1. Funds for Family Planning and Reproductive Health Presentation to the Third International Parliamentarian’s Conference on the Implementation of the ICPD Programme of Action J. Joseph Speidel, MD, MPH UCSF Bixby Center for Reproductive Health Research & Policy November 22, 2006

2. Outline This presentation will include a description of: Population and reproductive health issues Population and reproductive health issues Funding needs for population work in developing countries Funding needs for population work in developing countries Levels and sources of funds Levels and sources of funds Donor priorities Donor priorities Major donors Major donors Recommendations for action Recommendations for action

3. Population Growth: The Numbers YearWorldU.S. 1950 2.5 billion 158 million 2006 6.5 billion 300 million 2050(projected) 9.1 billion 420 million The combined population of Europe and North America is 1 billion.

4. Growth rates have declined, but growth of numbers remains high Year Average Births per Woman in World Annual Population Growth (millions) 19505.348 20062.776 Over 95% of growth is in developing countries.

5. Lack of access to and use of family planning is an important cause of population growth (Annual numbers in millions) World Pregnancies210 Unintended Pregnancies 80 Abortions46 Unplanned Births 34 Population Growth 76

6. What is reproductive health? The ICPD Definition is a broad concept: “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.”

7. Reproductive health services address: Routine and emergency childbirth services Routine and emergency childbirth services HIV/AIDS/STI prevention and care HIV/AIDS/STI prevention and care Breast, cervical, and uterine cancer Breast, cervical, and uterine cancer Safe abortion? Safe abortion? Comprehensive sexuality education? Comprehensive sexuality education? Infertility? Infertility? Harmful traditional practices? Harmful traditional practices? Breast feeding and infant health care? Breast feeding and infant health care? Post-menopausal care? Post-menopausal care? Male reproductive cancers and diseases? Male reproductive cancers and diseases?

8. Annual Deaths Related to Reproduction CauseNumbers AIDS 2.8 million Unsafe Childbirth 515,000 Breast Cancer 375,000 Cervical Cancer 300,000 Unsafe Abortion 78,000

9. ICPD Estimate of Funds Needed for Population Activities Original 1994 ICPD estimate of funding needs for 2005: Family planning: $11.5 billion Family planning: $11.5 billion Reproductive health: $5.4 billion Reproductive health: $5.4 billion HIV/AIDS: $1.4 billion HIV/AIDS: $1.4 billion Basic research and data collection: $0.2 billion Basic research and data collection: $0.2 billion Total in 2005: $18.5 billion (in 1993 dollars)

10. Source of Funds 1/3 of funds ($6.1 billion) from donors 1/3 of funds ($6.1 billion) from donors 2/3 ($12.4 billion) from domestic sources in developing countries 2/3 ($12.4 billion) from domestic sources in developing countries No estimates were made for the cost of other health and development activities included in the ICPD’s Programme of Action

11. Recent “Costing” Exercises Guttmacher/UNFPA Guttmacher/UNFPA UNAIDS UNAIDS UN Millennium Project UN Millennium Project Donor Landscape Analysis Donor Landscape Analysis

12. Guttmacher/UNFPA: Adding It Up $7.1 billion for family planning services in 2003 $7.1 billion for family planning services in 2003 $3.9 billion to meet unmet demand $3.9 billion to meet unmet demand Estimate includes: Estimate includes: Drugs and supplies Drugs and supplies Labor and hospitalization Labor and hospitalization Overhead and capital costs Overhead and capital costs Overhead/capital costs = 60-70% of total Overhead/capital costs = 60-70% of total

13. UNAIDS: Resource Needs 2006-2008 (USD billions) 200620072008 Total for 2006-2008 Prevention8.410.011.429.8 Treatment and care 3.04.05.312.3 Orphans/vulnerable children 1.62.12.76.4 Program costs 1.51.41.84.6 Human resources 0.40.60.91.9 Total14.918.122.155.1

14. UN Millennium Project: Public Choice, Private Decisions Component (USD billions) 200520102015 Basic RH/FP services 13.919.424.4 STD/HIV/AIDS services 4.19.711.1 Research/policy0.30.80.4 Total18.229.835.8

15. New Annual Funding Targets for 2005 (adjusted for inflation and program needs) Family planning: $15.6 billion (up from $11.5) Family planning: $15.6 billion (up from $11.5) Reproductive health: $15 billion (up from $5.4) Reproductive health: $15 billion (up from $5.4) HIV/AIDS: $14.9 billion (UNAIDS estimate for 2006 with 2/3 to be provided by donors; up from $1.4 billion) HIV/AIDS: $14.9 billion (UNAIDS estimate for 2006 with 2/3 to be provided by donors; up from $1.4 billion) Basic Research: $300 million (up from $200 million) Basic Research: $300 million (up from $200 million) Bottom line: An estimated $45.8 billion annually is needed for population activities; the original 1994 estimate was $18.5 billion (in 1993 dollars).

