Posted January 2000

Provision of reproductive health services in Sub-Saharan Africa: Lessons, issues, challenges and the overlooked rural majority

Part 1: Availability, accessibility and affordability of reproductive health services in sub-Saharan Africa

The introduction of family planning services in sub-Saharan Africa has come late, started in urban centers and expanded to the rural areas very slowly. Despite the fact that traditional Africa utilized different mechanisms to space child births, modern family planning was not readily accepted.

It was in the late 1970s and the early 1980s that the virtues of population programs started to become better understood. There were several reasons for this change of attitudes. Among them, the realization that family planning could have positive impact on the health of mothers and children played a critical role. In addition, the modernization and monetization of the economy, rapid urbanization, access to modern education by women and the economic crisis as well as the subsequent imposition of structural adjustment programmes in many African countries all had a positive influence on the attitudes of political leaders towards family planning. By that time, many developing countries, especially those in South-East Asia, were reaping the economic benefits of sustained family planning programs. African countries were able to learn from the experiences of other continents.

Today most African countries have embraced family planning as an integral part of their reproductive health programs. Twice in less than a decade (1984 and 1992), African leaders got together to declare their commitment to support population programs that are compatible with economic growth. In 1994 at the International Conference on Population and Development (ICPD), African countries played an active role in passing the final resolutions which called for the generalization of reproductive health services in member countries. Today, over twenty-five countries have official population policies with specific demographic targets.

Africa is a large continent with a variety of characteristics regarding reproductive health and sexuality. There are geographical differences (West Africa versus East and Southern Africa), historical differences (French-speaking versus English-speaking), religious differences (Muslims versus Christians) as well as differences between urban and rural populations in access to and use of family planning methods.

This article tries to assess the differences in the availability and accessibility of family planning services between the urban and rural regions in sub-Saharan Africa. It also proposes some solutions to respond to the huge unmet need for family planning especially in the rural areas. Obviously each country and each program needs to adopt its strategy to its unique requirements.

2) Availability and accessibility of services

In sub-Saharan Africa the health system is built around curative services and it is mostly concentrated in urban areas. Family planning was introduced in Africa as a clinical method. In most countries, less than half of the population, mostly those living in major urban centers, have access to a health facility. Even if the assertion of health officials in many countries that family planning is integrated into their primary health system is true, it is still unavailable for the vast majority of the population who live in rural areas.

The unmet need for family planning in Africa is huge (Table 1). It is estimated that almost 30 million married women of reproductive age would like either to stop childbearing or space the birth of their next child, but cannot do so because they have no access to family planning services. The real unmet need for family planning may be even greater if one includes women who are not married but are sexually active and wish to adopt a family planning method. Given the fact that the vast majority of the African population lives in rural areas and given that most urban areas are better supplied with family planning services, it is safe to assume that most of the unmet need for family planning in Africa is among the rural population. This means that, although tradition and cultural beliefs are more prevalent in rural Africa than in the cities, although information and services have not been made available to the rural population, nevertheless, millions of rural men and women want to regulate their reproductive lives, but are unable to do so.

The unmet need is expected to become even greater as the number of young women entering their reproductive ages increases and as more and more women will want to practice family planning. If the population programs in Africa would only respond to this unmet need, it is estimated that contraceptive prevalence would increase between 20 and 30% (Rosen and Conly 1998).

What are the problems facing the availability and accessibility of family planning services in Africa, especially in rural areas?

1. Lack of Strong Government commitment: Despite recent positive signs that African governments are in favor of family planning, in most cases they still fail to play an active role in the promotion of the population program. African governments' contribution, both financially and in human resources for family planning programs is still a small fraction of the overall requirements (Table 2) and, except on rare occasions, government authorities almost never mention family planning as a priority concern. Yet, experience shows that without strong and active government support, the chances of success for any population program is minimal. In Africa, like in many developing countries, the most successful programs are those which enjoy strong government support. This is particularly true in rural areas, because authority plays an important role in the lives of the rural population. The opinion of the local administrators and community leaders can be a determining factor in their reproductive behavior. Unfortunately, in family planning, as in all major social development undertakings (health, education, communication, etc.), African governments invariably neglect rural areas in favor of the few urban sites. As a result, their development efforts, when seen from a national perspective, becomes irrelevant for the majority of the population.

