PAI Progress and Promises- Trends in International Assistance for Reproductive Health and Population

Publication date: 2004

By Sally Ethelston with Amanda Bechtel, Nada Chaya, Andrew Kantner and Carolyn Gibb Vogel 1300 19th Street, NW, Second Floor Washington, DC 20036 USA www.populationaction.org Progress & Promises TRENDS IN INTERNATIONAL ASSISTANCE FOR REPRODUCTIVE HEALTH AND POPULATION ii © 2004 Population Action International 1300 19th Street NW, Second Floor Washington, DC 20036 USA Telephone: +1 202.557.3400 Fax: +1 202.728.4177 www.populationaction.org For copies of this publication, please send an email request to pubinq@popact.org. All rights reserved. The material from this publication may be reproduced provided Population Action International and the authors are cited as the source. Publications Manager: Brian Hewitt Production Assistant: Jennifer Shatwell Design and Production: Eason Associates Inc Creative Director: Sue Gubisch Printing: Stephenson Printing Photo credits: © Curt Carnemark/The World Bank (woman on cover, p. 1) © Ian Stanley/Alamy (p. 35) © Jennifer Shatwell (p. 50) © Rune Rasmussen (p. 57) © Jess Wendover (pp. 89, 101, 109) © Genie Ko/PAI (p. 148) ISBN: 1-889735-72-8 LOC Control Number: 2004099157 iii The authors wish to thank the many colleagues in devel- opment agencies, foreign affairs ministries, and nongovern- mental organizations in the donor countries profiled in this report for their assistance and cooperation. More than one hundred people provided assistance and we regret that we cannot acknowledge them individually. The authors appre- ciate the time they spent with the authors in meetings, responding to information requests, and reviewing the individual profiles of their respective countries’ and institu- tions’ population assistance programs. This report draws heavily on data provided by the United Nations Population Fund and the UNFPA/ UNAIDS/NIDI Resource Flows Project based at the Netherlands Interdisciplinary Demographic Institute. We appreciate in particular the assistance provided by Ann Pawliczko of UNFPA and by Jacqueline Eckhardt- Gerritsen and Mieke Reuser of NIDI in providing us with data and responding to our questions. Other major docu- mentary sources are listed in the key references, which follow the report, including those published by the Development Assistance Committee of the OECD. The authors acknowledge with gratitude the input of val- ued colleagues outside Population Action International, including Sono Aibe, Stan Bernstein, Tamara Fox, Duff Gillespie, Elizabeth Lule, Thomas Merrick, Susan Rich, Sara Seims, Denise Shannon, Steve Sinding, Joseph Speidel, and Eef Wuyts. We extend special thanks to Susannah Mayhew of the London School of Hygiene and Tropical Medicine for her case study on Ghana. Many colleagues at Population Action International helped make this publication possible. In particular, we would like to acknowledge the editorial support of Terri Bartlett, Dina Bogecho, Amy Coen, Robert Engelman, Sarah Haddock, Elizabeth Leahy and Jennifer Shatwell. A special note of thanks is due Joanne Omang for addi- tional editing of the text. We would also like to thank the participants in the Countdown 2015 Global Roundtable for their feedback on a preview edition of Progress and Promises. The authors made every effort to verify the information contained in this report; they regret and take responsibil- ity for any errors that remain. The authors and Population Action International acknowledge with gratitude the generous support of the Better World Fund, sister organization to the United Nations Foundation, the Winslow Foundation, and the Compton Foundation for this publication and for PAI’s Financing Project. Acknowledgements iv OVERVIEW AND ANALYSIS Summary and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 1: Why Population Assistance Matters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Special Topic: The Reproductive Health Supply Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 2: The Policy Environment for Population Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Special Topic: The Impact of U.S. Policies on Sexual and Reproductive Health in Kenya. . . . . . . 13 Chapter 3: Trends in Population Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Chapter 4: Geographic and Program Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Chapter 5: Population Assistance Channels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Conclusion: Building on Progress, Fulfilling the Promise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 CASE STUDY: Sexual and Reproductive Health in Ghana and the Role of Donor Assistance . . . . . . . . 35 DONOR COUNTRY REPORT CARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Report Card Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 DONOR COUNTRY PROFILES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 OTHER DONOR PROFILES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 European Commission. . . . . . . . . . 136 Foundations . . . . . . . . . . . . . . . . . 143 World Bank . . . . . . . . . . . . . . . . . 148 Table of Contents Australia . . . . . . . . . . . . 50 Austria . . . . . . . . . . . . . . 54 Belgium . . . . . . . . . . . . . 57 Canada. . . . . . . . . . . . . . 61 Denmark. . . . . . . . . . . . . 66 Finland. . . . . . . . . . . . . . 69 France . . . . . . . . . . . . . . 73 Germany. . . . . . . . . . . . . 78 Ireland . . . . . . . . . . . . . . 82 Italy . . . . . . . . . . . . . . . 85 Japan . . . . . . . . . . . . . . . 89 Luxembourg . . . . . . . . . . 94 Netherlands . . . . . . . . . . 97 New Zealand . . . . . . . . 101 Norway. . . . . . . . . . . . . 105 Portugal . . . . . . . . . . . . 109 Spain . . . . . . . . . . . . . . 112 Sweden . . . . . . . . . . . . 117 Switzerland . . . . . . . . . 121 United Kingdom . . . . . . 124 United States . . . . . . . . 129 v Illustrations FIGURES Figure 1: Donor and Developing Country Resources Pledged to Reach ICPD Goals . . . . . . . . . . . . . . . . . . . . . 5 Figure 2: Total Supply Need and Donor Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Figure 3: Trends in Total Official Development Assistance, 1994-2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Figure 4: Total Funds for Population Assistance, 1994-2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Figure 5: Relative Size of Donor Economies, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure 6: Donor Country Population Assistance per Million Dollars of GNI, 2002 . . . . . . . . . . . . . . . . . . . . . 18 Figure 7: Share of Official Development Assistance Allocated to Population Assistance, by Country, 2002. . . 19 Figure 8: Population Assistance by Donor Country, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Figure 9: Distribution of Population Assistance by Region, 1996 and 2002 . . . . . . . . . . . . . . . . . . . . . . . . 26 Figure 10: Top Twenty Recipients of Population Assistance Per Capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Figure 11: Final Population Assistance Expenditures by Type of Activity, 1995-2002. . . . . . . . . . . . . . . . . . 28 Figure 12: Allocation of Population Assistance Funds by Donor Country and Channel, 2002. . . . . . . . . . . . . 31 Figure 13: Total International Population Assistance, Including HIV/AIDS, by all Foundations . . . . . . . . . . . 144 Figure 14: Population Assistance Comparison: Country Governments and Foundations, 2002 . . . . . . . . . . . 147 TABLES Table 1: Country Grades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Table 2: Resources Needed to Reach ICPD Year 2005 Goal for Donor Population Assistance . . . . . . . . . . . . 21 Table G-1: Basic Statistical and Demographic Profile of Ghana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Table G-2: Sexual and Reproductive Health Indicators for Ghana, 1988-2002. . . . . . . . . . . . . . . . . . . . . . . 36 Table G-3: Sexual and Reproductive Health Services in Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table G-4: Top Ten Donors in Sexual and Reproductive Health, Ghana 1993-2000 . . . . . . . . . . . . . . . . . . . 39 Appendices Appendix 1: Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Appendix 2: Key References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Appendix 3: Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Appendix 4: Primary Funds for Population Assistance, by Major Donor Category, 1992-2002 . . . . . . . . . . . 160 Appendix 5: Primary Funds of Donor Countries for Population Assistance, 1994-2002. . . . . . . . . . . . . . . . 161 1 oney matters and policies count. Ten years ago, at the International Conference on Population and Development (ICPD) in Cairo, the inter- national community endorsed an approach to improving reproductive health based on meeting individual needs and respecting human rights. The 179 nations present agreed on a plan for achieving universal access to basic reproductive health care by 2015—and on the financial resources needed to make it a reality. They pledged to share the costs, estimated at US$18.5 billion annually by the year 2005, and donor nations committed to providing one-third of that total. It is now 10 years since that conference and as 2004 draws to a close, so does the process of tak- ing stock of progress. This report is part of that effort. It examines recent trends in funding and policy and profiles each of the major donor coun- tries, assigning each a grade. It is the third in a series by Population Action International and is also intended to complement the research on finan- cial resource flows by the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Netherlands Interdisciplinary Demographic Institute (NIDI). A key finding of this report is reflected in its title: Progress and Promises. In 2002, the world’s wealthiest countries made more progress toward fulfilling the financial promises made in Cairo than in either of the two previous years.* Similarly, donor policies on sexual and reproduc- tive health have strengthened over the last few years, to better reflect the comprehensive approach to meeting reproductive health needs that was at the heart of the ICPD agenda. Unfortunately, this progress is not uniform across the donor community. A handful of donor countries have yet to contribute even a tiny frac- tion of their fair share of donor resources, while others need to give substantially more in dollar terms. Thus, the donor countries together would still need to triple their population assistance to meet the funding goal for 2005 agreed to in Cairo. The grant assistance coming from other donors, primarily foundations, eases this shortfall, while development bank loans also add to the sup- ply of funds and some developing countries pro- vide significant resources. Nevertheless, the need for more resources from donor governments is inescapable. Summary and Recommendations Progress & Promises TRENDS IN INTERNATIONAL ASSISTANCE FOR REPRODUCTIVE HEALTH AND POPULATION M *2002 is the latest year for which comparable data are available. 2 KEY FINDINGS The Policy Environment for Population Assistance A number of donor governments continue to strongly support efforts to address poor sexual and reproductive health in their development programs, and others are joining their ranks. This support exists despite a lack of depth in public understanding of what their governments actually do for development, including in the area of sex- ual and reproductive health. The gov- ernments of Denmark, the Netherlands, Norway, Sweden and the United Kingdom remain committed to these issues. Canada, a consistent voice in international policy discussions, now has clearly articulated policies addressing sexual and reproductive health needs, as does Germany. Belgium, France and New Zealand have also strengthened their policies, while Luxembourg and Ireland have significantly increased their funding. The efforts of advocacy groups in the donor countries and the explosion of the HIV/AIDS pandemic have been critical to these advances in policy and funding. Political leadership has also been important, in particular that coming from the Netherlands, the United Kingdom, the European Commission and, indeed, the European Union (EU) as a whole. Countries such as Portugal and Spain have lagged behind, however, while the United States moved backwards, in 2001 reimposing restrictions on its assistance for family planning that had been eliminated eight years earlier. The policy environment is also affected by the donor community’s increasing adherence to the Millennium Development Goals (MDGs). With their overarching goal of poverty reduction and particular goals related to maternal and child health, HIV/AIDS, and gender equality, the MDGs should serve to reinforce donor support for population assistance. Trends in Population Assistance Population assistance increased dramatically from 2001 to 2002, from $2.5 billion to $3.2 billion. Assistance from the donor countries alone increased from $1.7 billion to $2.3 billion, the largest one-year increase ever recorded. The backdrop to this increase is the upward trend in offi- cial development assistance (ODA) from the major donor countries, as well as their increasing attention to the HIV/AIDS pandemic. Even with such a significant rise in funding, population assistance continues to lag far behind agreed upon goals, although the funding gap narrowed in 2002. The ICPD goal for funding from donor countries by 2005 is $7.5 billion annually ($6.1 billion in 1993 dollars). Reaching the $7.5 billion goal by 2005 would require a three-fold increase in donor countries’ 2002 spending of $2.3 billion. Total population assistance rose from $1.5 billion in 1996 to $3.2 billion in 2002, an 80 percent increase in real terms. Most donor countries increased their population assistance after 1996, but the sharing of the load remains woefully unequal. Although they are the largest donors in dollar terms, the United States, Japan and the United Kingdom contribute just one-third, or less, of their “fair shares” of the $7.5 billion spending goal for 2005. In contrast, Denmark, Norway and Luxembourg continue to fulfill their fair shares, while the Netherlands stands out as the fifth largest donor country in dollar terms and the third most generous donor relative to the size of its economy. Private foundations are another source of the significant increase in funds, providing at least $460 million in 2002, compared with less than $100 million in 1996. Development bank commitments averaged at least $450 million annually over the period 1996-2002, but their funds are provided as loans, rather than grants. Trends over time should be regarded as only indicative of progress made, however, given incomplete reporting and changes in the definition of population assistance applied to the tracking of resource flows. Following the ICPD, the definition of the term was changed to encom- pass a broader reproductive health agenda, with activi- ties grouped in four categories: family planning services, basic reproductive health services, prevention programs for sexually transmitted diseases (STDs), including HIV/AIDS, and population-related research. In 1999, the HIV/AIDS component was redefined to include all pre- vention activities, plus treatment, care and support. TABLE 1 COUNTRY GRADES Netherlands A Denmark A Norway A Sweden A Finland A Luxembourg A- United Kingdom B Belgium B Switzerland B Canada B Germany B New Zealand B Japan B Australia C France C United States C Ireland C Italy D Spain D Austria D Portugal D 3 Geographic and Program Priorities The most notable shifts in funding patterns can be seen in the dramatic increase for HIV/AIDS-related activities and for global or inter-regional programs. Expenditures for HIV/AIDS activities have increased slightly less than four-fold, in real terms, since 1996, from $242 million to $1,343 million in 2002. Spending on activities identified as reproductive health and family planning increased by 20 percent, in real terms, from $1,058 million to $1,468 million. Again, it is important to recall the addition of care, treatment and support under STD/HIV/AIDS activi- ties in 1999. Population assistance spending on global or inter- regional programs increased from 26 percent to 40 per- cent of the total over the period 1996-2002. At the same time, all regions saw increases in the volume of popula- tion assistance received between 1996 and 2002, even if their shares of funds decreased, as was the case for both the Latin America and Caribbean region and the Asia- Pacific region. Most notable was the doubling of popula- tion assistance to sub-Saharan Africa, to more than $850 million, as the donor response to HIV/AIDS and other sexual and reproductive health needs gained strength. As noted above, it is important to keep in mind the indicative nature of the data available. Many donors pre- fer to support comprehensive reproductive health pro- grams that integrate care in pregnancy, family planning, STD/HIV/AIDS prevention and treatment and other serv- ices. Donors are also increasing their support for sector- wide, more systems-oriented approaches to the provision of health care—support that is not captured in the fig- ures presented here. The tracking of financial flows for specific aspects of sex- ual and reproductive health—such as services for adoles- cents, efforts to address unsafe abortion, and reproduc- tive health supplies—is particularly challenging. Many donors shy away from supporting adolescent services or are shifting resources to approaches that have been shown to be ineffective, such as “abstinence-only” rather than comprehensive programs. Most donor governments are reluctant to support the provision of safe abortion services or even post-abortion care. Only a handful of donors provide significant resources for supplies, and thus the gap between the need for donated contracep- tives and condoms for HIV/AIDS prevention and avail- able funding is projected to reach hundreds of millions of dollars annually by 2015. Population Assistance Channels Donor governments continue to be the largest single source of international population assistance, far outpac- ing assistance from foundations, the development banks and non-governmental organizations (NGOs). In 2002, the major donor countries (members of the Development Assistance Committee of the Organization for Economic Cooperation and Development) supplied more than two- thirds of all population assistance, utilizing four major channels: bilateral, multilateral, multi-bilateral and NGOs. Since the mid-1990s, donor governments have tended to channel an increasing volume of population assistance funds through bilateral programs and NGOs. Core fund- ing of multilateral organizations such as UNFPA was only slightly higher in 2002 than in 1996, while donors dou- bled the amount of bilateral aid channeled to specific projects undertaken in collaboration with multilateral organizations (thus the use of the term “multi-bilateral”). These shifts in funding patterns have coincided with the continued expansion of bilateral programs by several leading donors, including Germany, Japan, the Netherlands and the United Kingdom. Most donor coun- tries that have increased their bilateral programming have also maintained or increased their support for inter- national institutions such as UNFPA, UNAIDS, the International Planned Parenthood Federation (IPPF) and, more recently, the Global Fund to Fight AIDS, Tuberculosis and Malaria. The European Commission is an increasingly important channel for development aid from the EU Member States and its assistance for sexual and reproductive health efforts continues to rise. The Netherlands stands out as the fifth largest donor country in dollar terms and the third most generous donor relative to the size of its economy. 4 KEY RECOMMENDATIONS Generating the necessary human, financial and other resources required to provide sexual and reproductive health services to all who need them will require commitment, capacity, and coordination, as well as improved methods for measuring success. o Commitment entails both sound policies and ade- quate financial resources. This is the responsibility of both donor and developing countries and will require leadership and action by government leaders, parlia- mentarians, and civil society. In the donor countries, including new and emerging donors, civil society and parliamentarians need to push their governments to allocate at least 0.7 percent of national income for offi- cial development assistance. They must make the case for adequate resources for sexual and reproductive health, including HIV/AIDS, and insist on concerted action to eliminate the shortfall in reproductive health supplies. o Greater capacity is needed in both donor and devel- oping countries in technical aspects of sexual and reproductive health and with respect to the systems for monitoring resource flows, evaluating outcomes, and for the delivery of reproductive health supplies. Government officials, parliamentarians and civil socie- ty organizations must be able to participate actively and effectively in resource allocation processes, includ- ing those related to health sector reform and poverty reduction strategies. They must be able to demonstrate the economic as well as the social benefits of investing in sexual and reproductive health. o Coordination must strengthen among donors, devel- oping country governments and institutions, and NGOs at the national, regional and international levels to ensure the effective use of financial and human resources and that sexual and reproductive health needs in smaller or otherwise disadvantaged countries are not neglected. o Different and better indicators for measuring progress are needed, so that donors, aid-receiving governments, institutions and NGOs can be held accountable. Such indicators must take into account inequalities within countries, and the importance of quality of care issues and respect for human rights in the design and delivery of services. Resources must also be made available to improve the tracking and transparency of financial and other resource flows. WHAT LIES AHEAD In 2002, donor performance clearly improved when measured against the financial goals adopted at the ICPD in 1994. But population assistance—and assistance to the health sector generally—will have to increase much faster in the future if it is to meet the world’s urgent and growing need for sexual and reproductive health servic- es. And the goalposts for assessing performance will need readjusting as well. A number of donors have made commitments to increase their development assistance relative to the size of their economies. Five countries—Belgium, France, Ireland, Spain and the United Kingdom—have pledged to provide 0.7 percent of gross national income (GNI) for ODA before 2015. Canada, Germany and Italy have also stated their intention to increase aid relative to national income. But the United States and Japan, the world’s two largest economies, remain far from the 0.7 percent goal. If they and all the other DAC donor countries were to allocate 0.7 percent of GNI, development assistance would effec- tively triple, to more than $175 billion dollars annually. That would help bring the Millennium Development Goals and those of the International Conference on Population and Development within reach. We must be able to demonstrate the economic as well as the social benefits of investing in sexual and reproductive health. 5 n 1994, at the International Conference on Population and Development (ICPD), the internation- al community endorsed an approach to improving reproductive health based on meeting individual needs and respecting human rights. The 179 nations present agreed on a plan for achieving universal access to basic reproductive health care by 2015—and on the financial resources needed to make it a reality. They pledged to share the costs, estimated at US$18.5 billion annually by the year 2005, and donor nations committed to providing one-third of that total. At the halfway point to 2015, the target year for the cen- tral goals of ICPD, it is time to take stock of how far we have come and how far we have to go. This report is part of that process, examining recent trends in funding and policy and the contributions of the donors involved. It profiles each of the major donor countries and assigns each country a grade based on financial and policy indica- tors crucial to bringing the promise of ICPD closer to reali- ty. Profiles of the European Commission and the World Bank are also included, together with an overview of the population assistance programs of leading foundations in the private philanthropic community. Complementing this analysis, a case study examines the experience of Ghana vis-à-vis the donor community. This report is the third in a series by Population Action International and is also intended to complement the research on financial resource flows done jointly by the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Netherlands Interdisciplinary Demographic Institute (NIDI). Today, the international community has some cause to celebrate. Population assistance increased by a record amount in 2002, to more than $3 billion.