U.S. financial support for overseas family planning and reproductive health programs peaked a decade ago at just over $600 million. The ramped-up U.S. commitment—$542 million through the efforts of the U.S. Agency for International Development (USAID) plus a $35 million contribution to the United Nations Population Fund (UNFPA)—came on the eve of the United Nations-sponsored International Conference on Population and Development (ICPD) in Cairo. At that landmark conference, 180 country's governments endorsed the integral role of population stabilization in worldwide development efforts, and its centrality to both women's rights and meeting people's sexual and reproductive health needs. Donor and recipient countries alike pledged to further increase their financial contributions over a 20-year timeline toward achieving the goals of the Cairo Program of Action.
Just two months after Cairo, however, the 1994 U.S. mid-term election put socially conservative Republicans in charge of both houses of Congress. Blocked by President Clinton in their attempts to reimpose the antiabortion, Reagan-era "Mexico City" global gag rule policy, they retaliated by slashing U.S. funding for international family planning assistance by a third. Upon taking office in 2001, President Bush reimposed the global gag rule and, a year later, cut off all U.S. support for UNFPA. Although funding through USAID has edged up—reaching a total of about $460 million in FY 2004—it remains far below its FY 1995 high-water mark.
The attacks on U.S. reproductive health programs are driven by the belief that promoting voluntary family planning services and subsidizing organizations such as those affiliated with the International Planned Parenthood Federation are tantamount to an official U.S. policy promoting abortion. It is not surprising that family planning advocates have focused their defense of these activities on the essential need for expanding access to voluntary and high-quality contraceptive services as a key strategy for reducing abortion, for which there is a clear and convincing case ("Contraceptive Use is Key to Reducing Abortion Worldwide," TGR, October 2003, page 7).
But the case for investing in sexual and reproductive health goes far beyond that. A recently released report by The Alan Guttmacher Institute (AGI) and UNFPA suggests that the United States and other donor countries cannot afford not to expand their financial commitment to the three key goals of sexual and reproductive health: preventing unintended pregnancy; improving maternal health; and preventing, diagnosing and treating sexually transmitted infections (STIs), including HIV/AIDS. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care brings together new data to demonstrate that the return on investments would be huge—and not just in terms of unintended pregnancies and abortions averted and lives of mothers and infants saved. It points out that the nonmedical costs of sexual and reproductive "ill health" are dramatic as well: A mistimed or unwanted birth, for example, can drastically limit a woman's life options and undermine family well-being, thus seriously hampering social and economic development. In that sense, the true impact of sexual and reproductive ill health has gone largely unrecognized, and the full benefits of services to prevent such ill health have been vastly undervalued.
The Need for Services and Their Benefits
Adding It Up outlines a new way of assessing the costs and benefits of investing in the three major areas of sexual and reproductive health: contraceptive services and supplies to help prevent unintended pregnancies; maternal health services;* and the prevention, diagnosis and treatment of STIs. As policymakers at all levels consider their funding priorities in health and development programs, this new report is intended to help them take into account the medical, social and economic benefits of sexual and reproductive health interventions. Not all of the many and varied benefits outlined in the report are quantified as of yet, and some may not be quantifiable; however, all are indisputably valuable to individuals, their families and society.
Burden of Disease
The value of these services is so high because the problem is so large. Worldwide, pregnancy-related conditions and STIs account for one-third of the global burden of disease among women of reproductive age (15-44) and one-fifth among the total population. Among women aged 15-44, 13% of the global disease burden is attributable to maternal conditions such as hemorrhage, infection or unsafe abortion, and 14% to HIV/AIDS. The toll in healthy years of life lost attributable to all these conditions has increased over the last decade, largely because of the escalation in HIV/AIDS (see chart).
|HIV/AIDS has become a major contributor to sexual and reproductive health–related deaths and disability worldwide.|
Note: DALYs = disability-adjusted life years. Source: Singh S, et al., Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care, New York: The Alan Guttmacher Institute and the United Nations Population Fund, 2004, page 30.
