The trip comes at the end of a year in which Gates, co-chair of the Bill & Melinda Gates Foundation, not only worked hard at promoting family planning and its benefits, but also put this topic back on the global agenda and helped secure pledges for $2.6-billion in funding for the cause.
Last week, the Mail & Guardian spoke with Gates to find out why family planning is so important, particularly in developing countries such as Malawi, where an estimated 3 000 women die during or shortly after pregnancy each year, and about some of the practical steps that can be taken to ensure that women who want to use contraception have access to it.
Why is family planning now so important for the foundation, which is better known for its work around vaccination?
We still focus hugely on HIV, tuberculosis; you’re hearing a big push with Bill being the strong voice on polio. Always on our agenda had been family planning. If you look at the history of the foundation – when Bill and I started – we actually started with vaccines and with family planning. There were some internal reasons why we got away from family planning for a while but it’s always been important to us and this felt like the right year to really move forward with family planning.
Also, this is the year we wanted to make sure family planning got back on the global health agenda, and it felt like the right time to do it … that’s why you see me speaking out on it much more. I’ve been very involved in maternal and child work for quite some time with the foundation, and as I travelled around this issue just kept coming up over and over again from women.
You often speak about putting women at the centre of family planning issues. What does this mean for you?
It means making sure women are both educated about contraceptives and making sure they have access to contraceptives. But this means more than just the contraceptives: it means girls can stay in school – hopefully all the way through secondary school – so that at the other end they have a different trajectory for economic output for themselves and their family.
Why is family planning so important, particularly for a country like Malawi?
One of the things we know from some long-term longitudinal studies that happened in Bangladesh, is that families who use family planning end up healthier and wealthier over the long term.
In Malawi, one of the great things going is that the [family planning] idea is already there. When you get up to 42% modern contraceptive use, to push it up to 60% honestly in some ways shouldn’t be that hard.
It’s one of the reasons why I was so enthused about coming to Malawi. One of the first times I met President Joyce Banda was in Washington DC, almost five years ago at the Women Deliver Summit, I was so impressed by what she had done by focusing on child mortality.
If it has such obvious benefits, why is access to contraception such a controversial issue in parts of the world?
That’s hard to answer by country. It’s still controversial in my country, which it shouldn’t be. In each country you have to look at what their religious issues are and what constraints have been placed on women, for example: do they or don’t they have power?
Part of the issue frankly is just education and supply. Once a woman knows that it’s not just God’s will, that she can do something about [her reproductive life], and gets educated about what her options are … it can take hold pretty quickly. And that’s why you’re starting to see contraceptives change a lot in places like Ethiopia, Senegal and Nigeria.
You spoke of supply as one of the things that keeps women from accessing contraception. Supply chain management is a very real and practical barrier to providing access to family planning. What sort of interventions can be made to get this one thing right?
I think part of the huge issue is we haven’t focused on family planning as a world. That’s why the family planning summit was so important, and because of that you have all these problems all the way down the chain.
If we focus on the supply chain issues like we’ve done with antiretrovirals (ARV), I think we can totally solve this. But we’ve got to decide that it’s important and we’ve got to put it in the clinics in the right way.
The clinics that I visited in Lilongwe already had good HIV or antiretroviral therapy (ART) services and now they’re putting in the family planning component. It’s a model for the country.
They’re doing all the right things. They’re not only making sure that they have the supply of contraceptives, but they’re doing something to integrate the services, by having a checklist and asking women who visit the clinic whether they have been asked about family planning. “Do you know about family planning, do you want contraceptives?”
In Senegal there’s a model where they’re combining the public and the private sector. So the public sector does all the family planning, in a holistic clinic. They have a checklist, they ask women all over the clinic, at any point they come into the clinic, about family planning, they get them over for family planning but they use the private sector to supply the channel of contraceptives.
The private sector does a push model where they fully stock the clinic and they come every 15 days. They get a report by cell phone ahead of time, telling them whether they need more Depo-Provera [birth control shot] or more IUDs.
Malawi’s maternal death rate is among the highest in the world. Some of this stems from the young age at which many Malawian women have their children. There’s a growing lobby in Malawi to raise the age of marriage from 16 to 18 years. Why is raising the legal age for marriage important?
It’s important for women and girls all over the world. There are still 10-million child brides across Africa; and those are the girls who often have very little power in their relationship to negotiate to use contraceptives.
