Family Planning Makes a Comeback with the U.S. Global Health Initiative, But Can We Make It Stay?

This is a joint post with Freddie Ssengooba.Family planning is making news again. A new 12 million dollar family planning drive was launched by the U.S. government highlighting how the Obama administration’s funding has kick-started a contraception drive in Africa and other developing countries AND the International Family Planning 2009 Conference just closed in Kampala, Uganda, apparently the first such conference in 17 years! This is a sign of changing times.In her opening remarks at the conference, Amy Tsui of Johns Hopkins University (one of the key conference organizers) and director of the Bill and Melinda Gates Institute for Population and Reproductive Health, lamented the decline in attention to family planning over the last decade, and called for action in a new era that will focus on this critical issue. “Welcome back to Family Planning!” she said at the opening plenary. By the end of the 3 day conference, after multiple sessions on topics ranging from integration, commodity security, male involvement in family planning, etc. closing comments from Ward Cates (FHI) suggest that we have “reached a tipping point” for family planning as it makes a comeback in this era of AIDS. The HIV/AIDS problem is nowhere near solved but where the issue fell silent/restricted in the Bush era, there is strong recognition by the Obama administration that HIV cannot be tackled without investments in family planning and reproductive health. And the message is clearly filtering across the Atlantic to Africa and other continents.My colleague Freddie Ssengooba, a key research partner in Uganda for the HIV/AIDS Monitor, participated in this conference. Below he shares his thoughts on the conference including the three key issues that stood out for him:

It is now over, and time to bid farewell to over 1300 delegates from about 59 countries that have camped at Speke-Resort Hotel in Kampala to discuss family planning. It has been a beehive of activity at the conference with over 70 technical session, about 400 scientific presentations with lots of side activities piggybacking on the conference. As I leave the conference, what stands out for me as the important observations are three issues:1) the focus on integration of family planning into HIV programs;2) the partnerships that have been on display on every presentation at the conference, and3) the scope of innovations for family planningIt was invigorating to see so many agencies implementing HIV services at the family planning conference. Many were bold about their motives to integrate FP now that the policy environment in the US had become favourable to do so. Of the six parallel tracks for the 3-day conference, one was dedicated to “Integrating Family Planning and HIV Programs”. For the last 3 days I spent most of my time attending presentations in this track and the track on “Effective Programming and Service Delivery”. Most of the papers about integration were coming from the context of agencies implementing HIV programs. The technical presentations were reflective of the efforts of HIV agencies to reposition themselves to the new policy environment. When I expressed my surprise to find a renowned HIV research director here in Uganda at the conference, he was frank about why he had come, “Family planning is not my area but with the Obama Administration turning the tables about the HIV programs, we are diversifying our work to include reproductive health and family planning; we are reading the times.”Indeed so many U.S. organizations are reading the times and have used the conference to showcase their work on family planning. The plenary sessions were dominated by U.S. agencies, U.S. funders and some UNFPA officials. The power point slides were full of logos of U.S. agencies working in partnership to implement FP programs in African and Asia. In the plenary session where I too presented, there were two papers that stuck in my mind. Both were celebrating the spirit of partnership in providing family planning services in Kenya. Despite the diplomacy that characterizes many plenary speeches, the presenter from Kenya kept talking about “tough fights” among partners and mentioned this issue about five times in her ten minutes speech. It wasn’t until her last PowerPoint slide that the evidence for her observation of the “tough fights” emerged. This slide had about 15 logos of all agencies working (or fighting) to implement one USAID grant for family planning services in Kenya. In there lies the challenges for a really effective and sustainable response to family planning programs. Talking about effectiveness and sustainability issues, the conference track about effective programming and service delivery had some serious and hilarious sessions. Innovations were broad and varied from the use of pay-for-performance incentives to hands-on assistance to build capacity of community groups to supply contraceptive commodities. However, what caught my attention was the use of the mobile phone and toll free lines for family planning information in DR Congo, a country with large areas that are still rural and sparse telephony. When they started the program, the younger innovators in DR Congo were very surprised to receive most calls from men from affluent towns – most of them seeking to find sexual partners! As I thought about the gender dynamics of mobile phone ownership in Africa, I was reminded that family planning is part of the broader concept of sexual and reproductive health! This is a fact that is all too easy to forget when family planning programs are targeted to women only.

Freddie’s reflections about country level responses to changing U.S. global health policy trigger three key issues/actions that the Obama Administration should be thinking about as they design a U.S. Global Health Initiative (GHI) and a new global development strategy:Ensure that responding to unmet need for family planning in countries is a core component of the US approach to global health and development beyond this administration’s termShifts in U.S. policy and funding can completely change the conversation and action about how health is packaged and delivered in the developing world. It did in the Bush era and it’s doing so now. Two examples of shifting policies stand out: 1) Consider the Mexico City policy. The August 1984 announcement by President Reagan directed USAID to withhold USAID funds from NGOs that use non-USAID funds to engage in a wide range of activities, including providing advice, counseling, or information regarding abortion, or lobbying a foreign government to legalize or make abortion available. The Mexico City Policy was in effect from 1985 until 1993, when it was rescinded by President Clinton. President George W. Bush reinstated the policy in 2001 and President Obama’s issued a memorandum to rescind the Mexico City policy in Jan 2009, two days after taking office!; 2) President Obama’s decision in March 2009 to restore U.S. funding for UNFPA, which had been suspended since 2002. How can the U.S. maintain its influential position responsibly (other than money) to let evidence rather than politics drive policies? The current administration is working very hard to build on the PEPFAR platform to create a Global Health Initiative (GHI) that will support evidence-based policies of the Obama administration, enabling the design and implementation of integrated health programs with U.S funding. But when this President and his men and women leave office, will family planning fall off the agenda all over again? Is there a way for the Obama administration to create an independent global health policy making body in government that would allow for the continuity of evidence based policies that are working, regardless of the administration? This could avoid the now-you-see-it, now-you-don’t foreign aid game we play with countries every 4-8 years?Design family planning programs for men and women as part of broader focus on sexual and reproductive health, and with other health programsFamily planning programs must target both women and men in the context of their sexual and reproductive health needs, including those related to HIV/AIDS. From a recent review of Integration of STI and HIV Prevention, Care, and Treatment into Family Planning Services “the weight of evidence demonstrates that integrated services can have a positive impact on client satisfaction, improve access to component services, and reduce clinic-based HIV-related stigma, and that they are cost-effective.” The inter-agency team that is working to develop the GHI strategy has all the right policy ingredients to make this happen. What remains to be seen is how these integrated programs will be designed and delivered at the country level for greater impact, not just on fertility outcomes but also for other health outcomes.Make family planning programs the country’s programs Freddie’s description of the dominance of USG agencies and NGOs all jostling for center stage at this conference drives home the point that family planning programs have to be owned by countries, not by U.S. agencies or U.S. NGOs. The GHI is being developed with a strong operating principle of country ownership, which should change the way in which the U.S. does its development business with partner countries. Will this change in ownership be reflected in the way that U.S. agencies and NGOs actually function in country?It is exciting that the Obama administration is bringing family planning back into global health and development. Let’s do what we can this time to ensure that family planning is here to stay.