Complex Problems, Simple Solutions

In October 1999, the seventh Secretary-General of the UN, Kofi Annan, traveled to Sarajevo to welcome the world’s 6 billionth person amid widespread nervousness around the new millennium about the world’s future. A public relations success, to be sure, but ultimately the event marked the beginning of nearly 10 years of what the United Nations recently labeled as failure in increasing funding for family planning programs in the developing world. By 2008, donor support for family planning programs remained below 2000 levels, despite unintended pregnancies adding an astonishing 75 million people per year.

At PSI, it is a bit hard to argue that funding for family planning during this period was inadequate or led to failure in our efforts to increase access and demand for modern methods of contraception. After all, PSI managed to increase the number of couples we serve with contraceptives in the decade starting in 2000 from about 8 million to more than 18 million, a 10-year growth rate of approximately 11 percent at a cost of about US$15 per couple. We publish these results monthly and annually in our health impact and cost-effectiveness reports at .

Undoubtedly, unintended pregnancies and unmet need for contraception are too high and the consequences for women, their families and communities are enormous. PSI and many other organizations could have done more with more resources.

Yet, in the midst of the public events and stirring calls for further support for family planning surrounding the birth of the 7 billionth person, it is worth reflecting for a moment on the conclusions of a simple case study recently published in the journal Contraception by our colleagues Josselyn Neukom, Jully Chilambwe, Joseph Mkandawire and their partners at the Zambian Ministry of Health and Family Health International.1 Their study shows the fresh approaches happening today on the frontline of family planning service delivery within PSI and how efforts to reduce unmet need for contraception are succeeding despite funding and other constraints.

The case study describes Zambia as typifying family planning programs in many sub-Saharan African countries. Just more than 20 percent of reproductive-aged women use modern methods of contraception, a rate increasing at about 1 percent per year. The most popular methods are condoms and oral and injectable contraceptives, whose high levels of effectiveness can be compromised by supply shortages or inconvenience, among other things. Intrauterine devices (IUDs) and hormonal implants, “long-acting, reversible contraception,” overcome those problems, but use rates for these were very low in Zambia, like elsewhere in sub-Saharan Africa, despite multiple pilot scale efforts throughout the past 30 years. Neukom and colleagues asked why.

Neukom and her colleagues steered clear of debate about the relative importance of demand or supply side barriers to family planning uptake. Instead they went to public health facilities where women were waiting for family planning and other maternal and child health services and spoke to them and the providers there about obstacles to getting the family planning method the women wanted. Those conversations led to a “dedicated provider” program to overcome barriers to adopting long-acting, reversible contraception. Their plan was to employ midwives to answer a litany of personal questions from women waiting for health services about long-acting, reversible methods and then to use these dedicated staff to deliver the services “on demand.” Nothing fancy. Just a personal service that all of us appreciate.

As Samuel Johnson said, the applause of a single human being is of great consequence. In 14 months, at a cost of about US$13 per couple year of protection, the dedicated provider program served more than 30,000 clients, with about half shifting from the short-acting to the more effective long-acting methods and the remainder shifting from not using to using contraception. Implant users were markedly younger and had fewer children than the average long-acting method user, demonstrating that new populations were being reached. By these and other metrics, the dedicated provider program met the criteria of high performance – a large-scale intervention, serving low-income and needy clients, cost effectively, with an ability to become a national effort.

The authors concluded that “although many elements of the program came together to make it successful, the role of the provider is perhaps most important.” “We hired enthusiastic providers committed to contraceptive choice and gave them excellent supervision and support to do their work.”

Yes, the arrival of the 7 billionth person and the likely consequences of the tens of millions of additional human beings arriving each year is startling. Yes, the tens of millions of unintended pregnancies and women with unmet need for contraception point to the need for millions in additional resources for family planning in the developing world.

Yet, amid these large numbers, the lesson here for family planning at PSI is not demographic in scale. It is the individual, and her or his specific needs, as a client or a provider, who counts the most.

1. 1. Neukom, J., Chilambwe, J., Mkandawire, J., Mbewe, R.K.,
   and Hubacher, D. (2011) Dedicated providers of long-acting reversible contraception: New approach in
   Zambia. Contraception 83: 447-452.