The 1994 International Conference on Population and Development (ICPD) was a pivotal global event. It shifted the world from one concerned with population growth to one committed to reproductive rights and justice. It placed female empowerment at the center stage of our development goals for the new millennium. It created a platform to help women and men have greater access to both modern contraceptive methods and also affordable, convenient family planning (FP) services [
- Carr B.
- Gates M.F.
- Mitchell A.
- Shah R.
Giving women the power to plan their families.
ICPD also established voluntary FP as a fundamental human right [
- Hardee K.
- Kumar J.
- Newman K.
- Bakamjian L.
- Harris S.
- Rodríguez M.
- et al.
Voluntary, human rights-based family planning: a conceptual framework.
]. This underlying premise enables women and couples to determine the timing and spacing of their pregnancies. With this control over their own fertility desires, women can help improve both their health and career aspirations. During the past two decades, evidence has demonstrated the contributions FP can make to global health and development, including achievement of the Millennium Development Goals (MDGs) [
- Cates Jr., W.
- Abdool-Karim Q.
- El-Sadr W.
- Haffner D.W.
- Kalema-Zikusoka G.
- Rogo K.
- et al.
Global development. Family planning and the Millennium Development Goals.
- Cleland J.
- Conde-Agudelo A.
- Peterson H.
- Ross J.
- Tsui A.
Contraception and health.
Our article describes the progress made and challenges faced in the 20 years since ICPD. We present case studies from 3 African counties to highlight factors affecting the evolution of the FP field.
3.1 Maintaining political will and global funding for FP
Many factors continue to challenge the progress made in FP since ICPD [
- Jacobstein R.
- Bakamjian L.
- Pile J.M.
- Wickstrom J.
Fragile, threatened and still urgently needed: family planning programs in sub-Saharan Africa.
]. These include sustaining the political commitment and community engagement to support the long-term value of FP at the individual and national levels. Political will for FP programs can be fragile. Not only is FP a politically polarizing issue, but some leaders establish their base on pronatalist positions. Continued emphasis on and evidence for the benefits of FP and reproductive choice on economic development will be needed to sustain gains.
At the global level, funding for FP services has stagnated for nearly two decades. Although the US government remained the overall largest contributor to FP programs globally, its funding for FP peaked at $545 million in 1995. The US contribution had remained at that level for nearly 15years and is thus an example of stagnation. Meanwhile, funding from other nations continued to increase. As a result, even with 2012 levels, the US government’s share of the total global health funding for FP dropped from 12% in 1995 to 6% in 2012 [
USAID: family planning guiding principles and U.S. legislative and policy requirements.
At a regional level, in 2001, to accelerate their ability to meet the MDGs, ministers of health from the Africa Union committed to increasing the health share of their national budget to 15% (the Abuja Declaration). Unfortunately, in 2010, WHO found that few countries were on track to meet this goal. More disturbing was the discovery that 19 countries were allocating even less than what they were spending before the Abuja Declaration [
- World Health Organization
The Abuja declaration: ten years on.
]. Since FP services are housed within ministries of health (MoH) and are often of lower health priority, African regional funding for FP has not improved to meet the growing demand for services.
3.2 Assuring access to FP information and services
Most FP information is in written formats (brochures, billboards and pamphlets) requiring that individuals be literate before they can access it. Illiteracy is still high in many developing countries. An estimated 122 million persons aged 15–24 years old are illiterate. The majority (77 million) of these are women. No provisions exist for making this information accessible by the blind. Although some of the messages are in audio form, one requires access to a radio.
An important determinant of FP use is level of education. demographic and health surveys (DHS) data show that nearly 60% of women with secondary education use FP, compared to 40% who do not complete primary education and only 14% of those with no education at all. Therefore, enrolling and keeping girls in school are important ways not only for FP programs to achieve their goals but also for the ICPD to achieve its vision. Global school attendance has seen measureable progress, especially in Africa. Enrollments have increased from 58% to 76%, and completion rates for primary school had reached 70% by 2010. Although not uniform across countries, the gender parity ratio (the ratio of women to men) has also improved from 91 to 97 [
Millennium Development Goals report.
School enrollment alone will not translate into greater access to FP by youth. Young people continue to face obstacles before receiving contraceptive information and services due to policies that require that they obtain parental consent. Only a few countries have developed policies to provide adolescents with comprehensive and reproductive health education — an essential part of ICPD —– as part of school curriculum. Some programs are addressing this challenge by taking advantage of the emerging technology that is becoming widespread and more available to the youth. Creative approaches are using text messaging, Twitter and Facebook to deliver FP messages to young people. Although these programs are in their early stages, they are already showing great promise by making both information and services more appealing to youth.
