Family Planning in the Democratic Republic of the Congo: Encouraging Momentum, Formidable Challenges

Political Will for Family Planning

During the first decade of the 2000s, several organizations offered family planning services, especially in Kinshasa, but they did so in the absence of strong leadership or a clear vision for family planning. The first sign of renewed interest in this topic emerged in 2009 with the Second National Conference on Repositioning Family Planning, which was held under the auspices of the First Lady. An important recommendation of the conference was to establish a key stakeholder group—the Technical Multisectoral Permanent Committee (Comité Technique Multisectoriel Permanent, or CTMP)—to guide future family planning initiatives in the country. Due to a lack of resources and organizational mechanisms, this committee existed but remained relatively inactive for several years.

As previously published in this journal,¹¹ the government of the DRC gave little priority to the issue of family planning prior to 2012. However, a series of positive events began in 2012 that have resulted in strong political support for family planning on the part of the government, emanating from the office of the Prime Minister. At a local conference held in June 2012 as a call to action for increased family planning funding, the Ministry of Health pledged to mobilize government funding for family planning. Consistent with growing support for family planning, the Prime Minister signed an official letter to the Minister of Planning in 2013, mandating greater engagement in family planning. The second Growth and Poverty Reduction Strategy Paper 2011–2015¹² highlights development strategies, including the need for access to reproductive health and family planning services.

In 2013, the DRC government publicly pledged commitment to family planning at the Third International Conference on Family Planning in Addis Ababa, Ethiopia.¹³ Shortly thereafter, the government launched the National Multisectoral Strategic Plan for Family Planning: 2014–2020.¹⁰ For the first time ever, in 2014 the government paid $300,000 for contraceptive procurement. In December 2014, it also pledged an additional $2.5 million during the round table at the Third National Conference on Repositioning Family Planning. In December 2015, the National Assembly approved a line item of $3.5 million in the national budget. In December 2016, the DRC government disbursed $1 million for the purchase of contraceptives. The DRC was the only country to send 3 ministers (Health, Education, and Plan) to the Fourth International Conference on Family Planning in Nusa Dua, Indonesia, where they presided over several panels. In addition, the Prime Minister of the DRC delivered a speech via video at the closing plenary session of this conference.

PNSA has also emerged as an important force in the DRC. In 2015, it organized a round table on the sexual and reproductive health of adolescents and youth, which gave more visibility and cohesion to partners working in this field. The following year, PNSA brought together donors and implementing partners to develop and publish the National Strategic Plan for the Health and Well-Being of Adolescents and Youth: 2016–2020,¹⁴ one of the first of its kind in a sub-Saharan African country.

Increased Donor Investment

Encouraged by these clear signs of political will in the DRC, the number of donors investing in family planning in the DRC has increased markedly over the last 5 years, as has the dollar amount of their investments. Whereas several major donors (e.g., USAID, DFID, the World Bank) continue to focus their support on large-scale integrated health delivery projects in rural areas, more recently donors have tended to support new approaches to service delivery, test innovative strategies, and fund adolescent/youth programs with an emphasis on urban areas.

Examples of major new investments include two 5-year programs that will extend coverage and reduce the financing gap for contraceptive procurement: the Global Financing Facility (GFF) under World Bank leadership and the Central Africa Forest Initiative (CAFI)/Reducing Emissions from Deforestation and Forest Degradation (REDD+) through the Norwegian Agency for Development Cooperation (Norad). In 2015 the DRC was selected among the focus countries for the GFF, a new initiative launched in 2015 to advance reproductive, maternal, newborn, child, and adolescent health.¹⁵ The country investment case developed under the GFF lists family planning among the priority interventions that will be implemented in 14 selected provinces showing the poorest track records in maternal, newborn, child, and adolescent health. CAFI/REDD+ is an environmental project that includes a family planning component in recognition of the role that population growth plays as one of the drivers of rapid deforestation in the Congo basin. In addition, 2 anonymous donors have begun to invest in both service delivery and demand creation activities in the DRC in recent years. Starting in 2016, the government of the Netherlands joined the list of international family planning donors, with support to youth programming in the 2 Kivu provinces under the title Jeunes S3 (Sécurité, Santé et Sexualité) and contraceptive supply chain management (2016–2020).

