Why Reproductive Health Supplies are Crucial to Achieving the Millenium Development Goals (MDGs)
Publication date: 2005
Why Reproductive Health Supplies are Crucial to Achieving the Millennium Development Goals (MDGs) w w w . r h s u p p l i e s . o r g MDG Target 1 – Reduce by 1/2 the number of people living on $1 per day The link to reproductive health supplies – falling fertility rates in low income countries have been correlated with a decline in poverty. 1 Provision of reproductive health services and supplies helped reduce fertility by 43 percent in developing countries from 1965-90.2 These vital contraceptive supplies are now under-funded by hundreds of millions of dollars annually. MDG Target 5 – Reduce by 2/3 the mortality rate among children under 5 The link to reproductive health supplies – almost 11 million children under 5 die each year, mainly in developing countries.3 Infant mortality rates can decrease by as much as 45 percent when births are spaced more than 2 years apart.4 The use of modern methods of fam- ily planning is critical to successful birth spacing and increased infant survival. MDG Target 6 – Reduce by 3/4 the maternal mortality ratio The link to reproductive health supplies – in industrialised countries a woman has only a 1 in 4,000 chance of dying in pregnancy or childbirth over the course of her lifetime; in the developing world, that risk increases to 1 in 60.5 The use of contraceptives to ‘space’ births is also a critical factor in reducing maternal mortality, yet 123 million women who want to use contraception are unable to do so.6 MDG Target 7 – Halt and begin to reverse the spread of HIV/AIDS The link to reproductive health supplies – 5 million people were infected with HIV in 2003.7 Actions to prevent HIV are 28 times more cost effective than treatment.8 Condoms are currently the only product able to prevent sexually-transmitted HIV, yet on average, just 4.6 condoms are available per year to each African man.9 1,2 Leete, R and M Schoch. 2003. “Population and Poverty: Satisfying Unmet Need as the Route to Sustainable Development.” Population and Development Strategies Series 8. New York: UNFPA. 3 Millennium Development Goals. 2004. “Reduce child mortality.” Available from http://www.developmentgoals.org/Child_Mortality.htm; Internet; accessed 4 January 2005. 4 DELIVER. 2003. “No Product? No Program! Reproductive Health Commodity Security for Improved Maternal and Child Health.” Paper presented at the Fourth Ordinary Meeting of the West African Health Organization, Banjul, Gambia, 14-18 July. 5 World Health Organisation (WHO), United Nations Children’s Fund (UNICEF) and United Nations Population Fund (UNFPA). 2003. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO. 6 Ross, J and W Winfrey. 2002. “Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate.” International Family Planning Perspectives 28(3): 138-143. 7 Joint United Nations Programme on HIV/AIDS (UNAIDS). 2004. 2004 Report on the Global AIDS Epidemic. Geneva: UNAIDS 8 Alan Guttmacher Institute (AGI) and United Nations Population Fund (UNFPA). 2004. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGI and UNFPA. 9 Shelton, J and B Johnston. 2001. “The Condom Gap in Africa.” British Medical Journal 323 (139). 10 United Nations Millennium Project. 2005. Investing in Development: A Practical Guide to Achieving the Millennium Development Goals. New York: United Nations Development Programme. F E B R U A R Y 2 0 0 5 This briefing sheet aims to make clear the urgent need forimproved access to contraceptives and other reproductive health supplies in order to help break the cycle of poverty and early death in much of the developing world and achieve the MDGs. According to the UN Millennium Project, “Universal access to sexual and reproductive health services, information and education should be guaranteed as an intrinsic part of strate- gies to reduce child deaths and improve maternal health.” Such access would also have “far reaching effects for …virtually every other MDG, including the Goals for HIV/AIDS, gender, education, environment, hunger and income poverty.” The Project’s report recommends “Expanding access to sexual and reproductive health services, including family planning and contraceptive information and services, and closing funding gaps for supplies and logistics” as an achievable short-term priority. 10 The Role of Reproductive Health Supplies in Reducing Poverty 1 in every 4 people in developing countries (1.1 billion people) subsist on less than US$1 a day, the standard mark of extreme poverty. 11 Poverty and poor reproductive health have mutually causal relationships: poverty is created and worsened when adults cannot work due to their own illnesses or the need to care for sick children. Similarly, being poor makes people less able to afford the nutritional and medical services that they need to stay healthy. Sexual and reproductive illnesses cause more than one third of the global burden of disease amongst women of childbearing age and one fifth among the population overall.12 “Impoverished people living in rural areas have the highest fer- tility rates and the largest families. Rapid population growth and shrinking farm sizes make rural poverty worse. Poor peo- ple (in rural and urban areas) have less access to information and services to space or limit their pregnancies… [Overcoming the poverty trap] is helped by a voluntary reduction in fertility, which promotes greater investments in the health, nutrition and education of each child.” Millennium Project “Investing in Development,” January 200513 According to one study, in poor countries (where more than 10 per- cent of people live in poverty), women have an average