Not surprising, people in developing countries are disproportionately affected. In Sub-Saharan Africa, for example, two-thirds of the disease burden for women of reproductive age is attributable to sexual and reproductive health problems. Just as the greatest burden of sexual and reproductive ill health falls on the world's poorest women and men, they would gain the most from increasing attention to and investment in sexual and reproductive health care. Indeed, most benefits would accrue to women, children and families living in developing countries where the average per capita income is less than $745. Viewing the situation only from a medical perspective, AGI and UNFPA calculate that 250 million years of productive life are lost each year to death or disability resulting from poor sexual and reproductive health.
The medical benefits alone of contraceptive and maternal health services and services related to STIs comprise a lengthy and compelling list. This includes the prevention of high-risk pregnancies, unsafe abortion and its complications, obstetric complications, cancers of the reproductive system and deaths to AIDS. These services also contribute to improved nutrition for women and their children, decreased risk of anemia and infertility for women, and increased survival rates and better health for infants.
Beyond a medical perspective, however, the social and economic implications are often overlooked, even though they are no less real. Women who can successfully delay a first birth and plan the subsequent timing and spacing of their children are more likely than others to enter or stay in school and to have more opportunities for employment and for full social or political participation in their community. Improved maternal health means fewer orphans and more time for and greater ability of mothers to care for and nurture their children. Fewer STIs means reduced infertility and the stigma associated with it and with HIV/AIDS. Moreover, at a societal level, the services to support these goals contribute significantly to a range of broader development goals, such as improving the status of women, contributing to economic growth and reducing poverty and inequality.
Adding It Up analyzes the broader costs and benefits of all three key areas of sexual and reproductive health, expanding the most on contraceptive services as a case example. The report makes use of the available data to illustrate an innovative way of measuring outcomes more comprehensively—one that more closely reflects the reasons that individuals use these services, that their families support their use and that communities and societies consider them a good investment (see box).
From ICPD to the Millennium Development Goals
The Cairo Program of Action laid out a 20-year plan, establishing clear goals to be reached by 2015 and at interim points along the way. Nations have agreed to meet important benchmarks in four key areas: reproductive health care and meeting the unmet need for contraception; maternal mortality reduction; HIV/AIDS prevention; and promotion of education and literacy. To do so, they agreed to increase their collective financial commitment to the array of sexual and reproductive health services described in Adding It Up to $22 billion by 2015, with developing countries meeting two-thirds of the cost themselves.
Halfway through the ICPD timeline, however, global funding priorities have begun to shift in other directions even though much remains to be done toward meeting the goals of the Cairo conference. By 2000, the gap between what had been promised just a few years earlier and what was delivered already began to widen. Clearly, developing countries still consider sexual and reproductive health services a priority for their own people, as measured by the fact that they have come much closer to contributing their financial share to the ICPD goals than have donor nations. (In 2000, donor countries and agencies provided about $2.6 billion for sexual and reproductive health services in developing countries—less than half of what they had promised in Cairo for that year; see chart, page 8).
|Funding Falls Short|
|Developing countries themselves contribute the most to sexual and reproductive health services and come closer to meeting their commitments than outside donors.|
*Includes government and multinational agencies. Includes individuals, nongovernmental organizations and government agencies. Source: Singh S, et al., Adding It Up, page 7.
The United States has been and continues to be the single largest donor to contraceptive and directly related services overseas; however, if economy size is taken into account, many smaller countries such as Denmark, Norway, Sweden and the Netherlands far exceed the United States in meeting their Cairo commitments. Very recently, the United States finally began a rapid escalation in funding to prevent and treat global HIV/AIDS. Holding essentially constant the funding levels for contraceptive, maternal health care and STI (other than HIV) services, however, is likely to undermine the critical synergies among these interventions. Together, those synergies work more efficiently and effectively to improve human health and prevent death, disease and disability.
In 2000, world leaders turned their attention to the United Nations-sponsored Millennium Summit, which brought them together for the purpose of making sustainable development and the elimination of poverty a global priority. The Millennium Development Goals (MDGs) emerged in 2002, growing out of the Summit and the many international conferences occurring during the previous decade, including the ICPD. The MDGs represent a common framework for assessing progress on the larger development agenda.
