Expanding and Improving Family Planning and Related Reproductive Health Services

With only half the population having easy access to health care, most countries face an enormous challenge increasing the coverage and quality of family planning and reproductive health services.

Expanding Access

Governments must increase overall coverage of basic health care to expand access to family planning and reproductive health services.

Over the long-term, governments need to aggressively expand primary health facilities and staff-especially in rural and urban areas lacking adequate services-and raise the quality of basic health services. Health sector reform efforts must include family planning and other reproductive health services within the package of basic health services they support.

Governments need to complete the process of building capacity within existing public sector health services to provide quality family planning care.

Government health services, despite their weaknesses, are the primary source of contraceptive services and often the only source of modern health care for the poor. Governments must ensure that all public sector health facilities have the trained staff and supplies they require to consistently offer an appropriate range of contraceptive services.

Governments need to expand and strengthen outreach efforts at the community level.

Community outreach programs can extend family planning education and services beyond the clinic and help bridge the cultural divide between the client and the clinic setting. To strengthen these programs, governments should allow community workers to distribute oral contraceptives, while providing training and adequate medical back-up to address concerns over nonprescription distribution of this method. Outreach programs need to build stronger referral networks to clinical services, intensify the coverage and frequency of home visits, and increase involvement of the community in all stages of program design and implementation.

Governments must remove legal and regulatory barriers that limit access to family planning and reproductive health services.

Governments should move quickly to repeal the outdated laws prohibiting the sale and promotion of contraceptives still in effect in some French-speaking countries, and ensure that the legal system supports efforts to implement reproductive health programs. They also need to remove import duties and taxes that contribute to higher commercial prices for contraceptives. With doctors in short supply, governments should modify regulations preventing trained nurses and nurse-midwives from performing procedures such as Norplant and IUD insertions.

With the support of donors, governments need to strengthen the basic management systems that support these services, especially contraceptive supply.

Public sector health and family planning services are expanding across Africa; at the same time, countries are decentralizing the management of these services. To meet these challenges, countries need to expand and improve training of managers and technical personnel at all levels. In particular, if services are to satisfy the rising demand for contraception, governments and donors must improve contraceptive supply systems by training staff and upgrading management information systems. Governments and donors must intensify efforts to tap the full potential of the private nonprofit and commercial sectors. Nongovernmental organizations (NGOs) in Africa continue to pioneer new approaches to family planning service delivery and to play an important advocacy role. Governments should draw on NGO expertise in areas such as training, and strengthen links between NGO outreach programs and public sector clinics. Meanwhile, international donors should expand funding for NGO services while helping NGOs move towards greater self-sufficiency.

Although many Africans cannot afford even low-cost health services, the private, commercial sector has some potential to expand its provision of family planning and related reproductive health services. To encourage greater participation of the private sector, governments must create a more positive legal and regulatory climate for private activities.

Social marketing programs, which promote and sell subsidized contraceptives through commercial networks, have expanded rapidly in sub-Saharan Africa. With AIDS prevention as their primary goal, most programs have focused on condom distribution. Social marketing efforts need to broaden the range of contraceptive methods provided, including highly popular oral and injectable contraceptives. Governments should also work to eliminate barriers to the effectiveness of these programs such as advertising bans and restrictions on sales outside of pharmacies.

Improving Quality

Both government and NGO programs must shift towards a more client-oriented approach to reproductive health services.

Both the choice of contraceptive methods available to African couples and public knowledge of these methods have steadily increased. Still, health staff in many countries place unwarranted obstacles to family planning use and clients do not always receive accurate and complete information. Improved support to front-line health staff is crucial to address these problems and improve counseling and service quality. Programs should use supervisors more in training of field staff and raise the frequency of supervisory visits. To correct misperceptions on the part of health workers about contraceptive methods, governments need to give field staff clear guidelines for provision of contraceptives based on medically sound criteria. To complement these efforts, public education must build a better base of knowledge about reproduction and contraception at the community level, including information on sources of services.

To promote availability of a broader choice of contraceptive methods, family planning services must improve access to long-acting clinical methods.

