Tropical Medicine and International Health
doi:10.1111/tmi.12219
volume 19 no 1 pp 65–73 january 2014
Family planning in Guinea: a need for better public commitment Alexandre Delamou1, Akoi Koivogui2, Dominique Dubourg3 and Th er ese Delvaux4 1 2 3 4
Centre National de Formation et de Recherche en Sante Rurale de Maferinyah, Conakry, Guinee Observatoire Regional de la Sante de Guyane, Guyane, France Department of Public Health, Maternal and Reproductive Health Unit, Institute of Tropical Medicine, Antwerp, Belgium Department of Public Health, HIV/AIDS Policy Unit, Institute of Tropical Medicine, Antwerp, Belgium
Abstract
objective To describe the evolution of family planning (FP) in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. methods Descriptive study of the evolution of FP in Guinea between 1992 and 2010. First, national laws as well as health policies and strategic plans related to reproductive health and family planning were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005). Third, FP services, sources of supply and data on FP funding were analysed. results Laws, policies and strategic plans in Guinea are supportive of FP programme and services. Public and private actors are not sufficiently coordinated. The general government expenditure on health has remained stable at 6–7% between 2005 and 2011 despite a doubling of total expenditures on health, and contraceptives are supplied by foreign aid. Modern contraceptive prevalence slightly increased from 1.5% in 1992 to 6.8% in 2005 among women aged 15–49. conclusion A stronger national engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent methods. keywords family planning, programme, review, Guinea
Introduction Family planning (FP) is defined as a set of services that enable individuals and couples to anticipate and attain their desired number of children by a better spacing and timing of pregnancies (Bongaarts & Sinding 2009). The inclusion of FP in the Target 5b of the Millennium Development Goal (MDG) in 2005 reflects the international consensus on its benefits, both for mother and child at individual level and for family income, national economy and environment at collective level (Bongaarts & Sinding 2009; Cates 2010; Potts et al. 2013). The London summit on FP 2012 aimed to help repositioning FP on the global agenda, pledging to halve the number of women living with unmet need for FP in the next 8 years (Potts et al. 2013). By preventing unwanted pregnancies among an additional 120 million women in the world’s 69 poorest countries by 2020, FP could potentially avert 1.1 million newborn and infant deaths and 79 000 maternal deaths (Burke & Shields 2005; Cleland et al. 2006; Stover & Ross 2010; Cohen 2012). Giving priority to countries where FP programmes have
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experienced stagnation will help achieve this goal (Robinson & Ross 2007; Cleland et al. 2011). Likewise, a better understanding of the evolution of FP programmes in these countries will increase the likelihood of being successful in improving their FP programmes and services. (Lee et al. 1998; RamaRao & Mohanam 2003; Burke & Shields 2005; Sharma & Dayaratna 2005; Dehlendorf et al. 2010). In Guinea, the national FP programme began in 1983 as a vertical programme, and FP was then integrated into all public health policies and programmes in 1990 (Guengant 2011). In addition to several strategic plans aiming at repositioning and strengthening FP, the adoption of the reproductive law in 2009 was seen as strong signal of political commitment towards FP (MSP Guinee, UNFPA 2007). However, after decades of implementation of FP programmes and policies, FP use remains very low in Guinea. The latest Demographic and Health Survey conducted in 2005 (DHS) reported a contraceptive prevalence for modern methods among married women aged 15–49 years at 5.7% (Direction Nationale de la 65
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A. Delamou et al. Family planning in Guinea
Statistique (DNS) de Guinee 2006), representing an annual increase of 0.12% from 4.2% in 1999. Unfortunately Guinea needs an annual increase of 1.5% to achieve MDGs 4 and 5 (Guengant 2011), gradually meet the needs for FP between 2010 and 2020 and avert approximately 600 maternal deaths and 40 000 infant deaths (Cleland et al. 2011; Health Policy & Planning Project 2011). Repositioning FP at the national level and providing individuals and couples with lasting contraceptive security is therefore required (Sharma & Dayaratna 2005). The aim of this study was to describe the evolution of FP in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. Methodology We conducted a descriptive study on the evolution of FP in Guinea between 1992 and 2010. First, laws as well as health policies and strategic plans related to reproductive health and FP put in place by the Ministry of Health (MOH) (1992–2010) were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005), and the annual reports (2006–2010) of the Association Guineenne pour le Bien Etre Familial (International Planned Parenthood Federation (IPPF) member Association). Collected indicators included modern and traditional contraceptive prevalence, the proportion of unmet needs, the Total Fertility Rate (TFR) and maternal and infant mortality. Third, FP services were described and sources of supply and provision of contraceptives were collected from ‘Reproductive Health Supplies Coalition’ reports. Finally, data on FP funding were collected from WHO’s National Health Accounts (2005–2011), and ‘Reproductive Health Supplies Coalition’ reports including public and private funding (grants, donations and others). Data analysis The first part of the analysis focused on the description of the policy and institutional framework, the involvement of different actors, the organisation of FP services and the financing of FP programmes. The method used was the framework for analysing health systems of the Institute of Tropical Medicine of Antwerp (Olmen et al. 2010) and the FP market segmentation approach of United States Agency for International Development (USAID; Guengant & De Mets 2008). The second part analysed the trend in FP indicators across the DHS (1992, 1999 and 2005) results. The last part of the analysis concerned the strengths, weaknesses, opportunities and threats of 66
the current FP programme in Guinea. This part was carried out using the SWOT analysis model of Humphrey (Commission Europeenne 2013).
Results Institutional and policy framework Family planning was integrated in the health system in 1990, and from 1998, the country started adopting FPrelated policies and developing FP-related strategic plans (Table 1). The Law L025/2000 on Reproductive Health promulgated in 2000 identified FP as a means to improve women’s health and prevent unwanted pregnancies. The Manual of Procedures, Standards and Protocols of Reproductive Health, which includes modern FP methods, was revised in 2006. The National Roadmap for Accelerating the Reduction of Maternal Mortality (Ministere de la sante et de l’hygiene publique de Guinee 2008), the National Strategic Plan for Repositioning Family Planning (Ministere de la sante et de l’hygiene publique de Guinee 2009) and the National Plan for the Security of Reproductive Health Products (Ministere de la sante et de l’hygiene publique de Guinee, UNFPA 2009) confirm the country’s commitment to promote FP (Guengant 2011). In 2008, the Strategic Plans for repositioning FP and for Reproductive health products security were adopted. Actors in family planning The PF programme is under the jurisdiction of the Division of Family Health and Nutrition, which itself depends on the National Directorate of Public Health within the Ministry of Health (MoH). This directorate is responsible for implementing the national FP policy and coordinating partners and stakeholders. The Division collaborates with the Ministry of Youth (in charge of youth reproductive health, especially youth friendly health centres) and the Ministry of Women’s Promotion and Childhood. The MoH through the Division of Family Health and Nutrition maintains relations with bilateral, multilateral partners and Non-Governmental Organizations (NGOs). The IPPF, the United Nations Population Fund (UNFPA), the USAID, the World Bank and the Kreditanstalt f€ ur Wiederaufbau (KfW) are also technical partners. The organisations in the private not for profit sector have two profiles: foreign NGOs such as Population Service International (PSI), Plan International, EngenderHealth, JHPIEGO, which act as technical and operational partners; and national NGOs such as AGBEF (IPPF member association), which act as service providers. Technical part-
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Table 1 Family planning and reproductive health in policies and strategic plans in Guinea
Policies/plans National population policy, 1996 National Health Development Plan 2003–2012 National Roadmap for Accelerating the Reduction of Maternal and Infant Mortality 2006–2015 Strategic Plan for Repositioning Family Planning 2008–2015 Strategic Plan for Securing RH Commodities, 2008–2012 National Strategic Framework for Fight Against STI/HIV/AIDS 2008– 2012
Infant mortality (/1000 LB*)
Maternal mortality ratios (/100 000 LB*)
Modern contraceptive prevalence rate
No quantified objective Reduce from 177 & in 1999 to 90 & in 2015 Reduced from 163 in 2005 to 121 in 2010 and 80 in 2015 No quantified objective
No quantified objective Reduce from 528 in 1999 to 220 in 2015
Reduce the TFR by 35% by 2010 Promote family planning, but no quantified objective
Reduce from 980 in 2005 to 780 in 2010 and to 580 in 2015. Reduce from 980 in 2005 to 700 in 2010 and to 580 in 2015
Increase contraceptive prevalence rate from 6% in 2005 to 17% in 2010 and to 21% in 2012 Increase contraceptive prevalence rate from 6% in 2005 to 21% in 2015 and reduce unmet need from 21% in 2005 to 10% in 2015 No quantified objective
No quantified objective
No quantified objective
No quantified objective
No quantified objective
Increase condom use by 50% in people of 15–49 years between 2008 and 2012
*LB, live births. Source: adapted from Guengant 2011.
