Elements of Family Planning Success
Interview with Jeff Spieler
Interview conducted on June 18, 2008 by Heather Sanders
Heather Sanders: Can you describe briefly to us your areas of expertise and background, and tell us how you got from zoology to where you are currently?
Jeff Spieler: In terms of my background, when I graduated college at the University of Florida as a zoology major, I wanted to go to graduate school. It was the height of the Vietnam War and I would have been drafted, there was no deferment. I was interested in research and I was told if I went to a pharmaceutical company, I could get a critical skill deferment. So I went to work for Lederle Laboratories in Pearl River, New York and after the first two years there, I moved into a program working on contraceptive development, because I was interested in reproductive biology. I also went to graduate school at night, was very interested in reproduction, particularly process of ovulation and fertility.
In 1972, the WHO began a new program called the Human Reproduction Program. It had just begun and they were looking for critical staff and my background fit perfectly. I moved to Geneva, Switzerland to work for WHO. At that point I got involved in international family planning and research related to developing new methods of contraception and service delivery research in family planning. That is how I moved from zoology to reproduction, to WHO and worked 11 years there, and joined USAID as a biomedical research advisor.
HS: How has reproductive health and family planning changed over the past 20 years?
JS: You probably have to go back further than 20 years. When I joined WHO in 1972, family planning was not a word that could be used in world health assembly. There were still questions about family planning, and we talked about fertility regulation and contraception, and helping couples make choices about the number of children they wanted to have. We were not allowed to talk about family planning. It was only towards the mid to late 70’s that we stopped talking about reproduction and started talking about family planning and contraception.
What happened over time was that as family planning became more popular and countries were adopting policies related to FP, we came across 1994 with the Cairo Population Development Conference, that recasts family planning as part of reproductive health and while there were many very positive things about that conference, it somewhat neutralized—or diminished—the importance of family planning, and for many unintended pregnancies, raised other important issues. We started to see less discussion about FP per se, and then the HIV/AIDS epidemic came, and that (with PEPFAR program’s billions of dollars) almost in some countries put family planning off the map. We then needed to create a program on revitalization, a reinvigoration of family planning and getting it back on the map. The amount of AIDS money was dwarfing any amount of money into family planning; HIV money was not allowed to be used for FP, and is still not allowed to be used for FP. We really needed to reinvigorate, revitalize, family planning in many countries.
During that same period of time, there have been huge changes in the use of contraception, in total fertility rate, and we have all kinds of figures showing the difference between the 70’s and the 90’s. On average 60% of couples practice family planning—of course those kinds of figures don’t represent everybody (they’re averages). India’s a very good example: North India has 40% of the population, a very high TFR and low contraceptive prevalence, except for sterilization. We lose some of that [with averages].
There have been huge changes in FP and we still have a huge unfinished agenda. We still have countries, our international organizations, have been working in for 20 or 30 years and have single digit contraceptive rates and huge unmet need.
HS: Can you talk about what you and other organizations are doing to revitalize and reinvigorate family planning?
JS: To revitalize family planning, we’ve developed a strategy at AID. We’ve picked specific countries that we want to work in and we have to gotten back to the bread and butter: programs, policy changes, governments to be supportive of family planning, best practices into those countries, ensuring a wide range of services both clinical and community-level, ensuring a supplies of contraceptives, lots of training, capacity building, standard things to develop a successful family planning program and putting extra money into those programs, trying to get all partners to work together in those programs.
HS: You were talking about Cairo Summit, what were some of the lessons learned back when you were working at WHO and you weren’t able to talk about family planning, and then were able to put it on the agenda. How can those lessons learned be used now, when we’re trying to reposition family planning?
JS: In terms of lessons learned from the past, one of the biggest is trying to make sure that what we have learned works in one place that is generalizable to other places, we export to other countries. Community-based services, task-shifting (you don’t need physicians to provide all methods—you can have lower level health workers provide trained to provide services and counseling and put together the whole package of FP services that will expand the use of methods) If physicians had to do everything is a country that doesn’t have many physicians, you would be doing nothing. We’ve learned a lot of lessons in family planning
….[feedback]
Frequently you need to do demonstration projects because many countries say “Just because it worked there doesn’t mean it will work here. Show us that it will work here.” It’s a shame when you need to do as many demonstration projects to show that women in one country behave similar to women in other countries. Policy work is desperately need adoptive and supportive policies at the government and management level.
