The case for investing in family planning in Solomon Islands

Transcription

1 WOMEN'S AND CHILDREN'S HEALTH KNOWLEDGE HUB COMPASS REPORT JUNE 2013 Credit: Family Planning International 2012 The case for investing in family planning in Solomon Islands Estimated costs and benefits of reducing unmet need Sean Mackesy-Buckley, 1 Elissa Kennedy 2 and Sumi Subramaniam 1 1: Family Planning International, New Zealand 2: Centre for International Health, Burnet Institute, Australia

2 Mackesy-Buckley S, Kennedy E, Subramaniam S The case for investing in family planning in Solomon Islands; a costbenefit analysis. Burnet Institute and Family Planning International on behalf of Compass: the Women s and Children s Health Knowledge Hub. Melbourne, Australia. For further information regarding this working paper please contact: Elissa Kennedy, Burnet Institute elissa@burnet.edu.au ACKNOWLEDGMENTS The authors would like to thank the members of the Pacific Reference Group for their advice on the methodology of this analysis and for providing feedback on the manuscript: Apisai Tokon, National Reproductive Health / Family Planning Coordinator, Vanuatu Ministry of Health; Judith Seke, Reproductive Health Coordinator, Solomon Islands Ministry of Health & Medical Services; Annette Sachs Robertson, Deputy Director, Pacific Sub-Regional Office, UNFPA; Rufina Latu, Technical Officer, Health Systems Development, WHO, Vanuatu; Arthur Jorari, Demographer, Statistics and Demography Programme, Secretariat of the Pacific Community; Kabwea Tiban, Director, IPPF ESEAOR Sub-Regional Office for the Pacific; and Andreas Demmke, population specialist. The authors are also grateful to: John Stover, Bill Winfrey and Robert McKinnon (Futures Institute) for technical advice regarding Spectrum; Rachel Sacks-Davis and Maelenn Gouillou (Centre for Population Health, Burnet Institute) for advice regarding the methodology and analysis; Natalie Gray for contributions to the initial conceptualisation of this work; Stanley Luchters (Burnet Institute) for comments on this manuscript; and Jane Hawtin (Burnet Institute) for overseeing the design of the report. This work has been funded by AusAID through Compass: Women's and Children's Health Knowledge Hub. The views represented here are not necessarily those of AusAID or the Australian Government. Compass: Women's and Children's Health Knowledge Hub is a partnership between the Burnet Institute, Menzies School of Health Research and the Centre for International Child Health, University of Melbourne. The Knowledge Hubs for Health are an Australian Agency for International Development (AusAID) initiative that aims to build knowledge, evidence and expertise and inform health policy dialogue relevant to Asia and the Pacific. Compass: Women's and Children's Health Knowledge Hub 85 Commercial Road Melbourne, Victoria Australia

3 EXECUTIVE SUMMARY Family planning is one of the most cost-effective investments a country can make towards sustainable development. It is also a fundamental human right and crucial to empowering women and girls. However despite decades of international agreement on the need to ensure universal access to family planning, progress in the Pacific has been slow and inequitable. In Solomon Islands, approximately one in nine women of reproductive age who are married or in union want to avoid pregnancy but are not using any method of family planning. This analysis explores the costs and benefits of meeting this need by Enabling all women with a need for family planning to access contraceptives by 2020 would have substantial benefits for the health of women and children. Compared with no progress over the next 16 years, meeting all family planning needs would mean that by 2025: 10,922 more women would be using an effective method of contraception. Contraceptive prevalence of modern methods would increase from 28.5% to 37.6%. There would be an average of 2,075 fewer unintended pregnancies each year. There would be an average of 50% fewer abortions each year. Over 1,200 deaths of mothers and babies would be averted over the next 16 years, reducing the average number of maternal deaths each year by 12% and infant deaths by 20%. There would be 14% fewer births to adolescent girls, reducing the adolescent fertility rate from 57 births per 1000 girls aged to 49 births by In addition, preventing unwanted pregnancies would: reduce the total fertility rate from 4.1 to 3.5 by 2025; slow population growth from 2.5% to 2.2%; and reduce the youth dependency ratio from 66 dependents per 100 people of working age to 58, contributing to increased household wealth. A substantial increase in funding is needed to achieve these goals. Over the next 16 years, at least US$3.4 million will be required to meet all family planning needs, US$1 million more than if unmet need remained unchanged. However, such an investment would have considerable economic benefits, resulting in US$30 million saved in public sector spending on health and education. In addition, the demand on scarce health and education infrastructure and human resources would fall by 5% and 10% respectively. At an average cost of just over $210,000 per year, meeting the need for family planning would make Solomon Islands health and development goals more achievable, more affordable and more sustainable. The case for investing in family planning in Solomon Islands iii

