will and commitment in improving access to family …...1 the role of political will and commitment...
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The role of political will and commitment in improving access to family planning: Case Studies from
Eastern and Southern Africa
Session 067. Evaluation of Family Planning/Reproductive Health policy, 27‐08‐2013 / 15:30pm‐
17:00pm
Violet I Murunga, Nyokabi R Musila, Rose N Oronje and Eliya M Zulu
African Institute for Development Policy, Nairobi, Kenya
Abstract
A few countries in Eastern and Southern Africa ‐ namely Ethiopia, Malawi, and Rwanda ‐ have
demonstrated a new wave of optimism and made good progress in addressing barriers of access to
modern contraception over the past decade or so. Whereas, progress in contraceptive use in Kenya
and Tanzania stalled in the 1990s, both countries have recently demonstrated potential for recovery
and good progress. This paper examines the origin, architecture and role of political will in
contributing to these successes, as part of a larger study that assessed the drivers of progress in the
5 sub‐Saharan countries. The objectives of this paper are to investigate factors that have propelled
changes in the attitudes of some political leaders to champion family planning; how such political will
has manifested in the different contexts of these countries; and how political will impacts the policy
and program environment. Policy analysis methods including literature review, review of policy and
program documents and semi‐structured key informant interviews with policy actors were used. The
findings show that clear evidence and its innovative use in advocacy efforts particularly in
demonstrating the link between family planning and development and family planning and maternal
and child health, coupled with the presence of political champions within government institutions,
were critical in generating and sustaining political will and commitment to FP in the countries
studied. Lessons from this study will help galvanize efforts to improve access to family planning
services in countries where little progress is being made.
Introduction and background
The United Nations projects that sub‐Saharan Africa (SSA)’s population will grow from the current
900 million to 1.2 billion by 2025, and to 2 billion by 2050 (UNPD, 2011). With an average population
growth rate of more than 2 percent for most countries, the region has the fastest growing
population in the world (Mutunga, Zulu, & Souza, 2012). Of the 2.4 billion people who are projected
to be added to the world by 2050, nearly half (46 percent) will be born in SSA. The rapid population
growth in SSA is mainly due to high fertility amidst declines in overall mortality. SSA has the highest
fertility in the world (5.1 children per woman relative to the global average of 2.4) (Population
Reference Bureau (PRB), 2012).
Notably, many of these births are unintended contributing to high maternal and child mortality, and
broadly to poor socio‐economic indicators. Yet, modern contraception, a proven cost effective
method for preventing unintended pregnancy, reducing maternal and child mortality and rapid
population growth is underutilized in the region even when evidence shows that there is high
“unmet need” for FP, meaning that they want to postpone or stop childbearing but lack effective
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contraception (Ahmed, Li, Liu, & Tsui, 2012; Cleland, Conde‐Agudelo, Peterson, Ross, & Tsui, 2012)
(Ahmed, et al., 2012; Canning & Schultz, 2012; Cleland, et al., 2012; Ezeh, Bongaarts, & Mberu,
2012). Only 26% of married women in SSA are using contraception relative to 56% in the world
(Population Reference Bureau (PRB), 2012), whereas an estimated 53 million women in SSA have an
unmet need for FP (The Guttmacher Institute, 2012).
While most African countries are signatories to international commitments promoting universal
access to reproductive health (the 1994 ICPD and the Millenium Development Goals (MDGs), recent
reviews show that governments in SSA have had limited success in translating well‐intended political
and policy commitments into adequately resourced and effective programs to ensure universal
access to family planning (FP) and other reproductive health (RH) services. Many countries in the
region are therefore unlikely to meet MDG 4 and 5 and goals related to socio‐economic
development (United Nations, 2013). There are however some emerging success stories such as
Ethiopia, Malawi and Rwanda, which are making notable progress. It is therefore worthwhile to
understand the key drivers of progress that have resulted in notable gains in contraceptive use in
these countries, whose leaders were once opposed to or reluctant to promote FP (Chimbwete &
Zulu, 2003).
Evidence documenting factors that have contributed to successful FP programs in developing
countries including some SSA countries, demonstrates that implementation of FP programs in such
settings is often a complex undertaking that is complicated by contextual factors which are often not
supportive of FP (Robinson & Ross, 2007). However, sustained political will matched by resource
commitment and well designed focused interventions have been found to be key factors that have
contributed to the success of the FP programs in these settings (Robinson & Ross, 2007; Shiffman,
2007). The studies further note that contextual differences among countries result in varied levels of
impact (Robinson & Ross, 2007).
These findings were corroborated in a recent study conducted by the African Institute for
Development Policy (AFIDEP) between 2011 and 2012 (not published) which found that a set of five
broad factors interacted synergistically to improve access to FP information and services in five East
and Southern African countries (Kenya, Ethiopia, Malawi, Rwanda and Tanzania) (Figure 1). The study
identified political will and commitment as a prerequisite to mobilization and allocation of financing
for FP programs and design and implementation of key interventions to increase access to FP
information and services. The effect of the five factors on FP programs however defers from country
to country as a result of the unique historical and current contextual circumstances of each country
and therefore manifest in varying levels of progress among the countries.
This paper seeks to understand the factors that contribute to the rise and/or fall of FP on the political
agenda of SSA countries (how political will and commitment for FP is generated), the manifestation
of the political will and commitment and the effect of political will and commitment on FP policies
and programs relative to the effect of lack of political will and commitment.
The paper draws on well‐established political science scholarship on agenda setting to assess these
factors. Agenda setting literature identifies four key factors that contribute to the ascendance of an
issue on the political agenda. They note that an issue is likely to rise on the political agenda if it is
marked with a salient indicator, it is backed by effective political entrepreneurs, it is given attention
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through focusing events, and if policy communities develop feasible proposals to address the issue
(Shiffman 2003).
Figure 1. The policy and program factors contributing to progress in improving access to family
planning information and services
Data Source: African Institute for Development Policy (AFIDEP). 2013.
Kingdon (1984; 2003) argues that in policymaking, issues (‘problems’) exist alongside ‘solutions’ and
‘politics’ as three parallel streams, and that issues only rise to the top of the political agenda when
the three streams merge. He argues that a ‘problem’ can become important to policymakers
depending on how it is framed or brought to policy maker’s attention (e.g., through data or focusing
events). A problem can then rise on the agenda, if there are feasible ‘solutions’ that are compatible
with policymaker’s values, and appealing to the public. Shiffman (2007: 796) found that in addition
to credible data highlighting the problem, focusing events to bring visibility to the issue and
presentation of feasible solutions to the problem, national and international advocates and financial
and technical support from international advocates were also critical in generating political will for
addressing high levels of maternal death in five countries.
