In recent years, family planning experts have undertaken a number of major policy efforts to shine a spotlight on reproductive health worldwide. With this renewed focus on the power and promise of family planning, now is an opportune time to step back; examine past family planning and reproductive health initiatives; and ensure that lessons we’ve learned inform the work we do moving forward.
Above all, programs and policies should focus on improving the health and lives of people around the world, not numerical demographic targets. An overemphasis on reaching quantitative goals should not take priority over quality of care, voluntary use of contraception, and informed choice. The needs, desires, and well-being of women are paramount.
Prior to the UN’s 1994 International Conference on Population and Development (ICPD), family planning programs in developing countries often focused on the goal of reducing fertility and, in turn, slowing population growth. Indicators such as the percent of women using, or whose partners are using, contraception (the “contraceptive prevalence rate”), or the average number of children each woman would have by the end of her reproductive period (“total fertility rate”), were used by governments and funders to measure program success.
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The assumption was that addressing population growth was critical for a country’s economic development, with governments expecting that through trickle-down processes, the result would be improvements in the lives and well-being of its people. But because these indicators only measured specific numerical goals, and not the underlying intent of improving individuals’ well-being, many family planning programs implemented activities that were not fully client-centered, were coercive, and/or did not improve individual well-being or promote the rights of individuals to have the number of children they want, when they want them.
In response to global advocacy and concern about this approach, in 1994 the ICPD Programme of Action articulated that reproductive rights—including the right to decide the number, timing, and spacing of children—are an integral part of human rights and are essential to the realization of other fundamental rights. This confirmation pushed family planning programs to move toward improving individuals’ reproductive health and well-being, and allowing them to achieve their family planning goals.
Following ICPD, efforts were made by governments and NGOs to align the design and goals of family planning programs by incorporating values like quality of care, voluntary adoption of contraception, and informed choice. While there has been an important shift toward client-oriented care since 1994, and new indicators to measure clients’ health and informed choice have been proposed, implementation and measurement has been spotty.
In 2012, the London Summit on Family Planning brought together the UK government, the Bill & Melinda Gates Foundation, UNFPA, USAID, national governments, donors, civil society, the private sector, and the research and development community to support the rights of women and girls to decide, freely and for themselves, whether and when to have children and how many they wish to have. At the summit, more than 20 governments made commitments to mobilize progress and donors pledged an additional $2.6 billion to enable 120 million more women and girls to use contraceptives by 2020. A global partnership, Family Planning 2020 (FP2020), was formed to achieve these goals.
In the March issue of Studies in Family Planning, a peer-reviewed journal published by the Population Council, we analyzed past family planning initiatives and renewed the call for new efforts like FP2020 to be built around one unifying goal: to meet the family planning needs and reproductive goals of their users—not simply to achieve macro level numerical targets like “120 by 20.”
FP2020’s goal was intended as a rallying call for the field, and to ensure that efforts are made at the large scale required to achieve public health benefit. Furthermore, FP2020 has nobly worked to identify core indicators that measure other kinds of progress than this numerical target. That said, this goal has also sparked some concern among those who remember family planning before ICPD, who fear that it may lead countries to unintentionally overemphasize the importance of reaching numerical thresholds, rather than concentrating on the well-being of their citizens.
What Does True Success Look Like?
To measure true success, new indicators are needed. Take “met demand,” meaning the percent of women who are using a modern contraceptive out of the total who would like to avoid or delay having a child.
Currently, met demand is one of the core indicators of success for FP2020 and has also been proposed for inclusion in the post-2015 goals, which seek to ensure universal access to sexual and reproductive health services by 2030. It is a useful indicator, but it misses the full picture. It doesn’t capture whether women made the choice to embrace modern contraceptives voluntarily, or the quality of overall information offered to women about their practices and options.
Instead, we should be measuring indicators like client-provider interaction, content of information provided to clients, voluntary use of contraception, and informed choice. These indicators can only be measured at the service level and in the field. Though it adds some complexity to program evaluation, we believe family planning initiatives must develop confidential, respectful ways of observing consultations between providers and clients, or conducting exit interviews with clients, in order to measure the quality of care provided by a program. What exactly constitutes high quality of care will be made by experts in close consultation with users and advocates.
Additionally, in order to ease the challenges related to monitoring progress, we recommend that family planning indicators and targets be standardized across FP2020, as well as two other major policy initiatives: the UN’s proposed Sustainable Development Goals, which seek to define a range of global development targets for the next 15 years, and ICPD Beyond 2014, the UN review of the ICPD. This will reduce confusion and allow countries to implement—and evaluate—multiple initiatives simultaneously and successfully. In order to monitor progress at the global level, we need comparable data to be available regularly from many countries, which these programs can also provide.
It is an exciting time in the field of family planning. Amid the formulation of new policies and programs, we have an opportunity to shape the reproductive health agenda and influence the services that will be offered to people for many years to come.
Now is the time to develop a set of common indicators for family planning and reproductive health programs that go beyond outcome and output goals, and include process, information, and informed choice. This will ensure that our programs maintain focus on service delivery, meet the reproductive needs of users, and uphold the preferences and rights of the women they serve.