Strategies for Overcoming Fertility Plateaus Suneeta Sharma PhD, MHA Chief of Party, ITAP Director, Futures Group India Sept 19, 2011

 Beginning of the program  After take off  After reaching the ceiling Plateauing CPR: Three Stages

Slackened Pace of CPR Average Annual Increase : :0.07 Average Annual Increase : : 0.9 Source: National Family Health Surveys Source: Demographic Health Surveys

 Why do programs plateau?  How long do they remain stagnant?  What has been done or needs to be done to get out of such situations?  Is it possible to predict such situations in advance? Questions on Plateauing

 A limited method mix  Program management weaknesses  Sheer growth of numbers  Changing demographic profile within the reproductive years  Shift in attention to other programs  Diminishing returns at high prevalence rates Reasons Behind Slackened Pace of CPR Source: John Ross et al Plateaus during the Rise of Contraceptive Prevalence, IFPP, 2004

Reasons for the Stall in Fertility  Changes in fertility preferences such as shifts in marriage patterns, timing of initiating child bearing  Shifts in local/national policies, reduced budgets or donor support  Increasing unmet need, unplanned childbearing  Increasing negative attitudes towards family planning or methods  Changes in age structure of population and migration Source: Ian Askew et al, Pop Council 2009

Can plateauing be anticipated? Case of India

Total Fertility Rate in Indian States Source: Sample Registration System, Registrar General of India, 2008

Trends in Modern Method CPR in India and Select States Source: National Family Health Surveys (NFHS)

Decline in Total Fertility Rate in India and Select States Source: National Family Health Surveys

Inequities in Contraceptive Prevalence Rates Source: National Family Health Surveys (NFHS)

Plateauing CPR in India  Significant proportion of declines in fertility and increase in CPR have come from select states  States that have achieved ceiling levels will not significantly contribute to increases in CPR and fertility decline  States that have experienced plateau in the past decade have to contribute to CPR increase significantly  If not, India will enter into plateauing phase this decade

How to Tackle Plateaus?

Andhra Pradesh

Andhra Pradesh – CPR v/s TFR Source: Sample Registration System and National Family Health Surveys

Three Pillars of Andhra Pradesh’s Family Planning Program

Uttarakhand Example

 High maternal mortality, infant mortality, and total fertility rates  Use of FP methods and institutional facilities for deliveries is the lowest among poor  Out-of-pocket expenditure on reproductive and child health (RCH) services  Enormous health barriers to the poor  Staff vacancies, lack of trained staff  Difficult geographic terrain, remote populations Analyze data sets to understand contributions of subgroups and prepare strategies

CPR v/s TFR for Wealth Quintiles, Uttarakhand Source: Calculated from the National Family Health Survey – 3 ( ), Uttarakhand State Raw Data

 New Health and Population Policy ( )  Increased state funding and innovative financing mechanisms  Promote a balanced method mix  Focused interventions in low performing districts  Develop capacity of the providers and health workers  Engage men to increase their participation in planned parenthood  Mandatory action: Modern spacing method services to newly married and couples having one child Keep FP program central to development efforts

 Mobile Health Vans  ASHA plus Program  Voucher System  Contracting out in urban areas  108 Vans for transportation  Adolescent NGO project Involve private sector in FP service delivery Develop strategic options Develop strategic options Ensure sustainable financing Ensure sustainable financing Establish links with policy framework Establish links with policy framework Develop costed scale up strategy Develop costed scale up strategy Evaluate impact Government Leadership and Ownership Government Leadership and Ownership Design and test appropriate models Design and test appropriate models Prioritize needs Determine shared goals Determine shared goals Engage right partners Engage right partners

 Voucher system scaled up to 38 blocks in five districts covering more than 50 percent of the State rural population  26 Mobile Health Vans in 35 districts covering 10 million people  ASHA plus program scaled up in 6 districts covering 3.13 million people Scaling Up Public Private Partnership Models Impact Assessment of Voucher Project in Haridwar, Uttarakhand (in 24 months)

 Formative research to identify barriers to behavior change  Workshop on BCC involving various stakeholders  ASHA Plus toolkit and IPC Training  BCC campaign on institutional deliveries (mass media, mid-media and IPC)  Branding, BCC strategy and IPC tools for Voucher scheme  Communication plan and IPC tools for mobile vans  UDAAN BCC strategy, and campaign developed  Workshop on strategic BCC to develop PIP Behaviour Change Communication Activities to Inform PPP Models

Promote evidence-based process of moving from policy to action Keep family planning central to development efforts Design, test, implement, evaluate, and scale up effective interventions Plan and monitor for impact Way Forward Photo by Meena Kadri

Thank You! The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development (USAID) under Cooperative Agreement No. AID-OAA-A , beginning September 30, It is implemented by Futures Group, the Centre for Development and Population Activities (CEDPA), Futures Institute, Partners in Population and Development Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), Research Triangle Institute (RTI) International, and the White Ribbon Alliance for Safe Motherhood (WRA).