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January 26, 2016

By Alyson Lipsky, HP+/RTI International

As countries around the world implement various forms of decentralization, I commonly hear reference to the assumed advantages of doing so—decentralization brings decision making closer to the people and results in greater opportunities for citizen participation. Many of my colleagues interested in family planning (FP) have a more specific hope: that decentralization will lead to improved FP results, mainly in the form of increased contraceptive prevalence rate. Unfortunately, I don’t think improved FP results are a foregone conclusion. A panel at the International Conference on Family Planning, “Fulfilling the Promise of Family Planning through Decentralization,” explored this theme a bit more.

Taylor Williamson, governance lead for Health Policy Plus, explained how decentralization changes political dynamics. In the Philippines, despite years of progress, decentralization precipitated a reduction in funding for family planning at both the local and national levels (most recently just a couple of weeks ago!), subjecting FP decisions to the strong and vibrant opposition found at local levels. On the other hand, Sam Mulyanga of Jhpiego presented evidence that devolution of Kenya’s health sector provided an opportunity to increase funding at the local level through concerted advocacy efforts. Loan Liem of Simavi and Inne Silviane of Yayasan Cipta Cara Padu Foundation talked about their own experiences at the community level, engaging citizens and district-level governments through citizen score cards and district working groups, thereby improving access and funding.

I appreciated the panel’s frank discussion of the many challenges associated with improving family planning in decentralized contexts: local governments may not support family planning, or even realize the commitments that have been made at the national level. Further, national governments may only be decentralizing for the sake of administrative efficiency, rather than increased community engagement. It takes careful planning and understanding of the political environment at national and subnational levels to ensure that FP goals are embedded locally, and deliberate effort to link global commitments with national policy and local programming.

Nongovernmental organizations, implementing partners, and civil society can take advantage of the opportunity that decentralization provides for greater citizen engagement. Civil society and individual citizens can be empowered to speak up for themselves and their communities through innovations like community score cards and district working groups. Fostering and encouraging government institutionalization of these and other mechanisms can ensure that communities have a sustainable voice in their countries’ FP policies and programs.

The panelists recognized that increasing FP use is often not a technical question—after all, FP methods and technologies are well-established—but, rather, a question of policy, planning, and governance. There’s no guarantee that decentralization will support FP goals. However, today’s panel showed that FP advocates and implementers can help ensure that FP commitments are realized at both national and subnational levels, by building strategies and implementing programs at each level of the health system based on how decentralization is being implemented.