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date: 10 December 2023

Operationalizing Human Rights in Sexual and Reproductive Health and Rights Programming: An Example from a Global Family Planning Partnershipfree

Operationalizing Human Rights in Sexual and Reproductive Health and Rights Programming: An Example from a Global Family Planning Partnershipfree

  • Karen HardeeKaren HardeeHardee Associates LLC


The International Conference on Population and Development (ICPD), which has guided programming on sexual reproductive health and rights (SRHR) for 25 years, reinforced that governments have a role to play in addressing population issues but in ways that respect human rights and address social and gender inequities. The shift at ICPD was partly in response to excesses that had occurred in some family planning programs, resulting in human rights abuses. The 2012 London Summit on Family Planning refocused attention on family planning as a crucial component of SRHR and, in part due to significant pushback on the announcement of a goal of reaching an additional 120 million women and girls with contraception by 2020 in the world’s poorest countries, ignited work to ensure that programming to achieve this ambitious goal would be grounded in respecting, protecting, and fulfilling human rights. This attention to human rights has been maintained in Family Planning 2030 (FP2030), the follow on to Family Planning 2020 (FP2020). While challenges remain, particularly in light of pushback on reproductive rights, widespread work over the past decade to identify human rights principles and standards related to family planning, integrate them into programming, strengthen accountability, and incorporate rights into monitoring and evaluation has improved family planning programs.


  • Public Health Policy and Governance
  • Sexual and Reproductive Health


The Programme of Action from the groundbreaking International Conference on Population and Development (ICPD) continues to be relevant 25 years after the 1994 conference in Cairo (UNFPA, 2020a). ICPD represented a paradigm shift from a demographic focus on reducing population growth to attention to gender equality and fulfilling sexual and reproductive health and rights (SRHR) (Dixon-Mueller, 1993; Hodgson & Watkins, 1997; Reichenbach & Roseman, 2009). ICPD shifted course from family planning programming that had too often relied on targets to reduce women’s fertility, which in some countries had led to coercive practices (Potts et al., 2018; Warwick, 1982).1 ICPD reinforced that governments have a role to play in addressing population issues but in ways that respect human rights for people of all ages and address social and gender inequities (Barroso, 2015; Sen et al., 2019). ICPD linked reproductive rights to the obligations of States to provide the services that will yield positive reproductive health outcomes (Ngwena & Durojaye, 2014, p. 6).

The ICPD Programme of Action noted that reproductive rights were based on existing human rights recognized in international human rights documents and consensus statements that had been accumulating for nearly 50 years by the time of the ICPD, starting with the 1948 Universal Declaration of Human Rights that established the right to health, among other rights, and the 1968 International Conference on Human Rights in Tehran that proclaimed that individuals and couples have the right to decide freely and responsibly on the number and spacing of their children (United Nations, 1968). ICPD was one of several United Nations conferences that applied human rights principles, following closely after the World Conference on Human Rights held in Vienna in 1993 and by the 1995 Beijing Fourth World Conference on Women that reaffirmed women’s rights are human rights. These conferences, in particular the Cairo and Beijing conferences, “led to the recognition that the protection of reproductive and sexual health . . . can be addressed through the improved application of human rights contained in existing national constitutions and regional and international human rights treaties” (Cook et al., 2003, p. 148). The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, a human rights instrument established by the African Union in 2003, states that “States Parties shall ensure that the right to health of women, including sexual and reproductive health is respected and promoted” (African Union, 2003). This includes the right to make decisions regarding fertility and to have the information and services to act on those decisions.

Building on the Right to the Highest Attainable Standard of Health, articulated in Comment 14 to Article 12 of the UN Committee on Economic, Social and Cultural Rights (UNCESCR) as Availability, Accessibility, Acceptability and Quality (AAAQ), the same committee published General Comment 22 defining the elements of the right to the highest attainable standard of sexual and reproductive health (UNCESCR, 2016). It explains State parties’ obligations to respect, protect, and fulfill an individual’s SRHRs, specifically assuring that programs apply the principles of AAAQ and nondiscrimination and equality. With reproductive rights established as human rights, what has occurred in the intervening years since ICPD to get human rights into programming using human rights-based approaches and to ensure that duty bearers (States that have signed international human rights conventions and consensus documents) respect, protect, and fulfill the rights of rights holders (individuals and communities)?

Given that SRH (sexual and reproductive health) encompasses a wide range of health areas (see Box 1 for the 2018 Guttmacher–Lancet Commission list of essential SRH services), this article focuses on one aspect of SRHR, namely, contraceptive care, more commonly known as family planning. While some would contend that separating out one aspect of SRH obscures the need to address all aspects of SRH, this article takes the view that while there are commonalities—and rights apply to all aspects of SRH—programming for the components differs, so addressing family planning as one aspect of SRH is justified and has the potential to yield family planning programming that better reflects human rights. Some factors related to family planning, which distinguish it from some other health services, make it particularly susceptible to rights violations (Kumar, 2015). For example, family planning is related to sexuality and fertility, which has religious and cultural sensitivities and is subject to gender and power dynamics. Furthermore, government attention to population size, growth structure, and distribution runs the risk for pressure to reduce fertility through use of contraception.

Box 1. Essential Sexual and Reproductive Health Services, According to the Guttmacher–Lancet Commission on Sexual Reproductive Health and Rights

Accurate information and counseling on sexual and reproductive health, including evidence-based, comprehensive sexuality education

Information, counseling, and care related to sexual function and satisfaction

Prevention, detection, and management of sexual and gender-based violence and coercion

A choice of safe and effective antenatal, childbirth, and postnatal care

Safe and effective antenatal, childbirth, and postnatal care

Safe and effective abortion services and care

Prevention, management, and treatment of infertility

Prevention, detection, and treatment of sexually transmitted infections, including HIV, and of reproductive tract infections

Prevention, detection, and treatment of reproductive cancers

Note. Adapted from Starrs et al. (2018, p. 2646).


This article describes how human rights principles and standards related to the family planning component of SRHR have been articulated and assesses how these principles and standards have been integrated into programming, have strengthened accountability, and have been incorporated into monitoring and evaluation. The article also identifies ongoing challenges related to human rights and family planning.

