“The Canadian government should refrain from advancing the failed right-wing ideologies previously imposed by the George W. Bush administration in the United States, which made humanitarian assistance conditional upon a ‘global gag rule’ that required all non-governmental organizations receiving federal funding to refrain from promoting medically-sound family planning,” said the Canadian Liberal Party about the country’s Conservative government in a Parliamentary motion last week.

Though Prime Minister Stephen Harper had pledged to include a voluntary family planning initiative in Canada’s foreign aid plan at last year’s G8 meeting in Italy, the Conservative government recently said that the initiative will not be part of its G8 plan at the upcoming meeting in Canada this June.

This move has surprised both Canadians and Americans. U.S. President Obama overturned the Mexico City policy last year, and has fully supported the inclusion of family planning methods as part of foreign aid.

Harper’s government has maintained that maternal and child health services, such as vaccinations and nutrition, will be a priority, but various components of family planning, including birth control and abortion, will not be included in the Canadian initiative.

The Tories, as along with three Liberal MPs, voted down the Liberal motion 138-144, which requested clarification of Harper’s maternal health initiative and pushed for the inclusion of the full range of family planning options. The Tories focused solely on what they called “anti-American rhetoric” in the motion, which drew attention away from the divisive issue of abortion.

The issue has got caught up in domestic Canadian politics, with opposition Liberals trying to equate the Conservatives with the George W. Bush administration and the Conservatives trying to avoid discussion of intra-party debates on the contentious issue of abortion.

Now it seems likely like that Harper will go to the G8 summit in Ontario with a foreign aid plan for maternal health that makes no reference to issues of contraception. According to Canada’s International Co-operation Minister Bev Oda, “saving lives” of women and children is a higher priority than family planning.

But most international maternal health advocates don’t agree. “Maternal mortality rates are high among women who do not have access to family planning services. Contraception can reduce the number of unplanned pregnancies,” said Calyn Ostrowski, program associate for the Wilson Center’s Global Health Initiative. “For example, at a recent event on our Maternal Health series, Harriet Birugni of the Population Council in Kenya described how integrating reproductive health services such as family planning can reduce maternal mortality rates, particularly for poor young women who have the least access to contraception.”

In response to Canada’s announcement, U.S. Secretary of State Hilary Clinton said that the United States will be promoting global health funding, including access to contraception and abortion, at the G8. “You cannot have maternal health without reproductive health,” she said during a news conference with other G8 ministers. Britain has also agreed with this position, which has led Canadian Liberal Party Leader Michael Ignatieff to say that Canada’s G8 position goes against the international consensus.

Laura Pedro is the program assistant for the Canada Institute, and a graduate of the University of Vermont.

Photo.: Prime Minister Stephen Harper, courtesy Flickr user Kashmera

“Family planning is to maternal survival what a vaccination is to child survival,” said Johns Hopkins professor Amy Tsui, quoting Khama Rogo of the World Bank, at the Woodrow Wilson Center event Maintaining the Momentum: Highlights From the Uganda International Conference on Family Planning on March 16. Rogo made the strong statement during the landmark November 2009 conference in Kampala, which has renewed interest in family planning and reproductive health among African leaders and development partners. Rhonda Smith of the Population Reference Bureau and Sahlu Haile of the David and Lucile Packard Foundation joined Tsui, the director of The Bill & Melinda Gates Institute of Population & Reproductive Health, to discuss their impressions of the Kampala conference and what it means for the future of family planning in Africa.

“An event that happened at the right time”

“Kampala was the work of a community,” said Tsui. More than 50 organizations—the U.S. Agency for International Development, the UN Population Fund, the World Bank, the World Health Organization, and the Gates and Packard Foundations—convened in Uganda, which was chosen not only for its central location, but also to highlight the country’s soaring unmet need for contraception—41 per cent—and rapid 3.1 percent population growth rate.

Panels focused on key issues in family planning, including:

• Integrating family planning into HIV/AIDS care
• Integrating family planning in post-abortion, postpartum, child, and other primary health care
• Expanding contraception delivery services by community health workers
• Increasing outreach to youth and men
• Capitalizing on private and public innovations in service delivery and financing

The conference also made a splash in the media. “If you want it to get a lot of media hype, you have to have someone ready to say ‘I’m giving money to X,’” said Tsui. Thus, the Johns Hopkins Bloomberg School of Public Health, David and Lucile Packard Foundation, USAID, and the Bill and Melinda Gates Foundation announced a new three-year, $12 million Advance Family Planning project to advance reproductive health and family planning efforts in regions with the greatest need—particularly, sub-Saharan Africa and Asia. The conference generated palpable excitement and renewed energy for family planning. Uganda was “an event that happened at the right time,” said Tsui. Conference organizers, who have been asked to replicate it in other parts of the world, are already looking for locations for 2011. The conference was not just a success in theory, but also in action, and several developments emerged in its wake:

• The United States announced its foreign assistance budget will increase support for family planning from $450 million to $715 million for the next fiscal year.
• The Global Health Initiative identified maternal/child health and family planning as one of its main priority themes.
• Secretary of State Clinton positively discussed girls’ education, family planning, and reproductive health at the ICPD + 15 anniversary.
• The Women Deliver 2010 Conference, to be held in June, has identified family planning as a third pillar of maternal health.

