Title: The Politics of Family Planning Policies and Programs in sub‐Saharan Africa
Abstract: Population and Development ReviewVolume 43, Issue S1 p. 308-329 POLICIES AND PROGRAMSFree Access The Politics of Family Planning Policies and Programs in sub-Saharan Africa John F. May, John F. MaySearch for more papers by this author John F. May, John F. MaySearch for more papers by this author First published: 03 October 2016 https://doi.org/10.1111/j.1728-4457.2016.00165.xCitations: 41AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat The 48 sovereign countries of sub-Saharan Africa (SSA) are at various stages of their demographic and fertility transitions. All have experienced specific, sometimes unique, historical and socioeconomic developments. It is therefore difficult to summarize in a few brush strokes the main features of the demographic evolution of such a vast and diverse continent. High African fertility levels are rooted in cultural and traditional reproductive regimes. Given the very high—by international standards—levels of infant and child mortality, couples have traditionally tried to protect and save as many newborns as possible. Their main strategy to ensure the survival of the largest possible pool of children has been to space births. In order to protect a new baby, couples have consistently delayed the occurrence of a next pregnancy. Social disapproval of an early next pregnancy has been widespread. The desire to cease childbearing, by contrast, is rare and the vast majority of African women say they want more children (see Frank 1987 for a general discussion of SSA reproduction regimes around that time; see also Caldwell and Caldwell 1987; Kokole 1994). Traditionally, the length of long birth intervals has shortened because, until fairly recently (i.e., before ca. 1990), less-effective forms of fertility regulation have generally been used. African couples have gradually abandoned traditional methods of birth spacing without immediately turning to modern methods of contraception. Among the inhibiting proximate determinants of fertility, the importance of postpartum infecundability (essentially linked to prolonged breastfeeding) has declined, whereas uptake of modern contraceptive use has not occurred on a large scale (May et al. 1990: 20–21). Similarly, couples have also gradually abandoned postpartum abstinence, separation, and withdrawal. As a result, fertility increased in many SSA countries in the 1980s, as a consequence of both improved health conditions and the abandonment of traditional birth spacing methods. Fatalistic attitudes toward reproduction, namely that "God will provide" or that children are "up to God," have also shaped African couples' traditional behavior, as have the social and economic advantages that may come from large families in rural settings and that encourage high fertility preferences (Caldwell and Caldwell 1987). Although urbanization is progressing at a rapid pace and catching up with the rest of the developing world, the continent is still largely rural, and this may favor traditional attitudes as well. Against this background, it is not surprising that sub-Saharan Africa has been a latecomer to the fertility transition. As noted by Bongaarts and Casterline (2012: 160), fertility preferences and ideal family size are higher in SSA than in other developing regions. The same authors have also noted that "the recent pace of the fertility decline in Africa is slower than the pace observed in Asia and Latin America in the 1970s" (ibid.: 155). Moreover, in several African countries, the fertility transition has stalled at a level of four, and sometimes five, children per woman (ibid.: 166; see also Bongaarts 2006, 2008: 108–109). Overall, progress in modern contraceptive prevalence rates (CPRs) has been slow (see Table 1). Between 1990 and 2010, the CPR for the entire African region (including Northern Africa) increased at the pace of 0.7 percentage points per year (Alkema et al. 2013: 1645). This is in sharp contrast to the experience of many emerging market economies (i.e., economies with middle per capita income) where contraceptive coverage has increased over sustained periods of time at the rate of 2 and sometimes 3 percentage points per year, resulting in much higher CPRs (Guengant and May 2013: 228–229). Table 1. Contraceptive prevalence, unmet need, total demand for contraception, and total fertility rate for 40 sub-Saharan African countries, 1990 and 2010 Contraceptive prevalence (%) Unmet need (%) Total demand for contraception (%) Total fertility rate 1990 2010 1990 2010 1990 2010 1990 2010 Western Africa Benin 10.9 19.4 28.1 28.3 39.0 47.7 6.0 5.1 Burkina Faso 6.8 16.8 26.5 30.2 33.3 47.0 6.6 5.9 Côte d'Ivoire 7.7 17.6 29.9 30.4 37.6 48.0 5.9 5.2 Gambia 10.2 20.8 31.6 31.3 41.8 52.1 5.9 5.8 Ghana 15.1 24.2 36.0 35.6 51.1 59.8 4.7 4.3 Guinea 1.8 10.8 24.6 24.6 