Human Rights Principles and Standards Related to Family Planning

Much of what was written about human rights immediately following ICPD focused on SRH broadly, with scant specific mention of family planning. Instead, family planning programming in the 1990s and 2000s focused on improving quality of care, a movement that started in the late 1980s and gained momentum after ICPD as a way to offer more client-centered care (Bertrand et al., 1995; Bruce, 1990; Jain et al., 2012; Kumar, 2015; Lynam et al., 1993; Rama Rao & Mohanam, 2003). The movement on client-centered care also emphasized voluntarism and informed choice in family planning programming (Bongaarts & Sinding, 2009; Kim et al., 1998; RESPOND Project, 2013). For example, programming funded by the U.S. Agency for International Development (USAID), the largest international funder of family planning assistance for more than 50 years, is guided by principles of voluntarism and informed choice:

People have the opportunity to choose voluntarily whether to use family planning or a specific family planning method.

Individuals have access to information on a wide variety of family planning choices, including the benefits and health risks of particular methods.

Clients are offered, either directly or through referral, a broad range of methods and services.

The voluntary and informed consent of any clients choosing sterilization is verified by a written consent document signed by the client (USAID, n.d.).

The need to articulate explicitly the application of human rights to family planning gained salience leading up to the 2012 London Summit on Family Planning with the announcement by the organizers—the Bill & Melinda Gates Foundation, the UK Department for International Development (in DFID), and the core conveners, the USAID and the United Nations Population Fund (UNFPA)—of an ambitious goal of expanding access and enabling use of contraception by an additional 120 million women and girls by 2020 (Brown et al., 2014).2 While the renewed attention to and resource commitments for family planning were applauded by many, to some civil society organizations, the numeric goal harkened back to “pre-ICPD” numbers-driven rather than client-centered family planning programming that had led in some instances to coercion (Hardee, Harris, et al., 2014). Civil society organizations were concerned that the numeric goal signaled a retreat from the human rights-centered approach that emerged from ICPD (Girard, 2012; Khosla, 2012; Krishnan, 2012). A group of nongovernmental organizations (NGOs) signed on to a petition and succeeded in getting the business plan for the summit to reflect the need for rights to be respected.

Taking the months of criticism leading up to the summit to heart, a press release from the 2012 summit clarified that, “The London Summit on Family Planning will mobilize commitments to support the rights of an additional 120 million women and girls in the world’s poorest countries to use contraceptive information, services and supplies, without coercion or discrimination, by 2020” (FP2020, 2012). The criticism and pushback were instrumental in shaping the agenda for programming. The Family Planning 2020 (FP2020) Partnership, constituted to achieve the goal of the 2012 London Summit, comprising governments, civil society, multilateral organizations, donors, the private sector, NGOs, and with support from a secretariat, has sought to ensure that human rights were at the center of programming, grounded in the ICPD framework for SRH (FP2020, 2012; Hardee & Jordan, 2019). Since the summit, a number of resources have been developed to articulate the rights standards and principles associated with family planning and to develop practice tools and approaches to implement voluntary human rights-based family planning programming, including for adolescents. These resources are described in relevant sections of this article.

The UNFPA published a family planning strategy, underpinned by human rights, to guide its work on family planning from 2012 to 2020 (UNFPA, 2012):

Over the life of this strategy . . . we are working to expand access to information, services and supplies for women, men and young people. We are improving quality of care, generating demand and meeting unmet need. We are supporting the efforts of countries to strengthen health systems for a reliable and secure supply of modern contraceptives, going the last mile to reach the poor, marginalized and underserved. Human Rights is at the core of our implementation.

(UNFPA, 2012, p. iii)

Earlier, UNFPA and the Center for Reproductive Rights (CRR) produced The Right to Contraceptive Information and Services for Women and Adolescents, a briefing paper that highlighted human rights related to contraception (UNFPA & CRR, 2011).

To understand what a voluntary, rights-based family planning program should include and how to effectively implement it, a group from the Futures Group (now Palladium) and EngenderHealth developed a programming framework that provides a vision for what a voluntary, rights-based family planning program entails at the policy, service delivery, community, and individual levels (Hardee, Kumar, et al., 2014). This work was undertaken to bridge the “chasm between theory and practice . . . in translating human rights norms into concrete programming guidance applicable in diverse policy contexts and national circumstances” (Arbour, in OHCHR, 2006, p. 3).

The framework provides a practical tool that illustrates a holistic family planning program that respects, protects, and fulfills human rights—expressed in programmatic terms; in other words, translating and operationalizing the rhetoric of human rights into actual programming. In addition to family planning programming literature and experience, the framework drew on human rights work by Erdman and Cook (2008, p. 537), who identified three broad categories of reproductive rights among the composite of human rights that are “guaranteed in national laws, constitutions, and regional and international treaties that can be applied to protect against the causes of ill health and promote sexual and reproductive well-being.” These categories include:

rights to reproductive self-determination (the rights of couples and individuals to decide freely and responsibly the number and spacing of their children)

rights to sexual and reproductive health services, information, and education (including contraception)

rights to equality and nondiscrimination (right to make decisions concerning reproduction, including family planning free of discrimination, coercion, and violence)

Box 2. WHO’s Ensuring Human Rights in the Provision of Contraceptive Information and Services












Informed decision making


Privacy and confidentiality





Note. Adapted from WHO (2014).

Subsequently, the World Health Organization (WHO) produced guidance on ensuring human rights in contraceptive information and services (WHO, 2014). The document notes WHO’s mandate to help member states achieve the goal of the highest attainable standard of health for all, including sexual and reproductive health. Provision of contraception is integral to achieving this goal, and respecting, protecting, and fulfilling human rights is critical for family planning services. The guidance provides stakeholders with needed actions to ensure that relevant dimensions of human rights are integrated into contraceptive information and services (WHO, 2014). Box 2 lists the nine rights highlighted in the WHO guidance. FP2020 also published Rights and Empowerment Principles that reinforced its commitment to rights (FP2020, 2015a).

Based on this work, the Family Planning Quality of Care Framework, which has guided programming since 1990 and is an integral component of rights-based family planning (Kumar, 2015), was revised to “better align it with quality in the rights-based approaches and the way quality in family planning has been applied in practice” (Jain & Hardee, 2018, p. 171).