ners support public sector health facilities through staff training, community awareness and mobilisation, health systems strengthening, quality improvement, monitoring and evaluation. Their projects are usually limited in time and often not renewed. Family planning funding
1000 800 600 400 200 0
Contribution in thousands of USD
Family planning funding is provided by the government, development partners and households. Government fund-
ing covers salaries, operating expenses, pre- and in-service training building and renovation of health structures (Figure 1). Table 2 summarises the evolution of health expenditures between 2005 and 2011. The general government expenditure on health has remained stable between 6% and 7% from 2005 to 2011 despite a doubling of total expenditures on health. Foreign aid focused on investments, training and drug supply. For example, it accounted for 14.1% of the total health expenditure and reached 37.5% in 2011. Finally, the private expenditure
2006
2007
2008
2009
2010
Years Figure 1 Evolution of family planning funding in Guinea from 2006 to 2010. Source: Reproductive Health Supplies Coalition website 2013.
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UNFPA IPPF Total contribution
USAID KFW
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Table 2 Evolution of health expenditure ratios and population between 2005 and 2011 in Guinea Years Health expenditure ratios
2005
2006
2007
2008
2009
2010
2011
Total expenditure on health (THE) in millions (USD) Total expenditure on health/capita at exchange rate (USD) Share of health in the national budget (%) Public expenditure on health as % of THE Private expenditure on health as % of THE Out-of-pocket expenditure as % of private expenditure on health Private insurance as % of private expenditure on health Rest of the world funds/External resources (USD) Population (in thousands)
158 17 6 17.7 82.3 99.4
163 18 6 17.0 83.0 99.4
251 27 8 18.6 81.4 99.4
276 29 8 21.6 78.4 99.4
295 30 7 27.3 72.7 99.1
294 29 7 32.5 67.5 92.7
304 30 7 27.3 72.7 92.7
0.6 14.1 9041
0.6 20.3 9202
0.6 37.6 9374
0.6 25.0 9559
0.9 32.3 9761
7.3 43.6 9982
7.3 37.5 10222
Source: WHO 2013.
2
1.79
Funding in millions USD
1.8
% of needs funded
1.58
1.6 1.37
1.4
1.42
1.12
1.2 1
1.08 1.06
0.8 0.6
0.94
0.47 0.55
0.4 0.2
0.26
0.35
225%
85%
40%
68%
79%
2009
2010
2011
2012
0 2006
2007
2008
Years Country’s need
Real funding
on health slightly decreased from 82.3% to 72.7% of the total expenditure on health in this period. Almost all of these expenses are covered by direct payments by households (out-of-pocket). An important part of foreign aid for FP is allocated to the purchase of contraceptives commodities. This assistance was estimated at U.S. $ 3 160 447 for the period 2006–2010 with most of the funding going towards the purchase of temporary methods (condoms, 44.0%; oral contraceptives, 29.6%; and injectables, 21.3%); limited funding was directed towards long-acting and reversible methods like the intrauterine device (IUD: 0.7%) and implants (0.7%; Reproductive Health Supplies Coalition 2013). Foreign aid comes in the form of technical, material and financial support to the Guinean health system. Funds are allocated through different channels depending 68
Figure 2 Comparison between family planning funding and the country needs from 2006 to 2012. Source: Ministry of Health, 2007; Reproductive Health Supplies Coalition website 2013.
on the type of partner and the beneficiary. Each partner is also more or less specialised in one field or focus on a specific geographical area. Based on the objectives of the national strategic plan for repositioning FP, the MoH projected contraceptive prevalences of 14% for 2009, 17% for 2010, 19% for 2011 and 21% in 2012. The financing needed to achieve these rates was estimated at USD 1.1 million in 2009, 1.4 million in 2010, 1.6 million in 2011 and 1.7 million in 2012. These financial needs were 85% covered in 2009, dropping down to 40% in 2010 and then improving to 68% in 2011 and 79% in 2012 (Figure 2). The 5-year project (2006–2011) funded by the World Bank to reduce maternal and under-five mortality also aimed to increase the utilisation of family planning services. The project provided additional funding to support FP services delivery.
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Family planning services and commodities In Guinea, 390 first line health centres representing primary health facilities in the national health system offer condoms, pills and injectables. They are responsible of supervising community distribution of condoms and pills by Community Health Workers (CHW). Some offer IUDs. Secondary hospitals (seven regional hospitals and 35 districts hospitals) offer the primary hospitals package in addition to IUDs and implants. The regional hospitals package and permanent methods are offered in the two tertiary hospitals (both located in Conakry). Regional hospitals of N’Zerekore and Faranah also offer permanent methods. Condoms, pills and injectables, mainly supplied by PSI, are also available in the private for profit sector. Private health facilities consist mostly of primary facilities (343) and of five secondary hospitals. The majority of them (54% of private hospitals and 79% of private pharmacies) are located in Conakry. The role of the public sector has decreased in terms of services delivered for all methods except for injectables. The private non-medical sector (shops, kiosks, bars) sees its place declining over the years, even with regard to condoms (Table 3). In the private not for profit sector, stakeholders mainly strengthen the capacities of public and private health structures. While AGBEF is engaged in community distribution of condoms and pills, the distribution of injectables has not yet started in Guinea and the use of mobile technology to support contraceptive uptake has not been investigated. The sources of FP commodities in the country have been diversified from 2006 to 2010. Oral contraceptives were supplied mainly by KFW (43.2%), USAID (39%) and UNFPA (13.7%). Table 3 Where people get their family planning method in Guinea, from 1999 to 2005
Oral (%)
Injectable (%)
Condom (%)
Sources
1999
2005
1999
2005
1999
2005
Public sector Private medical sector* Private not medical sector† Other/unspecified
49.9 21.0
41.9 26.8
82.4 12.0
84.7 8.5
12.6 27.1
7.4 19.0
22.6
19.8
5.6
1.6
56.0
27.4
6.5
11.5
0.0
5.2
4.3
46.2
*Private clinics, private pharmacies, NGOs/specialised associations. †Shops, kiosks, bars. Source: Guinea Demographic and Health Surveys 1999 and 2005.
