Volume 25, Supplement, January 1999

Paying for Reproductive Health Care:
What Is Needed, and What Is Available?

By Malcolm Potts, Julia Walsh, Jana McAninch, Nobuko Mizoguchi and Timothy J. Wade

Context: The 1994 International Conference on Population and Development (ICPD) established goals for the expansion of reproductive health services and estimated the funding that would be required from the international community and national governments to meet those objectives.

Methods: Available data are examined to determine the extent to which funding has met the ICPD estimates of resources needed.

Results: Annual global spending on family planning as of the mid-1990s was less than half the $17 billion that the ICPD estimated will be required in the year 2000. International lending has grown, but support from international donors has not increased to fill the gap; when adjusted for inflation, domestic spending in many countries has fallen. Funding for the prevention of sexually transmitted diseases also falls far short of the projected need. Some 4–17% of government health expenditures in developing countries are committed to maternal health. However, since many women lack even the most basic reproductive health services, the ICPD projections likely underestimate the resource requirements.

Conclusions: Funding for reproductive health services falls substantially below ICPD goals. Consumer spending may be able to fill part of the shortfall, but other strategies for meeting the goals will be needed that do not adversely affect demand or social justice. Priorities will have to be carefully set if available resources are to be used as cost-effectively and equitably as possible.

International Family Planning Perspectives, 1999, 25(Supplement):S10–S16

In a vivid and compelling way, the International Conference on Population and Development (ICPD), held in Cairo in 1994, drew the attention of the international community and of national governments to the need for improved reproductive health care, particularly in low-income countries. The ICPD Programme of Action recommends "that comprehensive and factual information and a full range of reproductive health care services, including family planning, [should be] accessible, affordable and convenient to all users" (para. 7.5a). It also states: "All countries should take steps to meet the family planning needs of their populations as soon as possible and should, in all cases by the year 2015, seek to provide universal access to a full range of safe and reliable family planning methods and to related reproductive health services which are not against the law"(para. 7.16).1

In the ICPD framework, reproductive health services are divided into three major components: family planning; prevention of sexually transmitted diseases (STDs), including HIV and AIDS; and basic reproductive health services (other services needed to reduce maternal mortality--e.g., safe motherhood programs, abortion-related services, reproductive health education and communication, STD diagnosis and treatment, and infertility prevention and treatment). The Programme of Action also includes estimates of the resources needed for a research, data and policy analysis component, focused on developing demographic and policy-relevant data.2

According to ICPD projections, reproductive health costs in developing countries will likely total $17 billion in the year 2000 and $21.7 billion in 2015 (Table 1). Developing countries are expected to meet approximately two-thirds of the aggregate costs, and international donors one-third, although considerable variation is anticipated, depending on the needs of particular countries.3

Table 1. Annual estimated reproductive health costs (in billions of U.S.$) for developing countries, by funding source and type of cost, according to year
Source and cost 2000 2005 2010 2015
Total $17.00 $18.50 $20.50 $21.70
International donors 5.70 6.17 6.83 7.23
Developing country govts. 11.30 12.33 13.67 14.47
Type of cost
Family planning 10.20 11.50 12.60 13.80
STD prevention 1.30 1.40 1.50 1.50
Basic reproductive health 5.00 5.40 5.70 6.10
Research, data, policy analysis 0.50 0.20 0.70 0.30
Sources: references 1 and 5.

The purpose of this article is not to answer the question of how to pay for reproductive health care in developing countries, but to set out the need for analyzing budgets and costs, critique the data available and identify work that needs to be done.

Why and What We Need to Know
Data on the cost of providing improved reproductive health care and estimates of the budgets available to the field are important for two reasons. First, valid financial figures can assist in closing the gap between what is needed and what is available. Decision-makers who are committed to the Cairo agenda can strengthen their arguments only by having facts that provide an overall sense of proportion and demonstrate what could be achieved with more money. Second, an assessment of costs and resources helps set priorities. It is tragically apparent that there is no way the whole ICPD reproductive health agenda can be implemented in the short term. Therefore, we need to know how much we can afford and where today's limited resources should be focused.

Data are needed to track cash flows and expenditures earmarked for reproductive health and family planning by governments and donors in the international community. Trends have to be identified, any potential change in the level or sources of support analyzed and levels of cost recovery from consumers explored.

Estimates are needed of the costs of all aspects of reproductive health. Existing data on how much developing country governments expend on reproductive health are seriously deficient, partly because government clinics and health centers are often multipurpose, and it is difficult to isolate costs of one type of service (e.g., STD treatment). In addition, government financial data on a given facility may be recorded under a variety of categories (e.g., personnel costs, capital building costs and central commodity purchases). Data on domestic private-sector spending are even more difficult to obtain.

