This chapter aims to illustrate the large and growing gap between the need for family planning services in sub-Saharan Africa and the availability of donor and government funds to meet this need. We begin by presenting available information on current and projected needs for family planning services. Next, we estimate the costs of meeting these needs, both today and in the future. We present data on current levels of government and donor expenditure on family planning in the region. Much of the information available on these topics -- and particularly on future resource requirements and current government expenditure -- is extremely rough. Nonetheless, it is possible to state with certainty that there is a need for additional resources, over and above donor and government subsidies, to finance current and projected needs for services.
The Costs of Family Planning Services
Need for services
Almost 10 million sub-Saharan African women currently use family planning. About three times this number -- or about 29 million women -- have an unmet need for family planning services. Traditional definitions of unmet need include married women of reproductive age who are fecund and who desire either to cease or delay childbearing, but are not currently using contraception (Curtis and Neitzel, 1996; Rutenberg et al., 1991; Westoff and Bankole, 1995; and Westoff and Ochoa, 1991). Clearly, many unmarried women (widows, divorcees, and younger, unmarried women) also need contraception. As a result, estimates of unmet need as traditionally defined underestimate the true need for family planning.
Figure 2.1 illustrates the extent of unmet need and current use of family planning among all women of reproductive age in the region.1 The sum of current use and unmet need in sub-Saharan nations by Demographic and Health Surveys (DHS) ranges from 21 percent of all women of reproductive age in Niger to 53 percent in Togo. In other words, in Togo, resources must be found to provide family planning services to 53 percent of all women of reproductive age. Currently, 20 percent of women are using contraception, and more than 30 percent of women have an unmet need for services.
Figure 2.1
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On the other hand, a significant proportion of women who are described as having an unmet need still say that they do not intend to use contraception, since they do not believe they need it. This can be for religious or cultural reasons, because of a lack of information, or for a host of other reasons. Family planning programs can alter some but not all of these client-described barriers to use. As such, conventional measures of unmet need overestimate the true extent to which current contraceptive delivery services fail to keep pace with true need as defined by individuals.
Westoff and Bankole (1995) estimate potential levels of contraceptive prevalence under a range of definitions of unmet need, including meeting all unmet need (conventionally defined) and meeting need as expressed by women themselves. About 15 million women consider themselves to be in need of contraception, and would use services if they were available. The results of these alternative scenarios are presented in Figure 2.2. In Burkina Faso, the potential contraceptive prevalence rate is reduced by half if only those women with an expressed desire for contraceptive services are taken into account. In Kenya, the rate is reduced by only five percentage points, because the expressed need for contraception accounts for a considerable proportion of unmet need.
Figure 2.2
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Regardless of which definition of unmet need is used, it is clear that a high proportion of sub-Saharan Africans wish to use contraception, and cannot.
The costs of meeting unmet needs today
It is possible to estimate the costs of providing services to the limited proportion of women in need who now receive them, as well as to estimate the additional funds that would be needed to provide services to all women who wish to use them. A total of approximately U.S. $283 million was spent annually in the early 1990s to provide family planning services to just over 9.7 million women in sub-Saharan Africa in 1995 (Conly et al., 1995).2 This translates to a cost per user of about U.S. $29. As noted above, about 29 million additional women wish to delay or limit childbearing but are not using contraception. Assuming constant costs per user, providing services to these women would cost approximately U.S. $841 million, about three times the amount now spent. Providing services only to those women who say they would use contraception -- about half of those defined as having unmet need -- would cost approximately U.S. $420 million. Total expenditure under this scenario would need to increase by 150 percent, just to meet existing needs for services.
For a number of reasons, these estimates of additional, current resource needs should be interpreted with caution. As we will discuss later in this chapter, information on total expenditure, and particularly government expenditure, is very rough. In addition, costs per user are likely to decline as programs expand due to economies of scale. Nonetheless, these rough estimates make it clear that substantial, additional resources are needed to meet existing needs.