Uganda on the Move

Rhonda Smith’s presentation “Uganda on the Move”—which she also presented in Uganda—is a prototype of the Population Reference Bureau’s new ENGAGE (Eliminating National Gaps—Advancing Global Equity) project, which is designed to “engage policy audiences and promote policy dialogue around issues of high fertility and high unmet need for family planning and their costs, consequences, and solutions,” she said. By using stunning, innovative graphics and avoiding confounding technical terms, ENGAGE’s products are designed to reach non-technical policy audiences and influential decision-makers.

As one of the Uganda conference’s most talked about presentations, “Uganda on the Move” wows audiences with visuals created using Hans Rosling’s Trendalyzer software. The presentation shows that although Ugandans are increasingly healthier, have a higher life expectancy, and are more educated, maternal health remains in jeopardy. Tellingly, 46 percent of pregnancies in the country are unplanned, 6,000 women die each year from complications related to pregnancy, and 1,200 women die each year from undergoing unsafe abortions.

Maternal deaths, however, do not tell the whole story: For every one woman dying, Smith said, 20-30 women suffer from short-term disability, which places a major strain on economic growth. From 2004 to 2013, maternal death will cost Uganda US$350 million in lost productivity; and disability will cost and additional US$750 million.

What Next? The African Perspective

“After 10 years of virtual clandestine work, [family planning] is just coming out of the closet,” said Sahlu Haile. Over the last few decades, family planning advocates have been struggling to: 1) keep family planning alive—without it being affected by political considerations 2) make family planning a health priority, without any associations with rights violations; and 3) be in solidarity with pioneering organizations of the family planning movement, like the International Planned Parenthood Federation, that were victims of discriminatory funding decisions.

The Uganda conference changed all that, said Haile. In Uganda, conference attendees were “talking about family planning…not reproductive health, not maternal/child health.” This, he said, was “probably the single most important lesson…that I took from the Kampala conference.”

Following the conference, Haile said that African government officials stressed family planning as a priority at meetings in Ethiopia and Nigeria—the first time he had witnessed such high-level attention to family planning from those countries in his 30-year career.

In Ethiopia, African leaders pledged to:

• Prioritize family planning, since family planning is one of the most cost-effective development investments;
• Ensure access to contraception, as 40 percent of maternal deaths are associated with unwanted pregnancies; and
• Integrate MDG 5b, universal access to reproductive health, into their international development plans and budgets.

In Nigeria, West African ministers of health agreed that making abortion safe was essential to reducing maternal mortality. Across the board, at each meeting, family planning was discussed as “an investment, not an expenditure,” said Haile.

Haile credited the Kampala conference for spurring these efforts. In December, he joined a task force of 14 Ethiopian organizations to plan the next steps. They will jointly develop research capacities, generate evidence, and strengthen monitoring and evaluation practices, especially with regard to integrating population, health, and environment efforts. In addition, they will engage with wider audiences via new tools such as the blog RH RealityCheck and Gapminder Foundation’s Trendalyzer program.

Haile believes we need to “work together to encourage national-level efforts…to make sure family planning stays where it is now and make sure it is not abandoned.”

To be a part of the new online family planning community, join the Kampala Conversation.

Photo 1: A women and her children in Jinja, Uganda. Courtesy Flickr user cyclopsr. Photos of Amy Tsui, Rhonda Smith, and Sahlu Haile courtesy of Dave Hawxhurst, Woodrow Wilson Center.

Nearly two months after the devastating 7.0 magnitude earthquake in Port-au Prince, Haiti, the country still needs assistance to provide basic healthcare and shelter, in addition to rebuilding Haiti’s economy, government, and institutions. As the international community and NGOs make the transition from emergency disaster relief to long-term reconstruction and capacity-building efforts, donor coordination and long-term commitment are crucial. Recently, on Capitol Hill, a panel of experts organized by Wilson Center on the Hill and the Wilson Center’s Latin American Program  discussed Haiti’s continuing problems and challenges.