Integration of Human Rights Standards and Principles Into Family Planning Programming

In 2012, there was not a common language or understanding of rights concepts related to family planning, and there was a lack of rights literacy among policymakers, healthcare personnel, and communities. Furthermore, rhetoric about rights at high levels did not translate into concrete, actionable steps required at different levels in the health system. Human rights legal constructs needed to be translated into family planning policies and programs. In an article, “Use of Human Rights to Meet the Unmet Need for Family Planning,” published on the eve of the London Summit in a Lancet Series on family planning, Cottingham et al. (2012) provided examples of how family planning programming could be strengthened by infusing human rights values and concepts into all aspects of programming.

Much work has been undertaken to apply human rights principles and standards in family planning programming since 2012 (CARE, 2012; FP2020 & IPPF, 2016, 2017; Newman & Feldman-Jacobs, 2015). Box 3 shows FP2020’s commitment to rights since 2012 in the face of global changes and pushback on reproductive rights by conservative groups and shifting donor government policies on reproductive health and rights (Filmer-Wilson & Mora, 2018; Sen et al., 2019). Despite the pushback from conservative groups that has sought to curtail reproductive rights, most notably abortion, significant gains have been made in a number of rights principles, including quality of care, informed choice, expanded access, increased method choice, services for youth, and promotion of gender equality. As noted by “applying a rights lens reframes the way we typically think about programs, including how we define goals, what we value and what we measure.” Attention to implementing human rights-based approaches to family planning should ideally include incorporating rights principles and standards in all phases of programming—from assessment and design to implementation and to monitoring and evaluation.

Box 3. Rights in Selected FP2020 Progress Reports

2013: “FP2020 envisions a world where the rights of women and girls, no matter where they live, to decide whether and when to have children is respected, protected and fulfilled.” (FP2020, 2013, p. 15)

2015: “Collectively, we’re working to ensure that rights and empowerment principles are built into the DNA of every family planning program.” (FP2020, 2015b, p. 8)

“Human rights are at the center of FP2020’s vision and goals… Rights-based family planning means listening to what women want, treating individuals with dignity and respect, and ensuring that everyone has access to full information and high-quality care.” (FP2020, 2015b, p. 29)

2017: “In an era of mounting global uncertainty, the mission of FP2020 remains as pertinent and compelling as ever. Every woman and girl must be able to exercise her basic human right to control her own reproductive health. Access to safe, voluntary family planning is fundamental to women’s empowerment. It’s also fundamental to achieving our global goals for a healthier, more prosperous, just, and equitable world.” (FP2020, 2017, p. 5)

2018: “In the past six years, this collaborative approach has enabled our partners to bring rights-based family planning programs and voluntary contraception to millions more women and girls than would have been thought possible just a decade ago.” (FP2020, 2018a)

2019: “What does health care look like from a woman’s perspective? What happens when women themselves are the architects of those systems?” (FP2020, 2019)

Note. Adapted from Hardee and Jordan (2019, p. 7).

To get closer to family planning programming, UNFPA and WHO (2015) further linked the nine rights principles and standards from WHO (2014) to eight categories of action that can be taken at different levels of the health system to fulfill human rights:

ensure access to contraceptive information and services for all (nondiscrimination)

contraceptive commodities, logistics, and procurement (availability)

organization of health facilities (accessibility)

quality of care (acceptability, quality, informed decision making, privacy, and confidentiality)

comprehensive sexuality education (accessibility)

humanitarian context (right to accessible services)

participation by potential and actual contraceptive users (participation)

accountability to those using family planning services (accountability)

To further augment WHO’s 2014 guidance, WHO published a checklist for health care providers working at the primary health care level who provide contraceptive information and services (WHO, 2017). The checklist is intended to be used to identify quality of care issues and link them with human rights standards, with suggestions for improvements.

Human Rights in Family Planning Costed Implementation Plans

Since 2012, countries in the FP2020 partnership have been encouraged to develop Family Planning Costed Implementation Plans (CIPs) to translate their commitments to FP2020 into concrete policies and plans. As of August 2019, more than 40 CIPs, mostly at the national level, had been developed, with eight countries having completed their first-round CIPs and developed subsequent CIPs. CIPs are available on the FP2020 website.3

An assessment of CIPs developed from 2012 to 2013 shows few mentions of rights; those created in 2014 and later showed increased attention to rights, although the plans contained little detail about how they would be operationalized in family planning programs. Uganda’s CIP, for 2015–2020, was the first to include extensive language on rights-based family planning, affirming that access to family planning is a reproductive right; that family planning helps women achieve other rights (education, health, and work); that nonfulfillment of rights is detrimental to the country; and that family planning services would be delivered in accordance with human rights and quality of care standards (MOH Uganda, 2014). CIPs developed since 2016 tend to include language on human rights. For example, Kenya’s 2017–2020 CIP notes that a

. . .rights-based approach entails implementing programmes that aim to fulfill the rights of all individuals to choose whether, when, and how many children to have to act on those choices through high quality SRH services and information and education; and to access those services free from discrimination, coercion and violence.

(MOH Kenya, 2017, p. 12)

This is a significant advance from Kenya’s first CIP (2012–2016), which made no mention of rights. Policies and plans are important; however, unless they are followed through with implementation, they remain words on a page.

Implementing Voluntary, Rights-Based Family Planning Services

Many examples of family planning programming that have incorporated rights principles exist, as highlighted at a 2018 meeting, “Rights in Practice: What Makes a REAL Difference to Programs,” hosted by FP2020 and UNFPA (2019), which included 60 participants from 10 countries. Meeting participants included human rights lawyers, clinic directors and practitioners, advocates, youth representatives, country development partners and foundations, researchers, midwives, and activists. Presentations from participants from Africa and Asia highlighted successes at the legal and policy level, reaching marginalized groups, and expanding access to services. Participants were also clear on the myriad challenges to rights-based programming, including the need to strengthen rights literacy among both duty bearers (governments) and rights holders (individuals) and to bring rights discourse out of the realm of treaties and conventions to speak to people’s lived experience. One participant from Nigeria said programs need to consider the following: “When you have the woman in front of you, what will it be like when she goes home? What are her choices?” (Effiom, 2018). Another participant asked how it is possible to work on rights without challenging the status quo in terms of gender.