HS: Who would be working …[feedback]…managers advocating?
JS: Well the standard way AID has operated, we have these cooperating agencies. It’s our job is to figure out what is needed, to develop projects that then compete—large programs like the Health Policy Project that the Futures Group has had for many years—and they work in the policy region. We have projects that do training, technical assistance for services, research, and communication. We try to put together the kinds of packages and expertise that can provide global and technical leadership, that can do innovation, that can provide technical assistance to country programs in areas such as leadership, training, policy change.
One of our technical priorities now includes community based services. In that context, one of the most important things were doing is to show that Depo Provera can be provided at the community-level. You can train community health workers to safely give a Depo injection and they do marvelously. We’ve done some research around this and we’ve also done some demonstration projects. But, in some countries, there’s a policy that says that only nurses or doctors can give intramuscular injections. So we need a policy project to advocate and to demonstrate that most skilled and unskilled health workers can be taught to safely do an intramuscular injection. We’ve got many examples and we’re trying to explain that widely, because that’s one of the only ways women in a community will have access to a very popular method. Sometimes it requires policy change to get non-physicians, non-nurses to be permitted to give am intramuscular injection.
HS: Can you talk about some innovations in FP that you and your colleagues and excited about?
JS: There are several of them. We’ve got a list of best practices that we would like to see incorporated into clinic and community-based services. We’re working on some improvements in technology that we would like to see. The best practices, for instance, which is not so new any longer, is the pregnancy checklist.
John Stanback at FHI discovered that many women are denied a family planning method when they go to a clinic because they are not menstruating. The provider is fearful that they might be pregnant. So the provider says, “Come back when you’re menstruating and then we’ll insert and IUD, give you the pill or give you an injectable.” That is a major constraint of provision of services, because frequently if that women leaves with out a method, you may never see her again or you will see her when she’s pregnant. So John developed a short checklist, called the Pregnancy Checklist, to exclude the likelihood that a client visits a clinic and is pregnant. It’s extremely effective at screening out pregnant women. If you’re not menstruating and you haven’t had sex yet during this cycle, there’s no risk of being pregnant—so you could provide a method immediately. So after developing a checklist, pre-testing the checklist, they did a study in Kenya. It was the most effective single intervention I have ever seen. 30% more women went home with a method after the visit to the clinic with the pregnancy checklist, than before the checklist. So a little innovation, and a huge impact on increasing take-home of a method from one visit to a clinic.
Community-based Depo is another innovation that has huge impact. In the area of implants—very popular method. Many countries I visited in Africa last year said, “we need more implants. We’re not interested in IUDs” (for many reasons, as an aside, that are not valid). But they are not interested in IUDs but they want implants. In places I visited said “The Ministry of Health has sent us 25 implants and we inserted them all on the first day and we’re waiting for more implants.” Implants are relatively expensive. Jadelle lasts for 5 years, Implanon lasts for 3 years (actually more than 5 years, but that’s what it’s labeled for 3). One of the constraints is cost. With the Gates grant, FHI has been studying Sinoplant. This is a product very much like Jadelle, produced in China, FHI is doing diligence in the manufacturing to ensure its safety, quality and that it could pass an FDA audit should there be one. They are now working on (with funding from Gates Foundation) the possibility of having an implant that would last 5 years and costs maybe $5 or $7. That kind of innovation will hugely expand the use of implants. Implants is a marvelous technology. It’s a long acting method, it’s great for birth spacing and it’s great for limiting and it works despite the woman’s behavior.
HS: How do you see ITC changing the face of family planning?
