Elements of Family Planning Success

Several readers have pointed out that the BMJ's recent coverage of climate change has ignored a key issue-the need for population control. John Guillebaud and Pip Hayes give the same rebuke in their editorial this week. They may be right that "population" and "family planning" are taboo words. The BMJ hasn't actively avoided these issues, but we could do more to highlight them. As Guillebaud and Hayes portray it, every week an extra 1.5 million people need food and somewhere to live, amounting to "a huge new city each week, somewhere, which destroys wildlife habitats and augments world fossil fuel consumption." Population control need not be coercive, they say. Half of pregnancies worldwide are unplanned. Simply by meeting women's unmet contraceptive needs, several developing countries have halved their fertility rates. Clear evidence points to the demand for contraception increasing when it is available, accessible, and properly marketed. Guillebaud and Hayes call on doctors to take an active role in overcoming barriers to the universal availability of contraception and ensuring that patients and the public understand the environmental consequences of population growth. Controversially, as evidenced by the responses to the editorial since it was published online on 24 July, they say that doctors should advise patients on limiting family size for environmental reasons and should set their own example. Not everyone will agree that this is a doctor's role. Most will agree, however, that it is the role of doctors to deal with uncertainty. (excerpt)

Mali, a large, landlocked country in western sub-Saharan Africa, has high fertility and low contraceptive use. Only 8% of married women use any method of contraception, with 6% using modern methods. Its approximately 13 million people are mainly Muslim (90%), and 80% live in rural areas with limited access to family planning services. The total fertility rate was seven children per woman in 2006, compared to an average of five in Africa. The government of Mali (GOM) actively promotes family planning and contraceptive security as part of improving quality of life. Unlike other countries in the AWARENESS Project, the GOM committed to national integration of the Standard Days Method® (SDM) without undertaking a pilot study. A relative newcomer to the AWARENESS Project, Mali began implementing project activities in 2006, utilizing the SDM and LAM as an approach to repositioning family planning. (excerpt)

This brief summarizes publicly available data on the amount of Global Fund financing that has been made available for the procurement of condoms in recent years, and outlines opportunities to strengthen reproductive health commodity security through the use of Global Fund financing.

In 2003, the USAID Mission and the National Reproductive Health Program (PNSR) invited IRH to introduce the SDM in the Democratic Republic of Congo (DRC). The strategy focused on training providers and integrating the SDM into existing clinic, community, and pharmacy services in Kinshasa, Lubumbashi, and Bukavu, and the rural area of Katako Kombe. By 2004, 14 organizations were able to offer the SDM. CycleBeads are included in the national list of essential medicines and the five-year contraceptive security plan. The SDM is part of in-service family planning training curricula. The PNSR is developing national norms and protocols and intends to include the SDM. IRH also worked with the MOH to incorporate the SDM into national policies and logistics and reporting systems. However, the lack of overall government norms and functioning distribution and reporting systems is an obstacle requiring more comprehensive attention than the AWARENESS Project could offer. The program leveraged significant resources, as most partners paid for their own training programs and CycleBeads. The Congolese program participated in a study to determine the impact of the social marketing campaign, a general evaluation of SDM integration in the DRC. Major findings from the simulated client study showed that 89% of clinic providers gave spontaneous information on the SDM as opposed to only 38% of pharmacists; confidentiality was observed in over 70% of both clinics and pharmacies; 96% of providers in clinics told clients that CycleBeads represent a woman?s cycle while only 35% of pharmacists did so; and 7% of clinic providers attempted to convince clients to use other methods of family planning as opposed to 23% of pharmacists. The success of recent initiatives in DRC to introduce the TDM through services of an faith-based organization (FBO) suggest that this method may also be an appropriate addition to family planning services. (excerpt)

The use of contraception varies widely around the world, both in terms of total use and the types of methods used. In many countries, women and couples rely largely on one or two contraceptive methods, because of government policies, the way that national family planning programs have evolved, and cultural or social preferences (see box below). Understanding why people prefer some contraceptive methods over others can be useful for strengthening family planning programs. Having a broad range of methods available is a key element of the quality of family planning services and raises the overall level of contraceptive use. Family planning programs ideally should offer choices of methods for all stages of people's reproductive lives, so that they can have the number of children they want, when they want them. (excerpt)

The use of contraception varies widely around the world, both in terms of total use and the types of methods used. In many countries, women and couples rely largely on one or two contraceptive methods, because of government policies, the way that national family planning programs have evolved, and cultural or social preferences (see box below). Understanding why people prefer some contraceptive methods over others can be useful for strengthening family planning programs. Having a broad range of methods available is a key element of the quality of family planning services and raises the overall level of contraceptive use. Family planning programs ideally should offer choices of methods for all stages of people's reproductive lives, so that they can have the number of children they want, when they want them.