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Injectable contraceptives were provided mainly by KFW (39.5%) and UNFPA (38.0%). Male condoms are mostly financed by KFW and UNFPA and spermicides almost exclusively by IPPF (98.3%). IUDs have been funded by the IPPF (57.1%) and USAID (25.5%) and implants by UNFPA and IPPF (Reproductive Health Supplies Coalition 2013). Levels and trends of FP and RH indicators from 1992 to 2005 Knowledge of modern contraceptive methods among men and women aged 15–49 has increased since 1992, exceeding 90% in 2005 across the country (Table 4). Modern contraceptive prevalence slightly increased from Table 4 Evolution of family planning and Reproductive health indicators in Guinea, 1992–2005 Indicators/Year
1992
Knowledge of modern methods Women aged 15–49 28.0% Men aged 15–49 55.3% Modern contraceptive prevalence Women aged 15–49 1.5% Married women 1% Rural 0.2% Urban 3.4% Regions Conakry – Lower Guinea – Middle Guinea – Upper Guinea – Forest Guinea – Level of education None – Primary – Secondary and above – Traditional contraceptive 0.7% prevalence Unmet needs 24.7% To space 18.3% To limit 6.4% Satisfied demand 4% Total Fertility Rate (TFR) 5.7 Ideal number of children – Infant mortality ratio 136 (& live births) Maternal mortality ratio(per 666 100 000 live births) WHO updated Maternal – mortality ratio National HIV Prevalence –
1999
2005
70.6% 80.9%
91.8% 95.4%
4.9% 4.2% 2.3% 9.5%
6.8% 5.7% 3.7% 11.4%
– – – – –
13.9% 4.5% 1.7% 6.5% 5.0%
– – – 1.8%
4.3% 9.3% 18.4% 3.4%
24.2% 16% 8.2% 15% 5.5 5.7 98
21.2% 13.1% 8.1% 21% 5.7 5.6 91
528 – –
980 680(2008) 1.5%
Source: Demographic and Health Surveys 1992, 1999 and 2005; WHO, 2011.
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1.5% in 1992 to 6.8% in 2005 among women aged 15– 49. Among married women, the use of modern FP methods was 1% and 5.7%, respectively, in 1992 and 2005. In the same period, FP use showed an increase from 0.2% in 1992 to 3.7% in 2005 in rural areas, while it increased from 3.4% to 11.4% in urban areas. Among regions, contraceptive prevalences for modern methods ranged from 1.7% in central Guinea to 13.9% in Conakry. Likewise, FP use is higher in women with secondary education (18.4%) than in those without education (4.3%). Unmet needs for modern contraceptive methods slightly decreased from 24.7% in 1992 to 21.2% in 2005. Between 1999 and 2005, the proportion of married women who wanted to space births decreased from 18.3% to 13.1%, whereas the proportion of women who wanted to limit births rose from 6.4% to 8.1%. The ideal number of children per woman (5.6) and her total fertility rate (5.7) remained unchanged. The maternal mortality ratio per 100 000 live births increased from 666 in 1992 to 980 in 2005. Strengths, weaknesses, opportunities and threats of FP in Guinea Strengths, weaknesses, opportunities and threats of the FP are summarised in Table 5. The domestic environment is conducive to improving the use of FP to the extent that the policy and strategy documents exist and that the health system is prepared to offer FP services. However,
efforts to ensure adequate and continuous supply, to expand and diversify the use of FP methods are insufficient. The severe shortage of public funding is a direct threat to the sustainability of FP current funding. One priority problem is the high level of the ‘ideal number of children’, which is nearly the same as the TFR. Other problems are weak coordination of the actors; the failure of the health information system, which makes it difficult to plan and monitor FP programmes, insufficient promotion of long-acting reversible methods; insufficient availability of contraceptives in public health facilities; and poor integration of the private sector. The major challenges to ensure sustainable contraceptive security include lack of staff training, inadequate equipment and the weakness of good logistics. Discussion Contraceptive security exists when every person or couple is able to choose, obtain and use quality contraception when desired (Sine & Sharma 2002). In Guinea, the political and institutional framework provides a favourable environment for FP. Policy is translated into action through legislation and national strategic documents. The coordination is ensured by the MoH. However, the political will expressed in the national policy and other documents contrasts with the poor results achieved so far. The capacity of the MoH to ensure the coordination of all actors and interventions remains low. Political will
Table 5 Strengths, weaknesses, opportunities and threats of family planning in Guinea Strengths
Weaknesses
Existence of policy documents and strategies supportive to family planning (FP) Existence of a framework for dialogue between stakeholders on reproductive health The integration of FP in the Minimum Package of Activities at all levels of the health pyramid Existence of social marketing to promote FP activities and products Creation of a National Directorate of Family Health and Nutrition (2011)
Ineffective coordination of actors Health information system not functional Inadequate public funding for FP Low use of long-acting and permanent methods Inequitable distribution of national healthcare staff Weak integration of FP services in the public and private sector Frequent contraceptives stock-outs
Opportunities
Threats
Existence of political commitment Involvement of partner in contraceptive supplies Involvement of some religious leaders or groups [or whatever is appropriate] in public awareness Free post-partum IUD and implant in the public sector (since 2009) FP integrated into medical, nursing and midwifery school curricula
Decrease in FP funding from key partners Strong national dependence on external partners funding of FP commodities and other aspects of the programme Lack of sustainability plan for ongoing projects of international NGOs Political instability since 2007 High national TFR level
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should be made more assertive by the establishment of a strong government body that could coordinate FP activities and boost interventions. In countries where FP programmes have experienced success (Tunisia, Iran, Rwanda), the existence of a coordination structure has been a great asset (Raftery et al. 1995; Lee et al. 1998; Robinson & Ross 2007; Habumuremyi & Zenawi 2012; Simbar 2012). Guinea needs a stronger structure with clearly defined prerogatives and resources that will share the vision and build a sustainable national plan involving all stakeholders. The contraceptive prevalence among married women remains very low in Guinea, even compared with the African average (Cleland et al. 2011). It has increased by 0.46% per year between 1992 and 1999 and by 0.25% per year between 1999 and 2005. The increase was 0.6% per year in West Africa between 1991 and 2004, and 1.4% per year in southern Africa between 1992 and 2004 (Cleland et al. 2011). To achieve MDG 5.b, Guinea will need to increase the modern contraceptive prevalence rate by 1.5% per year (Guengant 2011). The proportion of unmet needs has remained high in the country during the last decade (22% between 2002 and 2007), relative to the average proportion in many African countries (Cleland et al. 2011; Cleland & Shah 2013). By increasing its national contraceptive prevalence from 10% in 2005 to 45% in 2010 with a concomitant fall in fertility, from 6.1 to 4.6 lifetime births per woman, Rwanda has shown that progress can be made faster (Habumuremyi & Zenawi 2012). Ghana is committed to making family planning free in the public sector and supporting the private sector to provide services and Senegal is committed to doubling its contraceptive prevalence rate from 12% to 27% by 2015 (USAID, Bill & Melinda Gates Foundation 2013). Demographic and Health Survey (1992–2005) results show a decrease in contraceptive supply from the public sector. Sharma (Sharma & Dayaratna 2005) reported in an analysis of 10 developing countries from different regions that 45% of contraceptive pills and 56% of condoms provided by the public and private sector targeted people who can afford to pay. Contraceptive security therefore requires full mobilisation of all potential resources of public and private sector capable of meeting the demands and needs of contraceptives users, women and men. There is no designated government budget line allocated to the purchase of contraceptives. In addition, Guinea has not yet established national reproductive health accounts, which are essential to ensuring transparency and better monitoring of the flow of resources (WHO 2013). Public funding that is most likely to benefit the
