Strong performance in key family planning program dimensions, especially related to data collection and use, is associated with increases in mCPR.

To better understand the factors that may support or hinder increased access to and use of family planning across countries, we analyzed 17 measures included in the National Composite Index for Family Planning (NCIFP) for 21 of the 22 priority countries (NCIFP scores for Benin were excluded due to data quality concerns). The NCIFP is a tool developed to support decisionmakers as they work to improve the enabling environment for family planning, focusing on five dimensions of national programs―Strategy, Data Collection and Use, Quality of Care, Accountability, and Equity―each comprising a set of items against which country stakeholders score themselves.^c

NCIFP scores are gathered from national family planning experts across government, the private sector, nongovernmental and faith-based organizations, academic and research organizations, donor-assisted projects, and other influential actors. An analysis of global NCIFP scores globally demonstrates that higher scores are associated with higher mCPR, and that this relationship between programmatic performance and mCPR is more robust in SSA countries (see Figure 6).

Figure 6. NCIFP Ratings and mCPR Are Associated Globally, Especially in Sub-Saharan Africa

Source: PRB analysis of National Composite Index for Family Planning (NCIFP) 2017.

We examined FP2020 commitments as well as NCIFP scores in 2017. We further examined changes in scores between 2014 and 2017 for the indicators with data available for both years.

Across SSA, countries largely achieved improvements in dimensions for which FP2020 commitments were made. However, commitments were not exclusively associated with areas of program progress. Many countries achieved high scores in the Strategy dimension, which may have been supported by the push to develop costed implementation plans through the FP2020 partnership. Yet, several countries (Burkina Faso, Côte d'Ivoire, Madagascar, Mali, Niger, Senegal and Togo) have low scores in the Strategy item on high-level leadership and support for the family planning program.

While just half of countries made FP2020 commitments around Data Collection and Use, most countries had high scores in this dimension. But data challenges persist. In particular, countries score poorly on government collection of data from private sector providers, including on supply availability. Liberia is an exception; the government collects and integrates data on private sector commodities within the national logistics management information system (LMIS) to inform supply forecasting.

Quality of Care commitments and scores vary across countries. However, all countries except Burkina Faso and Tanzania reported lower scores in quality of care in the private sector compared with the public sector. This finding warrants further investigation to assess the extent to which it holds true across and within countries (for example, do quality of care scores in the private sector differ in urban versus rural settings and by the type of private sector provider). While nearly all countries pledged to increase private sector involvement or partnership, few countries identified specific actions or data needed to ensure high-quality services in private facilities. Malawi’s report to FP2020 notes that while the need to assess quality of care in the private sector is well established, private hospitals and pharmacies have no process available to them to report service statistics to the government.

Some countries did identify actionable steps to address quality of care in the private sector. After the Ghana Health Service committed to include DMPA-SC (a self-injected contraceptive method) in the method mix available at health facilities, the government supported master trainers in both the public and private sectors to coach providers on how to dispense the method. Guinea, Liberia, and Kenya committed to investments in capacity strengthening for providers in both the public and private sectors. Senegal pledged to revise laws governing family planning service provision by pharmacists. Notably, Malawi made a commitment to develop national supervision standards that include service providers’ accountability and quality of care measures.

While all countries committed to improving their logistics system and strengthening provider training, scores for both varied significantly, with nearly half of countries scoring below-average in each metric. Scale-up of digital technologies that strengthen LMIS, such as OpenLMIS, can generate time, cost, and management efficiencies that streamline procurement and reduce contraceptive stockouts.

Most countries had low or declining scores for collection of data on informed choice and provider bias, as well as the existence of systems for dialogue between clients and health providers or local officials on family planning services. For instance, DRC reported that, while it has no formal feedback system, client comments are collected through suggestion boxes available at some facilities. Ghana also uses suggestion boxes at facilities and implements periodic client exit interviews and surveys by health facility staff and district and regional health management teams. Togo conducts an annual survey on the availability of family planning products and services, as well as client satisfaction with services. The survey results are analyzed and disseminated to all regions to inform development and implementation of annual workplans. Relatedly, scores for the Accountability dimension are lowest across the board. Of particular note, few countries report that structures exist for clients to report denial of services or for regular program review of violations of rights or choice. Establishing or strengthening formal mechanisms to protect choice and promote dialogue will require dedicated attention and investment and must be prioritized in national and subnational strategies. Country stakeholders report challenges funding accountability structures when service delivery interventions are already underfunded. In such resource-constrainted environments, digital technologies that generate time and cost efficiencies may help create space in budgets for investment in essential accountability structures. In addition, digital approaches like PartME model, operating at scale in Ghana, can be used for cost-efficient accountability platforms that support community dialogue with decisionmakers.