Contraceptive security is a guarantee that all people have continuous access to the quality products they need for family planning and prevention of sexually transmitted infections. It is not only dependent on sufficient funding for procuring commodities, but also on designing and conducting effective service delivery programs, on rationalizing the role of the public and private sectors, and on the use of up-to-date methods for efficiently managing supply logistics. In June 2002, the Bangladesh Ministry of Health and Family Welfare hosted a symposium for government representatives, healthcare providers, and international experts to discuss how national policy can be developed to attain contraceptive security. The event was jointly organized by the Ministry and DELIVER, a project that works to strengthen the supply chains for health and family planning programs in developing countries. DELIVER is funded by the United States Agency for International Development (USAID) and managed by John Snow, Inc.(excerpt)

Contraceptive security is a guarantee that all people have continuous access to the quality products they need for family planning and prevention of sexually transmitted infections. It is not only dependent on sufficient funding for procuring commodities, but also on designing and conducting effective service delivery programs, on rationalizing the role of the public and private sectors, and on the use of up-to-date methods for efficiently managing supply logistics. In May 2002, the Ghana Ministry of Health hosted a two-day symposium for government representatives to discuss contraceptive security strategies with international donors, partner institutions, and non-governmental organizations. The event, called "Meeting the Commodity Challenge," was organized by DELIVER, a project that works to strengthen the supply chains for health and family planning programs in developing countries. DELIVER is funded by the United States Agency for International Development (USAID) and managed by John Snow, Inc.(excerpt)

Driven by the increasing demand for and popularity of family planning, increasing population size, and changing demographics with more couples entering their fertile years, the financing requirement for contraceptives has become increasingly onerous. Strategies to finance contraceptives include expansion of the donor base; increased use of cost recovery, including revolving drug funds; greater use of the private sector; and direct government financing of contraceptive procurement. None of these is mutually exclusive, and to ensure contraceptive security, most countries are likely to use some or all of these approaches, and many others. Evidence suggests that many governments are beginning to finance contraceptive procurement using national resources, but limited data are publicly available regarding the global extent of this financing. This brief details the findings of a survey of the extent to which national governments of developing countries are using national resources to finance contraceptive procurement. The brief examines the different types of financing used, some of the benefits of this type of financing, and some of the issues it raises. Hopefully, this study can be repeated to track spending and will spur more rigorous efforts to measure this practice. (excerpt)

West Africa has one of the most rapidly growing populations in the world, and on average, women here have 5.7 births during their lifetimes. The 16 countries in this region represent a variety of cultural and historic backgrounds. Their residents may speak French, English, or Portuguese, in addition to one or more indigenous languages. These countries have different health systems, levels of political commitment to family planning, and numbers and types of health care providers-all of which can contribute to differences in family planning use. In West Africa, approximately 13 percent of married women use some form of family planning. Hormonal contraceptives, including the pill and injections, are the most commonly used methods. Traditional family planning methods, including periodic abstinence and withdrawal, are in second place. In addition to those women using family planning, approximately 23 percent indicate that they would like to avoid become pregnant in the near future, but are not using a family planning method. In West Africa, the wealthier a woman is, the more likely she is to use family planning. These findings, which were presented in the first article in this series, "Family Planning in West Africa," provide insight into the region as a whole. Ghana, Burkina Faso, and Mali illustrate the richness that can be found when regional numbers are teased apart. Tables included: 1) Percent of married women who use family planning by method; 2) Total demand for family planning; and 3) Contraceptive use by wealth group. (excerpt)