4 ACRONYMS DHS GDP ICPD IPPF MDG MMR TFR UN UNESCO UNFPA UNICEF WHO Demographic and Health Survey Gross domestic product International Conference on Population and Development International Planned Parenthood Federation Millennium Development Goal Maternal mortality ratio Total fertility rate United Nations United Nations Educational, Scientific and Cultural Organisation United Nations Population Fund United Nations Children s Fund World Health Organization iv

5 TABLE OF CONTENTS Executive summary iii Acronyms iv Introduction: why family planning matters in the Pacific 2 Solomon Islands: an overview 3 Methods 5 Findings 7 Meeting the demand for family planning in Solomon Islands 7 Health benefits for women and infants 7 Population and demographic consequences 8 Economic benefits 8 Discussion 10 Recommendations 11 Appendix 1: Methods 12 References 14 The case for investing in family planning in Solomon Islands 1

6 INTRODUCTION: WHY FAMILY PLANNING MATTERS IN THE PACIFIC The ability to decide freely the number, spacing and timing of children is a fundamental human right. Family planning also has proven benefits for the health of women and children. Reducing global unmet need for contraception could prevent around 30% of all maternal deaths, reduce child mortality by up to 20%, and avert 36 million years of healthy life lost each year. 1-4 In addition, meeting all needs for family planning globally would save at least US$5.7 billion in maternal and newborn costs each year. 5 Ensuring universal and voluntary access to family planning has much broader health and socio-economic benefits, contributing to universal education, women s empowerment, prevention of HIV, poverty reduction and environmental sustainability, making it one of the most cost-effective global health and development interventions Despite these imperatives, progress to ensure universal access to family planning in the Pacific has been inadequate and inequitable. While use of family planning has increased in the region, in many countries the prevalence of modern methods of contraception is still well below the average of 55% for less developed regions and unmet need is among the highest in the world (figure 1). 11 Subsequently, a significant proportion of pregnancies are unintended, with more than half of all births mistimed or unwanted in some settings. In addition, up to a quarter of girls aged have already commenced childbearing and adolescent fertility rates in some countries are comparable to those in sub-saharan Africa. 12 While the region has experienced a gradual decline in fertility, six of the world s 39 high-fertility countries are in the Pacific and over the past decade the total fertility rates in at least four of these have remained between 4 and High fertility and rapid population growth, coupled with a large and expanding youth population, increasing urbanisation and climate change, present considerable challenges for small island states. 14 Lack of prioritisation and insufficient investment have contributed to slow progress. 15 Between 1995 and 2009, funding for family planning fell globally from 55% to around 7% of all sexual and reproductive health funding less than one quarter of the estimated US$ 3.2 billion needed per year. 16 While reliable data on family planning expenditure in the Pacific are scarce, the Organisation for Economic Cooperation and Development estimates that less than 0.03% of all overseas development assistance for the region in the past decade has been directed to family planning. 17 The International Conference on Population and Development s (ICPD) Programme of Action and the Millennium Development Goals (MDGs) have committed governments to ensuring universal access to reproductive health, including family planning, by With this deadline fast approaching, much still needs to be done if universal access is to be realised in the Pacific. With a recent emphasis on repositioning family planning on the development agenda in the Pacific, there is a critical need for region-specific, reliable and accessible data to assist policy and planning. 15 In recognition of this need, this analysis aims to identify the health, economic and social impacts of reducing unmet need for family planning in Solomon Islands and an estimate of the resources required to achieve these goals. Key terms Modern methods of family planning include permanent methods (male and female sterilisation), long-acting methods (intrauterine device [IUD] and implants), short-acting hormonal methods (oral contraceptive pill and injectables) and barrier methods (male and female condom). Traditional methods of family planning include periodic abstinence, lactational amenorrhoea, withdrawal, or other traditional practices. Contraceptive prevalence rate is the percentage of women aged between years who are using, or whose sexual partners are using, any method of contraception. A woman is considered to have an unmet need for family planning if she is of reproductive age and able to become pregnant, is married or in consensual union, wants no more children or wants to delay pregnancy by two years or more, and is not using any method of contraception. This includes pregnant or amenorrhoeic women whose pregnancy was mistimed or unwanted. The total fertility rate is the average number of children that would be born to a woman by the time she has ended childbearing if she was to bear children in accordance with current age-specific fertility rates. 100% % Marshall Solomon Islands Islands Nauru Tuvalu Kiribati Vanuatu Papua New Guinea Samoa FIGURE 1.A. Current use of contraception (modern methods) among currently married women aged Marshall Solomon Islands Islands Nauru Tuvalu Kiribati Vanuatu Papua New Guinea Samoa Less developed regions Less developed regions FIGURE 1.B. Unmet need for family planning among currently married women aged Source: Demographic and Health Surveys Marshall Islands, Solomon Islands, Nauru, Tuvalu, Kiribati, Papua New Guinea, and Samoa; 23, UNFPA KAP study Vanuatu; 47 UNFPA State of World Population

