1. The International Family Planning Movement INHL 681 October 8, 2001

2. Overview of the presentation Roots to the FP movement, objectives Design issues: – Supply and demand factors – Donor and in-country implementing agencies – Range of contraceptive methods – Mechanisms for service deliver Policies and controversies Successful programs

3. Roots to the FP movement Earliest programs: in Asia – Demographically driven – Part of nationalistic development programs Establishment of IPPF and the Population Council in 1952 Indian FP program began in the 1950s Expansion to Asia and L.A. in the 1960s-70s and to Africa in the 1980s (dates vary by country)

4. Objectives of family planning programs Demographic – Often linked to development goals Maternal and child health – Avoid births “too early, too late, too frequently, and too numerous” Reproductive choice – Primary concern in Western countries – Popularized by the Cairo Conference in 1994

5. Supply and Demand Demand: larger social, economic, cultural, and legal factors that affect the demand for children and (in turn) the demand for FP: – Social: status of women, levels of education – Economic: level of living, labor force participation – Cultural: religion, ethnic belief systems – Legal: age at marriage, laws re contraception Demand = “what people want”

6. Supply: the family planning supply environment Supply = what people can get (in terms of FP) Access: – How many facilities, how close? – What methods are available, how convenient? Quality: – Choice of methods, info given to client, interpersonal relations, technical competence, continuity, other services

7. International donor agencies Multi-national: UNFPA Bi-lateral: – US: USAID – Japan, EU, Canada, etc. Private foundations: – Ford, Rockefeller, Mellon – Hewlett, Packard, – Gates

8. In-country implementing agencies Ministry of Health Para-statal (vertical) organizations: “Office” in Tunisia, BKKBN (Indonesia) IPPF affiliate: the private FP association International and local PVOs/NGOs (e.g., CARE, Save the Children) Other private groups (e.g., missionaries)

9. POP QUIZ: Item #1 Does a country need to have an official population policy to have a successful family planning program?

10. The “cafeteria approach” to contraception: modern methods Female Sterilization IUD Pill Injectables Implants (NORPLANT) Condoms, spermicides (barrier methods) Vasectomy

11. Traditional methods Rhythm (calendar, sympto-thermal, Billings) Withdrawal Abstinence Post-partum abstinence “Folkloric” (cord, herbs, etc.)

12. POP QUIZ: Item #2 What is the best contraceptive method?

13. Types of service delivery mechanisms Clinic-based Community-based distribution (CBD) Social marketing Approaches: integrated vs. vertical Public versus private sector Expansion of FP toward RH: Cairo

14. Advantages and disadvantages to clinic-based services ADVANTAGES: “Western model of health service delivery Used for other family health needs Large range of methods Trained personnel DISADVANTAGES: Limited access, especially in rural areas Expensive to establish and maintain May have low QC

15. Advantages and disadvantage of community based distribution ADVANTAGES: Increases access, expands coverage Provider known to and trusted by community Open after “clinic hours” DISADVANTAGES: Controversial (esp. with medical comm.) Limited range of methods Limited info on management of S.E. High turnover of non- salaried personnel

16. Advantages and Disadvantages of Social Marketing ADVANTAGES: Shifts program costs from gov’t to private sector (sustainability) Increases access, esp. in urban areas Greater ease for consumer Preference to “buy” DISADVANTAGES: Less control by program personnel Less opportunity for IEC Lack of clinical services for side effects

17. POP QUIZ: Item #3 What is method mix?

18. Typical divisions within a national FP/RH program Management/supervision Training Commodities and logistics I-E-C Research/monitoring & evaluation (Note: these areas “map” to the curriculum in the Dept. of IHD)

19. POP QUIZ: Item #4 What is the relevance of this slide?

20. The three international population conferences 1974: Bucharest: – “Development is the best contraceptive.” 1984: Mexico City – The legacy of the Mexico City Policy 1994: Cairo – Compromise of demographers and feminists – Expansion of FP to broader RH services

21. What is reproductive health? Reproductive health is a state of complete physical and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. – International Conference on Population and Development, Cairo, 1994

22. Expansion of FP to reproductive health: adults Unintended pregnancy Unsafe abortion (if legal) Complications of childbirth Maternal anemia STD/HIV/AIDS Violence against women Infertility Family planning Legal, safe abortion Safe motherhood Prenatal care Prevention, treatment Legal action, awareness Treatment of STDs

23. Family planning is rarely boring…

24. Controversies in Family Planning: Part II Use of incentives and targets CYP and performance targets Abortion: U.S. and abroad The role of USAID Programs for unmarried youth

25. The use of targets and incentives Incentives: began in Asia in demographically driven programs India: transistor radios; sterilization targets China: incentives and disincentives to achieve the one child policy (“beyond FP”) “Grey areas” – compensation of clients for lost time from work, transportation, a clean sari???

26. CYP and performance targets CYP=couple years of protection Long-term methods contribute more CYP than resupply methods Pre-Cairo: promoting long-term methods was “good” for programs and for women Post-Cairo: is the promotion of long-term methods simply to increase CYP?

27. The spillover of the abortion debate in the US to international FP “Family planning prevents abortion” In the US, Planned Parenthood has vigorously defended abortion rights Conservative “Right to Life” groups in the U.S. extend their attack of Pro-Life groups in the U.S. to the international FP community Controversy in the US Congress over FP = is really about abortion Mexico City clauses

28. Controversy over adolescent programs for unmarried youth In many countries, FP is not longer an issue Why youth programs are needed: – Youth < 15 = 40% in many countries – Modernization, influences from Western media – Increasing age at marriage – Decreasing social controls with urbanization – Economic conditions increase risk to youth (e.g., the Sugar Daddy phenomenon in Africa) – Consequences: morbidity, mortality

29. Successful Programs POP QUIZ #4: HOW DO YOU MEASURE SUCCESSFUL PROGRAMS?

30. Successful Programs Asia: Thailand, Indonesia, China (?) Latin America: Colombia, Costa Rica Africa: Zimbabwe, Kenya, Botswana POP QUIZ #5: What are the elements of a successful program?

31. Elements of a successful program Access to services Quality of care Voluntarism Success facilitated by: – strong socio-economic conditions – strong political will

32. Final Pop Quiz Question Why is Bangladesh such a unique country in terms of its record for family planning?

33. Questions?