Meeting the ‘One Plan’ Goal for Family Planning

Meeting the ‘One Plan’ Goal for Family Planning

By AJAAT

A continuing high rate of population growth is presenting major challenges to social and economic development in Tanzania. According to the National Bureau of Statistics (NBS), at the current annual rate of growth of 2.9 percent, Tanzania’s population is projected to reach 65 million by 2025, putting increased strain on already overstretched health and education services, infrastructure, food supply, and the environment.

Early initiation of childbearing and a high rate of fertility are the principal factors contributing to this rapid population growth, and they also have detrimental effects on the health of women and children.

Tanzania has among the highest rates of maternal, newborn, and child deaths in the world. Gender issues play important roles in both affecting access to health and economic resources for women and limiting the roles women can play in the country’s social and economic development.

Early childbearing usually curtails educational attainment for girls and constrains women’s participation in economic productivity.

Family planning (FP) has for several decades been well documented as a key strategy to promote social and economic development, and to improve the health of women and their children.

The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania, 2008–2015 (One Plan) has set a goal to increase the contraceptive prevalence rate (CPR) from 20 percent to 60 percent by 2015, by making quality FP services more accessible to and equitable for all of Tanzania’s people.

Increased use of FP has a great potential to contribute to the One Plan target of reducing maternal mortality from 578 to 193 per 100,000 live births by 2015.

However, the Tanzania’s FP program has lost momentum over the past decade because of a number of factors. As a result, the national CPR for modern methods among married women of reproductive age at the time of the last Demographic and Health Survey (DHS) in 2004–2005 had reached only 20 percent, and the annual rate of growth in CPR had slowed from a high of 1.5 percentage points to 0.6 percentage points.

With the current level of investment in FP and the current rate of growth, the One Plan target will not be reached until 2030, with considerable negative consequences for the health and well-being of Tanzania’s people and increased challenges to the country’s economic development.

It was noted in a recent study on National Health Accounts that expenditures for FP had decreased drastically, from 54 percent of reproductive health (RH) spending in 2003 to 8 percent in 2006. Deliberate efforts must be taken to rectify the situation.

A renewed commitment to FP, a reinvigorated program, and significant investment of resources are thus required to achieve the One Plan target.

In recognition of the need to reinvigorate the national FP program, the Ministry of Health and Social Welfare (MOHSW) embarked on development of a costed implementation program for a ‘repositioned’ national FP program.

The National Family Planning Costed Implementation Program (NFPCIP) is guided by the vision and mission of the Reproductive and Child Health Policy Guidelines 2003 and the goals of the one plan, setting targets for increased use of all FP methods by all women of reproductive age.

The NFPCIP takes into consideration and builds on the substantial investments called for in other strategic plans and documents, namely the Health Sector Strategic Plan III (HSSPIII) July 2009–June 2015, the Primary Health Services Development Programme (PHSDP) 2007–2017, and the Human Resources for Health Strategic Plan (HRHSP) 2008–2013.

Through a collaborative, participatory, and consultative process involving a wide range of stakeholders, five strategic action areas (SAAs) have been defined, based on the issues and challenges that must be addressed to reposition FP successfully.

These are ensuring contraceptive commodities and logistics (adequate and timely supplies of contraceptive methods appropriate to meet individual needs); renewed efforts in capacity building to ensure that providers in the health sector have the skills required to provide and support integrated FP services; strengthened service delivery systems to increase access to quality, affordable, and sustainable services; a renewed focus on advocacy to increase visibility of and support for FP among development partners, program managers, service providers, and the public; and strengthening management systems, monitoring and evaluation (M&E) to ensure effective program implementation.

Background

The health benefits of Family Planning (FP) for women and their children have been well documented for several decades, as has its essential contributions to social and economic development. Limited FP services have been available in a few urban areas of Tanzania since the establishment of the family planning association of Tanzania (UMATI) in 1959.

Beginning in 1974, the Government of Tanzania allowed UMATI to expand FP services to public-sector maternal and child health (MCH) clinics throughout the country, but expansion was limited because of resource constraints, and levels of contraceptive use remained low.

Expansion of the program and growth in the contraceptive prevalence rate (CPR) were accelerated after a speech by the late first President Julius Kambarage Nyerere in 1989 that recognized the importance of FP to Tanzania’s development. In 1989, the Tanzanian government assumed responsibility for integrating FP into government MCH services from UMATI.