Interest in clinical methods such as voluntary sterilization has been steadily growing in Africa, but access to such services and levels of use remain very low. As a practical approach to meeting the demand for clinical methods, governments should establish services selectively in sites where quality-especially with respect to counseling and infection prevention-can be maintained. Programs also need to work to dispel rumors and misinformation through better counseling and information about clinical methods. With the increasing popularity of injectable contraceptives, programs should test safe and effective ways for health auxiliaries and community agents to administer injections.

Reaching Adolescents and Men

Governments must ensure that young people have the information, skills and means to protect themselves from unwanted pregnancy, AIDS and other STDs.

Despite growing awareness of the risks associated with unprotected sexual activity among adolescents, access to reproductive health services and information for young people remains severely constrained by laws, policies and the biases of health workers. Governments need to expand and improve school-based sexuality education, and make information and services more easily accessible to out-of-school youth, for example through community-based peer education programs. Public sector clinics need to make adolescents feel more welcome; where feasible, governments and NGOs should also establish special youth-friendly clinics or centers which provide both reproductive health and other services.

Family planning and reproductive health programs need to encourage men to take more responsibility for contraception and be more supportive of their partners.

Although African men play an important role in childbearing decisions and are crucial to efforts to prevent sexually transmitted diseases (STDs), family planning and reproductive health programs in the region have for the most part ignored their needs. To address this gap, clinics providing contraceptive services must be made more comfortable and welcoming to men. Countries must also expand the pool of physicians able to perform vasectomy and improve training to counteract the negative attitudes many health workers have towards the procedure. Public education efforts-especially those emphasizing AIDS and STD prevention-should strongly encourage men to use condoms consistently with casual partners and to improve communications with their partners on reproductive health issues.

Improving Population Policy

Governments must strengthen formulation and coordination of population policy.

Agreement at the 1994 International Conference on Population and Development (ICPD) on a comprehensive approach to slowing population growth raised awareness of a whole host of needs relating to improving reproductive health and women's status. To meet this new set of challenges, governments must strengthen existing national institutions charged with development and coordination of population policy. With support from the international community, they should build the capacity of these institutions to analyze the potential impact of demographic trends on various aspects of development.

Population policy institutions also need to address concerns about the impact of AIDS on population growth. These institutions need to stress the health benefits of family planning and reinforce the synergies between family planning and AIDS/STD prevention. Such institutions should provide policymakers with current and accurate information on important trends relating to AIDS-for example projections that population will likely continue to grow even in the hardest-hit countries.

Strengthening Links between Family Planning and Other Reproductive Health Services

Programs should improve links between family planning and other reproductive health services.

Despite growing evidence of the advantages of a comprehensive approach linking related reproductive health services, existing family planning programs have had difficulty effectively incorporating such services, especially in the area of STD prevention. To successfully integrate services, programs must train workers in new skills, make available equipment, drugs and other medical supplies required for diagnosis and treatment, adapt client counseling and information, and broaden public education campaigns. To achieve effective links, programs must carry out thoughtful testing and introduction of new strategies. While broadening the scope of population programs, governments must take care not to undermine family planning services, which are still new, weak and badly needed.

A top priority is for health and family planning services to do more to prevent the spread of HIV/AIDS and other sexually transmitted diseases.

The seriousness of the AIDS epidemic requires urgent government action. Family planning programs represent an important but underused vehicle to reach those at risk of HIV infection‹especially women. In the absence of a low-cost treatment for AIDS, programs should emphasize preventive efforts through education, promotion of condom use and infection control in clinical procedures. At the same time, health services should seek to improve STD screening and treatment‹especially since treatment of common sexually transmitted diseases appears to significantly lower chances of HIV transmission.

To lower risk of maternal death, governments must improve access to emergency obstetric care, with special emphasis on expansion of post-abortion services.

Despite heightened awareness, maternal death rates in Africa show no sign of decreasing. To prevent maternal death, countries must make long-term investments in upgrading facilities, equipment and staff skills to make emergency obstetric care broadly available. In the short-term, efforts to prevent maternal death should emphasize community-wide education to help identify potentially dangerous situations in pregnancy and childbirth, and when and how to take action. The establishment of emergency transportation networks at the community level should also be a priority.

To complement these efforts, health ministries and NGOs should continue to educate policymakers and the general public about the prevalence and health impact of unsafe abortion. Meanwhile, governments should redouble efforts to train health workers in emergency postabortion care, including easier access to family planning information and services for women treated for abortion complications.