How Senegal doubled modern contraception prevalence in just 8 years

Senegal has doubled its modern contraceptive prevalence rate since 2010 – an extraordinary turnaround for a country whose recorded contraceptive use rates were among the lowest in the world for many years. Between 2010 and 2018, the use of modern contraception among women of reproductive age in the country increased from 8.9% to 18.9%.

The increase in contraception usage has also supported the country's progress on a host of other important and related national health goals from improved child nutrition to historic reductions in both maternal mortality and under-five mortality. Senegal’s success in this area illustrates how family planning can support progress on a broad array of health goals and demonstrates that rapid improvement in modern contraception usage is possible even in a country with large numbers of rural and socially conservative communities.

New quantitative and qualitative research from Exemplars in Global Health and its partners, found that, like other low- and middle-income countries that have increased use of modern contraception, such as Malawi and Kenya, Senegal’s progress started with political commitment and increased financing. Also like other countries, Senegal earmarked funds to support family planning when donor funding declined. Malawi, Kenya and Senegal also expanded delivery mechanisms, including through community health workers. And all three countries broadly supported gender equality, including ending child marriage and promoting girls’ education. Senegal also used creative financing policy initiatives to increase access to family planning, including the Challenge Initiative, which helped mobilize matching funds for mayors and local authorities investing in family planning.

“The lessons Senegal offers health leaders include that you need political commitment, you need to include family planning in your budget, and you need to invest heavily in creating demand to overcome the significant barriers to family planning,” said Exemplars in Global Health research partner Sylvain Landry Birane Faye, an anthropologist of health.

But there are also unique elements to Senegal’s success story that may be instructive to health leaders. Faye continued, “Senegal’s health leaders studied barriers to family planning in the local context. They asked, ‘what does it mean to engage communities?’. And they tested and scaled different approaches to mobilizing people who were not health workers.”

Indeed, the country illustrates a multitude of effective pathways for supporting demand for and reducing taboos against family planning, including leveraging religious leaders, the media, respected matriarchs in communities, and husbands, among others. For example, health leaders in Senegal, a majority Muslim country in West Africa, invited religious leaders from all religions and doctrines to join a national conference to discuss family planning and share academic research on the harms women and children suffer from unplanned pregnancies.

Health leaders then asked Muslim scholars to examine and develop guidelines for family planning in the context of Islam. Their report, called 'A Declaration of Population Policy in Light of Islamic Teaching,' framed family planning in a way that was respectful of Islamic beliefs and practices and was shared with religious leaders across the country, including imams. It emphasized family planning as a tool for achieving healthy child spacing rather than limiting pregnancies. Religious leaders were invited to speak on the subject on television, on the radio, and from their pulpits.

Senegal’s health leaders also recognized the role of men in family planning decision making. Research in Senegal shows that husbands are involved in the decision to use contraception for 78% of women who use family planning. This prompted health leaders to expand their educational campaigns, which were historically targeted exclusively at women. In 2011, family planning awareness campaigns, including television, radio, and billboard ads, began to target men in addition to women. For example, the “Moytu Nef” campaign sought to educate both men and women about the poor health outcomes for mother and child when pregnancies are too close together.

Senegal also leveraged the Bajenu Gox initiative to educate women about spacing their children for their own and their children’s health – in the Wolof language Bajenu Gox means "neighborhood godmother" or "aunt of the neighborhood" and these women, often respected elder women or local leaders in their communities, act as health ambassadors to improve access to and the use of health services, particularly for women and children. Additionally, the Association of Midwives in Senegal were asked to ensure that the country’s midwives, who can today be found at every health post across the country, to join efforts to raise awareness about the benefits of child spacing and the availability of family planning. Mobile clinics were also tasked with educating and supporting the delivery of family planning.

But health leaders realized that creating demand alone was not enough. “The key slogan for health leaders in Senegal over the last decade has been ‘there is no program without the product,’” explained Faye. “That’s why Senegal invested for a decade in piloting, rigorously testing, and then rolling out longer lasting and more convenient family planning products, giving women a choice of products and innovating to reduce stock outs and make sure the product a woman wanted was available when and where she requested it.”

In 2014, for example, after years of testing, the health ministry began allowing frontline health workers to offer women contraceptive implants. Shortly thereafter, again after a rigorous pilot, the ministry approved self-injectable contraceptives. Likewise, the government piloted, adapted, and adopted an “informed push model” to reduce stock outs at public health facilities, where 85% of women access family planning.

“This was a game-changer,” said Dr. Marème Diallo, a senior research associate at the Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, who is based in Senegal and was not a part of the Exemplars in Global Health research. “This really served to make family planning products available everywhere in Senegal.”

Previously, surveys of facilities in the country had found stock outs of injectables 43% of the year and implant stock outs 83% of the year, on average. At least 60% of these facility-level stockouts occurred despite stock availability at the national level. To address this, Senegal was one of the first low and middle-income countries to shift its supply chain model for family planning from a “pull model” to an “informed push model.” So instead of each facility managing its stock, placing orders, and managing their delivery, a professional logistician at the national level managed stock and deliveries for all facilities. That logistician ensured that a delivery truck fully loaded with supplies made regular deliveries to all facilities.

And key to the success of this approach, explained Faye, was that the facilities were provided with the family planning products on credit and did not need to pay for the supplies until after they were sold. To make them more affordable, the government also launched a number of financing policy initiatives, such as eliminating import duties on family planning products and exempting contraception from most taxes.

This combination of government policies, community engagement, communications campaigns, women’s education, and improvement in access and availability of modern contraception methods, supported by broader cultural changes towards gender equality, helped Senegal achieve this remarkable success.

However, challenges remain, said Faye. Only a fraction of women who want to space their children are currently accessing modern family planning methods. Particularly disadvantaged are adolescents, who face significant and unique challenges to obtaining modern family planning. In response, the country has launched community conversations to help understand how young people can be better served by the health system and gain access to the modern family planning and reproductive health care they need.

“We can do better,” said Dr. Diallo. “We must listen to people’s needs. There are women who are using family planning who are unhappy with their experience because of side effects and other issues, such as not being able to get their implant removed because local health workers can put the implant in but not remove them. And there are women who are not yet using family planning but want to do so, such as adolescents. Senegal can continue to improve.”

Support from the private sector, such as funding health structures or facilitating access to contraception, could help the country build on its current momentum. Senegal’s goal has been to reach 46% contraceptive prevalence rate by 2025.

Editor's note: To learn more about the broad benefits of voluntary family planning for women and their families, visit Exemplars in Global Health.