Reproductive health and family planning are in a constantly shifting arena of challenges and opportunities. As the Dakar conference approaches, Duff Gillespie, director of Advance Family Planning (AFP), reflects on the U.S. reemergence in family planning, prospects for the Dakar conference and the particular challenges in West Africa and other topics in an interview with Brian W. Simpson, editor of Johns Hopkins Public Health magazine. Currently working in eight countries, AFP seeks to boost funding and policy commitments to family planning in developing countries.
What’s been the effect of the reemergence of U.S. leadership in family planning?
It’s made a huge difference. The situation under the Bush administration was that international donors and NGOs were actually hesitant to invite representatives from the U.S. government to meetings because they knew they were going to be disruptive. Even with career people there were limits on what they could say and do. Their ability to make a contribution was circumscribed by the policies of the government. I want to emphasize this was not a product of the career people but their political handlers, in terms of what presentations could be made, who could be invited and situations like that. Today, it’s just the opposite. They’re active partners not only supporting [the Dakar conference] but the earlier Kampala meeting and are extremely positive and influential in moving the agenda for family planning and reproductive health forward. The cloud on the horizon is, of course, what will happen with a strong anti-family planning, anti-government, anti-foreign aid [U.S. House of Representatives] and how that is going to influence USAID and other parts of the government in promoting family planning with election year [coming up].
Why is the Dakar conference important?
The Dakar conference is important for the field in a couple critical ways. The groundbreaking Kampala meeting unleashed a pent-up enthusiasm for family planning in the international community and amongst African countries to have a forum to exchange research findings, ideas and experiences. It led to a number of country-specific programs and a lot of initiatives that would not have taken place [otherwise]. It is very common now for people to say in a meeting, “Well, after Kampala …” and not even say “conference.” These things are exciting and useful [but] events have a way of quickly dissipating. If for no other reason Dakar is important to reinforce and reenergize the momentum that was unleashed in Kampala. It’s already been a success in that regard: The number of registrants, the richness of the presentations, the number of parallel sessions that various organizations are sponsoring… the outpouring has been tremendous. We’re nearing, if not exceeding, capacity in every sense of the word.
Why is Dakar important for AFP in particular?
Advance Family Planning was announced at Kampala. Two years later, we are pulling together our partners in the process to review what we have accomplished and to share that with other organizations, other countries. It provides a forum for our partners in eight different countries and multiple organizations.
Why host the conference in Senegal?
The reason Dakar was chosen is to try to have it as a catalyst for West Africa and francophone Africa, [which] in the areas of reproductive health and health in general lag way behind all of East Africa and Southern Africa, and parts of Central Africa. Look at maternal mortality, contraceptive use, and infant and child mortality. They are way, way behind such countries as South Africa, Kenya and even Ethiopia.
Why?
In terms of francophone countries, part of it is a legacy of French colonialism. Many of the laws and policies imposed by the French were very backward when it came to women’s right and reproductive health. The French are the dominant donor in francophone Africa. They had been indifferent to reproductive health and family planning. Fortunately, this position has dramatically changed. During an October meeting Ouagadougou [Burkina Faso], the French government came out with strong statement launching a reproductive health initiative in Francophone African countries. We hope that the Dakar meeting can build on and amplify the enthusiasm created by the French initiative.
The desire for fertility in West Africa and Francophone Africa is much, much higher than other parts of Africa. Understanding why desired fertility is so high is more challenging. Certainly, the fact that women’s education relative to other parts is much lower is an important consideration. But this is only part of the explanation. I also believe governance issues have held back socio-economic investments, including health.
One important thing to note is that this region has not benefited from the extensive research and programmatic experience that other parts of Africa have experienced. Our knowledge of the region is limited. Here again, we hope that Dakar will generate interest in and donor support for investing in knowledge generating research.
We’ll see if this conference is successful in continuing the bonfire started at Kampala and the spark ignited at Ouagadougou. The initial response is kind of disappointing.In this second part of his interview, Advance Family Planning (AFP) director Duff Gillespie frames the changes in family planning attitudes in the developing world. His wide-ranging interview with Brian W. Simpson, editor of Johns Hopkins Public Health magazine, concludes with strategies for adapting to decentralization trends in government.
Where are we historically in terms of family planning efforts in Africa?
Ten, fifteen years ago, the characteristics of the Kampala or Dakar meeting would be quite different. One reason is there would have been very few Africans. The changes in policies that have occurred in sub-Saharan Africa [have been dramatic]—especially in going from pro-natalist policies to being quite concerned about population growth and from having anti-family planning polices to those that are very supportive of family planning. Fifteen, twenty years ago, you would search for countries in sub-Saharan Africa that had positive policies. Now you have to search for countries that that have negative policies—a total revolution. Kampala and Dakar are building on that policy revolution.
How have attitudes to population levels changed in recent years?
According to official government responses [to UN surveys], in 1976 roughly 20 percent of the poorest countries—most of which are in sub-Saharan Africa—felt their rate of pop growth was too high. Today, that figure is over 70 percent. Most governments are acting in one way or other. The area where many of them fall down is actually using their own funds to support activities. Unfortunately, that is also case with child health, maternal health and lots of public health programs. They still depend on external funds.
Are you encouraged by this?
Absolutely. To use the trite characterization, a positive policy environment really is necessary, it’s just not sufficient. If you have country that has a hostile policy, you are always on the margins. You do a little here, a little there. In terms of making a difference, it’s not going to happen. When I started in this field in the 1970s outside, in South Asia, the vast majority of countries where we had programs had policies that were indifferent about reproductive health or were actually hostile to family planning. It was not unusual to work in countries where contraceptives were illegal. We worked with NGOs. It was a challenge to do anything. People were jailed. Some were murdered.
I was involved in a project in Tunisia. The policy toward family planning was very negative. When I would go there, I’d carry suitcases of contraceptives. One time I had two suitcases of condoms opened by customs officials. One asked if they were for my personal use. I said yes. I got a good laugh and gave them some handfuls. They let me through.
How has the trend of government decentralization in developing countries affected AFP’s strategies?
With decentralization throughout developing world, many of the decisions on priorities are done at the district level. Tanzania, for example, has 99 districts. Uganda has 112. In the case of Indonesia, there 502 districts in the country, and each of those districts controls how local money will be spent in the area of health, education, etc. If you want to do something about [Millennium Development Goal 5b—universal access to reproductive health], unless you take decentralization into consideration, you are not going to be successful. It makes a huge difference.
This has to hugely complicate AFP’s work.
Absolutely. Donors and organizations work at the national level and sometimes at the state or provincial level but even that is not enough. In Nigeria, it is the local government authorities that actually implement the program. If you have someone hostile at that level, even with strong governor, you are going to fail in that particular district. When you have Millennium Development Goals, and people in Geneva and New York pontificating and signing this or that, down in the trenches those you go to deal with are [at the district and local levels] and that’s what we are doing with Advance Family Planning.
How? You would have to go to every district.
In case of Indonesia, we’re training others. We have a developed a model for mobilizing support for family planning at the district level. Now, it’s being applied in only two districts. This year we will go to 13. At the same time we will work with NGOs so they can begin to spread [the model]. You don’t have to go to every district because some districts are doing quite well. What is exciting is that the Indonesian government, at all levels, is quite supportive of this effort.
Decentralization is the present and the future. We have to figure out how to best to deal with it.
