- Email: [email protected]
Making family planning a national development priority
Comment
Making family planning a national development priority Published Online July 10, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)60904-0
Giacomo Pirozzi/Panos
See Series page 149
78
We believe that every person should have the right and an equitable opportunity to live a healthy, productive, and fulfilling life. We are committed to steering the development of our countries and uplifting the wellbeing of our people by achieving the Millennium Development Goals (MDGs).1 We attest that development efforts should strike a sustainable balance between the wellbeing of people and the natural environment for the sake of current and future generations. We are pleased with the progress being made by our own countries, and many others in Africa, on MDGs and we recommit ourselves to reinforce action on MDGs where progress has been slow.1 Progress has been particularly slow on MDG 5, which focuses on improving safe motherhood and ensuring universal access to family planning and other reproductive health services.2 We believe that it will be difficult for us to make sustained progress on MDGs without making methods of family planning universally accessible to all women who would like to use them. This is because family planning makes a major contribution to improving the health of mothers and children,3 while also empowering women to participate more in economic productivity4 and enabling families to invest more in education of their children.5 Family planning also helps to slow the high levels of population growth in our countries, which would enhance the capacity of our governments to make necessary investments to improve the quality of
human capital, reduce poverty and hunger,5 preserve natural resources, and adapt to the consequences of climate change and environmental degradation.6 Family planning is about listening to what parents want, not dictating what they should do; it is about enabling women and their partners to decide freely when and how many children they want to have. Current estimates show that more than 40 million women in sub-Saharan Africa alone would like to stop or postpone childbearing but are not using family planning;1 this is a serious cause for concern and a lost opportunity to bolster our development efforts. The demand for family planning in our countries is likely to increase substantially in the near future, as more people decide to have fewer children and more women and men enter their fertile years. The unmet need for family planning in Africa is particularly high among young people, who require targeted interventions to improve their access to reproductive health information, services, and supplies.1 Rates of maternal mortality in most African countries are unacceptably high.2 There is an urgent need for concrete action to reduce the burden of disease among women that results from starting childbearing at a young age and giving birth frequently. In The Lancet’s Series on Family Planning, John Cleland and colleagues7 report that access to family planning can reduce maternal deaths by 40%, infant mortality by 10%, and childhood mortality by 21%. But we also know that family planning is a key investment: it helps to reduce the broader costs of health care since there will be fewer mothers seeking care for pregnancy complications, unsafe abortion, and delivery.8 Rapid population growth occurs when women and girls are not able to decide on the timing and number of children they have. Many countries in Africa have made progress in reducing the proportion of people living in absolute poverty, but partly as a result of population growth the actual number of people living in poverty has increased in many countries.9 Similarly, while sub-Saharan Africa as a region has reduced the percentage of urban residents living in slum settlements from 70% to 62% between 1990 and 2010, the actual number of slum dwellers has doubled to 200 million.10 Rapid population growth www.thelancet.com Vol 380 July 14, 2012
Comment
also undermines the capacity of communities and nations to adapt effectively to the consequences of climate change and environmental degradation.6 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.11 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 2010.12 In Ethiopia, contraceptive use increased from 8% to 29% between 2000 and 2010.13 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. Despite variations in the ways in which we have achieved this progress in our countries, the broad factors are strikingly similar. First, through open and multisector discourse, political leaders, policy makers in government, and other key stakeholders have prioritised family planning and put in place appropriate policies and intervention programmes to facilitate the delivery of contraceptives to people who need to use them, irrespective of their capacity to pay for the services. Second, we have strengthened the capacity of our health systems to deliver family planning—for example, by reinforcing local planning and evaluation capacity, enhancing stock-management systems, and improving training of health workers and www.thelancet.com Vol 380 July 14, 2012