The evidence from this paper will therefore add to the body of literature on generating political will
and agenda setting for FP in SSA, and contribute to galvanizing political support to improve access to
FP services in SSA countries where little progress is being made.
Study Design and Methodology
This paper uses data from a larger study that sought to investigate the policy and program factors
that contributed to increased access to FP information and services in five eastern and southern
African countries. A case study approach was undertaken focusing on 3 countries (Ethiopia, Rwanda
and Malawi) that have made notable progress in increasing contraceptive use over the past decade
and 2 countries (Kenya and Tanzania) that experienced a stall or slow progress during the 1990s (see
Figure 2). Ethiopia, Malawi, and Rwanda have registered notable increases in contraceptive use over
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the last decade or so with accelerated rate of increase in contraceptive use during the past 5 years or
so. Whereas, the progress in contraceptive use in the 2 comparative countries, Kenya and Tanzania,
momentarily stalled, particularly in Kenya, which has been documented as a pioneer of FP programs
in the SSA region in the 1980s (Chimbwete & Zulu, 2003). However, both countries have since
demonstrated potential for recovery and good progress, with accelerated rate of increase in
contraceptives use over the past 5 years.
Data Source: Demographic and Health Survey
While the study identified five main factors contributing to or hindering progress in the five countries
(see Figure 1), this paper focuses on highlighting the factors that have propelled the change in
attitudes of some political leaders to champion FP (how political will and commitment was
generated), how such political will and commitment has manifested in the different contexts of
these countries, and how it affects the policy and program environment. The paper also draws
lessons on what factors hinder or reduce political will for FP and the effect on policies and programs.
A triangulation of methods were used to assess the policy, systems and service delivery factors that
contributed to improving or hindering access to FP services the 5 study countries: 1) Literature and
policy and program documents review in order to understand the nature of policy and program
adjustments that the study countries have made to increase contraceptive use over the past two
decades; 2) Review of financial resource allocation and expenditure for FP and population issues; and
3) In‐depth key informant interviews with policy makers, development partners, program managers,
and civil society stakeholders using a semi‐structured interview schedule (see Appendix 1) to gain
insights into what changes were made and who played what roles in driving the reproductive
4.1
0.81.1
2.11.6
1.2
0.0
0.6
1.5
0.4
7.0
1.6 1.5
2.7 2.8
Rwanda Kenya Tanzania Ethiopia Malawi
Figure 2. Trends in annual rate of increase of modern contraceptive use (around 2000 to around 2010)
Average Annual % Points Change (Baseline to latest)
Average Annual % Points Change (Baseline to intermediate)
Average Annual % Points Change (Intermediate to latest)
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revolutions.
Key informants were identified from ministries of health, planning and finance, reproductive health
units, non‐governmental organizations (NGOs) and civil society organizations (CSOs) involved in
RH/FP service delivery and development partners. Further interviewees were identified through
snowballing. Interviews were conducted after verbal consent was obtained from all study
participants. Between 15 and 35 key informants were interviewed in each of the five countries with
more than half representation from government and development partners (donors and
international NGOs) and the rest from local NGOs, FBOs and academic institutions. Interviews were
recorded and transcribed.
In Tanzania, the investigators were invited as non‐participatory observers of the Family Planning
Technical Working Group (FP TWG) during the field work period. A focus‐group discussion was also
held with the FP TWG in Rwanda. Elaborate field notes were taken during these fora. Notably, fewer
interviews were carried out in Kenya. However, the evolution and factors affecting the FP program in
Kenya are relatively well documented.
Two of the authors conducted thematic analysis of the field notes and transcripts. Initial descriptive
themes were derived according to the interview guide framework and then discussed iteratively
among the four authors to produce a final set of descriptive themes. Literature reviews and
emergent descriptive themes were synthesized to identify the key factors that contributed to the
successes of the FP programs in the five countries. In order to better understand the interplay
between political will and commitment and increase in access to FP services, a second level of
thematic analysis of data pertaining to the “political will and commitment for FP” descriptive theme
was carried out in order to draw out the origin, architecture and role of political will in increasing
contraceptive use.
Findings
Experiences in Ethiopia, Malawi and Rwanda over the last decade or so demonstrate that political
will and commitment was a precursor towards efforts to strengthen FP programs which contributed
to the exceptional progress in increasing contraceptive use. On the other hand, Kenya and Tanzania,
offer lessons on the importance of sustained political will and commitment in maintaining strong FP
programs. The two countries demonstrate how gains made in increasing contraceptive use can be
slowed or reversed if political will and commitment wanes weakening FP programs.
Notably, our findings show that the origin and manifestation of political will and the level of its
impact on the FP policy and program environment varies in the five countries as a result of their
unique historical and current contextual circumstances.
1. How political will was generated
Our findings suggest that two key factors were important in generating political will in the five
countries: use of evidence and consideration of the socio‐cultural, political and economic context to
frame FP, and well networked FP champions and strong national advocacy institutions familiar with
the salient socio‐cultural and political sensitivities and concerns related to FP and how to effectively
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participate in the policy process. As African leaders became motivated to meet global development
goals and stimulate socio‐economic development, a window of opportunity emerged for evidence‐
informed policy influence, which demonstrated to government officials, that FP was central to
achieving health and development goals. The evidence helped to increase attention to FP among
political elites who were keen on advancing socio‐economic development. In addition, it was
emergent local FP experts and champions who were knowledgeable of the country contexts and
policy processes that led advocacy efforts, and thus helped to allay suspicions held by political elites,
that FP is a Western agenda.
1.1. Use of evidence and framing of the message
At the time the five study countries embraced national FP programs, the persistent development
problems they were all grappling with were poor maternal and child health outcomes relative to
global performance, rapid population growth, diminishing resources and increasing poverty amidst
pervasive socio‐cultural practices that promoted pronatalism further fueling these challenges.
Sensitization of political leaders on the importance of reducing high fertility and rapid population
growth in order to meet global and national health and development plans such as the ICPD program
of action, the MDGs, and country development blueprints and health plans increased attention and
support for FP.
Political leaders increasingly became aware that development goals are more likely to be achieved by
a skilled and healthy population, rather than large populations dominated by uneducated, hunger
stricken and unhealthy citizens, who do not contribute to the economy. As a result, FP targets have
been included in development blue prints of virtually all of the five countries which are broadly
anchored to meeting global development goals (ICPD POA and the MDGs). Further, the evidence
from Demographic and Health Survey (DHS) reports showing the high unmet need for FP in these
countries continues to provide a case for the need for governments to address the barriers to access
and use of FP.
