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This weekend I returned from a long period of travel, having visited programs in eight countries in six weeks—some where I have lived, others where IntraHealth has had a significant commitment in partnership with the local government and communities, and still more where I feel I have spent so much time visiting over the past 25 years that I have come to feel at home. This journey will fittingly conclude with the Family Planning Summit in London on July 11. The travel has given me ample time to reflect on the many successes and failures those of us dedicated to family planning and reproductive health have witnessed and lived through.
According to the Guttmacher Institute’s June 2012 report, Adding It Up, more than 215 million women across the world have a need for access to methods of preventing unintended pregnancy that is not met. The Bill & Melinda Gates Foundation and Government of the United Kingdom will host this summit, in partnership with stakeholders and thought leaders globally, to address the commitments and actions required to ensure 120 million women get the access they need by 2020. Participants will build on ideas in the talk Melinda Gates gave at the Berlin TEDxChange this April, citing her own passion and commitment to these issues; later joined by hundreds of voices united in the No Controversy pledge.
During my recent trip, I returned to Togo, which was home to me and my young family when I was IntraHealth’s regional director for West Africa early in my career. Togo is a country that has been struggling for years, much like many of the francophone countries in the West Africa region. Its population of 6.7 million1 lives in less than 60,000 square kilometers (slightly smaller than West Virginia, which has a population of 1.8 million). Most Togolese live in rural areas and are subsistence farmers or merchants, with women as the cornerstone of economic development in more and more cases. The country’s economy fluctuates greatly with the price of coffee, cocoa, and cotton—its major cash crops for export. For every 1,000 live births in Togo, 103 children die before the age of five; for every 100,000 live births, 300 women die giving birth2. The contraceptive prevalence rate remains low at 16.8% and the total fertility rate high at nearly 5 children born per woman (4.69). These numbers are respectively below and above global (and regional) averages. This health situation is not acceptable.
For Togolese women and families, especially those in rural areas, a health worker is often their only source of education about and access to family planning methods. These health workers are confidants and coaches who counsel their clients to make the right choices for themselves and their families. They are truly agents of change and provide high-touch solutions—deeply personal and confidential exchanges between providers of care and those in need. This type of exchange can be exactly what it takes for a woman to feel at home making the choice to plan her family and limit pregnancies. Donors, governments, and NGOs cannot reach women at this level. Frontline health workers can, and they are the ones who can close the gaps in advancing the family planning agenda and contribute dramatically to decreasing the number of lives of women and children lost.
In Togo, I had the pleasure of meeting a colleague who shared personal testimonials from women whose lives have been changed by frontline health workers. One of these women is Yaawovi Soubou, a young woman in the village of Totave in the Haho District. “I chose the injection. When I first started it, my periods lasted 12 days. I was a bit frightened but the community health worker reassured me. I can tell you that since then I haven’t had any problems.” Madame Soubou also mused about the stigmas attached to family planning in her community. “I’d like to add that before I started I hesitated because of what some of our sisters were saying. I would like to appeal to anyone who’s still dragging her feet to follow my example, for everyone’s benefit.”
Another young woman, Dopé Atajouma, is 30 years old and has seven children. She also decided to use Depo-Provera, an injectable contraceptive. “When the community health workers came to us with the project, it was a godsend for me in particular,” she said. “When my last child was born my husband asked me to do whatever was necessary to make sure I didn’t get pregnant again, even though he’s the one who gets me pregnant. So I told him that fortunately that was exactly what our community health workers did. So he had no doubts about it at all, he told me to go and get family planning as soon as I could so as not to miss the chance, particularly as it was free.” She explained that she went to the home of the community health agent, Mana, for her injection, and now “feels free. We no longer have to worry about another pregnancy.” This young family worried about confidentiality, as many do, but because Mana and her colleagues keep visits confidential, the family felt protected.
These women are among the many who have connected with a frontline health worker to learn more about family planning, to learn that they have choices, and to act on them. The right of women and men to choose to have children at a time when they are ready, when they feel they have met those personal conditions that allow them to give the best to their unborn, is a basic human right and represents the universal desire of a parent to provide the greatest opportunity to their children.
Successful provision of family planning at the community level requires a grassroots commitment to solving local problems. But it cannot succeed without political commitment all the way up the chain, from local health center managers, to district health officers, to the central-level Ministry of Health. In Togo, the districts of Blita and Aho started a program of teaching frontline workers to administer pills and injectables. Even though the national policy did not allow for community-based distribution of injectables, the Ministry of Health allowed the pilot initiative to see what would happen, and the results were astounding. In Blita, more than 1,800 women chose to participate over three months, and in Aho, in just six months, 5,000 women opted for the method of their choice.
Even though grassroots efforts keep the program going, the initiative started with the government itself. Dr. Charles Kondi Agba, the Minister of Health in Togo, shared with me that he was skeptical at first, but now he is newly convinced that with a little more support, a revolution in family planning can take place in his country, starting at the community level. To show the government’s support of these community health workers, a modest budget line of 81 million FCFA, or about $156,000, was included in this past year’s budget.
As I blogged in November 2011, when I look at the numbers, especially in my native West Africa, it is hard not to be discouraged. In so many of these countries, contraceptive prevalence rates still crawl in the single digits. At the forefront of my mind are the many countries in West Africa that lag behind other regions of the world—countries such as Benin, Burkina Faso, Chad, Ghana, Mali, Mauritania, Niger, Senegal, and Togo. All of these countries also have unacceptably high rates of infant, child, and maternal mortality.
What can be done to shake things up in West Africa? We must focus, of course, on contraceptive security and health systems strengthening in general, but I am more than ever convinced that real progress in family planning can be made only by those on the frontline, through community health workers, a focus on the basic human rights of women, and these high-touch solutions.
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