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5 Family Planning Programs and Policies To concentrate primarily on cultural and socioeconomic barriers as a main reason for low contraceptive prevalence in the African region belies the fact that small, well-managed projects and programs throughout the subcontinent have been achieving prevalence rates of 20 percent or more in recent years.) These include projects in Muslim and Catholic francophone countries (e.g., projects in Matadi in Zaire, Ruhengeri in Rwanda, Niamey in Niger), Muslim Sudan, and a host of anglophone countries (Kenya, Ghana, and others). Although it may be argued that some of these projects achieved such prevalence levels in the more educated and urbanized sectors of soci- ety, this pattern of uptake was also common in Asia and Latin America in the earlier days of family planning. In any event, although none of the projects discussed in this chapter were located in the deepest rural reaches, some such as Ruhengeri were outside urban areas. It is instructive to exam- ine those programs that are associated with increased contraceptive use in the last decade, as well as situations in which little program support and poor project effectiveness are associated with low prevalence rates. A review of program directions and potentials is particularly called for in this period of economic retrenchment in Africa. As reviewed in Chapters 3 and 4, economic factors may have substantial effects on the acceptance of iPrograms influence prevalence in two ways: They meet existing demand and stimulate interest in the adoption of family planning among nonusers. 128

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FAMILY PLANNING PROGRAMS AND POLICIES 129 family planning. There is growing utilization of family planning services in Africa, and the first indications of fertility decline were observed in several African countries in the 1980s. The future role of programs in sustaining and increasing the rate of contraceptive utilization and the lessons learned regarding factors necessary to maintain viable programs are ripe for review. This chapter describes the historical development of.population policies and contraceptive services in Africa, reviews the contributions of private versus public sector delivery, and discusses future prospects for family planning programs in the region. THE AFRICAN CONTEXT I?OR POPULATION AND FAMILY PLANNING PROGRAMS The sub-Saharan context for family planning information and service delivery differs from that of Asia, Latin America, or North Africa. Impor- tant factors in sub-Saharan Africa, include weak policy support, relatively late program implementation, generally inadequate resources, weak absorp- tive capacity, and interregional disparities, each of which is discussed be- low. Weak Policy Support Of the first ten governments to promulgate policies supporting family planning and slower population growth, only one Mauritius was in the African region.2 However, due to its unique cultural and geographic char- acteristics, Mauritius is not given emphasis in this volume. Until recently, political and policy support for family planning demonstrated by African governments was cautious at best. However, such support is increasing. In her analysis of policy support, Heckel (1986, 1990) indicated that by 1986, 13 sub-Saharan countries had established explicit population policies that encouraged slower population growth, 3 of them in separate policy docu- ments and 10 as part of national economic or social development plans. Ten of these statements emphasized the need to reduce or stabilize rapid rates of population growth but did not set specific targets. As of 1991, some 20 African governments had adopted population policies and established government agencies responsible for coordinating policies or programs (Roudi, 1991~. Regardless of the status of their popu- lation policies (or lack thereofy, almost all African countries now provide 2In 1951, India became the first country worldwide to have an official population policy; by 1965, five other Asian countries plus Fiji, Egypt, Turkey, and Mauritius had followed suit.

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130 FACTORS AFFECTING CONTRACEPTIVE USE either direct or indirect support for family planning programs (United Na- tions, 1989b, Population Reference Bureau, 1990~. The rationale supporting policies has varied from country to country. In Kenya, the pressure on land resources has been highlighted (see Chapter 4 for discussion), whereas Botswana has noted unemployment and a high dependency ratio (Heckel, 1986~. Relatively Late Program Implementation Although early family planning activities were initiated during the co- lonial period in much of Africa (particularly in English dependencies), post colonial implementation of programs in the 1960s was slow due primarily to low government recognition of the need for services and fluctuating government support, insufficient external assistance, opposition from the Roman Catholic Church in some regions, logistical problems, and lack of trained manpower (United Nations Population Fund, 1983~. By 1969, only five continental African countries, Benin, The Gambia, Ghana, Kenya, and Zimbabwe (12 percent of the total countries discussed in this report, among them containing 10 percent of the African population), had officially com- mitted themselves to the initiation of family planning programs (World Bank, 1985~. As of 1991, only three had carried through on this commit- ment to any substantial degree. During the same period, 1969 to 1991, three of the five North African countries and all of the most populous, as well as many smaller, countries of Asia had established family planning programs. Moreover, although a few nongovernmental family planning organizations were active in Africa as early as the l950s, most programs were not initiated until the end of the 1970s or later. Not only did family planning programs generally start later in Africa, the strength of government commitment to existing programs has tended to lag behind that of other regions. Assessments of national family planning activities and family planning effort, based on contraceptive availability, policy statements, and program activity, indicate that in the early 1980s, only one sub-Saharan country, Mauritius, demonstrated strong program com- mitment; the other countries of the region were judged to have either weak programs or no programs at all. In contrast, more than half the countries of North Africa, Asia, and Latin America were deemed to have moderate or strong programs (Ross et al., 1988; United Nations, 1989a). A 1986 World Bank review noted that only Zimbabwe provided substantial access to fam- ily planning outside urban areas; although Botswana and Kenya had pro- grams underway, the review indicated that "access by potential clients re- mained limited. Countries such as Ghana, Liberia, Malawi, Nigeria, Rwanda and Tanzania had all started programs but had made only limited progress to date." In the rest of Africa, "what services exist are provided in limited