Of importance, framing of FP differs from country to country with some political leaders being
sympathetic to the important role of FP in improving maternal and child health while others are
partial to the important role of FP in improving family welfare and economic development.
In 1967, Kenya adopted its first population policy which led to the establishment of a national FP
program. However, support for FP by President Mzee Jomo Kenyatta was weak. FP was not high on
Kenyatta’s government priorities and even the evidence that the country’s population was rapidly
growing did not sway the government. The population growth rate which was about 2.5% per annum
in 1969 increased to a peak of 3.8% per annum in 1979 (National Council for Population and
Development (NCPD), 2012). Moreover, FP was an unpopular concept among many politicians.
Political leaders from communities with a preference for large families did not want to go against the
beliefs and practices of their electoral base and risk chances for re‐election (ref). Consequently, the
program’s impact was dismal. However, the beginning of the 1980s presented an opportune time,
when Kenya’s total fertility rate of 8.1, as recorded in the 1978 KDHS, was highlighted as the highest
in the world at an international meeting where President Moi was in attendance. A respondent
noted that:
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“I think it was in 1981 when President Moi happened to attend the meeting I think it
was in China or somewhere and he was really embarrassed because he was told that it
[Kenya] was the country that was the fastest growing in the world. Around then the
children were 8.1 per woman and the doubling time of the population was 17 years. So I
think he came with a real momentum and really showed good political will ….. He came
with a threat especially to the civil servants… they were required to promote I think it
was 4 children or 3 children.” Academic representative
Moi was motivated to position Kenya in line with the international development standards of curbing
high fertility to reduce rapid population growth (Chimbwete & Zulu, 2003). He explicitly promoted FP
and directed leaders at all levels to promote FP. His dictatorial approach to leadership that had been
triggered by an attempted coup in 1982 meant that the socio‐cultural, political and religious
concerns that had dominated the 1970s FP program were repressed. In fact, the program promoted
the economic benefits (family welfare) of FP in addition to the maternal and child health benefits
(birth spacing), which had been the focus of messages in the 1970s program. The FP program was a
success leading to a steady increase in contraceptive use throughout the 1980s until the late‐1990s
when progress stagnated as a result of a decline in political attention to FP in the Moi government.
Following the 2003 Kenya DHS, national FP advocacy efforts were reignited when experts noted that
contraceptive use remained at the same level between 1998 and 2003 whereas fertility and unmet
need for FP showed marginal increases between the two time points (Kenya National Bureau of
Statistics (KNBS) & ICF, 2010). Further, the 2000 census had also recorded a marginal increase in the
population growth rate from that recorded in 1984(National Council for Population and
Development (NCPD), 2012). These findings resulted in heightened advocacy to parliamentarians,
which resulted in the established of a budget line for FP commodities and for the first time,
government contribution to the FP commodity budget, which was previously fully funded by
development partners. The advocacy also resulted in an increase in allocation of resources to the
National Council for Population and Development to promote integration of population activities in
all sectors of government. These efforts resulted in strengthening of the FP program evident by the
increase in contraceptive use and decrease in fertility recorded in the 2008/09 Kenya DHS.
In Rwanda, the persistent struggle with rapid population growth and diminishing land mass
prompted the 1980s national child spacing program (ref). Likely because of the strong influence of
religious leaders, the FP program focused on maternal and child health rather than promoting
smaller family norms. However, progress faltered and even reversed following the 1994 genocide
(RDHS 2010). By mid‐2000s Rwanda DHS findings demonstrated a decline in contraceptive use from
13% in 1992 to 4% in 2000 with a marginal decline in the fertility rate and unmet need. Whereas the
2002 census recorded a decline in the population growth rate (ref). However, experts in Rwanda
were aware that the country’s recorded decline in the population growth rate was being masked by
the effects of the genocide which included the death of nearly 1 million people and mass migration
out of Rwanda (ref). Therefore, experts suspected that population pressure and diminishing natural
resources remained a key challenge in Rwanda, a small landlocked country that needed to be
urgently addressed. Rwanda’s new President Paul Kagame, though at the time not supportive of FP
(according to key stakeholders), was also keen on moving beyond the effects of the genocide to
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rebuilding the nation to a middle income country as articulated in the Vision 2020 creating a policy
window for the role of FP in improving socio‐economic development.
Soon after, the RAPID advocacy tool developed by the Futures Group in collaboration with national
advocacy institutions was used to captivate the attention of the political elites in Rwanda to intensify
their support for FP and promote its positioning at the center of their national development
agendas. The RAPID evidence demonstrates how rapid population growth would make it difficult for
government to make the necessary human capital investments needed to spur economic
development. The evidence demonstrates the urgent need to rapidly reduce the fertility rate in
order to reap the largest benefits of socio‐economic development as experienced by the Asian
Tigers. A key feature of the RAPID tool is the evidence demonstrating the financial savings that a
country can accrue by investing in family planning and how it translates to savings for use in
developing other social services such as healthcare and education. The tool frames FP as a
development tool, emphasizing its health, economic and environmental benefits.
The presentation of the RAPID to the president and parliamentarians in 2005 helped to obtain and
solidify political support for FP, leading to the inclusion of FP targets in the country’s poverty
reduction strategy, Economic Development and Poverty Reduction Strategy (EDPRS), designed to
translate the country’s Vision 2020. This was an unlikely achievement, given that Rwanda had lost
nearly 1 million people during the 1994 genocide and it was expected that the notion of limiting child
bearing would not be acceptable. However, among the political elite, it was clear that their
development goals would be unattainable if Rwanda’s population continued at the same high rate,
as argued here by a respondent:
“After looking at all the data and closely examining our situation, we came to the
conclusion that we cannot develop into a middle income country without addressing
high population growth and prioritizing family planning. FP is a key tool for developing
the quality of our population, improving the health of mothers and children, and to
address the poverty challenges that we face” (Dr Ntawukuliryayo, President of the
Senate, Rwanda).
In Malawi, despite the need to manage population growth, the strong pronatalist attitudes of the
political establishment, particularly in President Hastings Banda’s government, in the 1960s,
translated to intolerance for FP. Furthermore, Banda believed that the country needed to have a
large population to fully realize its agricultural potential. He also believed that improvements in
education and literacy would eventually result in Malawians deciding by themselves to have fewer
children. He was once quoted asking the Germany Ambassador to Malawi “... did the German
Government tell people to have two children in Germany ... who are you to tell us what to do on the
number of children?” (Chimbwete & Zulu, 2003). FP was subsequently banned until the early 1980s.
By then Banda had developed an interest in promoting the welfare of mothers, therefore, when
evidence linking FP to reducing maternal and child deaths was presented to him, it prompted the
approval and establishment of Malawi’s national child spacing program.