* And while the donor nations still fall far short of the commitments made a decade ago in Cairo, the gap between what was given and what was pledged was smaller in 2002 than in either of the previous two years. Donor policies on sexual and reproductive health have also strengthened overall. Policy documents increasingly empha- size a health- and rights-based rationale for providing popu- lation assistance. A few donors still lack clearly articulated policies, however, while others (notably Australia and the United States) place restrictions on the use of funds that effectively undermine the policies they have. Ten years after the Cairo conference, some progress toward improving reproductive health has been made, but tremendous challenges remain. The HIV/AIDS pan- demic has raced through sub-Saharan Africa and is now hitting Asia and parts of Eastern and Southern Europe hard. Young people are now half the world’s population and more than one billion are in their teens. And each year, more than three and a half million women and men die of reproductive health-related causes, including AIDS, pregnancy, childbirth, and unsafe abortion. Money matters and policies count. Without money, good policies cannot be put into action. Without good policies, money may be spent ineffectively, or worse. The donor nations have made some progress, but still have far to go to fulfill the promise of Cairo: a world in which women and men can make decisions about sex and reproduction in good health, with hope rather than fear. CO NS TA NT 1 99 3 $U S BI LL IO NS 0 5 10 15 20 25 2015201020052000 $21.7 $20.5 $18.5 $17.0 $7.2 $6.8 $6.1 $5.7 $14.5 $13.7 $12.4 $11.3 ■ Donors ■ Developing Countries FIGURE 1 DONOR AND DEVELOPING COUNTRY RESOURCES PLEDGED TO REACH ICPD GOALS Note: Figures are for annual spending pledged Source: Programme of Action of the International Conference on Population and Development, paras. 13.15 and 14.11. Introduction *2002 is the most recent year for which comparable data are available. I 6 t the ICPD in 1994, the right to reproductive health was recognized as part of an individ- ual’s right to the highest possible standard of good health. Nations agreed that meeting individual needs was the organizing princi- ple of good reproductive health and population pro- grams, while they also acknowledged the contribution that early stabilization of world population size would make to the achievement of sustainable development. Ten years later, at the halfway mark in the countdown to 2015, vast differences remain in reproductive health sta- tus between rich and poor countries. The HIV/AIDS pan- demic has expanded its reach and its toll in human lives and threatens economic growth in some of the world’s poorest countries. At the same time, however, population growth still outpaces gains in economic productivity in some countries, adding to the challenge of providing the health care, education, skills and jobs needed by the young to thrive in the future. These are just a few of the reasons why population assis- tance still matters and why donors focused on achieving the Millennium Development Goals (MDGs)—and con- cerned with poverty reduction, human rights, health and development—must help ensure the adequate flow of resources for sexual and reproductive health services. The Gap in Reproductive Health Status As was the case more than 10 years ago, 99 percent of deaths to women from pregnancy-related causes still take place in developing countries today. This one statis- tic captures the impact of poor access to contraception, lack of skilled care in pregnancy and childbirth, as well as pregnancies that occur too early in life, too late or too often. Thus, women in sub-Saharan Africa face a 1 in 16 lifetime risk of dying in pregnancy or childbirth, while the risk for women in developed countries is just 1 in 2,800, according to the World Health Organization (WHO). The growing demand for contraception has yet to be met. The need for effective methods of contraception contin- ues to grow, as the number of women and men in their childbearing years increases, and as more of them want to plan their families. Indeed, the demand for contracep- tion is projected to increase by 40 percent by 2025. Thus while access to and use of contraceptives has increased more than ten-fold since the 1960s, UNFPA estimates that more than 200 million women still have an unmet need for effective methods of contraception. Unmet need is highest in sub-Saharan Africa, where 46 percent of women at risk of unintended pregnancy are using no method of contraception. Shortfalls of reproductive health supplies are at crisis lev- els. The gap between demand and supply for contracep- tives, condoms for HIV/AIDS prevention, and other reproductive health supplies is growing. One illustration of this growing crisis is that if all the male condoms made available by donors in sub-Saharan Africa were evenly distributed, each man would have just three or four per year. Yet while the demand for supplies contin- ues to soar, donor funding for both supplies and supply systems continues to fall. (See the Special Topic at the end of this chapter for more information.) Lack of care in pregnancy and childbirth is a fact of life— and death. Hundreds of millions of women still lack access to basic care in pregnancy and childbirth. While women in developed countries have almost universal access to care, one-third of pregnant women in developing countries receive no medical care whatsoever. Only half of all deliveries are attended by skilled personnel, a propor- tion that falls to less than one-third in the least developed countries. And the need continues to grow: currently, the number of women of reproductive age in developing countries is increasing by more than 20 million annually. HIV/AIDS prevention and treatment remain out of reach. An estimated 38 million people are living with HIV/AIDS, half of them women, and 5 million people were newly infected in 2003. AIDS has already reduced life expectancy in the hardest hit countries and, due to its impact on working-age adults, is projected to reduce national incomes as well. More than three-quarters of HIV infections are transmitted sexual- ly, while 10 percent are due to mother-to-child transmission. Yet proven means of prevention—such as condoms, volun- tary testing and counseling and drugs to prevent mother-to- child transmission—are available to less than 20 percent of people with a high risk of infection, according the Global HIV Prevention Working Group. The international communi- ty is even further from achieving the goal of treating 3 mil- lion people with anti-retrovirals by 2005. Chapter 1 Why Population Assistance Matters A 7 Reproductive Rights are Human Rights The ICPD Programme of Action broke new ground when it stated that “reproductive rights embrace cer- tain human rights that are already recognized in national laws, international human rights documents, and other consensus documents.” Going beyond the right to plan one’s family, first articulated in 1968, it placed the “right to attain the highest standard of sexual and reproductive health” firmly within the concept of the right to health. Thus population assistance can be seen as being as much about the promotion of human rights as it is about the promotion of human health. Human rights treaties underpin reproductive rights. Most donor countries have signed the major human rights treaties that lay the foundation for the right to reproduc- tive health. These treaties include the International Covenant on Economic, Social, and Cultural Rights adopted in 1966, which lays out the “right to health” in Article 10.2, and the International Covenant on Civil and Political Rights, also adopted in 1966, which lays out the right to liberty and security of person in Article 9(1). In 1979, the Convention on the Elimination of All Forms of Discrimination Against Women included the right to health care, including information, counseling, and fami- ly planning services in Article 14.2(b) and certain other Articles. In 1989, the Convention on the Rights of the Child established the right of women to appropriate maternal health services in Article 24(2)(d). Population assistance promotes human rights. All of these rights, taken together, build a firm basis for the right to reproductive health. Most importantly, countries that have ratified the above treaties are legally bound to protect, promote, and ensure the rights within the treaties—a fact that should encourage donor countries to invest in sexual and reproductive health services as a way to contribute to the exercise of the right to health. Reproductive Health, Population, and Development Reproductive illnesses and unintended pregnancies weaken or kill people in their most economically pro- ductive years, not only exacting a financial toll on indi- viduals and families but undermining the economic development of nations. The Millennium Development Goals, including both the overarching goal of poverty reduction and particular goals related to maternal and child health, HIV/AIDS, and gender equality, should serve to reinforce donor support for population assistance. Reproductive illnesses threaten health and impose eco- nomic costs. In sub-Saharan Africa, one-third of all dis- ability and premature death among women is due to reproductive illnesses, including complications of unsafe abortion and HIV/AIDS. Among men, one-quarter of the death and disability burden is attributed to reproductive health-related causes. These figures probably understate the impact of poor reproductive health, especially for women. In many developing countries, women earn 40 percent to 60 percent of household income, and grow 80 percent of the food consumed. This economic contribu- tion is lost when a woman dies in pregnancy or is unable to work due to poor reproductive health. Early pregnancy and lack of education contribute to a vicious cycle. For teenage girls in particular, the birth of a child often brings an end to their education, hurting their prospects for employment and their ability to provide for themselves and their children. Yet girls with a secondary education are between 3 and 13 times less likely to become mothers early in life and tend to have fewer and healthier children. Poorer and less educated women are less likely to have access to reproductive health care, with devastating results. They are more likely to die from pregnancy-related causes, to have to resort to unsafe abortion, or to have chil- dren who are malnourished or die from disease. All of these events carry both human and economic costs. HIV/AIDS exacts a human and financial toll. HIV/AIDS is cutting short the lives of people in some of the world’s poorest countries, damaging the prospects for economic development and adding to the financial burden faced by families and societies. Funerals for AIDS-related deaths are a major cause of job absenteeism and family debt in Poor men and women pay the ultimate price—their lives—for declining funding levels, weak coordination of supply procurement, and a lack of capacity to get supplies where they need to be. 8 sub-Saharan Africa. In Zambia alone, more than 2,500 teachers died of AIDS in 2001, the equivalent of 1 in 16 teachers in the country. At the World Economic Forum in 2002, AIDS experts estimated that a country with 15 per- cent of its population HIV-positive could expect its gross domestic product to decline by about 1 percent annually. Women’s ability to manage their fertility is critical to gen- der equality and reducing poverty. Access to reproductive health care, including contraceptive services, is crucial if women are to be able to make their own decisions about childbearing and, consequently, other aspects of their lives. In its absence, achieving gender equality and reducing poverty are not possible. Access to reproductive health care hastens the demographic transition. The shift from short lives and large families to long lives and small families that has occurred in the developed countries and some developing countries is due in part to access to key health interventions, such as antibiotics, immunization, and contraception. The lower birth rates—and thus slower population growth—that resulted are largely the consequence of women and men realizing their own childbearing intentions, but carried benefits for entire societies. Rapid population growth stresses the capacity of a country to feed, educate and otherwise provide for its people. It is a key factor in urban growth and increasing scarcities of water and cropland that, together with increases in working-age and school- age populations, continue to help push human develop- ment out of reach in many countries. It is critical to note, however, that in some countries today, rising death rates as a result of the HIV/AIDS pandemic are contributing unacceptably to the slowing of population growth. Access to comprehensive sexual and reproductive health services is thus doubly important to reduce AIDS-related deaths. Smaller family size supports savings and investment. Research has documented the impact of smaller family size on household savings and investment, and through these, on economic growth generally. The experience of the “Asian Tigers” points to a virtuous cycle in which use of contraception, higher levels of education among girls, and the entry of women into the work force result- ed in smaller average family size—and a high ratio of workers to dependent children. This in turn meant that both governments and families could invest more in each child, thereby ensuring their access to education and health care. Over time, both governments and households were able to save more, thereby increasing the pool of capital available for productive investments, and thus stimulating economic growth. The Cairo Conference and Burden Sharing The ICPD Programme of Action called on the interna- tional community to provide the necessary funds to meet basic reproductive health needs such as family planning, care in pregnancy and childbirth, and services for sexu- ally transmitted diseases (STDs), including HIV/AIDS (with an emphasis on prevention), and to support basic research and policy analysis on population-related issues. The emphasis was on the range of services that could be reasonably provided at the primary health care level, with referral available for more sophisticated services, such as emergency obstetric care. Thus the “costed pack- age” was born: a series of cost estimates for annual spending by 2000, 2005, 2010 and 2015 that would result in universal access to basic reproductive health care in 20 years. Nations participating in the conference agreed that the costs should be shared, with developing countries and countries in economic transition assuming two-thirds of the costs and the wealthy donor nations taking responsi- bility for the remaining one-third. For 2005, the ICPD cost estimates require US$12.4 billion in annual spend- ing by developing countries and $6.1 billion by donor countries. Adjusted for inflation, these figures would equal $15.2 billion and $7.5 billion, respectively. Developing country spending is inadequate to the need. Estimates of total spending on sexual and reproductive health by developing countries, whether by governments or individuals, are based on data that are far from com- plete. UNFPA/NIDI estimate spending at around $8 bil- lion annually from the late 1990s through 2000. Additional data from one country, China, increased that estimate by more than $3 billion for 2003. Even so, no more than a dozen developing countries account for the overwhelming bulk of what is spent—among them Brazil, China, Egypt, India, Iran, Indonesia, Mexico, Pakistan and Turkey—and some of them require very lit- tle external assistance. In contrast, all of sub-Saharan Africa accounts for less than 10 percent of these “domes- tic” expenditures and government spending per capita is inadequate to the need in almost every case. Indeed, per capita spending on sexual and reproductive health varies widely among developing countries in all parts of the world. But with respect to Africa in particular, the impact of HIV/AIDS makes the need for additional donor assistance clear. 9 A growing shortfall in the availability of the supplies needed for HIV/AIDS prevention, contraception and other vital sexual and reproductive health care services threatens the well-being of men and women in the devel- oping world. The gap between the need for donated sup- plies and the funding available to purchase them is project- ed to reach hundreds of millions of dollars annually by 2015. Supply stock-outs at the clinic level are widespread despite more than 30 years of experience by donors, NGOs, and the public and private sectors. Poor men and women pay the ultimate price—their lives—for declining funding levels, weak coordination of supply procurement, and a lack of capacity to get supplies where they need to be. Rising Need, Lack of Money among Causes of Crisis A record number of men and women are now in their reproductive years, or soon will be, due to continued population growth and the largest generation of young people that the world has ever seen. Between 2000 and 2015, the reproductive-age population in developing countries is expected to increase by more than 20 per- cent, and the number of contraceptive users by more than 40 percent. The devastating spread of HIV/AIDS, especially among young people, has also raised demand for services and protection. Despite the growing need, the availability of reproductive health supplies has been characterized by inconsistent and inadequate funding, as well as a lack of coordination at the global and national levels. Donor support, which comes from only a handful of bilateral and multilateral donors, has been erratic, and on an overall downward trend since the early 1990s. Many developing country governments have been reluctant to assume the increas- ing financial burden, while also suffering from a lack of capacity to manage procurement and supply systems. SPECIAL TOPIC The Reproductive Health Supply Challenge $ U S M IL L IO N S 0 500 1,000 1,500 2,000 2015201420132012201120102009200820072006200520042003200220012000199919981997 ■ Estimated Total Contraceptive Requirements, Including Condoms ■ Estimated Total Contraceptive Costs, Excluding Condoms ■ Donor Support Needed for Contraceptives Only (at 40.9% of Total Costs) ■ Actual Donor Support FIGURE 2 TOTAL SUPPLY NEED AND DONOR SUPPORT Source: UNFPA. 2004. Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2002. New York: UNFPA. The cost of supplies for family planning and prevention of HIV/AIDS is expected to double by 2015. 10 Falling Short of Commitments According to UNFPA, the cost of contraceptive supplies alone (not including condoms for HIV/AIDS prevention) rose from US$222 million in 1992 to an estimated $657 million in 2002, and continues to increase. Yet donor support fell from an estimated 41 percent of total supply costs (between 1992 and 1996) to 30 percent in 2002. Many developing country governments have been unable to fill the growing shortfall of funds. In addition to contraceptive supplies, the cost of con- doms needed to prevent STDs, including HIV/AIDS, will also rise—from $239 million in 2000 to $557 million in 2015—yet in 2000, donors provided barely 19 percent of the number of condoms needed to have a significant impact on the spread of HIV/AIDS. Thus the combined cost of supplies for family planning and for STD and HIV/AIDS prevention (contraceptives and condoms) is expected to nearly double over the next decade—from $1.0 billion in 2003 to $1.8 billion in 2015, while delivery and related costs will rise to $9 billion. To return to meeting 41 percent of just the needed supplies, donors would have to provide $739 million in 2015. Meeting the Need Awareness of this problem began growing in the late 1990s. Since then, a global movement of governments, institutions and individuals has mobilized to encourage governments, businesses, and non-profit groups in both rich and poor countries to take action on this urgent need. Those involved include UNFPA, the International Planned Parenthood Federation (IPPF), bilateral donors (including the United States, United Kingdom, and the Netherlands), foundations, the World Bank, advocacy NGOs and projects such as the Supply Initiative. Progress to date includes the establishment of the Reproductive Health Interchange, a Web-based tool for tracking pro- curement of supplies and related financial flows. A relat- ed initiative, the Reproductive Health Supplies Coalition, focuses on information exchange, mobilizing resources, and efforts to raise awareness and strengthen commit- ment among donor country governments. Some donors have shown concern and a willingness to help when called upon. The United Kingdom, the Netherlands and Canada provided additional funds in 2001 in response to an immediate supply crisis at UNFPA. In late 2004, the Netherlands as president of the European Union led another effort by donors to fill the supply gap, together contributing $75 million to UNFPA. Others still fail to grasp just how serious the crisis is, yet it is only through collective action that the growing shortfall of reproductive health supplies will be averted. 