3.3 Building stronger primary health systems
Despite improvements in health systems, many hurdles remain. At the primary care level, unclear roles among staff with different levels of training can be disruptive. Stockouts of key contraceptives threaten continuation of desired FP methods. The rapidly increasing demand for FP due to the demographic bulge among youth will likely force choices about priorities of services and systems. Expanding access to a wider method mix, especially at the community level, can improve contraceptive choices to meet a woman’s fertility intentions. Finally, countries need realistic, affordable and sustainable financing strategies, including both their own finance ministries as well as external funders.
Despite the progress in increasing access to FP services, inequities still persist for many populations. Poverty continues to define one’s access to and use of modern contraception. Data from DHS underscore that unmet need for contraception is highest among the populations in the lowest wealth quintile. Income inequities also define what types of contraceptives are used. While women in the richest wealth quintiles are more likely to use LARCs, women in lower wealth quintiles are more likely to be using short-term methods even when they have attained the desired number of children [
- Creanga A.A.
- Gillespie D.
- Karklins J.
- Tsui A.O.
Low use of contraception among poor women in Africa: an equity issue.
3.4 Optimizing integration of FP services
A holistic approach to SRH was envisioned in the ICPD recommendations. Siloed domains such as FP, HIV, TB and immunization miss opportunities to provide a full complement of services for the client. This broader interpretation of SRH services could go two ways: adding other services to existing FP programs or adding FP services to other programs. In the 1990s, a major concern was the integration of sexually transmitted infection (STI) management into FP services [
- Dallabeta G.A.
- Gerbase A.C.
- Holmes K.K.
Problems, solutions, and challenges in syndromic management of sexually transmitted diseases.
]. Under the leadership of WHO, the use of syndromic treatment was developed and adapted by many FP programs. This approach increased access to STI services for many FP clients. However, analysis of the impact and cost of syndromic management called into question its effectiveness as a public health intervention [
- Pettifor A.
- Walsh J.
- Wilkins V.
- Raqhunathan P.
How effective is syndromic management of STDs? A review of current studies.
]. As a result, syndromic management has been relegated to a lesser role in clinical practice.
By 2000, as the AIDS epidemic spread, the need to address the SRH needs of those with HIV became an urgent public health challenge. The number of children born to HIV-positive mothers was also on the rise, and the majority of pregnancies occurring to HIV-infected women were unplanned and unwanted [
- Wilcher R.
- Petruney T.
- Cates W.
The role of family planning in elimination of new pediatric HIV infection.
]. By ICPD +
20, some national HIV and FP programs have responded by developing creative strategies for integrating antenatal HIV services with postpartum FP access.
Besides the integration with HIV services, FP programs have also experimented with the integration with other health services including childhood immunization programs, postpartum provision of IUDs and postabortion FP services. Evidence from the pilot programs has supported the feasibility of implementing integrated services, with the potential to increase access and use of FP services [
- Wilcher R.
- Hoke T.
- Adamchak S.
- Cates W.
Integration of family planning into HIV services: a synthesis of recent evidence.
]. However, these integrated services have not been implemented at scale to be able to fully judge their impact on access and unintended pregnancies. We need rigorously designed evaluations, including appropriate comparison groups, to assess the benefits and costs of integrating FP services into other health services.
4. Case studies — Ethiopia, Rwanda, Malawi
Three countries in Africa have achieved more effective FP programs than others: Ethiopia, Malawi, and Rwanda. According to DHS reports, use of modern methods among married women of reproductive age increased 2.3% in Ethiopia (2005–2011), 2.4% in Malawi (2004–2010) and a dramatic 6.9% in Rwanda (2005–2010). All three countries have made important progress in improving contraceptive method mix — the usual methods offered in most African FP programs: condoms, pills and injectables — by making implants and IUDs more available. Together, these countries are moving rapidly to achieve what the development community calls the “demographic dividend,” whereby as unintended pregnancy and fertility rates go down, conditions for development improve [
- Population Reference Bureau
Harnessing the demographic dividend.
Four common themes emerge from and help explain the progress observed in all three countries:
4.1 Political commitment beyond the health sector
Broad support for FP has been essential for success. In 2000, both Ethiopia and Rwanda were recovering from major disruptions the Eritrean war, prolonged drought, and food shortages in Ethiopia and the genocide in Rwanda. Both had strong leaders determined to improve their citizens’ health and their country’s international reputation. The importance of FP for economic development had been emphasized by USAID, UNFPA and the World Bank. FP also fits into the national priorities of women’s empowerment, rural development and improved education.