Virtually no data exist on what people might pay for reproductive health care other than family planning services. Citizens in low-income countries often spend more from their own pockets on health care than their governments do on their behalf. Individuals pay approximately 50% of total health care costs in the Philippines, 55% in Egypt and 75% in Colombia and India.4

It is possible to rank family planning methods and delivery systems with respect to cost and cost-effectiveness.* In conjunction with such rankings, an assessment of resources also helps identify where additional research is likely to be productive.

While additional data on the cost of providing family planning services would be useful, the area of greatest immediate concern for reproductive health is the paucity of information on the cost and cost-effectiveness of HIV prevention and, most specifically, of providing diagnostic and curative STD services. It is intrinsically more difficult to estimate the cost of averting an HIV infection than to assess the cost of averting a birth or reproductive tract infection, because the probability of transmitting the virus varies much more and is less well understood than is the probability of conception. Moreover, comparisons of the impact of education, STD prevention efforts and condom distribution are complex. Many poor people with an STD seek the help of local physicians or untrained practitioners, but there are no systematic data on what they pay for their treatment. Women, who suffer the worst consequences from reproductive tract infections, do not always have the most notable symptoms, and nothing is known about individuals' willingness to pay for treatment.

In most large developing countries, inadequate budgets restrict programs' ability to provide condoms and antibiotics, and to subsidize prices for low-income consumers; the result is limited supplies and high prices. Given the limitation on resources and the imperative to slow the spread of HIV, research needs to be conducted on the feasibility of treating STD infections "in the community."Can self-diagnosis play a role? What STD prevention strategies are most acceptable to the young and unmarried? Would "mass treatment"of commercial sex workers for STDs be clinically and financially effective? Do new therapies permit treatment of core groups in a way that would reduce the viral load sufficiently to essentially eliminate the infectiousness of HIV-positive individuals?

By contrast, additional studies on such topics as male attitudes toward condoms are likely to be less useful. Behaviors and attitudes are often deep-seated; change occurs by the diffusion of shared peer ideas and will take time.

Estimates of likely levels of cost recovery from consumers are still in their infancy. In the family planning field, social marketing research indicates that couples in developing countries are willing to pay about 1% of their disposable income to control their fertility; empirical data support this, as do some national experiments on the impact of externally imposed price changes on sales in subsidized social marketing programs in low-income settings.5 Yet, the resulting insights have been unevenly applied. Some groups still have ideological reasons for insisting that all contraceptives be made available free of charge, while others find themselves driven by necessity to look again at cost recovery strategies.

Global estimates of unmet need for contraception, numbers of condoms required, population growth rates and HIV spread enhance our knowledge, but most problems get tackled at the national level. Therefore, more information is needed at the national and local levels to improve planning. Data on external funding, local government expenditures and plausible estimates of cost recovery from consumers are required for selected countries, both to improve decision-making in these countries and to test and refine more global estimates. One or two examples from low- and middle-income countries are likely to be broadly representative of nations with a similar income.

Current Resources
Unfortunately, while total foreign aid budgets are sizable, only a small proportion of these funds are expended for health and family planning projects; for example, in 1994, only about 3% went to family planning activities.6 Furthermore, while total official development assistance to developing countries has remained essentially unchanged or declined since 1991, assistance for population-related activities has declined substantially. For example, the 1996 total of $55.1 billion in official development assistance was 4% lower than the 1995 level,7 but donor assistance for population (excluding World Bank loans) declined 18% ($250 million) between 1995 and 1996.8 With populations in developing countries growing, aid resources available to developing countries are declining.9

A review of the currently available financial data allows us to make some useful estimates regarding trends in financial resources used and progress made toward reaching ICPD goals, as well as to identify areas of overlap in resources for the different components of reproductive health. However, the availability and quality of data vary tremendously. In general, information on family planning support is the most abundant, followed by data on STD resources; safe motherhood financing data are the scarcest and most difficult to interpret. Official financial figures are generally not available beyond 1995, and data for 1993 and later are often incomplete or preliminary, because of reporting delays.

Family Planning and Population

  • External resources. The Organization for Economic Cooperation and Development (OECD), Population Action International and the United Nations Population Fund (UNFPA) closely follow trends in international funding for population activities. The UNFPA sends questionnaires annually to OECD country governments and other organizations. Reported figures have become more difficult to interpret since the Cairo conference, though, because in accordance with the ICPD definition of population activities, some donor countries, as well as the World Bank, now include other reproductive health projects in their figures for population assistance.