26.4 35.4 6.1 5.3 Guinea-Bissau 5.1 13.6 28.7 30.3 33.8 43.9 5.8 5.1 Liberia 7.0 12.9 33.1 35.0 40.1 47.9 5.9 5.0 Mali 3.9 9.3 26.1 29.2 30.0 38.5 6.9 6.5 Mauritania 3.2 12.4 30.1 31.9 33.3 44.3 5.4 4.8 Niger 3.9 12.3 19.5 19.3 23.4 31.6 7.7 7.7 Nigeria 7.2 14.4 21.2 21.2 28.4 35.6 6.1 5.8 Senegal 7.2 12.7 33.3 33.2 40.5 45.9 5.6 5.2 Sierra Leone 2.7 7.6 28.4 29.9 31.1 37.5 6.2 5.2 Togo 25.0 16.7 42.4 36.4 67.4 53.1 5.4 4.9 Eastern Africa Burundi 8.4 21.9 27.3 29.2 35.7 51.1 7.1 6.3 Eritrea 5.4 15.2 28.9 29.7 34.3 44.9 5.4 4.6 Ethiopia 2.6 26.9 32.1 27.2 34.7 54.1 6.5 4.9 Kenya 28.5 47.3 36.5 24.7 65.0 72.0 5.0 4.6 Madagascar 14.3 40.4 31.0 20.5 45.3 60.9 5.5 4.7 Malawi 11.6 45.0 35.2 26.9 46.8 71.9 6.3 5.5 Mozambique 4.0 13.2 24.3 23.8 28.3 37.0 5.8 5.6 Rwanda 17.9 49.5 37.2 20.6 55.1 70.1 5.7 4.5 South Sudan 0.6 4.9 27.7 29.1 28.3 34.0 6.2 5.4 Uganda 6.9 28.4 32.2 35.6 39.1 64.0 6.9 6.2 Tanzania 11.1 34.3 27.2 25.6 38.3 59.9 5.7 5.4 Zambia 14.5 43.2 29.3 25.1 43.8 68.3 6.1 5.7 Zimbabwe 44.3 58.9 21.6 15.9 65.9 74.8 4.1 4.0 Middle and Central Africa Angola 4.2 12.9 27.4 28.8 31.6 41.7 6.9 6.4 Cameroon 12.1 25.6 22.9 22.2 35.0 47.8 5.6 5.0 Central African Rep. 11.8 26.3 21.3 22.7 33.1 49.0 5.4 4.6 Chad 1.9 5.5 19.8 21.8 21.7 27.3 7.3 6.6 Congo (Brazzaville) 24.6 44.6 25.4 19.8 50.0 64.4 5.1 5.0 Congo (Dem. Rep.) 13.9 19.3 28.4 27.8 42.3 47.1 7.0 6.4 Gabon 21.0 38.5 30.0 25.5 51.0 64.0 4.6 4.1 Southern Africa Botswana 34.7 53.1 26.4 18.6 61.1 71.7 3.4 2.9 Lesotho 20.7 47.9 33.4 23.4 54.1 71.3 4.1 3.3 Namibia 29.8 55.9 23.9 19.1 53.7 75.0 4.1 3.6 South Africa 49.5 63.7 20.2 12.7 69.7 76.4 2.9 2.5 Swaziland 21.7 62.6 34.7 16.6 56.4 79.2 4.3 3.6 SOURCES: Alkema et al. (2013) (contraceptive prevalence rates combine modern and traditional methods). Total fertility rates from United Nations (2015). Nonetheless, some sub-Saharan countries have experienced rapid uptake of contraceptive methods and subsequent fertility declines. As illustrated in Table 1, several countries (e.g., Ethiopia, Kenya, Madagascar, Malawi, Rwanda, and Zimbabwe as well as countries in Southern Africa) have led successful family planning programs. (Contraceptive prevalence data presented here combine modern and traditional methods.) Among these countries, Ethiopia, Malawi, and Rwanda have significantly increased their CPRs and reduced their fertility levels in the past 20 years. For example, Ethiopia has decreased its total fertility rate by almost two children between 1990 and 2010 (see Table 1), and fertility has declined even faster since (Admassie et al. 2015: 6). Southern Africa and Zimbabwe have experienced lower fertility and higher contraceptive use sooner than the rest of SSA. Despite successful family planning programs in some countries, several additional factors may explain the overall modest progress of family planning in the region. First, the attitude of African policymakers has often been at best lukewarm toward family planning programs, and, as such, their attitudes have reflected the opinions of their constituencies. Most African leaders have adhered to other development priorities and have not endorsed the need to promote modern contraceptive use. Second, external donors from multilateral, bilateral, and non-governmental organizations (NGOs) have to some extent influenced African leaders and policymakers. However, ideas on population issues advanced by donors have occasionally been challenged by African governments and their constituencies. Third, on the policy front, population, family planning, and public health paradigms and program priorities have also varied during the past 30 years or so, both among sub-Saharan governments and their development partners. Family planning programs have been prioritized at times, but have fallen out of fashion at others (e.g., during the HIV/AIDS crisis). Moreover, the rationale for family planning interventions has also evolved over time. This chapter examines the politics of family planning policies and programs in SSA. The analysis is carried out from three different angles, namely the attitudes of African policymakers and the opinions of their constituencies, the role of donors and NGOs, and the shifting family planning and public health paradigms and priorities. The chapter also assesses the effectiveness of family planning programs in SSA and offers some suggestions to chart the way forward. Attitudes of African policymakers Traditionally, sub-Saharan leaders and policymakers have not been proactively engaged in programs aimed at reducing fertility. Population and family planning issues have long been absent from discussions on population and development in the region. African media do not mention demographic issues on a regular basis. Very few countries have promoted family planning through widespread, repetitive, and consistent information, education, and communication (IEC) campaigns, although