PAI Mapping Supplies: Are Contraceptives Going Where They're Most Needed?
Publication date: 2006
Mapping Supplies: Are Contraceptives Going Where They’re Most Needed? By Elizabeth Leahy In this era of tight ﬁnancial resources for international family planning – as evidenced by the recent budget cuts proposed by President Bush in the United States – are the world’s donated contraceptives reaching the women and men who need them most? A review shows that while donors of such supplies often focus their resources on countries with high need, they could do so even more effectively. Population Action International recently compared developing countries that have the highest unmet need for family planning with those that receive the greatest value of donated contracept ives and condoms. Two of the countries with highest unmet need for family planning among the 41 analyzed (Cambodia and Pakistan) are among the ten that received the lowest value of donated supplies. Because poor access to reproductive health care has been linked to negative outcomes in other areas of health, to increased poverty, and to lower rates of girls’ education, it is critical that countries with high unmet need for family planning receive close attention from donors of reproductive health supplies. PAI’s research compared funding for contraceptives and condoms in 2003 and 2004 from seven key donors with demographic indicators for 41 countries across Africa, Asia and Latin America. The donors examined were the United Kingdom’s Department for International Development (DfID); DKT International/Population Services International (DKT/ PSI); the International Planned Parenthood Federation (IPPF); Germany’s KfW Entwicklungsbank (KfW Development Bank); the United Nations Population Fund (UNFPA); and the U.S. Agency for International Development (USAID). Three of these donors – IPPF, UNFPA and USAID – provide information on their procurements and shipments of contraceptives to the RHInterchange, a web-based tracking system. Data on the other donors came from their publications and information submitted to UNFPA. PAI also compiled demographic statistics for 41 developing countries, including: contraceptive prevalence rate (percentage of married women currently using any method of family planning; Research Commentary “Expanding access to reproductive health care and supplies among the poorest is critical to improving health and overall development.” volume 1, issue 3 MARCH 2006 measured in each country’s Demographic and Health Survey [DHS]);1 unmet need for family planning (percentage of married women who say they would like to delay or prevent their next pregnancy but are not using family planning; also compiled in the DHS); contraceptive security index score (a value based on supply chain, ﬁnance, health and social environment, access, and utilization; compiled by JSI/DELIVER).2 The 41 countries selected were those in which at least four of the donors listed above had provided reproductive supplies in 2003 and 2004 and those that had been discussed as of early 2005 at a monthly conference call focused on “Countries at Risk,” part of a collaborative donor effort to prevent and alleviate unexpected supply shortages. Among the countries, 11 received support from ﬁve donors during the two years studied. These were Benin, Guinea, Indonesia, Malawi, Nepal, Nigeria, Rwanda, Uganda, Vietnam, Zambia and Zimbabwe. One country, Kenya, received support from all six donors. For each country, a per capita value of contraceptives and condoms received was calculated by dividing the total value of supplies received from the three donors (IPPF, UNFPA, USAID) who provide information to the RHInterchange by the country’s population of women of reproductive age (15- 49).3 This value was compared to the country’s unmet need for family planning (described above). Ideally, as donors try to direct supplies to the places where they are most needed, countries with the highest unmet need for family planning would also be those that are receiving the highest per capita value of donated contraceptives and condoms. PAI’s review found mixed results in this regard. The ten countries with highest measured unmet need for family planning are Rwanda, Ethiopia, Uganda, Togo, Pakistan, Cambodia, Malawi, Burkina Faso, Mali and Nepal. Of these, three – Uganda, Togo and Nepal – are also among the ten countries with the highest per capita value of donated supplies. Two of the three countries with the highest per capita value of donated supplies, Swaziland and Figure 1: Highest per capita recipients of donated supplies 2003-04 (from RHI donors: IPPF, UNFPA, USAID) � � �� �� �� �� �� �� �� �� �� �� �� �� � �� �� �� � �� �� �� �� � �� �� � �� �� �� ��� �� �� �� �� ��� ��� �� �� � �� �� ��� �� �������������������������� ���������������� ���������������������� ������������ Note: Swaziland and Lesotho have no data on unmet need for family planning. Sources: Demographic and Health Surveys, United Nations Population Division, RHInterchange. Lesotho, do not have data on unmet need for family planning and due to the small size of their populations, per capita unmet need analysis may not be useful. Half of the top ten countries with highest per capita value of donated supplies are those where more than one-ﬁfth of married women have an unmet need for family planning. However, six of the ten countries with the lowest values of donated supplies have similar ratios of unmet need (20 percent and higher). In Pakistan, where 32 percent of married women have unmet need for family planning, the value of donated reproductive health supplies in 2003-04 amounted to $1.11 per woman of reproductive age. In Cambodia, where unmet need for family planning is 30 percent, the