Similarly, in Ethiopia and Tanzania, where there were strong perceptions that a large population was
necessary to stimulate economic development, promotion of FP to improve the maternal and child
health emerged as more acceptable. In fact, the late Prime Minister (Meles Zenawi) of Ethiopia,who
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came into office in 1995, was not supportive of FP for limiting child bearing and was often quoted
saying “people are coming to this planet with working hands not only empty stomachs" (Translated
from Amharic). Nevertheless, in the 1990s, a national FP program focusing on improving maternal
and child health outcomes in Ethiopia was established. A child spacing program was initiated in
Tanzania around the same time. Progress in the two countries however varied. It was slow in
Ethiopia in the 1990s and then accelerated in the 2000s. In Tanzania, it was modest in the 1990s but
decelerated during the 2000s coming to a near stall in the first half of the 2000s before improvement
in the second half.
Key stakeholders in all five countries often linked recent progress to the alignment of their health
and development policies to the ICPD POA and achieving the MDGs. The close scrutiny on
performance of countries towards achieving the MDGs coupled with the increasing evidence on the
central role of FP in improving maternal and child health strengthened support for FP among political
leaders from all five countries and also motivated support by those who were previously
uncomfortable with promoting FP to reduce fertility levels. A close look at the contraceptive use
trends in all five countries show improvements in progress following the 2005 inclusion of FP in the
MDGs (Figure 3). The rate of increase in uptake of contraceptives accelerated between 2005 and
2010 in all five countries.
Since 2010, the RAPID tool has also been developed for Ethiopia, Kenya and Malawi, and has become
a key tool for lobbying political leaders to support and mobilize resources for FP. While the role of FP
in promoting socio‐economic development has been well understood and promoted in Kenya,
Ethiopia and Malawi have recently started focusing on the health and economic benefits of FP,
promoting maternal and child health, as well as the benefits of smaller families. The ENGAGE,
another advocacy tool demonstrating the role of FP in achieving the MDGs, has been developed for
Ethiopia and Kenya.
Notably, the RAPID tool was also developed for Tanzania in 2006, however, its impact on increasing
political support and funding for FP was not mentioned by key stakeholders. In fact, Tanzania’s
progress has been modest since the establishment of the FP program. This may largely be explained
by the fact that robust and well presented research evidence alone cannot generate political
commitment for RH issues and decisions in support of FP uptake, but rather works in concert with
other factors to do so, such as sustained domestic advocacy, well‐networked national FP champions
and resource allocation to programs. This is further discussed below.
1.2. Well networked and credible FP champions and national advocacy institutions
In the 1960s, international efforts promoting the adoption of neo‐Malthusian population policies and
programs resulted in a backlash from African leaders who suspected their motives. Over the past two
decades, there has been an emergence of national actors and institutions leading domestic advocacy
efforts for the adoption of FP and population policies and programs. This has helped allay these
suspicions. Rather than participate at the forefront of domestic advocacy, international advocates
maintain the key role of providing financial and technical support for initiating and sustaining
domestic advocacy efforts. It emerges that recognized persons with expertise in FP/RH in relevant
government agencies (Ministers of Health and Directors of Planning Units or Divisions) and FP
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champions from civil society organizations (CSOs), their networks with political allies and access to
the political process, has been critical in captivating and sustaining political support for FP.
In Kenya, President Moi emerged as the key FP champion during the 1980s when he requested the
Ministry of Health and leaders at all levels of government to promote FP and ensure availability of FP
services. As noted in the section on evidence and framing, his dictatorial approach to leadership at
the time meant that government decision was implemented without much opposition; any political,
socio‐cultural and religious resistance to FP was not clearly apparent during this period.
Furthermore, couples were ready to control their fertility mainly because by then couples
particularly women in Kenya were highly educated resulting in reproductive preference for smaller
families. In fact, the 1984 Kenya Contraceptive Prevalence Survey (KCPS) recorded contraceptive use
at 17% and a very high unmet need for FP (60%).
However, in the 1990s, Moi’s attention shifted to address other government priorities, and as a
result Moi ceased to be at the forefront of FP advocacy. During the past decade, National Council for
Population and Development (NCPD) housed in the Ministry of Devolution and Planning, first
established in 1982 as a government agency and then restructured in 2004 as a semi‐autonomous
agency, by an Act of Parliament, emerged as a strong national FP advocacy agency. NCPD is
mandated to develop and support the implementation of population programs, including
repositioning FP as a development priority. The agency has earned credibility among
parliamentarians and other government officials and key stakeholders as the national institution
with expertise on population issues. Owing to its established strong networks with parliament, NCPD
has been successful in mobilising renewed political support for FP. A key strategy of NCPD was to
form a core group of parliamentarians, ‘parliamentary committee to reposition family planning’ to
cultivate FP champions, who then assisted with mobilization of other parliamentarians and high level
decision makers in government including treasury. In 2010, NCPD mobilized more than 1000 decision
makers from various Ministries and politicians at the 2nd National Leader’s Conference to highlight
the central role of family planning in achieving Kenya’s development blueprint, Vision 2030. At the
meeting, NCPD also obtained input into the development of the 3rd population policy which was later
passed by parliament and launched in 2012. Stakeholders view this as an accomplishment given the
political concerns in relation to population‐based resource allocation to decentralized county
governments in the then imminent devolved government structure which has since been rolled out.
In Ethiopia, the Minister of Health, Dr. Adhanom, has been the main advocate for FP since his
appointment in 2005. According to key stakeholders, despite the fact that the late Prime Minister
Meles Zenawi was not a supporter of FP, he place high value and trust in Dr. Adhanom’s ability to
make sound decisions on the strategies needed to address the country’s health priorities. Dr.
Adhanom was therefore able to roll out the health extension program countrywide, a health service
delivery model designed to reach rural women with maternal and child health services, which
included FP in the package of care. Likewise, in Rwanda, Dr. Ntawukuliryayo, who was the Minister of
Health in 2005, convinced President Kagame and the Prime Minister to support FP. Subsequently,
President Kagame, initially reluctant to support FP, emerged as the key FP champion, approved FP as
a development intervention and now openly speaks out about the benefits of FP. Dr.
Ntawukuliryayo, now President of the Senate, has served as the Chairperson of the Rwandan
Parliamentarians' Network on Population and Development (RPRPD), earned the nickname “Mr
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Family Planning”, and continues to rally support and resources for FP. RPRPD is a key institution in
Rwanda that was formed by an Act of Parliament to advance population and FP issues. RPRPD
constitutes of parliamentarians who are advocates of FP, and sensitizes other parliamentarians on
population and FP issues.