7 100% % SOLOMON ISLANDS: AN OVERVIEW Rural Urban Lowest Middle Highest None Primary FIGURE 2. Contraceptive prevalence rate by location, wealth status and education level (2007) Source: Solomon Islands Demographic and Health Survey 23 No method Secondary Traditional method Female condom / other Male condom Implant Injectable Intrauterine device Oral contraceptive pill Male sterilisation Female sterilisation FIGURE 3. Contraceptive prevalence by method (2007) Source: Solomon Islands Demographic and Health Survey Solomon Islands Unmet need for contraception Using a traditional method Using a modern method FIGURE 4. Total current demand for family planning Source: Solomon Islands Demographic and Health Survey 23 Solomon Islands is located in the Melanesian sub-region of the South Pacific Ocean and is an archipelago nation consisting of close to 1000 islands. The country currently ranks 142 on the Human Development Index, and is one of the poorest in the region. 18 The 2009 Census recorded a total population of 515,870 (making it the third largest in the region), with around 20% living in urban centres. The annual urban population growth rate of 4.7% is high and the urban population has nearly doubled in the past decade. The intercensal population growth rate has fallen from 2.8 to 2.6%, but the total population is projected to grow, most likely doubling by the year Typical of the region, Solomon Islands has a young population, with 59% under the age of 25 years and approximately 1 in 5 an adolescent aged between 10 and 19 years. In 2009, there were 125,941 women of reproductive age (accounting for nearly a quarter of the population) and this number is likely to increase by more than 50% by Accurate data for mortality in Solomon Islands are limited and should be interpreted with caution. However, based on that data available from the Ministry of Health & Medical Services as well as from the 2009 Census, Solomon Islands has made considerable progress in improving some of its health related MDGs particularly maternal and child mortality (MDG 4 and MDG 5A). The maternal mortality ratio (MMR) is estimated to have fallen from around 550 in the early 1990s to 162 in This suggests Solomon Islands is close to achieving the MDG 5A target of a three quarters reduction in MMR. The under-five mortality rate has fallen from over 70 in the early 1990s to 29 in 2009 and the infant mortality rate has fallen from over 30 to 23 over the same period. 19 These declines suggest the Solomon Islands is also making progress towards achieving the MDG 4 target of a two-thirds reduction to child mortality. However, these declines are slowing and the Solomon Islands Ministry of Health & Medical Services recognises that further reductions to maternal and child mortality are 20, 21 likely to be more difficult. Progress towards the achievement of MDG 5B universal access to reproductive health has been less notable. 22 In particular, available data shows access to quality family planning services could be significantly improved. The modern CPR is only 27.3% less than half the average of less developed countries with a further 7.3% using traditional methods. 23 Modern contraceptive use is lowest in urban areas, possibly reflecting increased efforts to provide health services in rural settings. Though data is mixed, it is also likely that modern contraceptive use is lower amongst poorer women and those with less education. By far the most commonly used methods are female sterilisation (13%) and injectables (8.8%). Available data suggests unmet need for family planning is 11%. 23 This is supported by data showing as much as 57% of all births are unplanned either not wanted (25%) or wanted later (32%); a high adolescent fertility rate of 62 births per 1000 women aged 15-19, and; a current total fertility rate (TFR) of The TFR remains one of the region s highest and well above the wanted fertility rate of It has also reduced little from its 1999 level of 4.8, adding to concerns that the pace of decline has stalled. 19 The case for investing in family planning in Solomon Islands 3

