At the United Nations Millennium Development Goals summit in 2010, President Barack Obama joined other world leaders in pledging to substantially step up financial support for development assistance. His commitment arises not merely out of altruism or charity. In a global economy and interconnected world, alleviating poverty, improving health and fostering economic development in the world’s poorest countries are increasingly seen as key to improving the chances for prosperity, stability and security everywhere. Indeed, as repeatedly characterized by Secretary of State Hillary Rodham Clinton, development has become the indispensable third leg—along with diplomacy and defense—of U.S. foreign policy.
For the Obama administration, health is a cornerstone of the U.S. development effort. Under its Global Health Initiative, reproductive health is deemed integral to achieving global health because reproductive health is essential to maternal and child survival and to enhancing the lives of women and girls more broadly. Being able to determine whether and when to have a child is fundamental to women’s educational prospects and economic opportunity. And increasing women’s status and autonomy is considered key to fostering development at the family, community and country levels. For all of these reasons, Clinton said recently, reproductive health is "an issue that cuts across much of what we do in development work."
Both globally and in the United States, official commitments to doing more to save the lives of mothers and newborns and to promoting the health and well-being of women and girls are perhaps stronger than they have ever been. Against the backdrop of the ongoing global recession, however, matching these commitments with the necessary financial resources will be more difficult than ever before. Some U.S. policymakers question and even disparage the value of development assistance generally and of family planning and reproductive health in particular. The role that family planning plays in saving women’s lives is indisputable, however, as are the critical contribution and leadership of the United States in making the global effort to promote maternal and reproductive health such a success.
Far-Reaching and Well-Established Benefits
In 2000, the United States joined the community of nations to devise the Millennium Development Goals (MDGs), a blueprint for reducing global poverty by 2015. Three of the eight goals relate directly to health: combating HIV/AIDS, promoting maternal health and improving child health. At last year’s United Nations (UN) summit, the spotlight focused on the woefully inadequate advances made thus far in meeting the goals for maternal and child health, MDGs 5 and 4, respectively. In the run-up to the summit and in its immediate aftermath, there has been a flurry of new energy and of new programmatic, policy and financial promises made at the highest levels to accelerate progress—and greater attention and access to family planning and reproductive health services has emerged as a prominent and recurring theme (see box).
Uganda First Lady Janet Museveni says that trying to achieve maternal health without family planning is like promoting child survival without vaccines. Indeed, this sentiment is now fully reflected in a global consensus, and action steps are underway to ensure that reproductive health and maternal health advance in tandem.
World Bank’s Reproductive Health Action Plan
To guide its own work toward meeting MDG 5 by 2015, the World Bank in June 2010 released a new five-year plan to help 58 countries with the highest fertility and maternal mortality rates to improve access to necessary services. The World Bank is focusing on working with partners to improve health systems "so that women gain significantly better access to quality family planning and other reproductive health services, skilled midwives at their births, emergency obstetric care, and postnatal care for mothers and newborns." The Bank intends to help countries with the financing and technical expertise they will need to achieve the twin targets of MDG 5: reducing maternal mortality by three-fourths and attaining universal access to reproductive health.
UN Secretary-General’s Global Strategy for Women’s and Children’s Health
Last year, UN Secretary-General Ban Ki-moon led a months-long process engaging donor and recipient governments as well as representatives of nongovernmental organizations (NGOs) that culminated in a global consensus document unveiled at the 2010 UN Millennium Summit. According to the Secretary-General’s report, full implementation of the strategy in the world’s 49 poorest countries between now and 2015—which assumes sufficient resources as well as political will—would mean preventing 33 million unintended pregnancies and helping to prevent 570,000 maternal deaths from complications associated with pregnancy, childbirth and unsafe abortion. In addition, it would help to avert the deaths of 15 million children younger than five, including three million newborns. The strategy is ambitious, calling on governments and NGOs to work together to increase financing, strengthen policy and improve services. That includes improving access to skilled birth attendants, treatment of neonatal infections, childhood immunization, the quality of health facilities and training of health workers. Notably, the strategy is explicit about the importance of the availability of a "universal package of guaranteed benefits, including family-planning information and services, …safe abortion services (when abortion is not prohibited by law), and the prevention of HIV and other sexually transmitted infections."