enabling lower level health workers to assume more responsibility in the provision of previously restricted family planning methods. Third, we have extended family planning provision to communities through the direct involvement of community members. This has helped overcome the geographical and financial barriers that many women encounter and has facilitated the direct involvement and support of men and other family members. Fourth, we have promoted and facilitated the involvement of social marketing and a wide range of private health providers in the provision of family planning. We have also forged strong partnerships with religious and traditional leaders, whose support and buy-in are valuable for successful family planning programmes. Finally, through close cooperation with our strategic partners, we have ensured that family planning is allocated the requisite funding to ensure a steady flow and supply of contraceptives to all parts of our countries. However, to ensure sustainable programmes, we call upon other African leaders to increase funding for family planning commodities and related services from national budgets. We are hopeful that the evidence in The Lancet’s Series on Family Planning will add immense value to ongoing efforts to reposition family planning as a key development intervention among African governments and the international community. Pierre Damien Habumuremyi, Meles Zenawi Office of the Prime Minister, Government of Rwanda, Kigali, Rwanda (PDH); and Office of the Prime Minister of the Federal Democratic Republic of Ethiopia, Government of Ethiopia, Addis Ababa, Ethiopia (MZ) PDH is Prime Minister of Rwanda. MZ is Prime Minister of the Federal Democratic Republic of Ethiopia. We declare that we have no conflicts of interest. 1
2
3 4
5
UN. The Millennium Development Goals Report 2011. New York: United Nations, 2011. http://www.undp.org/content/dam/undp/library/MDG/ english/MDG_Report_2011_EN.pdf (accessed May 28, 2012). WHO, UNICEF, UNFPA, the World Bank. Trends in maternal mortality: 1990 to 2010. Geneva: World Health Organization, 2012. http://www. unfpa.org/webdav/site/global/shared/documents/publications/2012/ Trends_in_maternal_mortality_A4-1.pdf (accessed May 28, 2012). Razzaque A, DaVanzo J, Rahman M, et al. Pregnancy spacing and maternal morbidity in Matlab, Bangaldesh. Int J Gynecol Obstet 2005; 89: S41–S49. Joshi S, Schultz PT. Family planning as an investment in development: evaluation of a program’s consequences in Matlab, Bangladesh. New Haven, CT: Yale Economic Growth Center, 2007. Bloom DE, Canning DE. Booms, busts and echoes: how the biggest demographic upheaval in history is affecting global development. Finan Dev 2006; 43: 8–13.
79
Comment
6
7
8
9 10
Guzmán JM, George M, Gordon M, Daniel S, Cecilia T, eds. Population dynamics and climate change. New York: UNFPA and International Institute for Environment and Development, 2009. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012; published online July 10. http://dx/doi.org/10.1016/ S0140-6736(12)60609-6. Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services—estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund (UNFPA), 2012. Hillebrand E. The global distribution of income in 2050. World Develop 2008; 36: 727–40. UN-HABITAT. State of the world’s cities 2010/2011: bridging the urban divide. London: Earthscan, 2011.
11
12
13
Bruce J, Bongaarts J. The new population challenge. In: Mazur L, ed. A pivotal moment: population, justice and the environmental challenge. Washington, DC: Island Press, 2010; 260–75. National Institute of Statistics of Rwanda, Ministry of Health of Rwanda, and ICF International. Rwanda Demographic and Health Survey 2010. Calverton, MD: National Institute of Statistics of Rwanda, Ministry of Health of Rwanda, and ICF International, 2012. Central Statistical Agency Ethiopia, ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia/Calverton, MD: Central Statistical Agency and ICF International, 2012.
Giving women the power to plan their families
Getty Images
Published Online July 10, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)60905-2
80
Millions of girls and women in the world’s poorest countries can transform their lives if needs for family planning—to delay, space, and limit the number of children that women have—are met. Across the developing world, some 222 million women who want to avoid pregnancy are not using a modern method of contraception.1 Despite progress in some areas of the world, this situation has changed little in the past decade.1 The results of providing women with universal access to voluntary family planning are dramatic and wide-ranging. The health benefits would include nearly 600 000 fewer newborn deaths and 79 000 fewer maternal deaths every year.1 Unintended pregnancies would drop by twothirds, resulting in 21 million fewer unplanned births and 26 million fewer induced abortions.1 Beyond health, there are many far-reaching, transformational effects of women being able to use contraception and take control of their fertility. At the
household level, families are able to invest more of their scarce resources in the health and education of their children. Girls from smaller families are more likely to complete their education and women with fewer children are more able to seek employment, increasing household income and assets.2,3 Falling birth rates also bring the potential for a “demographic dividend”, by increasing the ratio of working adults to dependants.4 Countries, including South Korea and Thailand, have capitalised on this window of opportunity for economic growth by investing in the health, education, and welfare of their citizens. And now, with the right investments and policies, countries across the developing world, including massive economies such as India and Indonesia, stand poised to benefit too—transforming the lives of their people and bolstering the global economy.5 It is deplorable that millions of women and men in the world’s poorest countries continue to lack access to quality family planning information, services, and supplies so that they are unable to choose whether, when, and how many children to have. Decades of research incontrovertibly show that family planning saves lives by reducing the number of high-risk pregnancies and reducing recourse to unsafe abortion.1 The persistent unmet need for family planning contributes to what the United Nations (UN) has termed “inadequate progress” towards reducing child mortality and improving maternal health6— Millennium Development Goals (MDGs) 4 and 5.7 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 www.thelancet.com Vol 380 July 14, 2012