Climate of Innovation

The DRC has often lagged behind other countries in the region in terms of innovation and experimentation in other areas of public health, in part for the reasons cited above of limited financial and human resources. Yet in family planning, the DRC has been a hub for innovation. In 2012 the website, www.familyplanning-drc.net (also available in French at www.planificationfamiliale-rdc.net), was the first of its kind to provide information on a large range of family planning topics in the DRC. In 2013, the DRC was the second country selected to participate in the PMA2020 survey program, an innovative mechanism for collecting population and facility-based data: interviewers who reside in the “enumeration area” collect data via smartphones that can be transmitted directly to a server for timely analysis.¹⁶ In 2015, a pilot study on the introduction of DMPA-SC demonstrated the acceptability and feasibility of having medical/nursing students provide this method (among others) at the community level.¹⁷ Efforts are underway to expand the use of the DHIS 2 platform as a routine health information system to analyze contraceptive availability throughout this immense country, incorporate geographic information system (GIS) data that will preclude the need for separate mapping exercises, and use the DHIS 2 as a complementary logistics management information system.

As of 2014, little programming focused on the sexual and reproductive health problems of adolescents and young people. Only 20 of the 516 health zones offered SRH services to adolescents and youth of all types. Yet the climate for youth programming changed shortly after the Third National Conference on Repositioning Family Planning in December 2014. PNSA worked with its technical partners to develop a package of SRH services, including both a clinical and outreach component. A round table on sexual and reproductive health among adolescents and young people, held in December 2015, showcased the fledgling but growing project activity in this area. In 2016, PNSA spearheaded the development of a strategic plan for this population.¹⁴ The Bill & Melinda Gates Foundation, the David and Lucile Packard Foundation, and the governments of Sweden and the Netherlands are investing in programs that focus on adolescents and youth. UNFPA provided contraceptives to these programs. In 2017, PNSA with support from the United Nations Children's Fund (UNICEF) developed a listing of all SRH services for youth and adolescents in the DRC, which indicated 120 health zones receiving support for this type of service. In short, support for SRH programming for adolescents and young people in the DRC—though still in its infancy—has risen steadily in a period of 24 months.

Unifying Mechanism for the Family Planning Community: The CTMP

Following the 2009 recommendation resulting from the Second National Conference on Repositioning Family Planning, the CTMP began functioning as a coordinating entity in 2012. Its organizational members included several ministries (Health, Plan, and Gender), donors, and international and local NGOs. Representatives from different donor organizations and international NGOs realized the benefits of this mechanism in planning for the local family planning conference in 2012. As family planning activity accelerated in 2013 with the prospect of the DRC publicly pledging at the Addis Ababa International Conference on Family Planning and the development of a national strategic plan, the CTMP took on new relevance. The monthly meetings focus on an array of issues, often depending on current issues (e.g., the Reproductive Health Law, participation in international conferences). They provide a forum for new implementing partners to quickly integrate into the larger community and for visiting donors to meet with family planning stakeholders in a single location. Although this type of coordination mechanism is by no means unique to the DRC, it has given an identity to members of the family planning community, which is then able to “speak as one” on given issues. The Prime Minister's office recognized the value of this group and issued a decree in March 2015, conferring official status to this entity.

Evidence of Change in Modern Contraceptive Prevalence in Kinshasa

Two DHS surveys conducted in 2007² and 2013–14³ showed very little increase in mCPR (from 5.8% to 7.8% among married women of reproductive age) at the national level. The PMA2020 surveys, limited to the capital city of Kinshasa (with the addition of Kongo Central since July 2016), showed an increase in mCPR from 18.5% in 2013 to 26.7% in mid-2017 among women who were married/in union, and from 31.0% to 39.6% among sexually active unmarried women in Kinshasa.^18,19 During this same period, the share of long-acting reversible methods among married women using modern methods increased from 10.8% to 40.0% (due almost entirely to use of implants).^18,19 As of 2017, unmet need for family planning ranged from 22% to 25% for these 2 groups of women, suggesting strong latent demand for modern contraception. Compared with mCPR in some other sub-Saharan African countries, mCPR remains low. However, the steady increase in contraceptive use and the shift toward long-acting methods in Kinshasa in recent years is promising.

