During the 1990’s many countries in Africa saw steady progress in family planning (FP) goals and an increase in contraceptive prevalence rate (CPR) (Jacobstein et al., 2009).FP programs were often fueled by donor funds and agendas rather than country ownership however, and were implemented separately from other health programs (WHO/AFRO, 2005). During the 2000s progress in meeting unmet need for FP began to slow and even plateau, despite FP playing a significant role in achieving the Millennium Development Goals (Jacobstein et al., 2009).HIV/AIDS, malaria, and tuberculosis programs began to dominate the global health agenda and received a majority of the global health resources. Isolated FP programs were left with little funding and a lower priority in the competitive allocation of scarce resources.

As a result, FP advocates worked to raise the profile of FP and reclaim its priority status within the global health context. In 2004, the WHO Regional Office for Africa drafted, Repositioning FP in Reproductive Health Services: Framework for Accelerated Action, 2005-2014, which was signed by African ministers of health (Jacobstein et al., 2009) (WHO/AFRO, 2005). The framework was written to “provide guidance on how to revitalize the family planning component of national reproductive health programmes in order to ensure a comprehensive approach to improving maternal and child health…” The framework calls for advocacy efforts, and the procurement of FP resources to ensure the sustainability of programs. The specific objectives are to:

• advocate (at all levels) for quality FP services;
• build capacity of FP services;
• improve access and use; and
• mobilize resources for FP services.

The guiding principles include emphasis on gender equity, stewardship by local governments, sustainability, multisectoral approaches, and coordination and collaboration between various levels of government. (WHO/AFRO, 2005)

In 2001, USAID’s Office of Population and Reproductive Health (PRH), in collaboration with USAID’s Africa Bureau, USAID Missions, WHO, and other partners, engaged in an initiative to reposition FP in sub-Saharan Africa. The stated goal of USAID’s Repositioning Family Planning initiative is to increase political and financial commitment to FP in sub-Saharan Africa, which will lead to expanded access and help meet women’s stated desires for safe, effective modern contraception (USAID, 2009). The initiative identified three key approaches or intervention areas for achieving this goal: advocating for policy change, strengthening leadership, and improving capacity to deliver services. As a result of these combined efforts, countries are in various stages of repositioning and revitalizing FP. (USAID, 2009)

In the indicators presented here, sustainability refers to the ability of host country entities to strengthen or maintain the enabling environment and meet established objectives for FP over a period of time, and to do so in spite of the strength or weakness of external funding and/or focus on FP  (USAID, n.d).

Strengthened enabling environment for FP is an observable improvement in the conditions that facilitate the efforts of all sectors to implement FP programs. The enabling environment may include such elements as an:

• increase in financial support for FP;
• appropriate curricula for health workers;
• inclusion of international best practices in FP; and
• environment favorable for procurement of a variety of different FP methods.

Strengthened stewardship and enabling environment for FP contribute to a positive change in country-level, long-term outcome indicators for FP, which include CPR, a shift in method mix to long-acting and permanent methods of contraception, and unmet need. However, because these indicators are also highly dependent on service delivery and other program variables, they have not been included in the repositioning section, and are instead included in the FP and Long-Acting Permanent Methods sections in this database. It is important to monitor these and other established outcome/impact indicators, but weakness may or may not be directly attributable to the repositioning efforts.

When is a country “repositioned”?  And how does a country know that it is going down the right path in its efforts to increase access to and demand for quality FP services?  Assessing and measuring the extent to which a country has repositioned FP in the broader health and development agenda involves a focus on documenting results at the national and subnational levels, monitoring change in traditionally monitored FP indicators, as well as sharing and replicating best practices.  Monitoring and evaluating many of these indicators requires baseline data in order to demonstrate an improvement or increased focus on technically sound FP programs.

The principles related to repositioning FP link directly to the principles of USAID’s Global Health Initiative and the indicators selected here can be used to help monitor implementation of those principles. Key linkages include a focus on increased impact through strategic coordination and integration; strengthen global health partnerships and private sector engagement; country ownership and investment in country-led plans; sustainability; and private sector partnerships.

Indicator Selection

____________

References:

Jacobstein, R., L. Bakamjian, et al. (2009). Commentary:  Fragile, Threatened, and Still Urgently Needed: Family Planning Programs in Sub-Saharan Africa. Studies in Family Planning. 40, 8

Travis P, Egger D, Davies P, Mechbal A. (2002). Towards Better Stewardship: Concepts and Critical Issues. WHO/EIP/DP 02.48. Geneva: World Health Organization.

U.S. Agency for International Development (USAID), World Health Organization (WHO), Academy for Educational Development (AED). (2008). Repositioning Family Planning: Guidelines for Advocacy Action. Washington: AED.

U.S. Agency for International Development (USAID). (2009). Repositioning family planning operational plan 2008-2013 [unpublished]. Washington: USAID.

U.S. Agency for International Development (USAID) Office of Sustainable Development, Bureau for Africa. (n.d). Health and Family Planning Indicators: A Tool for Results Frameworks Volume I [n.d]. Washington: USAID.

World Health Organization Regional Office for Africa (2005). Framework for Family Planning in Reproductive Health Services: Framework for Accelerated Action, 2005-2014. Brazzaville, Republic of Congo, World Health Organization: AFR/RC54/11 Rev. 1.