During the next few years—the ‘golden age’ of FP in Tanzania—the prevalence of modern FP method use more than doubled, increasing from 6.6 percent in 1992 to 13.3 percent in 1996, growing at an average of 1.5 percentage points per year.

Beginning in 2000, however, the increase in prevalence dropped to 0.6 percentage points per year, with contraceptive prevalence for all methods among married women of reproductive age reaching only 26.4 percent by the time of the last Demographic and Health Survey (DHS) in 2004–2005.

A number of factors contributed to the loss of momentum, including decentralization and integration of health programs and the shift in donor funding mechanisms and priorities.

As FP priority, visibility, and financial support declined, the fundamental elements needed to sustain a thriving FP program were also weakened at central, regional, and district levels.

These elements include a consistent and adequate supply of contraceptive commodities to meet increasing demand, capacity building to increase the number of skilled FP providers and ensure updated provider skills, well equipped and flexible service delivery systems, education and motivation to generate demand for services, advocacy to sustain support for FP from various funding sources, and effective management systems and leadership to guide program implementation.

Repositioning FP as a priority in the national agenda is a key strategy to improve maternal, newborn, and child health; to prevent mother-to-child HIV transmission; and to promote social and economic development. Renewed advocacy for FP and adequate funding for program implementation to meet these goals are therefore urgently needed.

Issues and Challenges of the Current Family Planning Program

The FP program faces a number of challenges and constraints that must be addressed for effective repositioning of FP to meet the country’s RH and development goals.

Five program areas or components are essential for implementing a successful FP program: a consistent and adequate supply of contraceptive commodities; sufficient numbers of health providers who have the necessary knowledge and the technical and client interactions skills to deliver FP services safely and effectively; appropriately equipped facilities with a flexible array of service delivery modalities and systems to meet the needs in different socio-cultural contexts and levels of development in Tanzania’s different regions; strong advocacy to increase visibility and support for the program and address the knowledge-use gap among FP clients; and strong management systems and leadership to ensure efficient and effective program implementation.

The issues and challenges for each area have been defined below based on a review of published literature and documents, through discussions with the National Family Planning Working Group and through a series of key informant interviews.

I.                   Contraceptives Commodities and logistics: Availability and Choices of Methods

Providing a choice of methods to meet the changing needs of clients throughout their reproductive lives increases overall levels of contraceptive use and enables individuals and couples to meet their reproductive goals.

The method mix available in a program influences not only successful client use and satisfaction, but also has implications for provider skills and the facilities and equipment needed to deliver certain methods.

All of these factors affect program cost and sustainability and, in turn, the amount of contraceptive protection that can be provided with various levels of financial support.

Maintaining an adequate supply of contraceptive commodities to meet clients’ needs, prevent stockouts and ensure contraceptive security is the most urgent issue facing the Tanzania’s FP program.

The inability to supply and sustain current users has considerable implications for expansion of the program to meet the CPR targets of the One Plan. Other key strategies (HSSPIII and PHSDP) recognize the importance of ensuring the availability of adequate contraceptive choices.

General strengthening of logistics systems planned in the PHSDP will benefit contraceptive security, but additional investments are needed to ensure adequate forecasting, budgeting, and tracking of supplies so that all contraceptive methods, especially those that are in greatest demand, are available when and where clients need them.

Funding allocations through the MTEF are not adequate to meet contraceptive commodity requirements because of competing priorities in the health sector. However, the government is progressing well towards meeting the Abuja declaration target of 15 percent of the total national budget to cover improvement in the health sector.

Furthermore, when requests for funding from the district level are prioritized and submitted for funding by the district-level health management teams, FP falls well below other health service priorities in some districts and is sometimes overlooked in these requests.

As a result, stock-outs of contraceptive commodities occur even when districts have returned unused funds to the Basket.

A key factor in ensuring contraceptive security, method-mix issues, has important implications for cost as well as for client acceptance and satisfaction needed to sustain successful use.

Short-acting methods are the most prevalent contraceptives in the current method mix, according to the 2004 DHS, which include pills, condoms, and, increasingly, injectable depotmedroxyprogesterone (DMPA).

Those methods require regular resupply; hence successful use must include access to a consistent supply of the product. Each ‘resupply’ visit to a service delivery point (SDP) entails additional costs.