Two interventions, one in Nigeria and the other in Uganda, attempted to incorporate all rights principles and standards related to family planning identified by WHO (2014) and FP2020 (2015a) and to incorporate them at the service delivery level as identified in the Voluntary, Human Rights-Based Conceptual Framework (Hardee, Kumar, et al., 2014). Similar and adapted tools and approaches were used during the implementation and results measurement at the service delivery level in both countries. The interventions, implemented between 2016 and 2017, shared some common components (Hardee et al., 2019). The intervention components, adapted to local contexts and available budgets, were as follows:

built provider and supervisor capacity in voluntary rights-based family planning using a tailored curriculum and supervision tool on rights-based family planning

developed facility level action plans and supported implementation of the action plans

used posters and handouts at the facility level to increase clients’ understanding of their rights

established or strengthened the health committee structures to support voluntary rights-based family planning

The interventions built on existing programs rather than on something completely new and resulted in beneficial outcomes in Nigeria, which were assessed through a baseline and end line survey after a year of implementation. Rights literacy increased and providers were able to see the benefits of taking a voluntary, rights-based approach to serving clients, particularly the importance of ensuring a client focus and supporting clients to make their own decisions and choices about family planning. For example, at the end line, a community health extension worker described improvements in minimizing bias, saying,

Before this training, there were certain things we do, for example how we decline teenagers and unmarried adults counseling or access to any method because they are not married, or we say she is not old enough to use them. But now we let them in and counsel them and let them make their choice.

(Hardee et al., 2019, p. 62)

Privacy and confidentiality were enhanced at the end line as a result of the intervention and providers and clients expressed increased recognition among providers of what violations of rights are and the need to report and address violations through strong accountability systems. At the end line compared to the baseline, there was a statistically significant increase in the percentage of providers and clients saying they would report abusive behavior of another provider if they saw it; for example, if a provider slapped a client during a consultation or if a provider yelled at or humiliated a client (Hardee et al., 2019).

Common lessons emerged from the interventions, including the continued importance of promoting rights literacy among all stakeholders; the need to strengthen health systems; the importance of strong and supportive supervision to reinforce provider provision of rights-based information and services; and the need to work on rights at multiple levels, including policy, community, and individual levels to reinforce interventions at the service level (Hardee et al., 2019).

Articulation of the rights principles and standards related to family planning has helped assess policies from a human rights perspective. Interrogation of polices related to adolescent reproductive health in the Philippines using the human rights principles by WHO (2014) (see Box 2) has shown “many Philippine norms are in agreement with adolescents’ human rights to contraceptive information and services as recommended by the WHO. However, a significant number are restrictive, reflecting the strong influence of conservative religious beliefs” (Melgar et al., 2018, p. 10). Based on the analysis, the authors made a number of recommendations for the Philippines to improve programming for adolescents, including, among others, supporting the education department to shift from abstinence only to comprehensive sexuality education, and to update the health department’s policies to enable the provision of contraceptive services to adolescents, which are allowed by the Responsible Parenthood and Reproductive Health Act of 2012 (known as the RH Law).

Family Planning and Universal Health Care and Financing Mechanisms

The movement toward universal health coverage (UHC), which is included among the Sustainable Development Goals (SDGs) for 2030, builds on the Alma Ata Declaration in 1978 that reinforced health as a human right. UHC calls for ensuring that everyone can equitably access quality services without facing financial hardship.4 In describing UHC, WHO notes that “UHC is not only about ensuring a minimum package of health services, but also about ensuring a progressive expansion of coverage of health services and financial protection as more resources become available.”5 WHO includes family planning, within reproductive, maternal, newborn, and child health, as a service within a minimum package of services.

It is important to ensure that family planning within UHC is underpinned by human rights (Holtz & Sarker, 2018; Smith, 2018). Based on a review of family planning and UHC and a framework that can be applied at the health systems level down to the user level (Appleford et al., 2019), Appleford et al. (2020) extended the analysis to SRH more broadly, including contraception, noting the need to take a rights-based approach, saying:

. . .how sexual and reproductive health (SRH) services are included in UHC and health financing matters, and that this has implications for universality and equity. This is a matter of rights, given the differential health risks that women face, including unwanted pregnancy. How traditional vertical SRH services are compensated under UHC also matters and should balance incentives for efficiency with incentives for appropriate provision using the rights-based approach to user-centred care so that risks of sub-optimal outcomes are mitigated.

(Appleford et al., 2020, p. 1)

Citing experience from Argentina and Rwanda, Smith (2018) highlights that family planning should be included in UHC packages, including in initial “thin packages” of transformative and cost-effective services, packages which can be expanded to include more people and services as UHC grows. Holtz and Sarker (2018) note that more work is needed, including in countries in which family planning is part of health coverage financing schemes on paper, but in practice coverage is limited. Fagan et al. (2017) examine family planning in the context of UHC in Latin America and find that while use of contraception has risen across the region, equity of access to services remains an issue and should be the focus of UHC efforts. To ensure the rights of marginalized groups, they note the need to “(1) target poor and informal sector populations, (2) include family planning in benefits packages, (3) ensure sufficient financing for family planning, and (4) reduce nonfinancial barriers to access” (Fagan et al., 2017, p. 382).

Performance-based financing (PBF) has been supported since 2007 by the Health Results Innovation Trust Fund (HRITF) that is managed by the World Bank, with funding from Norway and the United Kingdom, since 2007 and is linked to International Development Association (IDA) financing in 29 countries. Through this mechanism, health care facilities are paid fees for delivering specific services, often modified by performance scores on a quality checklist. In 2014, the UN General Assembly launched the Global Financing Facility (GFF), established in support of the global agreement from the UN, Every Woman Every Child, the global strategy for reproductive, maternal, newborn, child, and adolescent health to 2030, to coordinate additional support and funding explicitly for reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in the 63 highest burden low- and middle-income countries (LMIC) (World Bank Group, 2014). The GFF is an attempt to facilitate donor pooling of financial resources to promote country-led ownership of RMNCAH and to combine domestic resources with external financing (World Bank, 2015). The GFF incorporates PBF in its programming, which links financial compensation to the achievement of health program priorities, with the goal of increasing the use, quality, and efficiency of health services.