8 Based on current contraceptive prevalence and unmet need, there is considerable demand for family planning in Solomon Islands (figure 4). Almost 46% of women married or in union have a need for contraception, and around a quarter of this need is not being met. An additional 7% are using traditional methods.23 Even if unmet need was to remain constant, the expected growth in the number of women of reproductive age will result in a significant increase in the number of women using contraception and therefore requiring services. The government s National Health Strategic Plan identifies expanded family planning services including those for youth as a key objective. It has also set an ambitious modern CPR target of 40% by 2015 and is exploring ways to further increase the proportion of the health budget allocated to maternal and child health in rural areas where the greatest proportion of the population lives.20 At present, the majority of family planning services are provided by government facilities and are generally free of charge. Contraception is also available through the Solomon Islands Planned Parenthood Association (an IPPF member), other non-government organisations, some churches and through a small but growing number of private providers mostly located in urban centres.23 Nonetheless, there are considerable challenges to improving access to family planning, most notably the widely dispersed, predominantly rural population with limited transportation infrastructure, a lack of correct knowledge about contraception, socio-cultural and religious influences, poor access to user-friendly services (particularly for young people), shortages of trained health workers, and limited data to assist with forecasting and supply of commodities. Further, global financial instability and forecast declines in key exports such as hardwood mean future government revenue is not expected to grow significantly. Solomon Islands is therefore likely to remain heavily reliant on foreign assistance in order to maintain the provision of many basic services, including health.22 In particular, Solomon Islands currently remains dependent upon the United Nations Population Fund (UNFPA), for the procurement and supply of nearly all family planning commodities and supplies an arrangement that cannot be indefinitely sustained and for which there is not yet and agreed transition strategy. Solomon Islands is therefore in ever greater need of assistance from international and regional donors to make real progress in the achievement of MDG 5B. CREDIT: Family Planning International 2012 CREDIT: Family Planning International