The Issue of Political Stability

The current president Joseph Kabila came into power in 2001 (after the murder of his father, President Laurent-Désiré Kabila). His constitutionally mandated 2 terms of office ended in December 2016. The absence of elections in November 2016 provoked political tensions and intermittent demonstrations that made headlines in the global press.

In February 2018, new elections were announced to take place on December 23, 2018, with the new president to take office in January 2019. However, the opposition continues to make strident demands that President Kabila step down now, rather than wait until the elections. As such, the announcement of elections has yet to bring political stability to the country. Most international observers have taken a wait-and-see attitude.

Current and potential donors are keenly aware of the political situation in the DRC as they consider future investments in family planning and other sectors. The challenge is to maintain the confidence of donors, pending a return to conditions of political stability expected to follow successful general elections. Most current family planning donors remain strongly committed to the work already underway, but they remain vigilant of the political volatility in the country.

The Logistics and Management of Service Delivery

The DRC is the largest country in sub-Saharan Africa in terms of land mass, yet the transportation infrastructure is extremely weak. No highway or train system connects East to West; the 1,736 miles of paved road for the entire country consist of 2-lane highways. Several national airline carriers service the major cities throughout the country, but their safety record is poor. (International agencies depend heavily on the United Nations Humanitarian Air Service for domestic flights.) Less than 7% of the population has access to the Internet,²² although mobile SIM penetration has now reached 39.5%.²³

In addition to logistical challenges, the general shortcomings of the public health system hinder the delivery of family planning services. Inadequate human and financial resources to properly train and supervise health care providers and lack of equipment and the deterioration of physical infrastructure, some of which dates from the colonial era (before 1960), are all difficulties encountered by those working in family planning. Management systems are also inadequate, leading to a situation where health care providers set the prices of their services as they wish, rather than at established standardized prices. Contraceptives provided free of charge in the public sector are often leaked to the private sector, where they are sold for a profit by people whose knowledge of their proper use may be limited.

And as if this were not enough, starting in late 2016, sporadic social and political unrest in areas with heightened security risks endanger personnel trying to conduct activities and resupply health facilities.

Contraceptive Security and Supply Chain Management

Contraceptive security (having the right contraceptives in the right place at the right time at the right cost) requires astute management and sufficient financial resources to complete a complex series of tasks: quantifying (forecasting) contraceptive needs of a given population, estimating the costs of purchase and transport of the commodities, identifying procurement mechanisms, placing orders, clearing merchandise through customs, ensuring delivery to a central warehouse or directly to regional warehouses, ensuring transport to the facilities where clients will obtain the contraception, tracking the continuous flow of commodities through the system, accounting for all expenses, and financing this entire process.

Multiple factors contribute to the challenges of ensuring contraceptive security in the DRC. Different donors and family planning implementing organizations manage contraceptive procurement and distribution through parallel channels in the national system. Ideally, the supply chain used for essential drugs in the country could integrate contraceptive procurement to improve efficiency and reduce transaction costs. Although discussions are underway to explore this approach, contraceptive procurement and distribution occur outside the government supply chain for essential medicines.

In terms of purchasing contraceptive supplies, the government has used its own funds but is only able to cover a fraction of the costs for a population the size of that in the DRC. Donors are also unable to fill this gap. The logistics of contraceptive distribution—including purchasing, transportation, distribution, and storage—is a major challenge, especially in terms of delivering it to the “last mile” (the client).

The Influence of Sociocultural Norms That Favor Large Families

Demand for family planning services results from the desire to prevent pregnancy in the short term and to space/limit number of births in the long term. All else being equal, societies that favor large families will have less demand for contraception, although such norms evolve over time and in response to macrolevel economic changes (e.g., improved opportunities for women's education, increased urbanization). In the DRC, the total fertility rate is 6.6 children (5.4 in urban areas and 7.3 in rural areas).³ As Romaniuk has noted, couples tend not to be deterred from having a large family by their inability to provide for their children in material terms; nor do women limit fertility to participate in the labor force.²⁴

Recent qualitative research highlights many factors that contribute to the persistence of high fertility rates.^25,26 Having many children is a sign of social status for both men and women. Moreover, Congolese law makes women subordinate to their husbands from the day of their marriage, which gives them less power in their relationship. The husband's family may believe that his wife owes them many children in exchange for the dowry that the husband's family paid for her. If she does not give birth to these children, her husband's family can encourage him to marry another woman. To the extent that parents depend on their children when they become elderly, having many children is a way to ensure that they are taken care of later in life. Finally, children are an important source of labor for families, particularly in rural areas.