Projecting unmet needs
Without a significant expansion in the resource and service base, a much higher proportion of women will have unmet needs in the future. Unmet need is likely to grow substantially for two reasons: 1) Populations are growing, and women of reproductive age make up an increasingly high proportion of these populations; and 2) A growing proportion of women will desire to use contraception. In Kenya, for example, the population of women of reproductive age will increase by 40 percent between 1992 and 2000. The commensurate figure for Nigeria is 35 percent (United Nations, 1994). Providing contraception to all those who want to use it will imply an enormous increase in the number of contraceptive users. For example, an increase in the contraceptive prevalence rate of 15 percent in Kenya and Nigeria would imply an increase in the number of contraceptive users of 121 percent and 275 percent, respectively (Haaga and Tsui, 1995).
The costs of meeting future unmet needs
Numerous efforts have been made to estimate the cost of meeting family planning needs in the next century (Amsterdam Declaration, 1989; Gillespie et al., 1989; Janowitz et al., 1990; Kocher and Buckner, 1992; Lande and Geller, 1991; McNamara, 1991; and Lewis, 1992). The Amsterdam Declaration estimate, which was based on an amalgam of the estimates produced in the late 1980s, placed total family planning resource requirements for the year 2000 at U.S. $9 billion.
The most recent estimates, developed by the United Nations Population Fund (UNFPA), are the best available to date. While past efforts had been based on the cost of achieving the contraceptive prevalence rates required to meet demographic goals, UNFPA based its estimates on the cost of meeting unmet need for contraception, thereby emphasizing individual reproductive intentions and choice rather than fertility reduction targets. UNFPA also estimates need among all women of reproductive age, rather than limiting the analysis to married women, and makes provisions to account for the fact that not all those defined as having unmet need intend to use contraception.3 As such, total expenditure is likely to be somewhat higher than the estimate we use here.
UNFPA's estimated annual resource requirements for family planning in sub-Saharan Africa are provided in Figure 2.3. Resource requirements will grow from an estimated U.S. $1.2 billion in 2000 to almost $3 billion in 2015.
Figure 2.3
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We must emphasize that these resources are required to finance basic family planning services. Significant, additional funding will be needed to provide sub-Saharan African women with broader reproductive health services (see Box 2.1).
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Box 2.1. The Additional Costs of Providing Basic Reproductive Health Care
UNFPA's resource requirement estimates also consider the costs of providing a broader package of reproductive health care in accordance with the vision promulgated by the International Conference on Population and Development (ICPD) held in Cairo in 1994. Definitions of the content of "reproductive health care" beyond the provision of contraceptive services are variable. The UNFPA definition, based on the definition provided in the ICPD Programme of Action (see Chapter I), is very comprehensive, but includes only those aspects of care provided at the primary level.
If the costs of meeting reproductive health needs are added to those for meeting family planning needs, total estimated resource requirements for sub-Saharan Africa in the year 2000 will increase by more than 65 percent over the amount required to finance family planning services alone, to a total of almost U.S. $2 billion. By the year 2015, total requirements will be almost $4 billion.
However, it is likely that the UNFPA estimates of resource requirements for reproductive health care underestimate true needs. Due to data limitations, they include only the costs of providing primary level maternity care and HIV prevention. The estimates do not include the costs of providing the other services outlined in the ICPD Programme of Action, most notably the diagnosis and treatment of sexually transmitted diseases (STDs) and other reproductive tract infections (RTIs), and the prevention and treatment of other reproductive health conditions, such as cervical cancer. Some of these reproductive health problems will respond favorably to interventions in other areas; e.g., HIV prevention efforts will also help to prevent other STDs. But the bulk of screening and treatment is excluded. Some of these omitted services would increase resource requirements substantially. On the other hand, the estimate for family planning resource requirements already includes some elements of the joint infrastructure for family planning and other reproductive health services. This implies that the marginal cost of adding some reproductive health services may be lower than suggested by the estimates developed for each individual reproductive health program component.