The need to ensure that family planning programs funded through PBF mechanisms are underpinned with rights-based approaches has been highlighted by advocates, program implementers, donors, and researchers (Chowdhury et al., 2013; Cole et al., 2019; Eichler et al., 2010). Promoting voluntary rights-based family planning is crucial to ensure that family planning clients are not pressured to use services in order for providers to meet targets set by PBF programming. To that end, a review of 23 PBF manuals and indicators revealed that while they focus on implementation of the rights principles of quality and accountability, few address issues related to the rights principles of accessibility, availability, informed choice, acceptability, and nondiscrimination and equity, and attention to agency, autonomy, empowerment, and voluntarism of health care clients is absent (Cole et al., 2019). “If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced” (Cole et al., 2019, p. 329). Eichler et al. (2018) provide guidance on ensuring adherence to rights in PBF, noting that:

. . .strategic purchasing should reflect rights-based principles of voluntarism, informed choice, quality, and accountability. In many cases, these rights-based principles are specified in policy statements and not well translated into the operational documents that govern the details of strategic purchasing—such as the services that are covered, from whom services are delivered, and the outputs or outcomes on which conditional payments are based.

(Eichler et al., 2018, p. 3)

At the country level, examination of government budgets from a human rights lens is also being undertaken. For example, Weigelt and Sharma (2020) assess barriers to access in India’s family planning program in a context in which the legal system guarantees the right to health for all. They conclude the funding needs to be more aligned with human rights, arguing that disproportional spending on female sterilization limits women’s full, free, and informed choice and their ability to decide the number and spacing of their children.

Highlighting resource allocation for family planning is important. India’s family planning program has long focused on promoting female sterilization while underpromoting other methods of contraception. Among the 40% of women of reproductive age (15–49 years) using contraception in India, three-quarters of them use sterilization.6 Advocacy efforts by a range of civil society and other stakeholders, including the Advocating Reproductive Choices (ARC) coalition of civil society organizations, to expand the basket of contraceptive choices has had some success in expanding the range of methods offered to clients in India (Liberhan et al., 2013). Among these methods is the injectable contraceptive, which women’s groups in India had lobbied against for decades (Srivastava et al., 2012).

Family Planning in Humanitarian Settings

Following the ICPD, an Inter-Agency Working Group on Reproductive Health in Crises (IAWG) was established to ensure that SRHR was reflected in programing in humanitarian settings (Heidari et al., 2019). Based on work by the IAWG, SRH is included in the Minimum Initial Service Package (MISP) in the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings and a toolkit for SRH preparedness in emergency settings.7 Family planning is part of the standard of care in the MISP and the “standards to which the humanitarian community is accountable, and language now goes beyond commodity availability and speaks to method mix, informed choice, efficacy counseling, privacy and confidentiality” (Hardee & Jordan, 2019, p. 18). The need to link human rights and disaster risk reduction has been identified (Mizutori, 2019), and the Sendai Framework for Disaster Risk Reduction 2015–2030 includes provision of SRH services, including contraception, as a critical component of strengthening resilience.

An assessment of needs of Syrian refugees in Lebanon in 2017 used a human rights framing along with the Voluntary Rights-Based Family Planning Conceptual Framework to identify gaps at the policy, service delivery, and community levels (Jain et al., 2019). The study was based on assessment that:

Refugees maintain the same right to health as those who have not fled insecure situations. Although multiple international documents acknowledge the reproductive health needs of refugees, public health policy and interventions often fail to adequately address these needs. This can have dire consequences for some displaced families, particularly given that the average duration of displacement is approximately 20 years.

(Jain et al., 2019, p. 347)

The assessment found at the policy level that affordability of services was an issue for the refugees. The study identified the need for respectful treatment, access to a range of contraceptive methods, use of mobile clinics, and programs for adolescents at the service delivery level. At the community level, the study noted the need for social behavior change programs that promote knowledge of SRH, along with the need to address gender norms and power imbalances and engage men. At the individual level, the study identified the need for affordable and safe access to education and girl groups. The authors concluded that “changes at the policy, service, community, and individual levels are required to increase knowledge regarding and access to family planning services for Syrian refugees in Lebanon” (Jain et al., 2019, p. 346).

Strengthening Accountability for Family Planning

Accountability, a cornerstone in the human rights framework linking duty bearers and rights holders and encompassing “monitoring, review, and redress at the local, national and international levels” (Hunt & Gray, 2013), is critical for family planning among other components of SRH (Boydell et al., 2019). Accountability supports rights holders to seek redress for human rights violations and also to hold duty bearers responsible for their human rights commitments.

Given past instances of rights violations related to family planning, civil society called for a focus on reproductive rights with strong accountability systems associated with programming to achieve the goal of the 2012 London Summit on Family Planning. Among the nine rights principles and standards for ensuring human rights in contraceptive information and services, the WHO (2014) described accountability as being achieved through a variety of processes and institutions involving national and international human rights mechanisms with various administrative, social, political, and legal forms of review and oversight, and mechanisms for registering complaints.

In making pledges at the 2012 London Summit on Family Planning and again at the 2017 Family Planning Summit, governments made financial, policy, and programmatic pledges to contribute to achieving the FP2020 goal of expanding access to contraception. The WHO (2014) notes the important role of civil society in the developing and monitoring of laws, policies, budgets, and the use of public funds to hold governments accountable for their commitments. Countries engaged in the FP2020 Partnership include civil society representatives—and youth representatives—as members of their FP2020 Focal Point groups along with governments and donors.

Since 2012, a number of initiatives have strengthened accountability for family planning. As a Partnership, FP2020 developed an accountability framework that linked outcome tracking with commitment tracking (FP2020, 2018a). FP2020’s model focuses on collaborative accountability, focusing on dialogue among commitment makers and their stakeholders and constituents and shared responsibility to achieve goals (FP2020, 2019). Family Planning Costed Implementation Plans include sections on accountability.

Much of the focus on accountability related to FP2020 at the country level has been strengthening the capacity of country-based civil society to hold their governments accountable for FP2020 commitments. While some civil society advocates might have been involved in developing the country commitments, this work has focused on ensuring that a wide range of civil society advocates know about the FP2020 commitments and that they understand accountability structures and how to engage in them. For example, women leaders in Malawi mapped accountability linkages for implementing youth-friendly health services, in place since 2007, but still with gaps in the quality of services. With this mapping, the women leaders understood the complexity of the system and were able to engage with stakeholders responsible for improving the services (HP+, 2018a). Similar work in Pakistan related to Sindh province’s Family Planning Costed Implementation Plan resulted in improved confidence, capacity, and connections for the participants. In additional to recommendations related to implementing the Costed Implementation Plan, one participant said, “At the Sindh Human Rights Commission, I encouraged the inclusion of health and family planning matters in the human rights discourse” (HP+, 2018b, p. 18). Making this link is important so that national human rights commissions monitor family planning as part of their human rights monitoring.