the situation has started to change in the past 15 years. Limited economic and social development has also contributed to poor access to contraceptive services in the region. Moreover, African leaders' views on fertility have been affected by traditional cultures and social norms. In particular, African leaders' attitudes are framed by their relationship with their people and their ethnic groups as well as local social institutions. For example, polygyny, male dominance, attitudes and practices that treat women as "property" (e.g., passing on a widow to a brother), the notion that life begins even before conception, and beliefs that women must prove their worth in marriage through fertility are all factors, found in varying degrees across countries, that contributed to African leaders' views on population and family planning (Frank 1987; Caldwell and Caldwell 1987). Many African leaders have perceived large populations to be socially and economically advantageous, and probably to be a political advantage as well (Kokole 1994). In recent years, the economic successes of China have been highlighted in SSA as proof that a large population is conducive to rapid economic growth. However, proponents of this thesis never mention that since the early 1970s China experienced a rapid fertility decline (accelerated by the adoption of the one-child policy in 1979), which partly explains its current economic prowess. When prodded on the demographic dimensions of the population and development debate, one of the first arguments African leaders usually pose to family planning advocates is the geographical vastness of the continent. These African leaders routinely stress that Africa's population density is low. Indeed, at 41 persons per square kilometer, sub-Saharan Africa's population density is about a tenth of that of India (Population Reference Bureau 2014). In addition, African policymakers often questioned the motivations of Western countries wishing to mitigate rapid population growth in African nations, and pointed to the many other development needs of their countries (National Research Council 1993: 6–7). Their position is often akin to the motto voiced at the World Population Conference in Bucharest in 1974: "Development is the best contraceptive." Family planning and especially the rapid reduction of fertility were also perceived, and still are in many instances, as paving the way to rapid population aging. In the experience of this author, African leaders opposing rapid fertility reduction often claim that they do not want Africa to become "old like Europe and East Asia." The fear of population aging in the most developed countries is therefore used in Africa as an argument against embarking on a rapid fertility transition. It is no surprise, therefore, that few African policymakers have been genuinely committed to the introduction and expansion of family planning programs. An interesting observation in this connection is that African leaders have seldom staged public visits to a family planning clinic. African policymakers' pronatalist views might also be shared by many African demographers and population specialists, although not by African family planning professionals. Few African population specialists express views on population and development issues that might be perceived as being tainted by Malthusianism. In fact, the accusation of being Malthusian is often leveled at those who may try to flag population and development issues in the continent. African leaders usually posit that development efforts and faster economic growth per se will eventually lower high fertility levels. In a Francophone Western African country, a Minister of Finance recently dismissed the issue of rapid population growth altogether, claiming that the country was on track to reach double-digit economic growth. Indeed, in their public declarations African leaders claim that the core challenge at hand is to promote faster socioeconomic development and to invest in human capital formation (education and health) in order to foster economic growth. Such statements can be found in most national population policies adopted over the past 30 years. A striking exception was a speech made in Matameye in 1985 by the late President of Niger Seyni Kountché, who stressed the huge demographic challenge confronting Niger (Barrère et al. 1999: 3). However, whereas there is no consensus on the demographic and/or economic rationale for interventions on fertility through wider access to modern contraception, the health rationale for family planning has generally been accepted as a way to enhance the survival prospects of women and children. Today, very few leaders and policymakers in SSA accept the idea that rapid population growth might be detrimental to the development prospects of their countries and, consequently, that high levels of fertility need to