Viewpoint www.thelancet.com Vol 380 July 14, 2012 181 Lancet 2012; 380: 181–85 Published Online July 10, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)60782-X Department of Public Administration and Policy, School of Public Affairs, American University, Washington, DC, USA (J Shiffman PhD, K Quissell MPH) Correspondence to: Dr Jeremy Shiffman, School of Public Affairs, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8070, USA jshiffma@american.edu Family planning: a political issue Jeremy Shiffman, Kathryn Quissell After a decade of stagnation, support for family planning might be gaining momentum. Between 1998 and 2009, donor financing for family planning languished (rising only from US$722·8 million to $748·0 million and reaching a low of $393·5 million in 2006), even though total donor funding for global health nearly tripled. 1,2 Decreases in fertility and increases in prevalence of contraceptive use in several countries stalled. 3 However, since the late 2000s, the Gates Foundation, the UK, and other donors have augmented funding, 4–6 and several low-income countries have renewed their efforts to support family planning programmes. 7,8 Papers in The Lancet Series on Family Planning 9–13 provide several good reasons why family planning deserves support, including to address the unmet need of an estimated 215 million women 14 who would like to limit or space births but who are not using contra- ception. However, prospects for rekindling attention will depend on more than good arguments and evidence on benefits such as averting maternal mortality. Organised family planning, like many global health initiatives, 15 is a political issue with both support and opposition, with consequences for how programmes have been designed and undertaken. 7,16,17 For example, state-sponsored initiatives have faced objections from the Catholic Church on the ethics of fertility control and suspicion from minority groups over the aims of fertility reduction. Additionally, initiatives have sparked debates among proponents over what their primary aims should be: slowing population growth—which we term an ecological rationale because of the concern for the aggregate effects on society of individual behaviour—or the rationale of advancing women’s rights and health. The most recent surge in support for family planning could provoke similar objections and debates. In this Viewpoint, we discuss past and present political debates surrounding organised family plan- ning. We highlight three levels of politics: (1) national— discussions within low-income countries about the value and appropriate role of governments in provision of family planning; (2) global—deliberation surround- ing the proper role of donors and experts from high- income countries; and (3) internal—debates among the core proponents of family planning, including demographers and women’s health advocates, on why and which services should be made available. We propose that at each of these levels some political trends bode well for the future provision of family planning services whereas others do not, but that ignoring potential disagreement is counter productive: to sustain momentum, proponents of family planning will need to anticipate and appreciate objections and prepare strategies to address these. National politics Many countries adopted public and private family planning programmes between 1960 and 1990. Some provoked political reactions, including religious objections, revealing disagreements over the appropriate roles of governments and civil society organisations in the provision of these services. After independence in 1980, Zimbabwe gained recognition for its effective family planning programme; however, initially, African nationalists took a hostile position to family planning, arguing that it was part of a conspiracy to control the black population. 18 In the 1990s, the Indian Government abandoned numerical targets for new contraceptive acceptors partly in response to pressure from women’s groups. 19 This decision followed several decades of suspicion surrounding the national family planning programme—a legacy of an effort by the Indira Gandhi regime to sterilise men for population objectives, which in 1977 resulted in the fall of her government. 20 In Kenya, probirth tribal politics and religious concerns shaped opposition to government efforts to slow population growth in the 1960s and 1970s. 7 In Rwanda, in the wake of the 1994 genocide, there was political resistance to family planning; the government, responding to latent demand by Rwandan women for voluntary family planning, surmounted objections in the 2000s by making a convincing case that the provision of these services would facilitate poverty alleviation. 8 In each of these cases, groups have struggled over competing ideas of the role of contraception in society, influenced by both national and global politics. 21 Global politics Donors and experts from high-income countries have influenced adoption of national policy. From the end of World War 2 until the 1980s, bilateral and multilateral donors, foundations, and population experts in the USA and Europe identified a potential problem in rapid popu- lation growth and encouraged the governments of low- income countries to create family planning programmes to lower fertility. 22 The US Government, concerned that rapid population growth in low-income countries might lead to political instability, 23 contributed well over 50% of the global funds for population and family planning programmes from the late 1960s until the late 1990s. 24 Because of global influence and national policy decisions, by 1994 most low-income countries outside sub-Saharan Africa had adopted voluntary family planning pro- grammes. 24 The perceived value of slowing population growth has also gained acceptance, as by 2009 nearly all of the governments of the lowest income countries regarded their rates of population growth as too high— evidence of the spread of an acceptance of the value of slowing population growth. 25