| Where Does
the Money Come from Now? Estimates of global, regional and
domestic resource flows for population and development programmes, including reproductive
health, are based on information for countries and institutions reporting in 1997. 3
External Assistance
Donors are providing about $1.9-2.0 billion per year. Leading donors in the 1990s such as
the Netherlands, Norway and Denmark have allocated a relatively large share of their GNP
to development assistance including the share to population; others, notably Australia,
Finland and the United Kingdom, have begun to increase the population share. On the other
hand, the United States, while still the leading donor for population activities, has
recently reduced its level of support. Japan, UNFPA’s largest contributor since 1986,
has fulfilled its pledge for international assistance in global population-related issues
for the period 1994-2000.
The European Commission/UNFPA project for reproductive health projects in Asia (see
page 49) is an example of the will of EC members to fulfil the commitment they declared
prior to the ICPD. But much still needs to be done to streamline the process for moving EC
population funds through its bureaucracy.
Prospects for increased donor support include further development of the 20/20
Initiative. This is a mutual commitment between developed and developing country partners
to allocate, on average, 20 per cent of their official development assistance (ODA) and 20
per cent of their national budgets, respectively, to basic social services. The five
components of basic social services, in a definition agreed on at a 20/20 Initiative
meeting in Oslo in 1996, are basic health; basic education; reproductive health, including
family planning and sexual health; nutrition; and, basic water and sanitation.4
The World Bank is mobilizing resources for basic social services,
including reproductive health, for example, by taking measures to address the debt burden
of highly indebted poor countries. It has also provided $3.6 billion to help the poor cope
with economic hardships and change, and to assist refugees and people displaced by
emergencies.
The World Bank also provides loans for health, nutrition, and population; for
education; and for the social protection components of other loans ($8.48 billion in
1998). Bank lending has increasingly supported integrated reproductive health programmes,
both directly and through sector-wide assistance and health reform.
BOX 24
--------------
Debt Relief and the Resource Challenge
To add to their problems, many poorer countries are saddled with extremely high levels
of external debt, accumulated with the encouragement of the lending institutions before
the importance of basic social investments was appreciated. In some countries, debt
service is several times the total national allocations to health or education.
A helping hand One new mechanism to reduce debt burdens is to exchange debt for
increased social investment. Uganda has negotiated a "debt swap" with
international financial institutions, and other countries are discussing the
possibilities. Uganda’s savings have largely been used to eliminate fees for primary
school. In two years enrolment jumped from 54 to 90 per cent, in marked contrast to other
heavily indebted countries.
Donors have forgiven some of their bilateral debt as a response to natural disasters in
Central America. Expansion of the debt relief programme of the World Bank and the
International Monetary Fund (the Highly Indebted Poor Countries initiative) has been
proposed by donor countries. The five-year review of ICPD implementation urged further
exploration. |
Donations by foundations are becoming more important.
The Ford Foundation, the Rockefeller Foundation, the MacArthur Foundation, the Hewlett
Foundation and the Mellon Foundation 5 each
contributed between $10 million and $30 million for population activities in 1996 and
similar amounts in 1997. The Packard Foundation announced in November 1998 that it will
allocate more than $300 million to international population and reproductive health
programmes over the next five years.
In its first year of grants, the United Nations Foundation, set up with $1 billion by
Ted Turner in 1997, gave over $12 million to various reproductive health and women’s
empowerment projects, including several for adolescent reproductive and sexual health.
The William H. Gates Foundation, which supports efforts to improve global health and
education, has contributed $1.7 million to the United Nations, for specific use by UNFPA
to support collaboration among developing countries. This year it provided a multi-year
$50 million grant to the Columbia University School of Public Health to combat maternal
mortality, traditionally the most difficult of all reproductive health problems to solve.
Another $20 million dollars has been earmarked to support developing country professionals
in reproductive health. In June 1999, Bill and Melinda Gates added $5 billion to the
Foundation’s endowment, doubling the funds available.