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entire population, especially marginalised and hard-toreach people remains low in Guinea (Goldie et al. 2010; Gold & Sonfield 2011). This low level generates disparities in access to FP services and contraceptive methods and moreover raises the question of the sustainability of FP interventions and programmes in Guinea (Lee et al. 1998) as the purchase of contraceptives depends mainly on technical and financial partners. The reliance on outside funding reduces the power of decision of the country and even of local actors such as AGBEF (choice of contraceptive methods and quantities to import). It also leads to a discontinuity in services in case of temporary shortage of external supply of contraceptives and indeed when funding terminates. In Peru, the gradual reduction in FP funding (public and private) from 2000 led to a decline in the use of modern methods in the public sector (Gribble et al. 2007). Only long-term funding will ensure the institutional and financial stability necessary for the sustainability of FP programmes in Guinea (Lee et al. 1998, 2009; Gold & Sonfield 2011; Potts et al. 2013; Reproductive Health Supplies Coalition 2013). In Tunisia, for example, public funding helped offset the decline in external aid and ensured the sustainability of the programme (Lee et al. 1998). In Ghana and Iran, political commitment and government financial support led to increased use of modern contraceptive methods and programmes sustainability (Robinson & Ross 2007; Simbar 2012). It is in this context that the declaration of the African presidents in Abuja in 2001, supported by the ministerial meeting in 2008 in Ouagadougou, recommended that African governments should allocate 15% of their annual budgets to health (Guengant 2011). Guinea is still far from meeting these recommendations when considering the annual budget allocated to health between 2005 and 2011 (WHO 2013). A cost-effectiveness study of 40 health interventions conducted in Guinea in 2008 showed that the minimum package of health care amounted to $13 (Prabhat et al. 1998). This is two times more than public spending in the country’s health in the same period. The increase in public funding for health in general and FP in particular is therefore essential (Alkema et al. 2013). There are opportunities to expand and increase FP uptake through integration of FP in HIV, post-partum, post-abortion and fistula care programmes and services. Seventy-three hospitals in the country are offering postabortion FP counselling. FP counselling is part of voluntary testing and PMTCT services that are integrated in, respectively, 95 and 83 hospitals throughout the country. EngenderHealth is promoting FP use at six hospitals offering fistula prevention-only services and at three offering prevention and repair services. The government 71
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could increase the uptake of FP methods by supporting FP integration in reproductive health services and ensuring regular supply with FP methods to avoid frequent stock-outs. While FP services are theoretically available in the public sector from primary health facilities to tertiary hospitals, the national assessment of FP services conducted in 2009 reported that FP supply was good (availability of FP material ≥ 80%) in tertiary hospitals in Conakry and moderately good (availability from 50% to 70%) in some secondary hospitals (regional hospitals of N’Zerekore and Faranah). The offer was inadequate (availability ≤ 50%) in the rest of secondary hospitals and in all primary health facilities of the country with 25.7 stock-outs days per year in Conakry and 58.5 days in the rest of the country (MSP Guinee, UNFPA 2007). The public system also suffers of an inappropriate monitoring system, which is essential for monitoring activities, improving the quality of services, decision-making and planning. Indeed, data on FP activities are not often available in yearly national health statistical reports. These data are produced with a long delay. Decision-making is difficult or even impossible without accurate data on the current status of activities and results. Report of the 2008 national health statistics was only validated in 2012. This is because the national health information unit is poorly equipped with little funding to support its functioning. Moreover, the health information system is still based on paper reporting from primary to tertiary hospital. Access to information is not easier in the private sector either because of the existence of parallel information systems. Relevant information on the level of integration and quality of FP services in the private medical sector are lacking. Unless Guinea translates the political commitment into an ambitious national family programme, it is likely that MDG 5b will not be achieved with respect to FP targets. The country needs champions to advocate family planning and improved supply chains to reduce stock-outs. Quality of care, mobile outreach, social marketing and community-based distribution of FP methods need to be focused on to reach the most vulnerable. Innovative approaches such as the use of mobile technologies and community-based distribution of injectables should be piloted. Limitations of the study Our estimate of FP funding in Guinea does not include all programme costs due to the unavailability of national reproductive health accounts. The population figures 72
used date from the 1996 Census. The estimate of the target audience of FP programmes reflects the national target (6% of the total population instead of 25% as recommended by WHO). For some years, credible data were not available. Our work could not describe in detail the characteristics of the different actors and clients at national level. Such work requires a market segmentation study (Sharma & Dayaratna 2005). This work has nevertheless shown that the current funding is below the national projections. Conclusion The FP programme remains fragile in Guinea. The legislative framework is quite favourable. FP activities are split between actors, and the lack of a strong coordinating structure does not facilitate effective control and coordination of all services. Lack of staff training, of adequate equipment, and weak logistics are the major challenges to ensuring sustainable contraceptive security. Better public engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent FP methods. Acknowledgements We are grateful to Mark Barone (EngenderHealth), Cece Vieux Kolie (Ministry of Health and Public Hygiene of Guinea), Robert Sarah Tambalou (Association Guineenne pour le Bien-Etre Familial) and Mamadou Kaba for their comments and advice on the draft manuscript. References Alkema L, Kantorova V, Menozzi C & Biddlecom A (2013) National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet 381, 1642–1652. Bongaarts J & Sinding SW (2009) A response to critics of family planning programs. International Perspectives on Sexual and Reproductive Health 35, 39–44. Burke AE & Shields WC (2005) Millennium Development Goals: slow movement threatens women’s health in developing countries. Contraception 72, 247–249. Cates W Jr (2010) Family planning: the essential link to achieving all eight millennium development goals. Contraception 81, 460–461. Cleland J & Shah I (2013) The contraceptive revolution: focused efforts are still needed. Lancet 381, 1604–1606. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A & Innis J (2006) Family planning: the unfinished agenda. Lancet 368, 1810–1827.
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Cleland JG, Ndugwa RP & Zulu EM (2011) Family planning in sub-Saharan Africa: progress or stagnation? Bulletin of the World Health Organization 89, 137–143. Cohen A (2012) London summit puts family planning back on the agenda, offers new lease on life for millions of women and girls. Guttmacher Policy Review 15, 20–24. Commission Européenne (2013) L’analyse SWOT. Consulted on May 16, 2013 at: http://ec.europa.eu/europeaid/evaluation/ methodology/examples/too_swo_res_fr.pdf. Direction Nationale de la Statistique (DNS) de Guinée (2006) Enquête Démographique et de Santé, Guinée 2005. ORC Macro, Calverton. Gold RB & Sonfield A (2011) Publicly funded contraceptive care: a proven investment. Contraception 84, 437–439. Goldie SJ, Sweet S, Carvalho N, Natchu UC & Hu D (2010) Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. PLoS Medicine 7, e1000264. Gribble JN, Sharma S & Menotti EP (2007) Family planning policies and their impacts on the poor: Peru’s experience. International Family Planning Perspectives 33, 176–181. Guengant J (2011) Guinee: Comment Beneficier du Dividende Demographique?. Agence Francaise de Developpement, Paris. Guengant J, Mets N (2008) Le marche de planning Familial au Niger: Perspectives de Repartition Entre le Secteur Public et le Secteur Prive. Ministere de la Sante Publique, KFW, UNFPA, Niamey. Habumuremyi PD & Zenawi M (2012) Making family planning a national development priority. Lancet 380, 78–80. Health Policy and Planning Project (2011) La Guinee: Atteindre les OMD, la Contribution du Planning Familial. The Future Group International, Washington, DC. Lee K, Lush L, Walt G & Cleland J (1998) Family planning policies and programmes in eight low-income countries: a comparative policy analysis. Social Science and Medicine 47, 949– 959. Ministere de la sante et de l’hygiene publique de Guinee (2008) Feuille de Route Nationale Pour L’acceleration de la Reduction de la Mortalite Maternelle et Infantile 2006-2015. Ministere de la sante et de l’hygiene publique de Guinee; UNFPA, Conakry. Ministere de la sante et de l’hygiene publique de Guinee (2009) Plan Strategique National de Repositionnement de la PF, 2008-2015. Ministere de la sante et de l’hygiene publique de Guinee; UNFPA, Conakry. Ministere de la sante et de l’hygiene publique de Guinee (2009) Plan National de Securisation des Produits de Sante de la Reproduction. Ministere de la sante et de l’hygiene publique de Guinee; UNFPA, Conakry.