2. Medical Barriers: The provision of family planning services in Africa is full of barriers that are unnecessary and often discouraging to potential users. Such barriers include age and parity requirements for certain methods, requirements of husbands' consent, refusal to serve unmarried women, opposition to outreach program by health professionals who believe that family planning should be provided only in a medical set up, and unnecessary and time-consuming medical and laboratory examinations. In Zanzibar, for example, health professionals refuse to provide contraceptives to unmarried women. In Botswana, Burkina Faso and Senegal on the other hand, it is easier for unmarried women to get a contraceptive method than for married women because of requirements for husbands' consent for those who are married. In some countries (Kenya, Burkina Faso) there is a strict parity requirement to have an IUD (Population Council 1998). In Zimbabwe, many service providers set minimum age requirement despite guidelines that allow the provision of family planning services to all without restriction (Rosen and Conly 1998). The effect of these barriers is more severe on rural women than on urban dwellers. A rural woman in Africa takes a long time weighing her reproductive options. She has to take into consideration not only her personal feelings but those of her husband and the extended family. It is after a lot of thinking and consultations that she finally decides to see a health professional. In order to do so, she will have to travel long distances and give up her household responsibilities for the day. An unwelcome reception of any nature from the clinic will definitely discourage her to return back for services. Given the paucity of alternative service delivery mechanisms in the rural areas, this usually means exposure to unwanted pregnancy and child-birth.

3. Socio-cultural barriers: As indicated earlier, human reproduction is viewed in most of rural Africa as a natural process that should not be interfered with artificially. The lack of culturally-appropriate information and education reinforces this belief. And the fact that family planning services are almost exclusively targeted towards women excludes men who are, in most cases, responsible for making reproductive health decisions. For lack of adequate information and because of many unfounded rumors, rural African men are generally not in favor of family planning. Also, in most rural areas, women marry at a young age and start having children very early. By the time they are in their late twenties, they already have several children. For all these reasons, the environment for modern family planning in the rural areas is not always favorable.

4. Lack of communication between urban centers and rural areas: In most African countries communication facilities (transport, telephone, radio or television) between the decision making urban centers and the vast majority of people who live in rural areas are extremely poor. As a result, health information and education programs do not reach the rural population in time, if at all. The reverse is also true: due to limited communication between urban centers and rural areas, there are strong beliefs among the urban elite that rural African populations are opposed to family planning services. This, however, is not completely accurate, as is demonstrated by the introduction of successful outreach family planning programs in many rural areas in recent years. As findings from a study conducted in rural Ghana indicate, "..compound to compound service delivery can introduce family planning in rural communities. When services are offered, a steady but gradual uptake of contraception occurs. This suggests that demand for family planning exists, and that reproductive behavior will change if convenient services are offered to women in their homes " (Nazzar and Phillips 1995).

5. Lack of adequate resources: Because of the rapid expansion of family planning services, the resources necessary to address the demand are not always available. Such resources include not only finances but also commodities, medical equipment and trained personnel. This is especially true in recent years because of significant cut in outside funding for family planning, integration of family planning into reproductive health services and because of new and urgent priorities including the HIV/AIDS epidemics. When resources for social sector activities are reduced, those who suffer the most are the rural population because it's their share of the resources which is cut first. Most health activities in urban centers have incompressible costs in the form of staff salary and other recurrent costs.

In spite of these problems, however, significant progress has been achieved in many African countries in reaching the rural population with family planning information and services through a variety of outreach programs. These programs will be reviewed later in this paper.

