Repositioning Family Planning - Choice, Not Chance

Family planning saves lives and has long been considered a key aspect to socioeconomic development. Although this is widely acknowledged and well documented, the attention and resources directed toward improving family planning programs in developing countries have been decreasing, even though need remains high.

This is particularly true for Sub-Saharan Africa; for the region as a whole, only 14% of women are using modern methods of contraception (PRB, 2004). To address this need, the U.S. Agency for International Development (USAID) has identified Repositioning Family Planning as a priority for its work in Africa.


A three-person team conducted interviews and site visits in Malawi interviewing 42 key informants, visiting health facilities, and holding group discussions with community-based distribution agents and family planning clients.

Family planning has been remarkably successful in Malawi, particularly considering the constraints faced in the country. Malawi's contraceptive prevalence rate (CPR) for modern methods increased from 7.4% to 26.1% between 1992 and 2000, despite high rates of poverty, low rates of literacy, a predominately rural population (86%), and an HIV/AIDS prevalence rate of 14% in its adult population. It is particularly impressive to note that gains in CPR cut across the economic spectrum.

Although family planning had essentially been banned under President Hastings Kamuzu Banda (1964-1994), "child-spacing" had been adopted as an integral part of the maternal and child health program in the 1980s, emphasizing the health problems that women faced when pregnancies were too early, too many, too late, and too frequent. The change in the political system from an essentially totalitarian government to multi-party democracy meant that the words "family planning" could be used and that more intensive policy and programmatic activities could be undertaken.

As a result, the number of facilities providing family planning increased from two clinics in 1983 to 210 out of 742 sites in 1995; now, family planning is almost universally available.

A 1994 study identified a number of factors that limited access, including the fact that only 28% of facilities offered family planning services on a daily basis. After this, access was improved by ensuring that services were offered five days a week and for free. Malawi has had a good mix of both public and private services and both clinic and community-based services. In particular, Banja la Mtsogolo (BLM), a nongovernmental organization (NGO) with a network of 29 clinics and extensive outreach efforts, has played a significant role in expanding access to reproductive health services. BLM's subsidy fund helps to keep services affordable for poorer clients. When this was removed in 2000, utilization of family planning services dropped dramatically, but when the subsidy fund was restored in 2002, the number of family planning clients increased significantly.

Supply-side interventions focused on improving the contraceptive logistics and supplies through the introduction in 1997 of the Contraceptive Distribution Logistics Management Information System (CDLMIS), the training of providers, and the development and dissemination of service-delivery policies and guidelines. These 1992 guidelines removed barriers of spousal consent, age, and parity and allowed a wider range of cadres to offer various services.

On the demand side, multiple channels of communication in multiple languages were effectively used, including radio jingles, posters, dramas, health talks, and communitybased distribution (CBD) activities, so that Malawi was "flooded with IEC messages."

One reason for the effectiveness of these messages is that they were developed through consultation with communities, "asking them to analyze the situation. They talked about all these problems they had because of too many children," problems that included land disputes and disputes between husbands and wives.

Community-based distribution agents (CBDAs) began in Malawi in the late 1980s and have been a key contributor to the success of family planning in the country: "If we didn't have CBDAs, we wouldn't have made the headway that we managed." In a country where the majority of the population lives in rural areas, often far from health facilities, CBD has been essential to making services more convenient: "We need the CBDAs - people would rather have a child than queue for hours." In addition to directly providing pills and condoms, CBDAs also help to raise awareness and normalize the idea of family planning and serve as referral agents, in many cases even escorting women to clinics for services. Focus-group discussions in 2002 found that CBDAs were highly praised for giving clear explanations and for helping to overcome difficulties with hospital providers

CBDAs talk about the satisfaction of helping their communities, but they need more of an incentive than this to continue with their work. A 1999-2003 project that implemented district-wide CBD programs in three districts led to an increase in contraceptive prevalence from 24% to 36%, and project staff believed that "the incentives are what made the project successful."

The provision of bicycles was a particularly effective incentive, as well as refresher courses.