There is an urgent need for further work to refine and standardize definitions of reproductive health care and to assess the costs of integrated provision of reproductive health and family planning services. While the UNFPA estimates are a good starting point, they are not a substitute for conducting assessments at the country level. Until such studies are conducted, our knowledge of the costs of providing a package of family planning and reproductive health services will remain limited. |
Trends in Donor Funding to Family Planning Programs
The global picture
According to the 1994 Global Population Assistance Report (GPAR), published by UNFPA, global population sector funding grew at a steady pace over the last decade, reaching record high levels in 1994 (UNFPA, 1996a). As illustrated in Figure 2.4, this is true of both the funding made available by donors (primary funding) and funds spent on population activities in country (final expenditures).4 In real terms, primary funding for population assistance grew by an average of 5 percent per year between 1985 and 1994. Growth between 1993 and 1994, at 24 percent, was significantly above average (final expenditures grew by a record 62 percent during the same period). This is mostly likely due to funding commitments made prior to the International Conference on Population and Development (ICPD).
Figure 2.4
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The ICPD called for governments, international agencies and NGOs to adopt a broader view of population programs beyond family planning services by including a broader range of reproductive health services. The 1995 GPAR, therefore, documents total donor contributions to family planning programs as well as a range of other areas, including basic reproductive health services; maternal, infant, and child health care; and the prevention of STDs, including HIV/AIDS (UNFPA, 1997). While total funding under the new definition increased by 22 percent between 1994 and 1995, this appears to be due to the addition of new program categories. Indeed, if these new categories are extracted, funding for traditional population sector programs -- predominantly family planning services -- appears to have declined by about 15 percent between 1994 and 1995.
This information should be interpreted with caution. While it is possible that funding for conventional family planning services has declined somewhat -- due perhaps to a redistribution of donor funds toward other elements of reproductive health care -- this cannot be known with any certainty. It is unclear how much of the funding to traditional population programs outlined in prior GPAR reports actually supported elements of reproductive health care, even if these were not specified. Nor is it clear whether or not and how donors may have redefined their own funding categories. Most importantly, we have very little reliable data on country-level spending on these different categories of care, implying that global estimates are necessarily rough. Given that the objective of this chapter is to elucidate trends in funding to family planning programs per se, we will draw predominantly on information provided by the GPAR for 1994, the last year that UNFPA focused on traditional population programs. We will supplement this with information from the 1995 GPAR on trends between 1994 and 1995, with appropriate caveats.
According to the 1994 GPAR, developed-country governments provided almost 70 percent of all population funding between 1985 and 1994; almost half was provided by the United States. U.S. funding increased more between 1993 and 1994 than funding from any other source -- rising by U.S. $96 million. While funding from 12 of the 21 donor countries declined between 1993 and 1994, funding increases among the other donor countries far more than offset these declines. Increases were even more dramatic between 1994 and 1995, due in large part to the inclusion of other reproductive health program categories. U.S. funding, for example, increased by U.S. $204 million. Almost 85 percent of this funding -- or about U.S. $173 million -- was for family planning services. Twelve other donor countries also reported significant increases in funding. The Netherlands, for example, increased its contribution by U.S. $43 million, but only about 40 percent of this amount -- or U.S. $17 million -- was for family planning services; an equivalent amount was allocated to "basic reproductive health services" and prevention of STDs/HIV. Similarly, while the United Kingdom increased its overall contribution by over U.S. $40 million, less than 20 percent was allocated to family planning services.
Population funding represented 1.65 percent of total official development assistance in 1994, the highest percentage in ten years. Between 1994 and 1995, the proportion increased to 2.32 percent, due largely, if not completely, to the addition of new funding categories.