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FAMILY PLANNING PROGRAMS AND POLICIES 131 areas by small nongovernmental organizations that are often poorly funded" (World Bank, 1986:5~. Since then, family planning programs in Africa have been improving at a faster rate than those of other regions. In their assessment of policy and program strengths,3 Mauldin and Ross (1991) indicated that between 1982 and 1989, the sub-Saharan countries showed the greatest improvement in program effort of all regions. However, the overall score for family plan- ning programs in Africa still lagged well behind that in Latin America or Asia. Mauldin and Ross concluded that of 38 African countries, one (Botswana) had a strong program; five (Ghana, Kenya, Mauritius, Zambia, and Zimba- bwe) had moderate programs; and the remaining countries had weak, very weak, or no programs. Of countries worldwide in the weak or no-program category, Africa accounted for 60 percent. Poor contraceptive availability continued to represent a substantial program weakness in the region (Mauldin and Ross, 1991~. Generally Inadequate Resources Although it is difficult to obtain accurate information, available data suggest that per capita funding for family planning activities in the African region is less than half of that in Asia and Latin America. In most sub- Saharan countries, the annual per capita expenditure (government and donor sources combined) is less than $0.20 (Ross et al., 1988~. Such disparities have long existed: In 1980, only four African countries provided more than $0.50 per capita in public expenditures for population programs; more than half the countries in North Africa and Asia provided this amount or more (World Bank, 1985~. Resource disparities become even more important if we consider that per capita income, and thus personal resources available for the private purchase of health and family planning services, are substan- tially lower in Africa than in other regions. Weak Absorptive Capacity Merely increasing the funds for family planning services would not in itself address African resource problems. Absorptive capacity in the region is weak. To give but one example, the availability of health personnel, who may be expected to play a key role in contraceptive distribution, is much lower in sub-Saharan Africa than in other regions. World Bank data from 3The calculation of program effort is based on 30 items that fall into four broad categories: policy and stage setting activities, service and service-related activities, record keeping and evaluation, and availability and accessibility of family planning supplies and services (Mauldin and Ross, 1991).

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132 FA CTORS AFFECTING CONTRA CEPTIVE USE the mid-1980s indicate that of the 33 sub-Saharan countries for which data were available, half had fewer than one physician per 15,000 population, and almost all had fewer than one per 5,000 population (World Bank, l990b). In all other regions combined, only two countries (Nepal and Bhutan) had a physician/population ratio of 1/15,000 or less, and countries with fewer than one physician per 5,000 population were in the minority (World Bank, l990b). Although less extreme, the same differential held for nursing personnel (World Bank, l990b). Increasing resources for service delivery in Africa will require long-term emphasis on human capital and infrastruc- ture development, as well as the development of strategies to increase avail- able financing. Interregional Disparities Substantial interregional disparities in family planning program devel- opment exist within Africa. Historically, family planning programs have been more prevalent in anglophone than in francophone sub-Saharan coun- tries. In their review of family planning programs in francophone countries up to 1974, Gauthier and Brown (1975a) indicated that none of them had a policy aimed at reducing the rate of population growth. By the mid-1970s, all the anglophone countries of the region, except for Somalia and Malawi, had private associations promoting family planning, whereas only four francophone countries had such associations (Gauthier and Brown, 1975a,b). Francophone African countries have generally been substantially more con- servative in the promotion of contraception, whether their populations are predominantly Catholic or Muslim. Almost 10 years after the Gauthier and Brown analysis, Faruqee and Gulhati singled out six continental anglophone countries as making substantial progress in family planning program and policy development, but only one francophone country, Senegal; the latter was deemed to have the weakest policy and program support of the group (Faruqee and Gulhati, 1983~. In a number of francophone countries, a 1920 law based on the old French legal code (hereafter referred as the French law) still prohibits dis- tribution of contraceptive supplies and information (United Nations, 1989b). Although the law is generally not strictly enforced, it exerts a negative influence on program development. Many francophone countries also have highly centralized, physician-based public sector service delivery, and regu- lations that specifically prohibit the provision of contraceptives by person- nel other than doctors. Because the ratio of population to physicians is high in most sub-Saharan countries, as indicated above, such regulations se- verely restrict family planning availability. Moreover, as discussed below, community-based distribution, private sector delivery, and social marketing

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FAMILY PLANNING PROGRAMS AND POLICIES 133 have all been introduced later in the francophone countries and continue to be less common. Contraceptive prevalence rates in francophone countries are lower than those of their anglophone counterparts (see Chapter 2~. That this difference is due primarily to programmatic rather than cultural factors is suggested by the fact that contraceptive prevalence in areas of Niger, Zaire, and Rwanda, where effective service delivery has been initiated, has risen to rates com- parable to those of well-managed programs in anglophone countries (Direc- tion de la Sante Fam~liale and Population Communication Services, 1989; McGinn, 1990; Wawer et al., 1990; Bertrand et al., 1993~. The weak policy support, relatively late program implementation, gen- erally inadequate resources, weak absorptive capacity, and interregional dispandes in Africa indicate the problematic milieu within which family planning projects and programs have operated, and suggest reasons for the pattern of success in family planning programs or relative lack thereof seen in different coun- tries. INTERNATIONAL AND REGIONAL INFLUENCES ON POPULATION POLICY DEVELOPMENT A number of factors have influenced the gradual move toward govern- ment policies more favorable to family planning in Africa (Goliber, 1989~. The rapidity of population growth has been documented authoritatively in a series of national censuses.4 The degree to which rapid population growth is outstripping growth in social infrastructure (e.g., educational and health facilities) and job creation, has been brought home to governments through basic sociodemographic and economic analyses such as presentations by the Futures Group conducted to date in more than 20 African countries (Middleberg, personal communication, 1991~. The importance of external influences on policy development cannot be underestimated. In the early 1960s, the U.S. Congress passed legislation endorsing population research because of the perceived effect of population growth on economic development (Piotrow, 1973~. U.S. foreign policy emphasized an economic interdependence between the United States and developing countries (Donaldson and Tsui, 1990~. In 1967, Title X to the Foreign Assistance Act was passed, providing support to voluntary family planning programs overseas. The United States offered assistance to gov- ~rnm~nts U.S. agencies, and UN voluntary health or other qualified organi 4Most censuses were conducted with the assistance of external donors, notably the United Nations Population Fund and the U.S. Agency for International Development, with technical assistance from the U.S. Bureau of the Census.