of 4.6 births, whereas in richer countries (with a poverty level below 10 percent), they have a total fertility rate of 2.3.14 Lowering fertility rates, through expanded knowledge about family planning and access to contraceptive supplies, stimulates economic growth on the societal level but also has substantive benefits for indi- viduals and families. Just as national governments are able to spend more per capita on social welfare when population growth slows, par- ents can invest more in health and education costs for each child if they have a smaller family. Couples who have smaller families are often able to have women work outside the home and to save more of their income, thus increasing national labour supply, investment and growth. Reproductive Health Supplies are Vital to Reducing Child and Maternal Mortality The MDGs on maternal and child mortality are unlikely to be achieved by 2015. Maternal mortality rates “remain unacceptably high in every region,” according to the United Nations, and have not reduced significantly in the last 15 years. Progress in reducing child mortality levels is slowing in many regions and neo-natal mortality remains particularly high.15 Lengthening the interval between births (birth spacing) is a key means of improving both maternal and child health. Ensuring access to family planning services and supplies enables women to decide the timing and spacing of their children and this has both immediate and longer term health benefits for the mother, the child, and the family. In Mali, for example, infant mortality rates are 45 percent lower when births are spaced more than 2 years apart.16 A study of 15 West African countries found that those with the highest contraceptive use have the lowest maternal mortality rates and vice versa.17 Country Contraceptive use (%) Maternal mortality per 100,000 live births Sierra Leone 4 2,100 Burkina Faso 5 1,400 Cape Verde 46 190 These MDGs, although part of an overarching poverty reduction framework, are expressed as national averages and therefore do not require measurable improvement to occur among the poor. In certain countries, the goals could even be achieved with little impact on the mortality rates among the poorest, thus failing to address the overall goal of poverty reduction.18 A ”top down” approach to reducing maternal and infant mortality would, for example, prioritise the provision of new specialist obstet- ric and neonatal units, to which the richer, urban sections of society would have most access. A more ”bottom up” approach, in contrast, would focus more on the expansion of reproductive health care and access to contraceptives and other reproductive health supplies to rural or disadvantaged communities. According to the World Bank, spending and progress towards meeting health goals most benefits poor people – those in greatest need – when it is concentrated among them rather than distributed more broadly to society as a whole.19 Unless governments choose to actively target their MDG action plans towards the most disadvan- taged, the fulfilment of the health MDGs may not make a significant impact either on the disparity between mortality rates in different segments of the community or the actual number of deaths amongst the poorest. The ”bottom up” approach, prioritising access to care and contracep- tives, could also be highly cost effective. Research shows that an increase from zero to 20 percent contraceptive use in a high fertility, high mortality region would avert maternal and infant deaths for only US$140 per affected individual.20 Reproductive Health Supplies Help Halt the Spread of HIV/AIDS 40 million people worldwide are now infected with HIV/AIDS.21 The 11 Millennium Development Goals. 2004. “Eradicate extreme poverty and hunger.” Available from http://www.developmentgoals.org/Poverty.html; Internet; accessed 17 November 2004. 12 Alan Guttmacher Institute (AGI) and United Nations Population Fund (UNFPA). 2004. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGI and UNFPA. 13 United Nations Millennium Project. 2005. Investing in Development: A Practical Guide to Achieving the Millennium Development Goals. New York: United Nations Development Programme. 14 Mason, A and S Lee. 2004. “The Demographic Dividend and Poverty Reduction.” Paper presented at the Seminar on the Relevance of Population Aspects for the Achievement of the Millennium Development Goals, New York, 17-19 November. 15 UN Millennium Project. 2005. Investing in Development: A Practical Guide to Achieving the Millennium Development Goals: New York. United Nations Development Programme 16,17 DELIVER. 2003. “No Product? No Program! Reproductive Health Commodity Security for Improved Maternal and Child Health.” Paper presented at the Fourth Ordinary Meeting of the West African Health Organization, Banjul, Gambia, 14-18 July. 18 Gwatkin, D. 2000. “Health Inequalities and the Health of the Poor: What Do We Know? What Can We Do?” Bulletin of the World Health Organisation, 78(1). 19 World Bank. Undated. “Reproductive Health and Poverty.” Available from http://wbln0018.worldbank.org/HDnet/hddocs.nsf/vtlw/8FC90D3546E938CE85256DE9005A248C?OpenDocument; Internet; accessed 18 November 2004. 