How Many More Miles? Reflections on the Road to Contraceptive Freedom
By Jay Gribble
This blog was first published on Medium.
When I was growing up, it didn’t matter where my family was going, shortly after getting into the car, I would ask, “How many more miles?” With a focus on the destination, I found it hard to enjoy the journey. That’s how I feel about the state of family planning in 2019. Recently, I had the opportunity to attend a meeting on the future of family planning—an important topic that merits some thought as we approach both 2020 and the Nairobi Summit on the 25th Anniversary of the International Conference on Population and Development (ICPD+25). In looking back over the past seven years of Family Planning 2020 (FP2020) and the past 25 years of ICPD, I can’t help but ask the same question, “How many more miles?” Family planning has enjoyed a renewed limelight in the past few years. While that attention has helped get us further down the road to a set of goals and aspirations, it hasn’t gotten us to where we need to be. As I reflect on where things stand in 2019, the confluence of World Contraception Day, the future of family planning, and the run-up to 2020 should give us all a reason to ask, “How many more miles until all people have access to a full range of contraceptive methods that accommodate where they are in their life courses? How many more miles until technology is used to strengthen programs, information, and services and family planning programs have the resources they need? And how many more miles until gender inequity no longer exists?” We are on our way to addressing all these issues—and more—but we aren’t there yet.
New contraceptive methods are slowly working their way into family planning programs, and others are in the development pipeline. A few new methods, including DMPA-SC, SILCS diaphragm, and NES-EE vaginal rings are increasingly being offered in service delivery settings. And efforts to develop multipurpose prevention technologies that prevent both HIV and unplanned pregnancy continue to be the elusive goal of many researchers. I don’t pretend to know anything about the development of new contraceptive technologies, but a few weeks ago, I saw a friend who is working on human-centered designs for new contraceptive methods. I found it fascinating that my friend gets to talk to women about what they want in a yet-to-be-developed contraceptive: how should it be administered, what level of engagement do they want to have with providers, which side effects are acceptable, and what other features do they want these products to have? One stage in the introduction of a new contraceptive method is an acceptability study—the point of which is to find out if the benefits of a new method can outweigh its downsides—or whether users are willing to embrace (or tolerate) the new product in order to avoid becoming pregnant. The fact that my friend gets to do this work puts a smile on my face. Side effects of current methods, coupled with ineffective counselling, often lead to high levels of discontinuation; but what if a new method was designed that responded to what women want? We’re getting there, but how many more miles?
I’m happy to embrace new technology, but can’t help but notice that much of the today’s technology was science fiction not too long ago. The idea of an iWatch is not too dissimilar to what was in comic books a few short decades ago and the concept of an iPhone still blows my mind. Similarly, how we use technology to advance family planning program efforts doesn’t need to remain science fiction. Healthcare providers have phone-based job aids; clients can do self-screening for some contraceptive methods online; youth can obtain reproductive health information using high-quality websites. These uses of technology are great, as are the technology-driven supply chains that help get commodities and supplies to the last mile, where people have limited access. But while we often seem star-struck with the many benefits of technology, it’s important to remember that many of those most in need of family planning are the marginalized, underserved, rural populations who lack access to electricity, water, schools, and the ability to read. Technology offers direct benefits to many, but we need to remember that not everyone has direct access to it—or smart phones. Technology is changing how family planning is provided, but how many more miles until we reach that last mile?
Donor support for family planning is not increasing, but the demand for contraception is—both in terms of the number of users and contraceptive prevalence rates. If ministries of health and finance continue to look at family planning as donor driven, they will have little incentive to put the needed domestic funding into supporting program efforts. Years ago, a big challenge was getting governments to allocate money for family planning; today, they increasingly allocate it, but they don’t actually spend it. Part of the problem may be that the “fiscal space” for health isn’t large enough—meaning there isn’t enough money to deal with all the pressing priorities of the health sector. As governments take on the challenge of universal health coverage, we need to work to get family planning covered with local resources. We are in a time of transition, with donors pushing governments to step up their contributions to family planning and other health programs; with advocates making the case for the inclusion of family planning in universal health coverage and Global Financing Facility initiatives; and increasing attention to bringing blended financing mechanisms to different aspects of family planning programs. Efforts to make the case for family planning as a best buy in development and a driver of economic growth are solid, but too often fall on deaf ears. Local governments are starting to put money into family planning, but how much longer before we don’t have to put so much effort into advocacy efforts to mobilize needed funds for family planning?
Social and Gender Norms
Whether we’re talking about achieving goals for family planning programs, the demographic dividend, or the post-2020 global agenda, until greater progress is made in addressing gender equality, I don’t see how we can achieve our “big picture goals.” Gender inequality permeates into virtually all aspects of family planning programming. Gender roles impact women’s abilities to negotiate use of contraception and obtain health services for themselves and their children. Gender inequality is the underlying cause of gender-based violence, child marriage, sex-selective abortion, and son preferences. And these issues aren’t isolated to traditional societies; they exist to some degree in all cultures. Programs are working to address these barriers, but progress is slow because it is so culturally engrained. One of the ways family planning programs are working to address gender inequality is through engaging men more actively and effectively. A recent publication on engaging men and boys in family planning identified three key roles for them—as users, supports, and agents of change—and strategies to get on board. Another recent publication that examines whether men are well served by family planning programs comes to the conclusion that they are not particularly well served but proposes ten key considerations for better responding to men’s and boys’ needs. While male engagement in family planning is only one small way to address gender inequality, effective engagement may help jumpstart other ways to advance it.
We’ve been on this journey for a long time. The map took a needed detour in Cairo in 1994, when the focus of family planning programs shifted toward the individual. And it picked up speed since passing through London in 2012. The emergence of new donors, enhanced coordination mechanisms at national and global levels, and a renewed commitment for the journey are all making a big difference. The family planning field has come a long way because of the commitments of individuals, organizations, and governments, but how many more miles? With the momentum we have now, I can’t say with any certainty how many more miles we have to travel, but we are getting closer every day.