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134 FACTORS AFFECTING CONTRACEPTIVE USE zations for program implementation (Piotrow, 1973), and $35 million was earmarked for population programs. Support for population activities had become part of U.S. national policy, rather than an occasional technical assistance foray supported by private citizens or organizations. The special role of the United States in international population programs is based not only on its early interest, but also on its continued financial support. In terms of total dollars, the United States was the dominant donor to interna- tional population activities between 1965 and 1980 (Donaldson and Tsui, 1990~. Another major international player in the population field is the United Nations. From 1962 to 1972, a series of resolutions were adopted in the governing bodies of the UN agencies advising governments to examine their demographic circumstances and take appropriate action (Finkle and Crane, 1975~. The United Nations in 1969 designated a separate fund to respond to global population needs, the United Nations Population Fund (UNFPA), to be administered by the United Nations Development Fund (Futures Group, 1988b). The United Nations gave legitimacy to population programs because its endorsement meant approval of member states from developing countries. Population programs that might otherwise have been viewed with suspicion acquired credibility. In 1972, a resolution of the UN Economic and Social Council called for a Draft World Population Plan of Action to be prepared for the 1974 Bucharest World Population Conference (Mauldin et al., 1974~. This conference was the first major population meeting to invite political representatives from all over the world, rather than just international population specialists, to dis- cuss population strategies (Mauldin et al., 1974~. However, whereas devel- oped nations regarded the Bucharest conference as a potential catalyst to increase the role of the United Nations and its member governments in limiting population growth, many developing countries viewed the same event as one that would strengthen the unity of the Third World in achiev- ing a "new economic order" (Finkle and Crane, 1975~. Amendments were introduced to the draft plan that shifted the focus away from demography to socioeconomic development. The final version of the World Population Plan of Action examined population variables within the context of social and economic development (Mauldin et al., 1974~. At Bucharest, African countries did not indicate that rapid population growth was one of their major problems. Ten years later, African views on the necessity of fertility reduction had changed. The Kilimanjaro Pro gramme of Action for African Population and Self-Reliant Development was formulated at a regional conference for African governments, held in Tanzania in January 1984, to prepare for the second International Conference on Population, which took place in Mexico City later that year. The Kilimanjaro Programme declared that effective

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FAMILY PLANNING PROGRAMS AND POLICIES 135 programs were needed in Africa to reduce the high levels of fertility and mortality (Finkle and Crane, 1975~. It reaffirmed the rights of parents to decide the number and timing of their children, and called on all countries to ensure the availability of safe, effective, and affordable contraception (Futures Group, 1988b). At the Mexico City conference, Africa joined the other developing regions of the world in declaring that population problems must be addressed regardless of whether a "new economic order" was es- tablished (Finkle and Crane, 1975~. This stance represented a major change in attitudes and priorities. HISTORICAL EVOLUTION OF FAMILY PLANNING PROGRAMS On a national level, to what degree does the presence or absence of a population policy affect family planning programs? As demonstrated in the discussion of selected countries below, many pilot projects have been implemented successfully in the absence of a supportive government policy. Indeed, the presence of the projects themselves may promote policy development by providing evidence for government leaders that family planning will be culturally acceptable. However, there is evidence that the policy milieu is important for large-scale program success. Two of the three countries (Kenya and Botswana) currently having the most successful national programs and the highest contraceptive prevalence rates (CPRs) were among the first group to adopt population policies in Africa Zimbabwe being the one exception where strong government support of programs occurred without an explicit policy. In countries with centralized government control over service deliv- ery, such as the francophone countries, the lack of such policies has con- tributed to reluctance to expand programs and may in part account for their having, as a group, the lowest CPRs in Africa. The implementation of family planning programs in Africa has tended to follow four stages, which occur within different time frames depending on the country.5 These stages are: 1. implementation of early pioneering projects, most conducted by nongovernmental organizations (NGOs) or only weakly linked to the public sector; SThe four stages of African program development to date that are discussed here are congru- ent with a program typology developed by the U.S. Agency for International Development (USAID) to guide its assistance efforts in the 1990s and beyond (Destler et al., 1990). Accord- ing to the USAID model, most African countries are at the emergent (modern method preva- lence of 0-7 percent) or launch stages (prevalence 8-15 percent). Only three (or four if Mauritius is included) are at the growth level or beyond (prevalence greater than 16 percent). The implications of the different stages of program development for international donor techni- cal and funding assistance are discussed later in this chapter.

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136 FACTORS AFFECTING CONTRACEPTIVE USE 2. family planning service expansion, usually including both discrete projects and preliminary government involvement, setting in motion the initiation of a national program; 3. broad-based service expansion and consolidation, particularly in the national program, and relative policy stability that results in appreciable effects on the CPR; 4. substantial and sustainable increases in CPR resulting in a fertility decline. In most sub-Saharan countries in the fourth stage (principally Botswana, Kenya, and Zimbabwe), the public sector is the primary, al- though not the sole, service provider. First Stage: Pioneers Pioneer projects throughout Africa have introduced family planning and demonstrated its political and cultural acceptability. In most cases, such programs have been implemented in milieus having little or no experience in contraceptive delivery and weak or no policy support. The weak support resulted in part from the very dearth of experience: Lacking empirical evidence to the contrary, African leaders were concerned that contraception would not be perceived as a need by their populations. The role of the pioneer programs has been crucial in changing political attitudes. The early program activities have most frequently been implemented by NGOs, missionary groups, or as joint endeavors between in-country and developed country universities and research groups. In almost all cases, such projects have received external funding and technical support. With few exceptions, public sector involvement has been relatively minimal. Even where some degree of government involvement has been inevitable, such as within the highly centralized service delivery systems of francophone Af- rica, the pioneers have generally been small operations research programs, or other discrete entities outside the main health service delivery system. As such, they can be deemed "experimental" and disavowed quickly if the government perceives political fallout (Wawer et al., l991b). In francophone countries, the first stage has generally been limited, due to the relatively monopolistic and centralized role of government in service delivery. This limitation accounts for the slow development of family planning in these countries; francophone countries have had less exposure to the small, suc- cessful nongovernmental family planning projects that have influenced policy in anglophone countries. Exceptions to the general rule of weak government support for or in- volvement in early projects can be found in a few African countries. Kenya and Ghana were the first to formulate population policies, in 1966 and 1969, respectively. In these countries, government support of program ac- tivities occurred relatively soon after or in parallel with many of the early