Box 2.2 presents additional information on the donor funding patterns that must be considered in any discussion of resource requirements and program sustainability. Changes in donor funding patterns may have an impact on the availability of resources for family planning. The functional composition of donor funding to family planning programs must also be considered, as it is inextricably linked to sustainability concerns. External assistance may also affect African government spending patterns, and may do so in ways that detract from sustainability goals.
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Box 2.2. Key Issues in Donor Funding
Changes in donor funding patterns
Over the last few years, some major donors and development banks have begun a shift from targeted grants/lending to sectoral grants/lending. This implies that the World Bank, for example, is more likely to lend funds for activities that benefit the health sector as a whole, e.g., infrastructure investments or finance reform, than for activities such as family planning or diarrheal disease control.
Within targeted funding, donors are moving away from vertical funding for family planning toward integrated funding for reproductive health--as illustrated by the most recent edition of the GPAR, discussed above. In India, for example, the World Bank has shifted from a focus on family planning to a "reproductive and child health approach." A similar approach is being advocated by USAID, though the project cycle has not yet caught up with changes in strategy.
The impact of these dual trends toward sectoral investment and integrated reproductive health investment on the overall level of resources available for family planning is not clear. As discussed, it is difficult to compare family planning specific funding data through 1994 to more recent data that attempts to delineate spending on a broader range of reproductive health service categories. Based on the rough estimates available, however, it does appear that funding for family planning per se may have declined.
The composition of external assistance for family planning
While we have a fairly clear idea of the total amount of external assistance to family planning activities, we have less information on the way these funds are allocated across such functional categories as service delivery; information, education, and communication (IEC); training; policy; and research and evaluation. The composition of external financing should be assessed from a public finance perspective. There is more public finance justification for donor or public sector support for information dissemination than for other types of family planning activities. Concerns about program sustainability, however, call for donor spending on infrastructure and training to prepare countries to develop and manage their own programs. Within spending on service delivery, it is important to know if donor funding is focused on the development of innovative activities, which may strengthen the program, or on supporting recurrent costs, which may simply increase a country's dependence on donor funding.
The limited information now available suggests that donor funds are often used to finance recurrent program costs and especially commodities. It is argued that without this type of donor support, countries will develop or revert to programs with limited method choice. No research has proven this outcome, however, and the limited information available suggests a more complex relationship between funding sources and method mix. Thailand, for example, once received USAID commodities, and now does not. Nonetheless, its method mix continues to be one of the most varied of any country program. Other countries, such as Mexico and Brazil, have received U.S. commodities in quantity, but have programs that are heavily focused on a limited number of methods: female sterilization and IUDs in Mexico, and oral contraceptives and female sterilization in Brazil.
The influence of donor funding on African government expenditure
External assistance may also influence the magnitude and composition of government funding. In many countries, the size and focus of the family planning sector has been influenced primarily by donor interest in this area. Have governments diverted resources they might have used for family planning to other areas (either within or outside the health sector) because of the availability of donor funds for family planning? Will they consider family planning services to be worthy of domestic funding when donor funds are withdrawn? Case studies of USAID "graduate countries" (e.g., Botswana) would help to answer these questions. Similarly, an assessment of family planning financing in South Africa, which did not receive donor contributions until very recently, would be useful. Data on the composition of family planning financing should be collected both before and after donors withdraw (or make substantial changes in their funding levels) to assess the role of donors in influencing the composition of government funding. |
Trends in donor funding to sub-Saharan Africa
