Despite decades of progress that has dramatically changed the family planning landscape since the 1960s, an estimated 257 million people today do not use modern methods of contraception to prevent pregnancy, according to the UN Population Fund. Of those, 172 million do not use any form of family planning at all.
The consequences of unintended pregnancies include high maternal mortality rates and poor child survival rates, especially among the world’s most vulnerable. According to the Guttmacher Institute, unintended pregnancies, unsafe abortions and maternal deaths would decrease by about two-thirds if all women in low- and middle-income countries had access to effective family planning methods.
What is holding back progress? Misinformation, stigma and opposition from husbands, relatives, religious leaders, policy makers and others can all undermine women’s ability to practice family planning and achieve their reproductive goals. Understaffed, undersupplied family planning clinics in remote locations also make access a challenge. And insufficient government funding puts these services further out of reach.
One possible solution: integrating family planning and reproductive health services into fast-growing universal health coverage (UHC) initiatives so that they become part of the primary health care provided in district hospitals and local clinics.
“People naturally think of care institutions when they need care. It is more efficient to eliminate parallel systems. Community funding options, even on a very small scale, have worked well and been very acceptable,” said Funmilola OlaOlorun, MBBS, PhD ’13, MPH, who serves as co-principal investigator for Performance Monitoring for Action (PMA)/Nigeria.
The pandemic offered a glimpse into how this can work. Governments in several sub-Saharan African countries, including Kenya, Tanzania and Uganda, have designated family planning as an essential service in their response efforts. Local health officials partnered with local pharmacies to distribute oral contraceptives, emergency contraception and condoms — measures believed to help keep contraceptive use stable amid pandemic disruptions.
“One of the confusing things is that we were able to keep family planning in the early years of COVID-19,” said Beth Fredrick, executive director of Advance Family Planning, a global initiative of the Bill & Melinda Gates Institute for Population and Reproductive Health at the Bloomberg School. She praises local advocates’ long-standing effort with AFP and other groups to expand governments’ say in the agenda.
The pandemic also brought innovations, such as the delivery of health care at a distance or the community distribution of family planning methods, to new locations, says Celia Karp, PhD ’20, an assistant scientist in population, family and reproductive health . “I think of those efforts [to improve family planning] adopted as standard practice now illustrates an opportunity to potentially improve UHC delivery, building on the lessons learned from COVID-19,” says Karp.
It’s a pivotal moment for family planning advocates. Some have turned to UHC as a natural path to steel family planning services against the vagaries of politics and pandemics. They make a compelling argument: Including family planning services in UHC programs not only helps ensure access to everyone in need, it also makes financial sense. According to an estimate by the Guttmacher Institute, every dollar spent on contraceptive services (beyond current spending) can reduce costs for pregnancy and newborn care by $3.
But Fredrick and others are concerned that the funds spent on family planning prior to the pandemic may not be replenished. “As we move into the longer term, things are shifting… and it’s not clear whether the commitment will hold,” says Fredrick. Continued support for local advocates will be critical to ensuring governments continue to invest in family planning, she said.
Thailand, host of the international conference on family planning in November (see box), offers a compelling model. Long a proponent of family planning, the country introduced a UHC plan in 2002 that provided universal access to essential health services at no cost to all citizens. As part of the effort, Thailand has expanded access to primary health care sexual and reproductive health services by placing a family planning clinic in all government hospitals; providing family planning training to all midwives, nurses and physicians; and cover the cost of contraceptives. While UHC is not the only reason for Thailand’s success, contraceptive use among all women in the country rose from 15% to 70% between 1971 and 2019. In addition, between 2000 and 2017, the maternal mortality rate fell from 43 per 100,000 living. births in 2000 to 37 in 2017, the World Bank also noted.
However, other countries have less consistent political support for integrating family planning services into UHC. The Challenge Initiative (TCI), another Gates Institute-led program, supports local governments in urban areas in 12 countries to take the lead in scaling up impactful family planning interventions. TCI also advocates that city ministries of health spend their own money on family planning services — and several cities have already “graduated” on sustainability.
Kenya’s Kilifi County, for example, is making remarkable progress despite health problems, including a high rate of teenage pregnancy, according to Paul Nyachae, MPH, TCI’s project director for East Africa. “When we started the program, the province had no budget to run family planning as an independent program in line with their health strategy; by the end, it did – along with a significant increase in financial commitment from the Department of Health,” he says. County officials praise the partnership for reducing the county’s pregnancy rate among adolescents ages 10–19 from 31% in 2020 to 14% in mid-2021.
Huge challenges remain across East Africa, starting with a lack of political will. But seeing the success of other cities has helped convince more leaders to get on board. “The cities left behind can see what they are missing. Our goal is to support greater self-reliance of local governments, leading to sustainable improvement of urban health systems and inspiring them to develop their programs much further,” says Nyachae.