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FAMILY PLANNING PROGRAMS AND POLICIES 137 NGO activities (World Bank, 1980, 1986~. In Zimbabwe, the preindependence government, although not declaring an official population policy, was con- cerned about rapid population growth and, since the mid-1960s, has strongly supported private family planning activities (World Bank, 1982~. The implementation of pioneer projects in Africa has occurred in two distinct waves. The earliest projects were implemented in a small group of countries (Kenya, Ghana, and Nigena) between the mid-19SOs and the 1970s, and demonstrated that family planning was acceptable to substantial por- tions of the target populations even in what were considered to be pronatalist settings. Examples of such projects include those of the Family Planning Associations of Nairobi and Mombasa, which began providing contracep- tive information and services in 1955 (World Bank, 1980~; the Gbaja Fam- ily Health Nurse Project in Nigeria (1967-1970) (Ross, 19864; the project in Danfa in Ghana (Reinke, 1985) begun in 1969; and collaboration with the International Postpartum Program of the Population Council, which also began in Ghana and Nigeria in 1969 (Castadot et al., 1975~. For cultural and political reasons, many pioneer projects concentrated on family plan- n~ng as a maternal and child health issue. A number of the early projects demonstrated that service delivery strategies that had been or were being tested in Asia, including community-based distribution (CBD) and varia- tions on commercial sales of contraceptives, could be adapted to African settings (Black and Harvey, 1976; DeBoer and McNiel, 1989~. A second wave of "pioneer projects" was implemented or begun in the period from the mid-1970s to the present in countries that for political or cultural reasons were slower to promote family planning. (The early stages of family planning service delivery in Africa have thus occurred over a 30- year time span, depending on the country.) These projects have yielded lessons already learned elsewhere (i.e., family planning can be culturally acceptable; CBD can work in African settings; and contraceptive services can be successfully integrated into health care) (Senegal and U.S. Agency for International Development, 1982; Bertrand et al., 1984, 1993; Wawer et al., 1990), but served to demonstrate again the acceptability of family plan- ning on a regional level. In virtually all cases, the early pioneers helped to introduce family planning, but did not have a great effect on contraceptive prevalence rates, except in small, select populations. In the project populations themselves, ultimate contraceptive prevalence rates have varied substantially: from less than 5 percent in the Nigerian Oyo State CBD project, Sine Saloum in Senegal, Bouafle in Cote d'Ivoire (Ross, 1986; University College Hospital et al., 1986; Columbia University, 1990) to almost 20 percent or more in the populations served in Danfa, Ruhengeri in Rwanda, Matadi in gas-Zaire, Niamey in Niger, and the Sudan (Ross, 1986; Farah and Lauro, 1988; McGinn, 1990; Wawer et al., 1990; Bertrand et al., 1993~. The definitions of "suc

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138 FACTORS AFFECTING CONTRACEPTIVE USE cess" for early programs are thus highly variable. In the case of the Oyo State or Cote d'Ivoire projects, success was not necessarily demonstrated in the effect on the CPR, but rather in the very fact that these projects were implemented, showed some influence on prevalence (albeit limited), and laid the groundwork for an expansion and replication of these models in other regions (Wawer et al., 199 lb). , No attempt was made to assess the community CPR achieved as a result of the Market-Based Distribution Project in Ibadan, Nigeria (see Chapter 4), which focused on contraceptive sales by traders in an urban market. (The project did record the quantities of contraceptives sold.) However, this project has been replicated in two new settings in Nigeria and one in Ghana, at the behest of local governments (Wawer et al., l991b), suggesting "suc- cess" in making innovative family planning delivery more acceptable to policymakers and political leaders. With respect to the prevalence achieved, what may account for the great disparities among the various pilot projects? Given the great varia- tions in project design and implementation, direct comparisons are not very instructive. However, it seems that projects that established a clear identity for the family planning component (whether integrated with other health services or not) performed better. In both Oyo State and Sine Saloum, for example, there are indications of shortcomings in the promotion of family planning services: greater emphasis on the curative program elements at the expense of preventive and contraceptive services, and perhaps reluc- tance by project management or workers to stress family planning (Ross, 1986; University College Hospital et al., 1986~. The Ruhengeri project in Rwanda achieved more than 19 percent prevalence in one area, compared to 8 percent in the second project site. Although dissimilarities in the educa- tional level of the target populations accounted somewhat for the results, project staff emphasized the differences in the level of local political sup- port for the projects, which were said to affect the degree to which project workers carried out their 'promotional and distribution activities (McGinn, 1990~. Second Stage: Mixed Private and Public Activities and Service Expansion In the wake of the pioneering projects, countries have tended to follow one of several directions. In one model, found in Nigeria, early projects have loosened political constraints on the development of other, larger, nongovernmental projects. Countries such as Kenya and Ghana have ex- panded both governmental and nongovernmental activities. In a third model, found particularly in the francophone countries, governments have been