Cultural norms can change in response to the economic pressures experienced by families because of their size, particularly in urban areas. However, even women in the highest quintiles for economic well-being in the urban areas of the DRC wish to have an average of 4.9 children, and a higher level of education in the DRC has a minimal effect on the desired family size.²

Fees for Family Planning Services

Per capita GDP in the DRC is $405.²⁷ The country ranks 176 of 188 countries on the Human Development Index.²⁸ In terms of the percentage of the population living below $1.90 per day, the DRC at 77.1% is one of the most impoverished nations.²⁷ In the DRC, 70% of the public health system is financed by user fees, with only 13% covered by the government and 14% by external donors.²⁹ This method of direct payment by households constitutes an important financial obstacle to access to care by the poorest segments of the population.

In this climate of grueling poverty, cost can represent a prohibitive barrier to contraceptive use. Programs serving rural areas (e.g., PROSANI, ASSP) provide contraception free of charge. However, registered pharmacies in urban areas charge either market rates or subsidized rates (if they receive commodities from development programs). Hospitals and health centers in urban areas often provide contraception subsidized by the major donors; yet even if the product is low cost or free of charge, the facility may charge for the consultation and supplies required to administer the contraceptive method (e.g., syringes, cotton and alcohol for injections or implant insertions). Social marketing programs, including PSI and DKT International, sell a range of contraceptives at subsidized prices. In addition, PSI, through the Association de Santé Familiale (ASF), instituted a dual system of payant et gratuité (paying and free), whereby once a month they supply contraception free of charge, thus affording access to those otherwise unable to pay for the service.

According to FPwatch, an outlet survey conducted in 2015 in Kinshasa and Katanga provinces, the median price per couple-year of protection (CYP) in Kinshasa was $1.75 (and was slightly higher in Katanga).³⁰ The cost per CYP was $4.95 for implants and $0.55 for intrauterine devices. Some health facilities in Kinshasa charge between $10 and $20 for the highly popular implant, and a client must pay the full amount of the method on the day of service, even if the cost per year over the multiple years of protection is far lower.

Compounding client inability to pay, prices for contraception are not standardized. PNSR established a list of prices for all contraceptives sold in the public health system, but there is no enforcement of these prices. Moreover, rarely are the prices posted for the benefit of clients. In 2017, only 23% of service delivery points in Kinshasa that charge fees for family planning posted the prices of contraceptives.¹⁹

Governance and Leadership: Transforming the Provincial CTMP Network Into a National Family Planning Alliance

Given the effectiveness of the national CTMP as a coordinating mechanism that provides structure to the family planning community, efforts began in 2016 to establish CTMPs at the provincial level. Of the 26 provinces in the DRC, 12 currently have a provincial CTMP (Kinshasa, Bas Uele, Kasai Central, Katanga, Kongo Central, Lualaba, Nord Kivu, Sankuru, Sud Kivu, Tshopo, Ituri, and Lomani). The Ouagadougou Partnership—a group of 9 francophone West African countries that work together toward a single family planning objective—serves as a useful model for this partnership in the DRC.³²

A key criterion for establishing a provincial CTMP is the presence of an international NGO that provides family planning services in the province and is willing to play a coordinating role and provide financial support for the organization of CTMP meetings. PNSR remains highly engaged in this initiative. As currently structured, government representatives on the provincial CTMPs include the provincial representative of PNSR, the Provincial Division of Health (Division Provinciale de Santé, or DPS), representatives of at least 3 ministries (Health, Plan, and Gender), and in some cases the ministers of Environment and of Social Affairs, as well as other international and local NGOs.