Piloted in Uganda by the civil society organization (CSO) Samasha Medical Foundation as a tool for accountability, civil society and other family planning stakeholders have used the motion tracker in Uganda, Burkina Faso, Côte d’Ivoire, Ethiopia, Indonesia, Kenya, Nigeria, Tanzania, Togo, and Zambia to track those countries’ FP2020 commitments (HP+, 2017). Using the motion tracker, the CSO has led the process with other stakeholders

. . .of identifying and deconstructing the commitments to clarify them. The lead CSO then develops a set of process indicators to track the commitments. The process indicators are then validated by all stakeholders including government, donors and civil society—a key step to creating ownership.

(Guerrier, 2020, p. 1)

At the country level, “National Human Rights Institutions [NHRI] are key to the promotion and protection of human rights in their respective countries. Yet, in practice, many NHRIs have not addressed sexual and reproductive health concerns or have done so only partially” (UNFPA, 2019, p. 9). UNFPA has been engaged with NHRIs to strengthen their capacity to include SRHR, including family planning, in their monitoring effects (UNFPA, 2019; UNFPA, DHRI, & OHCHR, 2014). Countries report into the Universal Periodic Review (URP), a mechanism put in place by the United Nations since 2006 to assess the fulfillment of human rights obligations and commitments by each UN Member State every 4 and one-half years. In reviews of the first two cycles of the UPR to assess attention to SRHR issues, UNFPA has identified that contraception gets scant attention compared to some other components of SRHR (UNFPA, 2014, 2019):

Similar to the first cycle, second cycle recommendations . . . highlight stark differences in attention to different SRHR issues by reviewing States. For example, gender equality and violence against women received more than 4,000 recommendations in total. Whereas other SRHR issues such as sexuality education, early pregnancy, and contraception received 23, 35, and 48 recommendations, respectively.

(UNFPA, 2019, p. 4)

Still, the UPR process offers a platform to bring together state and nonstate actors and provides civil society an opportunity to advocate for issues raised during the process. The third cycle of the UPR (2017–2021) provides an opportunity to further highlight the neglected components of SRH, including contraception.

Social accountability, which “refers to the efforts of citizens and civil society to scrutinize and hold duty bearers (politicians, government officials, and service providers) to account for providing promised services, actions that most often take place at the sub-national or community level,” can improve access and use of contraceptive services through bringing communities and providers together to identify and solve challenges and bottlenecks in the health system (Boydell & Keesbury, 2014, p. 2). Assessment of the implementation of a social accountability intervention that included family planning and reproductive health in Uganda found “a web of accountability relationships at play,” ranging from opportunities for community participation in institutional processes, relationships between clients and health care providers, and relationships between the community and local officials. (Boydell et al., 2019, p. 73). Community participants noted increased confidence when interacting with health care providers, in their health-seeking behavior, or in their ability to represent themselves. The research highlighted ways that social accountability and family planning programming could be combined, such as incorporating civic and rights education with family planning outreach. This linking could “extend the reach and credibility of these services among community members while also counteracting barriers to women’s and young people’s participation” (Boydell et al., 2019, p. 73). In a district in Malawi, use of CARE’s community score card approach to social accountability in a randomized control trial resulted in a 57% greater current use of modern family planning in the intervention area (Gullo et al., 2017). A social accountability study in one province in Kenya that evaluated use of community dialogues about gender norms and family planning found that exposure to family planning dialogues, which addressed persistent myths and misconceptions about contraception and increased acceptability of family planning, was associated with 1.78 times higher odds of using a modern contraceptive method at end line for women (Weggs et al., 2016).

Boydell et al. (2019) explain that the contested nature of SRH, including contraception, which is affected by social and gender norms and by power distribution within societies, needs to be made explicit in accountability efforts. These conditions also affect people’s ability to demand their rights and duty bearers’ ability to respond. Continued vigilance against pressure on individuals to use contraception, or to accept certain methods, is needed (Senderowicz, 2019; Yirgu et al., 2020). Civil society is employing human rights to call out governments for practices that violate those rights. For example, calling a mid-2019 bill in India that would penalize people for having more than two children misguided, the executive director of the Population Foundation of India said that:

The policymakers, MPs and the government should reaffirm India’s commitment towards a rights-based approach to family planning. The government should raise budgetary allocations in order to ensure expanded contraceptive choices for delaying and spacing births and better access and quality of health care for young people.

(Sharma, 2019, p. 3)

The bill did not go through, in part due to the visibility brought by civil society advocates, but some states in India are also considering child limitation policies, highlighting the need for continued vigilance by rights advocates. Advocates in India also demanded change from the government when 13 women died and 65 others experienced complications in a sterilization camp in Chhattisgarh State in 2014 in which the doctor used unsterile practices (Muttreja et al., 2014); a ruling in 2016 from the Supreme Court ordered that sterilization camps be stopped (Mohanty & Bhalla, 2016). In 2020, China received widespread condemnation for “taking draconian measures to slash birth rates among Uighurs and other minorities as part of a sweeping campaign to curb its Muslim population.”8 These tragic incidents are vivid reminders that human rights violations related to family planning, while uncommon, continue to occur and that vigilance remains crucial.

Despite passage of the landmark Responsible Parenthood and Reproductive Health Act of 2012 in the Philippines that guarantees universal and free access to nearly all modern contraceptives for all citizens including impoverished communities at government health centers, among other provisions such as reproductive health education in government schools and postabortion care, opponents of reproductive health sought to ban the sale of hormonal contraceptives. With strong advocacy by civil society and other stakeholders, in 2017 the Philippines Food and Drug Administration recertified the contraceptives, effectively lifting the ban imposed by the Supreme Court in 2015.9

Incorporation of Human Rights Into Monitoring, Evaluation, and Research

With the articulation of human rights principles and standards associated with family planning, there have been advances over the past decade in monitoring and evaluating family planning programming from a human rights perspective to address the challenge that

while many agencies and organizations work to integrate human rights into public health policies and programs, as rigorous tools or resources in this area remain limited, they often struggle to monitor and evaluate how well human rights are actually being addressed or fulfilled in these efforts.