20 Walsh, J, et al. 1993. “Maternal and perinatal health.” Disease Control Priorities in Developing Countries. New York: Oxford University Press. Why Reproductive Health Supplies are Crucial to the MDGs massive impact of the pandemic compounds the negative cycle of high fertility rates and poor child and maternal health in many of the poorest countries. The spread of the HIV/AIDS pandemic has tremendous impact on both national economies and household income. Households affected by HIV/AIDS are more likely to be poor than those not affected by the disease.22 The care and treatment of individuals with HIV, as well as absence from a job, combined with eventual funeral costs, can shrink household income by 66 to 80 percent.23 The loss of skilled workers and the income they provide to their fami- lies erodes economic standards and quality of life in the region. This causes a further reduction in public funds for health and education, creating a cycle of deterioration. Children who are orphaned by AIDS lose access to income and education and therefore contribute less to the economy if they reach adulthood. Condoms – currently the only product which protects against sexual transmission of HIV – are an essential component of all strategies to halt the spread of HIV. Yet donors and governments provide the equivalent of only 4.6 condoms annually for each man in Africa, and by 2015 the gap in donor-provided condoms could be more than 12 billion condoms worldwide.24 The use of condoms and other contra- ceptives to prevent pregnancies among HIV-positive women is also essential if mother-to-child transmission of the virus is to be reduced.25 Although both prevention and treatment are necessary to minimise the impact of the pandemic on development and poverty reduction, interventions to prevent HIV are estimated to be 28 times more cost effective than anti-retroviral treatment.26 Greater Access to Reproductive Health Supplies - A Priority if the MDGs are to Succeed Access to high-quality, affordable condoms and other contraceptives, and the knowledge to use them correctly, can help people avoid unwanted births – estimated at over 22 million per year in developing countries – and protect themselves from HIV/AIDS.27 Unfortunately, most of the developing world experiences chronic shortfalls of these reproductive health supplies. • In 2003, donors provided US$216 million towards the cost of contraceptives and condoms, but total need was estimated at almost $1.3 billion. 28 Developing country governments are not able to fully meet the gap between total cost and the amount supplied by donors, and the unfilled need for these supplies is hundreds of millions of dollars annually. Moreover, they lack the capacity to consistently and reliably forecast, finance, procure and deliver the supplies necessary for repro- ductive health programs. The efforts of social marketing groups and non-governmental organi- sations (NGOs) to raise awareness about family planning, along with the AIDS pandemic, have increased demand for contraception, but provision of supplies has not kept up and the shortfall is expanding. Increased demand also stems from a rise in the number of young peo- ple reaching their reproductive years, a demographic pull that will help elevate the total number of potential contraceptive users in the poorest developing countries by almost 80 percent by 2015.29 Equality of Access to Supplies The poorest in developing world countries are those most affected by this supply shortfall. • If the worldwide need for contraceptives were met, the benefits, including the 1.5 million deaths that could be averted each year, would be concentrated in the lowest income countries.30 • The vast majority of this unmet need is concentrated among the world’s poor, in countries such as Haiti, Pakistan and Tanzania, where less than 10 percent of the poorest in the population use contraceptives. 31 • In sub-Saharan Africa, the poorest often have contraceptive use rates between 3 and 10 times lower than the richest income groups.32 People struggling to subsist from day to day are unlikely to be able to pay anything for the contraceptives and other reproductive health supplies that they desperately need and want. Ensuring their access to free or heavily subsidised supplies is vital, but in many developing countries, particularly in Africa, free, public sector reproductive health services and supplies are severely limited. Moreover, greater awareness and access among the richest sections of the community mean that it is these groups, rather than the poorest, which most often use free or sub- sidised supplies. In a recent study of 20 countries, the poorest people in the community accessed their fair share of services and supplies in only three countries (Bangladesh, Honduras and Paraguay). In the countries with least equitable access, nearly two thirds of users of public servic- es are from the highest income groups, as reported in a study of equity in family planning services by JSI/DELIVER.33 21 Joint United Nations Programme on HIV/AIDS (UNAIDS).2004. 2004 Report on the Global AIDS Epidemic. Geneva: UNAIDS 22 Greener, R. 2004. “The Impact of HIV/AIDS on Poverty and Inequality.” The Macroeconomics of HIV/AIDS. Washington, DC: International Monetary Fund. 23 UNAIDS. 2004. Report on the Global AIDS Epidemic. Geneva: UNAIDS. 24 UNFPA. 2004. Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2002. New York: UNFPA. 25 Sweat, M. 2004.”Linkages between Family Planning and HIV PMTCT Programs: Opportunities and Challenges.” Presented at WHO and UNFPA Consultation on Family Planning and HIV Integration, 3 May. 26 AGI and UNFPA. 2004. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGI and UNFPA. 27 Leete, R and M Schoch. 2003. “Population and Poverty: Satisfying Unmet Need as the Route to Sustainable Development”. Population and Development Strategies, Series 8. New York. UNFPA. 28 UNFPA. 2005. Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2003. New York: UNFPA. Cited in UNFPA “News from the Commodity Management Unit”, Number 1. January 2005. 29 Ross, J 2001. “Contraceptive Projections and the Donor Gap.” Meeting the Challenge: Securing Contraceptive Supplies. Washington, DC: Interim Working Group on Reproductive Health Commodity Security. 