In the absence of a national program able to provide financial resources for family planning operations at the provincial level, the CTMP constitutes a voluntary grouping of family planning stakeholders interested in advancing family planning at the provincial level. Provincial CTMPs are not operational units; they do not have a budget for program activities. However, these groups of provincial stakeholders will be able to oversee the evolution of family planning service delivery in multiple ways. They are already involved in quantifying contraceptive needs in their provinces. They will have access to rapidly improving service statistics through the adoption of the DHIS2 system in the DRC. These data will allow provinces to track the percentage of health zones (and within them, health areas) that provide family planning services. This type of evidence-based programming is likely to encourage existing funders to fill some program gaps and to attract new investment. Improving the advocacy skills of provincial staff will help secure these gains.

Three key activities in 2017 gave direction to this new initiative. In March, members of the provincial CTMPs met in Kinshasa for the first time, creating solidarity for this type of coordinated approach to promoting family planning in the DRC. In September, PATH organized a 3-day training, attended by 2 persons per province, to strengthen their skills in facilitation techniques using Advance Family Planning (AFP) SMART advocacy tools.³³ In October, a series of 3 week-long workshops were held (to cover all 12 provincial CTMPs), in which 4 members per province participated in training on the fundamentals of family planning programming, autonomous functioning of the provincial CTMP, improvement of the quantity and quality of family planning coverage, and monitoring progress using service statistics.

Although the provincial CTMPs operate relatively autonomously, the national CTMP will continue to play an important role as a coordinator and catalyst. It will organize annual meetings in which each province will present its achievements and identify areas for improvement, coordinate skills training/workshops at the provincial level, and create a communication platform via a new website (www.ctmp-pf.org).

Service Delivery: Initiatives to Improve Supply and Demand

The structure of service delivery in the DRC resembles that of most developing countries. Services are available through fixed health facilities (e.g., hospitals, health centers, health posts), pharmacies, and community-based distribution workers. Services are financed through the public sector, private commercial sector, and private not-for-profit (NGO) sector including faith-based organizations. “Hybrid” facilities also exist whereby the government owns the structure and pays the personnel, but an NGO is responsible for training personnel and providing contraceptive commodities.⁶ In addition to registered pharmacies, many informal pharmacies (drug shops) also provide one or more contraceptive methods, such as condoms.

We cite 3 illustrative initiatives designed to increase supply, improve quality, and generate demand. By no means unique to the DRC or innovative on the world stage, they nonetheless represent promising attempts to improve service delivery in the DRC.

Personnel: Institutionalizing Family Planning Through a National Network of Nursing Schools

In 2015 a research pilot on the acceptability and feasibility of having medical and nursing students deliver contraceptives including DMPA-SC at the community level created new awareness for the potential of this cadre as family planning service providers in the DRC.³² While the pilot research had set out to test the acceptability of distributing DMPA-SC at the community level, the greatest “discovery” of the study was the potential of using students to expand access to contraception. They are dynamic, well educated, eager to gain experience with service delivery at the community level, and young (thus approachable to young people seeking contraceptives). In addition, they represent tomorrow's leaders of the DRC health care system.³⁵

The 6th Directorate (6ème Direction, or D6) of the Ministry of Health oversees the 477 schools of nursing and midwifery in the country. (Medical schools operate more autonomously under a different directorate.) In 2016, efforts began within the D6 to institutionalize family planning within nursing schools; specifically, to establish a family planning curriculum that every nursing student will take as the first module of the third academic year; to train instructors from these schools to teach this subject matter; and to incorporate a community-based practicum into the curriculum in which students would provide 5 contraceptive methods (Implanon NXT, DMPA-SC, pills, condoms, and CycleBeads) at the community level. Because of the growing popularity of implants through the DRC, the use of this cadre of provider to administer Implanon NXT outside a clinical setting further enhances the potential effectiveness of this strategy.

To date, D6, PNSR, and other stakeholders have instituted this program in 11 nursing schools in Kinshasa and 6 nursing schools in the adjacent province of Kongo Central. Students are operating as community-based distributors. The National Health Information System (Système National d'Information Sanitaire, or SNIS) is modifying its family planning data collection forms to reflect the contribution of this new cadre of personnel.