be lowered through better access to modern family planning methods, enhanced female education and empowerment, as well as extensive IEC campaigns. A rare recent example of an African leader committed to family planning was Marc Ravalomanana, President of Madagascar between 2002 and 2009. Part of his rationale was to curb the high prevalence of induced abortion. At his request, the Malagasy Ministry of Health became in 2004 the Ministry of Health, Family Planning and Social Protection (Ravalomanana 2006). In the 2000s, contraceptive coverage increased rapidly in the country. However, these efforts were not supported by national policy coalitions. After 2009, the ministry was renamed Ministry of Public Health. Even African leaders who are convinced of the validity of the rationale to curb high fertility levels might decide not to intervene because they do not want to antagonize their constituencies and create unwanted political problems. As experienced by this author, this was the case of Modibo Sidibé, former Prime Minister of Mali (2007–2011), who had also been Minister of Health (1993–1997). One of several new amendments to that country's 1962 Family Code, prepared in 2009, would have defined marriage as a secular institution and, among other stipulations, would have raised the legal age for marriage to 18 years. The proposed Family Code amendments were aimed at launching a wave of modernization, which conflicted with the Muslim foundations of Malian society. The proposed changes were eventually altered after demonstrators had taken massively to the streets of Bamako. This setback in Mali points to the problem of "policy space," which can be defined as the support from the government's stakeholders (voters, lobbyists, beneficiaries, employees, political managers, critics, and donors) that enables the deployment of resources to agreed groups and purposes. Sometimes, pressing population issues cannot even be discussed, because the leadership does not have the "space" to address them. Indeed, in some socio-cultural and religious settings sensitive issues (e.g., early or child marriage, adolescent access to family planning services, induced abortion, etc.) are considered politically off-limits. African leaders and policymakers might well be aware of the challenges posed by rapid population growth, but they can rarely muster the political will and courage to counter entrenched views and established constituencies. In some countries, ethnic rivalries may render any reform on sensitive topics, such as population and family planning, even more problematic (Kokole 1994: 76–80). Last but not least, African public authorities do not consider that demographic variables are likely to be modified by deliberate public interventions. Public authorities seldom consider population and family planning issues to be their responsibility. Situations of strong population pressure may be met by a lack of proactive policy responses (May 2012: 59–60). Nonetheless, African policymakers and population professionals have been exposed to a wealth of information on population, development, family planning, and reproductive health issues. They have attended numerous international conferences and associated preparatory meetings that have embraced and promoted the population and family planning agenda. However, the gap between conference resolutions and the policies and programs implemented at the country level (the "implementation gap") remains wide. Conference recommendations are generally adopted in a specific, often euphoric context, more like declarations of principle than concrete engagements. Assurances for funding are seldom followed by concrete actions (May 2012: 110). Once back home, leaders, policymakers, and experts are confronted by local realities, which are not conducive to bold and significant changes on the family planning policy front. An example is the Africa Union's 2003 Women's Protocol and associated 2010 Maputo Plan of Action on Sexual and Reproductive Health. Among the many signatories, only one country, Rwanda, has updated national legislation as required ("implementation gap"). Several countries have not even signed the Plan of Action ("adoption gap"). Despite the generally negative attitudes of African leaders outlined above, some positive changes in the policy climate related to population and family planning occurred starting in the 1980s, as a result of major economic and political crises. The evolution of African governments' attitudes toward population issues, including their views on family planning, is illustrated by the United Nations series of periodic inquiries launched in 1963 and entitled United Nations Inquiry among Governments on Population and Development (United Nations 2013). At the end of the 1980s, 27 of 45 governments in the sub-Saharan region viewed their fertility levels as being too high (National