Making family planning a national development priority Published Online July 10, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)60904-0
Giacomo Pirozzi/Panos
See Series page 149
78
We believe that every person should have the right and an equitable opportunity to live a healthy, productive, and fulfilling life. We are committed to steering the development of our countries and uplifting the wellbeing of our people by achieving the Millennium Development Goals (MDGs).1 We attest that development efforts should strike a sustainable balance between the wellbeing of people and the natural environment for the sake of current and future generations. We are pleased with the progress being made by our own countries, and many others in Africa, on MDGs and we recommit ourselves to reinforce action on MDGs where progress has been slow.1 Progress has been particularly slow on MDG 5, which focuses on improving safe motherhood and ensuring universal access to family planning and other reproductive health services.2 We believe that it will be difficult for us to make sustained progress on MDGs without making methods of family planning universally accessible to all women who would like to use them. This is because family planning makes a major contribution to improving the health of mothers and children,3 while also empowering women to participate more in economic productivity4 and enabling families to invest more in education of their children.5 Family planning also helps to slow the high levels of population growth in our countries, which would enhance the capacity of our governments to make necessary investments to improve the quality of
human capital, reduce poverty and hunger,5 preserve natural resources, and adapt to the consequences of climate change and environmental degradation.6 Family planning is about listening to what parents want, not dictating what they should do; it is about enabling women and their partners to decide freely when and how many children they want to have. Current estimates show that more than 40 million women in sub-Saharan Africa alone would like to stop or postpone childbearing but are not using family planning;1 this is a serious cause for concern and a lost opportunity to bolster our development efforts. The demand for family planning in our countries is likely to increase substantially in the near future, as more people decide to have fewer children and more women and men enter their fertile years. The unmet need for family planning in Africa is particularly high among young people, who require targeted interventions to improve their access to reproductive health information, services, and supplies.1 Rates of maternal mortality in most African countries are unacceptably high.2 There is an urgent need for concrete action to reduce the burden of disease among women that results from starting childbearing at a young age and giving birth frequently. In The Lancet’s Series on Family Planning, John Cleland and colleagues7 report that access to family planning can reduce maternal deaths by 40%, infant mortality by 10%, and childhood mortality by 21%. But we also know that family planning is a key investment: it helps to reduce the broader costs of health care since there will be fewer mothers seeking care for pregnancy complications, unsafe abortion, and delivery.8 Rapid population growth occurs when women and girls are not able to decide on the timing and number of children they have. Many countries in Africa have made progress in reducing the proportion of people living in absolute poverty, but partly as a result of population growth the actual number of people living in poverty has increased in many countries.9 Similarly, while sub-Saharan Africa as a region has reduced the percentage of urban residents living in slum settlements from 70% to 62% between 1990 and 2010, the actual number of slum dwellers has doubled to 200 million.10 Rapid population growth www.thelancet.com Vol 380 July 14, 2012
Comment
also undermines the capacity of communities and nations to adapt effectively to the consequences of climate change and environmental degradation.6 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.11 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 2010.12 In Ethiopia, contraceptive use increased from 8% to 29% between 2000 and 2010.13 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. Despite variations in the ways in which we have achieved this progress in our countries, the broad factors are strikingly similar. First, through open and multisector discourse, political leaders, policy makers in government, and other key stakeholders have prioritised family planning and put in place appropriate policies and intervention programmes to facilitate the delivery of contraceptives to people who need to use them, irrespective of their capacity to pay for the services. Second, we have strengthened the capacity of our health systems to deliver family planning—for example, by reinforcing local planning and evaluation capacity, enhancing stock-management systems, and improving training of health workers and www.thelancet.com Vol 380 July 14, 2012