USAID’s Gloria Steele offers written testimony on the FY2011 Global Health and Child Survival (GH CS) budget request before the House Appropriations Subcommittee on State, Foreign Operations

Andrew Revkin gives a shout-out to family planning and notes the lack of population discussion at Copenhagen in his blog post, “From Wishful Thinking to Real-World Action on Climate“

Video of Secretary of State Hilary Clinton addressing the Commission on the Status of Women in which she discusses the Global Health Initiative, maternal mortality, family planning, and “gendercide“

Family planning-environmental connections headline PATH‘s March edition of Outlook

Youth bulges and social conflict are noted in Nicholas Kristoff’s recent article on child marriages in Yemen

Follow Geoff Dabelko on Twitter for more population, health, environment, and security updates

Among the many initiatives that have recently been launched to strengthen health systems in the developing world, there is little consensus on execution. Traditional strategies for improving the health system, such as the vertical approach, which prioritizes communicable diseases, or the horizontal approach, which prioritizes non-communicable diseases, are limited in scope and fail to include a comprehensive gender lens.

To overcome the shortcomings of these two health financing approaches, the “diagonal” strategy combines them by “clearly defining priorities and utilizing these priorities to drive general improvements of the health system,” said Julio Frenk, dean of the Harvard University School of Public Health, at the Global Health Initiative’s third event in the “Advancing Policy Dialogue on Maternal Health” series.

Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, a report by the Guttmacher Institute, asserts that “sustained and increased investment in sexual and reproductive health services in developing countries” would “contribute to economic growth, societal and gender equity, and democratic governance.” The report presents cost-benefit analyses of family planning and maternal and newborn health strategies in an effort to “guide decision makers, at the global, regional and country levels, in making investments that would reap the greatest returns for individuals and societies.”

“Training is probably one of the biggest interventions in terms of making human resources available,” says Pape Gaye, President and CEO of IntraHealth International, to ECSP’s Gib Clarke in this interview on improving maternal health services in developing countries. “Unfortunately, there are a lot of problems associated with training.”

Gaye says obstacles to scaling up maternal health services in rural areas include employee gender inequalities, poor coordination of supplemental training, and a tendency to only offer in-service training in urban areas. Properly emphasizing pre-service education, he underscores, could remedy some of the problems associated with service provider training.

Increasing retention of medical practitioners is also critical to improving maternal health services in developing countries, Gaye explains. In his experience, however, attempts to address perceived security and financial compensation inadequacies produced mixed results. Instead, Gaye suggests that positive recognition may be one of the best methods for retaining health care workers. “We’re seeing some very good successes in places where we have just simple ways to recognize the work… because if people feel valued in a community, then they are likely to stick it out.”

Bill Gates gave the PHE community a much-needed upgrade in his foundation’s 2nd Annual Letter, released this week. Unfortunately it still has a few bugs.

“In the long run, not spending on health is a bad deal for the environment because improvements in health, including voluntary family planning, lead people to have smaller families, which in turn reduces the strain on the environment,” concludes Gates.

This statement could dramatically raise awareness of and funding for population-environment programs. Any time Bill Gates talks, the world listens, as evidenced by the barrage of coverage from Reuters, AFP, and top IT newswires. For the public, it offers a rare glimpse into development strategy, so Gates’ thoughts (and financial commitments) could be seen as representative of the foundation community’s approach to global health problems.

Although it may seem obvious that fewer people place less strain on the environment, this connection has been largely absent from the environmental agenda, including the efforts to combat climate change. Some environmental leaders and organizations have dismissed population as an unimportant distraction from the real business at hand. Others have noted that population growth’s impact on climate change is far greater in the rich world than in poor countries, whose per capita emissions are a fraction of developed countries’.

Gates’ comment may cause those in the first camp to re-evaluate the importance of family planning, and it is likely to energize the converted. But it will have less impact on those focused on consumption. But if it encourages the environmental community to put population and family planning issues back on the table, it will have gone a long way.

However, Gates could have gone further, by explaining that family planning is a relatively inexpensive way to mitigate climate change, compared to complex and emerging technological solutions. He also could have pointed out that climate change is expected to increase the prevalence of vector-borne diseases such as malaria, or that sick or malnourished individuals may be forced to mismanage natural resources.

Because Gates didn’t make these explicit connections, many in the media missed his point. The wire headlines pit health against environment, when Gates was in fact pointing out how interdependent they are. This distortion is symptomatic of the media’s tendency to highlight the horserace. But maybe they would pay closer attention if the Gates Foundation put its money where its mouth is—and funded programs that integrate family planning and the environment.

Perhaps several years from now, we will look back and say that this letter marks the start of the Gates Foundation’s integrated approach to development. But we may need to wait for Letter 3.0 for a complete install.

Photo: Courtesy Flickr User World Economic Forum

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