Lee RB, Nacionales LP & Pedroso L (2009) The influence of local policy on contraceptive provision and use in three locales in the Philippines. Reproductive Health Matters 17, 99–107. MSP Guinee, UNFPA (2007) Analyse de la Situation de la Securite des Produits de Sante de la Reproduction. MSP - UNFPA, Conakry. Olmen J, Criel B, Van Damme W, Marchal B, Van Belle S & Van Dormael M (2010) Analysing Health Systems To Make them Stronger. In: Studies in Health Services Organisation & Policy 27 (eds W Van Lerberghe, G Kegels & V De Brouwere) ITG Press, Antwerp, pp. 21–80. Potts M, Weinrib R & Campbell M (2013) Why bold policies for family planning are needed now. Contraception 87, 393– 395. Prabhat J, Bangoura O & Ranson K (1998) The cost-effectiveness of fourty health interventions in Guinea. Health Policy and Planning 13, 249–262. Raftery AE, Lewis SM & Aghajanian A (1995) Demand or ideation? Evidence from the Iranian marital fertility decline. Demography 32, 159–182. RamaRao S & Mohanam R (2003) The quality of family planning programs: concepts, measurements, interventions, and effects. Studies in Family Planning 34, 227–248. Reproductive Health Supplies Coalition 2013. RHInterchange: a Website for Coordination of Contraceptive Orders and Shipments. Consulted on March 19, 2013 at: http://www.who.int/ nha/country/gin/fr/ Robinson W & Ross J (2007) The Global Family Revolution: Three Decades of Population Policies and Programmes. The World Bank, Washington, DC. Sharma S & Dayaratna V (2005) Creating conditions for greater private sector participation in achieving contraceptive security. Health Policy 71, 347–357. Simbar M (2012) Achievements of the Iranian family planning programmes 1956–2006. Eastern Mediterranean Health Journal 18, 279–286. Sine J & Sharma S (2002) Policy Aspects of Achieving Contraceptive Security. Policy Issues in Planning and Finance No. 1. Futures Group, POLICY Project, Washington, DC. Stover J & Ross J (2010) How increased contraceptive use has reduced maternal mortality. Maternal and Child Health Journal 14, 687–695. USAID, Bill & Melinda Gates Foundation (2013) The London Summit on Family Planning. Summaries of commitments. 4-22-2013. WHO 2013. Comptes Nationaux de Sante: Guinee. OMS. consulted on September 23, 2013 on: -http://apps.who.int/nha/ database/StandardReport.aspx?ID=REP_WEB_MINI_TEMP LATE_WEB_VERSION&COUNTRYKEY=84540
Corresponding Author Alexandre Delamou, Centre National de Formation et de Recherche en Sante Rurale de Maferinyah, PO Box: 4099, Conakry, Guinea. Tel.: +224 631 099 750; E-mail: [email protected]
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Family planning in Guinea: a need for better public commitment Alexandre Delamou1, Akoi Koivogui2, Dominique Dubourg3 and Th er ese Delvaux4 1 2 3 4
Centre National de Formation et de Recherche en Sante Rurale de Maferinyah, Conakry, Guinee Observatoire Regional de la Sante de Guyane, Guyane, France Department of Public Health, Maternal and Reproductive Health Unit, Institute of Tropical Medicine, Antwerp, Belgium Department of Public Health, HIV/AIDS Policy Unit, Institute of Tropical Medicine, Antwerp, Belgium
Abstract
objective To describe the evolution of family planning (FP) in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. methods Descriptive study of the evolution of FP in Guinea between 1992 and 2010. First, national laws as well as health policies and strategic plans related to reproductive health and family planning were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005). Third, FP services, sources of supply and data on FP funding were analysed. results Laws, policies and strategic plans in Guinea are supportive of FP programme and services. Public and private actors are not sufficiently coordinated. The general government expenditure on health has remained stable at 6–7% between 2005 and 2011 despite a doubling of total expenditures on health, and contraceptives are supplied by foreign aid. Modern contraceptive prevalence slightly increased from 1.5% in 1992 to 6.8% in 2005 among women aged 15–49. conclusion A stronger national engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent methods. keywords family planning, programme, review, Guinea
Introduction Family planning (FP) is defined as a set of services that enable individuals and couples to anticipate and attain their desired number of children by a better spacing and timing of pregnancies (Bongaarts & Sinding 2009). The inclusion of FP in the Target 5b of the Millennium Development Goal (MDG) in 2005 reflects the international consensus on its benefits, both for mother and child at individual level and for family income, national economy and environment at collective level (Bongaarts & Sinding 2009; Cates 2010; Potts et al. 2013). The London summit on FP 2012 aimed to help repositioning FP on the global agenda, pledging to halve the number of women living with unmet need for FP in the next 8 years (Potts et al. 2013). By preventing unwanted pregnancies among an additional 120 million women in the world’s 69 poorest countries by 2020, FP could potentially avert 1.1 million newborn and infant deaths and 79 000 maternal deaths (Burke & Shields 2005; Cleland et al. 2006; Stover & Ross 2010; Cohen 2012). Giving priority to countries where FP programmes have
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experienced stagnation will help achieve this goal (Robinson & Ross 2007; Cleland et al. 2011). Likewise, a better understanding of the evolution of FP programmes in these countries will increase the likelihood of being successful in improving their FP programmes and services. (Lee et al. 1998; RamaRao & Mohanam 2003; Burke & Shields 2005; Sharma & Dayaratna 2005; Dehlendorf et al. 2010). In Guinea, the national FP programme began in 1983 as a vertical programme, and FP was then integrated into all public health policies and programmes in 1990 (Guengant 2011). In addition to several strategic plans aiming at repositioning and strengthening FP, the adoption of the reproductive law in 2009 was seen as strong signal of political commitment towards FP (MSP Guinee, UNFPA 2007). However, after decades of implementation of FP programmes and policies, FP use remains very low in Guinea. The latest Demographic and Health Survey conducted in 2005 (DHS) reported a contraceptive prevalence for modern methods among married women aged 15–49 years at 5.7% (Direction Nationale de la 65
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Statistique (DNS) de Guinee 2006), representing an annual increase of 0.12% from 4.2% in 1999. Unfortunately Guinea needs an annual increase of 1.5% to achieve MDGs 4 and 5 (Guengant 2011), gradually meet the needs for FP between 2010 and 2020 and avert approximately 600 maternal deaths and 40 000 infant deaths (Cleland et al. 2011; Health Policy & Planning Project 2011). Repositioning FP at the national level and providing individuals and couples with lasting contraceptive security is therefore required (Sharma & Dayaratna 2005). The aim of this study was to describe the evolution of FP in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. Methodology We conducted a descriptive study on the evolution of FP in Guinea between 1992 and 2010. First, laws as well as health policies and strategic plans related to reproductive health and FP put in place by the Ministry of Health (MOH) (1992–2010) were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005), and the annual reports (2006–2010) of the Association Guineenne pour le Bien Etre Familial (International Planned Parenthood Federation (IPPF) member Association). Collected indicators included modern and traditional contraceptive prevalence, the proportion of unmet needs, the Total Fertility Rate (TFR) and maternal and infant mortality. Third, FP services were described and sources of supply and provision of contraceptives were collected from ‘Reproductive Health Supplies Coalition’ reports. Finally, data on FP funding were collected from WHO’s National Health Accounts (2005–2011), and ‘Reproductive Health Supplies Coalition’ reports including public and private funding (grants, donations and others). Data analysis The first part of the analysis focused on the description of the policy and institutional framework, the involvement of different actors, the organisation of FP services and the financing of FP programmes. The method used was the framework for analysing health systems of the Institute of Tropical Medicine of Antwerp (Olmen et al. 2010) and the FP market segmentation approach of United States Agency for International Development (USAID; Guengant & De Mets 2008). The second part analysed the trend in FP indicators across the DHS (1992, 1999 and 2005) results. The last part of the analysis concerned the strengths, weaknesses, opportunities and threats of 66
the current FP programme in Guinea. This part was carried out using the SWOT analysis model of Humphrey (Commission Europeenne 2013).