Domestic Resources
Globally, it is estimated that in 1997 governments and national NGOs spent almost $7
billion on population programmes from resources mobilized in developing countries. 6 It is further estimated, with considerably
less precision, that private channels in these countries were responsible for another $1
billion.
It is extremely difficult, however, to establish exactly what is being spent on
implementing the population and reproductive health package of the Programme of Action. 7 Accounting systems measure general
categories of inputs such as salaries and supplies rather than services provided. The ICPD
package costs only services delivered through primary health care, not hospital care or
other services needed at higher levels of the system.
More important, out-of-pocket expenditures by individuals are difficult to monitor. Not
all countries survey household expenditures, and surveys do not usually inquire about
specific health services. There is a growing body of information about payments for family
planning and maternal and child health services 8 but this does not address other
reproductive health outlays.
Programme countries in Asia and the Pacific mobilized the most for population and
reproductive health programmes in their countries (over $5 billion), followed by Latin
America and the Caribbean (over $1 billion). Smaller amounts were mobilized in Western
Asia, North Africa and sub-Saharan Africa. Over $100 million is estimated to have been
mobilized in countries in economic transition.
A small number of large countries accounted for most of this: the combined expenditures
of China, India, Indonesia, the Islamic Republic of Iran and Mexico amounted to $5.5
billion, approximately 80 per cent of all domestic resources for reproductive health and
family planning services. Most other developing countries, and particularly the 51
least-developed countries, had neither the public resources nor private income to meet
their domestic needs.
In some areas, the impact of funding shortfalls is already apparent. The ICPD Programme
of Action proposed $1.3 billion for STD/HIV/AIDS-prevention programmes in the year 2000,
compared with recent levels of less than $550 million yearly.9 Prevention programmes are
the most cost-effective strategy to reverse the pandemic.10 Additional resources, not part
of the ICPD estimates, will be needed for the care of individuals infected with HIV/AIDS
and to help families, communities and countries affected. Many countries are trying to
increase the contributions of the private sector and non-governmental organizations. More
than 37 countries had private-sector initiatives (most often the commercial marketing of
subsidized contraceptives) before 1994 and nine more have begun since the ICPD. Some
countries, such as Bolivia and Mexico, now include reproductive health services in
national insurance schemes. Despite many technical and managerial challenges, especially
reaching poor and other marginalized populations, private-sector involvement will probably
increase. A private-sector initiative co-sponsored by UNFPA encourages private-sector
interest and partnership to meet reproductive health needs.
Increasing Efficiency
Reaching high efficiency requires high initial investments, to pay both for current
services and for improving them. Health-sector reform, for example, will pay substantial
dividends, but the costs of transition should not be underestimated.
Efficiency cannot be seen in isolation. Advocacy, for example, is efficient in
stimulating demand for services; but the services must then improve to meet demand.
Referral is an efficient way to supplement clinic services, but only if the referral
points are well-placed and equipped to handle the additional load.
Making health services better and more
efficient
requires a high initial investment.
Investments often set the stage for later efficiency gains. Industrial countries
brought maternal mortality down to today’s very low levels by equipping more
institutions to handle all kinds of emergencies, including obstetric emergencies. Some
investments which appear to be inefficient produce gains later, such as monitoring the
self-medication of all tuberculosis patients. The initial investment stimulated
development of more cost-effective methods of ensuring compliance.
When efficiency considerations dominate decision-making, the outcomes measured must
reflect the full range of values and benefits sought. When the cost-effectiveness of
family planning programmes was measured by births averted, the emphasis was on permanent
methods (e.g., sterilization) over temporary (e.g., oral pills, IUDs, injectables and
barrier methods). Today, measures of cost-effectiveness seek to include the quality of
care offered, including a range of contraceptives, and the advantage for the client of
different methods at different stages of the life cycle.
| MAIN MENU | CONTENTS
| NEXT |
For more information:
United Nations Population Fund
Information and External Relations Division
220 E. 42nd Street, New York, NY 10017, U.S.A.
Tel. 212-297-5020; fax: 212-557-6416
E-mail: ryanw@unfpa.org. Web site: www.unfpa.org |