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FAMILY PLANNING PROGRAMS AND POLICIES 159 of crucial importance and that improved service provision will prevent abortion and unwanted births. A Range of Service Delivery Strategies Have Been Successful There appears to be no one "magic bullet" with respect to the type of delivery strategy that will be successful. In Ruhengeri, the most effective approach was intensive IEC and referral to clinics; in the Sudan and Bas- Zaire, door-to-door distribution proved feasible and effective; market-based distribution is showing itself to be a useful option in several sites in Nige- ria. Both integrated and vertical service delivery programs have improved family planning utilization; equally, both strategies have at times had mini- mal effects (Taylor, 1979; United Nations Population Fund, 1979; Trias, 1980~. Important components in achieving success are local support, good management, and a commitment to family planning by project directors, such that the service does not become lost among other interventions. Pilot and Operations Research Projects Have Contributed Substantially Pilot or operations research (OR) projects can be reassuring to local or national leaders who would like to see a test of family planning but are reluctant to undertake a potentially politically damaging activity. Under the guise of these projects, new approaches can be tested, carefully monitored, documented, and possibly, jettisoned as an experiment that failed should the need arise (an uncommon experience). In 1987, more than one-third of innovative service delivery approaches discussed at the Harare Conference on Community Based and Alternative Distribution Strategies in Africa had originated as operations research projects (Columbia University Center for Population and Family Health, 1987~. To some extent, the African situation with respect to pilot and OR projects mirrors the early days of family planning in Asia. Small demon- stration and NGO projects preceded national involvement or continued to play a critical role even as government programs came into their own (Freedman, 1987). Family Planning Effort Is Associated With Contraceptive Prevalence In 1985, Lapham and Mauldin developed an international family plan- ning effort score based on policy milieu, stage-setting activities, service 19The evidence in this section is based on data pooled from African and non-African coun- tries. There is no evidence for Africa alone.

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160 FACTORS AFFECTING CONTRACEPTIVE USE related activities, record keeping, evaluation, and availability and accessi- bility of fertility control supplies and services (Lapham and Mauldin, 1985~. They then examined the interactions between national socioeconomic indi- cators (based on indices from 1970) and program effort variables as predic- tors of contraceptive prevalence in the period 1977-1983.2 The key con- clusions were . . . the two conditions socioeconomic setting and program effort work most effectively together. Countries that rank high on both socioeconomic setting and program effort generally have higher contraceptive prevalence than do countries that rank high on just one, and still more than countries that rank high on neither. Furthermore, the path analysis suggests that program effort components are strongly associated with the availability and accessibility of family planning .... Moreover, the chances of achieving increased contraceptive prevalence by means of an aggressive family plan- ning program range from good to very good among all but the lowest socioeconomic setting countries (Lapham and Mauldin, 1985:132-133. Bongaarts et al. (1990) have updated the Lapham and Mauldin analysis and reconfirmed the conclusions that both socioeconomic development and family planning program strength influence contraceptive use and fertility, and that they operate synergistically, with one reinforcing the other. Of the 29 African countries considered in their analysis, 16 countries were in the low-development category (1980 data), and 21 had very weak or no family planning programs (based on the program in place in 1982~. Between 1965 and 1985, countries falling into the "low development index/very weak no program" category recorded on average no decline in fertility. The re- searchers concluded that "much can be done to improve service delivery, particularly in countries where programs are still weak. Although the de- velopment of effective programs is more challenging in settings where the demand for birth control is weak, well-designed programs can have a sub- stantial impact on fertility and population growth" (Bongaarts et al., 1990:307~. In an examination of programs worldwide, Mauldin and Ross (1991) identified strong associations between family planning program vigor and contraceptive prevalence. The prevalence rate ranged from 6 percent in those countries with very weak or no programs, to 20 percent in those with weak programs, to 45 percent or more in those with moderate and strong programs. The correlation between program effort score and CPR was .70, and the correlation between the contraceptive availability score and preva- lence was even stronger, .84 (Mauldin and Ross, 19919. Furthermore, they 200f the 26 sub-Saharan countries included in the Lapham and Mauldin analysis, 14 were in the lowest socioeconomic grouping in 1970.

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FAMILY PLANNING PROGRAMS AND POLICIES 161 suggested that the association between program effort and prevalence would have been stronger were it not for the fact that positive population policies, which increased the overall score, were not necessarily related to strong program implementation. The relationship between contraceptive availabil- ity and decline in the total fertility rate was also noteworthy (Mauldin and Ross, 1991~. Access to Family Planning Is Associated With Contraceptive Prevalence Modern contraceptive use cannot occur in situations where methods and information on correct use are unavailable. Lack of availability may be due to many factors, including distance to services, barriers intrinsic to delivery systems (such as limited hours of operation and low provider en- thusiasm), and high cost. DlIS has reported the effects of distance on service utilization for ten countries, of which three (Togo, Uganda, and Zimbabwe) are in sub-Saharan Africa. Despite some limitations inherent in the sampling methods used to collect much of the data (Wilkinson et al., 1991), the results are instructive. In Togo and Uganda, utilization rates of modern methods are highest among women living within 5 kilometers of a static family planning provider; in Zimbabwe, prevalence remained high even in women somewhat distant from stationary providers, in part due to adequate outreach and community-based approaches (Wilkinson et al., 19911. However, even in Zimbabwe, the use of contraception decreased for users living 5 kilometers or more from a provider, and the use of clinical methods (IUD, tubal ligation) increased. For all 10 countries examined, the effects of distance on use of modern methods were strongest in Togo and Uganda; in other countries, greater availability of clinical methods, alternative sup- ply strategies, and better transportation ameliorated the effects of distance to some degree (Wilkinson et al., 19919.2~ Based on analysis of the 1988- 1989 Kenyan DHS and Kenyan Community Survey, Hammerslough has suggested that the rise in service availability in Kenya accelerated but did not initiate the fertility transition; the acceleration was related in part to the increased likelihood that contraceptors used efficient contraceptives (Hammerslough, l991b). With respect to cost, as a rough rule of thumb, contraceptives are deemed to be "accessible" if their total cost does not exceed 1 to 2 percent of 2lCare should be taken in interpreting results of the relationship of distance to contraceptive use because skepticism has been voiced about the validity of distance as a measure of accessi- bility. It has been suggested that a variety of data collection techniques are needed to measure accessibility (Commitee on Population, 1991).