Research Council 1993: 9). More recently, African government leaders have come to appreciate the linkages between rapid population growth and socioeconomic development. They have also seen the potential health benefits of family planning interventions. In the 1984 Kilimanjaro Action Program, African leaders endorsed family planning and the need to integrate it within broader maternal and child health (MCH) interventions. At the 1984 International Conference on Population, held in Mexico City, African representatives requested more donor support for family planning programs (National Research Council 1993: 9). At that time, the three most successful programs in sub-Saharan Africa were found in Kenya, Botswana, and Zimbabwe. In the past 15 years, the possibility for countries to reap the benefits of a demographic dividend has come to dominate policy discussions on population and development in SSA. The first demographic dividend, which is in essence an economic surplus, is triggered when, owing to the fast decline of fertility, the working-age population becomes relatively larger and the dependency ratio for young people becomes more favorable. A second demographic dividend may become available when aging workers start to benefit from their savings and investments (Lee and Mason 2006). The literature on the demographic dividend in SSA has grown substantially in recent years (Gribble and Bremner 2012; World Bank 2015). In Ethiopia, for instance, the government has been keen to put into place the necessary human capital development policies to facilitate the capturing of the first demographic dividend (Admassie et al. 2015: 3, 16–18). In Uganda, President Yoweri Museveni, who had long opposed fertility reduction programs, was swayed by arguments about the potential of a demographic dividend for his country at the launch of Uganda's demographic dividend report in July 2014 (see http://www.afidep.org, accessed on April 14, 2016). Role of donors and NGOs Against the backdrop of the traditional reluctance to address population and family planning challenges in the region, one needs to ascertain the role of the international donor community, i.e., multilateral and bilateral donors as well as NGOs and the private philanthropic funders. The role of the donor community has been important on several fronts, including demographic data collection, funding of family planning programs, support to national population policies, and advocacy and policy dialogue on population and development issues. Donors have played a significant role in data collection, supporting four rounds of African censuses from 1965 to date (essentially funded by the United Nations and the US Census Bureau). In addition, they funded two major series of demographic surveys, namely the World Fertility Surveys (WFS) and, thereafter, the Demographic and Health Surveys (DHS) (the bulk of the funding coming from the US Agency for International Development). International donors also contributed to the development of demographic surveillance systems in several African countries, most notably in Navrongo in northern Ghana and in Pikine, in the suburbs of Dakar, Senegal. Finally, vital registration was strengthened, although it remains the weak link in African demographic data collection (Kekovole and Odimegwu 2014: 305). These broad-based efforts to collect demographic data have enabled African countries to achieve a greater understanding of their population and development challenges and eventually to design population and family planning policies and programs. These efforts were facilitated by comprehensive capacity-building and training programs going back to the 1950s (e.g., Population Council and University of Michigan fellows, and fellowships for Ph.D. students in North America, Europe, and Australia). Donors have also been instrumental in establishing the first family planning programs in the continent, which they funded extensively. The role of donors was quite clear in the case of Ghana and Kenya, which initiated family planning programs early on. In 1958, Kenya had benefited from financial assistance from the Pathfinder Fund to support local family planning associations. The Family Planning Association of Kenya, an affiliate of the International Planned Parenthood Federation (IPPF), was established in 1962. In 1965, the government of Kenya invited the Population Council to lead a mission on population policy. The following year, the Ministry of Health established a national family planning program, and beginning in 1967 family planning services were offered free of charge. In 1971, the World Bank started to support Kenya's expanded family planning program (Heisel 2007: 394). In the 1970s, the country had one of the highest TFRs in the world. By the end of the twentieth century, however, the fertility transition had started and fertility had fallen between 35 and 