13 July 2012

The Family Planning Summit is Over. Now What?

President Yoweri Museveni of Uganda, speaking at the London Summit on Family Planning
President Yoweri Museveni of Uganda, speaking at the London Summit on Family Planning - Credit: DfID
The Lancet is the latest to toss a raft into the very crowded and quickly escalating white water river that is family planning. A special series published earlier this week provides some important critical thinking about the solutions that will be implemented with the money raised.

In the introductory piece for the special Editor Richard Horton and Herbert Peterson lay out what the perceive to be the two challenges to family planning efforts.
We see at least two challenges ahead. First, countries and the global community need the political will and capacity to apply the best available evidence to inform and encourage policymakers to take family planning more seriously. That means addressing often large variations in knowledge about family planning within countries and the sometimes strong sociocultural barriers to its delivery that exist. Second, there need to be national and global commitments to ensure that the evidence we present here is translated into innovative interventions which are, in turn, effectively implemented to achieve the goal of universal access to reproductive health. If these twin challenges can be met—using, in part, the potentially powerful idea of independent accountability—then a judicious fusion of science and advocacy will have been achieved. We pledge to do our best to make sure this Series plays its part in what we believe can be the beginning of a new global movement for family planning.
The commentary section contains a veritable who's who of contributors. One that stands out more for notoriety rather than substance is a co-written piece by Bob Carr, Melinda French Gates, Andrew Mitchell and Rajiv Shah.
Family planning is recognised as a highly cost-effective development intervention to promote healthy families, increase opportunities for economic development, and enable strong and vibrant nations. At a time when value-for-money and cost-effectiveness are the watchwords for development agencies, it is critical that the global community commit to long-term investments in voluntary family planning to meet health and other development goals. The UN recognises that “for every dollar spent in family planning, between US$2 and US$6 can be saved in interventions aimed at achieving other development goals”. Yet global investments have not kept pace with increasing demand.

Engaging all stakeholders was an important part of the summit and is reflected in the special section.  The respective Prime Ministers of Ethiopia and Rwanda co-author a commentary that outlines how their countries have worked to provided family planning services and the way the two percieve the path forward for their own countries and other African nations.
Family planning empowers women to take charge of their lives whilst also enhancing their contributions to family wellbeing and overall national development. Some progress has been made towards improving gender equity so that women have greater involvement in decision-making processes and positions in government. Increasing educational opportunities for girls protects them from premature marriage and childbearing and helps address gender inequalities in economic participation. However, the large annual increase in the number of school-age children each year in our countries dilutes the investments that families and governments are able to make towards universal secondary education. We believe that improving education and improving access to family planning are not alternatives: they are rather complementary policies that African governments and the international community must pursue. 
We recognise these wide-ranging contributions to development and are committed to prioritising family planning and reducing the barriers to contraceptive use. We are proud of the progress that is being made to increase contraceptive use in our countries. In Rwanda, the percentage of married women using contraception rose from 13% in 2000 to 52% in 2010. In Ethiopia, contraceptive use increased from 8% to 29% between 2000 and 2010. But challenges remain. For example, 25—35% of married women in these countries, most of whom are the poorest people in our communities, still have unmet need for family planning.
Tom Paulson asked some important questions in Humanosphere following the summit in regards to what extent the rising political will for family planning will support overall women's health.
[N]ow, with a more nuanced and popular message maker, Melinda, the Gates Foundation has over the past few years shifted much more emphasis to improving maternal health.

A good thing, taken in isolation. But some women’s right advocates wonder:

Does the high-profile attention given to family planning, maternal health, as the new cause célèbre of global health send the wrong message — that the primary concern for women is their ability to make babies (or not), as opposed to women’s health overall?

I hear this grumbling often at meetings or press conferences held to promote reducing maternal mortality or improving women’s reproductive rights. Usually, the women (and they are almost always women) doing the grumbling feel a bit awkward about it — because they don’t want to look as if they are opposed to efforts to fight death in childbirth or family planning.

So they usually don’t say anything, or if they do offer the critique almost as an apology.

But I think it is actually a very important question, and one that should not be ignored.
It is an issue that Kate Gilmore of UNFPA and Ethiopian minister of health Tedros Adhanom Gebreyesus do not ignore. In the face of what might appear to be another example of the further verticalization of international health, the two argue for the strengthening of health systems.

By no means are health systems a new or revolutionary idea, yet active support for systems is a bit of a sideline issue with high profile events like the London Summit for Family Planning, the recent maternal and child health call to action and last year's fundraising event for GAVI. Toss in the clout of PEPFAR and the Global Fund along with the popularity of specific initiatives like bednets, and you end up with a sea of focused health interventions.

The two outline the importance of health systems writing:
Using a health-system-strengthening approach for scale-up, family planning should be made available in every community and in every facility, and round-the-clock maternity services should be offered with at least one basic emergency obstetric and newborn health centre per 100 000 population and one comprehensive emergency obstetric and newborn care district hospital per 500 000 population. Financial restrictions to contraceptive access, especially for the poorest women and those who are pregnant during adolescence, should be addressed by offering free or nearly free services at the point of care.
Then there is the question of how the money will be disbursed. Amanda Glassman raises some possibilities, but ends up advocating for the money to be allocated by USAID's Family Planning Office.
USAID has a well staffed operation of experts managing contracts for service delivery, data collection, logistics, supply chain, procurement, research and development, with constant oversight from the U.S. Congress on their compliance with informed consent. The international NGOs will do the technical assistance to service delivery and other areas. The UNFPA can procure the contraceptives and build the political consensus. The World Bank can do the impact evaluation.
All in all, there are some questions that have emerged from this week's summit. The important announcements and actions will take place in the coming weeks as the money pledged will be put into action.