11 ontrary to what is often said by policymakers and pundits, public support for aid to develop- ing countries is very high. Surveys undertaken in 13 major donor nations between 1999 and 2001 show very high levels of support for development assistance. Levels of support range from 71 percent in the United Kingdom and New Zealand to 90 percent and 95 percent in the Netherlands and Ireland, respectively. Public awareness of reproductive health needs in developing countries has also improved, due in part to the HIV/AIDS pandemic. Indeed, surveys suggest that public support for government aid to improve access to family planning and to prevent and treat HIV/AIDS in developing countries is very strong. At the same time, however, public understanding of development issues and policies in general remains limited. As one observer noted with regard to Australia, public support for development aid is “a mile wide and an inch deep.” People tend to think of aid in terms of emergency or humanitarian relief, rather than long term investments in people and infrastructure. Furthermore, most members of the public know very little about what their governments actually do to improve human well- being, including in the area of sexual and reproductive health. Indeed, the term “reproductive health” is not well understood by most members of the public, particu- larly in comparison with such terms as “family plan- ning” or “contraception.” Donor Commitment Has Strengthened Overall Despite this lack of depth in public understanding of development issues, many donor governments continue to strongly support efforts to address poor sexual and repro- ductive health in their development programs, and others are joining their ranks. The governments of Denmark, the Netherlands, Norway, Sweden and the United Kingdom remain committed to these issues. Canada, a consistent voice in international policy discussions, now has clearly articulated policies addressing sexual and reproductive health needs, as does Germany. Other donors have also strengthened their policies, including Belgium, France and New Zealand, while Luxembourg and Ireland have signifi- cantly increased their funding for programs. This increased commitment to reproductive health is not universal, however. In countries such as Portugal and Spain, conservative governments have continued to neg- lect these issues (although Spain’s newly elected govern- ment is expected to dramatically change course). In addi- tion, as noted above, the U.S. government has increased restrictions on the use of its funds since 2001, most notably through the reimposition of the Global Gag Rule (also known as the Mexico City Policy), and has attempt- ed to weaken the international consensus around sexual and reproductive health in international meetings. The efforts of advocacy groups in the donor countries and the explosion of the HIV/AIDS pandemic are two factors critical to the advances in policy and funding noted above. Advocacy groups are having an impact because today, 10 years after Cairo, NGOs are more numer- ous and have far greater capacity to play a role in the poli- cy process. Whether working with parliamentarians, direct- ly with development officials, or to raise awareness among other audiences, their efforts have increasingly made a dif- ference in the policies and funding of their respective gov- ernments. Indeed, NGO advocacy has been critical to the process of bringing the HIV/AIDS pandemic to the fore- front of donor concerns. Even those governments with conservative approaches to reproductive health overall, such as Italy and Ireland, have dramatically increased their financial support for the fight against AIDS. Political leadership has also been important to recent advances in policy and funding, including that coming from Canada, Germany, the Netherlands, Sweden, United Kingdom and from the European Commission in response to the increasingly conservative stance of the U.S. govern- ment. The Bush Administration’s decision to reimpose the Mexico City Policy (termed the Global Gag Rule by its opponents) in January of 2001 brought a swift reaction from leading European donors, as did the U.S. withdrawal of funding from UNFPA in mid-2002. Several donors pledged to fill what they called the “decency gap” caused by the resulting loss of funds for IPPF (as a result of the Global Gag Rule) and UNFPA. International organizations, most notably UNFPA and UNAIDS, have also exercised leadership by continuing to call attention to the need for financial resources for both programs and supplies. Chapter 2 The Policy Environment for Population Assistance C 12 Challenges in the Policy Arena Are Diverse and Complex The challenges ahead are significant, as both the landscape and architecture of development assistance changes. Security concerns increasingly stand out in donor govern- ments’ new development assistance policies. While framed in terms of contributing to human security, efforts by donors to strengthen the security systems of aid-receiving countries—for example, to manage politically motivated violence and other conflict—have raised human rights concerns and would draw on development resources. New mechanisms for delivering aid are also having an impact on the flow of development dollars. Leading donors in the sexual and reproductive health field are giving greater support to sector-wide approaches (SWAps) and other mechanisms for channeling aid monies. While these mechanisms are a positive develop- ment in terms of their potential impact on health sys- tems and host country ownership of the development process, they increase the difficulty of prioritizing sexual and reproductive health issues. A different type of challenge is posed by the rise in politi- cal opposition to sexual and reproductive health pro- grams. While long a factor in the United States, where anti-abortion groups have sought to link family planning programs to U.S. domestic abortion politics since the 1980s, such activism has been less of a factor in Europe historically. This has begun to change, in part as U.S.- based conservative groups have increasingly reached out to like-minded Europeans. For whatever reasons, opposi- tion to reproductive rights in Europe has intensified, although to varying degrees depending on the country. Within the European Parliament, for example, the number of hostile queries directed at European Commission staff has shot up, as have efforts to portray the Commission’s support for reproductive health as “promoting abortion.” Adding to the challenge is the expansion of the European Union (EU) in May 2004. The 10 new Member States have limited experience with development assistance and, in some cases, are more conservative with respect to repro- ductive health and rights. However, many of the most active opponents of sexual and reproductive health and rights in the European Parliament hail from within the 15 pre-accession Member States. On a positive note, most donor nations have placed poverty reduction and the MDGs at the forefront of devel- opment policy. This development should reinforce donor support for population assistance, given the role of good reproductive health in reducing poverty, but also adds to the urgency of increasing the flow of resources for devel- opment aid. RECOMMENDATIONS: Strengthening Support for Population Assistance Success in securing the financial resources and policies to meet reproductive health needs requires a supportive policy environment in which the contribution of good sexual and reproductive health to overall development is recognized. A key challenge is to ensure that donors recognize sound reproductive health policies and pro- grams as crucial to reducing poverty and achieving the MDGs and, consequently, to human security. Achieving this level of understanding will require that: o NGOs engaged in advocacy on population and repro- ductive health and rights issues increase further their effort to inform and influence policymakers in the donor nations, especially parliamentarians and devel- opment officials, including those in the relevant insti- tutions of the European Union. To be successful, they must strengthen collaborative relationships with NGOs working in related fields, including HIV/AIDS, human rights, gender, youth and debt relief, as well as devel- opment NGOs more generally. NGO should also help educate other key constituencies with influence in the policy process, including environmentalists and those working in security-related fields, about the impor- tance of good sexual and reproductive health. o Donor governments ensure that their commitment to sexual and reproductive health is communicated not only to their own development agencies, but to other relevant ministries, especially ministries of finance, education, and health, as the latter are increasingly involved in aspects of development cooperation. Donor governments also need to do more to inform and edu- cate their publics about their development cooperation programs, including specific efforts to address sexual and reproductive health needs, and should enlist NGOs and other civil society actors in the effort. o Those donor governments strongly supportive of popu- lation assistance work with other governments to strengthen their commitment. This is another area in which donor country NGOs can play a role, by building and strengthening relationships across borders, and providing technical assistance where necessary, in sup- port of efforts to improve policies and funding in other donor countries, including the new EU Member States. o Major international organizations, in particular UNFPA, help ensure that sexual and reproductive health are part of policy discussions around development cooperation, both in international meetings and at the country level. 13 U.S. policies on family planning funds and funds for the fight against HIV/AIDS have negatively affected the major providers of sexual and reproductive health services in Kenya. The Mexico City Policy (Global Gag Rule) In January 2001, the Bush Administration reimposed the Mexico City Policy. Under this policy, no U.S. family planning assistance can be provided to foreign NGOs that use funding from any other source to:* o perform abortions in cases other than a threat to the life of the woman, rape or incest; o provide counseling and referral for abortion; or o lobby to make abortion legal or more available in their country. Noncompliance results in loss of funding from the U.S. Agency for International Development (USAID) for fami- ly planning services. As a result of the Mexico City Policy’s restrictions on freedom of speech, those who oppose it refer to it as the Global Gag Rule. Under the Global Gag Rule, funds are denied to foreign NGOs that choose to counsel their patients on a full range of reproductive health options when those options include abortion, even if legal in their own country. When an NGO refuses to accept the gag rule, in addition to losing U.S. family planning funds, it also loses access to USAID-donated contraceptive supplies and technical support. Its ability to form partnerships with other U.S.- funded NGOs in the country also suffers. This loss of supplies, technical support, and partnerships is often more devastating than the loss of funds. (For a detailed update on the impact of the gag rule in Ghana, see the Ghana case study: “Sexual and Reproductive Health in Ghana and the Role of Donor Assistance—A Case Study” on page 35.) The Policy’s Impact in Kenya In Kenya, the effects of the gag rule are far-reaching. The two pioneers in the field of reproductive health, the Family Planning Association of Kenya (FPAK) and Marie Stopes International Kenya (MSI Kenya), refused to accept the terms of the gag rule. As a result, they lost U.S. family planning assistance, which made up a large part of their budgets, and had to close clinics. A total of five family planning clinics (three FPAK and two MSI Kenya clinics) closed in 2001 and 2002. In some cases, these clinics were the only source of health care for local communities. Community-based outreach programs were slashed, and family planning services were scaled back. FPAK’s attempts in the past two years to raise enough money to fill the void left by the gag rule have failed. As of mid-2004, six of their 12 remaining clinics faced imminent closure. The inability of major family planning providers like FPAK to recover in the wake of the gag rule not only affects access to reproductive health services. Most fami- ly planning clinics in Kenya provide a wide range of care in addition to contraceptive counseling, such as Pap smears, child immunizations, and childhood disease management. FPAK, for example, no longer carries out child immunizations due to its budget deficit. The train- ing of nurses has also been shortchanged. In addition to the budget deficit caused by the gag rule, Kenyan reproductive health service providers are also suffering as a result of the contraceptive supply crisis in the country. Decreased donor support for contraceptive supplies in combination with logistical and distribution problems have led to severe shortages of various contra- ceptive supplies. Finally, compounding all these prob- lems is the shifting of donor attention generally toward HIV/AIDS and away from basic reproductive health care, including family planning. U.S. HIV/AIDS Assistance In recent years, HIV/AIDS has become a focus of many donors, including the United States. Providers such as FPAK face enormous difficulties in fundraising for family planning programs in a climate where HIV/AIDS is receiving all the attention. The U.S. funding available for HIV/AIDS prevention and treatment dwarfs the amounts available for family planning and other reproductive health services in Kenya. The increased funding for HIV/AIDS treatment and care is critically important, of course, but U.S. HIV assistance is subject to such restrictive guidelines that it does not encourage coordination between HIV/AIDS activities and basic reproductive health services. Given that HIV is pre- dominantly spread through heterosexual sex, a crucial SPECIAL TOPIC The Impact of U.S. Policies on Sexual and Reproductive Health in Kenya *The term “family planning assistance” refers to specific U.S. assistance for family planning and thus is different from the more broadly defined term “population assistance” used in this publication. 14 link exists between HIV/AIDS and sexual and reproduc- tive health care. Unfortunately, U.S. assistance is struc- tured in such a way that coordinating and linking with comprehensive reproductive health activities is virtually impossible, according to Godwin Mzenge, the director of FPAK. Contracts detailing the use of funds are highly restrictive and leave no space for integration of HIV/AIDS prevention or treatment efforts with reproduc- tive health activities—not even in most prevention of mother-to-child transmission (PMTCT) programs, where the link between the two is vital. As for the HIV funds we receive, we cannot use the HIV money for family planning. For example if we are providing VCT [voluntary counseling and testing] serv- ices, when our clients come in they want VCT as well as…family planning [services]. However, we cannot do this for them. —Godwin Mzenge, Director of FPAK The large influx of funds for HIV/AIDS programs also means that more people are attracted to jobs in this area. Many experts in reproductive health and family planning are moving to focus solely on HIV/AIDS. FPAK has lost almost all its senior staff to well-funded HIV/AIDS pro- grams. “So even if we manage to keep our clinics open, we have no senior personnel to run them,” Mzenge said in a recent interview. Overall, interviews with leading reproductive health service providers in Kenya reveal the general fear that even if the gag rule is lifted, the overwhelming, donor- driven focus on HIV/AIDS—to the detriment of repro- ductive health services—will remain. Implications for the Longer Term What does all this mean for Kenya in the long run? The preliminary report of the 2003 Kenya Demographic Health Survey is ominous. The deterioration of reproduc- tive health care in the country has led to a startling reversal in trends of earlier years. The proportion of women receiving antenatal care from health profession- als rose between 1989 and 1993, but consistently declined thereafter. As for skilled attendance in delivery, the share of births attended fell from 50 percent in 1993 to 42 percent of births in 2003. In addition, contraceptive use has stagnated at 39 percent of women—high com- pared with many other countries in the region, but the same in 2003 as in 1998. And women are having slightly more children, on average, than five years previously: 4.9 in 2003, up from 4.7 children in 1998. A multitude of factors are to blame for this setback. Health indicators have been in decline for more than a decade in Kenya, while donor attention to sexual and reproductive health in the country has been waning for some time. Thus while the gag rule cannot be blamed solely for the decline in reproductive health indicators, it has certainly not helped. What the Future May Bring As this is written, the repeal of the Global Gag Rule is unlikely without some change in the balance of political forces within the United States. Efforts to document the impact of the gag rule are needed, however, in order to provide the kind of evidence base that may prove influ- ential in the U.S. policy arena in the longer term. Stronger advocacy efforts can make a difference too, by encouraging all donors—including the United States—to adequately fund sexual and reproductive health activities in addition to HIV/AIDS. Advocates can also help move the donor community toward a better understanding of the importance of link- ing or coordinating reproductive health and HIV/AIDS services—for example, in the testing and treatment of sexually transmitted diseases, when educating people on safer sex, and in prenatal care or PMTCT programs. Existing reproductive health and family planning struc- tures can also be used as an entry point for HIV/AIDS prevention and treatment efforts. Together, HIV/AIDS and reproductive health efforts can more effectively stem the epidemic. 15 opulation assistance increased dramatically from 2001 to 2002, from US$2.5 billion to $3.2 billion. This total includes $2.3 billion from donor countries, $460 million from founda- tions, $328 million in loan commitments by development banks, including the World Bank, and $70 million from NGOs. Assistance from the donor countries alone increased by $594 million, from $1.7 billion to $2.3 billion, the largest one-year increase ever recorded. The backdrop to this increase in population assistance is the recent upward trend in official development assis- tance (ODA) from the major donor countries. [These are defined as members of the Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development (OECD).] After declining in the mid- to late-1990s, ODA turned dramatically upward in 2002 to reach $58.3 billion, an increase in real terms of 7 percent over the previous year. Preliminary figures for 2003 indicate a further 3.9 percent increase to $68.5 billion, the highest level ever in both nominal and real terms, according to the OECD. Three additional factors help explain the upsurge in pop- ulation assistance recorded in 2002. Most important is the increase in spending on activities reported as HIV/AIDS-related, an increase reflected in the population assistance allocations of donor countries and founda- tions, in particular. Second, reporting by some donor countries appears to have improved. This is partly due to changes in information systems for a few donors, but also to the efforts of individual staff members in donor agencies committed to the reporting process. In addition, increased cooperation among organizations that track resource flows has made cross-checking of data easier. A third factor is the more than doubling of funds from foundations, which in 2002 contributed one of every six dollars of grant population assistance. Benchmarks of Performance: 0.7 Percent and the “Fair Share” Concept Putting all these numbers in a broader economic context is important. Aid figures are usually assessed relative to gross national income (GNI), since most of the major donor countries have agreed in principle that ODA should represent 0.7 percent of national income. Donor country population assistance is assessed in a similar manner, as measurements relative to income equalize the advantage very large economies have over small ones. Donor performance in population assistance can also be assessed relative to the spending goals agreed to at the ICPD in 1994. By combining these two meas- ures—giving relative to income and the donor share of ICPD spending goals—a “fair share” of total donor commitments can be derived for each donor country. This fair share concept is a key factor in the grade assigned to each donor country in this report. Data on donor performance reveal that official develop- ment assistance represented 0.23 percent of total national income for the DAC donor countries in 2002, and rose to 0.25 percent of GNI in 2003. While this weighted average is still well below the goal of 0.7 percent, it is important to note that the average effort among DAC donor coun- tries was much higher, at 0.41 percent of GNI in 2002. This difference is due largely to the very low proportion of national income allocated for development assistance by the United States, the largest donor economy. Indeed Chapter 3 Trends in Population Assistance P $ U S M IL L IO N S 40,000 50,000 60,000 70,000 80,000 2003200220012000199919981997199619951994 FIGURE 3 TRENDS IN TOTAL OFFICIAL DEVELOPMENT ASSISTANCE, 1994-2003 Source: Organization for Economic Cooperation and Development (OECD). Net ODA from DAC Countries from 1950 to 2002. Available from www.oecd.org; Internet; accessed 5 August 2004. NB: Data for 2003 are preliminary figures. 16 the United States remains the least generous donor rela- tive to its economy, contributing just 0.13 percent of GNI for ODA in 2002 and 0.14 percent in 2003. The contributions of other large donors of development assistance also appear less generous when compared to national income. Japan, France, Germany and the United Kingdom were the next largest donors after the United States (at $13.3 billion), each providing between $5 bil- lion and $10 billion in ODA in 2002. Yet aid from France and the United Kingdom was less than 0.4 percent of GNI, while that of Japan and Germany was under 0.3 percent of GNI. Only five donor countries have met or exceeded the benchmark 0.7 percent of GNI for official development assistance: Denmark, Norway, Sweden, the Netherlands and Luxembourg. Fortunately, a number of donors have made commit- ments to increase their development assistance relative to their economies. Five countries have pledged to provide 0.7 percent of GNI for ODA before 2015: Ireland (by 2007), Belgium (2010), France and Spain (2012), and the United Kingdom (by 2013). Other donors stating their intention to increase aid levels relative to national income include Canada, Germany, and Italy. The fulfillment of these com- mitments is crucial in light of the donor community’s increasing adherence to the Millennium Development Goals, and would no doubt improve the prospects for fur- ther increases in population assistance as well. The absence of such donors as the United States and Japan—the world’s two largest economies—from the above list must be noted however, given their potential for significant increases in ODA. Indeed, if all the DAC donor countries were to allocate 0.7 percent of GNI, develop- ment assistance would roughly triple compared with 2002 levels, to more than $175 billion dollars annually. Unequal Burden Sharing and the Funding Gap Unequal burden sharing also characterizes population assistance, which lags behind agreed upon goals. The ICPD goal for donor country funding in 2005 is $7.5 bil- lion ($6.1 billion in 1993 dollars), the equivalent of 0.03 percent of GNI or $300 per million dollars of GNI. Yet donor countries allocated an average of just $93 per mil- lion dollars of GNI for population assistance in 2002. Population assistance from the donor countries would need to triple, from the $2.3 billion level of 2002, to reach the goal of $7.5 billion by 2005. For example, the United States has long been the largest bilateral donor in absolute terms, but its contribution rel- ative to income still lags well behind those of Denmark, Norway, the Netherlands and, more recently, Luxembourg. These four countries contributed an aver- age of $400 per million dollars of GNI for population assistance in 2002. The United States provided just $92 per million dollars of GNI, ranking 11th among the 22 DAC donor countries. Spain, Portugal and Greece con- tributed less than $5 of population assistance per million dollars of GNI. The priority accorded to sexual and reproductive health activities can also be seen in the annual percentage of ODA allocated for population assistance. The United States, Finland, and Luxembourg provided the largest share of their ODA budgets for population assistance in 2002, among nine DAC donor countries that allocated more than 4 percent of ODA for this purpose. Seven donors con- tributed less than 2 percent of ODA for population assis- tance, most notably France and Italy, while Austria, Spain, Portugal and Greece allocated less than one-half of 1 per- cent. Together, the 22 DAC donor countries allocated an average of 4 percent of ODA to population assistance. This weighted average is less impressive, however, given that total ODA represented just 0.23 percent of GNI in 2002. It is also worth contrasting the weighted average with the average (unweighted) effort by donors, which is just 3 per- cent of ODA for population assistance. Trends in Donor Country Contributions Given the vast differences in the size of donor country economies, the dollars provided for population assis- tance remain critically important. In 2002, the United $ U S M IL L IO N S 0 500 1,000 1,500 2,000 2,500 3,000 3,500 200220012000199919981997199619951994 o CURRENT $US o CONSTANT 1993 $US FIGURE 4 TOTAL FUNDS FOR POPULATION ASSISTANCE, 1994-2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 17 States contributed a record $963 million in population assistance. Japan, the United Kingdom and the Netherlands each contributed more than $150 million, while Germany provided slightly more than $100 million. The European Commission, an increasingly important channel of development assistance for EU Member States, allocated an estimated $180 million for popula- tion activities in 2002. Another five donor countries provided between $50 mil- lion and $100 million in population assistance in 2002, of which Norway, Denmark and Sweden are also among the most generous donors relative to the size of their economies. Six donor countries contributed between $10 million and $50 million, including Belgium, Finland and Switzerland. Italy also falls into the group, with popula- tion assistance of $22.6 million in 2002. However, it is important to note that this figure represents just 1 percent of Italian development assistance and just $19 per million dollars of GNI. In contrast, the Netherlands stands out as the fifth largest donor in dollar terms and the third most generous donor relative to national income. Trends are also important, and most donor countries have increased their population assistance since 1996. Large gains were recorded by the United States, Japan, the United Kingdom, the Netherlands, France, Canada, Norway, and Belgium. Others made significant progress relative to 1996 levels. For example, Ireland increased its population assistance more than ten-fold, from less than $1 million to $11.8 million, while Italy and Luxembourg increased their support five times. Only Australia and Spain significantly decreased their support for sexual and reproductive health activities between 1996 and 2002. As noted below, however, incomplete and inconsistent reporting by donors is among the factors that complicate the assessment of trends over time, in particular with respect to Canada, France and Spain. Foundations, Development Banks and Emerging Donors Private foundations are another source of the signifi- cant increase in funds between 1996 and 2002. Together they provided at least $460 million in 2002, a near doubling of funds over 2001 levels and a five-fold increase since 1996. The bulk of this support has come from U.S.