programs reviewed, a range of strategies were used very few programs implemented integrated activities for integrated service delivery across the three models only through health facility providers; most included both both at the community and health facility levels. Service health- and community-level providers. Community-level delivery platforms and providers were not unique to providers were often organized in groups and a wide range a specific integration model. For example, in some of community-based groups were used as entry points or programs a platform was used to integrate only family platforms to deliver integrated activities. These groups planning education and the same platform was used by included care groups, mother’s/father’ clubs, farmer’s other programs to implement family planning education, groups, and associations for people living with HIV. Box 1 counseling, and commodity provision. Some programs used provides some program examples of the various platforms, routine service delivery platforms such as mobile clinics and contact points, and providers used for integrated service rally posts to deliver integrated services. Other programs delivery. added family planning into platforms such as nutrition weeks, farmer field days, or nutrition rehabilitation sessions. GAPS IN THE EVIDENCE BASE The use of specific lifecycle contact points (such as during Several important gaps in the evidence base and available antenatal care, birth and discharge, postpartum care, or program documentation were identified in the desk childhood) was a strategy employed by all three models. review, underscoring the need for stronger program Programs either targeted a specific lifecycle point or more documentation on the integration process and research often adopted a continuum of care approach that targeted that tests the effectiveness of integration models. several or all lifecycle contact points by implementing Specifically, across the programs reviewed there was scarce approaches such as essential nutrition actions (ENA) or information on family planning referral systems; significant timed and targeted counseling. variation in measurement of family planning, nutrition, and food security outcomes; and limitations of the existing Similar to the range of platforms used across the programs program evaluation data, which precluded the identification reviewed, a range of different providers were involved in of successful or promising integration models. delivering integrated services. Community-level providers The Sak Plen REP program in Haiti targeted caregivers of children under 5 years of age through Mothers’