1. Informed Choice & The Tiahrt Amendment APPENDIX F Optional Session Facilitative Supervision for Quality Improvement Curriculum 2008

2. What Is the Tiahrt Amendment? Legislation enacted by the United States Congress in 1999 as an amendment to the U.S. Foreign Assistance Act to ensure that international FP programs receiving USAID funding operate in a completely voluntary manner Named after Congressman Todd Tiahrt

3. To What Does Tiahrt Apply? FP service-delivery projects Funds, technical assistance, commodity assistance Governments, NGOs, and commercial partners

4. What Does Tiahrt Require? Compliance with the following: (1)No quotas or targets (2)No incentives, bribes, gratuities, or financial rewards for clients or program staff (3)No denial of rights or benefits for not accepting FP services (4)Provision of comprehensive information on health benefits and risks of the chosen method, plus inadvisable conditions and adverse side effects (5) Full disclosure for experimental contraceptive methods and procedures

5. What Is New? What Is Not? The concepts of voluntary choice are not new; they reflect long-held values and policies of informed and voluntary decision making and support for individuals’ right to choose. What is new is the legal requirement to report violations (subrecipient to recipient, recipient to USAID, and USAID to the U.S. Congress).

6. No Quotas or Targets Tiahrt prohibits the use of numerical performance targets for providers and referral agents, including numbers of births, of FP acceptors, and of acceptors of a particular method. It does permit the use of numerical estimates for planning purposes. Tiahrt also permits manufacturer, distributor, and retailer sales targets.

7. USAID Clarification Quota or target = a predetermined number of births, FP acceptors, or acceptors of a certain method that a service provider or referral agent is required to achieve

8. No Incentives or Financial Rewards Individuals may not be offered incentives for becoming an FP method acceptor. Program personnel may not receive incentives for achieving a target or quota of acceptors.

9. USAID Clarification Provider payments violate the amendment only when payment is based on a quota or target, set as a predetermined number Permitted: Small-value items given to providers or special training opportunities Per-case payment to providers, if number not predetermined Standard commercial discounts in social marketing programs

10. No Denial of Rights or Benefits Based on Decision Not to Accept FP Examples: Food assistance or health benefits not dependent upon accepting FP services Employment positions or privileges not limited to FP users

11. Comprehensible Information Clients must receive comprehensible information about risks, benefits, side effects, and contraindications of their chosen method.

12. USAID Clarification “Comprehensible” does not guarantee that information is comprehended. Information should be provided in accordance with local standards. Requirements can be met through counseling, posters, and/or package inserts.

13. Full Disclosure for Experimental Contraceptive Methods Experimental FP methods and procedures are to be provided only in the context of a scientific study. The client’s rights to informed consent to participate in the study, including knowledge of the risks and benefits, as well as other options for services, must be ensured.

14. USAID Clarification USAID regulations on human subjects (22 CFR 225) provide necessary guidance.

15. Reporting Requirements USAID is to be notified of an alleged violation of the targets, incentives, benefits, or experimental methods clauses. USAID is to be notified of an alleged violation of the comprehensible information clause if it affects a number of people over a period of time, indicating a systemic problem.

16. USAID’s Strategies for Ensuring Tiahrt Compliance Include voluntary FP requirements in all policy guidance and agreements. Inform and orient staff of USAID, implementing partners, and host country organizations. Put monitoring procedures in place. Develop a wallchart to provide guidance on comprehensible information and other aspects of informed choice. Conduct assessments in key countries.

17. Lessons Learned (1) The Tiahrt Amendment needs to be interpreted country- by-country in the context of that particular nation’s political, social, and service environment. USAID Mission leadership is essential for reaching a common understanding of Tiahrt requirements, monitoring and reporting protocols, and roles and responsibilities.

18. Lessons Learned (2) Vulnerabilities vs. Violations Focusing on Tiahrt “violations” can be too narrow, leading to staff overlooking, or failing to address, larger problems of informed choice and quality of care. Focusing on “vulnerabilities”—underlying conditions that need to be improved—results in better program quality and protection of informed choice, and prevents problems from becoming legal violations.

19. Lessons Learned (3) Put Tiahrt into perspective within informed choice and quality of care: Tiahrt compliance is necessary, but not sufficient to ensure informed choice. If we attend to broader quality issues and protect clients’ right to informed choice, we will automatically meet Tiahrt requirements.

20. CASE STUDIES

21. Case Studies: Targets and Quotas (1)Community health workers have annual workload projections for FP clients, based on community needs assessments. (2) Outreach workers are scolded, their salary is withheld, or they may be transferred to other sites if they do not achieve their workload projections.

22. Case Studies: Targets and Quotas (3) Using a performance-based disbursement (PBD) mechanism, USAID establishes “benchmarks” for sterilization or contraceptive acceptance that are linked to release of funds.

23. Case Studies: Incentives for Clients and/or Providers (4)Sterilization clients receive money, food, and/or clothing after completing the sterilization procedure. (5) Government employees get a pay increase if they provide documentation of a client’s sterilization after the birth of a second child.

24. Case Studies: Incentives for Clients and/or Providers (6) Providers receive a per-case payment for sterilization clients. (7) The best “performing” health centers in a program receive supplies and/or equipment as rewards, based on health indicators, including FP acceptance.