(Gruskin et al., 2017, p. 2)

Relevant Indicator Sets


The most visible of these efforts has been FP2020’s inclusion of indicators to measure rights and empowerment in its core indicators and its quest to expand measurement of rights-based family planning. Among their 18 core indicators, FP2020 monitors several indicators related to ensuring that women and girls have the ability to make a full, free, voluntary, and informed choice in selecting the method that will best meet their needs. For example, while there is no “right” contraceptive method mix, WHO (2014) recommends that family planning programs include at least five types of modern contraceptive methods: barrier (e.g., condoms), short-acting reversible (e.g., pill, injectable), long-acting reversible (e.g., implant, IUD), permanent (female and male sterilization), and emergency contraception. To measure full choice, programs can monitor the availability of this range of methods along with the method mix of what clients use. Voluntary and free choice are measured by indicators related to decision making on contraceptive use. Full choice is measured by asking clients if they were told about other contraceptive methods (other than the one they selected), about side effects, and about what to do if they experienced side effects. These three questions constitute the method information index, with a recommendation to add a fourth question asking if clients were told they could switch to another method.

FP2020 acknowledged early on that available indicators did not do justice to measuring rights-based family planning. Building on the Family Planning Effort Score (Ross & Smith, 2011), a platform that has periodically measured the strength of family planning programming since the 1970s, the National Composite Index on Family Planning (NCIFP) was developed to measure policies, systems, and standards around strategy and data use, in addition to the rights dimensions of quality, equity, and accountability. The NCIFP fielded in 2014 and 2017 uses a key informant approach (Rosenberg, 2020; Weinberger & Ross, 2015). Through 22 questions across the three components of quality, equity, and accountability, the NCIFP was able to go in-depth into these important aspects of rights-based family planning, which is not possible in national population-based surveys such as the demographic and health surveys (DHS). For example, for equity, respondents are asked the extent to which policies are in place to prevent discrimination toward special subgroups such as youth, the poor, people living with HIV, or those seeking post abortion care, and the extent to which providers discriminate against these groups. The accountability questions ask, for example, about mechanisms in place to monitor rights violations and if such violations are reviewed on a regular basis.10

Comparing NCIFP scores in 2014 and 2017 shows that out of a possible 100, the overall score across countries improved from an average of 53 in 2014 to 65 in 2017. Among the rights components of quality, equity, and accountability, quality scores improved in all regions from 53 to 64. Equity scores also improved more slowly from 57 to 61, while the score for accountability showed a 54% increase from 39 in 2014 to 60 in 2017. The score for accountability should be interpreted with caution, since the rise could be partly attributable to higher response rates on questions related to accountability.


As part of its work to identify and explain the human rights principles and standards associated with contraceptive information and services, WHO has published related indicators (WHO, 2014, 2017). To identify the indicators, Gruskin et al. (2017) developed a methodology to assess indicators for their human rights sensitivity—along with their public health validity. In addition to the indicator source, the analysis includes health and human rights principles and standards potentially addressed by the indicator; an explicit or implicit link(s) between the indicator and human rights; a human rights rationale; reflected user perspectives; a focus on a specific population and inequalities; and if the indicator lends itself to disaggregation and investigation for potential accordance with the nondiscrimination law. In their analysis of indicators to measure contraceptive programming, they concluded that “taken as a whole, findings from this analysis illustrate that while many indicators generally used to monitor contraception programmes have some degree of sensitivity to human rights, the breadth and depth one would expect are lacking” (Gruskin et al., 2017, p. 7). From this analysis, WHO (2017) prioritized 20 indicators (with an additional 21 indicators listed) related to ensuring access for all: commodities, logistics, and procurement; organization of health-care facilities, outreach, and integration; quality of care; comprehensive sexuality education; participation by potential and actual users of services; and accountability to those using services.

Sustainable Development Goals

The Sustainable Development Goals (SDGs) include targets and indicators that include contraception. Related to SDG Goal 5, Achieve Gender Equality and Empower All Women and Girl, the UNFPA, the UN agency tasked with measuring the goals, describes indicators 5.6.1 and 5.6.2 as providing “a comprehensive picture of key dimensions of sexual and reproductive health and reproductive rights, measuring women’s ability to make her own decisions on contraceptive use, reproductive health care and sexual relations, as well as the legal and regulatory environment” (UNFPA, 2020b, p. 2). Indicator 5.6.1 is the proportion of women aged 15–49 who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care. Based on 2019 data from 57 countries, this proportion is 55% of married or in-union women ages 15 to 49 who make their own decisions regarding sexual and reproductive health and rights, including family planning. Indicator 5.6.2 is the number of countries with laws and regulations that guarantee full and equal access to women and men aged 15 years and older to sexual and reproductive health care, information, and education.

The development of the methodology for indicator 5.6.2 has been guided by international human rights laws, which require that States repeal and eliminate laws, policies and practices that criminalize, obstruct or undermine individuals’ or a particular groups’ access to health facilities, services, goods and information.

(UNFPA, 2020c, p. 3)

Contraception is among the components measured, along with maternity care, comprehensive sexuality education, and sexual health and well-being. Based on data from 75 countries with complete data, countries have, on average, 75% of the laws and regulations needed to guarantee full and equal access to contraceptive services.

There are some overlaps among the indictor sets, although those are mostly standard indicators that can be measured through national surveys such as the DHS (e.g., the contraceptive prevalence rate, unmet need for family planning, the method information index, and contraceptive decision making). The NCIFP and WHO list of indicators include more qualitative measures of rights-based programming. Yamin (2019, p. 58) cautions about the need for indicators to “be constructed and interpreted carefully, and deployed in conjunction with qualitative information” to better understand “how they reflect and refract power between the global and national, as well as converting political issues into technical ones.”


In addition to the studies that comprehensively address all rights principles and standards (listed in Box 2) at the service delivery level in Nigeria and Uganda, which used a similar data collection package (Hardee et al., 2019; Wright et al., 2017), since 2012 a number of studies are advancing the understanding of right-based family planning and outcomes associated with it. For example, a study on contraceptive autonomy has yielded a measure that incorporates a rights perspective by defining contraceptive autonomy “as the factors necessary for a person to decide for themselves what they want in relation to contraception and then to realize that decision, this indicator divides the contraceptive autonomy construct into subdomains of informed choice, full choice, and free choice” (Senderowicz, 2020, p. 161).