    These inconsistencies have made it particularly difficult to determine the current resources devoted to family planning programs. For instance, while World Bank lending for population and reproductive health activities has risen substantially in recent years (combined lending was $500 million in FY 1996, up from $340 million in 1993),10 family planning programs make up a shrinking proportion of the total allocations.11 In 1995 and 1996, new loan commitments for family planning activities alone declined to slightly more than $100 million a year, half the annual average in the early 1990s. Furthermore, few World Bank staff have technical skills in population and reproductive health: In 1993, of 360 staff in the human development sector, only 6% were population specialists.12

    UNFPA's 1996 Global Population Assistance Report will employ the broader ICPD definition for all countries.13 While this will be useful for monitoring future trends in donor assistance, it can make it difficult to assess progress toward reaching specific ICPD goals. It is imperative that donor countries and international agencies track spending on the individual components of reproductive health.

    Despite the problems with the data, it is clear that with only about one year remaining until 2000, the gap between the ICPD estimated resource needs from external donors and available resources is large, and donors have not increased support adequately to fill this gap (Figure 1).14 This trend in reductions or slow growth in contributions to UN organizations from donor countries since 1994 is likely to continue for the next few years. Loans from development banks have increased but fail to bridge this gap.

    Figure 1. Family planning and population expenditures from donor sources, and projected resource requirements, by year
    Millions of U.S.$
    Figure 1
    Notes: Missing years or sources indicate that data were not available. Data for 1995 (except USAID) are preliminary because of reporting delays. The international development bank figure for 1986 is a three-year average for World Bank lending. Private donor figures for 1990 and 1991 are estimates based on 1989–1993 trends; 1995 figures are preliminary. Source: reference 13.

    External sources traditionally have accounted for only an estimated 25% of global spending on family planning, and they have tended to be most important in the poorest countries. ICPD projections reasonably assumed that external sources will need to cover a growing portion of the total reproductive health costs, estimating the international share at 33%. Nevertheless, many developing countries are unlikely to be able to increase their expenditures at the pace necessary to meet the rapidly expanding needs. Furthermore, the impact of the economic crisis in Southeast Asia on national family planning and reproductive health expenditures remains to be seen.

    It is somewhat unclear where development bank loans should be considered in this estimate, but we have included World Bank loans as a part of external population assistance. However, even "soft" loans (i.e., those with low interest rates and flexible payback periods), which constitute the majority of this support, will need to be repaid if they are ever spent; therefore, they should not be given the same value as grants when assessing progress toward ICPD projections.

    The available data suggest, as the 1997 State of the World Population concludes, that "while many governments increased their allocations for population programs since 1994, annual global expenditures are still well below half the $17 billion the ICPD estimated will be required in 2000."15 Such a shortfall must have enormous consequences. The agenda set out at Cairo will need to be cut back and increasing emphasis given to supporting only the most cost-effective programs.

  • Domestic resources. Approximately three-quarters of all family planning expenditures have come from developing country governments and consumers.16 The ICPD projects that domestic expenditures will cover only about two-thirds of reproductive health costs by the year 2000, because of limited resources and rapidly rising demand. Even so, a substantial increase in domestic spending would be needed to meet the goals set in Cairo.

    In 1995, Population Action International published a comprehensive analysis of developing country expenditures on family planning.17 In the 79 countries studied (representing 91% of the population of the developing world), domestic government expenditures accounted for an average of 65% of total global spending, or $2 billion. This proportion varied widely by region, however, ranging from 22% in Sub-Saharan Africa to 88% in East and Southeast Asia. These estimates may not fully reflect the public-sector expenditures of developing country governments, as budgets often include only the incremental costs of family planning activities and not costs for services that are difficult to disaggregate from overall health budgets. National budget figures may also not account for programs supported by local or regional governments.18

    Despite the difficulty of tracking trends in developing country public spending on family planning, a rough comparison can be made for 37 countries for which data are available for the early 1980s and the early 1990s.19 Overall, spending rose from nearly $1.4 billion in 1980 to more than $1.9 billion in 1990. If China is excluded from this (nonrandom) sample of countries, the total increases by about 40% during the 10-year period, from $490 million to $700 million (Table 2). When the 1990 value (excluding China) is adjusted for inflation to 1980 dollars, however, the total ($442 million) represents a decline of about 10% in real dollar value. Twenty-one of these countries, including China, spent less on family planning in 1990 than in 1980, after adjustment for inflation.