3) Affordability of family planning services in sub-Saharan Africa

Most of the family planning programs in Africa today are donor-driven. The contribution of governments and the population is only a fraction of the total expenditure. In most cases, family planning services are provided free or for nominal fees. The commercial sector has not ventured into the family planning market partially because of government policies and partially due to the small size of the market itself.

As the number of women of reproductive age grows and the demand for family planning increases, the cost of providing this service will become prohibitive both for the donor community and for the governments themselves. It is estimated that, in order to respond to the unmet need for family planning, spending will have to increase from an estimated US$ 300 million in 1993 to $ 1.1 billion in 2000 and $ 2.4 billion in 2015 (Rosen and Conly 1998). Inevitably, therefore, costs will need to be recovered through the contribution of the beneficiaries. The question is whether the beneficiaries, especially the rural population, can afford to pay for the cost of these services.

Experiences of cost recovery in Africa have shown encouraging results. Most people, even those with limited income, seem willing to pay some amount for family planning services. In fact, several studies on cost recovery have shown that a vast majority of the people, including people living in the rural areas, are willing to pay for services. In Kenya for example, a study found that 82% of clients in communities served by outreach workers were willing to pay for family planning services. In Blantyre (Malawi) and Bulawayo (Zimbabwe) 70 % and 80 % of family planning clients respectively pay for the services and of those who do not currently pay, a vast majority are willing to pay (Center for African Family Studies 1995). It is estimated that African households pay about 15% of family planning costs. This percentage is much higher than what African governments spend on family planning (9%; Janowitz, Measham and West 1999).

Many people, both urban and rural, understand that the cost of raising a child in Africa today has become increasingly expensive compared to their shrinking income. In Kenya, for example, the average family spends between 10 and 15 % of its annual income to send a child to school. At this rate, the choice is either to have the number of children one can afford to raise properly or to expose children to illiteracy and unemployment.

However, the possibility of recovering the total cost of family planning programs may not be possible in the near future. Poor rural inhabitants and the underprivileged urbanites, including the youths, will not be in a position to pay for contraception. In this case, governments will have to develop a mechanism which will allow these people to have access to family planning through some kind of subsidized program.

In fact, most primary health care services, including family planning for the rural population, can be subsidized with part of the enormous amount that African governments spend on curative services in urban areas, revenues that can be generated through service charges to those who can afford to pay and income that can be obtained from taxes levied on the private health service providers. To this effect, governments should allow the private sector to play an increasingly important role in the curative health program especially in urban areas. The role of the private sector in the health field is minimal; but the potential exists to increase this role.

4) What can be done?

The current population of Africa is around 625 million, constituting a little under 10 % of the total population worldwide. In 25 years time, Africa, with around 1.3 billion people, will contribute 15 % towards the world population. There is no sign that the continent's economy is growing as fast. On the other hand, contraceptive prevalence across the continent is around 10%. The unmet need for family planning is quite high at 26 % (Rosen and Conly 1998). The vast majority of the women with unmet need live in rural areas.

What can be done in order to face this enormous challenge? How can family planning programs reach the people who are outside the urban centers?

1. Stronger commitment by Governments. Only such commitment will enable the continent to address the issue of rapid population growth and give the population program legitimacy. In Africa, governments only have the necessary resources (financial, human and material), to make a difference. Governments' commitment should go beyond policy declarations and start to play a proactive role to make services available and increase the use of family planning.

   Government support to family planning programs can be in the form of increasing access to services to rural areas, pre-service and in-service training in family planning, encouraging the private and NGO sectors to get involved in the provision of family planning services, providing financial and tax incentives for those who are involved in such programs and launching and/or supporting information and education programs that reach all sectors of the population. In addition, governments should reduce their engagement from expensive curative services in urban centers in favor of the private sector so that they can focus their attention and resources to providing preventive and primary health care to the rural population.