40 percent to about 5 children per woman (Heisel 2007: 393). Thereafter, Kenya experienced a protracted fertility stall. In the present decade the fertility decline has resumed and the TFR was estimated in 2014 at 3.9 children per woman, down from 4.6 in 2010 (Republic of Kenya 2015: 12). Ghana launched a demographic program in 1959, which was supported between 1960 and 1966 by resident advisers from the Population Council. In 1967, the Planned Parenthood Association of Ghana, an IPPF affiliate, was created. In the early 1970s, the national family planning program expanded under the purview of a new Family Planning Administration, although the coordination of various government bodies' interventions proved challenging. In 1998, Ghana's TFR was estimated at 4.4 children per woman (Caldwell and Sai 2007: 380). Since then, the TFR appears to have stalled at about 4.2 (Republic of Ghana 2015: 12). The preparation in 1969 of a national population policy (Caldwell and Sai 2007: 380) also helped consolidate national family planning activities, which external donors supported financially. However, the policy was perceived to have been pushed from the outside along a top-down model, casting doubts as to Ghana's ownership of the policy. The policy was eventually revised in 1994 to better address the needs and aspirations of the population. It involved many actors from civil society and NGOs, in addition to the involvement of public authorities (Population Impact Project 1995). Kenya and Ghana are key examples of early family planning programs in the continent (Zimbabwe and Botswana also had early programs). External donors have been active in initiating, consolidating, and expanding family planning programs in many other SSA countries. Of importance here are the contributions of USAID, the United Nations Population Fund (UNFPA), and other bilateral development agencies, as well as the role of key NGOs such as IPPF. Family planning programs in Ethiopia, Madagascar, and Rwanda, for instance, have received substantial support from USAID. In Rwanda, the World Bank has supported family planning through its funding of the health sector and has piloted a Results-based Financing (RBF) approach to increase family planning uptake. Rwanda has also included a line item in its own budget to purchase commodities. The shift toward more favorable attitudes and policies vis-à-vis family planning on the part of leaders in SSA has been matched by increasing resources earmarked by donors for family planning programs. In particular, the contributions from USAID grew substantially in the 1980s. UNFPA also increased its support to family planning during the same period. Similarly, other multilateral and bilateral organizations, such as the UK Department for International Development (DfID) and the German Development Cooperation (GIZ), became more active in the sector (National Research Council 1993: 10). Some donors, such as the GIZ, have also been supporting family planning projects at the local level in several sub-Saharan countries. The preparation of comprehensive population policies has been another avenue used by donors to promote population and family planning programs in SSA. As mentioned, such policies had been developed early in a few countries, such as Kenya and Ghana. By the time the UN International Conference on Population convened in Mexico City in 1984, many more sub-Saharan countries had started to prepare national population policies. Policies formulated in the 1980s were inspired by the Kilimanjaro Plan of Action for African Population and Self-Reliant Development, crafted at the Second African Population Conference organized in Arusha, Tanzania, in 1984 in preparation for the Mexico City Conference. The Dakar/Ngor Declaration on Population, Family and Sustainable Development, which elaborated on the Kilimanjaro document, was adopted at the Third African Population Conference, held in Dakar, Senegal in 1992 (Kekovole and Odimegwu 2014: 304). The 1994 International Conference on Population and Development (ICPD), held in Cairo, led to the updating of several African national population policies. Given that most sub-Saharan governments were still lukewarm toward implementing proactive demographic actions to influence marriage and childbearing, the model adopted to prepare and implement national population policies was twofold. First, the policies focused on socioeconomic development and echoed what became known as the Kilimanjaro Declaration. These population policies integrated—and sometimes diluted—family planning goals into broader and more acceptable interventions on population and development. Population-focused interventions that aimed at "integrating population into development planning" actually fitted population issues within a more palatable development discourse. As exemplified in many national population policies formulated