-based foundations, although a small number of foundations in Europe and Japan also make signifi- cant contributions to the field. Among the largest donors in 2002 were the Bill & Melinda Gates Foundation, The William and Flora Hewlett Foundation, the United Nations Foundation, and the OPEC Fund for International Development. In contrast to the develop- ment banks, which provide their support overwhelming- ly in the form of loans, foundations provide grants, Japan 16% United States 42% Germany 8% All other donors 8% United Kingdom 6% Australia 2% Netherlands 2% Canada 3% Spain 3% Italy 5% France 6% FIGURE 5 RELATIVE SIZE OF DONOR ECONOMIES, 2002 (Percentage of combined donor country GNI) Source: Organization for Economic Cooperation and Development (OECD). 2004. Development Cooperation 2003 Report. Paris: OECD. Total GNI US$24.8 trillion Population assistance from the donor countries would need to triple, from the $2.3 billion level of 2002, to reach the goal of $7.5 billion by 2005. 18 which in 2002 represented 16 percent of grant population assistance from all sources. The population assistance loans provided by the devel- opment banks are another important source of funds. As loans, they can be viewed as the funds of last resort, but may also be seen as evidence of a borrowing coun- try’s commitment to the sexual and reproductive health of its people. Development bank commitments averaged at least $450 million annually over the period 1996-2002, although only World Bank loans were reported in 2002. These totaled $328 million, of which $232 million were highly concessional (low interest) loans from the International Development Association (IDA). The importance of the charitable foundations and develop- ment banks—in particular the World Bank—goes beyond their financial contributions. Foundations have often taken on controversial or neglected issues—such as adolescent rights, sex trafficking, the shortfall in reproductive health supplies, and abortion—that may be avoided by donor governments, and in so doing encouraged government U.S. DOLLARS Denmark Norway Netherlands Luxembourg Sweden Finland Belgium Ireland Canada United Kingdom United States Switzerland New Zealand France Australia Germany Japan Italy Austria Spain Portugal Greece 0 100 200 300 400 500 433 423 399 391 256 185 178 119 115 106 92 79 60 58 55 54 44 19 7 5 5 0.4 FIGURE 6 DONOR COUNTRY POPULATION ASSISTANCE PER MILLION DOLLARS OF GNI, 2002 Sources: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA; and Organization for Economic Cooperation and Development (OECD). 2004. Development Cooperation 2003 Report. Paris: OECD. 19 action. The World Bank exerts significant influence both on other donors and on national-level policies and invest- ments in sexual and reproductive health programs through its important role in the policy process including, for exam- ple, with respect to poverty reduction strategies. In addition to the new EU Member States, other emerg- ing donors could be expected to play a role in the sexual and reproductive health field. For example, the Republic of Korea (South Korea) provided $279 million in develop- ment assistance in 2002, more than such countries as Greece, Luxembourg and New Zealand, and Turkey increased its ODA to $73 million. Exchange of technical expertise is another means of sharing resources and was the idea behind the establishment in 1994 of Partners in Population and Development (PPD), a consortium of 20 countries. Thailand, a member of PPD, announced in the fall of 2004 its decision to establish a full-fledged inter- national cooperation and development agency. PERCENT OF OFFICIAL DEVELOPMENT ASSISTANCE United States Finland Luxembourg Netherlands Norway Denmark Switzerland Canada Belgium United Kingdom Sweden Ireland New Zealand Australia Germany Japan France Italy Austria Spain Portugal Greece 0 1 2 3 4 5 6 7 8 7.3 5.3 5.1 4.9 4.8 4.5 4.5 4.1 4.1 3.4 3.1 3.0 2.7 2.2 2.0 1.9 1.5 1.0 0.3 0.2 0.2 0.02 FIGURE 7 SHARE OF OFFICIAL DEVELOPMENT ASSISTANCE ALLOCATED TO POPULATION ASSISTANCE, BY COUNTRY, 2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 20 Progress Toward ICPD Goals The major donor nations deserve praise for the increases in overall development assistance and in support for sex- ual and reproductive health programs. Recent commit- ments to future increases in ODA and strong policy state- ments on sexual and reproductive health issues from cer- tain key donors are also cause for optimism. There is still far to go, however. While donor countries improved their performance in 2002, they would still need to increase their population assistance three-fold, in real terms, to reach the spending goal for donors endorsed at the ICPD. Taking into account all grants for population assistance in 2002, including those from foundations, NGOs, and other sources (but excluding bank loans), the donor communi- ty still provided only 40 percent of estimated need as spelled out in the ICPD Programme of Action. For individual countries, the progress required to achieve a “fair share” of the year 2005 goal of $7.5 billion differs greatly. The United States would need to raise its popula- tion assistance by the largest dollar amount—more than $US MILLIONS United States European Union Japan United Kingdom Netherlands Germany France Canada Norway Denmark Sweden Belgium Finland Switzerland Italy Australia Ireland Luxembourg Spain New Zealand Austria Portugal Greece 0 200 400 600 800 1000 963.0 184.9 180.2 168.8 164.3 106.8 83.7 82.8 80.8 73.8 61.1 44.1 24.4 23.4 22.6 21.3 11.8 7.5 3.3 3.3 1.5 0.6 0.1 FIGURE 8 POPULATION ASSISTANCE BY DONOR COUNTRY, 2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 21 a three-fold increase—from $963 million to $3.2 billion. Japan would need to spend an additional $1 billion, for a total of $1.2 billion. Portugal, Spain and Austria face the largest relative shortfall, each needing to increase its budget allocations more than 40 times. Other donors fac- ing large increases if they are to provide their fair share include Germany ($500 million in additional funds), France ($350 million), and both the United Kingdom and Italy (more than $300 million). While a useful tool for assessing performance, the finan- cial goals agreed to in Cairo were based on projections of resource needs that took into account only a limited range of sexual and reproductive health needs. For exam- ple, the ICPD cost estimates did not include the care, treat- ment and support components necessary to fully address the HIV/AIDS pandemic. Of the $18.5 billion required spending projected for 2005 (equal to about $23 billion if adjusted for inflation), the ICPD Programme of Action allo- cated $1.4 billion to cover four of the recommended HIV/AIDS prevention interventions. New cost estimates from UNAIDS include $6 billion for the full range of pre- vention interventions, $3.8 billion for care and treatment programs, and $1.1 billion for support programs, with total resource needs estimated at $12 billion in 2005 and $20 bil- lion for 2007. Given the scale of resources needed for HIV/AIDS, a more accurate estimate of the financial resources needed to improve sexual and reproductive health overall would incorporate elements of both the origi- nal ICPD estimates and UNAIDS estimates. Such a reassessment of total resource requirements is increas- ingly needed, given that in 1999 the definition of popula- tion assistance used in tracking financial flows was broadened to include the full range of HIV/AIDS inter- ventions (see the section, Population Assistance: Changing Definitions, for more details). Of course, there are synergies that can be realized through improved coordination and, where appropriate, integration of TABLE 2 RESOURCES NEEDED TO REACH ICPD YEAR 2005 GOAL FOR DONOR POPULATION ASSISTANCE 2002 Population Assistance 2005 ICPD Goal 2005 ICPD Goal Multiplier to ($US millions) (1993 $US millions) (2002 $US millions) reach 2005 goal Denmark $ 73.8 $ 42.1 $ 51.9 — Norway $ 80.8 $ 47.2 $ 58.1 — Netherlands $ 164.3 $ 101.7 $ 125.3 — Luxembourg $ 7.5 $ 4.7 $ 5.8 — Sweden $ 61.1 $ 58.9 $ 72.6 1.2 Finland $ 24.4 $ 32.4 $ 40.0 1.6 Belgium $ 44.1 $ 61.2 $ 75.4 1.7 Ireland $ 11.8 $ 24.4 $ 30.1 2.6 Canada $ 82.8 $ 177.4 $ 218.5 2.6 United Kingdom $ 168.8 $ 394.0 $ 485.4 2.9 United States $ 963.0 $ 2,591.6 $ 3,192.2 3.3 Switzerland $ 23.4 $ 73.4 $ 90.4 3.9 New Zealand $ 3.3 $ 13.5 $ 16.7 5.1 France $ 83.7 $ 355.6 $ 438.0 5.2 Australia $ 21.3 $ 95.6 $ 117.7 5.5 Germany $ 106.8 $ 491.0 $ 604.8 5.7 Japan $ 180.2 $ 1,004.3 $ 1,237.0 6.9 Italy $ 22.6 $ 290.2 $ 357.4 15.8 Austria $ 1.5 $ 50.4 $ 62.0 40.8 Spain $ 3.3 $ 161.0 $ 198.3 60.3 Portugal $ 0.6 $ 29.3 $ 36.1 63.3 European Commission $ 184.9 NA NA NA TOTAL $ 2,313.8 $ 6,100.0 $ 7,513.7 3.2 Note: Each donor’s share of the $6.1 billion donor target for the year 2005 was estimated based on its proportional share of aggregate 2002 GNI for the donor community. Division of each country’s year 2005 goal by its 2002 level of assistance may not be equal to multiplier due to rounding. Data for population assistance taken from UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 22 THE CHANGING ARCHITECTURE OF AID: Poverty Reduction Strategies and Sector-Wide Approaches Dissatisfaction with the limited success of traditional development aid was reaching a peak even before the adoption in 2000 of the Millennium Development Goals and their overarching goal of poverty reduction. The 1990s were also a time of increasing deterioration of health services in many developing countries, especially in sub-Saharan Africa. Key donors, including the World Bank, European Commission and several Northern European countries, sought a more country-driven way to identify and prioritize development needs. Two major responses emerged: the poverty reduction strategy (PRS) process and health sector reform. Both have their counterparts in donor financing: a shift away from narrower, project-oriented support and toward “pooled” budget or sector support. The poverty reduction strategy (PRS) process was ini- tiated by the World Bank in 1999. Central to the PRS process is a poverty reduction strategy paper (PRSP) that diagnoses the factors contributing to poverty in a particular country, identifies and prioritizes relevant policies, and details the indicators for measuring progress. Led in theory by country governments, but with significant involvement by donors, PRSP develop- ment is supposed to include civil society. PRSPs are the basis for highly concessional loans and/or debt relief from the World Bank and, increasingly, for grant assis- tance from other donors as well. The intent of health sector reform is to improve a pop- ulation’s health by making health services more afford- able, equitable, and responsive to consumer needs. These aims mirror key goals of the ICPD Programme of Action, which emphasized the role of the primary health care system in delivering reproductive health services. In practice, a number of obstacles to improv- ing access may arise, given that a primary impetus for reform is inadequate financial resources in the face of increasing demand for services. For countries significantly dependent on donor assis- tance, reform may be linked to a “SWAp,” a sector-wide approach. In this, donors and country governments agree on a policy and a spending plan, and donors move toward supporting the health sector as a whole, rather than funding specific projects or targeted programs. As in the PRS process, much responsibility is handed to country governments for implementation of reform and administration of aid funds through a set of procedures and guidelines defined collaboratively with donors. HIV/AIDS interventions with other sexual and reproduc- tive health services. Indeed, such synergy is critical to ensuring the long-term effectiveness of HIV/AIDS and reproductive health interventions, and would result in some cost savings as well. Challenges to Assessing Donor Contributions Two key factors further complicate efforts to assess donor progress in support of sexual and reproductive health. First, many donors encounter difficulties in reporting population assistance accurately. This is due in part to complex reporting requirements by organizations that track financial flows, but also to deficiencies in donor information systems and the lack of sufficient administrative staff. Accurate reporting is further chal- lenged by decentralization, which many donors are implementing as a way to shift authority and responsibil- ity for funding and programmatic decisions closer to where the needs are. Again, information systems and staffing are often inadequate to handle reporting needs. Second, leading donors in the field are moving away from providing funds for specific projects, in favor of providing funds to strengthen an entire sector (such as health), or contributing to a government’s overall budget. This trend comes on top of the difficulty of reporting, for example, on the reproductive health component of an integrated development project that crosses sectoral lines. In this context, performance will need to be assessed against indicators of outcome and impact, rather than money inflows. While the second development noted above may compli- cate tracking of financial flows for specific types of health interventions, it is good news overall. Health sys- tems in many developing countries need to be strength- ened, especially in sub-Saharan Africa. The donor com- munity is responding to this need and indeed, aid to the health sector has gone up since 1975, even when overall development assistance trended downward. A more inte- grated approach to health care delivery is also a key ele- ment of the ICPD Programme of Action, which recog- nized that stand-alone, vertical programs may improve one aspect of health but neglect others—to the detriment of overall health status. For all the reasons noted above, the bottom line on donor progress toward ICPD goals is not easy to read. Donor performance has clearly improved, but population assistance—and assistance to the health sector general- ly—will have to increase much faster in the future if it is to meet urgent and growing sexual and reproductive health needs. And the goalposts for assessing perform- ance will need readjusting as well. 23 RECOMMENDATIONS: Increasing Donor Country Financial Contributions Generating the financial resources needed to address sexual and reproductive health needs in developing and transition countries will require that: o Donor countries, including in particular the United States and Japan, increase their allocations of development assistance to meet the goal of 0.7 percent of gross national income for ODA. A majority of donor nations also need to increase the share of development assis- tance allocated for sexual and reproductive health activi- ties, in particular France, Italy and Spain. Those donor nations needing to increase their population assistance quickly should contribute more to international organiza- tions, including UNFPA and IPPF. Together, these steps would allow the burden of population assistance to be more equitably shared among countries. o NGOs strengthen their advocacy efforts in support of overall development assistance. A bigger pie is needed if social development needs are to be met, and it will be difficult to secure additional funds for sexual and reproductive health programs if other development and humanitarian programs are seen to suffer. o Donor nations strengthen their information systems and related staffing as needed to ensure accurate track- ing of financial transactions. The donor community and developing country governments must work together to increase the technical capacity of develop- ing country institutions to track health expenditures, including sexual and reproductive health spending. A similar effort is needed to strengthen developing coun- try capacity for the collection and analysis of health statistics, especially those identified as indicators for assessing reproductive health status. o Donors, developing country governments and civil society ensure that sexual and reproductive health needs are addressed in health sector planning and throughout the poverty reduction strategy process, including with regard to identifying and tracking out- comes and impacts. Thus there is a need for capacity building to ensure that government officials, parlia- mentarians and civil society organizations are able to participate actively and effectively in resource alloca- tion processes. They must be able to demonstrate the economic as well as the social benefits of investing in sexual and reproductive health. At the same time, donors and developing country governments must work together to ensure that civil society (NGOs and others) has a real voice in decision-making processes about health sector and overall budget priorities. o The increased flow of funds for HIV/AIDS activities be additive to existing funding levels and not take away resources from other critical sexual and reproductive health services, such as maternal health care and family planning. 24 The ICPD Programme of Action included estimates of financial resource needs for a set of basic reproductive health interventions plus population-related research to be implemented in developing countries and coun- tries in economic transition. The goal was “universal access to a full range of safe and reliable family-plan- ning methods and to related reproductive health serv- ices which are not against the law” by 2015. Total expenditures needed for this so-called “costed pack- age” were estimated in 1994 at US$17.0 billion annually in 2000, rising to $18.5 billion in 2005, $20.5 billion in 2010 and $21.7 billion in 2015 (all figures expressed in 1993 constant dollars). It was agreed that wealthy donor countries should shoulder one-third of the total, while developing and transition countries would shoulder two- thirds. Thus, in 2005, the donor share of the burden would be $6.1 billion, the equivalent of more than $7.5 billion in 2002 dollar terms. Prior to the 1994 conference, population assistance had primarily been defined as funding for family plan- ning services. After 1994 and in keeping with the Programme of Action, population assistance was rede- fined to encompass the broader reproductive health agenda, organized around four major components, each comprising specific activities. The ICPD Costed Package o family planning services: contraceptive supplies and service delivery; capacity building for information, education and communication on family planning, population and development issues; national capacity building through support for training; infrastructure development and upgrading of facilities; policy devel- opment and program evaluation; management infor- mation systems; basic service statistics; and efforts to ensure good-quality care. o basic reproductive health services: information and routine services for prenatal, normal and safe delivery and post-natal care; abortion;* information, education, and communication about reproductive health, includ- ing sexually transmitted diseases, human sexuality and responsible parenthood, and against harmful practices; adequate counseling; diagnosis and treatment of sexu- ally transmitted diseases (STDs) and other reproduc- tive tract infections, as feasible; prevention of infertili- ty and appropriate treatment where feasible; and refer- rals, education and counseling services for sexually transmitted diseases, including HIV/AIDS, and for complications of pregnancy and delivery. o STD and HIV/AIDS prevention programs: mass media and in-school education programs; promotion of voluntary sexual abstinence and responsible sexual behavior; and expanded distribution of condoms. o basic research, data and population and develop- ment policy analysis: national capacity building through support for demographic and program-related data collection and analysis, research and policy devel- opment, and training. Shifting Categories Prior to the Cairo conference, UNFPA tracked population spending in two major categories. So-called “core activi- ties” included family planning, population education and communication, population policy, demographic research, other population-related data collection and analysis. A second and much smaller category covered those activities that, while part of population assistance programs, did not meet the definition for core activities, such as efforts to improve women’s status. Overall, core activities dominated total population assistance. Since the ICPD, UNFPA has reformulated the defini- tion of population assistance used in its tracking of resource flows three times. The first change came in 1995, in order to more closely (but not identically) reflect the outcomes of the conference. In 1996, further changes were made, the most important being the shift of those STD/HIV activities previously captured under “basic reproductive health care” to the STD/HIV category, in order to ease the tracking of resource flows for this set of activities. The most recent change in definition occurred in 1999, when the Netherlands Interdisciplinary Demographic Institute (NIDI), which tracks financial resource flows on behalf of UNFPA and (since 1999) UNAIDS, began tracking flows for all AIDS-related activi- ties: prevention, treatment, care and support. At that time, funding for treatment and care accounted for only a small share of HIV/AIDS activities. These changes in definitions complicate the task of tracking and evaluating funding trends over time, in particular with regard to data prior to 1995 and fol- lowing the definitional changes of 1999. While other challenges to tracking resource flows are noted elsewhere in this report, it is important to note here the inherent tension between the need for comprehensive and inte- grated sexual and reproductive health programs in the field and the desire by those monitoring resource flows for disaggregated data. Population Assistance: Changing Definitions *As specified in paragraph 8.25 of the ICPD Programme of Action. 