It’s incredibly important because it has all kinds of ramifications for a young girl who has a baby too soon. Her chances of dying or ending up with fistula are incredibly high.
But even if the age of marriage is raised to 18 or higher, in a country like Malawi, which is very poor and dependent on agriculture, what is there for women afterwards? What can women do to empower themselves in other ways?
I’ve travelled just outside of Lilongwe, to visit the villages in 2009, and when you do community empowerment in the village, it’s the health worker and a lot of the community [members] going out to do dramatisations to elucidate the issue in the village and let the villagers realise themselves what’s going on.
In one of the dramatisations I saw a healthcare worker ask: ‘”Why is it that women are dying in childbirth in the village?” The villagers started to elucidate the problem themselves and said, “We don’t take them to the clinics”. Then we asked them, “Why don’t you take them to the clinics?” And they started to map out what the problems were: in the rainy season they didn’t have a bridge to get across, or they didn’t have transport money, or the men wouldn’t allow it because women don’t have power.
That’s when you start to get to the real [picture]: it’s because we’re not allowing girls to stay in school. If they don’t stay in school they don’t have economic means, if they don’t have economic means, they don’t have power in their village.
All of those things have to happen with empowerment at the village level and it often means on-going discussion between a community health worker, helping the village to come together to map themselves and then come together once a week to talk about the issues in the village. It has profound implications in places around the world. It really changes things for women.
Health workers can provide services but changing the mindsets of men is very tricky. How do you get men and women to relate in a different way so you don’t have cases where a woman can’t get access to contraceptives because her husband doesn’t allow her to?
At the Lighthouse Clinic in Lilongwe, I was speaking to women about the role of their husbands and it comes up over and over again that the husband doesn’t want the wife to use family planning.
You have to work at the issue from both angles, from the top and the bottom. Working with the youth is great because you’re getting them to talk about sexual empowerment at a younger age and you’re getting the girls and the boys to talk about it together but you also have to work at the issue from the top down.
President Banda wants us to meet with the chiefs. You’ve got to work from both sides so the chiefs then are also are saying to the villagers, how do we create economic empowerment? That means leaving our girls in school for longer. How do we keep our girls in school longer? You actually need to have family planning services even for the youth so that they don’t get married early and drop out of school, and then girls don’t have the chance to do secondary school and have economic means. So you work at both ends of the system.
Again, you have to understand the context of the country.
We were in Niger this summer and in Niger the power structure is held by the imams. So we talked with them, and that network is just starting to help us get the message out because they need to give the messages out.
They can help us in Niger, along with these husband schools that have being created in Niger, so the women start to understand through the men. If you don’t get through to the men in Niger, we won’t reach the women for quite a while.
In every country, you have to understand the context of who holds the power at the village level and at various levels of hierarchy.
With countries that are very aid-dependent, projects that are funded by donor organisations often collapse when that funding dries up. How do you build sustainability into a project so that it continues after that funding ends?
That’s why it’s so important to work with the government upfront.
Another thing is to have realistic goals for countries, to say what’s actually achievable in a country. We now have this large sum of money $2.6-billion with realistic plans by 2020 to get to 120-million new women but the plans are built from the bottom up.
Since the London Family Planning Summit there are six countries that have very specific plans that they’re rolling out now. Each of those plans has a component in it that says, what happens after 2020? Where does the government start to plan for itself in its health budget?
One of the things the governments have to plan for is, as we drive more demand for family planning it will create more demand as well. The other piece that needs to happen between now and 2020, which the foundation and others will be involved in is to drive the prices of contraceptives of down.
By having this $2.6-billion we can now purchase in bulk and already we’ve got a couple of agreements with pharmaceutical companies to bring down the prices of the implants and Depo-Provera.
You’ve known Joyce Banda for some time now, and she’s only become president this year. What are your hopes for Banda’s presidency?
One of the things about Joyce Banda is that she’s a bold leader; she’s not afraid to do things that are unpopular sometimes and she’s already said that she wants to also focus on family planning. The fact that she decided not to have Sudanese President Omar al-Bashir at the AU meeting, and that meant not having the AU meeting here was a bold move by a brand new leader.
I think Joyce is willing to stand up and do some things that are hard to do. She has believed in women for a long time and she knows the power of women for her own country.
[This conversation has been edited for clarity, brevity and grammar.]