    Table 2. Domestic spending on family planning (in millions of U.S.$), by country, according to year
    Country ca. 1980 ca. 1990
    ca. 1990
    Total $1,473.6 $1,916.7 $1,208.39
    (Excluding China) (486.2) (701.1) (442.03)
    Bangladesh 11.7 32.0 20.17
    Bolivia 0.016 1.5 0.95
    Brazil 1.38 22.0 13.87
    China 979.6 1,229.7 775.27
    Colombia 2.1 6.2 3.91
    Costa Rica 2.5 3.5 2.21
    Dominican Rep. 0.3 0.2 0.13
    Ecuador 4.47 0.1 0.06
    Egypt 11.2 8.9 5.61
    El Salvador 4.0 1.7 1.07
    Ghana 1.23 2.1 1.32
    Guinea 0.0 1.0 0.63
    Guatemala 5.5 0.5 0.32
    Hong Kong 1.3 2.7 1.70
    Honduras 0.42 1.2 0.76
    India 174.7 255.0 160.77
    Indonesia 50.0 160.6 101.25
    Iran 50.6 13.8 8.70
    Jamaica 1.39 2.3 1.45
    Jordan 0.0 0.5 0.32
    Kenya 3.77 0.8 0.50
    Malaysia 16.0 9.5 5.99
    Mauritius 0.78 1.6 1.01
    Mexico 48.4 65.0 40.98
    Morocco 8.0 8.3 5.23
    Nepal 4.1 2.2 1.39
    Pakistan 16.7 20.0 12.61
    Panama 2.6 0.2 0.13
    Peru 1.2 0.2 0.13
    Philippines 23.7 5.9 3.72
    Singapore 1.3 0.3 0.19
    South Korea 16.3 10.4 6.56
    Sri Lanka 1.24 11.0 6.93
    Taiwan 4.5 19.0 11.98
    Tanzania 1.1 0.6 0.38
    Thailand 11.0 23.3 14.69
    Tunisia 2.7 7.0 4.41
    *Adjusted to 1980 dollars, using U.S. consumer price indices. Source: reference 18.

    According to calculations using the midyear populations for 18 of these countries for which 1980 and 1990 age-specific population information is available, family planning spending totaled about $1.28 per woman aged 15–44 in 1980 and $0.97 (adjusted for inflation) in 1990.20 Although the calculations did not take into account increases in program efficiency and effectiveness, these figures are deeply disappointing, because not only is the number of fertile couples growing, but considerable potential for increasing contraceptive prevalence is going unfulfilled.

    The need for sustainable family planning programs in the face of perpetually insufficient resources has inspired a number of studies addressing the potential for cost recovery and expansion of the private-sector contribution in developing countries.21 Clearly, each country's and region's circumstances will determine the success of efforts to shift costs to the private sector or increase revenue in public and nongovernmental organization programs, such as through user fees. In general, though, efforts to expand private-sector funding (e.g., through private insurance coverage or employer-based programs) have met with limited success, and such a change will not alone close the resource gap for family planning.

    However, social marketing has proved very successful in a number of countries,22 and modest or sliding-scale fees are acceptable to many clients.23 Individual projects have demonstrated that some reproductive health services (e.g., abortion, ultrasound and Pap smears) can be profitable enough to subsidize other family planning services, as occurs in some clinics managed by Marie Stopes International.24 As donors increasingly focus on program sustainability in making funding decisions, more research is needed to determine the optimal means of tapping available resources within a given client community without adversely affecting demand or social justice. Nevertheless, the bottom line remains that hundreds of millions of couples are too poor to pay the full cost of family planning.

    Some data on consumer spending on family planning are available from national surveys, private-sector and social marketing contraceptive sales activities, and International Planned Parenthood Federation affiliates' records of client fee revenues. Estimates based on these sources for 79 countries showed consumer spending in the private sector totaling $427 million, or 14% of global spending on family planning.25 This total may underestimate consumer expenditures because, as the analysts note, the prices used reflected the low end of the scale. Additionally, they observe, there is wide variation among regions in the proportion of total spending that comes from private consumers--49% in Latin America, compared with only 5–7% in South and Southeast Asia.

    If the assumption that people will pay about 1% of their disposable income on family planning is correct,26 then this is a large potential resource. The potential market for commercial family planning services in developing countries has been estimated at 87 million users (assuming that all urban women with some education, plus some rural women and some urban women with no education, could buy from pharmacies);27 only 15 million married couples currently buy contraceptives from pharmacies. The ability to tap this potential financial resource depends on marketing and pricing policies, as well as the rational utilization of user fees in the public sector. Further research and experimentation are needed in this area.

    ICPD projections indicate that domestic sources of funding will need to reach almost $7 billion to achieve family planning goals for the year 2000. In terms of real dollars, only 10 of the 37 countries shown in Table 2 increased their family planning spending by 40% or more during the 1980s. Yet even if developing country governments increase spending by 40% between 1990 and 2000, and private consumer spending increases by 40–50%, total domestic spending on family planning still would reach only $4–4.5 billion by the year 2000.

