DAVID J. OLSON
“In Mali, at a family planning clinic, I saw a woman who couldn't afford the services so the clinic staff were sending her home. I said to the staff ‘Do you have a sliding scale [for paying the fee]? She's poor. She needs this. It's good for her. It's good for your country.’”
So for this woman, the cycle of poverty continued. That’s the experience — and exasperation — recounted by Roy Jacobstein, senior medical advisor of IntraHealth International, of the obstacles he saw a woman face recently. Some women don’t even go the clinic if they know they can’t afford it, he says. And financial barriers are only one of the impediments to family planning in West Africa and beyond.
The Ouagadougou Partnership, an initiative of nine French-speaking, West African countries to promote family planning, says that, taken together, those nine countries have the lowest modern contraceptive use and the highest fertility rate in the world. The modern contraceptive prevalence rate (CPR) for all of sub-Saharan Africa is 23%; in West Africa, it’s 11%. The highest CPRs for modern methods in West Africa (not including the island nation of Cape Verde) are Senegal with 20%, Liberia with 19% and Ghana with 18%. More typical are Mali and Nigeria, the seventh most populous country in the world, both with only 10%.
But West Africa is on the cusp of change. It’s in the early stages of catching up to the rest of Africa, and the world. The Ouagadougou Partnership, started in 2011, is a major demonstration of that commitment to change. At its annual meeting in December, the Partnership announced that new data from 2013 shows the nine countries are on track to reach their goal of creating one million new users with modern contraception by 2015.
“Family planning is going to take off in West Africa,” says Jacobstein. “It’s just a matter of time. You can already see it in the cities and higher wealth quintiles. It’s exactly the same pattern that was followed everywhere else in the world. West Africa is not different, it’s just not as far along, but it’s happening.”
Senegal is a case in point. It has experienced a significant increase in modern contraceptive prevalencefrom only 12% in 2011, to 16% in 2013, and 20% in 2014. Senegal’s achievements have been facilitated by political will and engagement, in addition to innovative approaches such as the informed push model to address contraceptive supply chain challenges, funded by the Bill & Melinda Gates Foundation and Merck for Mothers, and implemented by the Ministry of Health, the National Pharmacy and IntraHealth.
“Senegal demonstrates that Francophone West Africa is capable of catching up in the field of family planning if governments and donors honor the commitments they made in Ouagadougou in 2011,” said Fatimata Sy, director of the Coordination Unit of the Ouagadougou Partnership. “Senegal’s progress has been possible due to the government’s commitment and donor support, as well as high impact interventions.”
Sy points out that Senegal must keep up this momentum and other countries must follow suit for the Ouagadougou Partnership to stay on track to meet its goal later this year. She says three other countries are emerging as family planning leaders —Burkina Faso, Niger and Togo.
Why is West Africa so far behind East and Southern Africa in terms of family planning? According to Jacobstein and Sy, it is due to a combination of factors, starting with the fragility of the health systems. This includes inadequate numbers and distributions of health workers, unnecessarily restrictive family planning policies and practices and the fact that family planning services are not usually provided free or at low cost, as in other parts of Africa. Other impediments include:
Pro-natalism:Sy says that many West Africans consider children as “richesse” (wealth). “The more children you have, the better you feel,” she said.
Religion: Many believe that family planning is against their religion. However, that may not always be the case. For example, many Islamic religious leaders have been vocal advocates, demonstrating that Islam permits use of modern methods to space births.
Lack of political will: This is extremely important, says Jacobstein. Until recently, there was little political will in the region, at any level, for family planning, leading to minimal strategic planning and investment on the part of governments.
Lack of money: Until the Ouagadougou Partnership in 2011 and the London Summit on Family Planning in 2012, there was little national funding and limited donor support of family planning. The ONE Campaign’s 2014 DATA Report shows that only two West African countries — Liberia and Togo — have met the Abuja target of allocating 15% of their national budgets to health.
But all of these things are now changing. The idea of small families is taking hold, especially in cities. Some religious leaders have become champions of family planning. Political will is growing. For example, Sy notes that Niger President Mahamadou Issoufou has recently spoken publicly about the importance of family planning. And there is more money, from international donors and, to a lesser degree, from some West African countries themselves.
Although the Ouagadougou Partnership focuses on French-speaking countries, English-speaking countries in the region also stepped up at the 2012 London Family Planning Summit. Nigeria committed to increase its CPR from 10% in 2008 to 36% in 2018. Ghana pledged to make family planning free in the public sector and support the private sector to provide services. Even Liberia andSierra Leone made commitments before they were ravaged by Ebola.
More organizations are focusing on West Africa and trying new approaches. DKT International, a non-profit organization that uses social marketing to provide couples with affordable options for family planning and HIV prevention, started two major programs in Nigeria and Ghana in the last two years.
“We started the programs because we saw a need and felt that a new approach with a new player could help address some of the issues and shake up the traditional way of solving these problems,” says Christopher Purdy, president and CEO of DKT.
Sy is hopeful on the prospects for family planning in West Africa. “I’m optimistic when I see high-impact family planning at the country level,” she says. “I’m optimistic when I see that family planning investment in the region increased by $29 million between 2012 and 2014. I’m optimistic when I see more innovation in terms of approaches for delivering family planning. I’m very optimistic.”