30 AGI and UNFPA. 2004. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGI and UNFPA. 31, 32 Leete, R and M Schoch. 2003. “Population and Poverty: Satisfying Unmet Need as the Route to Sustainable Development.” Population and Development Strategies Series 8. New York: UNFPA. © P op ul at io n A ct io n In te rn at io na l A woman in rural Madagascar instructs a neighbour on how to use oral contraceptives Why Reproductive Health Supplies are Crucial to the MDGs Socioeconomic profile of public sector family planning users 34 Compounding the problem of unequal access, there is also widespread weakness in the public sector logistics systems in many developing countries. Since a great many poor people live in rural areas, inade- quately functioning systems for placing and receiving orders often prevent people from having consistent access to the supplies they need. “Governments of recipient countries are encouraged to ensure that public resources, subsidies and assistance received from international donors for the implementation of the goals and objectives of the Programme of Action are invested to maximise the benefits to the poor and other vul- nerable population groups…” - Report of the International Conference on Population and Development +5, 199935 What Can Be Done? Many governments and NGOs are now looking at how to ensure more equitable access to services and supplies through a whole market per- spective and improved targeting. A whole market approach requires that all partners (public, subsidised/social marketers, commercial providers) understand their varying roles in supplying contraceptives and other reproductive health products. Proper market segmentation results in less competition among partners for the same clients, allowing each partner to better target appropriate groups. Studies on willingness and ability to pay can help identify dif- ferent income groups within a country or region and assess whether and how much each group can pay for supplies. This kind of analysis can dis- tinguish those least able to pay and help in developing strategies to get free supplies to them. In countries with a significant or emerging middle class, the commercial sector can expand to provide appropriately-priced and marketed sup- plies for the wealthier individuals. Governments can encourage this by reducing regulatory barriers. For moderate income groups that can afford to pay a small amount, social marketing schemes can be successful in marketing and selling supplies at subsidised prices through the private sector and other channels. Sustained investment in capacity building and enhanced political acknowledgement of the importance of a well functioning supply chain would help reduce supply shortages particularly evident in poor rural communities. Increasing access to reproductive health supplies, estimated to cost just US$20-25 per person annually,36 is an investment with multiple divi- dends for the developing world. At present, its importance to the attain- ment of the MDGs and the reduction of poverty is in danger of being overlooked. Recommendations In relation to achieving the MDGs, the Supply Initiative offers the following recommendations: 1. Governments should explicitly recognise the importance of universal access to reproductive health care and supplies for the attainment of the MDGs in both international and national policy and implementation. 2. Donors should increase their financial commitments to reproductive health products, in order to help alleviate the gap between unmet need and supply. They should also encourage similar commitments from developing country governments. 3. Reproductive health strategies should prioritise universal access to supplies and public spending should be more effectively targeted towards meeting the needs amongst the poorest sections of society. 4. Developing country and donor governments should work together with civil society and industry to build capacity in supply chain management and also to extend and develop public-private partnerships which contribute towards the goal of universal access to reproductive health supplies, through, for example, research on market segmentation and pricing structures. 5. Tracking and co-ordination of supply donations should be improved to avoid duplication and/or undersupply situations, thereby maximising available funding. Donors and in-country programme managers should routinely monitor and co-ordinate funding and supply donations. It is recommended that they use the RHInterchange, a web-based system that harmonises procurement and shipment data, to facilitate their tracking and coordination. (http://rhi.rhsupplies.org) 6. Local and international NGOs should be recognised for their contributions to the reproductive health sector and should be given a greater role in the design and implementation of national strategies to achieve the MDGs. De si gn : w w w .in ex tre m is .b e Poorest 20 percent 0 10 20 30 40 50 60 70 Richest 20 percent Pe rc en t o f p ub lic s ec to r u se rs Rich and poor as percent of users of public sector contraceptives Et hi op ia Bu rk in a Fa so N ig er M al i N ig er ia Ug an da Ba ng la de sh Ho nd ur as Pa ra gu ay 33, 34 Karim, A, et al. 2004. “Equity of Family Planning in Developing Countries.” Washington, DC: DELIVER Project/John Snow, Inc. 35 UN General Assembly 1999. “Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development.” Report of the Twenty First Special Session of the GA. UNGA. New York. 36 PAI. 2000. “How Reproductive Health Services Work to Reduce Poverty.” Washington, DC: PAI.
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