In Malawi, in the 1980s, FP experts and practitioners from the Family Planning Association of Malawi
(FPAM) and the Ministry of Health with close links to the political establishment convinced President
Banda, an advocate of maternal health, to establish the child spacing program. The initiative
overturned the more than a decade long ban on FP. The same experts convinced President Banda to
review Malawi’s first population policy promoted FP to improve family welfare which was
subsequently approved by President Bakili Muluzi, Banda’s immediate successor. Though, Bakili’s
approval of the policy was motivated by his need to mobilize support and resources from
development partners(Chimbwete & Zulu, 2003).
1.3. International technical and financial support
At the center of successful national advocacy efforts was the facilitation of technical and financial
support from international agencies which set global norms and standards for FP programs. Post
independence, these entities sought to work with new African governments to help them
understand the challenge of high fertility and rapid population growth relative to development and
the role of FP in facilitating improvement of the health of mothers and children and accelerating
socio‐economic development. In setting global norms and standards, international agencies views
evolved over the period from a focus on meeting demographic targets to one promoting individual
rights to sexual and reproductive health including FP making the message easier to sell to African
leaders, who, as noted earlier, held suspicions that Westerners were attempting to limit the African
population relative to the global population. International advocate therefore have served as a
conduit of information and support to help African governments understand the benefits of FP and
articulate FP policies and programs which take into account socio‐cultural, economic and geo‐
political factors. In the recent past Futures Group, PRB, USAID and UNFPA have been the major
providers of technical and financial support in these countries.
2. How political will for FP manifests
Two types of manifestation of political will for FP are emergent among the five countries. The first
and most unlikely is top level leadership support whereby the President emerges as the FP champion
and promotes the entrenchment of FP throughout the political establishment and the communities,
as currently seen in Rwanda, and was the case in Kenya during the 1980s. The second, which is
common to Ethiopia, Malawi, Tanzania and now Kenya, is when top level leadership provides an
enabling policy and program environment for the institution with the mandate to promote FP, to
fully expel its duties. While countries may share a common style of political support for FP, the
impact differs at country level based on contextual differences.
2.1. Top level leadership
In Rwanda, political will and commitment is at top leadership level with President Kagame openly
promoting FP. Notably, Rwanda’s explicit top level leadership support for FP has resulted in its
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inclusion on the national development agenda and thus the institutionalization of promotion of FP
throughout all levels of leadership. Increasing contraceptive use is one of the performance goals for
leaders in the political hierarchy, including District Mayors and relevant ministers such as the
Minister of Health. Such political will has created a common vision on promotion of FP as a
development intervention among leaders and the public alike. While this style of political will has
raised questions about the potential for coercion, the phenomenal increase in contraceptive use has
been credited to this type of political will and committment.
As noted elsewhere, in the 1980s, Kenya’s President Moi explicitly promoted family planning. He
directed leaders at all levels of government to promote FP. However, unlike Rwanda, FP was not
included as a target on leaders’ performance contracts. Nevertheless, the FP program gained
recognition as a pioneer and successful program as it resulted national expansion of the FP program
and consequently phenomenal increase in contraceptive use (NCPD, 2010). As noted earlier, Moi’s
support for FP waned in the late 1990s giving way to a different type of support discussed below.
2.2. Leadership at Ministry level
In Ethiopia, Malawi, Tanzania and Kenya (post Moi era), political will and commitment manifests at
the Ministry of Health (MOH) and Ministry of Planning (Kenya) levels. Although neither of the Heads
of State of these countries is vocal about supporting FP, there is recognition among key stakeholders
of the enabling environment to implement the national FP programs. While this is a common style of
leadership in the four countries, the impact differs significantly at country level because a number of
factors in addition to political will and commitment mutually reinforce each other to increase
contraceptive uptake.
After the collapse of Kenya’s successful FP program in the late 1990s, President Kibaki, who took
office in 2003, maintained a silent role whilst creating an enabling environment for NCPD within the
Ministry of Planning and top officials at the Division of Reproductive Health (DRH) within the MoH to
lead the FP agenda. Kibaki’s government relaunched NCPD in 2004 as a semi‐autonomous entity that
could operate with more flexibility. NCPD works with the implementers of the FP program, DRH to
formulate policies, identify inequities in contraceptive use and develop advocacy strategies. The
immediate past Minister of Planning (Hon. Wycliffe Oparanya) and the outgoing director of NCPD
(Dr. Boniface K’Oyugi) were been at the fore‐front leading efforts during the past decade to refocus
the FP program as a development intervention towards meeting Vision 2030 goals. Key stakeholders
note that K’Oyugi’s technical expertise in the area of demography afforded him good understanding
of the role of population in development and a passion for the issue, which was a plus. The
rejuvenation of political will for FP in Kenya has resulted in recovery from the stall in progress
experienced between 1998 and 2003. Despite having been successful in increasing political support
for FP over the past decade, there is a common view among key stakeholders, that there is need to
sustain efforts to increase political will and commitment to the level of the 1980s and 90s where top
level leadership explicitly promotes FP. Notably, President Mwai Kibaki, the immediate former
president of Kenya, worked with Mr. Tom Mboya in the 1960s to convince Kenya’s first president
Mzee Jomo Kenyatta to adopt a population policy. One would have therefore presumed that Kibaki
would explicitly promote FP during his tenure as President given this historical context. A respondent
noted that:
13
‘In the 80s and 90s they talked about it all the time ‐ small family for better health. You
don’t hear that now. I would say political will is there but it’s not to the level where we
had it in the 90s.’ (Local RH expert and advocate)
However, the importance role that competing priorities and other contextual factors that inform
agenda setting at the highest level are apparent in this case.
In Ethiopia, the FP program has been driven from the Federal Ministry of Health (FMOH) with the
Minister of Health, Dr. Adhanom, at the fore front of the efforts. Of note, the Ethiopian FMOH is
structurally different to the Ministries of Health in Malawi, Kenya and Tanzania, and may explain the
difference in level of support at the Ministry level. The Ethiopian FMOH is structured on the basis of
geographic boundaries (urban, rural and pastoral) implying a holistic approach to implementing
health sector programs relative to the Ministries in the other 3 countries which have adopted
disease‐oriented departments. The apparent political will and commitment, emanating from the
highest office in the Ministry, could explain the notable progress in expanding FP information and
services countrywide and increasing contraceptive use in Ethiopia. Recently, the Federal Ministry of
Finance and Economic Development (MOFED) has been assigned a more prominent role in
promoting FP and is now the only agency that can advocate for FP. In fact, Civil Society Organizations
can now only support the government’s advocacy efforts e.g. provide evidence. The impact of this
change will be assessed during the next Demographic and Health Survey report in 2016 or so.