25 he geographic and programmatic allocations of population assistance vary greatly within the donor community. Historical and cultural ties, domestic political considerations, and geopolitical concerns are among the factors influencing decisions about development assistance overall. These factors play a role in allocations of pop- ulation assistance, as do relative reproductive health needs among partner countries. The commitment of leading donors to the overarching goal of poverty reduction and to achieving the Millennium Development Goals is reinforcing a needs-based approach to development cooperation. This trend has positive impli- cations for the priority accorded to sexual and reproduc- tive health issues, as does the growing attention paid by donors to issues of governance and human rights. Lastly, the presence of conflict also affects funding decisions, as it can pose a major obstacle to the provision of aid; this has been the case in recent years in such countries as Afghanistan, Côte d’Ivoire, Sierra Leone, Somalia, Sudan and several Central African countries. Geographic Priorities The most notable shift in geographic allocations of popu- lation assistance was the tripling of spending on global or inter-regional programs between 1996 and 2002, to US$1.2 billion. Far less dramatic are the shifts in propor- tional funding levels among the regions. For example, while the shares of funds going to both the Latin America and Caribbean region and the Asia-Pacific region have declined, the volume of funds has still increased. Indeed, all regions have seen their population assistance increase between 1996 and 2002, reflecting the overall increase in expenditures from $1.5 billion to $3.1 billion, an increase of 80 percent in real terms. The flow of resources to sub-Saharan Africa doubled between 1996 and 2002, to more than $850 million, as the donor response to HIV/AIDS and other sexual and reproductive health needs gained strength. Funding for Eastern and Southern Europe also doubled, although total funds were less than $50 million in 2002. Funds flowing to both the Asia-Pacific and Western Asia/North Africa increased by roughly 50 percent. The volume of funds going to the Asia-Pacific region was much larger, at $562 million in 2002, due to the much larger and poorer population in that region. Finally, population assistance to Latin America and the Caribbean increased by about 25 percent, to more than $250 million in 2002. At the country level, allocations of population assistance vary much more. Funding levels do not necessarily cor- respond to either reproductive health needs or the ability of countries to bear more of the costs, due in part to some of the political considerations noted earlier. Also important is the capacity—and willingness—of a host government to prioritize sexual and reproductive health efforts. While an exhaustive analysis is not possible here, Figure 11 shows the top 20 recipients of population assis- tance on a per capita basis in 1996 and 2002. For exam- ple, Uganda continues to be favored by donors, and con- sistently receives high levels of population assistance in both absolute terms and on a per capita basis, the latter reaching $2.18 per capita in 2002. In contrast, the impact of conflict can be seen in countries such as Somalia and Sudan, which despite abysmal reproductive health indi- cators receive just pennies per capita. Meanwhile, Mozambique has only recently made it onto the list of leading recipients, despite poor reproductive health among women, high infant mortality, and very low per capita income. Program Priorities The range of sexual and reproductive health activities supported by different donors is generally more difficult to capture than the geographic allocation of financial resources. For example, multilateral contributions from donor governments are generally not assigned to a spe- Chapter 4 Geographic and Program Priorities T At the country level, funding does not always correspond to reproductive health needs. 26 cific type of activity, but to overall support for the organ- ization. Funds passing through NGOs are also often not reported by the donor as to the specific activity being supported. It is possible to see how financial resources are allocated globally, thanks to the work done by UNFPA and NIDI, as well as the OECD/DAC. While expenditure data are slightly different than the budgetary allocations discussed above, the trend was also solidly upwards in 2002. Final expenditures— excluding loans—reached $3.1 billion in 2002, an increase of $1 billion over the previous year. It is in this data that the impact of the HIV/AIDS epidemic is most clearly visible. Spending on HIV/AIDS activities increased from $800 million in 2001 to $1,343 million in 2002, an increase of more than $500 million. Spending on basic reproductive health service and family planning also increased, from $1,107 million in 2001 to $1,467 mil- lion, for an increase of more than $350 million, while research activities absorbed $312 million, again an increase compared with the $164 million spent in 2001. When compared with 1996 figures, the growth of expen- ditures for HIV/AIDS activities appears far more dramat- ic, keeping in mind the expanded range of HIV/AIDS activities (prevention, care, treatment and support) now tracked within population assistance. Thus while spend- ing on reproductive health and family planning together increased by 20 percent, in real terms, HIV/AIDS expen- ditures witnessed a nearly four-fold increase. 1996 Total Assistance US$1,511 Million Global/Inter-Regional 26% Asia and the Pacific 24% Latin America and the Caribbean 13% Western Asia and North Africa 7% Eastern and Southern Europe 2% Sub-Saharan Africa 28% Global/Inter-Regional 40% Asia and the Pacific 18% Latin America and the Caribbean 8% Western Asia and North Africa 5% Eastern and Southern Europe 2% Sub-Saharan Africa 27% 2002 Total Assistance US$3,123 Million FIGURE 9 DISTRIBUTION OF POPULATION ASSISTANCE BY REGION, 1996 AND 2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 27 FIGURE 10 TOP TWENTY RECIPIENTS OF POPULATION ASSISTANCE PER CAPITA 2002 1996 Botswana Zambia Nicaragua Malawi Jordan Bolivia Namibia Jamaica Haiti Cambodia Uganda Guatemala Mozambique Honduras Eritrea Swaziland Mauritania Mali Kyrgyzstan Kenya 7.16 4.32 3.42 3.26 3.08 2.82 2.65 2.52 2.49 2.32 2.18 2.11 2.10 2.10 2.08 1.98 1.96 1.80 1.70 1.55 0.00 1.00 2.00 3.00 4.00 $US 5.00 6.00 7.00 8.00 $US Haiti Nicaragua Malawi Botswana Senegal Bolivia Jamaica Namibia Zambia Guinea-Bissau Zimbabwe Mali Uganda Jordan Swaziland Papua New Guinea Honduras Morocco Dominican Republic Tanzania 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 3.44 2.92 2.67 2.41 2.21 2.17 1.79 1.66 1.57 1.49 1.45 1.37 1.29 1.24 1.19 1.18 1.17 1.06 1.02 1.01 Sources: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA; Population Reference Bureau (PRB). 2002. 2002 World Population Data Sheet. Washington, DC: PRB. Sources: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA; Population Reference Bureau (PRB). 1996. World Population Data Sheet 1996. Washington, DC: PRB. 28 More detail on the relative programmatic emphases of different donors can be found in the individual profiles that follow. In general, it is important to note the prefer- ence of many donors to support comprehensive repro- ductive health programs that integrate care in pregnancy, family planning, STD/HIV/AIDS prevention and treat- ment and other services. Donors are also increasing their support for sector-wide, more systems-oriented approaches to the provision of health care. For these rea- sons, the breakdown by activity illustrated in Figure 11 does not represent how services are actually delivered. Indeed, some donors no longer report funding for family planning separately from other reproductive health activ- ities, in most cases because they view the ability to con- trol one’s own fertility as central to good reproductive health and the exercise of reproductive rights. As the flow of financial resources continues to increase in sup- port of the fight against HIV/AIDS, all donors will face the challenge of ensuring that this kind of comprehen- sive approach to meeting sexual and reproductive health needs is embraced. It is important to note that services for adolescents, reproductive health supplies, and unsafe abortion are critical priorities in sexual and reproductive health pro- gramming for which the flow of resources is difficult to assess. As noted above, half the world’s population of 6.4 billion is under age 25, and more than 1 billion of them are 10 to 19 years old. While several important donors support the provision of information and services to young people, others shy away or, in the case of the United States, are shifting resources to approaches that have been shown to be ineffective. Supplies are crucial to success in meeting the reproduc- tive health needs of young people, as well as the mil- lions of other women and men with little or no access to services. Yet there is a growing shortfall in the availabili- ty of the supplies needed for HIV/AIDS prevention, con- traception (including emergency contraception) and other vital reproductive health services. Supply stockouts at the clinic level are widespread, and the gap between the need for donated supplies and the funding available for purchasing them is rising. Only a handful of donors, led by the United States, UNFPA, World Bank, Germany and the United Kingdom, provide ongoing, significant resources for the provision of supplies. Thus the recent efforts by these donors to coordinate activities take on added importance, as do the efforts of the Supply Initiative and private donors to address this problem. Finally, the continuing toll of unsafe abortion on women’s lives and health is one that too few donors address. While increasing access to contraception has been proven to reduce abortions, it is critical that abor- tion services be safe and accessible to the full extent of the law. This requires supplies, training for doctors and other medical personnel, and adequate facilities. Again, many donors are reluctant to address this area of repro- ductive health, often hesitating even to support access to post-abortion care. $ U S M IL L IO N S ( C U R R E N T ) 0 300 600 900 1,200 1,500 20022001200019991998199719961995 o Family Planning Services o Basic Reproductive Health Services o Sexually Transmitted Diseases and HIV/AIDS Activities o Basic Research, Data and Population and Development Policy Analysis FIGURE 11 FINAL POPULATION ASSISTANCE EXPENDITURES BY TYPE OF ACTIVITY, 1995-2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. NB: The development banks are not included in the final expenditures shown, as the banks' loan agreements are often disbursed over several years. Distribution for Germany in 2002 has been partially estimated based on 2001 percentages. Distribution for Luxembourg in 2002 has been estimated based on 2001 data. Distribution for Italy in 2002 has been estimated based on 2000 data. Distribution for the EU in 2002 has been estimated by NIDI based on data from the European Commission and the DAC Watch of the EU, IPPF, January 2002. 29 There is an urgent need for donors to balance their own population assistance priorities with program- matic needs at the country, regional and international levels. This will require that: o Donor governments and other donor institutions ensure that population assistance is allocated according to need, taking into account sexual and reproductive health status, income levels, and other relevant indica- tors. To this end, donors must strengthen coordination at the regional and international levels and support the efforts of developing country governments to strengthen coordinating mechanisms at the country level. Efforts to harmonize aid programs, in terms of reporting and other requirements, are also critically important. o Donors ensure that population assistance funds embrace the linkages between reproductive health and HIV/AIDS, as well as linkages between reproductive health and broader health issues. For example, family planning and voluntary counseling and testing should be included in programs for prevention of mother-to- child transmission, as recommended in the Glion Call to Action of May 2004. People benefiting from HIV/AIDS programs should also have access to an essential package of sexual and reproductive health information and services, and vice versa, as endorsed in the New York Call to Commitment (June 2004). o Donor governments and other members of the donor community increase their support for controversial and neglected aspects of sexual and reproductive health programs. This would include funding for reproductive health supplies—including contraceptives and condoms for HIV/AIDS prevention—and to strengthen capacity for logistics in host countries. Another priority should be to ensure that medical and other personnel are ade- quately trained in critical aspects of reproductive health care, including emergency obstetric care, safe abortion, and post-abortion care, as well as any applicable laws. Donors should also allocate sufficient resources for building and strengthening capacity among partner institutions, including NGOs, to work in unfamiliar aspects of sexual and reproductive health, such as HIV/AIDS, abortion care, female genital mutilation/cut- ting, and services for young people. NGOs, including IPPF and its member associations, can help these efforts through advocacy in support of reproductive health activities considered controversial by donors or recipient countries. o All donors and their partners ensure that population assistance funds are not burdened by conditions or restrictions that reduce the effectiveness of service delivery and limit their ability to be used for compre- hensive and integrated health programs. Restrictions on funding that violate international human rights standards are also inimical to the effectiveness of population assistance. RECOMMENDATIONS: Improving the Allocation of Population Assistance Funds Supplies are crucial to success in meeting the reproductive health needs of young people, as well as the millions of other women and men with little or no access to services. 30 he donor community has traditionally relied upon three principal channels in disbursing population assistance funds: bilateral, multi- lateral, and NGOs. In recent years, the ear- marking of bilateral funds by donors for spe- cific projects in collaboration with multilateral organi- zations, so-called “multi-bilateral” aid, has grown in importance. Various factors influence donor preference for each of these channels, including staff capacity, the capacity of civil society organizations with which they collaborate, and differing perspectives on the role and effectiveness of each. Donor Government Use of Channels Donor governments continue to be the largest single source of international population assistance, and in 2002 supplied more than two-thirds of all funds. The donor community provided its US$2.3 billion in assis- tance through four major channels: bilateral, multilater- al, multi-bilateral and NGOs. o The bilateral channel consists of funds that flow directly from donor governments to recipient country governments; o The multilateral channel consists of funds not ear- marked for specific population activities or projects that are provided to multilateral organizations such as UNAIDS, UNFPA and WHO; o The multi-bilateral channel consists of bilateral funds that are earmarked for specific activities or projects that are sent through multilateral organizations; and o The NGO channel consists of general contributions to NGOs active in the field of sexual and reproductive health and bilateral expenditures for specific popula- tion activities that are executed by NGOs. Since the mid-1990s, donor governments have tended to channel an increasing volume of population assistance funds through bilateral programs and NGOs. Core fund- ing of multilateral organizations such as UNFPA was only slightly higher in 2002 than in 1996, while donors doubled their earmarking of funds for activities under- taken in collaboration with multilateral organizations (multi-bilateral aid). In 2002, donor governments supplied 34 percent of their population assistance through bilateral channels, 18 per- cent through multilateral organizations, 4 percent as multi-bilateral assistance, and 44 percent went to NGOs. Figure 13 illustrates how the DAC donor countries and European Commission channeled their assistance in 2002. Bilateral funding increased from slightly more than $500 million in 1996 to nearly $800 million in 2002, while NGOs received nearly $1.2 billion from donor governments, a near doubling of funds since 1996. Donor government contributions to multilateral organiza- tions rose significantly in 2000 and 2001, increasing from $395 million in 1999 to $470 million in 2001, but dropped to an estimated $427 million in 2002 and were thus only slightly higher than in 1996. Finally, use of the multi-bilateral channel, although still the smallest share of assistance, has more than doubled since 1996 to almost $100 million. This indicates the increased use of earmarked funds for activities undertaken in collabora- tion with multilateral organizations. Expenditure data for 2002, which take into account the additional funds channeled to programs by foundations in particular, illustrate even more clearly the role of NGOs in the field. Of the $3.1 billion in expenditures that year, 57 percent ($1.8 billion) went to NGOs. These shifts in funding patterns have coincided with the continued expansion of bilateral programs by sever- al leading donors, including Germany, Japan, the Netherlands and the United Kingdom. Among donor countries that have increased their bilateral program- ming, however, most have maintained or even increased their support for multilateral institutions such as UNFPA. Meanwhile, the increased volume of funds passing to NGOs likely reflects three factors: the increased capacity of organizations in donor countries, the growing emphasis on funding NGOs in developing countries, and their role in the fight against HIV/AIDS. Within the NGO community, it is important to note the vital role of international NGOs such as IPPF. Its net- work of member associations spans the developed and developing world, providing valued services and, increasingly, acting as a forceful advocate for sexual and reproductive health priorities. Chapter 5 Population Assistance Channels T 31 Multilateral Organizations and International Partnerships UNFPA, UNAIDS, WHO and other multilateral organiza- tions also play a crucial role in the sexual and reproduc- tive health field. With programs in 140 countries, UNFPA has broad reach and can help fill the gaps when other donors shift funding priorities. Multilateral organizations are often viewed as more neutral by host country gov- ernments and institutions, thereby providing these organ- izations with an opportunity to influence the develop- ment of program agendas. These organizations also have an important role as advocates for their issues in policy discussions, whether at the national, regional or interna- tional level. Since its formal launch in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria has emerged as another key player in the field, helping to ensure that HIV/AIDS efforts are effectively coordinated and funded at the country level. 0 20 40 60 80 100 PERCENT OF TOTAL POPULATION ASSISTANCE Germany United Kingdom Australia Luxembourg Ireland Sweden Netherlands Italy Portugal Japan France United States Canada Austria Switzerland Finland Denmark Belgium Norway New Zealand Greece Spain European Union ■ Bilateral ■ Multi-Bilateral ■ Multilateral ■ NGO FIGURE 12 ALLOCATION OF POPULATION ASSISTANCE FUNDS BY DONOR COUNTRY AND CHANNEL, 2002 Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. NB: For notes, see those in Appendix 5. 32 It is important to note the growth of the European Commission as a channel for development assistance from the EU Member States. While still struggling to increase the efficiency of its complex bureaucracy, EC assistance for sexual and reproductive health efforts con- tinues to increase. In addition to its population assis- tance, the EC’s role as an agent of change within the European Union is also important, helping move for- ward the policy process within EU institutions, such as the European Parliament. EC representatives, in par- ticular former Development Commissioner Poul Nielson, have been vocal and consistent advocates of forward- looking sexual and reproductive health policies. The European Commission’s role as both an implementer of programs and a voice on policy issues will be tested over the next few years, as new Member States are incorpo- rated into the Commission’s governance and also encouraged to become donors themselves. RECOMMENDATIONS: Strengthening Population Assistance Channels The donor countries vary significantly in their approaches to programming of population assistance funds, including their preferred channels of assis- tance. Given the diverse needs and political contexts of recipient countries, donors should recognize the importance of effective and complementary channels for programming population assistance funds. Strengthening and enhancing the effectiveness of pop- ulation assistance channels will require that: o Donor country governments review their contributions to international organizations (UNFPA, UNAIDS, WHO, UNICEF and others) to ensure that their roles in improving sexual and reproductive health are ade- quately supported and encouraged. Those donor gov- ernments that provide little support for UNFPA relative to their economic capacity, in particular France, Italy and Spain, should increase their core funding, in order to reinforce the unique global leadership role of this organization. Donors should fulfill their pledges to the Global Fund to Fight AIDS, Tuberculosis and Malaria and encourage its efforts to ensure comprehensive, country-owned programs that build upon existing reproductive health programs wherever possible. Donors should also increase their core support for IPPF, another organization with a distinct role in both advocacy and program implementation in the sexual and reproductive health field. The United States should resume funding for both UNFPA and IPPF. o Donors continue their efforts to improve the efficiency and effectiveness of international organizations. European Union Member States should continue to actively monitor and support the European Commission’s efforts to expand its population assis- tance and improve the effectiveness of its aid in this area. At the same time, the European Commission must continue its leadership role as a voice for pro- gressive sexual and reproductive health policies and programs, providing guidance in particular to the new EU Member States. Donors should also support UNFPA’s effort to strengthen its representation in the field in order to both increase the effective use of its funds and play a more prominent role in formulating health and development policies, particularly at the country level. o Donor governments strengthen their own technical expertise and staffing while also encouraging and ade- quately funding NGOs, in both developed and develop- ing countries, to strengthen their capacity for involve- ment in international sexual and reproductive health programs. Donor country NGOs should contribute to capacity building among their Southern partners, including that required to advocate for adequate fund- ing and sound policies. o Advocacy NGOs encourage lagging donor governments to increase support to multilateral organizations and monitor all donor governments to ensure that existing support does not falter. At the same time, NGOs must be a strong and consistent voice calling on multilateral organizations to include civil society in planning and implementation of program activities, and help moni- tor their effectiveness in the field. 