Factors Affecting Contraceptive Use in Sub-Saharan Africa (1993) / Chapter Skim
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5 Family Planning Programs and Policies
5 Family Planning Programs and Policies
Pages 128-169
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From page 128... ...
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 examine 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.
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From page 129... ...
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.
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From page 130... ...
As of 1991, only three had carried through on this commitment 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.
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From page 131... ...
However, the overall score for family planning programs in Africa still lagged well behind that in Latin America or Asia. Mauldin and Ross concluded that of 38 African countries, one (Botswana)
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From page 132... ...
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.
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From page 133... ...
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 comparable to those of well-managed programs in anglophone countries (Direction 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, generally 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 countries.
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From page 134... ...
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.
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From page 135... ...
In countries with centralized government control over service delivery, such as the francophone countries, the lack of such policies has contributed 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.
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From page 136... ...
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 Africa, the pioneers have generally been small operations research programs, or other discrete entities outside the main health service delivery system.
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From page 137... ...
(The early stages of family planning service delivery in Africa have thus occurred over a 30year 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)
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From page 138... ...
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 reluctance 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.
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From page 139... ...
Although the government infrastructure may be weak, it remains the only means of providing truly national coverage in most settings. The primary and valuable role of the nongovernmental sector at the third stage of program development appears to consist in the testing of innovative service delivery strategies that are then adopted by and adapted to the public sector.
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From page 140... ...
PROGRAM DEVELOPMENT IN SELECTED COUNTRIES This section reviews the development or lack thereof of family planning activities in a number of countries with different policy and program commitments. Countries with Programs Demonstrating the Most Success to Date Kenya Among the earliest organized family planning services in Africa were those provided by the Family Planning Associations of Nairobi and Mombasa, starting in 1955.
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From page 141... ...
A World Bank review concluded that in its first four years, the national maternal and child health/family planning program had made satisfactory progress in reaching operational targets, particularly in establishing about 300 service delivery points (World Bank, 1980~. Initially, however, the family planning component met with limited success.
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From page 142... ...
Botswana and Zimbabwe Botswana and Zimbabwe, the other continental African countries that have achieved substantial rates of contraceptive use, have experienced longterm and strong government involvement in family planning service delivery. Botswana implemented a small maternal and child health and family planning project in 1967, in conjunction with the IPPF affiliate (Botswana, 1989~.
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From page 143... ...
Zimbabwe has achieved a CPR of 36 percent for modern methods (see Chapter 2~. Prior to independence, the government had not established an official population policy, but encouraged the development of family planning services.
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From page 144... ...
By 1977, contraceptive prevalence had risen to 18 percent in the most successful project area that received comprehensive health and family planning services. (Prevalence in the control area was 5 percent and only 2 percent in the area receiving family planning services without health services.)
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From page 145... ...
Family planning was offered in 135 clinics throughout the country; more than half were MOH facilities. In that year, the GNFPP also extended its commercial distribution program by allowing nonprescription contraceptive sales through nongovernmental commercial outlets; prior to that, all social marketing had been conducted through the parastatal Ghana National Trading Company, which supplied more than 600 outlets (McNamara et al., 1990~.
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From page 146... ...
Since 1985, there have been signs of renewed public sector commitment to family planning programs. A short-term primary health care plan for 1986 gave priority to MCH and family planning, and signaled a turnaround made possible by improvements in the national economic situation.
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From page 147... ...
The project consisted of hospital-based family planning service delivery and full-time community motivators. Within four years, contraceptive prevalence in the target population rose from 1 to 24 percent.
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From page 148... ...
, a finding thought in part to reflect the greater emphasis placed on health service delivery to the detriment of the family planning component. However, the project met with political approval, illustrated the feasibility of integrating family planning with basic health care in a community-based distribution strategy in rural Nigeria, and showed that government personnel could sustain and expand the project after the involvement of the University College Hospital had ended.
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From page 149... ...
Countries with Consistently Weak Support for National Family Planning Programs Sudan In the Sudan, lack of government interest in population issues is now coupled with civil and economic disturbance to create a situation in which 1
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From page 150... ...
The MCH infrastructure through which contraceptives are to be delivered is itself very limited in the coverage it provides (McNamara et al., 1990~. A 1985 UNFPA needs assessment mission noted the lack of an institutional base for MCH, administrative difficulties, the absence of guidelines for service delivery, and economic hardship as reasons that family planning delivery has not progressed (United Nations Population Fund, 19911.
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From page 151... ...
Countries Where Rapid Progress in Family Planning May Occur Rwanda Until fairly recently, Rwanda exemplified countries with slow development of family planning programs. However, increased political will to address population issues is resulting in progress.
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From page 152... ...
Despite these cultural, religious, and programmatic constraints, Rwandan pilot projects have demonstrated that a sizable proportion of the population may be ready to accept family planning services. The Ruhengeri operations research project introduced community education and distribution of contraceptives by volunteers belonging to the network of the Centers for Development and Continuing Education of the Ministry of the Interior and Community Development.
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From page 153... ...
The greatest current challenge may be ensuring adequate coverage in this Sahelian country facing economic hardships. MAJOR DONORS FOR POPULATION ACTIVITIES Estimates of the proportion of population related expenditures covered by developing country governments range from 60 to 75 percent, with donor agencies contributing between 15 and 20 percent, and the remainder of expenditures covered by individuals (Population Crisis Committee, 1990; United Nations Population Fund, 1991~.
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From page 154... ...
In addition there are several other countries in Africa, such as iOIPPF is the largest nongovernmental agency providing family planning services and educational programs to increase public and government awareness of population programs (Johns Hopkins University Population Information Program, 1983)
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From page 155... ...
IPPF has played a major role in encouraging service delivery through its support of community-based distribution and other innovative service delivery strategies. Like IPPF, the Population Council was founded in 1952 with a mission to promote knowledge and action leading to fertility reduction (Suitters, 1973~.
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From page 156... ...
UNFPA spent more than $900 million on population funding from its creation in 1969 through 1982. Most of UNFPA's support goes toward family planning programs.
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From page 157... ...
. USAID seeks to assist developing countries that favor population reduction and have an existing infrastructure in which family planning programs can be developed.
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From page 158... ...
. Such study results suggest that there are subgroups of women for whom the prevention of unwanted pregnancy is 18Estimates are based on current contraceptive prevalence and on country-specific projections of users corresponding to the United Nations high population growth scenario.
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From page 159... ...
In Ruhengeri, the most effective approach was intensive IEC and referral to clinics; in the Sudan and BasZaire, door-to-door distribution proved feasible and effective; market-based distribution is showing itself to be a useful option in several sites in Nigeria. Both integrated and vertical service delivery programs have improved family planning utilization; equally, both strategies have at times had minimal effects (Taylor, 1979; United Nations Population Fund, 1979; Trias, 1980~.
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From page 160... ...
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~.
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From page 161... ...
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 enthusiasm)
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From page 162... ...
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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From page 163... ...
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.
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From page 164... ...
USAID projections 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 planning services; indeed, acceptance of modestly priced contraceptives has at times been higher than that of free commodities in the same setting (Lewis, 1985~.
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From page 165... ...
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)
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From page 166... ...
, 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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From page 167... ...
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 marketing programs. However, they do suggest that commercial approaches are likely to become widespread much more gradually in the sub-Saharan region 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.
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From page 168... ...
on family planning programs in the next decade. Unfortunately, little data is available and what can be said about the impact of AIDS is more speculation than fact.
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From page 169... ...
Information regarding successful programs is being disseminated to other regions, through exchanges, conferences, 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)
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