16. 2005 ICPD Funding Targets (in billions) 2005 Projected Expenditures Original Target (1993$) % of Target New Target Broadened* (2005$) % of Target Donor Share $6.1$6.1100%$20.230% Developing Country Share $14.9$12.4120%$25.658% Total$21.0$18.5114%$45.846% * The new target is broadened to include updated estimates for HIV/AIDS and reproductive health services Note: Donor share of the total is 1/3, except for the broadened target for HIV/AIDS, which is 2/3. Adapted from: Speidel JJ. Population Donor Landscape Analysis for Review of Packard Foundation International Grantmaking in Population, Sexual and Reproductive Health and Rights. Unpublished report 9/6/05: http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdf http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdf

18. Resource Flows for Population Activities Domestic expenditures in developing countries: Largest source of funds for population and AIDS Largest source of funds for population and AIDS 2005 projection: $14.9 billion 2005 projection: $14.9 billion More than half are out-of-pocket expenditures by consumers More than half are out-of-pocket expenditures by consumers 78% of all domestic funds from both governments and consumers are expended in Asia, 6% in Sub- Saharan Africa 78% of all domestic funds from both governments and consumers are expended in Asia, 6% in Sub- Saharan Africa

19. Population Assistance from Donors $3.2 billion in 2002 $3.2 billion in 2002 $4.7 billion in 2003 $4.7 billion in 2003 $5.6 billion in 2004 (preliminary) $5.6 billion in 2004 (preliminary) $4.5 billion from Development Assistance Committee (DAC) country governments $4.5 billion from Development Assistance Committee (DAC) country governments $588 million from development banks $588 million from development banks $434 million from NGOs and foundations $434 million from NGOs and foundations $6.1 billion in 2005 (projection) $6.1 billion in 2005 (projection) Increases are almost entirely for HIV/AIDS activities.

20. Changing Donor Priorities Funding explicitly for family planning decreased from a high of 55% in 1995 to 9% in 2004. Funding explicitly for family planning decreased from a high of 55% in 1995 to 9% in 2004. However, some family planning is now funded from the reproductive health category. However, some family planning is now funded from the reproductive health category. Funding for family planning decreased from $723 million in 1995 to $442 million in 2004. Funding for family planning decreased from $723 million in 1995 to $442 million in 2004. Funds for HIV/AIDS activities increased 13-fold to $2.65 billion by 2004. Funds for HIV/AIDS activities increased 13-fold to $2.65 billion by 2004.

21. Final Donor Expenditures for Population Assistance by Category Source: http://www.resourceflows.org/index.php/articles/text_item/225http://www.resourceflows.org/index.php/articles/text_item/225

22. 2005 ICPD Funding Targets for Donors (in billions) 2004 Donor Expenditures Estimated Original DonorTarget (1993$) % of Target Donor Target Adjusted for Inflation, HIV/AIDS & Repro-health* (2005$) % of Target Family Planning $0.442$3.812%$5.29% Repro- health $1.227$1.868%$5.025% STI/HIV/AIDS$2.649$0.5530%$9.927% Basic Research $0.589$0.1589%$0.1589% TOTAL $4.907$6.279%$20.224% * The new target is broadened to include updated estimates for HIV/AIDS and reproductive health services Adapted from: http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdf http://www.resourceflows.org/index.php/articles/275 http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdf http://www.resourceflows.org/index.php/articles/275

23. Bottom Line In spite of recent, large increases in funding for STD/HIV/AIDS, funds needed to address AIDS are inadequate. Funds for reproductive health, and especially for family planning, are not keeping up with the needs of an increasing number of couples of reproductive ages in developing countries—a projected increase from 1.6 to 2.1 billion between 2005 and 2050.

24. Additional Detail about the Donor Community Governments DAC members provide more than 80% of all population assistance, $4.5 billion in 2004. DAC members provide more than 80% of all population assistance, $4.5 billion in 2004. Denmark, Norway, the Netherlands, Luxemburg, Sweden, Finland, and the U.K. are relatively generous donors. Denmark, Norway, the Netherlands, Luxemburg, Sweden, Finland, and the U.K. are relatively generous donors. Japan, Germany, Italy, France, and many other donor countries are very far from providing their “fair share.” Japan, Germany, Italy, France, and many other donor countries are very far from providing their “fair share.” The U.K. and U.S. are generous donors for HIV/AIDS. The U.K. and U.S. are generous donors for HIV/AIDS.

25. Governments: The U.S. The U.S., at $1.8 billion, remained the largest donor in 2003, representing 48% of the resources of donor countries.