Many donor countries (although not the United States, so far) have been conforming their own overseas development assistance to the MDGs. Because the MDGs do not identify sexual and reproductive health as a specific goal, there is great concern that some donors—both governments and philanthropic entities—may perceive that it is no longer a worldwide priority. Indeed, although attaining sexual and reproductive health is not an MDG in and of itself, Adding It Up makes clear that virtually none of the MDGs can be achieved without enhanced access to services that improve sexual and reproductive health (see box).
Between apathy on the part of some European donors and the ongoing ideological battles in the United States, investment in sexual and reproductive health is suffering. And so are the women and men—especially in developing countries—who rely on these essential services not just to preserve their health but to improve their lives. The HIV/AIDS epidemic can be turned back, maternal deaths can be prevented and women can be helped to balance work and family by being able to plan the timing and spacing of their children if increased investments are made now. The savings for individuals, families and societies will add up for years to come.
MILLENNIUM DEVELOPMENT GOALS
Improved sexual and reproductive health directly underpins goals 3–8 and indirectly affects the achievement of goals 1 and 2.
1. "Eradicate extreme poverty and hunger"
2. "Achieve universal primary education"
3. "Promote gender equality and empower women"
4. "Reduce child mortality"
5. "Improve maternal health"
6. "Combat HIV/AIDS, malaria and other diseases"
7. "Ensure environmental sustainability"
8. "Develop a global partnership for development"
Source: Excerpted from Singh S, et al., Adding It Up, page 6.
Altogether, donor and recipient countries, as well as individuals, are spending more than $7 billion dollars annually—including labor, overhead, capital and contraceptive supplies—so that 500 million women in the developing world who do not wish to become pregnant are able to prevent:
- 187 million unintended pregnancies,
- 60 million unplanned births,
- 105 million induced abortions,
- 2.7 million infant deaths,
- 215,000 pregnancy-related deaths (including 79,000 related to unsafe abortions); and,
- 685,000 children from losing their mothers from pregnancy-related causes
Moreover, investing in contraceptive services is highly cost-effective. In its 1993 Disease Control Priorities report, The World Bank found that in a typical low-fertility Latin American country, each dollar spent on family planning saved the government $12 in health and education costs alone. Clearly, these estimates support what common sense would suggest: that it is always more cost-effective and beneficial to invest in preventive measures now than to pay for the costs of inaction later.
Because pregnancy—the condition that contraceptive use prevents—is not a disease, many of the direct benefits of contraceptive use are often discounted. Yet, in preventing so many maternal and infant deaths and disabilities, universal access to high-quality services would substantially reduce the global disease burden. A year of healthy life in a developing country can be saved for a global investment of a mere $144 in these services, and this spending brings a number of other social and economic benefits as well.
Preventing unplanned pregnancy is only one benefit of using and creating a system for the delivery of contraceptive services. Condom use, for example, also protects against STIs, including HIV/AIDS. Health screening for cervical cancer or STIs during a contraceptive visit can expedite diagnosis and treatment of these conditions. Contraceptive clinics often are a first entry point into the health system for many women, providing a link for other primary health, prenatal and emergency obstetric care.
Pregnancy prevention is an ongoing process, of course, not a one-time event. The financial commitment, therefore, also must be ongoing. Just maintaining the current level of world commitment, however, leaves more than 200 million women with an unmet need for contraceptive services—women at risk of unintended pregnancy because they do not want to have any more children or do not want to have a child soon but use no method of contraception or use a traditional method with a high failure rate, such as withdrawal. The added cost of meeting the needs of these additional women would be another $3.9 billion worldwide per year; however the benefit would be 23 million fewer unplanned births (72% below the current level) and 22 million fewer induced abortions (a 64% reduction).
*Includes prenatal care, obstetric services, postpartum care, treatment of complications of unsafe abortion, postabortion family planning counseling and safe abortion (where consistent with national law).
The global burden of disease is measured in disability-adjusted life years (DALYs), which represent years lost as a result of premature death and healthy years of life lost to disability.
This article is adapted from the AGI and UNFPA report, <i>Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care.</i> The research for that report was supported by a grant from UNFPA. The views expressed in that report and this article, however, are those of the authors and AGI.