    STD Prevention

  • External resources. Donor assistance for STD prevention is not monitored as closely as is support for family planning. No published summaries of development assistance provide detailed information about allocations of funds to STD programs or HIV and AIDS programs. Moreover, it is difficult to separate funding for HIV prevention, the component of particular interest for reproductive health goals, from support for AIDS care. In 1994, the Global Management Committee of the World Health Organization (WHO) Global Programme on AIDS developed a database to track international financing of HIV and AIDS programs; however, it is incomplete and has not been updated for several years.28 An updated analysis of global financing for STD programs is under way, and a preliminary report is anticipated by early 1999.29

    The most complete analysis of global HIV and AIDS financing is contained in AIDS in the World II. Results of an international survey that collected data on multilateral assistance from the WHO program and the European Union, in conjunction with information on domestic spending for national AIDS programs for prevention, care and research, revealed that 35% of HIV and AIDS expenditures in low-income countries go to prevention activities. This proportion is even lower for countries with transitional economies, such as Thailand.30

    An examination of data for the early 1990s illustrates that while overall international assistance for HIV prevention has grown, the increase has occurred only in the form of loans (Figure 2).31 Since the late 1980s, the World Bank has expanded loans for projects with HIV and AIDS components, and it is planning to support 18 additional projects over the next three years. In fact, international HIV and AIDS grants declined in constant dollars between 1991 and 1994. Moreover, figures for 1993 (the last year for which survey data were available) may significantly overestimate spending because of the inclusion of new multiyear grants.32 The inability to mobilize international funds to meet the rising resource needs for HIV and AIDS programs has been referred to as "donor fatigue syndrome."33

    Figure 2. HIV prevention funding and projected donor resource requirements, by year
    Millions of U.S.$
    Figure 2
    Note: Missing sources indicate that data were not available. Source: reference 31.

    While the shift in financing from government grants to development bank loans has appeal as an immediate source of much-needed funding, it also has obvious drawbacks. First, it is unclear what proportion of the loans allocated for HIV projects actually is spent, or is spent in useful ways. Developing country governments are generally reluctant to use loan money for recurrent expenses such as condoms and antibiotics, critical commodities for slowing the spread of HIV. Second, while these are soft loans, in the long term they may have adverse effects on reproductive health, as poor countries often must eventually cut spending on health and social programs to repay their debts.

  • Domestic resources. In roughly 1993, spending on HIV prevention in low-income countries amounted to $350 million. Of this total, approximately $90 million came from donor countries and $260 million derived largely from domestic sources.34

    Private consumer spending on HIV prevention (e.g., on antibiotics and condoms in pharmacies or on the street) probably represents a substantial proportion of expenditures in this area. Quantifying these expenditures on a country or global level, however, is exceedingly difficult. Classifying private expenditure as going to prevention (e.g., for antibiotics to treat STDs that facilitate HIV transmission) or to the care of AIDS-associated illnesses (e.g., treatment of concurrent infections) is probably impossible. Expenditures for condom social marketing programs have already been accounted for under family planning resources. What kind of cost recovery schemes may be appropriate in the arena of HIV prevention is an unanswered question.

    To meet the Cairo goals, developing countries will need to spend an estimated $870 million by the year 2000. While no data are available to assess trends in domestic spending for HIV prevention, the gap between 1993 expenditures ($260 million) and projected resource requirements is substantial and of concern.

    Basic Reproductive Health Services
    Efforts to determine financial resources for the third component of the ICPD Programme of Action are problematic for several reasons. First, there are no universally agreed-upon definitions of what activities are included in this area. Safe motherhood interventions are the largest part, but the ICPD definition also lists activities that overlap with other components (e.g., STD treatment). Second, even less information is available about what donors, developing country governments and individuals are spending. Expenditures for basic reproductive health care are often hidden in the budgets of projects not specifically defined as reproductive health projects, such as programs to reduce iron-deficiency anemia at the population level.

  • External resources. A 1990 World Bank working paper analyzed trends in international support for safe motherhood programs during the years immediately before and after the launching of the Safe Motherhood Initiative in 1987.35 The author surveyed OECD countries and international organizations such as UNFPA, UNICEF and WHO, and partitioned the funding into "core"and "inclusive"support. Core funding was assistance to family planning and specific maternal health projects. Inclusive funding was based on the estimated proportion of a project's activities likely to contribute to safe motherhood goals. For example, in primary health projects that include components to improve pregnant women's geographic access to services, 30–50% of activities--and, therefore, funds--are estimated to be directed at achieving that goal.