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162 FA CTORS AFFECTING CONTRA CEPTI VE USE household income per annum (Lewis, 1985~. A recent set of studies con- ducted by the Population Council examined private sector costs of contra- ceptives in relation to per capita income in 94 countries (Population Crisis Committee, 1991~. The annual cost of 100 condoms represented more than 2 percent of per capita income in 19 out of 23 sub-Saharan countries repre- sented in the analysis. In Benin, Burundi, Central African Republic, Ethio- pia, Madagascar, Mali, and Togo, it was estimated that the private sector price of 100 condoms represented more than 15 percent of annual per capita income. Similarly, for oral contraceptives, the annual cost of 13 cycles was estimated to represent more than 2 percent of per capita income in 20 sub- Saharan countries. The need for public sector or subsidized family plan- ning delivery is thus evident in the African region; the Population Council study suggested that in many of the sub-Saharan countries in question, less than one-third of couples currently has access to such low-cost supplies. Donor Support Is Essential In 1986, a World Bank document noted that "the cost of providing family planning in Africa is not great in absolute terms, but it will not be easily met by domestic resources" (World Bank, 1986:6~. The bank esti- mated that average costs per user fall to approximately $20 per year as contraceptive prevalence reaches 20 percent or more of couples of repro- ductive age. The document suggested that "an increase in external assis- tance not only for family planning but also for policy planning, data collec- tion and analysis, and training will be necessary for several decades if family planning is to be a realistic option for Africans . . ." (World Bank, 1986:6~. The authors urged that population assistance to Africa increase as rapidly as the absorptive capacity allows and pointed out that "even a tri- pling of the external assistance currently spent on population in Africa, from $53 million to $160 million, would imply an increase in assistance from $0.12 to just $0.36 per capita, half the $0.75 figure cited as a goal for overall spending" (World Bank, 1986:61. The difficulty of developing strong family planning programs in poor socioeconomic settings has been noted (Mauldin and Ross, 1991~. Most African countries fall into the lowest economic categories in rankings de- veloped by the World Bank and USAID. Given the economic downturn in much of Africa in recent decades, coupled with the potential for major increases in contraceptive use, the critical role that donors can play in popu- lation programs in Africa cannot be overemphasized. To date, the history of population and family planning programs in Africa has been inextricably linked to donor support. Donor inputs into pilot and operations research projects, policy development, data collection, service delivery, information campaigns, and technical assistance at all phases have played a crucial role

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FAMILY PLANNING PROGRAMS AND POLICIES 163 in achieving what success is now evident. The quality and effectiveness of many family planning projects have depended fundamentally on the inter- play between donor organization budgets and technical assistance, and host country health care infrastructure, laws, and regulations. The importance of this assistance reflects economic constraints faced by African governments and NGOs, as well as the hesitancy of national leaders to undertake a con- troversial activity without some external assistance. One important problem faced by donor agency grantees may be de- scribed as donor fatigue. Any one strategy for service delivery is likely to demonstrate its effects only slowly or may be applicable in only a limited segment of the population. Donors often feel the pressure from their own constituencies to show more dramatic results or at least demonstrate that they support dynamic innovation. Thus, over the years, programs in Africa have experienced sequential or short-lived donor enthusiasm for clinic-based approaches, community-based distribution, commercial retail sales, and variations on these themes. Donor support for innovation has many positive effects. However, it is detrimental if the emphasis on a new approach reduces sup- port (financial, political, technical) for a tried-and-true strategy that can and will pay off over time. As indicated earlier in this chapter, the USAID population program development typology was developed to guide funding and technical assis- tance efforts at different program stages (Destler et al., 1990~. At the earliest emergent stage (prevalence less than 8 percent), it is argued that assistance needs are broad and substantial, and multidisciplinary technical assistance is required. At the launch stage (prevalence 8-15 percent), it is suggested that donor support may be directed to more specialized technical assistance and implementation agencies, in particular to meet training needs and promote programmatic and financial sustainability. From the launch stage onward, growing emphasis is placed on involving the commercial sector. The typology and the suggested directions for action provide a conceptual framework for donor strategies. The model recognizes that a mix of private and public sector involvement in family planning is desirable and that the move to sustainability is gradual. In the African setting, appli- cations of the model would have to take into consideration the weak overall economic base and the potential for setbacks in population programs if national economies deteriorate further. True financial independence and autonomous sustainability will be harder to achieve in Africa than in set- tings having preexisting strong private sectors and more solid economic bases. The current economic situation in Africa, the opportunity to expand family planning much more rapidly in the next decade, and a continuing need for technical input suggest that donor involvement will continue to be essential for the foreseeable future.

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164 FACTORS AFFECTING CONTRACEPTIVE USE New Mechanisms Are Needed to Increase Resources Governments, donor agencies, and programs need to address the prob- lem of static resources at a time of growing family planning demand and costs. Strategies to improve the use of existing resources and to coopt new sources of manpower and funds include direct cost recovery (fees for ser- vice and supplies), social marketing, employer donations, leveraging of re- sources (matching requirements, collaborative service delivery arrangements, debt conversion), service coverage by third parties, expansion of private sector services, and increasing program efficiency (economies of scale, less costly service delivery models, introduction of more effective contraceptive technologies; Destler et al., 1990; Lande and Geller, 19914. USAID projec- tions indicate that, over time, a greater proportion of service delivery costs will need to be met with local private resources (Destler et al., 1990~. There is evidence that some clients can and will pay for family plan- ning services; indeed, acceptance of modestly priced contraceptives has at times been higher than that of free commodities in the same setting (Lewis, 1985~. Within programs, the trend has been to provide services free of charge in the initial phases and to institute fees only after demand has been stimulated. The merits of such phasing in of payments remain controver- sial. In the Oyo State CBD project in Nigeria, contraceptive use fell in project areas where fees were introduced some time after project initiation; areas in which similar prices were charged from program inception achieved and maintained distribution levels equivalent to those in the initial free service areas (University College Hospital et al., 1986~. The more pressing question is not whether it is possible to charge for services, but rather the degree to which fee-for-service and other fund- raising schemes can cover the true cost of family planning delivery. As indicated earlier, contraceptives may be considered accessible if their total cost does not exceed 1-2 percent of average annual income per capita. Lewis has concluded that most cost recovery efforts do not cover more than one-quarter of total costs, or half of noncommodity costs (Lewis, 1985~. Commercial prices that reflect true costs are often too high for the average household, particularly in Africa where such prices relative to income are generally the highest in the world. Donor and government subsidization of services will likely remain important in Africa, whether contraceptives are distributed through the public or private sector. More small-scale research is needed to determine the extent of price elasticity and to improve market segmentation in order to set realistic fees for different population subgroups. Worldwide, the proportion of the total population served by the private sector tends to increase as family planning services mature, with developed countries being much more dependent on private providers than developing countries (Destler et al., 1990; Lande and Geller, 1991~. It is also notewor- thy that a comparison of family planning costs in developing countries

