Informing family planning research priorities: a perspective from the front line in A sia

Abstract

Impressive reductions of up to 29% in maternal deaths may be expected from satisfying unmet need for contraception, as shown in a recent analysis covering 172 countries (Ahmed et al. 2012). Despite the cost-effectiveness of family planning (Prata et al. 2010), investments remain low (Osotimehin 2012), a concern declared under Goal 5 on the UN Millennium Development Goals website, ‘Inadequate funding for family planning is a major failure in fulfilling commitments to improving women's reproductive health.' Alongside investment and political commitment, clear indicators for the coverage and quality of family planning services are required to design and implement strategies to improve family planning. However, the evidence used in planning and monitoring of family planning is often suboptimal and poses a serious problem for effective, efficient responses to scale up these services. The 2012 London Summit on Family Planning signalled renewed interest in this important intervention by the global community. Large investments were pledged and ambitious targets of access to contraception for 120 million women and girls by 2020 were set. This has also prompted the Alliance for Reproductive, Maternal and Newborn Health to work with WHO and development partners to facilitate a prioritisation of the family planning research agenda. With a view to informing these discussions, we were commissioned by the Australian Agency for International Development (AusAID) to identify the key knowledge gaps for evidence-based planning and budgeting for family planning. As part of a multicountry initiative working with policy makers to effect a more rational use of resources for reproductive, maternal, newborn and child health (Jimenez-Soto et al. 2012), we collated the data necessary to inform local decision-making on scaling up family planning services. Our work highlighted major evidence gaps that have the potential to undermine efforts to plan and invest in family planning and interfere with monitoring progress. The seven leading knowledge gaps identified are outlined in this short paper and provide an essential ‘front-line’ perspective to inform research priorities for effective scaling-up of family planning. We draw on examples from our study sites in four countries: two districts and two cities in Indonesia, two provinces and one city in the Philippines, three clusters of districts in Nepal, two districts in the Indian state of Orissa and two districts in the state of Uttar Pradesh. We believe that this view from the front line provides a much-needed link between global agendas and the realities of implementation at a local level. The dearth of locally relevant data regarding family planning is a significant barrier to effective planning and monitoring. Estimates of contraceptive prevalence rate (CPR), total fertility rate (TFR) and unmet need for contraception are typically available at national level, but not at the peripheral level, where health service delivery decisions are often made. For example, in Indonesia, information regarding fertility preferences and TFR was not available at levels lower than the Province, despite the fact that the family planning programme is delivered at district level. In the absence of district-level survey data, even frequently reported measures such as CPR are crude estimates, based on numbers of married couples within the district and records of contraceptives dispensed from health facilities. These estimates can be unreliable for two reasons. Firstly, contraceptive users accessing private providers, an increasingly important source of contraception, are often excluded from usage numbers. Secondly, population estimates can differ substantially according to the method (and data sources) used to calculate them and the level of internal migration. This is particularly relevant in urban settings, where it is very challenging for local governments to maintain information systems on a highly transient and rapidly changing population (La Vincente et al. 2012). The quality of care offered by a health service is critical not only in ensuring that couples use the service, but also in maximising the protective coverage of the population. Despite its importance, the health information systems of the four countries included in the study entirely overlook service quality in their composition of indicators. Our study revealed that the quality of government family planning services was a major factor limiting utilisation in Indonesia, Nepal, the Philippines (Byrne et al. 2012) and India. Complications from incorrect insertion of intrauterine devices, poor counselling for appropriate methods and mismanagement of side effects were frequently reported (Aldaba et al. 2011; Morgan et al. 2011; Trisnantoro et al. 2011; Varghese et al. 2011, 2012). Information surrounding health system supply issues that affect the quality of care, such as funding, staffing, training and logistics, also is unreliable. For example