Speeding the reproductive revolution
Posted: 18 September 2000
Author: Bryant Robey and Ushma Upadhyay
Author Info: Bryant Robey is editor of Population Reports and Ushma Upadhyay is research writer at the Population Information Program, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.
For a very small price the reproductive revolution, allowing all children today born by choice not chance, with good health care, can be achieved in the first 15 years of the new century. But if that price is not paid, everyone will count the cost. Bryant Robey and Ushma Upadhyay report.
In 1994, in Cairo, the world's nations set the goal of universal access to reproductive health care by the year 2015 and agreed to finance its costs. Imagine, then, a world in which access to care brought good reproductive health to all people:
- HIV/AIDS and other sexually transmitted diseases no longer plague the planet.
- Women have safe pregnancy and safe delivery of their children.
- Sexual violence is a thing of the past.
- Husbands and wives share responsibility for family health.
- All pregnancies are intended; all births are planned. People have only the number of children they want, when they want them.
Pressures on natural resources and the environment diminish, while living standards rise. Adequate supplies of freshwater and arable land help assure ample food production, proper sanitation, and good health. Soon, development becomes sustainable.
Could such a world exist sometime in the future, or is it only a Utopia? There is reason for concern. Few governments and donor nations have delivered on commitments made at the International Conference on Population and Development (ICPD) in 1994. Reproductive health is not improving, and it may be getting worse:
- More than 33 million adults and over 1 million children are infected with HIV/AIDS. Other sexually transmitted diseases (STDs) are on the rise; about 333 million new cases appear each year.
- Of the 175 million pregnancies each year, an estimated 75 million are unintended. In developing countries unintended pregnancies carry a health risk 20 times greater than the risk of using contraception.
- An estimated 585,000 women die each year from complications of pregnancy, childbirth, and unsafe abortion. Unsafe abortions cause between 50,000 and 100,000 women's deaths each year.
- Around the globe, between one-quarter and one-half of women have been physically abused by a sexual partner.
In developing countries an estimated 100 million married women of reproductive age are considered to have unmet need for family planning - that is, they do not want to become pregnant but are not using any contraceptive method.
While fertility has fallen in most countries, population is still growing rapidly, at almost 77 million every year, as estimated in 2000 - the equivalent of the current population of Vietnam. Continuing population increases of this magnitude, added to a population base already over 6 billion, would carry ominous consequences for the planet and its people in the future.
The 179 countries assembled at the ICPD agreed to an expanded reproductive health agenda, addressing not only fertility, family planning, and development but also reproductive rights, gender equality, women's empowerment, and men's participation. Country representatives agreed to some specific reproductive health goals to be reached by 2015, including:
- To meet all unmet need for family planning;
- To reduce maternal mortality by three-fourths compared with 1990 levels; and to reduce infant mortality to below 35 deaths per 1,000 births.
Far short of the goal Reaching these and related reproductive health goals of the conference was calculated to cost about US$17 billion per year in 2000, rising to $22 billion per year by 2015 (in constant 1993 US dollars). Developing countries agreed to pay two-thirds of the cost; donor countries, one-third. While $22 billion per year represents a substantial increase over existing support for reproductive health, it is less than the world now spends on military expenditures in only 11 days.
Of the annual $22 billion, $14 billion would provide family planning information and services and improve the quality of care for over 600 million couples and would offer everyone access to safe and reliable contraception. Another $6 billion would support maternal health programmes and other primary health care related to reproductive health, including information and services for antenatal and postnatal care, emergency obstetric care, and treatment and counselling about STDs. And $1.5 billion would go for prevention of HIV/AIDS and other STDs through mass media and in-school education programmes, promotion of voluntary abstinence and responsible sexual behaviour, and expanded distribution of condoms.
Immediately after the ICPD, reproductive health funding by developed countries increased substantially but then fell back again, and is still uneven. In 1996 donor countries provided about $1.8 billion for population activities, $2.0 billion in 1997, $2.1 billion in 1998 and back down to $1.9 again in 1999. Funding levels are still only roughly one-third of the $5.7 billion target for developed countries. All together, expenditures for population activities yielded a global estimate of $10.6 billion in 1999, far short of the total $17 billion per year pledged by all countries in Cairo.
One might expect that reaching the ICPD goals would be easiest to achieve and fairest if the distribution of assistance among donor countries was relative to their ability to pay. Yet each country determines its own funding amounts, not according to the international need but to domestic priorities and politics. Most recent reports find in absolute amounts, the top three donors are, in order, the United States, Germany, and Japan. On a per capita basis, however, Norway, Denmark, Sweden, and the Netherlands contribute most, setting a world example.
The United States, which has previously provided half of donor population assistance, has made cuts in recent years that have seriously set back efforts to achieve ICPD goals. Japan also does not appear to be increasing their funding. The United Kingdom has protected reproductive health and family planning programmes from recent budget cuts and continues to expand its population assistance. Belgium, Italy, and Spain, which historically have not provided population assistance, have begun to do so in a small way.
Multilateral sources, including the World Bank and regional development banks, agreed to contribute towards the donor-country target of $5.7 billion per year. The World Bank has adopted the ICPD agenda and is paying more attention to expanded reproductive health issues, instead of demographics. Still, the Bank could play a greater role, while other international banks could expand their health lending further.
Consequences of failure
The UNFPA has calculated the consequences for reproductive health of failure to deliver on promised financial support for the ICPD goals. Official assistance for 2000 has not yet been reported, but under the most optimistic funding scenario, in which the funding falls $2.1 billion short per year, the number of unintended pregnancies would be 42 million more this year - in 2000 - than if funders met their commitments. The number of induced abortions would be 17 million more. An estimated 99,000 more women would die of maternal causes in 2000, and there would be 1.2 million more infant deaths. Nearly 100 million people would be left without access to family planning information and services - a number equal to the current entire estimated unmet need for family planning.
Such dismal numbers would appear not only this year but would be repeated in 2001, 2002, and every year thereafter, as long as countries continued to fall short of the goal.
Obviously, these numbers would become much worse if governments and donor nations fell further short, while progress toward meeting the goal would save lives and improve health. Improved funding would also increase the availability of contraceptive methods, the number of programmes and projects carried out, the quality of services offered, and the amount of information that people could receive. Ultimately, failure to meet the goal would mean higher fertility rates and faster population growth, putting more pressure on the environment and making sustained development only an empty promise.
What can be done?
Countries at the ICPD did not intend to describe a Utopian world of the future but to set forth realistic and achievable goals for the international community. It is no secret that family planning and other reproductive health programmes work. Thanks in large part to family planning programmes, as well as other progress in development, fertility rates in developing countries have fallen by nearly half compared with levels in 1960, while contraceptive use has risen from just one person in every ten in 1960 to about half of all women of reproductive age today. But what of the future?
Six years after the ICPD there is still time to continue the progress of recent years and, as promised, to expand the reproductive revolution. But governments still need to be convinced that paying for reproductive health programmes is an urgent priority and that developing countries, donor countries, and multilateral institutions all have much to gain from reaching the ICPD goals.
Reducing human suffering and improving the quality of life is everybody's responsibility. Over the long run, increased national wellbeing also strengthens the global economy, international trade, political stability, and co-operation on such critical international issues as the environment, human rights, and security. Delay in meeting the ICPD goals means more problems in the future. The sooner the international community recaptures the spirit of the ICPD, the more the world can be a place future generations will be able to inhabit.
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