value of donated supplies was just $0.80 per women of reproductive age. Eighty cents is equivalent to the value of 17 male condoms purchased by USAID or less than three months’ supply of oral contraceptive pills purchased by UNFPA. Table 1: Lowest per capita recipients of donated supplies 2003-04 (from RHI donors: IPPF, UNFPA, USAID) Country Value of Donated Supplies Per Capita (US$) Unmet Need for Family Planning (%) Indonesia $0.16 8.6 Chad $0.31 9.4 Georgia $0.33 23.8 Vietnam $0.61 4.8 Cambodia $0.80 29.7 Kenya $0.96 24.5 Ecuador $0.99 10.0 Pakistan $1.11 32.0 Benin $1.59 27.2 This research is far from complete. So far we have measured just two years of supply provision and only examined 41 countries. Some of these have no data on unmet need for family planning or where multiple donors are present. We were also only able to consider the contributions of three donors of reproductive health supplies (the only three who currently provide shipment data to the RHInterchange), and we did not consider the size of the commercial/private sector or other means of ﬁlling the gap between supply and demand in each country. Still, the research does show that donor priorities could be more effectively aligned to meet demand in countries with high unmet need for family planning. In the ten countries with highest unmet need analyzed by PAI, at least 25 percent of married women have an unmet need for family planning. These countries often measure poorly in other aspects of health. Among the countries with highest unmet need, two are among the 20 countries with the highest HIV prevalence in the world; half are among the 20 countries with the highest maternal mortality rates; and three are among the 20 countries with the lowest per capita national incomes. All of these problems can be linked to reproductive health. Increasing access to reproductive health supplies can have a favorable impact throughout a country’s health and economic sectors. Only one product, condoms, can prevent sexually transmitted HIV and other sexually transmitted infections as well as unintended pregnancies. Access to contraceptives and condoms also allows women to lengthen the interval between their pregnancies, a key factor in reducing the incidence of maternal and infant mortality. Expanding access to reproductive health care and supplies among the poorest is critical to improving health and overall development. In sub-Saharan Africa, contraceptive use can be 3 to 10 times lower among the poor than the well-off.4 Increased contraceptive use and lowered fertility rates lead to improvements in the health and survival of women and children, rates of girls’ education, national investments in social welfare, and economic productivity. Table 2: Health and economic indicators in countries with high unmet need for family planning Country Unmet need for family planning(%) Adult HIV prevalence rate (%)5 Maternal deaths per 100,000 live births 20006 Gross national income per capita 2003 (US$)7 Value of donated RH supplies per capita (US$) Rwanda 35.6 5.1 1,400 $1,290 $3.36 Ethiopia 35.2 4.4 850 $710 $5.82 Uganda 34.6 4.1 880 $1,440 $12.79 Togo 32.3 4.1 570 $1,500 $16.07 Pakistan 32.0 0.1 500 $2,060 $1.11 Cambodia 29.7 2.6 450 $2,060 $0.80 Malawi 29.7 14.2 1,800 $600 $5.89 Burkina Faso 28.8 4.2 1,000 $1,180 $6.09 Mali 28.5 1.9 1,200 $960 $9.82 Nepal 27.8 0.5 740 $1,420 $13.05 There is already a severe global shortage of reproductive health supplies. In 2003, the gap between the total cost of contraceptives and condoms in the developing world and the value of donated supplies was over $700 million.8 Some of this difference can and should be met by developing country governments, the private sector, and higher- income users who can afford to purchase supplies. However, donors should work together more efﬁciently to ensure that their scarce resources are being targeted effectively to the places and people who most need them. In order to ease the burden on program staff in countries that receive supplies from multiple sources, donors should strengthen the monitoring and evaluation of their resource ﬂows and unify their procurement data in the RHInterchange, as the three donors considered in this PAI research have done. Speciﬁcally, countries in which hundreds of thousands of women and couples would like to delay or prevent a future pregnancy but lack the means to do so should be given higher priority as donors decide where to allocate their funding. Elizabeth Leahy is a research assistant at PAI. Notes 1 MEASURE/DHS. Various years. See www.measuredhs.com 2 John Snow, Inc. /DELIVER and Futures Group/POLICY Project. 2003. Contraceptive Security Index 2003: A Tool for Priority Setting and Planning. Arlington, Virginia: John Snow, Inc./DELIVER. 3 United Nations Population Division. 2005. World Population Prospects: The 2004 Revision. New York: United Nations Population Division. 4 Leete, R and M Schoch. 2003. “Population and Poverty: Satisfying Unmet Need as the Route to Sustainable Development.” Population and Development Strategies, Series 8. New York: United Nations Population Fund (UNFPA). 5 UNAIDS. 2004. 2004 Report on the Global AIDS Epidemic. Geneva: UNAIDS. 6 World Health Organisation (WHO). 2004. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO. 7 World Bank. 2004. “GNI Per Capita 2003, Atlas Method and PPP.” World Development Indicators Database. Available from http://www.worldbank.org/ data/databytopic/GNIPC.pdf; Internet; accessed 4 April 2005. 8 UNFPA. Unpublished. Donor Support for Contraceptives and Condoms for STI/ HIV Prevention 2003. © 2006 Population Action International 1300 19th Street NW, Second Floor Washington, DC 20036 USA +1-202-557-3400 e-mail: email@example.com www.populationaction.org