2. Outreach programs: Outreach programs are appropriate for rural Africa because they are culturally acceptable as they involve the community in the design and implementation of the programs. They are also cost effective because they do not require a huge medical set up. As shown in a Ghanaian experience, '..a simple community health agent equipped with a motorbike and a packet of essential drugs provides more services than an entire level B clinic for a fraction of the cost' (Nazzar and Phillips 1995). Kenya and Zimbabwe have the most developed CBD programs. In Zimbabwe, over 20 % of modern FP clients are served by CBD agents; and in Mali, the government has introduced CBD in almost 2000 villages with significant impact on the overall contraceptive prevalence.

   CBD (and other outreach) programs have also succeeded in reducing the gap between the contraceptive prevalence in urban and rural areas in Africa. In the beginning, the use of contraceptives was limited only to major towns. Now, these services are reaching a relatively significant number of people in the rural areas. As shown in Table III, there is still a significant gap in contraceptive use between urban and rural areas. However, this gap becomes smaller in countries where the contraceptive prevalence is high. For example, while the urban-rural ration in contraceptive use is over 4.5 in Uganda, Niger and Mali where the overall CPR is under 5 %, the ration is around 1.5 in Botswana, Kenya, Mauritius and Zimbabwe where the CPR is over 30 %. This indicates that after the initial introductory period, invariably in the urban centers, the relative increase in contraceptive use is higher in rural areas than urban areas, and this can be attributed mainly to outreach programs.

   For a CBD program to be successful, it has to be supported and managed by the community. In many rural areas in Africa, community leaders play an important role in influencing the attitudes of their fellow residents. Their support to any community program is therefore critical. CBD programs should also have strong referral systems for clinical methods including long term and permanent contraceptives.

   Box 1 New Approaches to Rural Outreach in Northern Ghana An innovative project in Ghana is demonstrating that it is possible to increase acceptance of family planning even in conservative rural areas of Africa. The Community Health and Family Planning project began in 1994 and is managed by the Navrongo Health Research Center. Operating in rural district where family planning use has traditionally been extremely low, the project upgraded health clinics and trained government community health nurses (CHNs) and village volunteers to provide contraceptive services and other basic health care. Rather than waiting for clients to come to them in the clinics, CHNs now make scheduled visits on their motorcycles to every family compound in the villages they serve. Nurses provide basic preventive health care, including family planning counselling and supplies of oral contraceptives, condoms, injectables and foam tablets. Full community participation is assured through continuous involvement by chiefs, elders, soothsayers and others with influence over reproductive decision-making. The project also uses traditional channels of leadership, communication and participation, such as village meetings and social groups. The investment in understanding the cultural setting and the comprehensive approach to community outreach appears to be paying off. When the project began, just 2 of 900 women in pilot villages were using modern contraceptives; after one year, 255 women became contraceptive users. (Rosen and Conly 1998)

3. Social Marketing of Contraceptives (SMC): SMC has made tremendous progress in Africa in the last few years, not only in increasing contraceptive distribution but also in reaching areas that are not accessible through government or other NGO health programs.

   SMC employs strategies that could benefit many similar programs. Such strategies include an aggressive and high profile marketing (one such strategy had a social marketing product aired on television in more than twenty African countries during the African Nations Football tournament), an excellent logistics system, information and education campaigns that take many forms and shapes, coordinating with other government and non government programs, and, whenever possible, working with local authorities to obtain their support and participation in the promotion of the social marketing program.

   In Ethiopia, the SMC program enjoys the full support of the government and obtains a substantial amount of its contraceptives from the government's warehouse. In many Southern African countries, sales of condoms through SMC has reached an impressive level because of its integration in the national HIV/AIDS program. The people who benefit from the SMC program in Africa are both rural and urban. However, for many rural areas, it has become the only source of contraception.

