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Action Priorities
The ICPD Programme of Action was the first international
consensus document to include estimates of the
cost of implementing specified interventions.(3) It
defined a basic programme of priority actions to be
undertaken in the primary health system, including:
- Family planning and infrastructure for service
delivery;
- Additional reproductive health services (including
prenatal care, normal and safe delivery; information,
education and communication about
reproductive health—including STIs, human sexuality
and responsible parenthood, and against
harmful practices such as female genital cutting—
prevention of infertility; counselling, diagnosis and
treatment of sexually transmitted infections; and
referrals, education and counselling for complications
of pregnancy and delivery);
- Prevention of STIs including HIV/AIDS;
- Data, research and policy development for population
and reproductive health.
The annual cost of this intervention package was
estimated at $17.1 billion in 2000, increasing to $18.5
billion in 2005, $20.5 billion in 2010 and $21.7 billion
in 2015. The consensus reached was that developing
countries would mobilize two thirds of the requirements
out of domestic resources and that donor countries
would provide international assistance on the
order of one third of the total.
The Programme of Action noted that these estimates
would be reviewed over time,(4) and that
additional resources would be needed at different levels
of health systems and for supportive interventions
in areas such as education, mortality reduction,
women’s empowerment and social participation.
NEW PROJECTIONS. After the ICPD, other cost estimates
were generated for the broader development
agenda. The 20/20 Initiative for meeting basic social
service needs, endorsed by the World Summit for
Social Development in 1995, called on developing
countries to devote 20 per cent of their national
budgets for health, education and other social aspects
of development, and on donor countries to allocate
20 per cent of their development assistance to these
areas. The Commission on Macro-economics and
Health estimated total requirements for a priority set
of health interventions in low-income countries at
$66 billion per year.(5)
Within reproductive health, an estimate of $7-10
billion needed annually for a comprehensive package
of HIV/AIDS prevention, treatment and care was presented
to the UN General Assembly Special Session on
HIV/AIDS in 2001. Subsequent analyses increased that
projection.(6) It was estimated that $9.2 billion per year
would be needed by 2005 to implement key interventions
and develop infrastructure. The prevention
components of these estimates were only marginally
higher than the ICPD estimate.(7)
New estimates of requirements for the total
HIV/AIDS package are now being developed to reflect
both the continuing spread of the pandemic and the
need for additional funds to strengthen health infrastructure
in order to deliver needed services.
This example demonstrates the dynamic nature of
resource projections, as intervention priorities are
adjusted to local conditions and implementation costs
and system requirements are better understood. Costs
of the transition to new planning, management and
service delivery systems are always hard to anticipate.
Linking HIV/AIDS prevention with reproductive
health programmes is a priority policy concern.(8) New vertical programmes addressing HIV/AIDS have startup
costs for dedicated management systems and other
institutional requirements.(9) While it is easier to track
resource flows for special vertical programmes (rather
than having to tease out targeted costs from general
health system budgets), integrated programming can
address multiple needs and capitalize on synergies
between different components, while providing the
advantage of economies of scale.(10)
Despite the inherent difficulties in tracking
resource flows, UNFPA regularly reports on funding
for the ICPD basic population and reproductive health
package. Donors in 2003 contributed about $3.1 billion,
just 54 per cent of the Programme of Action’s
donor commitment for 2000 and 51 per cent of the
requirement for 2005.
Developing country domestic expenditures for
the package in 2003 were estimated at $11.7 billion.
However, a large proportion of this outlay comes from
a few large countries such as Brazil. China, India,
Indonesia and Mexico. Many countries—particularly
the poorest, with low per capita expenditures on
health—depend mainly on donor funding for their
family planning, reproductive health, HIV/AIDS and
population-related data, research and policy needs.(11)
The constraints on progress are not only financial.
Exchange of information and technology and other
forms of technical assistance will be needed so that
resources can be most effectively deployed.
HUMAN RESOURCE NEEDS. Progress cannot be
accelerated and quality cannot be improved unless
programmes can recruit, train and retain staff.
Different positions require different skills—technical
medical training, counselling abilities, community
outreach capacity, supervisory and managerial talents,
etc.—and these are frequently in short supply.
Civil service salaries are often insufficient to attract
the most capable men and women.
Expanding the range of coverage of programmes
also requires the ability to ensure that people are
available where needs are greatest—often in settings
that are remote or lacking amenities. Each of these
human resource challenges must be addressed
systematically, usually within the context of overall
system reform.
COMMODITY NEEDS. Additional progress cannot be
made without provision of the essential commodities
needed to implement programmes. UNFPA, in collaboration
with other major donors, has worked to ensure
a reliable supply of quality reproductive health drugs,
equipment and supplies.
It is estimated that donors today supply much less
than their historical share of contraceptive commodity
costs: in the early 1990s, donors provided 41 per cent of
commodity requirements, about twice what they provide
today. Due to this funding shortfall, systems have
had to be developed to handle emergency requests
from countries to prevent stockouts and shortages.
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POPULATION DYNAMICS AND POLICY DEVELOPMENT |
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Nicaragua’s 2003 National Development Plan is a good example of how countries can integrate population dynamics
in the national policy and planning process.
Drafted with technical assistance from UNFPA, the plan
notes that population growth and internal and external migration all have important implications for poverty reduction. It calls for improved demographic data collection systems, employment
creation, and a special focus on young people’s needs for reproductive and sexual health education and services.
The plan has influenced other development processes the
Government has participated in or initiated, including the drafting of a Poverty Reduction Strategy Paper, the formulation of the UN Development Assistance Framework, identification
of actions needed to meet the MDGs, and national plans on population, youth and development. It has also led to fruitful dialogue among national policy makers in various sectors of
development work, and to local collaboration among different sectors, notably in providing adolescent services. See Sources
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MILLENNIUM DEVELOPMENT GOALS. The UN
Millennium Project(12) is giving priority to needs-based
assessments of resource and capacity requirements to
attain the MDGs over the next 11 years. The expert
assessments recognize that the availability of reproductive
health services (including family planning,
safe motherhood and prevention of sexually transmitted
infections) is central to achieving the MDGs.(13)
Achieving the MDGs will therefore require multisectoral
investments, including investments in
population and reproductive health.
Resources (both from donors and within national
allocations) for implementing the ICPD and achieving
the MDGs must be significantly increased, but the
resources must be used effectively. In the changing
institutional landscape of decentralization and devolution
of decision-making authority in the social
sectors, this will require development of skills and
capacity at national and lower administrative levels.
Many countries, particularly the poorest, lack sufficient
financial and human resources; serious plans
are needed to overcome these constraints.
Donors reaffirmed their aspiration to provide international
assistance at a level of 0.7 per cent of their
gross national product at the Funding for Development
conference in Monterrey, Mexico, in 2002. Only five
donor countries have reached that level of support.(14)
To attain the MDGs and the critically important
goals of the ICPD, and make serious progress in reducing
the many dimensions of human poverty, past
commitments to development assistance must move
from declarations of good intentions to active partnerships
and investments.
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