In Malawi and Tanzania, political support is at the level of the leadership of the Reproductive Health
Unit or Department in the MOH. In Malawi, there are moves to enhance the level of political will and
commitment for FP. Over the past 5 years, the population unit of the Malawian Ministry of Economic
Planning and Development has been successful in integrating FP in the development blueprint. The
country has been moving towards multi‐sectoral implementation of FP and population activities with
a new population policy released in 2012. The model of FP promotion and implementation of FP and
population activities is evolving to mirror that of Kenya and Ethiopia, so that it is within a broader
context of development rather than just health. Further, in 2012, the government elevated the
Reproductive Health Unit into a directorate, which reflects the increasing prioritization of RH issues in
Malawi. On the other hand, progress in increasing contraceptive use in Tanzania remains modest in
comparison to Malawi. Over the past 5 years, Malawi has emerged as having made phenomenal
progress in increasing contraceptive use.
3. How political will and commitment for FP impacts the policy and program environment
While countries may share a style of political will and committment, the impact at country level may
very well vary due to other factors. Nevertheless, political will and commitment is critical for the
success of FP programs facilitating the development of an enabling policy environment and
necessary health system reforms to support implementation of key FP interventions. It also
facilitates mobilization of financial and technical resources from multilateral and bilateral
development partners, and consequently enables increased local budgetary allocation for family
planning programs. These ultimately, increase access to FP information and services.
Notably, political will and commitment for FP may not necessarily translate into domestic resource
allocation, which is critical for the sustainability of the program. The governments of the five
14
countries rely heavily on external financial resources to procure FP commodities, train health
workers and equip health facilities while contributing relatively less support from domestic revenue
which could compromise the sustainability of FP programs. Kenya offers a lesson in this respect.
Kenya’s successful FP program of the 1980s was funded entirely by donors, which largely explains
why the program collapsed when donors shifted attention to HIV/AIDS and other priorities in the
1990s. Nevertheless, the creation of budget lines for FP commodities as in all five countries may
indicate some level of government commitment to ensuring funds for the FP program and an
opportunity for increasing government contributions as has been the case in Kenya over the past
decade. In addition, government prioritization of allocation of funds to the health sector and policy
direction in favor of integration of FP with other key health services that have strong political
backing, such as maternal and child health services and HIV/AIDS services, has also played a role in
increasing access to and use of FP in the countries.
In Rwanda, FP was included as one of the national development targets in 2009 within the Economic
Development and Poverty Reduction Strategy (EDPRS). As a national development target, FP was
institutionalized at all levels of leadership, and at health facility, community and family levels
through performance contracts, performance based incentives and mandatory monthly community
meetings. This resulted in the rapid scale‐up of the FP program nationally. The establishment of this
governance and accountability mechanism for monitoring and evaluating achievement of key
development targets, including FP, demonstrated Rwanda’s commitment to making progress
towards addressing its development challenges and has attracted a substantial amount of donor
funding to support Rwanda’s efforts. The creation of a budget line for contraceptives also
demonstrates Rwanda’s commitment to ensuring supplies to meet the FP needs of the population.
Consequently, FP information and services have become available and accessible to a large
proportion of people.
Rwanda’s policy environment also encourages the adoption of innovative interventions to make
information and services available to vulnerable and underserved population. For instance, a large
proportion of health facilities in Rwanda are operated by the Catholic Church, which has a policy not
to provide modern contraceptives. Rwanda established an agreement with the Catholic Church
leaders to build secondary posts adjacent to Catholic health facilities so as to ensure access to
modern FP methods to community members who wish to use them. Furthermore, by the end of
2011, Rwanda was scaling up various interventions to increase access to modern contraceptives to
underserved communities including community based distribution of injectable contraceptives,
establishment of youth friendly spaces at existing health facilities and training health workers to
provide SRH services to youth.
In Ethiopia, including FP in the package of essential services delivered through the health extension
program (HEP) countrywide, particularly in rural areas, means that FP information and services have
become accessible to a large proportion of the people particularly in rural areas. Ethiopia’s health
system is anchored on the HEP. It has high level government political backing and is accredited by
the international community as a model intervention. Hence, it has attracted a significant amount of
both domestic and donor funding. By 2005, FP targets were included in Ethiopia’s Plan for
Accelerated and Sustained Development to End Poverty (PASDEP) and the follow‐up Growth and
Transformation Plan (GTP) demonstrating the government’s commitment to ensuring access to FP.
15
Further, the creation of a budget line for FP commodities and the removal of the import tax on
contraceptives, both in 2007, also demonstrate Ethiopia’s commitment to ensuring supplies to meet
the FP needs of the population. Like Rwanda, the policy environment also encourages the adoption
of innovative interventions to make information and services available to vulnerable and
underserved population. For instance, Ethiopia’s health extension workers provide both injectables
and implants to women in rural Ethiopia. By 2011, they were also being trained to provide pre and
post counseling for IUD. Ethiopia is reaching out to youth and pastoral communities using modified
versions of HEP – the urban HEP for youth and the Pastoralist HEP. Youth are also being reached
through social marketing.
Malawi’s initially tumultuous experience with promotion of FP put it in the spot light so that when
the policy environment improved, there was increased international goodwill to help Malawi address
its high fertility and population growth rate. The policy environment allowed for the creation of
strong public‐private partnerships to ensure information and services were expanded country‐wide.
Malawi has also been able to further expand reach by establishing community based distribution of
injectable contraceptives. Recently, a budget line for FP commodities has been created, further
demonstrating Malawi’s commitment to ensuring supplies to meet the FP needs of the population.
In 2012, Malawi integrated population into the second installment of the Malawi Growth and
Development Strategy (MGDS) 2012‐2016, which will ensure multi‐sectoral implementation of the FP
program further expanding its impact. Efforts to ensure girls stay in school longer and youth have
access to SRH services are also being intensified. The Malawi government believes these strategies
will curb the country’s high teenage pregnancies, which they believe are contributing to the
country’s high fertility.
Kenya’s and Tanzania’s FP programs between the 1980s and 1990s also benefited from immense
donor support. In fact, in both cases government financial contribution to FP commodities, training
and equipent was very little. Strong political will and financial support translated to implementation
of effective nation‐wide information, educational and communication (IEC) campaigns and
community based distribution programs. The policy environment allowed for the creation of strong
public‐private partnerships to support the two governments to expand information and services
country‐wide. Notably, the impact of the Kenya FP program was much higher than that of Tanzania’s
likely due to the difference in level of political will in the two countries. Kenya’s contraceptive
prevalence rate peaked at 39% in 1998, the year the stall begun, compared to Tanzania’s 16.9% in
1999, the year progress begun to decelerate.