   Box 2 The Family Planning Options Project (FAMPOP) - Guinea This project involves private sector social marketing, integration of family planning services into primary health care clinics, and policy and institution building. The project has also actively cultivated the support of Islamic religious leaders through a series of seminars. Not only have the leaders removed barriers to cultural acceptance of family planning and AIDS prevention, they have used their positions actively to educate their congregations. Before Population Services International arrive in Guinea, fewer than 200,000 condoms per year were distributed nation-wide, and the contraceptive prevalence rate was less than 2%. In 1995, FAMPOP social marketed over 2.8 million condoms and contributed over 60% of the country's total contraceptive prevalence. (Population Services International 1996)

4. Men's Participation: It is a widely held belief that African men, especially in the rural areas, are opposed to family planning. And at the surface of it, it appears that they are. In reality, however, the situation is complex.
   

   Family planning services in Africa are built around maternal and child health programs, which means they cater almost exclusively to women. Family planning information and services are designed and implemented with women in mind. Yet, men do have their own reproductive health problems and concerns. They would like to get information and services in a culturally appropriate environment. In the absence of such information, it is difficult for them to understand and support family planning activities. In few places where men have been involved either in the program design and/or implementation, they have shown support to the program. In fact, in some places men tend to show stronger support for family planning than women. In Burkina Faso, for example, over 80% of men interviewed were interested in getting information about family planning. In North-West Cameroon, a program that had the support and participation of community leaders (all of them men) was able to increase the use of contraceptives in the community(Population Council 1998). In a survey conducted in four countries (Burundi, Ghana, Kenya and Mali), more than three quarter of the men approved of family planning except in Mali where the level of support was lower (36 %; Population Council 1998).

   It is clear, therefore, that family planning programs, if designed to address the reproductive health needs of African men, can have their support. This will have an important impact on the overall program because of the role men play in the reproductive decision of their families.

   Box 3 Ethiopian Husbands As in most sub-Saharan cultures, men in Ethiopia tend to dominate a couple's decision about family size and whether to use contraception. A study in Addis Ababa suggests that involving husbands in family planning education significantly influences a couple's decision on whether to begin using contraceptives. More than 500 married women who were not using any modern method agreed to home visits by a two-member family planning educational team. About half of the women received this counselling alone, while the education for others was given to both husband and wife. After one year, contraceptive use was nearly double among couples who received husband-wife counselling (33%), compared with use among couples in which women were counselled alone, without their husbands (17%). (Family Health International 1998)

5. Women's empowerment: In countries where women have access to modern education and employment, they tend to marry at a later age and have fewer children. "There is mutual synergy between educating girls and expanding reproductive health services. When mothers use family planning, their daughters are less likely to stay home from school to help care for younger siblings and help with house work. If teenage girls have access to good family life education and reproductive health services, they are less likely to get pregnant and drop out of school. When women are educated, they can more easily insist that their partners use condoms" (Rosen and Conly 1998). In Africa, fewer girls than boys have access to education and even fewer have employment opportunities. In general, the minority of girls who are able to attend school live in the urban centers, while rural women's access to education is extremely limited. In the urban centers, access to education and gainful employment has contributed, more than any other factor, to the high prevalence of contraceptive. Unfortunately rural women, who are the vast majority of those who are in reproductive age, do not have access to such opportunity. As a result, and as indicated earlier, rural girls in Africa marry very young and have more children than their urban counterparts. A comprehensive approach to a successful population program should therefore include universal access to modern education and gainful employment.