33 s this is written in late 2004, the international community has some cause to celebrate the progress made in meeting reproductive health needs since the Cairo conference 10 years ago. Within the donor community, the funding gap has narrowed slightly, although donor countries still fall far short of the commitments made in 1994. Tremendous challenges remain. The distance to ICPD spending goals has narrowed only slightly—and the goal- posts need readjusting to reflect the costs of meeting urgent and growing sexual and reproductive health needs, including those related to HIV/AIDS. Both the landscape and architecture of development assistance are changing. Security concerns increasingly stand out in donor governments’ new development assistance poli- cies, and new mechanisms for channeling donor assis- tance are gaining support—two developments that could make the prioritization of reproductive health more diffi- cult. In contrast, reproductive health concerns should benefit from the move by most donor nations to place poverty reduction and the Millennium Development Goals at the forefront of development policy. Part of the challenge lies in ensuring that donors and their partners in development recognize good reproduc- tive health as essential to reducing poverty and achieving the Millennium Development Goals. Donors must also ensure that reproductive health and HIV/AIDS initiatives are mutually reinforcing: they must embrace—and use— the linkages between reproductive health and HIV/AIDS, as well as linkages between reproductive health and broader health issues. It is essential that population assistance donors bal- ance their own priorities with the critical reproductive health needs of developing countries. Too often, fund- ing at the country level does not correspond to either reproductive health needs or the ability of countries to bear more of the costs. Governments and other donors must confront—and take on—controversial issues, such as youth services and abortion, given the large numbers of young people at risk of unwanted pregnancy and deadly disease, and the tremendous toll exacted by unsafe abortion on millions of women each year. When donors do take on such issues, they must have strong, vocal and consistent support from civil society. The ability of civil society organizations, especially NGOs, to speak out in support of progressive policies and generous funding is more important than ever. Opposition from conservatives to funding of sexual and reproductive health programs has gained strength in recent years and is not going to evaporate—and govern- ments, including parliamentarians, are under increasing pressure. But the question is clear: can we afford to live in a world where three million people die each year from AIDS, where half a million women die in pregnancy or childbirth, and where millions more live with debilitating health conditions directly related to the lack of reproduc- tive health services? The answer, surely, must be “no.” A Conclusion Building on Progress, Fulfilling the Promise 35 Overview Ghana was among the first African countries to formulate a comprehensive population and family planning policy. The country has a generally well-functioning system for delivering health services and has progressive policies on sexual and reproductive health. However, Ghana still faces significant challenges: maternal mortality remains high, as do rates of unsafe abortion; young people have little access to reproductive health care; and family plan- ning is losing out in political commitment to HIV/AIDS interventions. In addition, a recent decision by the oldest and largest family planning organization in Ghana (the Planned Parenthood Association of Ghana) not to comply with the Mexico City Policy/Global Gag Rule1 and thus forgo much needed U.S. family planning assistance, has created further challenges to the provision of sexual and reproductive health services in the country. Ghana has one of the most stable political regimes and economies in Africa, but remains heavily dependent upon donor assistance for funding sexual and reproductive health services. This is true even though the Ministry of Health has been more assertive in recent years and government- donor relations are generally good. National coordination of donor assistance is problematic because of donors’ diverse funding approaches—through projects, through non-govern- mental organizations (NGOs), through the health sector, and recent moves to direct budget support—and because of donors’ differing points of contact in Ghana’s government. Key to success will be first, an increased political and financial commitment to tackling the challenges outlined above; and second, better coordination of donor and government responses. This requires both donors who support “systems” and donors who support “programs” to better coordinate and integrate their activities at mid- management and service delivery levels. This may involve negotiating ways to include sexual and reproduc- tive health program needs, indicators and earmarked funding within the sector-wide approach. The Ghana Health Service needs to clarify its decentralized authority and support to district managers in order to help them coordinate planning and implementation. Ghana’s Efforts to Address Sexual and Reproductive Health Endorsing the 1994 International Conference on Population and Development (ICPD) Programme of Action at Cairo was pivotal in Ghana’s approach to sexual and reproductive health. Ghana’s family planning policy was first formulated in 1969, but made only limited progress in its first 20 years. Response to other reproduc- tive health issues was also fragmentary, but services have A Case Study Sexual and Reproductive Health in Ghana and the Role of Donor Assistance TABLE G-1 BASIC STATISTICAL AND DEMOGRAPHIC PROFILE OF GHANA Total population, 2002 20.2 million GNI per capita (Purchasing Power Parity, $US 2002) $2,000 Annual health expenditure per capita ($US 2000) $11 Annual population growth rate (%) 2.2 Population ages 0-24 (%) 62 Literacy among youth ages 15-24 (male/female) (%) 93 / 86 Primary education gross enrollment ratio (male/female) 84 / 74 Secondary education gross enrollment ratio (male/female) 40 / 32 Sources: Countdown 2015. 2004. Countdown 2015: Sexual & Reproductive Health & Rights for All. Washington, DC: Family Care International, International Planned Parenthood Federation and Population Action International; Greene, M, Z Rasekh and K Amen. 2002. In This Generation: Sexual and Reproductive Health Policies for a Youthful World. Washington, DC: Population Action International; Population Reference Bureau (PRB). 2002. World Population Data Sheet 2002. Washington, DC: PRB. Susannah Mayhew, Ph.D., is a lecturer at the London School of Hygiene and Tropical Medicine. 36 improved since Cairo. Wide regional differences in health status persist, but in general the key challenges are to continue expanding access to family planning and adoles- cent-friendly reproductive and sexual health services, and to decrease maternal mortality and unsafe abortions. Tables G-1 and G-2 provide a profile of Ghana and its sexual and reproductive health status from 1988 to date. Policy Development and Service Delivery Just two years after endorsing the 1994 ICPD Programme of Action, Ghana’s government drafted a comprehensive Reproductive Health Policy and Standards document, finaliz- ing it in 2003. It covers the entire spectrum of reproductive health, including maternal death audits, screening for repro- ductive cancers, and prevention and management of unsafe abortion, and acknowledges the need to address gender- based violence and female genital mutilation/cutting. The document is a gold standard for what is expected at each level of the health system. Training on its use has begun, but is challenged by resource and capacity con- straints together with unclear implementation proce- dures. Adolescent reproductive health, central to the Cairo declaration, received separate attention in a policy drafted in 1996 that outlines a broad multi-sector approach to adolescents, including links among the Ministry of Education, Youth and Sports and the Ministry of Health. This is not yet fully implemented, and its commitment is weak on addressing adolescent sexuality and the need for dedicated reproductive health services, including access to contraceptives. In total, three different national bodies produced at least seven separate policy documents on sexual and repro- ductive health after 1994. While the attention is positive overall, it has confused providers on which guidelines to apply and where accountability and responsibility should lie.2 Confusion also reigns over the roles of the Ministry of Health (which is expected to handle policy develop- ment and monitoring) and of the Ghana Health Service, created in 1996 (which is supposed to take care of imple- mentation, day-to-day management and staffing). This policy-executive split has never been properly defined. The difficulty with all policies is how to transform them into practice. It involves training on new guidelines and Indicator 1988 1993 1998-2002 Average births per woman (total fertility rate) 6.4 5.5 4.5 Births to women aged 15-19 (% of all births) n/a 22 14 Births to women aged 20-24 (% of all births) n/a n/a 27 Contraceptive prevalence rate among currently married women (% use of modern/any contraceptives) 5 / 13 10 / 20 22 / 13 Antenatal care (% of women receiving) n/a n/a 98 Skilled attendance at birth (% of births) n/a n/a 45 Postnatal care (% of women receiving) n/a n/a 54.2 Maternal mortality ratio (deaths per 100,000 live births) n/a n/a 540 Abortion ratio (abortions per 100 live births) in four regions n/a n/a 27 HIV prevalence (%): - national average 4.0 - in females 15-24 (3.0% end-2001) n/a n/a 2.4 – 4.4 - in males 15-24 (2.4% end-2001) 0.8 – 2.0 Female genital mutilation/cutting - national prevalence (%) n/a n/a 9-12 (est.) - Upper East Region n/a n/a 77 Sources: Ghana Statistical Service (GSS) and Macro International, Inc (MI). 1999. Ghana Demographic and Health Survey 1998. Calverton, Maryland: GSS and MI; Ghana Statistical Service (GSS) and Macro International, Inc (MI). 1994. Ghana Demographic and Health Survey 1993. Calverton, Maryland: GSS and MI; Ghana Statistical Service (GSS) and Institute for Resource Development/Macro Systems, Inc (MI). 1989. Ghana Demographic and Health Survey 1988. Columbia, Maryland: GSS and MI; Ghana Ministry of Health Reproductive and Child Health Unit (RCHU). Annual Report 2002. Accra: RCHU; Ghana National AIDS Control Programme (NACP). Annual Report 2002. Accra: NACP; Ahiadeke, C. 2001. "Incidence of Induced Abortion in Southern Ghana." International Family Planning Perspectives (27)2:96-101 & 108; USAID-Ghana. 2001. Post-abortion Care in Ghana. Annex 7 of Global Evaluation of USAID’s Post-abortion Care Program. USAID Internal Document, 11/29/2001; Countdown 2015. 2004. Countdown 2015: Sexual & Reproductive Health & Rights for All. Washington, DC: Family Care International, International Planned Parenthood Federation and Population Action International; Greene, M, Z Rasekh and K Amen. 2002. In This Generation: Sexual and Reproductive Health Policies for a Youthful World. Washington, DC: PAI; Population Reference Bureau (PRB). 2002. World Population Data Sheet 2002. Washington, DC: PRB. Adapted from Mayhew & Adjei 2004. TABLE G-2 SEXUAL AND REPRODUCTIVE HEALTH INDICATORS FOR GHANA, 1988-2002 37 protocols and equipping facilities for the new activities. Table G-3 indicates achievement on this for key sexual and reproductive health activities. The sections below detail Ghana’s progress and key remaining challenges. Family Planning In 1989, two decades after Ghana passed its population policy, contraceptive use stood at just 13 percent, with only 5 percent of married women using a modern method, despite an apparently comprehensive policy and a high level of contraceptive knowledge (79.4 percent of all married women knew at least one method).3 Research identified poor political commitment and socio-cultural reasons for this failure.4 An upsurge in donor support, notably from the U.S. Agency for International Development (USAID) and UN Population Fund (UNFPA), saw the program re-structured and revitalized, and the National Population Council (NPC) was established as a dedicated policy making body and channel for donor funds. The NPC developed the 1996 revised National Population Policy and strategic implementation frame- work, and by 1998 the data showed a much improved, though still modest, use of family planning (Table G-2). A number of problems still need to be addressed if family planning use is to rise further. These include waning polit- ical commitment; socio-cultural constraints; poor access for adolescents (nearly 25 percent of the population) and unmarried women; and continuing low quality of care.5 Maternal Mortality and Abortion The late 1980s saw greater government and donor com- mitment to improving safe motherhood services. The maternal and child health program was expanded, and in 1994 the UN Children’s Fund (UNICEF) supported development of the Clinical Management Protocol on Safe Motherhood. The inclusion of maternal mortality reduction in the Millennium Development Goals has fur- ther increased the profile of this issue and attracted sup- port from a wider group of donors. Ghana has made sig- nificant improvements in antenatal coverage and in num- bers of babies delivered by skilled attendants. The wor- ryingly high maternal mortality rates persist, however, for reasons that are poorly understood. In 2002, audits of each maternal death were instigated in an attempt to unravel the causes. Recent research has linked unsafe abortion to the high maternal mortality rates.6 Abortion is legal for certain clear- ly defined conditions (e.g. rape, mother’s life at risk), when performed at registered clinics by qualified practitioners. The law tends to be interpreted, however, as prohibiting abortion, so availability is extremely limited and not fully understood in the public sector. Unsafe abortion therefore remains widespread, particularly among adolescents.7 Providers show increasing commitment to post-abortion care, though this is limited at present. Decision makers are reluctant to address the need for accessible safe abortion, especially for adolescents, that could reduce maternal death rates and prevent the need for costly post-abortion care. Sexually Transmitted Diseases Including HIV/AIDS The government has had an education campaign to increase awareness of sexually transmitted diseases (STDs) and HIV/AIDS since 1986, so knowledge of HIV issues is high, but behavior changes are not yet appar- ent.8 The National AIDS Policy has remained in draft since 1996; HIV surveillance sites are functioning but STD surveillance is almost nonexistent. STDs are report- ed neither by the Ministry’s Reproductive and Child Health Unit nor by the National AIDS Control Program. Some efforts were made in the late 1990s to train family planning and antenatal staff in “syndromic manage- ment” of STDs (i.e., diagnosis and treatment based on observable symptoms, not laboratory tests), but it’s not clear if this approach is working.9 Recent increased donor commitment to reducing HIV/AIDS reflects the issue’s status as a key Millennium Development Goal. Ghana has made a high-profile com- mitment to provide voluntary counseling and testing and antiretroviral drugs (ARVs). In 2001, the National AIDS Commission was established, and in December 2003 Ghana’s government received money from the Global Fund to Fight AIDS, Tuberculosis and Malaria to provide ARVs in the three largest cities. AIDS interventions now receive more funding than family planning ever did. This funding for HIV/AIDS treatment is important, but care must be taken to ensure integration with comprehensive HIV prevention efforts. Preventing the spread of HIV/AIDS is particularly crucial in countries like Ghana, where HIV prevalence is currently moderate. Adolescent Reproductive Health In general, Ghana remains a relatively conservative coun- try where discussion of sexual issues, abortion and ado- lescent use of contraceptives are still widely taboo. An adolescent reproductive health policy is in place, but in practice many organizations emphasize abstinence until marriage. This is despite demand from an estimated 22 percent to 27 percent of young people who want to use family planning but do not because they cannot easily obtain contraceptive services.10 Adolescents often do not know where to go for impartial advice and contraceptives, 38 } } } TABLE G-3 SEXUAL AND REPRODUCTIVE HEALTH SERVICES IN GHANA: AVAILABILITY OF KEY SERVICES, EXISTENCE OF GUIDELINES/PROTOCOLS AND RELATED TRAINING Sexual and reproductive Number of facilities Technical guidelines/ Staff training health service needs offering services protocols exist conducted Primary health care: – Family planning 2,289 primary health Yes Yes – Antenatal care care facilities Yes Yes – Postnatal care Yes Yes Safe motherhood: – Skilled delivery 1,583 maternity units Yes Yes – Emergency obstetric care 89 units with blood banks Yes Yes & other emergency equipment Abortion: – Safe abortion n/a No No – Post-abortion care n/a No Yes (42% of providers) HIV: – Voluntary counseling and testing 4 facilities Limited 50 GHS staff – Antiretroviral drugs 3 planned for 2003 Yes (2002) Limited – Opportunistic infection treatments n/a Yes (2002) No – Prevention of mother-to-child transmission 2 facilities Yes Yes STI screening/treatment: – Syphilis n/a Yes for non-specific Yes for – Gonorrhea n/a syndromic management; syndromic – Other n/a revised 2003 management Adolescent reproductive health: – Counseling – Pregnancy services 4 “adolescent friendly” In process Yes–primarily on – Contraceptives facilities in Greater Accra Region “counseling” Reproductive cancers: – Breast cancer limited to Accra, Yes Yes – Cervical cancer Kumasi and Yes No – Prostate cancer Tamale No No Infertility Private/NGO & No No teaching hospital only Gender-based violence No, but female police corps No No, but awareness established campaign launched Female genital mutilation/cutting — Advocacy No Sources: Ghana Ministry of Health Reproductive and Child Health Unit (RCHU). Annual Report 2002. Accra: RCHU; Ghana National AIDS Control Programme (NACP). Annual Report 2002. Accra: NACP. Adapted from Mayhew & Adjei 2004. 39 and the number of teen-friendly clinics providing these services is limited, especially outside the main cities. Challenges Posed by the Global Gag Rule In addition to the challenges noted above, recent restric- tions tied to U.S. family planning assistance have increased the difficulties Ghana faces in promoting the sexual and reproductive health of its citizens. In September 2003, the Planned Parenthood Association of Ghana (PPAG) refused to sign the Mexico City Policy/Global Gag Rule and lost $200,000 in U.S. family planning assistance. Given the country’s reliance on donor assistance, this was a huge blow. The loss in funding has been acutely felt in Ghana’s peri-urban and rural areas where PPAG was the primary provider of community-based clinic and outreach services, and supplied remote communities with vital family plan- ning services and HIV/AIDS prevention education in addi- tion to other basic reproductive health services. PPAG’s rural outreach programs were funded entirely by USAID, and represented a long-term partnership with USAID since the 1970s. The loss of U.S. funds has curtailed rural out- reach programs and reduced nursing staff by 40 percent, severely limiting the number of clients served. It is now doubtful whether U.S. population assistance funds can be used effectively in Ghana when the country’s largest spe- cialist reproductive health service provider is excluded. The restrictions imposed by the gag rule also hampered PPAG’s efforts to integrate HIV/AIDS activities into its pro- grams, thereby limiting the expansion of such efforts. Worst of all, the gag rule has perpetuated an environment of fear and silence surrounding the topic of abortion in Ghana, which is making it even harder for organizations to address the need for safe abortion and post-abortion care.11 Donor Assistance Ghana is heavily dependent on donor funding, with the most recent data indicating that 48 percent of Ministry of Health income is from donors. Local NGOs working in sexu- al and reproductive health receive virtually all their income from international donors. Tracking resource flows became much more difficult in the late 1990s with the introduction TABLE G-4 TOP TEN DONORS IN SEXUAL AND REPRODUCTIVE HEALTH, GHANA 1993-2000 Donor Program and geographical area Amount pledged and time-frame ($US unless otherwise stated) USAID Population and AIDS (GHANAPA) $45 million, of which: $31 million in project assistance (United States) National (including $11 million for contraceptives); $14 million in non-project assistance 1995-2000 DFID Health and AIDS $30 million ($750,000 to NACP 1995-96) (United Kingdom) National and Volta Region 1993-1996 (post-1996, all funds pooled in the SWAp) CIDA HIV/AIDS/STDs Canadian $ 200,000 (Canada) National 1996-2000 WHO Health and AIDS $2.7 million National 1993-1995 Danida Health and AIDS $22.4 million, incl. $9.7 million for primary health care in Upper West Region (Denmark) National and Upper West 1993-1998 UNDP AIDS $500,000 (through WHO and National AIDS Control Programme) National 1996 UNAIDS AIDS $3 million plus National 1997-2000 UNFPA AIDS and Family Planning $8 million + contraceptives National 1996-2000 UNICEF AIDS, Population/Family Planning, $13 million Safe Motherhood 1996-2000 National World Bank Health, Population/Family Planning $27 million National 1992-1995 NB: Accurate financial figures are almost impossible to obtain and great caution must be exercised when interpreting these data. Sources: Donor and Ministry of Health financial documents, various dates. 40 of the sector-wide approach and phase out of earmarked program funding. Until 1996 it was possible to disaggregate donor finances coming to the Ghana Ministry of Health that were earmarked for sexual and reproductive health, but after 2000 there are virtually no disaggregated data. USAID and UNFPA have given strong support for family planning and related activities since the 1970s, and UNICEF has supported safe motherhood since the 1980s. During the 1990s the donor base expanded in the wake of the ICPD. Chief among new donors were the United Kingdom and Denmark (see Table G-4). Most continue to support “programs” rather than a sector-wide approach; this can create tension and impede coordination. Program Assistance vs. Systems Assistance Donor assistance in Ghana has changed substantially over the past decade, with the introduction of the sector- wide approach (SWAp). The SWAp was intended to improve coordination by bringing all donors together in a common framework. Donors favoring structural systems changes (notably the World Bank and United Kingdom) have now pledged to pool their funds through the Ministry of Health according to nationally defined priori- ties rather than donor-defined programs. (A further possi- bility is full budget support, in which donor monies go directly to the Treasury for disbursal to different sector ministries.) However, Ghana’s key sexual and reproduc- tive health donors, such as USAID and UNFPA, remain committed to program approaches and continue to dis- burse their funds through separate earmarked channels. The parallel existence of these two channels of funding (non-specific sector-wide channels and program-specific earmarked channels) creates difficulties described below. Importance of Donors and NGOs Ghana’s dependence on external funding is illustrated by the fact that officials see donors as providing “sustain- ability” to health programs through their financing. Funds also come into Ghana through NGOs. More and more local NGOs are establishing themselves, and virtually all are completely funded by international agencies. While inconsistent reporting may be a factor in year-to-year varia- tions, the figures highlight the very large NGO contribu- tion. Many international NGOs also have offices and proj- ects in Ghana, sometimes partnering with local groups. Local NGOs provide key sexual and reproductive health services; the largest partner with the government and are incorporated into the Ministry of Health’s own statistics. For example, the Christian Health Association of Ghana (CHAG), an umbrella group for church-managed facilities, has a formal Memorandum of Understanding with the gov- ernment to provide health services where government facilities are limited. Coverage and use statistics for facili- ties run by both CHAG and PPAG are included in the Ministry of Health Annual Report, together with those of government clinics. Challenges of Coordination Relations between Ghana’s government and international donors have improved greatly since the period of political dictatorship and donor intransigence of the 1980s and are now generally cordial and mutually respectful. Relations and coordination among the donors themselves, however, tend to be fragmented along the lines dividing systems and program approaches as described above. A characteristic of donor-government relations in Ghana is the grouping of different sets of donors with particular parts of the Ministry of Health (MoH). The Reproductive and Child Health Unit (RCHU) has strong and close links with USAID, UNFPA and UNICEF, while the National AIDS Control Programme (NACP) works most closely with UNAIDS. The MoH Reform Group (at central head- quarters), which supports the sector-wide approach, links primarily with DFID and the World Bank; the Reform Group also receives some support from Denmark and the Netherlands. The UN agencies have