EDITORIAL Defining a New Pathway for Family Planning in Africa After 2014

Friday Okonofua


The International Conference on Population and Development (ICPD)was a landmark event that shifted emphasis from concerns with population growth to commitment to reproductive equity, rights and social justice in the implementation of all components of reproductive health. It placed women at the centre stage of development, creating a justifiable foundation for women to access safe and affordable modern contraceptives. ICPD positioned family planning as a fundamental human right of all sexually active couples, with the expectation that the new approach will galvanise efforts and lead to an improved use and acceptance of family planning by those who need them.   

Since ICPD, the evidence has shown that indeed, contraceptive prevalence rates (CPR) increased worldwide between 1990 and 2013, with a parallel decrease in unmet need for family planning1,2.  The most changes in these parameters occurred in the 1990s, with a slower increase in CPR and decrease in unmet need occurring between 2003 and 2012.  However, although increases in contraceptive prevalence also occurred in African countries during the period, the increases were less as compared to other regions.  Both in Central and West Africa, CPR has remained low with little change occurring in unmet need which has remained at around 20% between 1990 and 2010.  This slow progress in CPR and unmet need in Africa has led some to suggest that the principles of ICPD have not worked in the region. With the increasing emphasis on family planning both from the recognition of the possible impact of climate change on resource limitation (with Africa most likely to bear the greatest brunt)3, and projections made on the increasing number of women that would require family planning after 2014 (mostly in the African region)4, there is a call for new approaches to address gaps in family planning provision and access in Africa. Indeed, the commitment shown by world leaders at the London Summit in 20135 to provide family planning to an additional 120 million women and girls points to this need for galvanized and quicker action.   

Many factors account for the slow progress in family planning indicators in the African continent over the past two decades.  These include the poor uptake of the principles of ICPD with many African women still suffering the effects of social exclusion, marginalization and discrimination; the donor driven nature of family planning with many African governments still poorly committed to the principles and practice of family planning principles; limited efforts to address quality of care of available services with clinics still lacking trained staff, a constellation of commodities and youth-friendly approaches; the lack of integration of family planning to high prevalent reproductive health problems such as HIV/AIDS prevention and care; and limited attention paid to addressing the background factors that drive low utilization of family planning in Africa such as ignorance, illiteracy, poverty and harmful cultural beliefs and practices.

Four articles in this edition of the African Journal of Reproductive Health provide evidence of efforts being made in various parts of the region to understand the context of family planning provision in Africa needed to identify new approaches for improving key indicators of development.  The paper by Olatoregun6 and his colleagues compare fertility differences between Ghana and Nigeria and conclude that preferences for high fertility are still dominant in both countries, while the paper by Kuang7 explains how couples in Uganda are being motivated to accept family planning methods using self-motivational and rights-based techniques. Although injectable contraceptives belong to the WHO group of second tier methods in terms of method effectiveness, they are often the most preferred methods by African women. The paper by Nakayiza and her colleagues8 from Uganda describes how the source of an injectable contraceptive influences the use of the method by rural women.  It points to the need to integrate local needs and considerations in the design and implementation of family planning programs in Africa if increased uptake of these methods is to be achieved. Despite the high prevalence of HIV/AIDS in Africa, there have been little systemic efforts to understand the family need of affected populations and to design programs to address their needs.  The paper by Sarah Gutin and her colleagues9 from Uganda is presently one of the few available empirical data that investigates fertility desires of HIV-positive women in the postpartum period.

However, these papers are not only a good exposition of the nature of the problem but they point only to a limited direction.  There is a need to identify systemic approaches for improving contraceptive availability and use in the African continent after 2014. The 17-points Sustainable Development Agenda being proposed for world development after 201410 appear to be a good start with many issues being included that will address the background social and economic factors that influence poor use of family planning in Africa.  However, what will be most important and crucial is the political commitment of national governments both to implement the solutions embodied in the sustainable development agenda, and also to owe the process of change in terms of increased family planning provision. Most African governments have shown poor commitment to family planning services over the past two decades in part due to their internal conflict and beliefs about family planning, and also because of their limited prioritization of health and social development issues. The three countries that demonstrated powerful political commitment to development and family planning over the past years – Ethiopia, Rwanda and Malawi – have also witnessed the fastest growth in CPR and declines in unmet need, which testify to the importance of political commitment and leadership in promoting social development in the African continent.  Additional factors that would need to be addressed to boost family planning provision and access in Africa include:   increased indigenous funding of family planning (rather than reliance on donor funding), increased public education and advocacy with use of notable champions and partnership building, community provision of services

(including the use of task-shifting), health systems strengthening, promoting the inclusion of youth and men in family planning, and the integration of family planning services to other reproductive health services such as HIV/AIDS.

In conclusion, family planning is an important consideration in efforts to foster development, reduce maternal mortality and promote the wellbeing and social development of women and youth in Africa. The 1990-2013 period witnessed a slow growth of family planning indicators in Africa, but the 2014 period and beyond offers a new window of opportunity to galvanise efforts to accelerate the trend. The Sustainable Development Agenda being proposed for world development after 2014 is a good entry point, but political commitment is critically needed both to implement the agenda and also to prioritise the implementation of family planning and social development programs in Africa.  While not downsizing the importance of other areas of development, it is predictable that family planning would be the centre-piece of growth and development planning in the African region in the coming years. 

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