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FAMILY PLANNING PROGRAMS AND POLICIES 165 suggests that social marketing and clinics offering primarily voluntary ster- ilization were the most cost-effective family planning delivery modes (with respect to cost per couple-year of protection, CYP); community-based dis- tribution services had the highest costs per CYP, but became somewhat more cost-effective if coupled with clinics offering long-term methods such as the IUD and tubal ligation (Huber and Harvey., 1989~. The relative success of social marketing with respect to cost-effectiveness was attributed in part to such programs' ability to reach massive audiences quickly once they are introduced. Project and Program Success Needs to Be Interpreted Broadly Increase in contraceptive prevalence is not necessarily the only measure of success in many early family planning projects. The Oyo CBD project, for instance, may not have had a substantial effect on the use of modern methods but did result in greater acceptance of community-based distribu- tion of family planning by the state government. Projects with limited size and scope have had important effects in reassuring policymakers of the acceptability and feasibility of family planning services and have resulted in policy changes and expansion of services (Destler et al., 1990; Wawer et al., l991b). To ensure that the lessons learned have reached policymakers, the involvement of such leaders in the project from its early stages is fre- quently desirable, as in the cases of the Danfa project, the Oyo State CBD project, the Sudan CBD project, and Ruhengeri. All resulted in policy changes or were sustained and replicated by the public sector following their OR/pilot phase. Projects that provide less opportunity for policymakers to become aware of and comfortable with their approaches, as in the case of the Calabar project in Nigeria, may not stimulate future family planning efforts. PRIVATE VERSUS PUBLIC SERVICE DELIVERY, INCLUDING SOCIAL MARKETING The degree of coverage that may ultimately be provided by the private sector in Africa is still unknown. According to DHS data (Cross, 1990), there currently exist wide variations in the source of contraceptives by country. In Botswana, Kenya, and Zimbabwe, countries with the highest contracep- tive prevalence in continental sub-Saharan Africa, government sources sup- ply between 73 (Kenya) and 92 percent (Botswana) of all modern contra- ceptive methods. The public sector is also the major supplier in Burundi (87 percent of users) and Mali (76 percent of users); contraceptive preva- lence in both these countries is less than 2 percent. In five other sub- Saharan countries (Ghana, Liberia, Senegal, Togo, and Uganda all low

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166 FA CTORS AFFECTING CONTRACEPTIVE USE prevalence countries), the government sector supplies half or less of all users. Pharmacies supply between 11 and 23 percent of users in Ghana, Liberia, and Togo; other private sources (which may include private health providers or nongovernmental organizations) account for between one-quar- ter and one-half of users in Ghana, Kenya, Liberia, Senegal, and Uganda. Interestingly, government sources of contraception predominate in the three Asian countries with DHS data (Thailand, Sri Lanka, and Indonesia),22 whereas pharmacies and other private sources service the majority of users in most Latin American countries. The patterns noted above persist when supply methods are considered separately from clinical methods. Experience to date and the data above suggest that public sector in- volvement has been a critical element in national expansion of family plan- ning services in Africa, and that those countries with relative success stories continue to rely in large part on government sources. The data also make clear, however, that in the majority of countries, the public sector, although it may be the predominant source of methods, is actually reaching only a portion of the population. Thus, there remains a need to expand the net- works available for service provision, both in countries where progress is being made and in countries with little family planning delivery to date. Expansion of services into the private sector, including pharmacies, private practitioners, and nonmedical retailers and traders, has recently become an area of great interest. Social marketing, wherein contraceptive supplies are generally sold at subsidized prices, represents a model that may be used to involve private distributors. As yet, social marketing remains a small component in family planning delivery in Africa. Statistics compiled by DK-Tyagi (DKT) International (a subsidiary of Population Services International) indicate that there were eight sub-Saharan.countries where social marketing projects provided more than 10,000 CYPs in 1991 (DK-Tyagi International, 1992~. The CYPs reported ranged from 18,000 in Cote d'Ivoire to 200,000 in Zaire. Condoms were the sole method delivered in five of the countries; the Zaire program also included foaming tablets; the Ghanaian, oral contraceptives; and in Zimbabwe, oral contraceptives and IUDs. In both Ethiopia and Zaire, the program was estimated to have provided coverage for 4 percent of the target market, the latter defined as being 80 percent of women in union, aged 15- 44; in the other five countries, the coverage provided was 2 percent or less (DK-Tyagi International, 19921. Social marketing programs, and indeed any attempts to reach the private sector (outside both governmental and NGO programs), are recent in origin 22In some Asian countries such as Taiwan, the private sector played a large role in service delivery in the early implementation of family planning programs.