    The total external resources for safe motherhood projects increased from about $1.1 billion in 1986 to $1.3 billion in 1988. In 1988, $470 million of this went to family planning, leaving $830 million that presumably funded activities contained in the ICPD basic reproductive health component. Approximately $170 million of this went to core maternal health projects. The ICPD estimated requirements for the year 2000 for this component is $5 billion, of which $1.7 billion would need to come from external sources.

    An updated analysis of financing trends for this area is very much needed; however the 1990 paper demonstrates the substantial methodological difficulties in estimating funding for maternal health projects. Trends in funding from the U.S. Agency for International Development during the 1990s may serve as a rough guide: Between 1990 and 1995, the agency's support for maternal health and nutrition fluctuated between approximately $30 million and $70 million. In fact, 1995 spending returned to the 1990 level of around $30 million, demonstrating a lack of serious commitment to increasing resources for basic reproductive health services.36

  • Domestic resources. Again, domestic expenditures are even more difficult to track than is external donor spending. One analysis found that for countries where data were available, about 6% of all developing government health expenditures went to maternal and child health or family planning.37 However, a review of analyses of financial trends revealed that domestic government expenditures on maternal health might come to 4–17% of total developing country government expenditures on health: The Pan American Health Organization has estimated that 17% of national health expenditures in Latin America and the Caribbean go to maternal health care. A 1985 study conducted in Sri Lanka found that approximately 13% of the government's total health-sector expenditures went to maternal health care. A 1983 report on Malawi attributed about 4% of government health expenditures to "maternities"and "dispensary/maternities."38

    In 1990, developing country governments spent an estimated $81.7 billion on health;39 $3.3–13.9 billion went to maternal health care. A substantial proportion of these resources likely overlap with those for family planning, upon which developing country governments spent an estimated $2 billion annually during the early 1990s.

    Reliable data regarding private expenditures on basic reproductive health services are limited to one or two local studies. An analysis from Sri Lanka suggests that household health expenditures on safe motherhood activities equal government expenditures.40 Likewise, results of a regression analysis that estimated private spending in countries for which no data were available suggested that private expenditures on health care may be roughly equal to government spending in developing regions overall.41 Expenditures on safe motherhood, a costly aspect of reproductive health, undoubtedly place a heavy burden on the household budget for many poor women and their families.

    Doubling the 1990 estimates for public expenditures to account for private spending suggests that domestic sources provided $6.6–27.8 billion for safe motherhood activities, making it the most costly part of the basic reproductive health component. Unfortunately, the inexact definitions, as well as the scarcity of data, render even this broad estimate debatable. Furthermore, this estimate suggests that while many women continue to go without even the most basic services, developing country governments may already be spending substantially more for this component of reproductive health than the $5 billion that the ICPD projected (on the basis of several cost estimates for implementing Safe Motherhood Initiative interventions at primary health centers42) would be needed in the year 2000.

    Research, Data and Policy Analysis
    The smallest component of the ICPD Programme of Action was devoted to research, data and policy analysis; this component added $220–670 million per year between 2000 and 2015 to the projected resource requirements. From population project descriptions, spending on these types of activities generally appears to be included in estimates for family planning assistance.

    The Need for Speed
    Population growth and the spread of HIV will slow in response to immediate investments; conversely, they will accelerate and become more expensive to address when interventions are delayed. Although the rate of population growth has been falling for some years, and the absolute increase in worldwide population has peaked, the number of young people entering the reproductive years is at an all-time high and rising.43

    Failure to meet the needs of an expanding number of young people and to keep pace with a continued rise in contraceptive prevalence will add to long-term demographic momentum. The cost at the human level will be great. According to the WHO, an estimated 585,000 women die each year from causes related to pregnancy, childbirth and unsafe abortion, 80,000 more per year than was previously reported, and 99% of these deaths occur in developing countries.44

    The prevalence of HIV has been rising relentlessly in the general population. For example, in several cities of Sub-Saharan Africa and Southeast Asia, prevalence among pregnant women doubled or tripled in only three years. In some groups, such as sex workers, HIV prevalence rose as much as 40% in one year.45 Failure to invest in adequate levels of HIV prevention will be associated with continued exponential growth of this deadly disease and great suffering and increased costs down the road.

    Where Are We Going?
    Despite large holes in the data, it is apparent that as we approach five years after the ICPD, both external assistance and domestic spending are falling substantially short of the trajectories necessary to meet both the ICPD goals and the needs of developing countries. More data or analyses are needed in several key categories:

  • Ways of tracking the donor community need to be refined, and the results analyzed within 1–2 years, rather than 3–4.