The heart of LAPM service delivery is the encounter between client and provider. The fundamentals of care are the bedrock of quality LAPM service programs. LAPM service programs need to be holistic, integrating 'supply side' and 'demand side' program elements. Evidence-based advocacy for political support at all levels is important to sustain LAPM service programs. Stakeholder participation is critical to fostering ownership and sustainability. Use locally generated, context-specific data and other evidence to inform policy and program decisions. Apply principles and best practices of behavior change theory to achieve sustained LAPM program improvement. LAPM training and supervision need to be maintained and updated. Security of LAPM commodities, equipment and supplies is critical for reliable service availability. LAPMs must be accessible to be used. (excerpt)

El Salvador has already reached several important milestones in its efforts to achieve contraceptive security-the guarantee that all people who wish to use contraceptives can choose, obtain, and use them at all times. With support from the United States Agency for International Development (USAID), the Salvadoran Ministry of Health (MOH) has recently worked to expand people's access to contraceptives, particularly through community-based distribution. It has also helped to improve product management in health facilities by training service providers and by implementing a contraceptive logistics management information system. El Salvador's next challenge on the pathway to contraceptive security is to become financially self-sufficient in procuring reproductive health commodities. USAID is progressively phasing out its contraceptive donations to the country, and is providing technical assistance to guarantee that the MOH will be able to accurately forecast contraceptive demand and manage its own budget for meeting that demand. (author's)

The 2003 Rural NGO Service Delivery Program (NSDP) Evaluation Survey in Bangladesh provides data to evaluate the rural component of the NSDP, a four-year health and population project funded by the U.S. Agency for International Development (USAID). It provides information on the use of Essential Service Package (ESP) components for 7,507 women in NSDP project areas and 4,372 women in non-NSDP areas, including utilization of services at the NSDP network of facilities (static and satellite clinics, and depotholders) and alternative providers, knowledge of health promotion behaviors, awareness of NSDP services, and the quality of treatment at NSDP clinics. The survey, part of a continuing evaluation that began with a baseline survey in 1998 followed by a mid-project evaluation survey in 2001, was conducted by Associates for Community and Population Research (ACPR), a Dhaka-based research firm, with technical assistance from the MEASURE Evaluation project at the University of North Carolina at Chapel Hill. To assess changes in behaviors and outcomes, an effort was made to utilize the same clusters as the 2001 survey. However, substantial changes in the project catchment population occurred between 2001 and 2003 (including the departure of BRAC and expansion into new areas), complicating straightforward comparison of indicators across the two surveys. Accordingly, a separate chapter focuses on a sample of common clusters (ie those appearing in the 2001 and 2003 samples). (excerpt)

A workshop on contraceptive security was held in Malaysia from September 28 to October 1, 2003. This interactive CD contains various materials and document related to the workshop and the topic of assuring that adequate supplies of contraceptives are available to developing countries in Asia. Included is "Media Advocacy for Contraceptive Security : Key Findings and Recommendations from an Asia Regional Workshop", photographs and contact information of the workshop attendees, presentations from the workshop, and a video entitled. "Contraceptive Security in Bangladesh".

This report is the outcome of a request by USAID's E&E Bureau to the Private Sector Partnerships-One (PSP-One) project to conduct a desk review of the body of knowledge regarding private sector contribution to RH/FP in the region. This document is designed to inform USAID Missions and bilateral RH/FP programs in the E&E region about the private sector's current activities, as well as opportunities for further leveraging this sector in meeting RH/FP goals. The paper includes the following sections: a methodology to analyze the "total" RH/FP market - that is, both the public and private sectors - in assessing demand for and access to FP services and products; an overview of opportunities and constraints to the private sector in the legal, regulatory, and policy environment in the E&E region; a description of current practices in the E&E region that foster a greater private sector role in the provision of FP services and products; recommendations for leveraging and maximizing private sector contribution to RH/FP goals in three defined country contexts. This report compiles and analyzes information collected during assessment visits to six countries of the E&E region in 2005-2006. The assessment analyzed the private sector market in those countries and looked at contraceptive security issues for FP. Assessment findings were supplemented with a literature review of project reports from existing USAID bilateral projects implementing FP and other health-related programs. Countries studied were Albania, Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Romania, Russia, Tajikistan, Ukraine, and Uzbekistan. These countries are considerably diverse in terms of income, economic and social development, unmet RH/FP need, and market maturity. At the same time, they share characteristics unique to this part of the world, particularly with respect to reproductive behavior, private sector growth, and health sector reforms. (excerpt)