9 METHODS To identify the costs and health, social and economic impacts of reducing unmet need for family planning, three population models were generated using the demographic modeling program Spectrum (Futures Institute, Glastonbury, CT, USA). Models were created for the period based on three hypothetical family planning scenarios: 1. Constant unmet need for family planning (11%) 2. All family planning needs met by All family planning needs met by 2020 Each model required data for over 40 inputs which were sought from a range of sources (table 1). The direct costs of providing family planning per contraceptive method (per couple-year of protection for short-acting methods and per acceptor for long acting methods) were calculated from estimates of: commodities, supplies and equipment procurement; shipping, storage and distribution; and staff costs for counselling, method provision and follow-up. Commodity, equipment, transport and storage costs were obtained directly from the Pacific Sub-Regional Office of UNFPA (the major supplier of family planning commodities in Vanuatu and the Solomon Islands), International Planned Parenthood Federation (IPPF) East and Southeast Asia and Oceania Region (the major non-government supplier) and the Ministry of Health of each country. Staff costs were based on estimates of average staff salaries and time spent per client per method obtained from key informants within the Ministries of Health and IPPF clinics. For each family planning scenario, Spectrum was used to project: contraceptive prevalence and number of users; family planning costs and commodities required; health outcomes for women and children (unintended pregnancies, births, induced abortions, births with any risk, and maternal and infant deaths); total fertility rate and population growth; health and education expenditure and required resources (infrastructure and human resources); and dependency ratio and GDP per capita. Data for each scenario for the period were extracted and analysed in Excel. The impact of reducing unmet need by 2020 and 2050 was compared to the baseline scenario (constant unmet need) for each output of interest. Future costs and health outcomes were discounted at 3% per year. All costs are reported in US dollars. A detailed description of the methodology and data sources is provided in Appendix 1. Input Population and demography Family planning use, unmet need and costs Proximate determinants of fertility Maternal, infant and child survival Economy Health Education Data sources Solomon Islands 2009 National Population and Housing Census [Provisional] Solomon Islands Demographic and Health Survey Solomon Islands Ministry of Health & Medical Services, National Health Strategic Plan UNFPA Sub-Regional Office IPPF ESEAOR Solomon Islands Planned Parenthood Association Solomon Islands Demographic and Health Survey Solomon Islands 2009 National Population and Housing Census [Provisional] Guttmacher Institute Solomon Islands Demographic and Health Survey Solomon Islands 2009 National Population and Housing Census [Provisional] World Bank Development Indicators International Monetary Fund Solomon Islands 2011 Ministry of Health & Medical Services, National Health Strategic Plan WHO Western Pacific Country Health Information Profile Solomon Islands Ministry of Education and Human Resources Development, Performance Assessment Framework TABLE 1. Main inputs and data sources The case for investing in family planning in Solomon Islands 5

10 Contraceptive use Base year (2010) Estimated projections for 2025 Constant unmet need met by 2050 met by 2020 Total users (modern methods) 22,382 34,353 42,949 45,275 Contraceptive prevalence rate (all methods) % Contraceptive prevalence rate (modern methods) % Contraceptive prevalence rate (long-acting or permanent methods) % Contraceptive prevalence rate (traditional methods) % TABLE 2. Projected total number of contraceptive users and contraceptive prevalence rate per unmet need scenario Contraceptive use Base year (2010) Estimated projections for 2025 Constant unmet need met by 2050 met by 2020 Female sterilisation 10,846 15,079 18,852 19,873 Male sterilisation ,052 Pill 1,152 3,394 4,243 4,473 Injectable 7,158 9,532 11,917 12,562 Implant 0 1,166 1,458 1,537 Intrauterine device 1,732 2,572 3,215 3,389 Condom (male or female) 1,221 1,813 2,266 2,389 TABLE 3. Projected total number of contraceptive users by method of contraception, per unmet need scenario Commodities required at five year intervals to meet all needs by 2020 Male condoms Pill cycles Injectable vials Implants , , , , ,161, , ,907 1,056 4, ,631, , ,249 2,924 5,926 Intrauterine devices Total 3,704, , ,776 3,980 14,236 TABLE 4. Projected contraceptive commodities (reversible methods) required to meet all family planning needs by 2020 Projected average per year ( ) Constant unmet need met by 2050 met by 2020 Total pregnancies 20,286 18,281 17,340 Unintended pregnancies 4,147 2,742 2,072 Induced abortions 1, Unplanned births and miscarriages 2,778 1,840 1,390 Births with any avoidable risk 8,922 7,720 7,185 Maternal deaths Infant deaths TABLE 5. Summary of projected health outcomes for women and infants per unmet need scenario Total costs (US$ millions) Family planning Health Education Total costs Net savings Constant unmet need , na met by , met by , TABLE 6. Projected expenditure on family planning, health and education sectors per unmet need scenario 6