Trends in population funding in sub-Saharan Africa have been even more positive than in the world as a whole. Year-to-year growth in population assistance to the region from 1985 to 1994 is shown in Figure 2.5. The average annual growth rate over the decade was high, at almost 15 percent (constant dollars). Growth between 1993 and 1994 was particularly high, at 52 percent. Sub-Saharan Africa was the only region in which population assistance increased between the quinquennia 1985-89 and 1990-94 (data not shown). In addition, according to 1993 data, the region receives a disproportionate share of international population assistance in per capita terms (see Figure 2.6), at nearly U.S. $0.30 per person -- almost double the next highest regional level of per capita funding. Sub-Saharan Africa has also had the greatest increases in per capita expenditures over time -- the amount doubled between 1984 and 1993 (data not shown).5
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Figure 2.5
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Figure 2.6
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The proportion of family planning expenditure made up by donor contributions is far higher in sub-Saharan Africa than in any other region (see Table 2.1). Donor funds cover 54 percent of all family planning funding in the region. If South Africa (which accounts for most regional spending, but until recently received no donor funds) is excluded from the estimate, the donor contribution rises to more than 70 percent. By contrast, the donor contribution is only 3.5 percent in East and Southeast Asia, 22 percent in Latin America and the Caribbean, 16 percent in South Asia, and 27 percent in North Africa and West Asia.6
Table 2.1. Source of Family Planning Expenditure, by Region (percentage)
| Region |
Donors |
World Bank |
Government |
Consumers |
| Sub-Saharan Africa |
53.9 |
10.1 |
22.3 |
13.7 |
| Sub-Saharan Africa (excluding South Africa) |
71.2 |
13.3 |
8.7 |
6.7 |
| East and Southeast Asia |
3.5 |
1.6 |
88.1 |
6.8 |
| South Asia |
15.6 |
23.8 |
55.2 |
5.4 |
| Latin America and the Caribbean |
21.6 |
2.0 |
27.8 |
48.6 |
| North Africa and West Asia |
26.7 |
5.7 |
36.0 |
31.6 |
| All Developing Regions |
13.9 |
7.0 |
65.4 |
13.7 |
Source: Conly et al., 1995.
The fact that family planning programs in the region are overwhelmingly donor supported implies that governments and consumers contribute very little. If World Bank loans -- many of which are provided at concessionary interest rates -- are included as part of donor funding, governments and consumers can be estimated to contribute only 15 percent of total funding in sub-Saharan Africa (excluding South Africa) compared to nearly 95 percent in East and Southeast Asia, for example. Patterns of government spending on family planning in the region are discussed in detail later in this chapter.
Intra-regional donor funding patterns
There are considerable differences in the amounts of absolute and per capita funding received by the countries of the sub-Saharan region. According to the GPAR, 45 sub-Saharan nations received a total of almost U.S. $182 million in international population assistance in 1994. Amounts received by country ranged from a low of about U.S. $51,000 (Comoros) to a high of almost U.S. $26 million (Kenya). The regional total for 1995 was about U.S. $361 million. Amounts received by country ranged from a low of about U.S. $57,000 (Comoros) to a high of about U.S. $41 million (Kenya). Again, however, it is not clear what proportion of the 1995 amount was allocated to family planning versus other elements of reproductive health care.
Government Funding of Family Planning Programs in Sub-Saharan Africa
Estimating government expenditure on family planning services is a difficult exercise. Conly et al. (1995) attempted to develop empirical estimates of the approximate magnitude of family planning expenditures -- including government expenditure -- based on a review of the literature and the responses of key informants (primarily local donor agency representatives) to a questionnaire (see Table 2.2). In addition, more detailed, country-level analyses of government expenditure are now available for three countries of the region: Ghana (Thompson and Janowitz, 1997), Côte d'Ivoire (Stewart and Koffi, 1997), and Kenya (Abel, 1995).7,8
Table 2.2. Government Family Planning Expenditures, by Country
|
Country |
U.S. $ (millions) |
% of Total Expenditure |
| Botswana |
0.2 |
8.3 |
| Burkina Faso |
1.0 |
18.9 |
| Central African Republic |
0.4 |
19.0 |
| Chad |
<0.1 |
NA |
| Côte d'Ivoire |
0.1 |
2.0 |
| Congo |
<0.1 |
NA |
| Ethiopia |
0.3 |
3.9 |
| Ghana |
2.1 |
18.6 |
| Guinea |
1.0 |
32.3 |
| Guinea-Bissau |
0.2 |
20.0 |
| Kenya |
0.8 |
2.6 |
| Lesotho |
<0.1 |
NA |
| Liberia |
0.1 |
7.7 |
| Madagascar |
0.1 |
2.5 |
| Malawi |
0.2 |
4.0 |
| Mali |
3.7 |
43.5 |
| Mauritania |
<0.1 |
NA |
| Mozambique |
1.0 |
24.4 |
| Nigeria |
0.7 |
3.3 |
| Rwanda |
1.2 |
9.2 |
| Senegal |
0.2 |
2.3 |
| South Africa |
22.3 |
64.5 |
| Tanzania |
0.6 |
5.4 |
| Uganda |
0.3 |
3.5 |
| Zaire |
0.2 |
3.8 |
| Zambia |
0.1 |
NA |
| Zimbabwe |
2.5 |
16.9 |
Source: Conly et al., 1995.