The Contraceptive Security Strategic Plan for Egypt 2006-2010 (CSSP) was developed in consultation among all concerned stakeholders. These include the Ministry of Health and Population (MOHP), National Population Council (NPC), Ministry of Finance (MOF), Ministry of Planning, Ministry of International Cooperation, NGOs, private sector, public and private sector pharmaceutical companies, donor agencies, technical support agencies, representatives from health and population committees in the Shura and People's Assembly, heads of the physician and pharmacy syndicates, research institutes, and USAID cooperating agencies and projects like the Population Council, JSI/DELIVER, Frontiers in Reproductive Health Program, and the TASHEEN/POLICY and CATALYST projects. USAID provided technical assistance through the POLICY Project based in Cairo, Egypt. This plan was developed in response to a series of gaps identified by a Contraceptive Security Working Group and stakeholders. Gaps included financial pressures on public resources; insufficient financing for contraceptives; lack of adequate user fees and the absence of an exemption and waiver policy; limited information for decision-making; lack of appropriate quality control measures in manufacturing; commodity testing, and service delivery; lack of collaborative between sectors and partners working toward contraceptive security; and an overall lack of awareness of contraceptive security issues. (excerpt)

In light of the phaseout of donor funds in Latin America and the Caribbean, Peru will be facing increasing responsibility to finance and procure contraceptive commodities in the near future. The Government of Peru will need to look at regional and international procurement opportunities to ensure contraceptive security is not compromised during this transition period. This report presents findings from a legal and regulatory analysis and pricing study of different procurement options to identify efficient, economical, high quality and timely distribution of contraceptives. A summary of the current country situation, procurement practices, laws, policies and regulations are presented along with a comparison of regional contraceptive prices. Options and recommendations are presented for next steps. (author's)

This study of Brazil has been commissioned by the Commodity Security and Logistics Division of the Global Health Bureau of the United States Agency for International Development (USAID), with Global Leadership Project funding, to identify important lessons learned following USAID's phaseout of Brazil as a recipient of contraceptive donations and other family planning funding. This document reports on the state of contraceptive security in Brazil, more than five years after USAID stopped donating contraceptives to the country. The report is based on interviews with key informants from the public, non-governmental organization and commercial sectors, a review of public policy and published documents, and databases of pricing information. In addition to lessons learned about phaseout, a summary of the current country situation, procurement practices, laws, policies, and regulations is presented. This information will help in the preparation of a procurement strategy for USAID presence countries and help these countries prepare for their eventual phaseout from USAID donations. (author's)

In 2002, Rwanda's Ministry of Health carried out a survey on the performance of the logistics system for contraceptives, with technical support from DELIVER. In 2003 and 2004, routine surveys were undertaken as a follow-up to the program to ensure the availability of contraceptives and to strengthen the contraceptive logistics management system. This 2006 assessment report identifies areas where improvements have since been achieved and suggests remedial recommendations as well as actions to improve the logistics system. Information on the performance of the logistics system, the availability of products, and the availability and quality of logistics data is also presented. The report notes that Rwanda's logistics management system for contraceptives is in place, and that it correctly fulfills expected tasks. Products are available and the system runs smoothly. Critical logistics data are sent to the central level on a regular basis, and the reporting rate has reached 100 percent. Stockouts are marginal. This report illustrates the conditions that contributed to the satisfactory results achieved by the existing contraceptive management system. (author's)

In light of the phaseout of donor funds in Latin America and the Caribbean, Nicaragua will be facing increasing responsibility to finance and procure contraceptive commodities in the near future. The Government of Nicaragua needs to look at regional and international procurement opportunities to ensure that contraceptive security is not compromised during this transition period. This report presents findings from a legal and regulatory analysis and pricing study of various procurement options to identify efficient, economical, and timely distribution of high-quality contraceptives. A summary of the current country situation, procurement practices, laws, policies, and regulations is presented along with a comparison of regional contraceptive prices. Options and recommendations are presented for next steps. (author's)