The Ethiopian, Malawian and Rwandan FP programs dovetailed with the general government decentralization and focus on rural development at the local and regional levels. The Health Extension Worker (HEW) program in Ethiopia, the community-based health package in Malawi and the national CHW system in Rwanda are integrated directly into the formal health care system. This facilitates referrals, reporting and linkages.
4.2 Notable champion(s)
Within this broader political commitment, notable champions emerged at every level of government, from the President to Ministers of Health to Members of Parliament. The Rwanda and Ethiopian Heads of State recruited strong leaders to be the Ministers of Health, people who could work closely with other key ministries such as finance and education and who could develop innovative new health delivery systems. Malawi has multiple ministries working on public health, FP, and economic development and population initiatives. In all three countries, program managers at national, district and community levels also emerged for various reasons, ranging from a culture of support for FP to key leaders at various levels to performance-based contracting.
4.3 Community provision of services
In Ethiopia, the FP program was “packaged” into the HEW program as one of 16 essential health services provided at the community level. The emphasis on task-shifting was a critical element, with some 34,000 HEWs being trained to work in 17,000 new health outlets, a massive investment in a country as poor as Ethiopia. These auxiliary health personnel provided injectable contraception and in recent years have begun to insert implants. The government supports the salaries of the HEW staff and coordinates additional resources from other development partners.
In Rwanda, a similar vision has driven the plan for providing injectables and other methods by some 30,000 CHWs in villages nationwide [
- Rwanda Ministry of Health
Rapid assessment of adolescent sexual reproductive health programs, services, and policy issues in Rwanda.
]. It has expanded access to vasectomy, postpartum IUDs and other methods beyond major hospitals. In Malawi, the MoH is training and supporting health surveillance assistants to provide FP information and services, including injectables and implants [
Republic of Malawi National Sexual and Reproductive Health and Rights (SRHR) policy.
]. Clinical officers provide female sterilization in the public and private sectors, creating greater access and use.
4.4 Health systems strengthened
These three countries have been leaders in both developing innovative health systems and strengthening existing systems. Strong logistics for contraceptive security have greatly reduced stock-outs in Ethiopia and Rwanda (but not Malawi). All three countries have substantial decentralization, with national leadership also needed to support and guide the FP systems. Expanded services for maternal and child health have also brought more women into contact with FP systems, through postpartum, child immunization and other services. Public–private partnerships, including mobile services and social marketing, have also played roles in these countries, especially in Malawi. Performance-based contracts for program managers and government staff in Rwanda contribute to accountability and a norm of good practice. Finally, affordable health insurance at the community level in Rwanda results in families having greater access to health services including information on FP (FP services are free).
How have the increased FP method mix and use of contraception in these three countries affected fertility rates, both actual and desired? In Rwanda, total fertility rate (TFR) is dropping quickly; its actual fertility in 2010 equaled its desired fertility in 2005 — a noteworthy achievement. In Ethiopia, fertility has also dropped fairly rapidly — from TFR of about 5 in 2000 to 4 in 2004 to 3 in 2011. Although Ethiopia has a CPR (27%) that is lower than Malawi’s CPR (42%), Ethiopia has a substantially lower TFR as well (4.8 compared to 5.7 for Malawi).
While every country has distinct cultural geopolitical and historical contexts, these three countries are prototypic of instituting successful FP programs. In the end, political commitment, champions, partner collaboration, innovative human resource strategies, community provision of services with a scale-up vision and more effective health systems are essential.
Since ICPD, measurable progress in access to FP services has occurred worldwide. However, the CPR improvement has slowed in recent years, and demographic forecasts predict an even greater unmet need for effective contraception. Given the centrality of FP to achieving both the MDGs by 2015 and the global development goals thereafter, the FP 2020 initiative is a crucial strategy. With a rights-based lens, we need to better understand the nuances of fertility intentions as we offer women and couples contraceptive choices pertinent to their stage of life. With a public-health lens, we simultaneously need better metrics than the current CPR to reflect the realities of contraceptive effectiveness.
As the world prepares for the post-2015 sustainable development agenda, we are in a good position to take advantage of the ICPD successes. Access to rights-based FP enables women to make vital choices about their health and childbearing that will also improve the lives of their families. FP 2020 has committed financial resources and provided an operational plan to decrease unmet need for effective contraception. Science has generated the evidence to demonstrate which contraceptive methods are most effective in typical situations. Country leaders have shown how political will can improve both the extent and the method mix of FP services. Advocates have monitored the essential rights-based foundation for offering high-quality FP services. Now is the time to build on two decades of FP progress after ICPD.
Published online: June 13, 2014
Received in revised form:
☆Prepared for ICPD @20 Supplement in Contraception.
☆Presented at the ICPD @20 Conference, Mexico City, October 2, 2013.
© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.