11 $4 million MEETING THE DEMAND FOR FAMILY PLANNING IN SOLOMON ISLANDS REDUCING UNMET NEED In 2010, 11% of women of reproductive age who are married or in union (9,078) had an unmet need for family planning. Meeting all of this need by 2020 would increase the prevalence of modern methods of contraception from 27.4% to 37.6%, resulting in an additional 22,893 users by 2025, equating to 10,922 more users than if unmet need remained constant (table 2). Compared with no change in the proportion of women with unmet need, meeting all family planning needs by 2020 would mean that by 2025 there would be: 5,048 more couples using sterilisation (254 whose partner is using male sterilisation, 4,794 using female sterilisation) 1,188 more women using a long-acting method (371 using implants, 817 using an intrauterine device) 4,109 more using short-acting hormonal methods (1,079 using the oral contraceptive pill and 3,030 using injectables) COSTS AND COMMODITIES The cost of providing family planning services to 22,382 users was almost $154,000 in The bulk of contraceptive commodities and equipment are currently procured and supplied by UNFPA, with IPPF also providing commodities for part of the non-government sector. The government bears most of the financial cost of service delivery and staff time, providing an estimated 80% or more of family planning services. Approximately $2.6 million would be required over the next 16 years for family planning if unmet need remained constant (figure 5). Eliminating unmet need by 2020 would require an additional investment of $1 million ($3.4 million), a 30% increase in funding, at an average cost of $210,000 per year or $7.50 per user. Reducing unmet need by 2050 would require an additional $565,000 between 2010 and 2025 compared with constant unmet need. The commodities required to meet all needs would double for most reversible methods over the next 16 years (table 4) met by 2020 met by 2050 Constant unmet need FIGURE 5. Projected cumulative family planning costs Key terms Unintended pregnancy is a pregnancy that is either mistimed (occurred earlier than desired) or unwanted (occurred when no more children were desired) Maternal mortality ratio (MMR) is the number of maternal deaths per 100,000 live births during a given time period. Care needs to be taken interpreting MMR for countries with small populations as a small change in the number of deaths can result in large fluctuations in MMR. Infant mortality rate is the number of deaths of children less than one year of age per 1000 live births during a given time period Adolescent fertility rate is the annual number of births to girls aged between years per 1000 girls in that age group HEALTH BENEFITS FOR WOMEN AND INFANTS UNINTENDED PREGNANCIES Meeting the need for family planning by 2020 would reduce unintended pregnancies by 50%, averting an average of 2,075 unintended pregnancies and 1,388 unplanned births each year between 2010 and 2025 (table 5). The rate of unintended pregnancies would fall from 31 per 1000 women aged if unmet need remained constant to 12 per 1000 women if all needs were met by Such investment would also reduce the demand for services for maternal health care, management of obstetric complications, and postabortion care associated with unintended pregnancies. There are very little data about induced abortion in Solomon Islands and the Pacific in general. These estimates are based on the only available data from Guttmacher and WHO for the Oceania region (excluding Australia and New Zealand), and so should be interpreted with caution. The absolute numbers of induced abortions are likely to be inaccurate, however, reducing unmet need by 2020 is estimated to reduce induced abortions by 50% between 2010 and Abortion is permitted in Solomon Islands only to save a women s life, however, this rarely occurs in practice and a significant proportion of induced abortions are likely to be unsafe. Reducing the number of unintended pregnancies, the leading cause of abortion, could therefore have significant benefits in terms of reducing maternal mortality and morbidity associated with unsafe abortion. MATERNAL AND INFANT MORTALITY High-risk births are those that occur at extremes of maternal age (less than 18 and more than 34 years), are spaced less than 24 months apart, or are birth order 4 and higher. 24 Allowing healthy timing and spacing of pregnancies by meeting all the need for family planning by 2020 would reduce the number of avoidable highrisk births in Solomon Islands by 20%, decreasing the incidence of poor maternal and perinatal outcomes. The case for investing in family planning in Solomon Islands 7

