Strategies for
Overcoming Fertility
Plateaus
Suneeta Sharma PhD, MHA
Chief of Party, ITAP
Director, Futures Group India
Sept 19, 2011
Plateauing CPR:
Three Stages
 Beginning of the
program
 After take off
 After reaching the
ceiling
Slackened Pace of CPR
Modern Contraceptive
Prevalence Rate, Bangladesh
50
45
40
35
30
25
20
15
10
5
0
Modern Contraceptive
Prevalence Rate, India
60
50
40
30
Average Annual Increase
1991-2004: 1.24
2004-2007:0.07
20
10
Average Annual Increase
1992-98: 1.05
1999-2005: 0.9
0
1991 1994 1997 2000 2004 2007
Source: Demographic Health Surveys
1992-93
1998-99
2005-06
Source: National Family Health Surveys
Questions on Plateauing
 Why do programs plateau?
 How long do they remain stagnant?
 What has been done or needs to be done to get out of
such situations?
 Is it possible to predict such situations in advance?
Reasons Behind Slackened Pace of CPR
 A limited method mix
 Program management weaknesses
 Sheer growth of numbers
 Changing demographic profile within the reproductive years
 Shift in attention to other programs
 Diminishing returns at high prevalence rates
Source: John Ross et al Plateaus during the Rise of Contraceptive Prevalence, IFPP, 2004
Reasons for the Stall in Fertility
 Changes in fertility preferences such as shifts in marriage
patterns, timing of initiating child bearing
 Shifts in local/national policies, reduced budgets or donor
support
 Increasing unmet need, unplanned childbearing
 Increasing negative attitudes towards family planning or
methods
 Changes in age structure of population and migration
Source: Ian Askew et al, Pop Council 2009
Can plateauing be anticipated?
Case of India
Total Fertility Rate in Indian States
Bihar
Uttar Pradesh
Rajasthan
Madhya Pradesh
Jharkhand
Chhatisgarh
Assam
INDIA
Haryana
Gujarat
Orissa
Jammu & Kashmir
Delhi
Maharashtra
Karnataka
Himachal Pradesh
West Bengal
Punjab
Andhra Pradesh
Tamil Nadu
Kerala
3.9
3.8
3.3
3.3
3.2
3.0
2.6
2.6
2.5
2.5
2.4
2.2
2.0
2.0
2.0
1.9
1.9
1.9
1.8
1.7
1.7
0.0
0.5
1.0
1.5
2.0
TFR = 2.1, replacement level of fertility
2.5
3.0
3.5
4.0
4.5
Source: Sample Registration System, Registrar General of India, 2008
Trends in Modern Method CPR in India
and Select States
67
70
58.9
60
50
48.5
42.8
46.9
46.5
40
30
56.5
53.3
36.3
29.3
28.9
22
22.4
20
18.5
10
India
Andhra
Pradesh
1993
Source: National Family Health Surveys (NFHS)
Gujarat
1999
Uttar Pradesh
2006
21.6
Bihar
Decline in Total Fertility Rate in India
and Select States
4.82
5
4.5
4.06
4
3.5
3.39
3
2.85
2.5
2.68
2.59
2.25
2.42
2
1.5
2.99
2.72
3.82
4
3.7
4.0
1.79
1
India
Source: National Family Health Surveys
AP
Gujarat
1993
1999
UP
2006
Bihar
Inequities in Contraceptive Prevalence
Rates
4.5
70
4
3.5
3.89
3
T 2.5
F
2
R
1.5
3.17
55.2
58.0
60
49.8
48.5
2.58
2.68
43.5
34.6
2.24
M
50 o
d
40
C
30
R
P
20
1.78
1
0.5
0
10
Lowest
Second
Middle
Fourth
Wealth Quintile
CPR - Mod
Source: National Family Health Surveys (NFHS)
TFR
Highest
India
Plateauing CPR in India
 Significant proportion of declines in fertility and
increase in CPR have come from select states
 States that have achieved ceiling levels will not
significantly contribute to increases in CPR and
fertility decline
 States that have experienced plateau in the past
decade have to contribute to CPR increase significantly
 If not, India will enter into plateauing phase this
decade
How to Tackle Plateaus?
