I found it quite interesting that the first issue of the journal with your new, more comprehensive name (Vol. 35, No. 1) contained an article that exemplifies the problems faced by continuing to view the various elements of sexual and reproductive health in distinct silos. John Bongaarts and Steven Sinding's "A Response to Critics of Family Planning Programs" (pp. 39–44) addresses several lingering and often harmful myths about family planning, refuting them all with solid evidence and sound arguments.
I take no issue here with their myths and facts, but I do find problematic the very premise underpinning the article, which is that funding for family planning programs "has declined by 30% since the mid-1990s." This assertion has been repeated in the advocacy community for years. I believe, however, that the unclear and unverifiable data on which the claim is made have led to dubious assertions regarding spending trends.
The Netherlands International Demographic Institute (NIDI) has worked with the United Nations Population Fund (UNFPA) since 1995 to collect and report on funding data from donor countries and foundations. Donors provide NIDI with information on their giving, which must be divided into four categories: family planning, reproductive health, STIs/HIV/AIDS and basic research. The results of these surveys are frequently utilized by advocacy organizations, and also served as the basis for the Speidel report that is cited by Bongaarts and Sinding.
The NIDI/UNFPA data indicate that, indeed, expenditures for family planning declined markedly between 1995 and 2005, both in total dollar figures and—largely due to the enormously increased funds for HIV/AIDS in the past decade—as a percentage of total population assistance. Indeed, in total dollars, family planning funding appears to have decreased from $723 million in 1995 to $501 million in 2005.1 But as a NIDI researcher admitted to me last year, "the ICPD categories don't work."
Not all donors provide detailed categorical allocations for their funds, leaving NIDI to estimate what proportion of funding to assign to each of the four categories. Furthermore, several important donors, including some private foundations that provide hundreds of millions of dollars for international family planning and other reproductive health programs, do not provide any data to NIDI, leaving the database incomplete.
Having responded to NIDI's survey on behalf of both the U.S. government and the foundation at which I now work, I know first-hand how challenging it is to allocate appropriate percentages to each of the four rather limiting categories. I also believe there is good reason for this difficulty. Namely, the 1994 International Conference on Population and Development (ICPD) warned donors away from vertical programs and instructed them to instead support comprehensive approaches to sexual and reproductive health. Many programs are therefore no longer designed or funded as "family planning" programs, as distinct from reproductive health or STI/HIV/ AIDS programs. Rather, with the exception of the U.S. Agency for International Development and a few large private foundations, which retain separate budget line items for family planning, maternal health, child survival and HIV/AIDS, most donors— government and private—support integrated programs, and therefore find it difficult to classify these categories distinctly. (This challenge has become even greater with the advent of new foreign aid modalities, such as sectorwide approaches and direct budget support, which have increased since the turn of the century.)
This may be the reason that, according to UNFPA and NIDI, funding for reproductive health actually increased fivefold between 1995 and 2005—from $237 million to $1.15 billion.1 It is likely also the reason that the UK, Sweden and Norway each reported giving zero dollars for family planning in 2005, even though they support family planning services under their broader maternal, sexual and reproductive health and rights programs.
UNFPA now recognizes that its data collection over the past decade may not have accurately captured all donor expenditures. In April 2009, it revised its estimates of the investments needed to achieve the goals of the ICPD Programme of Action and broke those investments down into the following categories: sexual and reproductive health, which includes family planning and maternal health; HIV/AIDS; and basic research, data collection and policy analysis.
This new categorization, based on the one originally adopted at the ICPD, will likely lead to more accurate data collection and reporting from donors in the future. In the meantime, advocates and scholars should exercise prudence when citing the earlier data.
The Summit Foundation
1. United Nations Population Fund (UNFPA), Financing the ICPD Programme of Action: Data for 2005; Estimates for 2007, New York: UNFPA, 2008.
Bongaarts and Sinding reply:
We agree with Suzanne Petroni that estimates of funding for various population assistance activities are subject to inaccuracies and error, mainly because a number of donors include family planning expenditures in their reproductive health budget lines. It therefore makes sense to combine the family planning and reproductive health categories as Petroni suggests and as UNFPA is apparently planning to do. But we do not believe that our statement about the decline in family planning assistance is incorrect or misleading. Here is why.
The 2009 report of the UN Secretary General to the Commission on Population and Development estimates that the proportions of population expenditures on family planning and on reproductive health both declined between 1995 and 2007 (from 55% to 5% and from 19% to 17%, respectively).1 We do not know exactly what proportion of reproductive health funding is actually spent on family planning; however, we can be sure it is not 100% because important non–family planning reproductive health activities, such as emergency obstetrical care and STI diagnosis and treatment, have been expanding rapidly. For present purposes, we assume that half of reproductive health funds support family planning services. This split implies that the actual (adjusted) proportion of funding for family planning declined from 64% to 13%. In constant dollars, this amounts to a reduction from $842 million to $718 million between 1995 and 2007. So we stand by our conclusion that investments in family planning have declined in both absolute and relative terms.
This is old news to program managers and researchers working at the field level. The combination of massive shifts in "population" funding to HIV/AIDS and inattention to family planning within the health budgets of many developing countries have led to a decline in the availability of both contraceptives and the information and services that support their delivery. UNFPA executive director Thoraya Obaid and other leaders in the field have decried the fall in attention to family planning and the adverse health consequences of high levels of unmet need and unwanted pregnancies that attend it. It is one thing to favor integrated and holistic approaches. It is quite another to ensure that they include all the vital services women need—including family planning.
Steven W. Sinding
1. United Nations Commission on Population and Development, World population monitoring, focusing on the contribution of the Programme of Action of the International Conference on Population and Development to the internationally agreed development goals, including the Millennium Development Goals, report of the Secretary-General, <http:// daccessdds.un.org/doc/UNDOC/GEN/N09/215/67/PDF/N0921567.pdf?OpenElement>, accessed Aug. 26, 2009.