6. Youth programs: One major reason which impedes the accessibility of family planning services in Africa is the attitude of service providers towards adolescents' sexuality. It is clear that more and more men and women engage in sexual relations at increasingly younger ages. It is also clear that, due to lack of access to proper family planning counselling and services, young women are exposed to premature and unwanted pregnancy and, as a result, to unsafe abortion. Many service providers in Africa refuse to serve adolescents or make it extremely difficult for them to get family planning services. Also, the stigma attached to pre-marital sex, especially in rural Africa, makes it difficult for adolescents to admit their sexual practices and be seen to be using a family planning method. The situation of adolescents is dramatic. For example, in Kenya more than 50 % of those between 12 and 19 years of age are sexually active. In Malawi, 65 % of girls aged 15-19 are either pregnant or mothers. School drop-out as a result of pregnancy is quite common in many African countries. Young women are often forced to drastic measures, including seeking unsafe and illegal abortion. In Senegal, for example, it was found that more than 12 % of teenage students have abortion each year (Population Council 1998). In one secondary school in Nigeria, over 30 % of the students had had abortions. Nearly a million babies are born to adolescent mothers every year in Nigeria (Sai 1994). A sustained campaign needs to be undertaken to improve this situation and create a more favorable environment where adolescents can have access to reproductive education and services. There are some concrete measures that could be taken immediately in order to improve the situation. These include family life education for in and out of school adolescents, peer-based outreach programs, professional training and better employment perspective for the youths and family planning information and services exclusively for adolescents. Parents and teachers need to understand that sexuality education for school-aged children does not increase their sexual activities. To the contrary, it helps them to make informed decision about their sexuality.

   Box 4 Reaching Special Groups in Ethiopia In a country where, because of strong cultural taboos, parents rarely discuss issues related to sexuality with their children, the youth project of the Family Guidance Association of Ethiopia (FGAE) has made great strides in increasing awareness of reproductive health among adolescents in Addis Ababa. FGAE's youth center provides one-on-one counselling, sexual health education sessions, and family planning services for teenagers. From the outset, the program obtained the commitment of key community leaders and government members, gained the trust of youth and their parents and built on this trust to encourage responsible sexual behavior among young people. The program was sensitive to the particular needs of youth, and consulted with young people regularly to ensure that the program developed at a pace set by the youth themselves. In just four years, the program was able to serve 7,000 young people with condoms, initiated programs in 10 city schools and reached over 100,000 people through drama performances. (PRB 1994)

In conclusion, Africa has come a long way in making family planning services accessible to the population. But a lot more needs to be done, and only African Governments can make it happen. Of course, they will need the collaboration of the private and NGO sectors and the international community. Nevertheless, until they assume the leadership in the expansion and management of family planning programs, we should not expect significant results. How African governments respond to this challenge will determine the path that the continent will follow in its development endeavor.

Part 2: Meeting reproductive health needs of rural people in sub-Saharan Africa: an overlooked part of the agenda?

Family planning is frequently portrayed as one of the success stories of development. According to current estimates, over half of all couples in developing countries are presently using some form of contraception, whereas less than 10 per cent were doing so 30 years ago. Consequently, the average size of households has dropped, the wellbeing of women and their families has generally improved, and the rate of population increase is slowing down in most areas of the developing world. Many would agree that this change could not have been achieved without reproductive health programmes, even if their contribution is difficult to quantify given the multitude of interacting factors at play.

However, in spite of all the progress made, there is still a long way to go before a wide choice of family planning methods is available to all. There are still hundreds of millions of couples, mainly in developing countries, who wish to plan their families but have limited access to information or quality services. Therefore, there is an urgent need to critically evaluate the performance of different reproductive health programmes in concrete settings and explicitly assess the trade-offs of various formal approaches.

Sahlu Haile's paper (Part 1) synthesizes past experience with the delivery of reproductive health services in the countries of sub-Saharan Africa and makes a number of important recommendations about how to better meet the needs of African women and men. The paper is based on the author's extensive experience in the field and thus represents the view of a highly qualified family planning specialist. Like much of the mainstream family planning literature, however, it looks at the topic primarily from the perspective of national populations and pays rather limited attention to population subgroups. The immediate purpose of this concluding remark is to extend Haile's paper by focusing on the relevance of existing reproductive health strategies to rural inhabitants. Its broader aim is to stimulate discussion about how to intensify, improve and accelerate reproductive health efforts in Africa.