Analyze data sets to understand contributions
of subgroups and prepare strategies
Keep FP program central to development
efforts
Introduce new FP technologies if they are not
part of current programs
Involve private sector in FP service delivery
Andhra Pradesh
Andhra Pradesh – CPR v/s TFR
5.0
4.5
80
70 C
P
60 R
67.0
4.6
4.0
58.9
4.0
3.5
47.0
3.0
T
F 2.5
R 2.0
50 40
2.6
2.3
2.2
2.1
1.5
1.8
1.8
NFHS 200506
SRS 2008
1.0
0.5
0.0
M
30 o
d
20 e
r
10
n
0
SRS 1971
SRS 1981
NFHS 1992- NFHS 199893
99
AP TFR
SRS 2003
SRS 2004
AP CPR
Source: Sample Registration System and National Family Health Surveys
Three Pillars of Andhra Pradesh’s Family
Planning Program
Political Commitment and
Leadership
• Mission mode implementation
• State specific FP intervention under
directions of State Population Policy
• Leadership by Chief Minister
• Supplemented central funding
through special state budget
• Ensured high level monitoring by the
Chief Minister/Health Minister
• FP as top agenda item of District
Collectors’ meetings – Monthly
Robust Administrative Systems
and Execution
• Developed a Strategic Framework to
implement State Population Program
• Established District Population
Stabilization Societies
• Identified and prioritized on poor
performing districts
• Designed special state- specific
interventions
• Provision of FP State share
• Support to Camp Approach
• State level mobile teams
• Uninterrupted provision of supplies
• Rewards for providers
• Special focus on legal issues and
treatment of complications
• Continuation of Post Partum FP
Centers
Effective Monitoring and
Feedback
• Initiated Tele/ Video-conferencing
facilities to monitor the program
• Chief Minister reviewed program of
all 23 districts
• District Collectors reviewed and
facilitated mobilization of programs
Uttarakhand Example
Analyze data sets to understand contributions
of subgroups and prepare strategies
 High maternal mortality, infant
mortality, and total fertility rates
 Use of FP methods and
institutional facilities for
deliveries is the lowest among
poor
 Out-of-pocket expenditure on
reproductive and child health
(RCH) services
 Enormous health barriers to the
poor
 Staff vacancies, lack of trained
staff
 Difficult geographic terrain,
remote populations
CPR v/s TFR for Wealth Quintiles,
Uttarakhand
70
C 60
P
R
50
-
3.5
3.21
63.4
2.72
48.3
56.1
49.9
55.5
2.55
2.5
3
2.5
42.1
2.04
40
2
T
F
1.5 R
M
30
o
d
20
e
r
10
n
1
0.5
0
0
Lowest
Second
Middle
Fourth
TFR
Highest
CPR
Source: Calculated from the National Family Health Survey – 3 (2005-06), Uttarakhand State Raw Data
Total
Keep FP program central to
development efforts
 New Health and Population Policy (2010 2020)
 Increased state funding and innovative
financing mechanisms
 Promote a balanced method mix
 Focused interventions in low performing
districts
 Develop capacity of the providers and
health workers
 Engage men to increase their
participation in planned parenthood
 Mandatory action: Modern spacing
method services to newly married and
couples having one child
Involve private sector in FP service
delivery
 Mobile Health Vans
 ASHA plus Program
Ensure sustainable
financing
Prioritize needs
 Voucher System
 Contracting out in
urban areas
 108 Vans for
transportation
 Adolescent NGO
project
Determine shared
goals
Government
Leadership and
Ownership
Engage right
partners
Develop strategic
options
Establish links with
policy framework
Develop costed
scale up strategy
Design and test
appropriate
models
Evaluate impact
Scaling Up Public Private Partnership
Models
 Voucher system scaled up
to 38 blocks in five
districts covering more
than 50 percent of the
State rural population
 26 Mobile Health Vans in
35 districts covering 10
million people
 ASHA plus program scaled
up in 6 districts covering
3.13 million people
I m p ac t A s s e s s m e nt o f
Vo u c h e r P ro j e c t i n Hari d war,
U ttarak h and ( i n 2 4 m o nt hs )
47
50
43.1
40
30
20
10
32.8
28.9
5.9
10.6
0
3+ ANC
Checkups
Institutional
delivery
Baseline
Mod CPR
Endline
Behaviour Change Communication
Activities to Inform PPP Models
 Formative research to identify barriers to behavior
change
 Workshop on BCC involving various stakeholders
 ASHA Plus toolkit and IPC Training
 BCC campaign on institutional deliveries (mass media,
mid-media and IPC)
 Branding , BCC strategy and IPC tools for Voucher
scheme
 Communication plan and IPC tools for mobile vans
 UDAAN BCC strategy, and campaign developed
 Workshop on strategic BCC to develop PIP 2011 -12
Way Forward
Promote evidence-based
process of moving from policy
to action
Keep family planning central to
development efforts
Design, test, implement,
evaluate, and scale up effective
interventions
Plan and monitor for impact
Photo by Meena Kadri
Thank You!
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The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development
(USAID) under Cooperative Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures
Group, the Centre for Development and Population Activities (CEDPA), Futures Institute, Partners in Population and
Development Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), Research Triangle Institute (RTI)
International, and the White Ribbon Alliance for Safe Motherhood (WRA).