In the last 20 years, Ethiopia has emerged as a family planning powerhouse. In Studies in Family Planning, I reported that, from 1990 to 2011, modern contraceptive use increased ninefold, from 2.9% to 27.3%, and the total fertility rate (the average number of children born to a woman in her lifetime) dropped from 7.0 to 4.8.
Now Ethiopia’s reputation has been further burnished by the results of a report released May 27th by Performance Monitoring and Accountability 2020 (PMA2020) that show an increase in the use of modern contraception from 27.3% in 2011 to 33.3% in 2014 and a drop in the fertility rate from 4.8% to 4.4%.
Four Central Determinants of Success
This prompts the question: What are the factors that lead to family planning success? And what are the factors that stall such progress? Our article in Studies in Family Planning identified four determinants of success in Ethiopia. I suspect that many, if not all of these, ring true elsewhere in sub-Saharan Africa:
Political Will: Although not necessarily indispensable, success is much harder to achieve when political will is weak or absent. In setting its development policies, the Government of Ethiopia focused on demographic factors, recognizing population growth as one of the main obstacles to addressing poverty, and consistently set ambitious goals for family planning, and it sustained that support over time.
Generous Donor Support: From 2000 to 2010, Ethiopia was the largest recipient of international family planning assistance in sub-Saharan Africa. International donors have provided continuous support for purchasing products, strengthening government capacity and improving policy, research and training.
Nongovernmental Organizations and Public-Private Partnerships: A number of national and international NGOs have supported government’s efforts and employed strategies such as social marketing, behavior change communications and mobile clinics as ways of providing access to — and stimulating demand for — contraceptives in low-resource settings.
Health Extension Program: The government’s flagship health program played a major role in the provision of contraceptives, especially in the rural areas, where 83% of its people live. The government invested in a network of 38,000 health extension workers based at 17,000 health posts to bring education and contraceptive products and services to rural areas that previously lacked trained health personnel and high-quality facilities.
“What is remarkable about Ethiopia’s success is that it has been achieved through improving access not just to the urban and wealthier segments of the population, but among rural and poorer segments — a testament to outreach into rural and peri-urban areas and the reach of the health extension workers,” said Scott Radloff, director of PMA2020 and senior scientist at the Bill & Melinda Gates Institute for Population and Reproductive Health.
Political Will Plays a Key Role
In a 2013 research brief, “Drivers of Progress in Increasing Contraceptive Use in sub-Saharan Africa,” the African Institute for Development Policy posited that political will is “the most critical enabler” of family planning progress, and identified five countries as having developed the political will necessary to expand family planning — Rwanda, Ethiopia, Malawi, Tanzania and Kenya.
“Rwanda stands out with strong leadership by the President who openly supports and promotes family planning as a development tool,” according to AFIDEP. “This has been institutionalized in Rwanda, and traverses all levels of leadership and government.”
In the other four countries, says AFIDEP, political will manifests itself at the Ministry of Health (and, in the case of Kenya, Ministry of Planning) and the heads of state are not vocal about family planning.
What Causes Family Planning to Stall?
However, family planning progress has stalled in both Kenya and Tanzania over the last 20 years.
Kenya’s fertility rate hit 5.4 in 1993 but has not changed much since then, and now stands at 4.6, according to the 2008-09 Kenya Demographic & Health Survey. The Daily Nation, Kenya’s largest circulation newspaper, reported on this last month in an article entitled “Five children per woman: How Kenya lost the family planning battle.” A similar phenomenon occurred in Tanzania: After getting its fertility rate down to 5.8 in 1996, it barely moved. In 2010, it was estimated at 5.4.
In its research brief, AFIDEP attributed the stalled progress in Kenya to “the shift in top leadership prioritization of family planning, which was compounded by the shift in donor priority and funding” towards HIV/AIDS and away from family planning. In addition, Tanzania’s program was adversely affected by the decentralization of the health sector during that period.
Radloff added that the commitments in Kenya and Tanzania — among both donors and governments — “have been more volatile and tepid, accounting largely for the stalls that we have seen there.”
The main take-away from the stalled progress in Kenya and Tanzania, according to AFIDEP, is that sustained efforts are required from all stakeholders to ensure that funding and technical inputs for improving the quality and outreach of FP services is maintained.
AFIDEP says both countries have gone a long way in addressing these challenges and revitalizing their FP programs. Radloff agrees that both countries are in “an up-tick period in terms of revitalization but still have a ways to go” before they match Ethiopia’s prioritization of family planning. PMA2020 expects to have results for Kenya on the PMA2020 website in July.
Lessons Learned in Ethiopia
Our article in Studies in Family Planning highlighted lessons learned in Ethiopia that may help other countries emulate the Ethiopian success including:
- Positioning of population and family planning at the center of development is critical.
- More efforts must be made to diversify the contraceptive mix. The success in Ethiopia depends heavily on injectables and, to a lesser extent, implants.
- The presence of a large and active social marketing program can contribute to higher contraceptive prevalence.
- African countries should follow Ethiopia’s example of investing its own funds in family planning.
- More progress must be made in integrating the response to HIV/AIDS with family planning.
- Governments should fully engage the broad civil society – including NGOS, the private sector and faith-based organizations – so they can each bring their own unique contribution to family planning success.
- The private sector should be better exploited. For example, governments could license more private pharmacies, drug stories and clinics; permit the sale of more reproductive health drugs through the pharmaceutical network; and liberalize the advertising of contraceptives.