Drivers of Increased Contraceptive use in sub- Saharan Africa: Case studies from Malawi, Ethiopia, Rwanda, Kenya and Tanzania 1 African Women Leaders Network for Reproductive Health and Family Planning Meeting Intercontinental Hotel, Nairobi 15 th October, 2012 Nyokabi Ruth Musila, Ph.D.

Introduction to AFIDEP Policy think tank Sub-Saharan Africa focus

How we work: Research to Policy 1. Knowledge generation – Secondary analyses of national/regional data sets – Stakeholder analysis – Systematic reviews – Policy analysis 2. Knowledge synthesis, translation and packaging 3. Dissemination and Advocacy  Policy briefs, fact sheets  Presentations

Public Health Research Themes Maternal and Child Health Family planning Integration of Sexual and Reproductive Health and HIV Health system strengthening and health financing Population change and sustainable development (including climate change)

Most women who need to use family planning are not using it in sub-Saharan Africa Source: Guttmacher Institute and UNFPA, 2009

Population Growth Source: United Nations Population Division Africa’s share of global population will increase from 17% in 2010 to 24% in 2050 and 35% in 2100 – Medium Variant 6

Effects of Rapid Population Growth High child dependency ratios Poor health and wellbeing outcomes for mothers and children Depletion of natural resources such as forests Fragmentation and overuse of agricultural land Limited resources to invest in human capital development (education and health) Undermines poverty alleviation efforts

Presenting the Malawi Report to the Vice President & the Minister of Environment and Climate Change Management

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Background to FP Drivers Project (1) Trends in contraceptive use amongst married women % uptake

Trends in annual rate of increase of modern contraceptive use in Rwanda, Malawi, Ethiopia, Kenya and Tanzania (around 2000 to around 2010)

Background to FP Drivers Project (2) New wave of optimism in Africa Aim: To identify lessons and disseminate to less well performing countries Objectives: To conduct rapid assessments of policy, system, and service delivery drivers of progress in increasing contraceptive use in Ethiopia, Malawi, and Rwanda; and make comparisons to Kenya and Tanzania

Methods Desk review and synthesis of literature to summarize key drivers of change or lack thereof Review of population, reproductive health, and FP policies and strategies, as well as service guidelines Review of national and external financial resources for FP and population issues, and review reports on commodity security Conduct stakeholder interviews

These were found to be identical across the countries, However, the contextual circumstances within the 3 countries (political, systems, infrastructure, cultural) inform how the drivers have uniquely played out in individual countries to achieve phenomenal increases in contraceptive use in the recent past Drivers of Progress in increasing Contraceptive Use

1. Political will and commitment for FP Manifestation of political will: – Conducive policy environment – Development and prioritization of FP programs by government and other actors. – Demand creation for FP by leaders through changing negative attitudes that ordinary people may have about FP and family limitation

The Architecture of Political Will Definition: The way in which leaders champion FP Malawi, Ethiopia and Tanzania: no visible political stewardship of FP Rwanda: Explicit top-level stewardship – Public support and promotion of FP by President Kagame and leaders at all levels – FP was declared a national priority – FP uptake is a performance indicator for leaders – Informal family contracts at community level

“We can not develop into a middle income country without addressing high population growth” Dr. Ntawukuliryayo, Senate President, Rwanda

The Origin of Political Will Sustained advocacy Local and international champions Evidence that demonstrated: – Prevailing demand for FP – Health benefits of FP use – Broader development benefits of FP use

2. Enabling policy environment Global framework: MDGs National development framework – e.g. Growth and Transformation Plan in Ethiopia Population policies Multisectoral institutionalization in Rwanda

3. Improved financing mechanisms Decentralisation Over-dependence for commodities in all case study countries Concern of sustainability of programs needs to be addressed Budget line to monitor government allocation and expenditure – except in Malawi

4. Good coordination of donor and government FP Programs to maximize aid effectiveness Rwanda - Aid policy and accountability framework Fora for government and development partners FP and Commodity Security Technical Working Groups

5. Sustained Advocacy and Community Engagement in support of FP Buy-in from civic, faith-based and traditional leadership to strengthen demand creation for FP in the community by breaking cultural, religious and other barriers

6. Improved access to quality FP services and products Access Task shifting (Community Health Worker Program); “demedicalization” of FP products in Rwanda, Malawi and Ethiopia Human resource capacity strengthening – pre-service and in-service training in RH/FP – integration of FP and HIV services – supply chain management Quality Performance-based incentives Supply chain management

7. Youth-friendly FP services Facilitating access to FP by sexually active youth by – addressing cultural taboos – training of healthcare providers

Conclusion Political will and strong leadership engineered the overall successes of FP programs Understanding the form and architecture of political will can help – Governments achieve FP uptake goals – Align technical and financial support of non- government actors Examine drivers of success within specific in- country contexts of less-well performing countries

Acknowledgements FP stakeholders in Malawi, Rwanda, Ethiopia, Kenya and Tanzania This study was jointly funded by UNFPA- ARO, Packard-Foundation and AFIDEP

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