JS: ITC—information, technology and communication. I am not an expert in communication technology, but I follow it a little bit. Shockingly, every developing country I go to, I see more cell phones on the street than in the U.S. I first saw that in South Africa, 1999 or 2000, and I couldn’t believe it. I understand that text messaging is the way young people communicate—they don’t even call each other—it’s text messaging. So I think new technology could have a huge impact.
Can you imagine getting a text message that says, “It’s time for your next injection. Three months have passed, you have two weeks to a month to come back for another injection if you want to ensure protection against unintended pregnancy.” That alone would be a marvelous contribution to getting clients to come back to programs. Innovations in technology and communication could really change the way services are provided, reminders on follow-up visits. Women who have implants, they have to have a system that the service provider knows when the implant was put in and then woman needs to know when 5 years are up. Just think about what you did 4 years ago, can you remember what you need to do next year? Can you imagine if there was a system that automatically reminded somebody, “Your fifth year will be up in 6 months. You need to come back for another implant or another method.”
I think information technology can really change the way services are provided and I was very skeptical that that would have developing country applications, and I’m not skeptical anymore. We still have a long way to go in the digital divide, computer access, but cell phone technology is so cheap and so easy, and it’s going to only get better.
HS: How is USAID’s role in family planning unique?
JS: USAID is unique amongst most (not all) of the bilateral donors because USAID is a development assistance agency, and we have the expert technical staff in every area that we work in, who provide technical assistance, design projects and help make critical decisions about investments. We’re not a bank; we just don’t transfer money to a government to fund whatever they wish to fund. We actually provide technical assistance and we have a large staff with a cadre of collaborating agencies that are an extension of our staff, who are out in the field, providing technical assistance. We have missions in most of the countries that we work in, with technical staff in the missions. We’re truly a technical assistance agency. And most of the people that work at USAID-Washington, who are managing these projects, are also qualified to be the doers. They could be in a cooperating agency doing the work. We understand what the work is, and hence we can be better stewards of the public money, and making investments, and working with our partners to make sure that our partners are doing what really needs to be done.
HS: What makes a FP program successful?
JS: As you know, the INFO project was involved in a community of practice, trying to determine the successful elements of family planning programs. It went on for a week or two, I think there were 700 participants from a lot of countries, raising questions about what makes for a successful FP program. Shortly, there will be a Population Report on the 10 most important elements of successful FP program.
There’s more than 10. My list included 15. Of my 15, all of them could be found with the 10 that were the most popular reasons. I can go over some of those with you, maybe I would tell you what my top 15 from the survey. In the big survey, budget and money wasn’t one of the top ten. However, people developing the Population Report know that budget is an important factor, and it will be part of each of the elements.
Some of those elements, besides funding, there is a conducive policy environment; we talked about strong advocacy, advocacy for limiting and spacing methods; good demand-generation, good behavior change communication programs. One thing that makes for an excellent family planning program is a champion. The ProFamilia of Colombia had a guy named Miguel Triaz, who was a dynamic world-leader who had fire in his belly and he made ProFamilia what it is; having a broad range of methods available in the program, so you’re not just dealing with one or two; ensuring a constant supply. There’s actually nothing worse than a stock out of oral contraceptives. A woman comes for oral contraceptives, and there are no pills there—what is she going to do? A good logistics system; good commodity-security. How are we going to ensure that the methods are in country and find their way into programs that are serving clients; health systems strengthening. Family planning is not usually a vertical program and the same person that is providing family planning is probably also providing child immunization or maternal care. You need a strong health system; the stronger the health system, the more likelihood the worker will be working in an atmosphere with good supervision and management. Use of job aides to help providers ensure that they’re doing a good job in presenting methods that are available to those women who aren’t sure of what they want.
For me, providers giving women the methods that they request, not giving them methods that they don’t request. A wonderful study was done in Indonesia that showed that when women get the method that they ask for, the continuation rate is superior to when they get a method that they didn’t ask for—much higher discontinuation rates for those methods. Having good service delivery guidelines, having good training, having supervision in programs, having the funding needed to ensure that workers are paid and the electricity’s on and the contraceptive supplies are available. Good INC materials. We still have a lot of demand-generation that is needed; there’s still an issue of generating demand. There’s some good information about the importance of family planning that helps a program work. And then there’s the issue of good ethical approaches, non-coercion, informed choice, the principles of good ethical practices.