The recent recovery from the stalled progress between 1998 and 2003 in Kenya, and the relaunch of
NCPD as a semi‐autonomous institution responsible for repositioning FP, led to the establishment of
a budget line for FP commodities in 2005, inclusion of population targets in the Vision 2030’s first
medium term plan (2008‐2012), a doubling of funding for population activities in 2011 and the
launch of Kenya’s 3rd population policy for national development in 2012. Kenya’s program also has
significant support from donors. However, at the same time, learning from past experience, Kenya
now makes a significant contribution to the program. Key informants stated that in 2012, the
government was contributing 60% of the contraceptives budget. However, its contribution declined
to 34% in 2013 due to an increase in the annual requirement of FP commodities. Nevertheless,
funding allocation for contraceptives has increased incrementally every year since the establishment
16
of the budget line. Kenya has revived its strong IEC campaigns and strong public‐private partnerships
that contributed to the success of the program during the 1980s and 1990s. Recently, a policy has
been formulated to allow provision of community based distribution of injectable contraceptives in
selected parts of the country defined as ‘hard to reach’. Efforts to expand SRH services to youth and
the urban poor have also intensified. Further, other policy options such as out‐based aid vouchers
are being explored for scale up nationally.
Likewise, in Tanzania, with the recent recovery from the decelerated progress that occurred during
the early part of the 2000s, Tanzania has demonstrated renewed commitment to FP by integrating it
into the national development plans – the development blueprint, Vision 2025, and the National
Strategy for Growth and Reduction of Poverty, MKUKUTA I (2005‐2010), and MKUKUTA II (2010/11‐
2014/15). IEC campaigns, social marketing and public‐private partnerships have been revived and are
being strengthened. However, unlike Kenya, Tanzania still relies on donors for most of the funding
for the program with little contribution from domestic resources. Tanzania is also in the process of
scaling up the community based distribution program, though with a focus on only short term
methods at this time. In addition, there are other policy options being explored such as performance
based financing and innovative models of public‐private partnerships e.g. the ADDO program which
aims to increase access to contraceptives through accreditation of retail drug outlets in areas where
few or no registered pharmacies exist.
4. The importance of sustained political will and commitment
The experiences of Kenya and Tanzania demonstrate the importance of sustained political will in
increasing contraceptive use. Shifts in political will from FP to HIV/AIDS prevention and treatment
efforts and other priorities deemed more important led to under‐resourced national FP programs,
both in terms of financing and services in both Tanzania and Kenya. The overdependence on donor
funds resulted in the collapse of FP programs when donors shifted their focus to HIV/AIDS in the
1990s. The two governments were unprepared to take full responsibility of the program. The national
institutions with the mandate to implement FP activities had weak capacity to continue providing
information and services with minimal to no resources allocated to the programs. This led to a
decline in contraceptive commodity security, and in the number of trained health workers as they
shifted to work in the vertical HIV programs. The community based distribution of FP information and
services also collapsed as programs evolved to provide HIV/AIDS services. The impact would have
been less significant if there were dedicated domestic resources to sustain the FP program. What
emerges is the importance of framing FP so that it remains relevant in light of a dynamic environment
characterized by shifting interests.
Discussion and Conclusions
This study examined the origin, architecture and role of political will and commitment in contributing
to the success of various African countries in addressing barriers to access to modern contraception
over the last decade. In agreement with political science literature on agenda setting and generating
political priority for an issue (see Kingdon 1984; 2003; Shiffman 2003; 2007), our findings show that
evidence that clearly defines the problem and political champions for the issue remain critical in
generating political will. In all the countries, research evidence was critical in demonstrating the high
rates of fertility, the existing need for contraceptives (unmet need), and in demonstrating the link
17
between high rates fertility and dismal development, and high rates of fertility and poor maternal
and child health. Evidence was also used in demonstrating how FP would enable countries to achieve
their development goals and/or save women’s live from maternal deaths and improve child survival.
Similarly, local champions in the form of top political leaders (presidents or ministers) or government
institutions played an important role in generating political will and commitment in all the countries.
The role of local champions was critical given the political, cultural and religious sensitivity to FP in
much of SSA. Indeed, expert national actors at the forefront of FP advocacy efforts, who served as
advisors to top level leaders as seen in Rwanda, Malawi and Ethiopia, helped to allay the notion that
FP is a Western agenda.
Another important factor in generating political will and commitment to FP in these countries was
international influence. Shiffman (2003) has pointed out that political science literature on political
priority has not highlighted the important role of international influence in generating political
priority because this has been largely focused on Western countries. However, in developing
countries, which largely depend on donor funding, international influence is an important factor in
generating political priority. Our findings show direct international influence in Kenya’s 1980s political
priority for FP, which emerged largely after Kenya’s President Moi was embarrassed at an
international conference where Kenya was cited as having the highest fertility rate in the world.
However, in the other countries, the role of international influence was not visibly important in
generating political will. In fact, direct international efforts to promote FP in African countries
particularly in the 1960s and 1970s were easily scoffed at as seen in the case of President Banda of
Malawi. However, indirect influence, particularly through funding of local advocacy efforts, remains
evident in generating political will for FP in the countries studied.
Our findings also support Shiffman’s (2003) observation that the power of political entrepreneurs as
discussed in much of political science literature in Western countries, has been underestimated. He
argued that in developing countries where the rules of the political game are less formalized ‘a
politically‐savvy entrepreneur may not only have the capacity to couple the streams at the chance
emergence of a policy window outside his or her control, but actually move to create the window
himself or herself, mobilizing a political system to devote priority to an issue that might otherwise
have been ignored by that system’ (Shiffman 2003:15‐16). This is what happened in Rwanda, where
Dr. Ntawukuliryayo, the Minister of Health in 2005, convinced President Kagame and the Prime
Minister to support FP at a time when population was not seen as an urgent political issue following
the 1994 genocide.
Our findings also reveal the importance of context in determining whether political will emerges or
not. This is especially the case given the initial sensitivity to FP in the 1960s by African leaders, which
was compounded by cultural and religious opposition to FP. The context in the different countries
that we studied shaped not only how the political will and commitment was generated, but also the
way it manifested and impacted policy and programs. For instance, in Ethiopia given the Prime
Minister’s vocal opposition to the argument that links FP to development, the health minister who
was a champion for FP, framed FP as critical in improving health rather than in ensuring Ethiopia’s
development. This finding supports Shiffman (2007)’s findings in five developing countries that the
political and social environment in the countries determined the country’s priority for maternal
health.