begun to coordinate around a Theme Group on reproductive “I think we make sustainability arguments as if Ghana were self-sufficient. We’re not self-sufficient… sustainability has to be seen in the context of how well our systems can absorb the resources and use them and give the donors the confidence to sustain their donations into the country.” —Senior Ministry of Health official12 41 health that involves some of the reform donors. But for the most part, donors tend to work within their distinct groupings, without seeking broader collaborations. The parallel existence of a separate group of program-spe- cific (reproductive health) donors undermines coordinat- ed planning through the SWAp. In the long term, sexual and reproductive health could suffer if the field is seen as the preserve of a particular group of donors rather than as a mainstream health issue. As one senior advisor said: “Coordination of programs at the national level is still not done. There is still competition between programs.” Coordination within the SWAp Sexual and reproductive health donors are reluctant to pool their funding under the SWAp in part because the SWAp appears to eliminate specialized programs, such as sexual and reproductive health, that require technical knowledge (e.g., capacity to monitor the quality of servic- es such as emergency obstetric care, sterilization or safe abortion). This threatens the delivery of quality services. Under sector-wide planning, supervisors who monitor quality of care must do so for a range of services and are not likely to be trained in the special needs of, say, ado- lescent counseling. Neither are the provision of special- ized adolescent contraceptive services or the importance of quality specialized care reflected in SWAp indicators. Nevertheless, the SWAp and decentralization policies developed over the past 10 years profoundly affect the way sexual and reproductive health services are organized, managed and financed, whether or not donors choose to get involved. In Ghana, program donors now recognize that their representatives must be involved in negotiating reform structures and indicators if they wish to avoid the potentially negative effects of structural changes. Similarly, reform donors now recognize that SWAp and other nation- al strategies need to incorporate the needs of specialist pro- grams like sexual and reproductive health.13 Avoiding Disruption in Implementation Decentralization of the health system has led to faster, more efficient disbursements directly from central min- istry coffers to district and sub-district management teams and hospitals. Districts are required to report on antenatal coverage, family planning uptake, postnatal care and maternal health and death audits, but do not disaggregate spending by these categories.14 Under the SWAp, districts receive their funds not through program budget lines but split among salaries, capital expenditure, administration and service-related expenses. Earmarked funds from the non-SWAp donors (USAID, UNFPA and other reproductive health donors) also continue to reach districts for specified program activities such as training for family planning providers. These activities are rarely mainstreamed into the district’s regular activities, causing disruption to routine service delivery. While it can be argued that earmarked funds provide nec- essary security for funding sexual and reproductive health services that may not be a district priority, the parallel functioning of two different systems results in complex administration and reporting systems with substantial duplication. Coherent coordination by the Ghana Health Service (GHS) through its decentralized offices (e.g., District Chief Executives) could go a long way toward integrating donor activities into routine health service delivery. The Ghana Health Service, however, still does not have a clear role vis-à-vis the Ministry of Health, so that it is difficult to plan and implement coherent deliv- ery and supervision of services at the district level. Successes and Future Perspectives Significant improvements have been made in the breadth and depth of reproductive health services, and Ghana now has a well-functioning sexual and reproductive health program with specialists at all levels. As noted above, donor support for sexual and reproductive health in Ghana has been strong, and donor-funded NGOs con- tinue to provide a significant proportion of sexual and reproductive health services. So far, improvements in rates of antenatal care and skilled attendance at delivery, as well as modest gains in family planning use and signif- icant declines in average family size show that the long- term commitment of Ghana’s government, donors and NGOs has paid off. Nonetheless, this success must be balanced against the recent negative impact of U.S. poli- cies on the Planned Parenthood Association of Ghana. An issue of particular importance at the present time is how to balance investment in preventive as well as cura- tive services in the face of increasing donor attention to HIV/AIDS. It is difficult to measure the success of pre- vention efforts, but it is important that expensive HIV/AIDS treatment does not drain financial resources from other health needs and compromise the wider reproductive health gains of the last decade. Such a shift in funding could ultimately impede efforts to slow the HIV/AIDS epidemic, particularly if funds are then short for reproductive health services such as condom promo- tion, education and counseling on youth sexuality, and prevention of gender-based violence, which all tackle the underlying causes of HIV transmission. Donors still have difficulties coordinating their efforts, and the reform process has exposed critical ideological 42 and functional differences among donors favoring struc- tural reform and those still committed to program sup- port. Government planning and implementation within the decentralized Ghana Health Service could integrate these approaches at the district and service delivery lev- els, but district capacity and power remain weak and the Ghana Health Service role still lacks clarity. Unless addressed soon, these issues could undermine efforts to further improve sexual and reproductive health in Ghana. The critical challenges facing the Ghanaian government and its donors are therefore two-fold: first, to increase political and financial commitment to tackling key remain- ing sexual and reproductive health concerns; and second, to better coordinate donor and government efforts. Greater political and financial commitments could: o Expand commitment to the provision of family plan- ning services; o Continue support for maternal health audits and inves- tigation of links between maternal mortality and unsafe abortion, to identify ways to reduce maternal mortality; o Decrease unsafe abortion by ensuring that the public, medical professionals and lawyers know when abortion is legal, and expanding access to public-sector abortions; o Consolidate a comprehensive, coordinated response to adolescent sexual and reproductive health needs; o Tackle HIV/AIDS as part of a holistic approach to sex- ual and reproductive health, rather than separately from, or in opposition to, broader sexual and repro- ductive health needs; and o Continue support for research, advocacy and training in neglected areas such as gender-based violence. RECOMMENDATIONS Better coordination of donor and government efforts around sexual and reproductive health will require all donors and government officials to: o Better coordinate and integrate all donor activities to avoid problems caused by separate approaches; o Clarify delegation of authority and give particular support to district-level managers to plan and imple- ment services in a coordinated manner; o Negotiate ways to integrate sexual and reproductive health program needs, indicators and earmarked funding within the sector-wide approach; and o Remove restrictions on family planning assistance that harm reproductive health service provision, impede access to safe abortion services, and prevent the coor- dination and/or integration of basic reproductive health services with HIV/AIDS activities. 1 The Mexico City Policy was re-instated by President George W. Bush in January 2001. Under the policy, no U.S. family planning assistance can be provided to foreign NGOs that use funding from any other source to: perform abortions in cases other than a threat to the life of the woman, rape, or incest; provide counseling and referral for abortion; or lobby to make abortion legal or more available in their country. Noncompliance will result in loss of funding from the U.S Agency for International Development (USAID). Due to its restrictions on the freedom of speech, those who oppose the Mexico City Policy refer to it as the Global Gag Rule. Access Denied: U.S. Restrictions on International Family Planning, The Global Gag Rule Impact Project, 2003. 2 Lush, L, and others. 1999. “Integrating reproductive health: Myth and Ideology.” Bulletin of World Health Organization 77(9):771-777; Mayhew, S.H. 1999. “Health care in context, policy into practice: a policy analysis of integrating STI/HIV and MCH/FP services in Ghana.” PhD thesis, University of London; Mayhew, S.H, and others. 2000. “Integrating component services for reproductive health: the problem of implementation.” Studies in Family Planning 31(2):151-162; Mayhew, S.H. 2002. “Donor dealings: the impact of international donor aid on sexual and reproductive health. Viewpoint.” International Family Planning Perspectives 28(4):220-224. December 2002. 3 Ghana Statistical Service (GSS) and Institute for Resource Development/Macro Systems, Inc (MI). 1989. Ghana Demographic and Health Survey 1988. Columbia, Maryland: GSS and MI. 4 Owusu J.Y. and Baste Z. 1991. “Family planning services in Ghana.” Report of the National Population Conference 158-183; Binka F. and others. 1994. “The Navrongo community health and family planning project.” Presented at the Health Research Unit Third Consultative meeting on Health Research Development, January 13-14. Adongo, P, and others. 1998. “The influence of traditional religion on fertility regulation among the Kassena- Nankana of northern Ghana.” Studies in Family Planning 29(1):23-40. 5 Adongo, P, and others. 1997. “Cultural factors constraining the introduc- tion of family planning among the Kassena-Nankana of Northern Ghana.” Social Science and Medicine 45(12):1789-1804; Adongo, P, and others. 1998. Ibid.; Parr, N. 2002. “Family planning promotion, contraceptive use and fertility decline in Ghana.” African Population Studies 17(1):83-101. 6 USAID-Ghana. 2001. Post-abortion Care in Ghana. Annex 7 of Global Evaluation of USAID’s Post-abortion Care Program. USAID Internal Document, 11/29/2001; Ghana Ministry of Health Reproductive and Child Health Unit (RCHU). 2002. RCH Annual Report. Accra: RCHU. 7 Ibid. 8 Ghana Statistical Service (GSS) and Macro International, Inc (MI). 1999. Ghana Demographic and Health Survey 1998. Calverton, Maryland: GSS and MI. 9 Mayhew 2000, “Integration of STI services into FP/MCH services: health service and social contexts in rural Ghana.” Reproductive Health Matters 8(16):112-124. Mayhew et al, 2000 op cit. 10 Ghana Statistical Service (GSS) and Macro International, Inc (MI). 1999. Ghana Demographic and Health Survey 1998. Calverton, Maryland: GSS and MI. 11 Information from research carried out in the summer of 2004 by Population Action International and the Global Gag Rule Impact Project; available on www.globalgagrule.org in the fall of 2004. 12 Cited in Mayhew 1999. Ibid p. 209. 13 Cited in Mayhew S.H. and Adjei S. 2004. “Sexual and reproductive health: challenges for priority setting in Ghana’s health reforms.” Health Policy and Planning Vol 19(Suppl):45-60. 14 Ghana Ministry of Health (MoH). 2002. Common Management Arrangements for the implementation of the second health sector five year programme of work 2002-6. Donor Report Card 44 Donor Country Report Card 2 0 P O I N T S 2 0 P O I N T S 2 0 P O I N T S ODA AS PERCENT OF GNI POPULATION ASSISTANCE DISTANCE FROM AS PERCENT OF ODA ICPD 2005 GOAL 2000-2002 2000-2002 Multiplier to Average Score Average Score Reach Goal Score Netherlands 0.82 16 4.84 19 0.0 20 Denmark 1.02 20 3.39 14 0.0 20 Norway 0.82 16 4.23 17 0.0 20 Sweden 0.80 16 3.51 14 1.2 19 Finland 0.34 7 5.57 20 1.6 18 Luxembourg 0.75 15 5.84 20 0.0 20 United Kingdom 0.32 6 2.99 12 2.9 17 Belgium 0.39 8 2.75 11 1.7 18 Switzerland 0.33 7 2.30 9 3.9 16 Canada 0.25 5 2.37 9 2.6 17 Germany 0.27 5 2.04 8 5.7 14 New Zealand 0.24 5 2.22 9 5.1 15 Japan 0.25 5 1.36 5 6.9 13 Australia 0.26 5 1.71 7 5.5 14 France 0.34 7 0.68 3 5.2 15 United States 0.11 2 7.40 20 3.3 17 Ireland 0.34 7 2.31 9 2.6 17 Italy 0.16 3 1.44 6 15.8 4 Spain 0.26 5 0.51 2 60.3 0 Austria 0.26 5 0.23 1 40.8 0 Portugal 0.26 5 0.20 1 63.3 0 45 4 0 P O I N T S POLICIES TOTAL POINTS & GRADES Population/ Gender Policy IPPF/UNFPA “Tiedness” Total Current Previous SRH Policy Policy Restrictions Contributions of Aid Score Grade Grade (1998) 8 8 8 8 8 96 A A- 8 8 8 8 8 94 A A 8 8 8 8 8 93 A A 8 8 8 8 8 89 A A- 8 8 8 8 8 85 A B- 4 4 8 4 8 83 A- NA 8 8 8 8 8 75 B B- 4 8 8 8 8 73 B D 8 8 8 8 8 72 B C 8 8 8 8 5 69 B C 8 8 8 8 8 68 B C 4 8 8 8 8 65 B D- 8 8 8 8 8 64 B C- 6 8 4 8 5 58 C C 4 8 8 4 8 56 C F 4 6 0 0 3 52 C B 0 0 8 4 0 45 C F 4 4 8 4 2 35 D F 4 4 8 4 6 33 D F 0 4 8 4 6 28 D F 4 0 8 4 3 25 D F A= 81-100 B= 61-80 C= 41-60 D= 21-40 F= 0-20 46 This report card assigns letter grades to countries on a scale of “A” to “F” according to their performance as donors, based on the following indicators: o The generosity of each donor’s overall development aid program in relation to the size of that country’s economy; o The proportion of development assistance funds allo- cated to reproductive health and population programs; o The distance each donor has to go to reach its “fair share” of the ICPD spending goal for 2005 from 2002 spending levels; and o The extent to which a country’s policies foster the max- imum level of impact in addressing the goals of the ICPD Programme of Action based on their official repro- ductive health and population policies, gender policies, percentage of “tied” aid, and contributions to key United Nations and non-governmental organizations. As with PAI’s 1998 analysis, this grading system empha- sizes financial and policy commitments to population assistance, rather than on the quality and type of programs supported. The weighting reflects the focus of this report on financial resources and on the policy environment at the halfway point of the ICPD Programme of Action. The grading system allocates 20 points to each of the three financial indicators, for a maximum potential score of 60, and 8 points to each of the policy indicators, for a maximum potential score of 40. Thus the total maximum potential score is 100 points. Points are allocated on a relative scale— donors are compared to each other rather than to an objec- tive standard. To minimize bias resulting from a wide distri- bution of values, the scores for each of the three quantita- tive indicators were capped at appropriate levels. The grad- ing system was applied to 21 member countries of the Development Assistance Committee of the OECD, excluding Greece, which lacked sufficient data, and the European Commission, to which some of the indicators used to score individual donor countries do not apply. Indicator #1 Development Assistance as a Share of National Income The volume of official development assistance (ODA) rel- ative to gross national income (GNI) reflects the generosi- ty of each donor country relative to the size of its econo- my. This indicator represents each nation’s commitment to the developing world. It also reflects donor invest- ments in broader economic and social development that may ultimately benefit reproductive health status through their impact on incomes, educational status, and other aspects of human well-being. Total aid volume also influ- ences the availability of funds for population assistance. Countries are scored on the average of their development assistance to GNI ratio for the three-year period from 2000 to 2002, and their performance relative to each other. The ratio was capped at 1 percent, with all scores above 1 percent receiving the full 20 points, and all scores below receiving points on a proportional basis. Over this period, the average effort of the 21 donor coun- tries was 0.4 percent of GNI for ODA—slightly lower than the average from 1994 to 1996 and significantly lower than the UN goal of a 0.7 percent annual contribu- tion for each country. Denmark was the only donor country whose development assistance exceeded 1 per- cent of GNI between 2000 and 2002. Only four other countries met or exceeded the UN goal of 0.7 percent: Norway, Sweden, the Netherlands, and Luxembourg. All other countries gave less than the average donor effort of 0.4 percent of GNI for ODA. The United States and Japan, the two largest donors in total aid volume, allo- cated only 0.11 and 0.25 percent of GNI, respectively, to development aid over the period 2000-2002. Indicator #2 Population Assistance as a Share of Development Assistance The share of overall development assistance allocated to population assistance reflects the level of importance the donor places on these issues within its foreign aid pro- gram. This measure gives credit to donors that have demonstrated a financial commitment to population assis- tance whether they do so through the bilateral, multilater- al, multi-bilateral, or NGO channels. At the Amsterdam Forum in 1989, it was recommended that donors allocate 4 percent of their development aid to population assistance (as defined at the time), a percentage also based on donors achieving the international goal of 0.7 percent of GNI for development aid. Countries are scored on the percentage of development aid they allocated to population assistance, again aver- aged over the three-year period of 2000 to 2002. The per- centages were capped at 5 percent, with all scores above 5 percent receiving the full 20 points and those below receiving points on a proportional basis. The United States ranks highest on this measure, allocating an aver- age of 7.4 percent of its development aid budget to pop- ulation and reproductive health programs between 2000 and 2002. Luxembourg ranks next highest, giving 5.8 percent of its aid budget for population assistance between 2000 and 2002, followed by Finland, the Netherlands, and Norway—all exceeding the 4 percent goal. Although Japan is a large donor of population assistance in terms of total volume, it gave only 1.4 per- cent of its development budget on average to population assistance in the period studied. Report Card Methodology 47 Indicator #3 Multiplier Required to Reach ICPD Year 2005 Funding Goal Resources remain central to the challenge of improving reproductive health status worldwide. Each donor’s respec- tive share of the US$6.1 billion ICPD goal for donor contri- butions for 2005 (adjusted for inflation to 2002 $US) was estimated based on its proportional share of aggregate GNI for the donor community. Scores were assigned to each country based on how many times its 2002 funding would need to increase to achieve its 2005 goal. Countries with multipliers of 20 or more receive zero (0) points, while scores for countries with multipliers of less than 20 were calculated by subtracting the multiplier from 20. Denmark, Norway, the Netherlands, and Luxembourg have met their ICPD 2005 goals, and Sweden is very close. Five others, including the United States, must increase their current levels of assistance two to four times by 2005, and another five countries, including Japan, must increase current levels five to seven times. Italy’s fair share for 2005 is 16 times its current level of population assistance, while Spain and Portugal are furthest from their 2005 goals, and would need to increase their assis- tance more than 60 times. Indicator #4 Policy Environment The 40 points awarded to each country based on its policy environment are broken equally into five separate cate- gories: population and reproductive health policy or strate- gy; gender policy or strategy; restrictions on population assistance; contributions to the United Nations Population Fund and/or the International Planned Parenthood Federation; and “tiedness” of development aid. o Donor nations committed to population assistance are more likely to have articulated a reproductive health and population policy. The existence of such a policy reflects the importance governments assign to these issues and time invested by aid officials in dialogue and debate on international sexual and reproductive health issues. The scoring system gives 8 points to those donor countries that have published official reproductive health and population policies or strategies. Those countries that have health, HIV/AIDS, or development policies that substantively address reproductive health issues are given 4 points, while zero (0) points are given to those that have no policies or strategies that substantively address sexual and reproduc- tive health. Between 2 and 4 points are deducted from a country’s score for the presence of published restrictions that undermine the policy’s effectiveness. o The existence of a gender policy also demonstrates support for population and reproductive health issues. The ICPD Programme of Action emphasized the impor- tance of interventions aimed at improving the status of women, such as increasing the number of girls receiving primary education. Women who are educated and eco- nomically active in society generally have greater control over their fertility, while the enhancement of women’s status in general is an essential step toward reducing poverty and promoting development. The scoring system is identical to that for reproductive health and popula- tion policies; countries with an official, published gender strategy or policy (including strong positions on gender mainstreaming) receive 8 points. Donor countries that significantly address the issue of gender in their develop- ment policies but have no formal strategy receive 4 points, and countries that place little emphasis on gen- der receive zero (0) points. As above, points are deduct- ed from a country’s score for the presence of published restrictions that undermine the policy’s effectiveness. o Countries that impose restrictions on their population assistance significantly reduce the effectiveness of their aid. In this category, 8 points are awarded to donor countries with no published restrictions on their popula- tion assistance. Countries that place some restrictions, such as not allowing their assistance to be used to per- form abortions but without caveats on how recipient agencies use other funds, receive 4 points. Countries that impose more severe restrictions on their population assistance, for example, by requiring compliance with restrictions with respect to the use of other donors’ funds, receive zero (0) points. o Core funding from donor country governments to the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) is needed in order to support the unique global leadership role these organizations have in the expansion of repro- ductive health services in the developing world. Countries are awarded 4 points for contributions made to each of the two agencies in 2002. o Donor countries that “tie” their population assistance with requirements on how it can be spent reduce the effectiveness of their aid. The international community has agreed on the importance of removing requirements that assistance to a recipient country be used to purchase goods and/or services from a donor country. The range of scores is based on the percent of bilateral tied aid reported to DAC in 2002, using the methodology developed by the Center for Global Development, to award each country between zero (0) and 8 points. Higher scores are awarded to the countries that have little or no tied aid. Donor Country Profiles Australia is one of the few donor countries making little progress since PAI’s last analysis in 1998, largely due to declines in overall development assistance relative to wealth and the smaller share of ODA reported as population assis- tance. Australia would need to increase its support for sexual and reproductive health activities, including HIV/AIDS, more than five-fold to fulfill its fair share of ICPD funding goals by 2005. In addition, Australia is one of only two donor