The results of these studies and a description of the methodology used in each case are shown in Box 2.5. The estimate derived by Conly et al. (1995) for each country, and the source used to develop the estimate, are provided for comparison. In Ghana, for example, Thompson and Janowitz (1997) estimate that the government spends approximately U.S. $4 million on family planning. Conly et al. (1995) place government spending closer to U.S. $2 million. Similarly, in Kenya, Abel (1995) places government spending at about U.S. $2 million, while the Conly et al. (1995) estimate is U.S. $800,000. Finally, in Côte d'Ivoire, Stewart and Koffi (1997) estimate that government expenditure on family planning program salaries only is about U.S. $120,000, while Conly et al. (1995) place total government family planning expenditure at approximately $100,000.
While the estimates from the detailed country analyses are likely to be more reliable than those provided by Conly et al. (1995), both should be interpreted with caution given the paucity of accurate data and degree of estimation required. In both Ghana and Côte d'Ivoire, central level information on government spending was not available: In Ghana, where health services have been decentralized, information was only available at the level of service delivery sites; in Côte d'Ivoire, access to government spending records was not permitted. (See Table 2.3 for a summary of the estimation methodology used in the absence of expenditure records.) Even when records are available, as in the Kenya case, they often need adjustment before they can be used. Since expenditures on health and family planning services are generally integrated in ministry of health accounts, allocation rules must be developed to determine the way in which shared personnel, facility, equipment, and other costs should be divided among health and family planning programs. UNFPA is now supporting a project to obtain country-level information on funding for and expenditures on family planning and other reproductive health services, which should improve our knowledge in this area.
Table 2.3. Estimates of Government Family Planning Expenditure in Ghana, Kenya and Côte d'Ivoire
| Country |
Government Expenditure |
Methodology |
Source |
| Ghana |
$3,770,491 |
Because no data were available from government accounts, government expenditures were assessed using an estimation process that drew on a range of sources. First, provider salaries were estimated based on interviews with donors. Estimates of expenditures on other items were based on the ratio of salary and commodity expenditures to expenditures on other program items found in expenditure analyses conducted for the Planned Parenthood Association of Ghana, and in Bangladesh and Ecuador. |
Thompson, Andy, Barbara Janowitz, and Population Programming, Monitoring and Evaluation Division, Ministry of Health, Ghana. 1997. Country Report: Estimating Family Planning Expenditures in Ghana. Research Triangle Park, NC: Family Health International. |
| |
$2,100,000 |
Figures obtained from USAID's 1993 Final Report, The Analysis of Government of Ghana/Ministry of Health Expenditures on Family Planning and AIDS. |
Conly, Shanty R., Nada Chaya, and Karen Helsing.1995. Family Planning Expenditure in 79 Countries: A Current Assessment. Washington: Population Action International. |
| Kenya |
$2,195,125 |
Recurrent and development expenditures for the National Council for Population and Development and the Ministry of Health (MOH), as reported in official government documents, were added together, using a range of allocation assumptions when not all the reported expenditures could be assumed to be for family planning. For example, it was assumed that a certain portion of the recurrent expenditures of the Division of Family Health (DFH) of the MOH were for family planning services (the DFH is also responsible for maternal and child health (MCH) services). A recent analysis found that 18 percent of MCH service visits were for family planning services. Therefore, it was assumed that 18 percent of DFH expenditures were on family planning. |
Abel, Edward and National Council for Population and Development, Kenya. 1995. Family Planning Financial Resource Requirements (1993-2010): Technical Notes and Methodology. Washington: The Futures Group International (RAPID IV). |
| |
$800,000 |
