In the debate about demography in the context of sub-Saharan African countries, often the key messages focus on high expected population growth. Sub-Saharan Africa’s population is projected to at least double to around 2.5 billion by 2050, according to the United Nations World Population Prospects. However, what is lost in these numbers is that many countries in sub-Saharan Africa already are spurring a demographic transition (albeit at differing rates and stages) with both declining infant mortality and fertility rates. Ethiopia, Malawi and Rwanda are leading the way and providing evidence that within the African context it is possible to manage an acceleration of the demographic transition without a dramatic change of economic status.
How these champion countries achieved this is explained in a recently published literature review that is part of the K4D (Knowledge, Evidence and Learning for Development) Learning Journey on Supporting a Demographic Transition in Sub-Saharan Africa. All three countries’ transition is primarily the result of political commitment and leadership combined with comprehensive population policies that put voluntary family planning at the centre by linking it to other policies (education, health, job creation, etc.) and laws (e.g. revision of abortion laws and child marriage laws).
Population policy shifts
Although population policy was contested on the continent (and often for good reason), there has been a broader shift in sub-Saharan Africa more recently. Political engagement has increased, often related to the idea of reaping the economic benefits from a demographic dividend, when population growth slows following an accelerated demographic transition. Donors are becoming more involved in the subject while the young population of sub-Saharan Africa increasingly recognises that their demand for sexual reproductive health information and distribution of contraceptives is not met by the current supply. In sub-Saharan Africa, both women and men have consistently reported that their ideal family size is smaller than the national total fertility rate. Therefore, the primary objective of policy and intervention is not fertility decline per se, but to put in place voluntary services and systems to bring the total fertility rate closer to the desired family size of women and couples. By doing this the hope is that countries can economically benefit from an accelerated transition over time.
Political commitment in the champion countries went beyond the health sector, and family planning was explicitly recognised as a key contributing factor to national priorities of gender, youth, women’s empowerment, rural development, and improved education. Furthermore, interventions to tackle the unmet need in family planning services target the supply (e.g. family planning clinics) and demand (e.g. education in sexual reproductive health and rights) side simultaneously. The supply and demand side interventions must relate to an enabling political, sociocultural and economic environment, and enforcement of legislation (e.g. laws for maternity pay and against forced marriage).
For example, the revision of the Family Law in Ethiopia in 2000 eradicated the legal obstacles to women’s employment outside the home. In Rwanda, following peace and reconstruction efforts after the 1994 genocide, many policies were put in place to help keep women in work (e.g. three months of paid maternity leave). Both countries have shown that after this legal change, more women entered the workforce. Research also found clear evidence that stalls in the fertility transition in several sub-Saharan African countries can in part be explained by earlier stalls in the education improvement of females that entered the prime childbearing ages around that time. Because access to education has improved recently for young women, there could be a renewed acceleration of fertility decline when these women move into childbearing ages.
For education and job creation to have any impact, family planning services should be available and accessible for young women. The current Covid-19 crisis shows how fragile any success from the past is. Many family planning services have been suspended, increasing the barriers to access modern contraceptives. Teenage pregnancies are reported to have increased significantly during the last months across sub-Saharan Africa. Girls seem to have been hit the hardest by school closures. Covid-19 responses, therefore, need to counter these step backs and take a wider and long-term systems approach, as advocated for by organisations such as the African Population and Health Research Center (AFHRC), UNFPA, and Family Planning 2020.
The earlier mentioned K4D literature review shows that to implement such a systems approach, an emphasis on task shifting and working across sectors is key. The champion countries addressed different providers (NGOs and private sector organisations) to supply contraception (e.g. via social marketing and social franchising). The countries also trained community health workers to deliver basic services and provide modern contraceptive methods to the people. This is only possible when family planning programmes are integrated within a wider health system strategy.
For example, Ethiopia is unique in training a new cadre of government health workers, the Health Extension Workers (HEWs), to staff rural health posts. Strong logistics for contraceptive security has greatly reduced stock-outs in Ethiopia and Rwanda. However, in Malawi, value chain management is less strong which has resulted in stock-outs mainly in rural areas. The three countries have a strong focus on improving the family planning services for adolescents (girls and boys), consulting them for improvements in service delivery, and establishing youth-led campaigns via mass media and interpersonal communication. For example, the Smart Start programme has identified the wedding ‘seasons’ as key months for promoting adolescent contraception in Ethiopia.
Building coalitions of support with civil society, community and faith leaders is also key. One way to do this is by inviting them to participate in advisory committees along with experts. For example, in Rwanda faith leaders signed a common declaration of support for family planning and HIV prevention policies. Overall, the success of family planning programmes has not been uniform. It depends on several factors, including well-designed and implemented programmes, the availability of quality services and a wide range of methods, flexibility and responsiveness in adapting to local conditions, adequate monitoring and information systems combined with sustainable funding sources.