countries that place explicit restrictions on the use of its funds. Development assistance monies cannot be used for activi- ties that involve abortion training or services, even in coun- tries where abortion is legal. Development Assistance: Policy and Funding Australia’s official development assistance has begun to recover from the sizeable reductions experienced between 1997 and 2000. ODA rose from US$873 million in 2001 (its lowest level in more than 10 years) to $989 million in 2002. This coincided with expansion in Australia’s gross national income (GNI), so the ODA/GNI ratio increased only very slightly to 0.26 percent in 2002. While it is encouraging that Australia’s ODA is now ris- ing for the first time since 1997, funding has yet to return to its peak levels of the mid-1990s and is still well below the average DAC country effort of 0.41 percent. It is also short of recommended ODA proposed by the 1996 Simmons Committee Report and the 1997 Australian gov- ernment White Paper, entitled In the National Interest, that affirmed the importance of development cooperation in promoting international trade and economic growth, particularly in the Asia-Pacific region. G R A D E 50 C Australia Australia’s population assistance has yet to recover fully from cutbacks imposed after the election in 1996 of John Howard’s Liberal/National Party coalition govern- ment. While incomplete reporting complicates any assessment of trends over time, the country’s support for sexual and reproductive health activities appears to have stagnated in recent years, although the Australian aid agency, AusAID, anticipates a real increase in 2003. Figures reported for 2002, however, place population assistance at little more than 2 percent of overall devel- opment assistance. The country’s support for UNFPA and other international organizations working in sexual and reproductive health has still not returned to the peak levels of the 1990s. Australia’s support for integrated projects and sector- wide approaches adds to the difficulty of assessing how different aspects of population programming were affected by the funding cuts noted above. Currently, the Australian government gives considerable emphasis to supporting HIV/AIDS interventions (now the largest com- ponent of Australian population assistance) in the Asia- Pacific region. Reported figures indicate a smaller share of resources flowing to reproductive health activities, including family planning. While Australia’s support for HIV/AIDS is important, the government should ensure that coordination of reproductive health and HIV/AIDS services occurs wherever possible. Australia has embraced the UN Millennium Development Goals (MDGs) and poverty reduction as overarching rationales for its foreign assistance efforts, which focus on five sectors: health, education, agriculture and rural development, infrastructure investment, and governance (emphasizing peace and conflict resolution). However, the government emphasizes the importance of high-level consultations with host country governments and institu- tions to identify local needs and priorities. Australia maintains that reproductive health (including family planning) requires attention in order to meet MDG poverty reduction goals. Such issues as gender equality and environmental quality are now “mainstreamed” within Australian development cooperation. The Australian government makes an effort to highlight the benefits of its aid program for Australians, for exam- ple, in terms of employment. And, as is increasingly the case with other donor countries, security concerns are part of the policy framework for development coopera- tion, with a focus on such regional issues as refugees and migration. Australia’s ODA is administered by the Australian Agency for International Development (AusAID). AusAID’s role is to provide policy advice and support to the Minister and Parliamentary Secretary on develop- ment issues, and manage Australian development coop- eration programs. The Director General of AusAID reports directly to the Minister for Foreign Affairs on all aspects of aid policy and operations. Included within the governing structure of AusAID is the Aid Advisory Council (AAC), an expert advisory body that provides the Minister for Foreign Affairs with independent expert views on the planning and delivery of Australia’s aid program. The AAC is made up of 11 Australians from academia, the private sector, NGOs and community groups. In existence since 1998, the AAC is intended to open up Australia’s aid program to new ideas and approaches to development that reflect the wider values of the Australian community. The Policy Environment for International Population Assistance A 1998 national survey found that 84 percent of Australians supported development assistance as a means of addressing humanitarian needs, promoting eco- nomic growth, and projecting a positive image of Australia abroad. However, the same survey indicated that many Australians know little about their govern- ment’s development cooperation efforts, causing some to observe that Australian support is “a mile wide and an inch deep.” It is interesting to note, however, the steady upward trend (close to 10 per- cent annually) in private contri- butions by Australians to NGOs working in international devel- opment between 1998 and 2003. Australia’s domestic family planning and reproductive health programs have encoun- tered determined conservative opposition over the years. This controversy has compromised the ability to fund reproductive health activities abroad, in par- ticular those related to abortion. Generally, however, the Australian public supports repro- ductive health efforts, particularly promotion of maternal and child health and work against the HIV/AIDS epi- demic in Asia and sub-Saharan Africa. The Australian Reproductive Health Alliance (ARHA), established in 1995, remains a leading NGO engaged in advocacy around international reproductive health and rights. ARHA seeks to promote the goals of the ICPD and as part of its activities provides secretariat support for the All-Party Parliamentary Group on Population and Development. The Alliance is vocal in its support for a 51 $ U S M IL L IO N S Because the definition of population assistance was broadened, data from before 1995 are not comparable to later years. 0 10 20 30 40 50 60 200220012000199919981997199619951994 o NGO o Multilateral o Multi-Bilateral o Bilateral Trends in Population Assistance 1994-2002 Australia NB: 1999 figures do not include expenditures for the population component in integrated development projects. 2001 program figures are estimated at the 2000 level. Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. $18.0 $26.9 $32.6 $30.5 $14.7 $13.1 $21.3 $45.2 $44.6 TRENDS IN POPULATION ASSISTANCE 1994-2002: AUSTRALIA 2002 population size: 19.7 million Total Official Development Assistance (ODA), 2002: $989 million ODA as a percentage of GNI, 2002: 0.26% Total population assistance, 2002: $21.3 million Population assistance as percentage of ODA, 2002: 2.15% Population assistance per $US million GNI, 2002: $55 V I T A L S T A T I S T I C S 52 rights-based approach to population-related issues and has, for example, expressed concern for the govern- ment’s approach to immigration and asylum issues. The IPPF member association, Sexual Health and Family Planning Australia (SH&FPA), is also active in the advo- cacy arena. Both are part of the Asia Pacific Alliance, a network of NGOs, donor agencies and foundations dedi- cated to increasing support for the ICPD Programme of Action and the Millennium Development Goals. While more conservative than the Labor government that preceded it, the coalition government in power since 1996 remains committed to the goals of the ICPD Programme of Action and has been an active member of the Asia Pacific Alliance. While the Programme of Action serves as an important reference point for AusAID in set- ting policy standards, it does not necessarily determine the design of specific country programs or project activi- ties. These are carried out in consultation with Australia’s partner countries and largely reflect indige- nous needs and program priorities. In 2001, AusAID released a list of Guiding Principles for its international assistance in reproductive health, a list largely consistent with ICPD principles. These guidelines stipulate that individuals should be free to choose the number and timing of their children; that women and men should have access to the widest possible range of family planning services; that reproductive health servic- es should be available to all sexually active individuals; and that Australia’s assistance should be directed to improving the quality of reproductive health care. The list also includes a prohibition on the use of Australian development assistance for services related to abortion, including training of medical personnel. This prohibition also applies to any activities, including research, that involve abortion drugs. It does not prevent recipients of Australian aid funds from using other monies for this purpose, however, nor does it apply to the use of Australian funds for post-abortion care. The Australian government also specifies the types of contraceptives that can be purchased with Australian aid funds; emer- gency contraception is among those specified as eligible for purchase. Trends in Funding for Population Assistance Overall Funding Levels Australia’s population assistance stood at US$21.3 mil- lion in 2002. This represented just 2.2 percent of ODA and placed Australia well below the average DAC coun- try effort of 4 percent of ODA for population assistance. Relative to national income (GNI), Australian population assistance places the country 15th among 22 major donor countries, at just $55 per million dollars of GNI, down from more than $80 in 1996. Incomplete reporting and exchange rate fluctuations complicate any assessment of Australia’s performance over time, but data from other sources indicate that the bulk of any increases in population assistance in recent years has gone to HIV/AIDS activities, while funding for other aspects of sexual and reproductive health has risen little or not at all. In 2002, 92 percent of Australia’s reported population assistance could be disaggregated by type of activity. Of this amount, 5 percent was provided for family planning, 20 percent for other reproductive health activities, 69 percent for HIV/AIDS, and 6 percent for research. It is important to note, however, that multi- sectoral projects often contain embedded reproductive health components not included in the accounting of population assistance commitments or expenditures. Multilateral Funding Australian support for reproductive health and popula- tion activities through multilateral organizations has fall- en substantially since the mid-1990s. In 1996, 42 percent went through multilateral channels, but by 2002 only 8 percent did, according to UNFPA. An additional 16 per- cent was provided for multi-bilateral activities, in which bilateral resources are committed for specific projects as part of multilateral consortium programs. Australia’s contributions to UNFPA have risen slightly in recent years. Australia’s UNFPA donation rose from $1.1 million in 2002 to an estimated $1.5 million in 2003. However, these funding levels are still well below Australia’s annual contributions of around $4 million in the mid-1990s. Prior to 2004, Australia did not contribute to the Global Fund to Fight AIDS, Tuberculosis and Malaria, deciding to take a “wait and see” approach to Fund activities in the Asia-Pacific region before commit- ting resources. More recently, Australia pledged $18.9 million to the Global Fund for the period 2004-2006. Since UNAIDS’ inception in 1995, Australia has been its 14th largest donor. It contributed $1.2 million in 2003, the country’s most generous level of support since 1997. Bilateral Funding Slightly more than half of Australia’s population assis- tance has been provided through bilateral programs in recent years; it was 54 percent in 2002. AusAID has direct responsibility for managing these funds. Country programs are developed in close consultation with recipi- ent nations and respond to mutually identified needs. C Australia 53 Funding for NGOs Australian support for NGOs in sexual and reproductive health remains modest and below the average for all DAC countries. In 2002, 21 percent of Australia’s popula- tion assistance was allocated to NGOs. NGOs funded by AusAID were more active in HIV/AIDS work than in family planning or reproductive health, although NGO involvement in sexual and reproductive health may be greater than suggested by budget information. Australia’s contributions to IPPF fell substantially between 1997 and 2001, but rose to $850,000 in 2002, with further increas- es expected in both 2003 and 2004. Program Priorities Geographic Priorities Australia’s foreign assistance continues to be concentrat- ed in the Asia-Pacific region, with some going to East Africa. In 2002, Indonesia, Papua New Guinea and China were the largest recipients of Australian population assis- tance. Post-conflict reconstruction needs have had a major bearing on the geographic allocation of Australia’s ODA in recent years. For example, both East Timor and the Solomon Islands have received considerable Australian assistance over the past five years to rebuild their health delivery infrastructures. Areas of Program Emphasis Australia’s foreign assistance gives priority to addressing child and maternal mortality and morbidity; funding vol- untary, non-coercive family planning and reproductive health programs; and providing support for HIV/AIDS prevention and treatment services. Australia has become much more active in HIV/AIDS work since 2001. It con- vened a meeting of 31 leaders from the Asia-Pacific region in Melbourne in 2001 to identify regional needs and priorities, and that led to formation of the Asia- Pacific Leadership Forum on HIV/AIDS in August 2002. Later that year, Australia announced a major six-year program to support regional HIV/AIDS activities. Australia is now mainstreaming gender issues in its for- eign assistance programs. Development projects increas- ingly incorporate gender-sensitive initiatives that take women’s welfare into account. Greater attention is being given to improving educational opportunities for girls, reducing violence against women, enhancing women’s economic empowerment, and securing the human and reproductive rights of women. A key element of AusAID’s gender strategy is promoting women’s equal participation in decision-making. To help achieve this objective, AusAID is providing funding for women’s information and research centers in several countries working to strengthen women’s participation in commu- nity and national fora. While Australian foreign assistance gives considerable emphasis to improving health sector managerial efficien- cy and upgrading health systems, Papua New Guinea is the only country where Australia supports a sector-wide approach (SWAp). It has funded health projects for women and children and initiatives to reduce domestic violence. AusAID works to build capacity in reproductive health by funding medical schools in the Asia-Pacific region and providing long-term professional training opportunities at Australian universities and short-term in-service training programs. Technical Capacity Staffing AusAID has undergone substantial restructuring in an effort to improve the quality of its personnel and reduce the high level of staff turnover in recent years. Administrative systems are being revamped to give greater attention to program evaluation and reporting of project results. AusAID has developed a new Multilateral Assessment Framework (MAF) for annual assessments and periodic in-depth reviews of multilateral programs funded with Australian resources. This system will apply to UN-funded activities but, at least initially, not to proj- ects of multilateral development banks (e.g., the World Bank and the Asian Development Bank). Technical Expertise of Collaborating Institutions AusAID relies on an experienced network of Australian- based commercial and non-profit firms, NGOs and uni- versities to assist in design and implementation of sexu- al and reproductive health activities, in particular with respect to HIV/AIDS. For example, Sexual Health and Family Planning Australia provides technical support for a number of reproductive health programs overseas, and the Burnet Institute undertakes international projects on HIV/AIDS. Program development and project delivery work is largely outsourced by AusAID, while quality assurance and evaluation are usually coordinated by technical advisory groups established for specific proj- ects or technical sectors. AusAID’s project activities are increasingly reliant on local-hire professional staff. Efforts are being made to increase local participation and move more management and contracting functions to the field. Development Assistance: Policy and Funding Austria’s foreign assistance program is small compared to other European donors. It provided US$520 million in official ODA in 2002, a modest decline from $533 million in 2001, and its 2002 ODA/GNI ratio of 0.26 percent is well below the average DAC country effort of 0.41 per- cent. The federal government has announced that it plans to increase development assistance to 0.33 percent of GNI by 2006. Close to one-third of Austria’s ODA is channeled through the European Union, development banks and UN agen- cies. This has curtailed the country’s bilateral aid com- mitments and reduced the need for administrative staff in Vienna, although this may change in light of proposed increases in development aid. Austria’s plan to increase its development assistance is among the outcomes of the new Development Cooperation Act of 2002, an effort to enhance the coher- ence and impact of the country’s aid program. The act also provided the legal basis for the establishment of the new Austrian Development Agency (ADA) in January of 2004 as a government-owned corporation and successor to the Department for Development Cooperation. The ADA will manage the country’s bilateral aid programs and cooperation with NGOs, while the overall direction of Austrian development policy will remain the responsi- bility of the Ministry of Foreign Affairs. Funding for the International Monetary Fund and World Bank is chan- neled through the Ministry of Finance. Consultative mechanisms coordinate program strategies between these two ministries. The Development Cooperation Act identifies three pri- mary objectives for Austrian development assistance: poverty reduction, securing peace and security, and improving environmental quality. The main sectors addressed include rural development; governance and human rights; water and sanitation; education; energy; G R A D E 54 D Austria In the ten years since the launch of the ICPD Programme of Action in 1994, Austria has not provided significant resources for international population pro- grams. As of 2002, it provided less than one-half of 1 percent of its ODA for population assistance, a fraction of the average donor country effort of 4 percent. While Austria supports the ICPD Programme of Action, it has still not developed a formal policy on population assistance. Efforts to promote ICPD objectives are large- ly focused on education and gender equality rather than on sexual and reproductive health, including HIV/AIDS. Furthermore, Austria does not currently have a formal bilateral international health program, preferring to address this area through its modest contributions to multilateral organizations. Austria has recently taken steps to reformulate its for- eign assistance programs and plans to increase its for- eign assistance to 0.33 percent of GNI by 2006. This substantial increase may allow more resources for sexu- al and reproductive health activities. Early signs of this came in late 2003, when the government announced a significant increase in its core funding for UNFPA, as well as support for specific projects in Nepal, Afghanistan and the Occupied Palestinian Territories. and investment in small and medium enterprises. These sectors are included in the government’s new three-year aid program (2004-2006), which cites them as areas of comparative advantage. Health is not identified as a sec- tor for bilateral support in the current program of work, the government having ended almost all its bilateral international health programming in the early 1990s. Austria has never had an active population assistance program and the country still has no formal policy on reproductive health and population. Despite its support at the policy level for the ICPD Programme of Action, Austria has shown little interest in supporting most ICPD priorities programmatically, the major exception being education. As noted above, however, the government has recently increased its support for UNFPA and the coun- try’s new three-year program enshrines gender equality as a principle of Austrian development policy. The Policy Environment for International Population Assistance Austria’s international development assistance efforts are neither widely publicized nor well known by the general public. There is little public discussion of reproductive health topics, although the global HIV/AIDS epidemic has become a major issue of concern. The Austrian Foundation for World Population and International Cooperation (SWI) was founded in 1999 to help create greater awareness of reproductive health issues and mobilize support for the Cairo Programme of Action. Its efforts and those of the IPPF member association, Öster- reichische Gesellschaft für Familienplanung (ÖGF), have had some impact—in particular their advocacy efforts vis-à-vis the parliament which helped to secure the increase in support for UNFPA. Trends in Funding for Population Assistance Overall Funding Levels Austria has never been a large contributor to internation- al reproductive health and population programs. In 2002, the country provided just $1.5 million for population assistance. This figure is a recovery from support in 2000 and 2001, but is still less than record funding of $1.8 million in 1998. In 2002, Austria only committed 0.29 percent of its total ODA budget for population activities, and spent just $7 per million dollar of GNI on population assistance, one of the lowest funding levels of any European donor. One-third of Austria’s assistance flowed through multilateral organizations in 2002 and thus is not reported by type of activi- ty. The bulk of the remaining two-thirds (more than 90 per- cent) was classified as support- ing reproductive health activi- ties other than family planning and the rest was for HIV/AIDS. Austria has made only marginal progress since PAI’s 1998 analy- sis and would need to increase its annual population assistance more than 40 times, to $61.2 million, to meet its fair share of ICPD donor commitments by 2005. Multilateral Funding In 2002, Austria allocated 34 percent of its population assistance through multilateral organizations, the bulk of which appears to have gone to UNFPA. An additional 10 percent was assigned to multi-bilateral project support. This is a substantial decline compared to the late 1990s, although it is unclear whether these figures reflect all multilateral giving to sexual and reproductive health. Austria has not been a significant contributor to UNFPA, the major channel for multilateral population assistance, 55 $ U S M IL L IO N S Because the definition of population assistance was broadened, data from before 1995 are not comparable to later years. 0.0 0.5 1.0 1.5 2.0 2.5 3.0 200220012000199919981997199619951994 $1.52 $0.98 $0.87 $1.45 $1.78 $0.58 $0.86 $0.75 $2.87 o NGO o Multilateral o Multi-Bilateral o Bilateral Trends in Population Assistance 1994-2002 Austria NB: In 1999, Austria reported only contributions to multilateral sources. 2001 project and program figures are estimated at the 2000 level. Source: UNFPA. 2004. Financial Resource Flows for Population Activities in 2002. New York: UNFPA. 2002 population size: 8.1 million Total Official Development Assistance (ODA), 2002: $520 million ODA as a percentage of GNI, 2002: 0.26% Total population assistance, 2002: $1.5 million Population assistance as percentage of ODA, 2002: 0.29% Population assistance per $US million GNI, 2002: $7 V I T A L S T A T

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