Results Institutional and policy framework Family planning was integrated in the health system in 1990, and from 1998, the country started adopting FPrelated policies and developing FP-related strategic plans (Table 1). The Law L025/2000 on Reproductive Health promulgated in 2000 identified FP as a means to improve women’s health and prevent unwanted pregnancies. The Manual of Procedures, Standards and Protocols of Reproductive Health, which includes modern FP methods, was revised in 2006. The National Roadmap for Accelerating the Reduction of Maternal Mortality (Ministere de la sante et de l’hygiene publique de Guinee 2008), the National Strategic Plan for Repositioning Family Planning (Ministere de la sante et de l’hygiene publique de Guinee 2009) and the National Plan for the Security of Reproductive Health Products (Ministere de la sante et de l’hygiene publique de Guinee, UNFPA 2009) confirm the country’s commitment to promote FP (Guengant 2011). In 2008, the Strategic Plans for repositioning FP and for Reproductive health products security were adopted. Actors in family planning The PF programme is under the jurisdiction of the Division of Family Health and Nutrition, which itself depends on the National Directorate of Public Health within the Ministry of Health (MoH). This directorate is responsible for implementing the national FP policy and coordinating partners and stakeholders. The Division collaborates with the Ministry of Youth (in charge of youth reproductive health, especially youth friendly health centres) and the Ministry of Women’s Promotion and Childhood. The MoH through the Division of Family Health and Nutrition maintains relations with bilateral, multilateral partners and Non-Governmental Organizations (NGOs). The IPPF, the United Nations Population Fund (UNFPA), the USAID, the World Bank and the Kreditanstalt f€ ur Wiederaufbau (KfW) are also technical partners. The organisations in the private not for profit sector have two profiles: foreign NGOs such as Population Service International (PSI), Plan International, EngenderHealth, JHPIEGO, which act as technical and operational partners; and national NGOs such as AGBEF (IPPF member association), which act as service providers. Technical part-
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Table 1 Family planning and reproductive health in policies and strategic plans in Guinea
Policies/plans National population policy, 1996 National Health Development Plan 2003–2012 National Roadmap for Accelerating the Reduction of Maternal and Infant Mortality 2006–2015 Strategic Plan for Repositioning Family Planning 2008–2015 Strategic Plan for Securing RH Commodities, 2008–2012 National Strategic Framework for Fight Against STI/HIV/AIDS 2008– 2012
Infant mortality (/1000 LB*)
Maternal mortality ratios (/100 000 LB*)
Modern contraceptive prevalence rate
No quantified objective Reduce from 177 & in 1999 to 90 & in 2015 Reduced from 163 in 2005 to 121 in 2010 and 80 in 2015 No quantified objective
No quantified objective Reduce from 528 in 1999 to 220 in 2015
Reduce the TFR by 35% by 2010 Promote family planning, but no quantified objective
Reduce from 980 in 2005 to 780 in 2010 and to 580 in 2015. Reduce from 980 in 2005 to 700 in 2010 and to 580 in 2015
Increase contraceptive prevalence rate from 6% in 2005 to 17% in 2010 and to 21% in 2012 Increase contraceptive prevalence rate from 6% in 2005 to 21% in 2015 and reduce unmet need from 21% in 2005 to 10% in 2015 No quantified objective
No quantified objective
No quantified objective
No quantified objective
No quantified objective
Increase condom use by 50% in people of 15–49 years between 2008 and 2012
*LB, live births. Source: adapted from Guengant 2011.
ners support public sector health facilities through staff training, community awareness and mobilisation, health systems strengthening, quality improvement, monitoring and evaluation. Their projects are usually limited in time and often not renewed. Family planning funding
1000 800 600 400 200 0
Contribution in thousands of USD
Family planning funding is provided by the government, development partners and households. Government fund-
ing covers salaries, operating expenses, pre- and in-service training building and renovation of health structures (Figure 1). Table 2 summarises the evolution of health expenditures between 2005 and 2011. The general government expenditure on health has remained stable between 6% and 7% from 2005 to 2011 despite a doubling of total expenditures on health. Foreign aid focused on investments, training and drug supply. For example, it accounted for 14.1% of the total health expenditure and reached 37.5% in 2011. Finally, the private expenditure
2006
2007
2008
2009
2010
Years Figure 1 Evolution of family planning funding in Guinea from 2006 to 2010. Source: Reproductive Health Supplies Coalition website 2013.
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UNFPA IPPF Total contribution
USAID KFW
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Table 2 Evolution of health expenditure ratios and population between 2005 and 2011 in Guinea Years Health expenditure ratios
2005
2006
2007
2008
2009
2010
2011
Total expenditure on health (THE) in millions (USD) Total expenditure on health/capita at exchange rate (USD) Share of health in the national budget (%) Public expenditure on health as % of THE Private expenditure on health as % of THE Out-of-pocket expenditure as % of private expenditure on health Private insurance as % of private expenditure on health Rest of the world funds/External resources (USD) Population (in thousands)
158 17 6 17.7 82.3 99.4
163 18 6 17.0 83.0 99.4
251 27 8 18.6 81.4 99.4
276 29 8 21.6 78.4 99.4
295 30 7 27.3 72.7 99.1
294 29 7 32.5 67.5 92.7
304 30 7 27.3 72.7 92.7
0.6 14.1 9041
0.6 20.3 9202
0.6 37.6 9374
0.6 25.0 9559
0.9 32.3 9761
7.3 43.6 9982
7.3 37.5 10222
Source: WHO 2013.
2
1.79
Funding in millions USD
1.8
% of needs funded
1.58
1.6 1.37
1.4
1.42
1.12
1.2 1
1.08 1.06
0.8 0.6
0.94
0.47 0.55
0.4 0.2
0.26
0.35
225%
85%
40%
68%
79%
2009
2010
2011
2012
0 2006
2007
2008
Years Country’s need
Real funding
on health slightly decreased from 82.3% to 72.7% of the total expenditure on health in this period. Almost all of these expenses are covered by direct payments by households (out-of-pocket). An important part of foreign aid for FP is allocated to the purchase of contraceptives commodities. This assistance was estimated at U.S. $ 3 160 447 for the period 2006–2010 with most of the funding going towards the purchase of temporary methods (condoms, 44.0%; oral contraceptives, 29.6%; and injectables, 21.3%); limited funding was directed towards long-acting and reversible methods like the intrauterine device (IUD: 0.7%) and implants (0.7%; Reproductive Health Supplies Coalition 2013). Foreign aid comes in the form of technical, material and financial support to the Guinean health system. Funds are allocated through different channels depending 68
Figure 2 Comparison between family planning funding and the country needs from 2006 to 2012. Source: Ministry of Health, 2007; Reproductive Health Supplies Coalition website 2013.
on the type of partner and the beneficiary. Each partner is also more or less specialised in one field or focus on a specific geographical area. Based on the objectives of the national strategic plan for repositioning FP, the MoH projected contraceptive prevalences of 14% for 2009, 17% for 2010, 19% for 2011 and 21% in 2012. The financing needed to achieve these rates was estimated at USD 1.1 million in 2009, 1.4 million in 2010, 1.6 million in 2011 and 1.7 million in 2012. These financial needs were 85% covered in 2009, dropping down to 40% in 2010 and then improving to 68% in 2011 and 79% in 2012 (Figure 2). The 5-year project (2006–2011) funded by the World Bank to reduce maternal and under-five mortality also aimed to increase the utilisation of family planning services. The project provided additional funding to support FP services delivery.