  • National budgets need to be tracked and countries categorized as those where local inputs are likely to be sufficient and those where external support will remain a significant source of funding, and may even become more important.

  • The ICPD cost estimates need to be reanalyzed. Levels of cost recovery must be estimated through more careful analysis of existing data and well-designed field studies. Improved and more realistic analyses of the proportion of costs that may be recovered from the consumers of family planning and reproductive health are essential.

  • Much more information is needed on the cost of disease prevention (HIV prevention in particular and STD prevention and treatment in general), safe motherhood and the other aspects of reproductive health that do not involve family planning. Consistent methodologies need to be applied in estimating the costs of reproductive health programs. As Janowitz points out, "cost comparisons are problematic because of inconsistencies in the costing methods used in various studies."46

    Appropriate analyses of these areas will manifest even more clearly the large shortfalls. The wide gap between resources and needs will raise many important questions related to setting priorities, maintaining existing programs, launching new ones, and even structuring and staffing national and international implementing agencies.

    Recognizing the need for improved information on both international and domestic resources, UNFPA, in collaboration with the Netherlands Interdisciplinary Demographic Institute, has initiated the development of an improved system for collecting annual data on global resource flows for population and reproductive health activities. This database should greatly improve the tracking of funding.

    Good financial data should help lead to informed discussion of the priorities for allocating scarce resources: Do programs offer a range of reproductive health services for the few, or a limited package for the many? It is also hoped that better data on resources and costs will lead to long-term increases in resource availability, both by providing advocates for reproductive health, family planning and STD control with compelling arguments for increased funding and by suggesting innovative ways to increase the level of cost recovery and private spending.

    1. United Nations (UN), Report of the International Conference on Population and Development, Cairo: UN, 1994.

    2. Ibid.

    3. Ibid.

    4. Rannanoeliya RP and Berman P, National Health Accounts of Egypt 1995, Boston, MA, USA: Data for Decision Making Project, Harvard School of Public Health, 1995; and Berman PA, National health accounts in developing countries: appropriate methods and recent applications, Health Economics, 1997, 6(1):11–30.

    5. Lande RE and Geller JS, Paying for family planning, Populations Reports, 1991, Series J, No. 39.

    6. UN, Statistical Yearbook 1994, New York: UN, 1996.

    7. Organization for Economic Cooperation and Development, Aid and other financial flows in 1996, news release, <http://www.oecd.org/>, June 19, 1997.

    8. Speidel J, Speech to Pathfinder Fund board, Nov. 1997.

    9. Conly S, Rosen F and de Silva S, Washington Population Update: News and Analysis of U.S. and International Population Assistance, Washington, DC: Population Action International (PAI), 1997.

    10. Conly SR and Epp JE, Falling Short: The World Bank's Role in Population and Reproductive Health, Washington, DC: PAI, 1997.

    11. UN, 1994, op. cit. (see reference 1); and Conly SR, Chaya N and Helsing K, Family Planning Expenditures in 79 Countries: A Current Assessment, Washington, DC: PAI, 1995.

    12. Conly SR and Epp JE, 1997, op. cit. (see reference 10).

    13. United Nations Population Fund (UNFPA), Global Assistance Report, 1996, New York: UNFPA (forthcoming).

    14. UN, 1994, op. cit. (see reference 1); Conly SR and Rosen JE, International Population Assistance Update: Recent Trends in Donor Contributions, Washington, DC: PAI, 1996; U.S. Agency for International Development (USAID), Reproductive Health Programs Supported by USAID: A Progress Report on Implementing the Cairo Program of Action, Washington, DC: USAID, 1996; Conly SR and Speidel JJ, Global Population Assistance: A Report Card on the Major Donor Countries, Washington DC: PAI, 1993; Tinker A, Merrick T and Adeyi A, Improving reproductive health: the role of the World Bank, www.worlbank.org, May 1996; UNFPA, Flows of Financial Resources in International Assistance for Population, New York: UNFPA, 1997; and UNFPA, Background Note on the Resource Requirements for Population Programmes in the Years 2000–2015, New York: UNFPA, 1994.

    15. UNFPA, State of the World Population: Reproductive Rights and Reproductive Health, Washington, DC: UNFPA, 1997.

    16. Lande R and Geller J, 1991, op. cit. (see reference 5).

    17. Conly SR, Chaya N and Helsing K, 1995, op. cit. (see reference 11).

    18. Murray JCL, Govindaraj R and Chellaraj G, Global Domestic Expenditures on Health, Boston, MA, USA: Harvard Center for Population and Development, 1993.