Within the Equity dimension, scores for community-based distribution (CBD) mechanisms are especially revealing. While nearly all countries made FP2020 commitments related to establishing or scaling-up community-based distribution programs, scores for this item were often low or stagnant, with high scores over 65 points only seen in Ethiopia, Malawi, and Rwanda. These three countries also received relatively high scores for their logistics systems, while the opposite was true for South Sudan, Côte d'Ivoire, and DRC. Other factors that affect effective CBD programs include the lack of staff (in part due to high turnover), the need for trained personnel, and limited resources to cover wide and often remote geographic areas.

To better understand the programmatic factors associated with increases in mCPR, we further categorize countries by S-curve stage (see Figure 7).

Figure 7. NCIFP Scores for Selected Countries in Sub-Saharan Africa by S-Curve Stage, 2017

Hover over a country to see its performance across selected NCIFP items, either for all countries or for those that made an FP2020 commitment related to that item.

Source: National Composite Index for Family Planning (NCIFP) 2017.

Countries in Stage 1 had low ratings for most NCIFP items outside of the Strategy dimension.

Scores around Data Collection and Use were positively associated with increases in mCPR.

Stage 1 countries largely scored over 50, Stage 2 countries scored between 50 to 60 (except Rwanda, a strong performer with scores over 80), and Stage 3 countries scored over 60. Stage 3 countries (Kenya and Malawi) and Rwanda were the only countries to score above average in the Accountability dimension. The other 17 countries scored below average in the item structures to report denial of services on non-medical grounds (such as age or marital status). While many countries have policies against denial of service on such grounds, they may lack the infrastructure to support accountability.

The rights-based orientation of family planning programs in all of the SSA countries we reviewed, even countries with comparatively high scores in Accountability, must be strengthened through policy and program mechanisms that protect choice and equity. Official policy avenues for documenting, reporting, and using information on rights and choice in family planning programs should be accompanied by public communication initiatives that inform communities and individuals―as well as frontline providers―that client choice is a fundamental cornerstone of the family planning program and that advertise and encourage confidential reporting of issues or violations, including refusal to remove methods or denial of services based on age or spousal consent. Digital reporting tools highlighted in this report may serve as effective and confidential platforms for clients to report service issues ranging from limitations in choice (for example, reporting lack of availability of preferred methods) to experiences of discrimination or denial of services and violations of rights. Providers may also be encouraged to report on structural limitations to the provision of client-centered, rights-based services (for example, documenting when they are unable to provide a preferred method to a client due to lack of supplies or training).

Family planning programs may be better assessed through person-centered metrics, despite the limitations of available metrics.

Weak performance in the NCIFP Accountability dimension may reflect, at least in part, family planning programs’ emphasis on population-level contraceptive uptake rather than person-centered, rights-based service provision. Calls to reimagine this approach to benchmarking the success of family planning programs are leading to the collection and analysis of new and/or refined metrics that emphasize client autonomy and quality of care. This reimagining includes overdue efforts to better define and measure women’s “need” or “demand” for family planning, recognizing that intention to avoid pregnancy is not synonymous with wanting to use contraception.⁵

Even as efforts to systematically integrate more person-centered metrics in nationally representative data collection continue, decisionmakers can immediately act to ensure metrics beyond mCPR are used to assess the robustness of family planning programs. Table 3 presents DHS metrics addressing demand for family planning satisfied with any contraceptive method, the proportion of women who were counseled about potential side effects when accessing their current method, and the proportion of women—among those who do not want more children—who do not intend to use contraception.