I look forward to the Population Report that will really build on the 10 and discuss the others. I think it’s an important document.
HS: How can family planning mangers promote their agendas to policy makers? Maybe on a lower level?
…[feedback]…
JS: Within country, it’s not just the managers, there has to be an advocacy within-country. If the Ministry of Health doesn’t have supportive policies—it has policies that are interfering with good delivery of services—program managers and the community needs to work to advocate for more funding for family planning, for changing policies that will enable FP managers to run their programs correctly. Managers need to have budget, frequently there’s not enough funding for it, particularly in the era of swaps or basket-approaches, where countries have said to donors, “Put money in the basket and we will direct those monies to where the need is the greatest.” In that kind of environment, how much of the money comes out of the basket to support family planning versus other things? It’s a big question. FP managers need to make sure that from the money that’s going into the basket, there is money coming out to support the FP programs.
In the area of reproductive health, some of that support needs to be meeting other needs of FP clients, whether it be testing for HIV or treating of STIs, supporting breastfeeding, promoting breastfeeding. There are a lot of other things that FP managers need to do, and if money’s tight, they won’t do it all. I think managers need to be advocating for more support.
Some people ask, “How do I get AID support? We don’t get any AID support.” My response is always, “Go to your Ministry of Health. Engage your Ministry of Health to ask for assistance.” If your Ministry of Health asks for assistance related to family planning, it will find its way to the Population Health Nutrition Officer, maybe to the Mission Director, back to Washington. But without asking for help for family planning, you’re not going to get it from AID. You’re not going to get it from UNFPA. UNFPA only responds to country requests—individuals do not write to UNFPA—countries tell UNFPA what it wants. People within countries have to advocate within the UNFPA advisor in a country to advocate back to New York for support.
HS: What do you see today as the biggest challenges facing FP and what is AID doing to address that?
JS: One of the biggest challenges is again reinvigorating, reinventing family planning in many countries where there are still single digit contraceptive prevalence, high TFR, reliance on only one method, no community or very limited community services, or countries that only have maybe 10 to 12%. There is so much low hanging fruit that if you just provide services in a quality fashion, there’s so much unmet need that would be met by getting services out there and making services available (even if you only have two or three methods). But certainly, expanding the method mix will increase the use of services.
What we’re doing is we’ve identified priority countries, we’re putting focus on those 13 high propriety countries and then within that, we have a range of other tier-1 countries. So we focus more on specific countries. We’re going to try to focus on meeting some of the unmet need, on contraceptive security, on making sure that people understand the rationale behind healthy timing and spacing of pregnancy. Most providers know there are good reasons why women should practice birth spacing, but many times they don’t know the data. One of our technical priorities is tools and approaches to healthy timing and spacing of pregnancy. Making sure that programs understand that birth spacing saves mother’s lives and saves children’s lives. Expanding the use of long-acting and permanent methods where appropriate. The integration with maternal health. A wonderful example is the universal immunization programs were trying to meet the MDGs, and have all immunizations in all kids, and who bring the kids to the programs? One approach that we want to push is when a mom brings a child to an immunization program, we ask the mom what her needs are too: “Do you intend to have another pregnancy? When? Are you using a method? Let’s help you choose a method.” Let’s not deal with only the child, let’s deal with the mom’s needs also.
Integration with HIV/AIDS; how do we ensure that women who are coming to HIV/AIDS counseling and testing programs, somebody is saying something to them about preventing unintended pregnancy. There’s a big question in the reauthorization of PEPFAR, there can be any counseling or provision of family planning (it’s unlikely). But, that doesn’t mean there can’t be referral systems and using other funding to ensure that unintended pregnancy is prevented among HIV negative women and HIV positive women. Another extremely important lesson learned is that preventing unintended pregnancy in an HIV positive woman is the single most important and critical way of preventing mother-to-child transmission of HIV. Nevirapine for mom and baby works great, but preventing the unintended pregnancy is a much more cost effective approach. Surprisingly, there’s a ton of work that needs to be done for HIV+ women to ensure that they have universal access to counseling and provision of contraception, to prevent unintended pregnancy. You will NOT have maternal-to-child transmission if the woman does not get pregnant.