Pills and condoms also require high levels of user adherence and motivation, with inconsistent and incorrect use leading to method failures and high rates of discontinuation.

Condoms protect not only against unintended pregnancy but also against STIs, including HIV. They have been widely promoted in HIV-prevention programs and, less often, as ‘dual protection’ against pregnancy and STIs/HIV.

Their association with STI and HIV prevention, however, means that for many couples, condoms are stigmatized as being associated with extramarital sex, and therefore partners may resist using condoms for pregnancy prevention.

Long-acting methods give contraceptive protection for a year or more. They include intrauterine devices (IUDs) and implants. These methods have higher initiation costs than short-acting methods, but because they can be used without resupply for several years, they are often less expensive per year of use.

 Initiation costs for those methods are higher because the costs of the commodities themselves are higher. In addition, they require providers to have special training and skills for insertion and removal as well as good counseling skills to ensure that clients can make informed choices about these long-acting methods.

Unlike short-acting methods, which can be discontinued simply by the user stopping the method, discontinuation of IUDs and implants requires removal by a trained provider.

Prevalence of IUD use in Tanzania is low, despite it being the most cost-effective form of reversible contraception, having a good safety record, and providing highly effective contraceptive protection for up to 10 years.

Expanding the use of IUDs will require considerable attention to addressing myths and misinformation about IUDs among both providers and clients. Hormone-releasing sub dermal implants provide safe, highly effective contraception and have been growing in popularity among Tanzanian women.

Permanent methods of contraception (sterilization) include tubal ligation for women and vasectomy for men. Worldwide, these two surgical methods account for the majority of contraceptive users and are highly effective and safe when provided by trained personnel with appropriate attention to infection control.

Although the prevalence of permanent methods is low in Tanzania, the use of tubal ligation is growing, especially for women who do not want more children, and a pilot program to provide vasectomy in the Kigoma region is meeting with considerable success.

Provision of permanent methods is limited both by weaknesses in health facilities as well as by lack of provider skills. Additionally, widespread rumours—for example, equating vasectomy with castration— undermine acceptance of these highly effective methods.

Because those methods limit future childbearing, client education and counseling to ensure informed choice and informed consent are essential parts of service provision. However, weaknesses exist in such client-provider interaction skills.

Expanded availability of permanent methods for those who do not want more children can help Tanzania achieve its CPR targets, but this will require significant investments in capacity building to ensure proficiency in surgical skills, counseling, and informed consent procedures.

Vision, Mission, Goals and Objectives of the NFPCIP

Vision

A healthy and well-informed Tanzanian population with access to quality reproductive and child health services that are acceptable, affordable, and sustainable and provided through efficient and effective support systems.

Mission

Promote, facilitate and support in an integrated manner the provision of reproductive and child health services to men, women, adolescents, and children in Tanzania.

Goal

Increase the CPR among women of reproductive age from 28 percent to 60 percent by 2015.

The denominator used for the CPR target is women of reproductive age and not married women of reproductive age (MWRA). This is to take into consideration all women of reproductive age regardless of their marital status.

Furthermore, the CPR target includes all methods and not just modern methods. According to the DHS 2004–2005, the CPR among MWRA for modern methods is 20 percent and the CPR among MWRA for all methods is 26.4 percent, while the CPR for women of reproductive age for all methods is 28 percent. The latter figure of 28 percent is thus used.

Although guidance is also provided by the HSSPIII, which has a goal CPR of 30 percent by 2015, the higher CPR goal of 60 percent specified by the One Plan was chosen so that repositioning FP can be addressed more aggressively and, as a result, will have greater potential impact on reducing maternal and newborn mortality and improving child survival.

Furthermore, there is a wide degree of variation across regions in current CPR as well as considerations of culture and context, such as the availability of infrastructure, human resources, service modalities, and current demand. These factors increase the challenges to be addressed and the level of resources that will be needed to reach the 60 percent CPR One Plan target by 2015.

The regional variations and the different scenarios for repositioning FP are discussed in more detail in the Analysis of Demographic Determinants of Resource Requirements section.

Strategic Action Area I: Contraceptive Security

This SAA refers to expanded availability and choices of safe, effective, acceptable and affordable contraceptive methods. It addresses contraceptive logistics and security, ensuring that supplies of all contraceptive commodities are adequate to meet the needs and preferences of family planning clients.