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Family planning services and commodities In Guinea, 390 first line health centres representing primary health facilities in the national health system offer condoms, pills and injectables. They are responsible of supervising community distribution of condoms and pills by Community Health Workers (CHW). Some offer IUDs. Secondary hospitals (seven regional hospitals and 35 districts hospitals) offer the primary hospitals package in addition to IUDs and implants. The regional hospitals package and permanent methods are offered in the two tertiary hospitals (both located in Conakry). Regional hospitals of N’Zerekore and Faranah also offer permanent methods. Condoms, pills and injectables, mainly supplied by PSI, are also available in the private for profit sector. Private health facilities consist mostly of primary facilities (343) and of five secondary hospitals. The majority of them (54% of private hospitals and 79% of private pharmacies) are located in Conakry. The role of the public sector has decreased in terms of services delivered for all methods except for injectables. The private non-medical sector (shops, kiosks, bars) sees its place declining over the years, even with regard to condoms (Table 3). In the private not for profit sector, stakeholders mainly strengthen the capacities of public and private health structures. While AGBEF is engaged in community distribution of condoms and pills, the distribution of injectables has not yet started in Guinea and the use of mobile technology to support contraceptive uptake has not been investigated. The sources of FP commodities in the country have been diversified from 2006 to 2010. Oral contraceptives were supplied mainly by KFW (43.2%), USAID (39%) and UNFPA (13.7%). Table 3 Where people get their family planning method in Guinea, from 1999 to 2005
Oral (%)
Injectable (%)
Condom (%)
Sources
1999
2005
1999
2005
1999
2005
Public sector Private medical sector* Private not medical sector† Other/unspecified
49.9 21.0
41.9 26.8
82.4 12.0
84.7 8.5
12.6 27.1
7.4 19.0
22.6
19.8
5.6
1.6
56.0
27.4
6.5
11.5
0.0
5.2
4.3
46.2
*Private clinics, private pharmacies, NGOs/specialised associations. †Shops, kiosks, bars. Source: Guinea Demographic and Health Surveys 1999 and 2005.
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Injectable contraceptives were provided mainly by KFW (39.5%) and UNFPA (38.0%). Male condoms are mostly financed by KFW and UNFPA and spermicides almost exclusively by IPPF (98.3%). IUDs have been funded by the IPPF (57.1%) and USAID (25.5%) and implants by UNFPA and IPPF (Reproductive Health Supplies Coalition 2013). Levels and trends of FP and RH indicators from 1992 to 2005 Knowledge of modern contraceptive methods among men and women aged 15–49 has increased since 1992, exceeding 90% in 2005 across the country (Table 4). Modern contraceptive prevalence slightly increased from Table 4 Evolution of family planning and Reproductive health indicators in Guinea, 1992–2005 Indicators/Year
1992
Knowledge of modern methods Women aged 15–49 28.0% Men aged 15–49 55.3% Modern contraceptive prevalence Women aged 15–49 1.5% Married women 1% Rural 0.2% Urban 3.4% Regions Conakry – Lower Guinea – Middle Guinea – Upper Guinea – Forest Guinea – Level of education None – Primary – Secondary and above – Traditional contraceptive 0.7% prevalence Unmet needs 24.7% To space 18.3% To limit 6.4% Satisfied demand 4% Total Fertility Rate (TFR) 5.7 Ideal number of children – Infant mortality ratio 136 (& live births) Maternal mortality ratio(per 666 100 000 live births) WHO updated Maternal – mortality ratio National HIV Prevalence –
1999
2005
70.6% 80.9%
91.8% 95.4%
4.9% 4.2% 2.3% 9.5%
6.8% 5.7% 3.7% 11.4%
– – – – –
13.9% 4.5% 1.7% 6.5% 5.0%
– – – 1.8%
4.3% 9.3% 18.4% 3.4%
24.2% 16% 8.2% 15% 5.5 5.7 98
21.2% 13.1% 8.1% 21% 5.7 5.6 91
528 – –
980 680(2008) 1.5%
Source: Demographic and Health Surveys 1992, 1999 and 2005; WHO, 2011.
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1.5% in 1992 to 6.8% in 2005 among women aged 15– 49. Among married women, the use of modern FP methods was 1% and 5.7%, respectively, in 1992 and 2005. In the same period, FP use showed an increase from 0.2% in 1992 to 3.7% in 2005 in rural areas, while it increased from 3.4% to 11.4% in urban areas. Among regions, contraceptive prevalences for modern methods ranged from 1.7% in central Guinea to 13.9% in Conakry. Likewise, FP use is higher in women with secondary education (18.4%) than in those without education (4.3%). Unmet needs for modern contraceptive methods slightly decreased from 24.7% in 1992 to 21.2% in 2005. Between 1999 and 2005, the proportion of married women who wanted to space births decreased from 18.3% to 13.1%, whereas the proportion of women who wanted to limit births rose from 6.4% to 8.1%. The ideal number of children per woman (5.6) and her total fertility rate (5.7) remained unchanged. The maternal mortality ratio per 100 000 live births increased from 666 in 1992 to 980 in 2005. Strengths, weaknesses, opportunities and threats of FP in Guinea Strengths, weaknesses, opportunities and threats of the FP are summarised in Table 5. The domestic environment is conducive to improving the use of FP to the extent that the policy and strategy documents exist and that the health system is prepared to offer FP services. However,
efforts to ensure adequate and continuous supply, to expand and diversify the use of FP methods are insufficient. The severe shortage of public funding is a direct threat to the sustainability of FP current funding. One priority problem is the high level of the ‘ideal number of children’, which is nearly the same as the TFR. Other problems are weak coordination of the actors; the failure of the health information system, which makes it difficult to plan and monitor FP programmes, insufficient promotion of long-acting reversible methods; insufficient availability of contraceptives in public health facilities; and poor integration of the private sector. The major challenges to ensure sustainable contraceptive security include lack of staff training, inadequate equipment and the weakness of good logistics. Discussion Contraceptive security exists when every person or couple is able to choose, obtain and use quality contraception when desired (Sine & Sharma 2002). In Guinea, the political and institutional framework provides a favourable environment for FP. Policy is translated into action through legislation and national strategic documents. The coordination is ensured by the MoH. However, the political will expressed in the national policy and other documents contrasts with the poor results achieved so far. The capacity of the MoH to ensure the coordination of all actors and interventions remains low. Political will
Table 5 Strengths, weaknesses, opportunities and threats of family planning in Guinea Strengths
Weaknesses
Existence of policy documents and strategies supportive to family planning (FP) Existence of a framework for dialogue between stakeholders on reproductive health The integration of FP in the Minimum Package of Activities at all levels of the health pyramid Existence of social marketing to promote FP activities and products Creation of a National Directorate of Family Health and Nutrition (2011)
Ineffective coordination of actors Health information system not functional Inadequate public funding for FP Low use of long-acting and permanent methods Inequitable distribution of national healthcare staff Weak integration of FP services in the public and private sector Frequent contraceptives stock-outs
Opportunities
Threats
Existence of political commitment Involvement of partner in contraceptive supplies Involvement of some religious leaders or groups [or whatever is appropriate] in public awareness Free post-partum IUD and implant in the public sector (since 2009) FP integrated into medical, nursing and midwifery school curricula
Decrease in FP funding from key partners Strong national dependence on external partners funding of FP commodities and other aspects of the programme Lack of sustainability plan for ongoing projects of international NGOs Political instability since 2007 High national TFR level
