Repositioning Family Planning in West Africa Repositionnement de la Planification Familiale en Afrique de l’Ouest Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO), Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project Program GAP: Family Planning Need vs. Use in West Africa Prof Wole Akande, FRCOG Chairman African Reproductive Health Task Force

Objectives Increase awareness of the gap between expressed need and FP use – and the challenges this poses for Repositioning Famly Planning. Convey information on the gap related to: access, quality, utilization and coverage.

Themes Family planning as a critical health intervention for women and children Huge unmet need for family planning (spacing and limiting) The geographical, financial and operational barriers to access to FP services Quality of Care issues Use and coverage issues

The Consequences of Unmet Need on the Outcome of Family Planning Programs

Contraceptive Prevalence Rates* low and TFR high in West Africa Source: PRB 2004 World Population data Sheet, 2004 * Married women, Modern Methods CPR TFR

West African CPR trends relatively static over the the past 10 years * Percent of married women ages 15 to 49 using modern contraception. Source: Demographic and Health Surveys Women using contraception (%)*

Program Factors Contributing to Unmet Need for Family Planning in West Africa Shifting / stagnating donor and government resources for family planning Shortages of contraceptives and other commodities Lack of trained managerial and technical staff Inequity in access to family planning (urban versus rural) Vertical programming leading to missed opportunities (need for FP/MCH/HIV/AIDS integration) Communications focus on population control rather than health needs of women and children, and high risk fertility behaviors linked to mortality

Shortfalls in Funding for Commodities and its Consequences Additional: 360,000Unintended pregnancies: 360, ,000Induced abortions: 150, Maternal deaths: ,000Infant deaths: 11,000 14,000Deaths of children under 5: 14,000 For every $1 million shortfall in contraceptive commodity assistance: UNFPA, RH/CS, Sept. 2000

Inequity in Access to Family Planning Services Between the Poor and the Rich Poorer segments of the population tend to have less access to subsidized FP public services than wealthier segments; In Niger and Burkina Faso: 60% of public sector users are from the most prosperous 20% of the population; Less than 20% of the public sector users in these countries are from the poorest 40% of the population. Ali K. & al, JSI, Deliver, 2003

Programmatic Challenges Determining the Low or Stagnating Contraceptive Prevalence in West Africa

Lack of knowledge about contraception Low female education levels, and lack of knowledge and programmatic support, are among the major causes of unmet need even where family planning commodities are available and accessible; Women in many countries including West Africa are uncertain about whether they are able to delay becoming pregnant, they may feel ambivalent about whether they want a pregnancy now or later, or about how contraceptive methods work and where and how to get them. Source: William R, Finger, FHI & PRB unmet need for FP,2003

Poor Communication: Consequences of Fear of Side Effects Many providers do not counsel women about side effects to counter bad rumors ; In 12 countries in in sub-Saharan Africa, only about half who choose a new method received information on that method’s side effects; Discontinuation rates were four times higher in women not receiving adequate information on side-effects; Inadequate or insufficient method mix (e.g. failure to include SDM and LAM) is common in most FP delivery points. Source: William R, Finger, FHI & PRB unmet need for FP,2003

Opposition from families to Family Planning Women with unmet need for family planning are most likely to come from families where control over fertility or family planning was not discussed or encouraged; Opposition to family planning accounts for 20 to 30% of the reason why women are not using family planning in sub-Saharan Africa; Most religions and traditions are against irreversible tubal ligation. Source: William R, Finger, FHI

Poor Geographical and/or Financial Access Contraceptive use in rural areas is 5-10 times lower than in urban in most West African countries (5 times in Mali, 6.5times in Senegal); User fees for preventive MCH, including FP, exclude a significant segment of the population and increase inequity to access to FP services. Opening times of service delivery points prevent some potential clients accessing services – clinics may need to open on weekends or later in the evenings to facilitate access for formal sector workers.

Negative effects of vertical FP programs Vertical programs operated by non-governmental organizations (NGOs) appear to be the major sources of FP services in most West African countries; These vertical programs have separate logistics systems that serve the NGO’s goals at times at the expense of the strengthening the system and its Essential Drug Program component; 44% of all couple – years protection in Côte d’Ivoire, about a quarter in Benin and Guinea, come from vertical programs operated by nongovernmental organizations that are not sustainable.

Limited Range of Contraceptive Choices Dissatisfaction with available methods and the limited number of methods available cause most programs to fail to address the population in needs; Poor or non-utilization of natural methods such as the Standard Days Method (SDM) and longer term methods (IUD, Norplant, Mini-lap) Lack of exclusive breast-feeding during the first half-year of child life leading to short birth interval diseases and deaths among infants.

Very few service delivery points have contraceptives continuously available during a six month period in most of the countries Lack or poor utilization of appropriate Tools for monitoring and evaluation of contraceptives logistics systems; Poor coordination between government and NGO supply systems Poor procurement, delivery and management systems. Lack of Continuity of FP services

Poor Quality of Services Providers lack technical knowledge and communication skills about contraceptive methods; Inappropriate client provider interaction leading to high drop-out rates; client-centered perspective is not used; Lack of user-friendly service delivery guidelines to standardize FP services and reduce inconsistencies and harmful practices Lack of access to “adapted” and “scaled-up” best practices Failure to integrate FP policy, norms and protocols in the curriculum, supervisory checklists, FP clinics forms, and IEC materials; Inadequate supervision of providers to deal with their technical and logistics difficulties- like fuel shortages, supervisors’ inadequate practices, etc.

Provider Bias Providers’ lack of knowledge leading to unnecessarily restricting of FP services to women who need them, In most West African countries showed that more than half providers deny services to clients because of age, marriage requirements, spousal consent for at least one reversible FP method, In Burkina Faso, 69% of men and 64% of women in a 1992 study require spouse’s approval for family planning services. FHI contraceptive technology & research program, November 1996; Askew I. et al, 1992

Limited Community Involvement and Poor coverage of Rural Areas Failure to scale-up community based programs in poor rural areas where there are no facilities to sustain re-supply of contraceptives The few existing community based programs (Mali, Senegal, Benin, Guinea) are limited in scope and duration; The utilization rate in rural areas where 60 to 80% of the population live is very poor ranking from 0.5 to 2%.

Conclusions To ensure satisfactory progress in Family Planning in West Africa, strategic and targeted action is needed; There is a need for Program managers to prioritize programmatic issues that jeopardize programs’ success; and take strategic action to attain maximum results; Government, donors and NGOs should eliminate user fees (or charge minimal fees) and scale up models that support the access of the poorest to FP services; Programs should focus on integrating HIV/AIDS services into RH/FP and vise versa, FP into HIV/AIDS programs;

Finally Governments should strive to align their programs with their MDG plans and ensure that by 2015 all primary health-care and family planning facilities are able to provide, directly or through referral, the widest achievable range of: Safe and effective family planning and contraceptive methods; Essential obstetric care; Prevention and management of reproductive tract infections, including sexually transmitted diseases and; Barrier methods, such as male and female condoms and microbicides to prevent infection and unwanted pregnancies. Adapted form Paragraph 53, ICPD +5

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