This innovative mechanism represents a first step in expanding and strengthening the delivery of family planning services in the DRC. It is by no means the total solution to this enormous challenge. Yet it has emerged as one of the potentially most effective means of jump-starting service delivery, especially where it can expand to provinces beyond Kinshasa.

Commodities: Ensuring Contraceptive Security Through Improved Supply Chain Management

It is hard to overstate the enormity of the challenge of ensuring contraceptive security in a country that is physically immense, has weak transportation systems, is extremely underfunded for contraceptive procurement, and lacks a unified procurement/distribution system. The DRC can boast little “innovation” in this area. Rather, it must focus on establishing the basic elements of a functional contraceptive logistics system, which is itself an ambitious objective but fundamental to achieving increased mCPR. The enormity of the logistical challenge has caused some to ask if the DRC should be a testing ground for using drones to deliver contraceptive commodities.

Several positive steps in this domain include the following:

• Establishing a multiagency contraceptive logistics task force, including government, international NGOs, and donors

• Quantifying contraceptive needs for the country, by province, from 2016–2020

• Estimating the cost for contraceptive procurement and family planning service delivery, as well as the financial gap that exists to meet these needs

• Establishing an early-warning system for contraceptive stock-outs at the health zone level, with mechanisms to trigger resupply

• Lobbying the country's health donors to allocate a budget for contraceptives

Key activities are either underway or in the planning stage that will contribute to improving the effectiveness of contraceptive logistics:

• Implementing a national strategic plan for the supply chain to improve the alignment and effectiveness of government, donors, and partners (recently signed by the Minister of Health)

• Developing greater cohesion and coordinated action among members of the multiagency contraceptive logistics task force

• Developing an accurate, comprehensive, and transparent information system on contraceptive procurement and distribution of contraceptives flowing into the country for use in the public and private, nonprofit sector

• Maintaining a strong advocacy initiative to mobilize funding among international donors to cover the contraceptive financing gap

In 2016, an initiative began to review the possibility of incorporating contraceptives into a larger government-supported system for procuring and distributing essential commodities. At the heart of the system is a quasigovernmental organization responsible for the procurement of health commodities in the DRC called FEDECAME (Fédération des Centrales d'Approvisionnement en Médicaments Essentiels). FEDECAME is a network composed of a Kinshasa-based procurement and supply chain coordination unit linked to 19 regional distribution centers or centrales de distribution régionale (CDR) for medication throughout the country, whose mandate is to ensure the supply of health commodities through the health system down to the community level. FEDECAME has successfully procured many essential medicines but lacks experience in procuring commodities for family planning, HIV/AIDS, and tuberculosis among other programs, primarily due to historical arrangements whereby vertical donor such as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President's Malaria Initiative (PMI) ensured procurement of specific commodities.

Yet should the latter continue to be the long-term objective? A reasonable long-term strategy (for example, 10 years) could perhaps rely on a state-owned and publicly owned supply chain, with major intermediate steps to be accomplished, while continuing to receive meaningful help from donors.

Information: Strengthening Information Systems to Monitor Progress

The significant progress in this area should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind. Three types of information useful to monitoring ongoing programs and advancing family planning programing include the routine health information system, population- and facility-based surveys, and special studies.

Financing: Developing the Funding Streams to Cover a Highly Under-Resourced Program

Financing remains a major challenge in a country with few resources and a very small percentage of the national budget allocated to health. Family planning programming in the DRC remains highly donor-dependent, despite the politically important but relatively small contribution of the DRC government to contraceptive procurement. The increased donor investment over the past 5 years shows no signs of slowdown.

At the international level, the GFF is poised to leverage funds from the International Development Association in support of family planning as a priority within the reproductive, maternal, newborn, child, and adolescent health and nutrition continuum. At the national level, several provincial CTMPs—Lualaba, Nord Kivu, and Sud Kivu—have successfully created a line item for contraceptive procurement in the provincial budget.

Efforts to involve the private sector may further contribute to financing family planning service delivery, for example, in the mining sector. Yet if the DRC aspires to universal coverage in family planning by 2030, much work remains to be done to achieve this ambitious goal.