International Alliance for Reproductive, Maternal and Newborn Health
At the same time that the Secretary-General unveiled his global strategy during last fall’s UN Millennium Summit, U.S. Secretary of State Clinton, United Kingdom Deputy Prime Minister Nick Clegg, Australia Foreign Minister Kevin Rudd and Melinda Gates, co-chair of the Bill & Melinda Gates Foundation, announced a new international alliance "to support country-led progress in reproductive, maternal and newborn health." The goal of the alliance is to contribute to reducing the unmet need for family planning by 100 million women, to expand skilled birth attendance and facility-based deliveries, and to increase the numbers of women and newborns receiving quality postnatal care by 2015. Together, the founding alliance members pledged $40 billion over the next five years toward these efforts, about $27 billion of this being new funding; the alliance encourages new members to join along the way. "Family planning plays a crucial role in improving the health of women and their children throughout the world," USAID administrator Rajiv Shah said at the launch. "By bringing the comparative advantages of country partners and donors through this Alliance, we will bolster health outcomes in countries striving to improve the lives and health of its women, girls, and newborns."
Countless studies have documented the essential contributions that family planning makes to maternal health, child survival, reducing the incidence of abortion and recourse to unsafe abortion, and preventing STIs including HIV. Beyond its direct health benefits, the ability to control one’s fertility is fundamental to being able to stay in school, obtain a good job and provide for one’s family—all of which relates to a woman’s status in her family and society, which in turn relates to economic development and social and political stability (related article, Summer 2008, page 13).
Moreover, a study conducted by Guttmacher and the United Nations Population Fund in 2009 concluded that more maternal deaths can be prevented—and for less money—by investing simultaneously to meet the current global need for family planning and for maternal and newborn health care services than by investing in maternal and newborn care alone. Dramatically reducing unintended pregnancy through increased access to family planning services would mean fewer pregnancies overall, fewer high-risk pregnancies and the availability of more resources to care for women with wanted pregnancies. The World Health Organization estimates that 350,000 women still die each year from pregnancy-related causes, including from unsafe abortion. By doubling the current global investment in both family planning and maternal and newborn health care—to about $25 billion—maternal deaths would plummet by more than two-thirds, newborn deaths would be cut in half, unsafe abortions would decline by three-fourths and deaths from unsafe abortion would virtually disappear. In all regions of the world, the results would be dramatic (see table).
|FAMILY PLANNING + MNH = DRAMATIC RESULTS
|Meeting the unmet need for family planning and maternal and newborn health (MNH) care simultaneously would lead to immediate and vast improvements in maternal and reproductive health.
|South Central and Southeast Asia
|Latin America and the Caribbean
|Unintended births and miscarriages
|Source: Guttmacher Institute, 2010.
U.S. Role Is Central
"When…I have talked about investments that could make a real difference quickly, family planning is at the top of the list," asserted Secretary Clinton at a recent public forum discussing the Global Health Initiative. Indeed, the United States has always been and remains the largest single donor to global family planning and reproductive health efforts. This year, the United States is contributing $648 million for family planning and closely related reproductive health care, such as STI screening and information and counseling related to HIV and AIDS. Other major governmental donors to the global effort include Australia, Canada, the European Union, France, Germany, Japan, the Netherlands, Norway, Spain, Sweden and the United Kingdom.
Over and above the amount the United States contributes, though, its role may be unique—and uniquely important—in at least three respects. First, the core of the U.S. family planning and reproductive health program, administered by the U.S. Agency for International Development (USAID), is family planning: services, contraceptive supplies, training, community outreach, operations, and biomedical research, monitoring and evaluation. (Unlike many other country programs, the United States by law does not fund abortion as a method of family planning. It can and does provide assistance for treatment of incomplete or septic abortion, lessening the consequences of unsafe abortion.)
In addition, from the program’s inception in the 1960s, the United States has invested heavily in providing technical assistance and is the only governmental donor to deploy professional staff around the world to work alongside local counterparts, enhancing effectiveness and local ownership. By contrast to most European donors’ programs, the U.S. program relies heavily on nongovernmental organizations (NGOs), especially indigenous NGOs, as key implementing partners. Although development assistance cannot succeed without the support and participation of host country governments, most development experts agree that NGOs tend to be more innovative, efficient and accountable than governments. They are capable of attracting staff who provide high-caliber technical and managerial assistance to developing country partners, including the recipient governments themselves. Thus, USAID enhances capacity-building on the ground that improves the chances for sustainability. Finally, NGOs are motivated by a commitment to their mission of providing services to people and are likely to be less susceptible to political winds than government officials must be.
