J. Joseph Speidel, MD, MPH UCSF Bixby Center for Reproductive Health Research & Policy November 22, 2006

1. Funds for Family Planning and Reproductive HealthPresentation to theThird 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 • Funding needs for population work in developing countries • Levels and sources of funds • Donor priorities • Major donors • Recommendations for action

3. Population Growth: The Numbers The combined population of Europe and North America is 1 billion.

4. Growth rates have declined, but growth of numbers remains high 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

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 • HIV/AIDS/STI prevention and care • Breast, cervical, and uterine cancer • Safe abortion? • Comprehensive sexuality education? • Infertility? • Harmful traditional practices? • Breast feeding and infant health care? • Post-menopausal care? • Male reproductive cancers and diseases?

8. Annual Deaths Related to Reproduction

9. ICPD Estimate of Funds Needed for Population Activities Original 1994 ICPD estimate of funding needs for 2005: • Family planning: $11.5 billion • Reproductive health: $5.4 billion • HIV/AIDS: $1.4 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 • 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 • UNAIDS • UN Millennium Project • Donor Landscape Analysis

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

13. UNAIDS: Resource Needs 2006-2008

14. UN Millennium Project: Public Choice, Private Decisions

15. New Annual Funding Targets for 2005(adjusted for inflation and program needs) • Family planning: $15.6 billion(up from $11.5) • 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) • 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) 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

18. Resource Flows for Population Activities Domestic expenditures in developing countries: • Largest source of funds for population and AIDS • 2005 projection: $14.9 billion • 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

19. Population Assistance from Donors • $3.2 billion in 2002 • $4.7 billion in 2003 • $5.6 billion in 2004 (preliminary) • $4.5 billion from Development Assistance Committee (DAC) country governments • $588 million from development banks • $434 million from NGOs and foundations • $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. • 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. • 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/225

22. 2005 ICPD Funding Targets for Donors(in billions) Adapted from: http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdfhttp://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. • 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.” • 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 • Bans use of funds for abortion-related activities • Withholds funds from the UNFPA and IPPF • Only 20% of HIV/AIDS funds can be used for prevention • 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 • 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

28. Development Banks Population growth seldom addressed as a development issue • Not on research agenda • Rarely included in country-based Poverty Reduction Strategy Papers (PRSPs) • 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

29. UNFPA In 2005, UNFPA’s budget of $565 million supported work in 148 countries. • Most countries received from $0.5-$3 million • Only 13 countries received more than $5 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. • 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 • U.N. projections of population growth ending about 2050 • 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 influence of vocal anti-abortion activists, conservative religious leaders, and conservative think tanks • 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 • “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. • 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. • 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. • 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: • Contraceptive supplies • The lack of a compelling body of research that would convince economists and development planners to address population issues • Training of population experts.