Population Action International (PAI) distributed a questionnaire regarding the level of government expenditure on family planning. Where family planning was subsumed within the health budget, respondents were asked to make an informed estimate of the percentage of the health budget allocated to family planning and to explain how the estimate was derived. The Population Council/Nairobi completed the questionnaire. |
Conly et al., 1995. |
| Côte d'Ivoire |
$120,172 (salaries only) |
Because government accounts were not available, an estimate of government expenditure on salaries only was derived by combining government information on the salaries of family planning workers with an estimate of the number of family planning visits to government facilities (using the records of AIBEF, the International Planned Parenthood Federation (IPPF) affiliate in Côte d'Ivoire, which supports many government family planning clinics with training, logistics, etc.) and data on staff time per family planning visit(from a survey of facilities). |
Stewart, John F. and Kouame Koffi. 1997. Country Report: Estimating Family Planning Expenditures in Côte d'Ivoire, 1994. Draft. Chapel Hill, NC: University of North Carolina and Association Ivoirienne pour le Bien Etre Familial. |
| |
$100,000 (total expenditure) |
PAI distributed a questionnaire regarding the level of government expenditure on family planning. Where family planning was subsumed within the health budget, respondents were asked to make an informed estimate of the percentage of the health budget allocated to family planning and to explain how the estimate was derived. UNFPA/Abidjan and USAID/Abidjan completed the questionnaire. |
Conly et al., 1995. |
According to the estimates in Conly et al. (1995), government support for family planning in Africa ranges from a low of 2 percent of total expenditure in Côte d'Ivoire to a high of 64.5 percent in South Africa.9 In more than half of the countries for which this information is available, the government's contribution to total family planning expenditure is less than 10 percent, and in nine of these countries, it is less than 5 percent. Only in four countries does the government's contribution exceed 20 percent of all family planning expenditure. As noted earlier in this chapter, this is far less than the contribution made by most governments in other developing regions.
Future government funding for family planning services in the region could be affected positively by such factors as growing female participation in the political process, though this is slow to change. It could also be affected either positively or negatively by economic growth or political change. Even allowing for the possibility of substantial growth in public sector family planning expenditure, it is unlikely that African governments will be able to fill the gap between available resources and growing needs for services.
Conclusion
The need for family planning services in sub-Saharan Africa is high and rising. Meeting current need for family planning would require spending more than twice the amount spent today. Future needs and funding requirements will be even greater, since the population of women of reproductive age will increase and a higher proportion of these women will want to use contraception.
While the most recent assessments of donor funding for family planning are quite optimistic, they must be interpreted with caution. In the last decade, donor funding for family planning in sub-Saharan Africa appears to have grown dramatically. Between 1994 and 1995, however, the growth in the overall resource base for both family planning and reproductive health care appears to be due in large part to increased funding of other elements of reproductive health care. Indeed, funding for family planning per se may have declined.
Funds from donors and The World Bank account for about 85 percent of all family planning expenditure in sub-Saharan Africa (excluding South Africa). This contrasts dramatically with donor contributions to other developing regions, which never exceed 40 percent. Governments in the sub-Saharan African region contribute significantly less toward overall family planning expenditure than those in other regions, and this is unlikely to change. However, it is likely that donors will aim to subsidize lower proportions of overall expenditure over time. At the same time, resource requirements will increase dramatically.
