London School of Hygiene & Tropical Medicine

A leading population expert will today make a plea for a revitalisation of the family planning agenda in the world's poorest countries, cautioning that soaring population rates are now a bigger threat to achieving the MDGs than HIV/AIDS.

John Cleland, Professor of Medical Demography at the London School of Hygiene & Tropical Medicine, has contributed a paper to a major series on sexual and reproductive health which is launched online today in the Lancet.

Professor Cleland and his co-authors assert that investment in family planning should have a higher priority than investment in HIV prevention and treatment in most poor countries, because it poses a greater threat to international development. He also maintains that leadership may now need to come from European governments and agencies, rather than the United States which has, historically, led on this issue.

Family planning promotion is unique among medical interventions in the breadth of its potential benefits in terms of achieving the MDGs. It reduces poverty, maternal, and child mortality (in 2000, about 90% of global abortion-related and 20% of obstetric-related mortality an morbidity could have been averted by the use of effective contraception - amounting to 150,000 deaths avoided). It contributes to achieving universal primary schooling, empowers women by reducing the burden of excessive childbearing, and enhances environmental sustainability by stabilising the population of the planet.

In the past forty years, family planning programmes have played a major part in raising the prevalence of contraceptive practice from less than 10% to 60% and reducing fertility in developing countries from six to about three births per woman. But the battle is by no means over - in half the 75 low- and lower-middle-income countries (mainly in Africa) contraceptive practice remains low and fertility, population growth and unmet need for family planning remain high. Many countries in sub-Saharan Africa are projected to see their populations double in the next few decades, yet in the last ten years or so family planning has dropped right down the international development agenda, and global funding and support has waned.

Professor Cleland comments: 'A convincing case can be made that investment in family planning should have a higher priority than investment in HIV prevention and treatment. Yet, current priorities are the reverse. For instance, in Ghana, HIV/AIDS is sucking funds, staff, and political energy from family planning, and this is a country where women are more likely to die of unsafe abortion than of AIDS . . . In Uganda, with a moderately severe longstanding HIV epidemic, population size is nevertheless projected to grow from 30 million today to 61 million by 2025, and further to 127 million by the middle of this century, posing huge difficulties for economic advance.

'Historically, leadership has come from the US government, and more than half of all international assistance for family planning still comes from that country. But leadership cannot now be expected from that quarter. A separate paper by Professor Anna Glasier¹, which appears in the Lancet today, discusses how the adoption of effective family planning policies has been compromised by an increasingly conservative approach to sexual and reproductive health and rights by the Bush administration, including moves to refuse US family planning assistance to foreign NGOs working in abortion.

'Hopefully, others will be prepared to take the lead, perhaps European countries, the World Bank, or even the Gates Foundation with its massive funds and prestige. Most poor countries already have population policies in place but need encouragement from development agencies to implement them with conviction and commitment'.

The keys to effective and sustainable family planning programmes are well established, say the authors. These include high-level political commitment, which is what is lacking at the moment, a broad coalition of support from elite groups, adequate funding, the legitimisation of the idea of smaller families and modern contraceptives through mass media, and the availability of a range of methods which ca be accessed via medical facilities, outreach services and social marketing initiatives.