26. Problems with commitment and effectiveness The U.S.: Promotes abstinence Promotes abstinence Bans use of funds for abortion-related activities Bans use of funds for abortion-related activities Withholds funds from the UNFPA and IPPF Withholds funds from the UNFPA and IPPF Only 20% of HIV/AIDS funds can be used for prevention Only 20% of HIV/AIDS funds can be used for prevention 1/3 of prevention funds must promote abstinence 1/3 of prevention funds must promote abstinence

27. Problems with commitment and effectiveness Other DAC donors: Insufficient numbers of population experts to design, manage, and program population assistance Insufficient numbers of population experts to design, manage, and program population assistance Weak NGO sector to implement programs Weak NGO sector to implement programs Trend to sector wide—rather than program or project funding—makes it difficult to target funds on population issues, evaluate results, and make mid- course corrections Trend to sector wide—rather than program or project funding—makes it difficult to target funds on population issues, evaluate results, and make mid- course corrections

28. Development Banks Population growth seldom addressed as a development issue Not on research agenda Not on research agenda Rarely included in country-based Poverty Reduction Strategy Papers (PRSPs) Rarely included in country-based Poverty Reduction Strategy Papers (PRSPs) Lack of population experts on Bank staffs hampers program Lack of population experts on Bank staffs hampers program Bank commitment to Health Sector Reform and Sector Wide Approaches (SWAps) makes it difficult to program and track funding levels for population and reproductive health Bank commitment to Health Sector Reform and Sector Wide Approaches (SWAps) makes it difficult to program and track funding levels for population and reproductive health

29. UNFPA In 2005, UNFPA’s budget of $565 million supported work in 148 countries. Most countries received from $0.5-$3 million Most countries received from $0.5-$3 million Only 13 countries received more than $5 million Only 13 countries received more than $5 million Only India, Indonesia, and Peru received more than $10 million Only India, Indonesia, and Peru received more than $10 million

30. Bottom Line As the only organization providing technical assistance and funds to many countries, and the only organization acceptable in some countries for these purposes, UNFPA has a unique and important role.

31. Foundations Foundations, predominantly those based in the U.S., gave about $434 million in 2005 for population activities. Foundations, predominantly those based in the U.S., gave about $434 million in 2005 for population activities. 83% of funds were provided for international or global purposes. 83% of funds were provided for international or global purposes.

32. Bottom Line U.S. foundations are an important source of funds for a broad array of population work. With close to 80% of funds coming from only 6 foundations, this source of funding is vulnerable to a change in priorities on the part of just a few foundations.

33. Why Population Work Lost Salience Success of family planning and declining birth rates Success of family planning and declining birth rates U.N. projections of population growth ending about 2050 U.N. projections of population growth ending about 2050 Low fertility in most developed (and a few developing) countries Low fertility in most developed (and a few developing) countries The ICPD criticized past population work and advanced a less focused “new paradigm” of reproductive health The ICPD criticized past population work and advanced a less focused “new paradigm” of reproductive health The influence of vocal anti-abortion activists, conservative religious leaders, and conservative think tanks The influence of vocal anti-abortion activists, conservative religious leaders, and conservative think tanks The AIDS crisis suggest that population growth is less important The AIDS crisis suggest that population growth is less important The influx of funds for HIV/AIDS work has co-opted the personnel and attention of many NGOs and health ministries The influx of funds for HIV/AIDS work has co-opted the personnel and attention of many NGOs and health ministries “Donor fatigue” “Donor fatigue”

34. An Action Agenda: Recommendations for Parliamentarians Work to ensure that population and related reproductive health (RH) issues are considered important and integral to donor and national development strategies. Work to ensure that population and related reproductive health (RH) issues are considered important and integral to donor and national development strategies. Increase commitment and resources to family planning and other areas of population/RH work. Increase commitment and resources to family planning and other areas of population/RH work. Support sustained research and advocacy to ensure that the resource needs for population/RH work are realistic, recognized, and acted upon. Support sustained research and advocacy to ensure that the resource needs for population/RH work are realistic, recognized, and acted upon. Every country should have an organization carrying out research and advocacy. Every country should have an organization carrying out research and advocacy.

35. An Action Agenda: Recommendations for Parliamentarians Advocacy to strengthen population/RH work at the World Bank, regional development banks, and the UNFPA. Advocacy to strengthen population/RH work at the World Bank, regional development banks, and the UNFPA. Support research and pilot studies to develop practical ways of integrating family planning and reproductive health into STD/HIV/AIDS programs. Support research and pilot studies to develop practical ways of integrating family planning and reproductive health into STD/HIV/AIDS programs. Seek out and address critical factors that limit population/RH programs, such as: Seek out and address critical factors that limit population/RH programs, such as: Contraceptive supplies Contraceptive supplies The lack of a compelling body of research that would convince economists and development planners to address population issues The lack of a compelling body of research that would convince economists and development planners to address population issues Training of population experts. Training of population experts.