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should be made more assertive by the establishment of a strong government body that could coordinate FP activities and boost interventions. In countries where FP programmes have experienced success (Tunisia, Iran, Rwanda), the existence of a coordination structure has been a great asset (Raftery et al. 1995; Lee et al. 1998; Robinson & Ross 2007; Habumuremyi & Zenawi 2012; Simbar 2012). Guinea needs a stronger structure with clearly defined prerogatives and resources that will share the vision and build a sustainable national plan involving all stakeholders. The contraceptive prevalence among married women remains very low in Guinea, even compared with the African average (Cleland et al. 2011). It has increased by 0.46% per year between 1992 and 1999 and by 0.25% per year between 1999 and 2005. The increase was 0.6% per year in West Africa between 1991 and 2004, and 1.4% per year in southern Africa between 1992 and 2004 (Cleland et al. 2011). To achieve MDG 5.b, Guinea will need to increase the modern contraceptive prevalence rate by 1.5% per year (Guengant 2011). The proportion of unmet needs has remained high in the country during the last decade (22% between 2002 and 2007), relative to the average proportion in many African countries (Cleland et al. 2011; Cleland & Shah 2013). By increasing its national contraceptive prevalence from 10% in 2005 to 45% in 2010 with a concomitant fall in fertility, from 6.1 to 4.6 lifetime births per woman, Rwanda has shown that progress can be made faster (Habumuremyi & Zenawi 2012). Ghana is committed to making family planning free in the public sector and supporting the private sector to provide services and Senegal is committed to doubling its contraceptive prevalence rate from 12% to 27% by 2015 (USAID, Bill & Melinda Gates Foundation 2013). Demographic and Health Survey (1992–2005) results show a decrease in contraceptive supply from the public sector. Sharma (Sharma & Dayaratna 2005) reported in an analysis of 10 developing countries from different regions that 45% of contraceptive pills and 56% of condoms provided by the public and private sector targeted people who can afford to pay. Contraceptive security therefore requires full mobilisation of all potential resources of public and private sector capable of meeting the demands and needs of contraceptives users, women and men. There is no designated government budget line allocated to the purchase of contraceptives. In addition, Guinea has not yet established national reproductive health accounts, which are essential to ensuring transparency and better monitoring of the flow of resources (WHO 2013). Public funding that is most likely to benefit the
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entire population, especially marginalised and hard-toreach people remains low in Guinea (Goldie et al. 2010; Gold & Sonfield 2011). This low level generates disparities in access to FP services and contraceptive methods and moreover raises the question of the sustainability of FP interventions and programmes in Guinea (Lee et al. 1998) as the purchase of contraceptives depends mainly on technical and financial partners. The reliance on outside funding reduces the power of decision of the country and even of local actors such as AGBEF (choice of contraceptive methods and quantities to import). It also leads to a discontinuity in services in case of temporary shortage of external supply of contraceptives and indeed when funding terminates. In Peru, the gradual reduction in FP funding (public and private) from 2000 led to a decline in the use of modern methods in the public sector (Gribble et al. 2007). Only long-term funding will ensure the institutional and financial stability necessary for the sustainability of FP programmes in Guinea (Lee et al. 1998, 2009; Gold & Sonfield 2011; Potts et al. 2013; Reproductive Health Supplies Coalition 2013). In Tunisia, for example, public funding helped offset the decline in external aid and ensured the sustainability of the programme (Lee et al. 1998). In Ghana and Iran, political commitment and government financial support led to increased use of modern contraceptive methods and programmes sustainability (Robinson & Ross 2007; Simbar 2012). It is in this context that the declaration of the African presidents in Abuja in 2001, supported by the ministerial meeting in 2008 in Ouagadougou, recommended that African governments should allocate 15% of their annual budgets to health (Guengant 2011). Guinea is still far from meeting these recommendations when considering the annual budget allocated to health between 2005 and 2011 (WHO 2013). A cost-effectiveness study of 40 health interventions conducted in Guinea in 2008 showed that the minimum package of health care amounted to $13 (Prabhat et al. 1998). This is two times more than public spending in the country’s health in the same period. The increase in public funding for health in general and FP in particular is therefore essential (Alkema et al. 2013). There are opportunities to expand and increase FP uptake through integration of FP in HIV, post-partum, post-abortion and fistula care programmes and services. Seventy-three hospitals in the country are offering postabortion FP counselling. FP counselling is part of voluntary testing and PMTCT services that are integrated in, respectively, 95 and 83 hospitals throughout the country. EngenderHealth is promoting FP use at six hospitals offering fistula prevention-only services and at three offering prevention and repair services. The government 71
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could increase the uptake of FP methods by supporting FP integration in reproductive health services and ensuring regular supply with FP methods to avoid frequent stock-outs. While FP services are theoretically available in the public sector from primary health facilities to tertiary hospitals, the national assessment of FP services conducted in 2009 reported that FP supply was good (availability of FP material ≥ 80%) in tertiary hospitals in Conakry and moderately good (availability from 50% to 70%) in some secondary hospitals (regional hospitals of N’Zerekore and Faranah). The offer was inadequate (availability ≤ 50%) in the rest of secondary hospitals and in all primary health facilities of the country with 25.7 stock-outs days per year in Conakry and 58.5 days in the rest of the country (MSP Guinee, UNFPA 2007). The public system also suffers of an inappropriate monitoring system, which is essential for monitoring activities, improving the quality of services, decision-making and planning. Indeed, data on FP activities are not often available in yearly national health statistical reports. These data are produced with a long delay. Decision-making is difficult or even impossible without accurate data on the current status of activities and results. Report of the 2008 national health statistics was only validated in 2012. This is because the national health information unit is poorly equipped with little funding to support its functioning. Moreover, the health information system is still based on paper reporting from primary to tertiary hospital. Access to information is not easier in the private sector either because of the existence of parallel information systems. Relevant information on the level of integration and quality of FP services in the private medical sector are lacking. Unless Guinea translates the political commitment into an ambitious national family programme, it is likely that MDG 5b will not be achieved with respect to FP targets. The country needs champions to advocate family planning and improved supply chains to reduce stock-outs. Quality of care, mobile outreach, social marketing and community-based distribution of FP methods need to be focused on to reach the most vulnerable. Innovative approaches such as the use of mobile technologies and community-based distribution of injectables should be piloted. Limitations of the study Our estimate of FP funding in Guinea does not include all programme costs due to the unavailability of national reproductive health accounts. The population figures 72
used date from the 1996 Census. The estimate of the target audience of FP programmes reflects the national target (6% of the total population instead of 25% as recommended by WHO). For some years, credible data were not available. Our work could not describe in detail the characteristics of the different actors and clients at national level. Such work requires a market segmentation study (Sharma & Dayaratna 2005). This work has nevertheless shown that the current funding is below the national projections. Conclusion The FP programme remains fragile in Guinea. The legislative framework is quite favourable. FP activities are split between actors, and the lack of a strong coordinating structure does not facilitate effective control and coordination of all services. Lack of staff training, of adequate equipment, and weak logistics are the major challenges to ensuring sustainable contraceptive security. Better public engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent FP methods. Acknowledgements We are grateful to Mark Barone (EngenderHealth), Cece Vieux Kolie (Ministry of Health and Public Hygiene of Guinea), Robert Sarah Tambalou (Association Guineenne pour le Bien-Etre Familial) and Mamadou Kaba for their comments and advice on the draft manuscript. References Alkema L, Kantorova V, Menozzi C & Biddlecom A (2013) National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet 381, 1642–1652. Bongaarts J & Sinding SW (2009) A response to critics of family planning programs. International Perspectives on Sexual and Reproductive Health 35, 39–44. Burke AE & Shields WC (2005) Millennium Development Goals: slow movement threatens women’s health in developing countries. Contraception 72, 247–249. Cates W Jr (2010) Family planning: the essential link to achieving all eight millennium development goals. Contraception 81, 460–461. Cleland J & Shah I (2013) The contraceptive revolution: focused efforts are still needed. Lancet 381, 1604–1606. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A & Innis J (2006) Family planning: the unfinished agenda. Lancet 368, 1810–1827.
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Corresponding Author Alexandre Delamou, Centre National de Formation et de Recherche en Sante Rurale de Maferinyah, PO Box: 4099, Conakry, Guinea. Tel.: +224 631 099 750; E-mail: [email protected]
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