    19. Speidel JJ, Cost implications of population stabilization, in Sirageldin I, Salkever D and Osborn R, eds., Evaluating Population Programs: International Experience with Cost-Effectiveness Analysis and Cost-Benefit Analysis, London: Croom, 1983; Conly SR, Chaya N and Helsing K, 1995, op. cit. (see reference 11); and Haddix A and Schaffer P, Time preference, in Haddix A et al., eds., Prevention Effectiveness: A Guide to Economic Evaluation, New York: Oxford University Press, 1996, pp. 80 and 186.

    20. McDevitt TM, World Population Profile: 1996, Washington, DC: U.S. Government Printing Office, 1996.

    21. UNFPA, Report on Family Planning Programme Sustainability, Technical Report, Washington, DC: UNFPA, 1995, No. 26.

    22. Carlson C, lecture on USAID population programs and efforts to expand the private sector in developing countries, 1997; and Lande RE and Geller JS, 1991, op. cit. (see reference 5).

    23. Lande RE and Geller JS, 1991, op. cit. (see reference 5).

    24. Ibid.; and McMahon A, Fort CJ and Gold E, Enterprise in Brazil: a strategic approach to private sector family planning, Enterprise Program, Arlington, VA, USA, 1990.

    25. Conly SR, Chaya N and Helsing K, 1995, op. cit. (see reference 11).

    26. Lande RE and Geller JS, 1991, op. cit. (see reference 5).

    27. Ibid.

    28. Laws M, International funding of the global AIDS strategy: official development assistance, in Mann J and Tarantola D, eds., AIDS in the World II, New York: Oxford University Press, 1996; and World Health Organization (WHO), Global Programme on AIDS: 1992–1993 Progress Report, Geneva: WHO, 1993.

    29. Laws M, 1996, op. cit. (see reference 28).

    30. Ibid.

    31. USAID, 1996, op. cit. (see reference 14); Laws M, 1996, op. cit. (see reference 28); WHO, 1993, op. cit. (see reference 28); and World Bank, World Development Report 1996, New York: Oxford University Press, 1997.

    32. Conly SR and Epp JE, 1997, op. cit. (see reference 10).

    33. Howard LM, Supporting Safe Motherhood: A Review of Financial Trends, Population and Human Resources Department Working Paper, Washington, DC: World Bank, 1990.

    34. Laws M, 1996, op. cit. (see reference 28); and Bromberg J and Schopper D, Global spending on HIV/AIDS prevention, care and research, in Mann J
    and Tarantola D, 1996, op. cit. (see reference 28).

    35. Howard LM, 1990, op. cit. (see reference 33).

    36. USAID, 1996, op. cit. (see reference 14).

    37. Murray CJL, Govindaraj R and Chellaraj G, 1993, op. cit. (see reference 18).

    38. Howard LM, 1990, op. cit. (see reference 33).

    39. Murray CJL, Govindaraj R and Chellaraj G, 1993, op. cit. (see reference 18).

    40. Howard LM, 1990, op. cit. (see reference 33).

    41. Murray CJL, Govindaraj R, Chellaraj G, 1993, op. cit. (see reference 18).

    42. UNFPA, 1994, op. cit. (see reference 14).

    43. McDevitt TM, 1996, op. cit. (see reference 20).

    44. Wallace HM, Girik K and Serrano CV, eds., Health Care of Women and Children in Developing Countries, second ed., Oakland, CA, USA: Third Party Publishing, 1995, p. 15.

    45. Mann J and Tarantola D, 1996, op. cit. (see reference 28).

    46. Janowitz B and Bratt JG, Costs of family planning services: a critique of the literature, International Family Planning Perspectives, 1992, 18(4):137–144.

    *Tubal ligation is usually more cost-effective over time than sponges, diaphragms, spermicides or female condoms. Social marketing is usually more cost-effective than clinic-based delivery of reversible methods. (Sources: Trussell J et al., The economic value of contraception: a comparison of 15 methods, American Journal of Public Health, 1995, 85(4):494–503; and Barberis M and Harvey PD, Costs of family planning programmes in fourteen developing countries by method of service delivery, Journal of Biosocial Science, 1997, 29(2):219–233.)

    Low-income countries are defined by the World Bank as those with a per capita gross national product of $725 or less in 1994; middle-income countries had a per capita gross national product of $725–8,956 in 1994. (Source: World Bank, World Development Report 1996, New York: Oxford University Press, 1997.)

    Malcolm Potts is a professor, Julia Walsh is an adjunct professor, and Nobuko Mizoguchi and Timothy J. Wade are graduate student researchers, all at the School of Public Health, University of California, Berkeley, CA, USA. Jana McAninch is a resident at the School of Medicine, University of California, San Francisco, CA, USA.

    © copyright 1999, The Alan Guttmacher Institute.

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