These metrics retain significant limitations. The metric of demand satisfied arguably conflates wanting to avoid pregnancy with wanting to use contraception. Counseling about side effects is just one feature of high-quality, client-centered counseling. A lack of intention to use family planning among women who do not want to become pregnant may be a signal of women executing their right not to use contraception regardless of their pregnancy intentions, or it may be a signal of reproductive coercion by partners, parents-in-law, or others. Still, these metrics, among others, may contribute to reframing how program progress is conceptualized to better serve the reproductive, personal, and professional needs and preferences of family planning clients.

Table 3. Demand for Family Planning Satisfied, Counseling on Side Effects, and Intention Not to Use Family Planning, by S-Curve Stage

Source: Demographic and Health Surveys.

The COVID-19 pandemic reinforces the importance of investment in country data systems that are resilient to shocks.

The COVID-19 pandemic is the most significant potential disruptor to family planning programs since the last review. At the pandemic’s onset in March 2020, many experts predicted stalls in family planning program progress, including substantial declines in contraceptive use and increases in unmet need and unintended pregnancy.⁶

Analyzing pandemic-related disruptions in family planning programs proved challenging, as countries struggled with conducting data collection (including for the DHS). Data collected through national HMIS became a key early source of information on potential disruptions. In March 2021, findings from a convening examining HMIS data from multiple countries indicated that, for the most part, family planning services experienced a brief period of acute disruption but quickly recovered. The timing, speed, and scale of this recovery varied, with disruptions persisting or recurring across some countries, like Niger, over multiple cycles.

Emerging data on pandemic-related disruptions are largely reinforcing these early findings. For example, an analysis of survey data from six SSA countries (Burkina Faso, Côte d'Ivoire, DRC, Kenya, Nigeria, and Uganda) implemented between June 2020 and February 2021 confirm that disruptions were largely temporary and well below initial estimates. However, the ongoing pandemic could lead to future disruptions, whether driven directly by the pandemic or indirectly by resulting shortfalls in domestic financing for family planning. On the other hand, the pandemic also created a window for innovation, including accelerated adoption of digital technologies in family planning programs, which may have contributed to family planning program resilience. Successful programmatic adaptations―including virtual training for providers, online marketplaces supporting client self-care, and telehealth approaches to family planning service delivery―may enhance program impact and efficiency beyond the pandemic.

While disruptions in service delivery were more limited than originally feared, disruptions in data collection have been extensive and remain ongoing as the pandemic enters its third year. The pandemic halted new DHS across the globe because of health and safety concerns. Other surveys were stalled or conducted with limited and potentially biased samples (such as surveys implemented by phone, which may disproportionately reach women with higher incomes).

These disruptions have drawn attention to the importance of having strong country data collection systems, particularly HMIS, that are resilient to health system shocks.

While the limitations of HMIS data are well recognized―including challenges around data quality, accuracy, and fragmentation―findings from analyses of HMIS data during the pandemic are increasingly being verified by survey findings. Countries are leading efforts to address HMIS challenges, and these efforts should be met by commitment and investment from the donor community.

Family planning financing is vulnerable heading into the next decade.

At the time of the last report, donor funding for family planning had increased steadily between 2008 and 2014. While USAID remained the largest bilateral donor for family planning assistance in low- and middle-income countries, the governments of the United Kingdom and France became larger actors in the space.

In the intervening years, domestic resource expenditure for family planning appears to be increasing, although refinements in how such expenditures are tracked limit the extent to which changes over time can be clearly assessed. In the same period, donor commitments (including bilateral, multilateral, and private commitments) to family planning assistance in SSA have stagnated (see Figure 8).

Figure 8. Official Donor Commitments to Family Planning and Reproductive Health in Sub-Saharan Africa, 2010-2019 ($USD millions)

Source: Organisation for Economic Co-operation and Development, QWIDS (Query Wizard for International Development Statistics), data accessed as of March 17, 2022.

A 2020 Kaiser Family Foundation analysis of bilateral donor funding among 10 major donors shows continued declines as of that year. Decreases in bilateral assistance are largely driven by the United Kingdom because of pandemic-related constriction in their overall economy.

Investments in domestic resource mobilization, led by policymakers and civil society across countries in SSA, have generated new or increased financial commitments for family planning. However, sustaining both donor and country financial commitments over the next decade may be challenging as the pandemic’s economic effects continue to influence national economies. In this context, it is essential for family planning programs to identify and integrate approaches that increase efficiencies in implementation, including scale-up of proven digital solutions.