HS: You mentioned technical priorities before, can you talk a little bit about what those technical priorities are?
JS: Sure. In terms of technical priorities, the Office of Population and Reproductive Health went through a visioning exercise about a year ago. Part of that visioning exercise, we asked ourselves a few questions. One of those questions was: what ought to be our priority countries? The Director of Office of Population, Scott Radloff, led a working group on picking the priority countries. The next thing we asked was: should we choose some technical priorities to focus on? And I was asked to chair the working group on technical priorities. And then we asked the question on policies and procedures, and the way we do business, and Ellen Starbird, the Deputy Director, is leading a group on that work.
For the technical priorities, we had many discussions about what were our priorities. For many years we had Global Leadership Priorities (special things that we wanted to work on): youth, gender, post-abortion care, are examples. We needed some higher priorities. We recognized that there were 6 priorities that we wanted to ensure were in programs. I need to make it clear that these are not the only things we work on, because these technical priorities fit within what I call the “bread and butter family planning”, what makes for a successful FP program. All the elements of a good program would have these technical priorities but we wanted to make sure that there would be a special focus on certain things in our program.
Those technical priorities include (not in order of priority): healthy timing and spacing of pregnancy and ensuring that services understand the rational of spacing and that we provide the tools and models to promote birth spacing; community based family planning services, Depo at the community level, if you don’t have communities providing methods sometimes people will not get methods; contraceptive security, if you can’t ensure products and supplies and good logistic systems are in country than you’re not going to ensure access (whether public or private); FP/HIV integration is a huge integration; FP and maternal/newborn/child health integration is a priority; and then; long-acting and permanent methods. The permanent methods are for limiters, the long-acting methods are for limiters and spacers. It’s very surprising when you look at some countries and you look at unmet need for limiting and spacing, and then you look at what people are using or look at met-need and look at what people are using. Too many limiters only have access to temporary methods. Our LAPM is to ensure that, particularly where women want to practice birth spacing, women have access to long-acting methods, 3 to 5 years is ideal. With limiting, a long-acting method or a permanent method works.
HS: What would you say to those who you were trying to convince, what would you say would be the rationale for supporting family planning?
JS: How would I convince my president or my minister of health that there’s a good rationale for family planning? The Director of Population and Reproductive Health has a performer statement which is critical. Family Planning is a solution to many problems. And we fund solutions to problems. Issue One: family planning enables couples to have the number of children they want and to space their children. Family planning reduces child mortality. Family planning reduces maternal mortality and morbidity. Family planning reduces abortion. The only way to reduce abortion is to reduce unwanted pregnancy and there is excellent data from eastern Europe—a beautiful regression—as contraceptive prevalence increases, abortion rate decreases. Family planning improves women’s opportunities, by not having pregnancy after pregnancy and spacing your pregnancies, there’s an opportunity for education and economic development.
In HIV epidemic…[feedback]…to prevent maternal to child transmission, first prevent an unintended pregnancy. Secondly, there’s actually some good data (although there is other data that contradicts this), but when the jury is out on this issue for the most part, unintended pregnancy is a risk factor for the acquisition of HIV/AIDS. Ron Gray and Maria Wawer in Rakai [Uganda] show that those women who became pregnant had a two-fold higher increase in HIV than those who were not pregnant. Somehow, being pregnant predisposes a woman to the acquisition of HIV. It doesn’t cause HIV but it makes her more vulnerable to infection.
Family planning is an essential part to all programs. I mentioned maternal and child health, it’s just part of a health program. And finally, family planning mitigates a lot of issues associated with population dynamics—needs for natural resources, increases economic growth, state stability. There’s lots of great rationale for why family planning is important in the whole spectrum of development.