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FAMILY PLANNING PROGRAMS AND POLICIES 167 and cannot be expected to have achieved their full potential. Unfortunately, there is a dearth of information from which to project what this potential may ultimately be. Data on the numbers and distribution of private sector providers not affiliated with public or nongovernmental programs are often unavailable for a given country. Country assessments carried out by the Social Marketing for Change (SOMARC) program of the Futures Group, point to potential obstacles to social marketing. The Togo assessment noted that the parastatal pharmaceutical company had a monopoly on pharmaceu- tical imports, which may reduce flexibility, efficiency, and resupply, and hinder plans for cost recovery and self-sustainability; the parastatal distri- bution network was limited, reaching only approximately 165 points of sale; and current regulations would permit the sale of oral contraceptives in fewer than 70 outlets nationwide (Baird et al., 19909. Commercial distribu- tors lacked experience with the product line, and the report further noted that ". . . since the volume of product is limited and the profit margin very small compared to the rest of their product lines, there is the possibility of a lack of interest in the long term benefits of this program" (Baird et al., 1990~. Based on these observations, SOMARC ultimately recommended that the social marketing program be housed within a nongovernmental organization, the IPPF-affiliated Association Togolaise pour le Bien-Etre Fami li al (B. aird et al., 1 9 9 0) . In Rwanda, it was noted that "the country's commercial infrastructure is rudimentary .... Distribution and marketing activities are passive in nature and advertising is not widely used. There are very few commercial entities which provide a significant coverage of the country in terms of distribution despite the fact that the network of pharmacies has increased from 28 in 1987 to 124 in 1989" (Karambizi and O'Sullivan, 1989~. This report also noted that import duties on contraceptives, although lower due to their classification as essential drugs, were still "high enough to increase the retail price beyond the purchasing capacity of the majority of the people." The concerns noted do not preclude the establishment of social market- ing programs. However, they do suggest that commercial approaches are likely to become widespread much more gradually in the sub-Saharan re- gion than, for example, in Latin America, and it is thus too early to dismiss the importance of CBD and other noncommercial approaches, despite their potentially higher cost. It should also be mentioned that the cost-effective- ness of social marketing mentioned above was based on assessment of pro- grams in four Latin American, three Asian, one North African, and two sub- Saharan countries: the last two, Kenya and Nigeria, are not representative of the potential for social marketing in Africa as a whole. In neither case are programs overly constrained by restrictive policies, and both countries have better than average networks of commercial distributors who can be mobilized to provide services, thus achieving the broader distribution asso

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168 FA CTORS AFFECTING CONTRACEPTIVE USE elated with lower unit cost. Thus, social marketing per se is unlikely to be a programmatic magic bullet for Africa, and diversified approaches will continue to be needed 23 THE IMPACT OF AIDS ON FAMILY PLANNING PROGRAM ACTIVITY No discussion on population activities in Africa is complete without some reference to the potential impact of acquired immune deficiency syn- drome (AIDS) on family planning programs in the next decade. Unfortu- nately, little data is available and what can be said about the impact of AIDS is more speculation than fact. It is thought that AIDS may affect family planning services in two ways. First, it may decrease the resources available for these services both financial and human. Public health officials may target their limited re- sources to addressing the AIDS epidemic resulting in fewer resources avail- able for other health services, such as the promotion and delivery of family planning. Health workers may be reluctant to promote family planning among populations severely affected by AIDS, for fear of going against the possible pronatalist response to AIDS or because they too believe it is important to promote childbearing to offset AIDS-related deaths. Further- more, some health providers may be reluctant to insert IUD s because of the possible connection between the use of an IUD and increased spread of sexually transmitted diseases, including human immunodeficiency virus- which causes AIDS and because IUDs may increase bleeding (Williamson, personal communication, 1993~. Second, AIDS may increase the demand for contraception, particularly condoms. Information, education, and communication (IEC) efforts regard- ing the use of condoms in preventing AIDS are already under way in Africa and the flow of condoms to Africa has increased dramatically (Williamson, personal communication, 19931. Although condoms are not as well ac- cepted as other methods as a means of pregnancy prevention within mar- nage, such education efforts have at least made many Africans more aware of the potential usefulness of this method. In addition, it is generally be- lieved that governments, in response to the spread of AIDS, have become more willing to broadcast information on condoms and AIDS via the mass 23It should also be noted that in a number of non-African countries there has been a decrease in the use of the private/commercial sector (particularly pharmacies) for family planning sup- ply in the last decade. This decline has been attributed in part to an increase in the use of clinical methods (the IUD, sterilization) (Lance and Geller, 1991). In these cases, cost savings on a national level are more likely to result from the adoption of more effective methods than from commercial cost recovery per se.

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FAMILY PLANNING PROGRAMS AND POLICIES 169 media. In the wake of these efforts, messages in the media on other family planning methods may seem more acceptable in the future. CONCLUSION As noted by Freedman, ". . . in the rapidly changing world, the reports of traditional cultural constraints in developing countries may be more rep- resentative of the past than of the present. All developing countries in- creasingly are linked to the world communication and transportation net- work carrying ideas and messages that permeate cultural barriers to varying degrees . . ." (Freedman, 1987:58~. Information regarding successful pro- grams is being disseminated to other regions, through exchanges, confer- ences, and word of mouth, and is resulting in successful replication of service delivery strategies (Columbia University, Center for Population and Family Health, 1987, 1990; Wawer et al., l991b). The relative success or weakness of family planning implementation in each of the countries discussed above is largely predicated on very specific political and economic circumstances. Caution is therefore in order in drawing any conclusions as to the determinants of the different outcomes. However, in a general sense, programs have tended to encounter particular problems where original national commitment was weak, or where it faltered as a result of political instability or economic decline. To date, the contribution of nongovernmental sources to contraceptive use in African countries has been important in introducing the services, reaching specific target popula- tions, and opening the door to innovations. However, private and voluntary services have had a modest effect at best on national contraceptive preva- lence rates and coverage. The qualitative evidence in this chapter suggests that limited access to contraceptives contributes to the relatively low use of family planning in sub-Saharan Africa. Government programs are beginning to have substan- tial effects on contraceptive use and to produce indications of an effect on fertility in a number of African countries (Botswana, Kenya, and Zimba- bwe). The potential for major increases in contraceptive use in the next decade is great in a group of nations that includes Ghana, Niger, and Rwanda. Elsewhere, attitudes favoring family planning and resources for contracep- tive delivery programs are at least becoming more prevalent. For the poten- tial to be realized, programs will require sustained domestic and donor assistance, in the form of favorable political and policy support and fund- ing.