1. The issue

   It is increasingly recognized that to make reproductive health services accessible to every segment of society, general national policies have to be translated into programmes that suit the needs of different population subgroups. Yet those living in underprivileged circumstances - such as in rural communities - are all too often overlooked while others decide what is best for them, or simply ignore them on the basis of cost-effectiveness criteria.

   The relatively low level of family planning use in rural settings is a problem for a vast majority of reproductive health initiatives in sub-Saharan Africa. Why is this so? The critical factors behind the generally low levels of family planning use in rural Africa include:

   • seclusion from main centers of development
   • lower population density
   • poorer infrastructure, fewer services
   • greater distances to travel to reach those services
   • generally lower levels of education, higher levels of poverty
   • social and economic organization dependent on the local pattern of agricultural production, thus quite different from that in towns
   • cultural norms constraining the acceptability of modern family planning methods. (Arguably, this is a grossly simplified account. In reality, the circumstances rural communities live in can be very diverse, making generalization difficult.)

   Do reproductive health programmes in Africa adequately reflect the specific socio-cultural characteristics of rural populations? On the whole, the answer seems to be 'no'. The majority of presently applied reproductive health strategies tend to be clinic-based, physician-oriented and urban-centered; they concentrate on supplying information and services in ways which are known to work in urban settings. In addition, these strategies are typically highly technical and quite costly, thus draining national health budgets.

   As a consequence, rural people are in principle disadvantaged, although to a different extent depending on circumstances. Some sections of the rural population - people living reasonably 'close' to urban centers, whether physically or socially - can still be reached through urban-based strategies of reproductive health service delivery. But for those who live in more isolated areas, such approaches may not be very relevant. In addition to geographic inaccessibility, the provision of reproductive health services in remote areas is often hampered by demographic, socio-cultural, economic or historical factors unique to these settings (Simmons and Phillips 1987, Hardee and Yount 1999, Lucas and Jhamba 1999). On the other hand, evidence exists that certain service delivery approaches can have a significant impact on family planning use in rural areas, but the more general causal basis for this impact remains poorly understood (Phillips et al. 1999).

   It should be pointed out that such an 'urban bias' is detectable not only in reproductive health strategies but also in many other policies and programmes applied in African countries, as can be illustrated through a number of examples. For instance, at the First Sub-Regional Conference on HIV/AIDS and Agriculture in West and Central Africa held in Ghana in November 1999, it was observed that many governments still tend to regard the HIV/AIDS epidemic as an urban issue and leave rural areas much to themselves as far as AIDS control and mitigation efforts are concerned (Rugalema 1999). Like policy-makers, demographers and other research scientists are also inclined to neglect rural issues. Take for example the Third African Population Conference that took place in South Africa in December 1999 (UAPS 1999). Of the more than one hundred papers presented at this Conference, the vast majority did not even tackle the question of rural-urban disparities although available evidence clearly demonstrates that the demographic and socio-economic contrasts between rural and urban areas are vast and increasing in a number of African countries. Thus, one may conclude that the failure to pay sufficient attention to the specifics of rural people is a systemic problem, not just a shortcoming peculiar to reproductive health initiatives.

2. Some challenging questions

   In view of the above, several fundamental questions about reproductive health programmes can be posed:

   • Why the 'urban bias'? To what extent is it due to donors and funds available, and/or national priorities and concerns?

   • What can be done to redress the rural-urban imbalances in policies and programmes?
   • What general lessons can be learned from programmes that proved to be successful in rural areas? Are successful programmes transferable from area to area, from country to country?
   • What are the elements of the urban-based approach that make it problematic or even meaningless for rural inhabitants?
   • To what extent can the reproductive health needs of rural people be met relying primarily on urban-centered strategies?
   • Can urban-centered strategies be realistically expected to increase the use of family planning services in rural areas, including the remote ones, to reduce fertility levels significantly?
   • If urban-centered approaches are not enough to significantly reduce fertility of rural women, what alternative or complementary strategies (which may not necessarily be reproductive health related) could be applied with the presently available know-how and resources?