enabling lower level health workers to assume more responsibility in the provision of previously restricted family planning methods. Third, we have extended family planning provision to communities through the direct involvement of community members. This has helped overcome the geographical and financial barriers that many women encounter and has facilitated the direct involvement and support of men and other family members. Fourth, we have promoted and facilitated the involvement of social marketing and a wide range of private health providers in the provision of family planning. We have also forged strong partnerships with religious and traditional leaders, whose support and buy-in are valuable for successful family planning programmes. Finally, through close cooperation with our strategic partners, we have ensured that family planning is allocated the requisite funding to ensure a steady flow and supply of contraceptives to all parts of our countries. However, to ensure sustainable programmes, we call upon other African leaders to increase funding for family planning commodities and related services from national budgets. We are hopeful that the evidence in The Lancet’s Series on Family Planning will add immense value to ongoing efforts to reposition family planning as a key development intervention among African governments and the international community. Pierre Damien Habumuremyi, Meles Zenawi Office of the Prime Minister, Government of Rwanda, Kigali, Rwanda (PDH); and Office of the Prime Minister of the Federal Democratic Republic of Ethiopia, Government of Ethiopia, Addis Ababa, Ethiopia (MZ) PDH is Prime Minister of Rwanda. MZ is Prime Minister of the Federal Democratic Republic of Ethiopia. We declare that we have no conflicts of interest. 1
2
3 4
5
UN. The Millennium Development Goals Report 2011. New York: United Nations, 2011. http://www.undp.org/content/dam/undp/library/MDG/ english/MDG_Report_2011_EN.pdf (accessed May 28, 2012). WHO, UNICEF, UNFPA, the World Bank. Trends in maternal mortality: 1990 to 2010. Geneva: World Health Organization, 2012. http://www. unfpa.org/webdav/site/global/shared/documents/publications/2012/ Trends_in_maternal_mortality_A4-1.pdf (accessed May 28, 2012). Razzaque A, DaVanzo J, Rahman M, et al. Pregnancy spacing and maternal morbidity in Matlab, Bangaldesh. Int J Gynecol Obstet 2005; 89: S41–S49. Joshi S, Schultz PT. Family planning as an investment in development: evaluation of a program’s consequences in Matlab, Bangladesh. New Haven, CT: Yale Economic Growth Center, 2007. Bloom DE, Canning DE. Booms, busts and echoes: how the biggest demographic upheaval in history is affecting global development. Finan Dev 2006; 43: 8–13.
79
Comment
6
7
8
9 10
Guzmán JM, George M, Gordon M, Daniel S, Cecilia T, eds. Population dynamics and climate change. New York: UNFPA and International Institute for Environment and Development, 2009. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012; published online July 10. http://dx/doi.org/10.1016/ S0140-6736(12)60609-6. Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services—estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund (UNFPA), 2012. Hillebrand E. The global distribution of income in 2050. World Develop 2008; 36: 727–40. UN-HABITAT. State of the world’s cities 2010/2011: bridging the urban divide. London: Earthscan, 2011.
11
12
13
Bruce J, Bongaarts J. The new population challenge. In: Mazur L, ed. A pivotal moment: population, justice and the environmental challenge. Washington, DC: Island Press, 2010; 260–75. National Institute of Statistics of Rwanda, Ministry of Health of Rwanda, and ICF International. Rwanda Demographic and Health Survey 2010. Calverton, MD: National Institute of Statistics of Rwanda, Ministry of Health of Rwanda, and ICF International, 2012. Central Statistical Agency Ethiopia, ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia/Calverton, MD: Central Statistical Agency and ICF International, 2012.
Giving women the power to plan their families
Getty Images
Published Online July 10, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)60905-2
80
Millions of girls and women in the world’s poorest countries can transform their lives if needs for family planning—to delay, space, and limit the number of children that women have—are met. Across the developing world, some 222 million women who want to avoid pregnancy are not using a modern method of contraception.1 Despite progress in some areas of the world, this situation has changed little in the past decade.1 The results of providing women with universal access to voluntary family planning are dramatic and wide-ranging. The health benefits would include nearly 600 000 fewer newborn deaths and 79 000 fewer maternal deaths every year.1 Unintended pregnancies would drop by twothirds, resulting in 21 million fewer unplanned births and 26 million fewer induced abortions.1 Beyond health, there are many far-reaching, transformational effects of women being able to use contraception and take control of their fertility. At the
household level, families are able to invest more of their scarce resources in the health and education of their children. Girls from smaller families are more likely to complete their education and women with fewer children are more able to seek employment, increasing household income and assets.2,3 Falling birth rates also bring the potential for a “demographic dividend”, by increasing the ratio of working adults to dependants.4 Countries, including South Korea and Thailand, have capitalised on this window of opportunity for economic growth by investing in the health, education, and welfare of their citizens. And now, with the right investments and policies, countries across the developing world, including massive economies such as India and Indonesia, stand poised to benefit too—transforming the lives of their people and bolstering the global economy.5 It is deplorable that millions of women and men in the world’s poorest countries continue to lack access to quality family planning information, services, and supplies so that they are unable to choose whether, when, and how many children to have. Decades of research incontrovertibly show that family planning saves lives by reducing the number of high-risk pregnancies and reducing recourse to unsafe abortion.1 The persistent unmet need for family planning contributes to what the United Nations (UN) has termed “inadequate progress” towards reducing child mortality and improving maternal health6— Millennium Development Goals (MDGs) 4 and 5.7 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 www.thelancet.com Vol 380 July 14, 2012