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.