18
Our study has however shown some variation with the main factors that are acknowledged to
generate political will in political science literature. For instance, although political science literature
highlights the importance of focusing events in generating political priority, our case studies did not
reveal an important role of focusing events in generating political will for FP. This could be because
the factors that have been highlighted to contribute to generating political priority for an issue work
in interaction rather than in isolation to produce political priority, and will vary in different contexts.
Thus, while organizing focusing events can contribute to generating political priority for an issue, it
was not necessarily a critical factor in the countries that we studied, implying that political priority
can still be generated without focusing events.
On the other hand, our research has revealed the importance of framing issues in generating political
will and commitment, a factor that has not featured much in political science scholarship. In Rwanda
and Kenya, the framing of reducing population growth as critical to development or of FP as an
important development tool was critical in generating political will and commitment. Similarly, in
Malawi and Ethiopia, the framing of FP as important in improving maternal and child health was
important in generating political will and commitment. Malawi’s experience particularly stands out
where President Banda in the 1960s was completely opposed to FP when it was presented as a tool
to control fertility, but two decades later supported it when it was demonstrated as important in
reducing maternal deaths and improving the health of women. This study points to the importance of
framing, and although framing has not been highlighted as an important factor in much of political
science’s agenda setting scholarship, it has been acknowledged by studies in health policy analysis in
the developing world as important in bringing about reforms, particularly on neglected or
controversial health issues (Theobald et al 2005; Oronje et al 2011).
This understanding of the main factors that influence the generation of political will and commitment
for FP in the African countries that have made progress on the issue provides lessons for the many
other African countries that have not made much progress in increasing FP uptake over the last
decade (Uganda, DRC, Niger and Mali). Indeed, the shift in the ‘progressive’ countries from lack of
support for FP to demonstrable support for FP gives hope that those African countries lagging behind
can overcome the perennial challenges that have prevented them from improving FP uptake in order
to slow population growth and realize meaningful development.
Our findings demonstrate that African leaders’ appreciation of the role of reduction in population
growth in aiding development, and the role of FP in improving the quality of life of their citizenry has
the potential to generate political will for FP and motivate the positioning of FP as a national
development intervention as was the case among the Asian tigers in the mid‐60s (Robinson & Ross,
2007). The availability of evidence and the compelling ways in which it was used to link FP to
development, and to health, as well as its use in international forums to pressure poor countries,
were critical in generating political will and commitment.
Besides evidence and its innovative use in advocacy, the presence of political issue champions, what
Kingdon (1984; 2003) and Shiffman (2003; 2007) call ‘political entrepreneurs’ either in the form of
powerful individuals within government (e.g. Dr. Ntawukuliryayo of Rwanda, Dr. Adhanom of
Ethiopia, President Moi of Kenya and President Kagame of Rwanda) or government institutions (e.g.
NCPD in Kenya) was critical in generating political will and commitment. Other important factors in
contributing to generating political will and commitment included international influence through
19
technical and financial support, framing of issues to resonate with the concerns of top political
leadership, and a consideration of the contextual sensitivities (social, cultural, and political). Even
though these factors are discussed individually, they did not bring about political priority for FP as
separate entities; rather, it was their interaction that generated political priority.
Regarding the manifestation of political will and committment, our findings revealed that strong
political will from government institutions mandated to promote health or population management
can substitute open/vocal political support from top level leaders and result in strong FP programs as
in the case of Kenya (post‐2000) and Ethiopia. In this case, an enabling policy and program
environment exists for promotion of FP and ensuring access to FP services, implying silent top level
leadership support. In this case, power relationships play a critical role where top level leaders have
confidence in the recommendations made by their Ministers and/or their institutions. In Ethiopia, the
supportive power relationships between the Prime Minister and the Minister for Health meant that
the Prime Minister did not oppose the Health Minister’s efforts to prioritize FP even though he did
not necessarily support the issue. In Kenya (post‐2000), the NCPD led the push for the repositioning
of government’s attention on FP. While Kenya’s president or some of the ministers of planning were
not vocal on the issue, they did not stand in the way of NCPD in pushing this agenda.
On the impact of political will on policy and programs, our findings show that political will and
commitment for FP has provided an impetus for increased technical and financial assistance from
donors. Successful FP programs in the study countries have led to significant increases in
contraceptive use and notable decline in fertility. This finding challenges the argument by some
scholars that political commitment does not necessarily translate to implementation (Reich 1995;
Schneider and Stein 2001). Reich (1995:72) has argued that the concept of political will ‘assumes that
decisions of political leaders are both necessary and sufficient for major policy change…[it] posits a
technocratic approach with a rational actor model of decision‐making…’ Schneider and Stein (2001)
have gone further to warn that much political commitment could result in financial scandals
orchestrated by politicians. Studying the South African government’s commitment of HIV/AIDS
shortly after the end of apartheid, they argued that the:
‘“political commitment” which led to the National AIDS Plan, ensured that sufficient
resources were mobilised, funded the National Association of People with AIDS, and
more recently initiated an inter‐sectoral response, has also had a problematic side. AIDS
“scandals” have broken out at regular intervals in South Africa and have dominated
media coverage of AIDS. These scandals have been precipitated by centralised actions of
politicians suggesting that they, in fact, are already under pressure to act on AIDS, and
are searching for short‐term solutions.’ (Schneider and Stein 2002:727)
While we do not refute this claim, our findings suggest that the presence of political will and
commitment did in fact translate into programs (i.e. implementation). For instance, in Kenya when
President Moi in the 1980s started supporting FP, he required civil servants to put in place programs
that ensured access to FP. This requirement attracted donor investments which culminated in the
implementation of a strong community distribution program for contraceptives in Kenya in the
1980s. In Rwanda, President Kagame’s requirement that Mayors set and meet FP goals is ensuring
implementation of the FP program in the country and likewise has attracted donor investments to
support the program. On the other hand, Tanzania’s lack of clear political push for FP has contributed
20
to the country’s weak implementation mechanisms. Therefore, while political will on its own may not
bring about improved access to services, it remains critical in galvanizing implementation efforts.
Finally, our findings have demonstrated the fact that it is not enough to generate political will and
commitment; actors need to continuously work on sustaining it. The importance of sustained political
support in ensuring sustained implementation is demonstrated in Kenya and Tanzania, where waning
support from the political establishment led to the collapse of a successful program in the case of
Kenya in the 1990s, and a deceleration in progress in Tanzania and consequently, a retardation in
progress in increasing contraceptive use. Kenya’s recent improvements in FP uptake indicators have
indeed resulted from NCPD’s sustained efforts in reviving political priority for reducing the population
growth rate which is viewed as a hindrance to the country meeting its development goals. This makes
the lessons shared in this paper critical not just to countries performing poorly, but also for those
performing well as it is also critical to focus efforts on sustaining the existing political support.
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