Other studies have addressed quality rights-based counseling (Holt et al. 2017, 2019), providing full, free, and informed choice (Chakrobotti et al., 2019; Jarvis et al., 2018), measuring quality of care (Elewonibi et al., 2020; Jain et al., 2018, 2019); reproductive empowerment (Edmeades et al., 2018; MEASURE Evaluation, 2020); and reproductive coercion (Silverman et al., 2020). Evidence is also emerging from studies on social accountability (Boydell et al., 2019; Gullo et al., 2017; Steyn et al., 2021; Weggs et al., 2016). The Performance Monitoring and Accountability (PMA) Project, formerly PMA2020, includes rights indictors related to access, equity, quality, and choice in their surveys.

Rights Measurement Moving Forward

While the rights-based family planning measurement agenda has advanced significantly over the past decade, additional work is needed on enhanced measures of rights-based family planning—both indicators for monitoring the fulfillment of rights in family planning programming and studies to assess the outcomes of such programming.

Ongoing Challenges and Opportunities

Application of human rights to family planning programming, which has gained speed particularly since 2012, has strengthened policies and programming and has provided civil society with tools to hold governments accountable. Still, there is much more to do. In a review of progress on advancing rights-based family planning in 2019, undertaken under the auspices of FP2020, 23 key informants from governments, civil society, implementers, and multilateral and bilateral organizations gave a number of practical recommendations to advance this work through 2030 (Box 4). The participants recognized that institutionalizing rights-based family planning will take time. Among the suggestions were to maintain a focus on rights and to be flexible with rights language where it is sensitive to talk about rights directly in countries that do not recognize rights generally; this is where fluency with rights principles and standards is important. Another suggestion was to expand work at the country level through promoting political support for rights, fostering rights literacy, linking rights with budgets, increasing attention to adolescents, and promoting their participation and strengthening accountability. Continued dissemination of tools and documentation of programming outcomes were also recommended.

Box 4. Recommendations on Moving Forward with Rights-Based Family Planning


Keep rights at the center of the vision for family planning.


Be flexible with rights language.


Focus at the country level.


Promote political support for rights-based family planning at the global and country levels.


Promote rights literacy.


Pay more attention to accountability, including social accountability.


Focus on equity.


Increase attention on adolescents and give them leadership in advancing this important agenda.


Incorporate rights into global financing facility programming.


Link a focus on the supply side with attention to the demand side.


Link reproductive rights with other rights and promote integration.


Continue working on rights metrics and guidance.


Conduct research on rights-based family planning and disseminate findings widely.


Support development and dissemination of practical tools and training materials.


Link rights and budgets.


Continue FP2020’s catalytic role in working with partners and increase the visibility of rights work.


Understand that institutionalizing rights will take time.

Note. Adapted from Hardee and Jordan (2019).

The global COVID-19 pandemic was unfolding as this article was written in 2020 and 2021 and the full scale of its effects on individuals, communities, health systems, and countries will eventually be fully revealed going forward. Experience around the world has highlighted the particular effects on women and has reinforced the importance of ensuring reproductive rights and access to SRH services, including contraception, as essential services. The director general of the World Health Organization has emphasized that “All countries must strike a fine balance between protecting health, minimizing economic and social disruption, and respecting human rights.”11

The consequences of deeming SRH services as nonessential are dire (Hussein, 2020). “When SRHR is deemed non-essential, health systems may be unable to fulfill these rights, and communities will lose a formal justification for claiming them” (Schaaf et al., 2020, p. 1). Disrupting access to contraception will have strong negative consequences. An estimated 15 million unintended pregnancies over a year could result from a 10% reduction in the proportional use of short- and long-acting contraception in lower- and middle-income countries (Riley et al., 2020). Plans for ensuring access to contraception has implications for providing clients with full, free, and informed choice of methods and includes a renewed focus on self-care, with potential increased interest in contraceptive pills, condoms, patches, rings, emergency contraception, Standard Days Method, and self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (Weinberger et al., 2020).

The pandemic has highlighted that women’s rights, including to SRH, remains contested and clashes with social, cultural, and gender norms and with power dynamics (Oronje et al., 2011; Pizzarossa, 2018). The language—and legal teeth—of human rights provide the foundation for ensuring access to SRH, including family planning:

The principles of human rights can help us think through how to take action: through fostering community participation; focusing on non-discrimination; working to ensure the availability, accessibility, acceptability and quality of services; providing access to information; and striving to ensure transparency and accountability in the response to the pandemic.

(Hussein, 2020, p. 2)

In 2020, the secretary general of the United Nations issued a Call to Action for Human Rights—to refocus attention on respecting, protecting, and fulfilling universal human rights, noting that “human rights and human dignity will never be realized without a special emphasis on the human rights of women” (UN, 2020, p. 3). Among these rights is for SRHR to include family planning. In the face of continued political, religious, and social pushback by conservatives on reproductive rights, more work is needed by countries, donors, civil society, and implementing organizations to guarantee that rights are respected, protected, and ensured.

In 2020, the FP2020 Partnership was extended to 2030 based on a vision that does not include a numeric goal:

Working together for the future where all women and adolescent girls everywhere have the freedom and ability to make their own informed decisions about using modern contraception and whether or when to have children, lead healthy lives, and participate as equals in society and its development. Building 2030

FP2030’s work will be underpinned by principles that include, among others, voluntary, person-centered, rights-based approaches, with equity at the core. While the focus remains women and girls, FP2030 recognizes the need to also work with men and boys and to build intentional and equitable partnerships with adolescents, youth, and marginalized populations to meet their needs, and to support country-led global partnerships, with shared learning and mutual accountability for commitments and results.

Work since ICPD, reaffirmed on its 25th anniversary in 2019 (UNFPA, 2020a), has provided the guidance, tools, and language to strengthen family planning programs through a human rights lens and hold governments accountable for programs that support individuals and couples in exercising their rights to choose the timing and spacing of their pregnancies, to have the information, services, and agency to act on that right, and to be treated respectfully, equally, and without discrimination by providers.