The United States’ reliance on NGOs as key partners, as opposed to working almost exclusively with foreign governments as most other governmental donors do, is no accident. It is a natural outgrowth of the United States’ orientation toward greater reliance on the private sector than on government to get services to people. And it turns out, according to a recent report from the Seattle-based Institute for Health Metrics and Evaluation, that in addition to all the other known advantages of working through the private sector, this approach seems to help spur developing country governments to maintain their own contributions to their own country programs. By contrast, where support from external sources went primarily to the government, this aid tended to replace domestic investments in health spending. This is critical because, as important as external donors are, the fact is that the bulk of the roughly $9 billion spent on family planning and reproductive health worldwide comes from the recipient country governments themselves.
Finally, the United States has a tradition of providing development assistance by funding particular project areas, instead of "budget support" favored by the European Union and European countries. Specifically, Congress appropriates funding for programs such as maternal health, child survival or family planning. Under the budget support model, decisions about whether these activities are funded and to what extent are basically left to the recipient government to decide. Few strings are attached to the funds beyond broad direction: for example, that they be reserved for health or for education. A main idea behind budget support is to promote greater flexibility at the country level and to promote decision making closer to the people being served. The U.S. system ensures that the funding more closely follows U.S. priorities and areas of expertise, and also takes into account needs on the ground. This approach has given the family planning and reproductive health effort greater visibility, and likely has made it a bigger political target than it might otherwise be. But it has also afforded much greater accountability than is possible under the budget support approach, something akin to block grants to U.S. states.
It is indisputable that women in the world’s poorest countries, just as women everywhere, want and need to determine whether and when to have a child. Similarly, it is well-established that the 603 million women in the developing world who are already using modern birth control to prevent unwanted pregnancies need ongoing access to contraceptive methods and services. And then there are the additional 215 million women with an unmet need for contraceptive services—those who want no more children or to delay their next pregnancy, but are not currently practicing contraception or are using only traditional methods—who also need access to quality services. Such women account for 82% of the 75 million unintended pregnancies that occur in the developing world each year.
Providing women with the services and information they need to control their fertility and control their own lives is not complicated or expensive. Overall, U.S. foreign assistance accounts for less than 1% of the entire federal budget. Global health programs constitute only a small portion of that total, at a level of $7.8 billion, including $5.4 billion for HIV/AIDS programs. And U.S. support for family planning and reproductive health overseas makes up only about 8% of all U.S. spending to achieve global health—about $2 per capita. Former Reps. Mark Green (R-WI) and Jim Kolbe (R-AZ), and Robert Mosbacher, former CEO of the Overseas Private Investment Corporation, recently wrote in The Daily Caller that foreign aid should not be eliminated but made stronger: "Developing countries have the fastest growing economies in the world, and they are the next frontier for American businesses and products….The more we do to help keep people healthy and give them the tools they need to thrive, the better these market opportunities will be."
Global health, and family planning in particular, are good investments—and popular ones. Historically, aid for family planning overseas has garnered strong public support. According to a recent poll, 91% of Americans believe that "every woman on the planet deserves access to quality maternal and reproductive health care." Another found 89% in favor of "health care services, including access to basic health care and family planning services" as a way to promote economic development and advance the status of women and girls.
Indeed, the U.S international family planning and reproductive health program stands out as one of the country’s flagship foreign aid investments. It delivers basic health services to women who want and need them in a manner that is consistent with American values while sensitive to foreign cultures and traditions. It does so in a way that is highly cost-effective and relies more on the private sector than foreign governments. It yields health and social benefits not only for women and their families in the world’s poorest countries but for the global community. It makes good public health sense, good economic sense and good political sense. It values women and their families. Even now, in this fiscally austere climate where foreign aid seems to have become a budgetary piñata and social conservatives are piling on to target family planning specifically, policymakers would do well to bear in mind what would be lost by forcing the United States to step back from helping women move forward.