These three forces -- probable declines in the proportion of expenditure covered by donors, limited potential for increasing government subsidies, and a rising level of contraceptive use and unmet need -- imply an urgent need to identify and mobilize additional, alternative sources of funding for family planning. This will be necessary even to sustain current, inadequate levels of service provision. Meeting high and rising unmet need levels increases the need for additional, domestic resources substantially. While it is not possible to predict the gap between future donor and government subsidy levels and resource requirements with any certainty, even the most optimistic projections suggest that the need for additional resources will be enormous.
Immediate efforts must be made to identify alternative sources of funds for family planning services and/or to decrease the need for funds by improving the cost-effectiveness of services. One resource-mobilizing strategy is to charge fees for services in subsidized programs, as discussed in Chapter III. Chapter IV addresses the potential for mobilizing resources through client payments in the commercial sector, by promoting the growth of this sector. Finally, Chapter V considers ways in which the costs of services can be minimized to increase the impact of existing resources.
POLICY ACTIONS
1. The sub-Saharan region has high levels of unmet need for family planning services, as well as a large gap between need and both actual and potential resources. As a result, this region should continue to receive its proportionate share of donor resources in the short and medium term.
2. In the short term, donors should increase their support to African family planning programs in order to sustain them in the face of increasing demand for services. In order to prevent dependence and to minimize host-country displacement of resources, donors need to work with governments to set clear time frames for phase-out of increased assistance and assist countries to develop their own plans for domestic resource mobilization.
3. The resources needed to implement the broad Programme of Action from ICPD in Cairo are not available. Donors must prioritize among the various elements of the Programme. Care must be taken to ensure that funding for family planning services is not diminished as implementation of the Cairo agenda moves forward.
Footnotes
- The sum of current use and unmet need for contraception is often referred to as "demand" for contraception. Economists define demand as the willingness and ability to pay for a product or service at various prices -- a narrower definition. Individuals may be classified as being "in need" of a service for which they have no demand. For this reason, we have opted not to use the term "demand" to refer to the sum of current use and unmet need for contraception.
- As discussed later in this chapter, there is some evidence that government expenditure is underestimated in Conly et al. (1995).
- UNFPA also takes into account the fact that costs per user do not remain constant. Economies of scale will tend to reduce average costs over time, as will efficiency enhancements and the mobilization of underutilized capacity, which is extensive in family planning services in the region (see Chapter V for a discussion of underutilized capacity). On the other hand, urgently needed quality improvements will tend to increase costs per user. Research on the true cost implications of such factors as mobilization of underutilized capacity and efficiency enhancements on the one hand, and quality enhancements on the other, is warranted.
- Because of funding/expenditure cycles and reporting variations, these two figures differ by an average of 24 percent in any given year.
- Editions of the Global Population Assistance Report since 1993 have not provided information on per capita expenditures.
- The donor contribution would be higher in East and Southeast Asia if China were excluded. Of the other countries in that region, the proportion of expenditures covered by donor funds is highest in the Philippines (55 percent). Worldwide, the proportion of total funding covered by donors exceeds 70 percent in very few countries (Nepal, Guatemala, Peru, El Salvador, and Haiti).
- Both the Ghana and Côte d'Ivoire analyses were developed as part of an effort by Family Health International and the EVALUATION Project of the Carolina Population Center at the University of North Carolina at Chapel Hill to develop a simple, standard, and replicable methodology to estimate expenditures on family planning, including government expenditure.
- Detailed, country-level information on family planning and reproductive health care expenditures is currently being collected by the Netherlands Interdisciplinary Demographic Institute (NIDI) for counties worldwide. At the time this report was written, data were too preliminary for our use.
- At the time of the Conly et al. study, the South Africa case was an anomaly in the region. There was no donor funding; government funding and consumer payments financed services in their entirety.