   Of course, providing answers to these questions is far from easy, and perhaps we will have to openly admit that there are no feasible solutions with the kind of knowledge, resources and funding environment presently available to bridge the urban-rural gap in family planning use through the provision of reproductive health services. This, however, does not make the above questions any less relevant. Or do we just have to accept for the years to come the rural-urban differences in reproductive health?

3. Epilogue As most African countries continue to be predominantly rural, family planning behaviour of rural inhabitants has serious implications for national reproductive health indicators and the magnitude as well as sustainability of fertility declines at the country level. Thus, reproductive health needs of rural Africans should not be overlooked; doing so would be discriminatory and also short-sighted. Those in charge of reproductive health programmes do have a responsibility to rural areas, whatever the constraints they are subject to. To correct the existing rural-urban imbalances, policy-makers and service providers need to be more active in assessing the relative merits of different service delivery approaches and developing effective strategies to specifically address the needs of rural inhabitants. Family planning efforts in sub-Saharan Africa may be successful in bringing fertility levels down - and, consequently, in enhancing reproductive health, reducing poverty, improving food security and nutrition, and making the use of natural resources more sustainable - but only if they take into account the problems and opportunities faced by rural people. There is no one model for delivery of reproductive health services and it is therefore necessary to look at what type of service is appropriate in a given socio-cultural context. Decentralizing services, encouraging cooperation between reproductive health workers and other specialists at the local level, including rural representatives in the policy-making process, intensifying the search for innovative solutions that recognize the differing needs of different rural settings - all that could lead to better national reproductive health policies and programmes. The questions posed in this concluding remark may serve as a basis for future discussions on reproductive health strategies for rural communities.

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Family Health International, 1998a: Men and Reproductive Health. Family Health International, In Network.

Family Health International, 1998b. Improving Service Quality. Family Health International, In Network.

Futures Group International, 1996: The commercial Sector in Family Planning: Preliminary Results. Futures Group International, Washington.

Hardee, K. and K. M. Yount, 1999: From rhetoric to reality: delivering reproductive health promises through integrated services. Family Health International, Research Triangle Park, N.C. Retrieved at http://resevoir.fhi.org/en/wsp/wspubs/rhetor.html.

International Planned Parenthood Federation, 1990: Family Planning for Life: Experiences and Challenges for the 1990s. International Planned Parenthood Federation, London.

Janowitz, B., Measham, D. and West C., 1999: Issues in the Financing of Family Planning Services in Sub-Saharan Africa. Family Health International, Research Triangle Park, N.C.

Lucas, D. and T. Jhamba, 1999: Provincial views of the African fertility transition. In: Proceedings of the Third African Population Conference: The African Population in the 21st Century (Durban, 6-10 December 1999), Union for African Population Studies, Dakar, pp. 49-63.

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Table 1: Unmet need for contraception in sub-Saharan African countries

Country	Unmet Need for Family Planning	Contraceptive Prevalence
Zimbabwe	15	48
Central African Rep	16	13
Niger	19	4
Nigeria	22	5
Cameron	22	16
Namibia	22	29
Mali	23	7
Tanzania	24	15
Burundi	25	9
Benin	25	15
Botswana	26	33
Eritrea	28	8
Uganda	29	14
Senegal	29	7
Zambia	31	16
Madagascar	32	16
Burkina Faso	32	8
Liberia	32	7
Ghana	32	20
Comoros	34	21
Kenya	35	33
Malawi	35	21
Rwanda	38	21
Togo	40	12
Côte d'Ivoire	44	11
Sub-Saharan Africa	26	18

Source: Rosen and Conly 1998.

Table 2: Government family planning expenditures, by country

Table 3: National, rural, and urban contraceptive prevalence in selected sub Saharan countries