12 There are limited data for maternal mortality in Solomon Islands. The Census estimates the MMR to be 162 per 100, Based on this estimate, meeting all unmet need for family planning by 2020 would result in a 12% reduction in maternal deaths. This equates to 3 fewer deaths per year over the next 16 years compared with projections if unmet need remained constant (table 6). Approximately 8% of maternal deaths would be averted if unmet need were met by These results need to be interpreted with caution given the relatively small numbers of live births and maternal deaths in Solomon Islands. Meeting all family planning needs by 2020 would reduce the infant mortality rate from 23 to 20 deaths per 1000 live births, contributing to progress towards MDG 4. Between 2010 and 2025 over 1,100 deaths of children under the age of 12 months could be averted, reducing infant deaths by approximately 20%. Reducing unmet need by 2050 would result in approximately 13% fewer infant deaths compared with constant unmet need. However the contribution made towards the achievement of MDG 4 would be smaller. POPULATION AND DEMOGRAPHIC CONSEQUENCES ADOLESCENT FERTILITY Adolescent pregnancy, intended or unintended, carries an increased risk of poor health outcomes for girls and their infants. 25 Early pregnancy also has socio-economic implications: adolescent pregnancy often leads to lower education attainment, contributing to a cycle of poor health, poverty, gender inequality and disadvantage that affects girls, their families and communities. Meeting the need for family planning by 2020 is estimated to reduce the number of births to adolescent girls aged by 14%, dropping the adolescent fertility rate from 57 births per 1000 girls aged if unmet need remained constant, to 49 births per 1000 girls in 2025 (figure 6). Solomon Islands total fertility rate would fall from 4.1 to 3.5 in 2025 if unmet need was met by 2020 (figure 7). In contrast, the total fertility rate would remain above 4.1 if unmet need and contraceptive prevalence remained unchanged. By meeting all needs by 2020, annual population growth would decline to 2.2% in 2025, versus 2.5% if unmet need remained constant. The difference in total population in 2025 would be 37,605 (776,488 if all needs were met versus 814,093 if unmet need remained constant [figure 8]). By 2050, Solomon Islands population would be more than 1.5 million if unmet need remained constant, 15% greater than the population if unmet need was met by In addition, population density would increase from 18 people per square kilometre in 2010 to 49 in 2050 (versus 43 if unmet need was met by 2020) placing a significant demand on natural resources with consequences for environmental and economic sustainability. ECONOMIC BENEFITS ECONOMIC GROWTH AND POVERTY REDUCTION In addition to reducing annual population growth, reducing unmet need for family planning by 2020 would also reduce the proportion of the population who are dependent compared to people of working age (15-59 years). By 2025, if unmet need remained constant the youth dependency ratio would be 66 dependents (10-14 years) per 100 people of working age. If all family planning needs were met by 2020, approximately 60% of the population would be aged 15-59, reducing the dependency ratio to 58 (figure 9). With appropriate investment, this demographic dividend could lead to accelerated economic growth and contribute to poverty reduction. 10 Assuming that GDP growth is the same across all three scenarios, by 2025 GDP per capita could increase to $1,387 if all needs were met by 2020, 5% more than if unmet need remained constant. HEALTH AND EDUCATION SAVINGS Reducing unmet need for family planning would result in substantial savings to the health and education sectors. Meeting all needs by 2050 would cost an additional $565,000 in family planning expenditure but would save $18.7 million on health and education between 2010 and 2025 compared with constant unmet need (table 6). Eliminating unmet need by 2020 would require an additional $1 million but would save $30.1 million in health and education expenditure (figure 10). Between 2010 and 2025 for every $1 spent on family planning to reduce unmet need by 2020, $9 would be saved in health and education costs. In addition, reducing unmet need for family planning would reduce the demand on other public resources. By 2025, 10% fewer schools and teachers and 5% fewer health facilities and health workers (doctors, nurses and midwives) would be required to meet the needs of the population (figure 11). These savings will make development goals in education and health both easier to achieve and more affordable Birrths per 1000 girls aged Constant unmet need met by 2050 met by 2020 FIGURE 6. Projected adolescent fertility rate in 2025 (births per 1000 girls aged years) 8

13 5 children Constant unmet need Need met by 2050 Need met by million Constant unmet need Need met by 2050 Need met by FIGURE 7. Projected total fertility rate per unmet need scenario FIGURE 8. Projected population per unmet need scenario Female Population at working age Constant unmet need met by 2050 met by ,000 50,000 40,000 30,000 20,000 10,000 10,000 20,000 30,000 40,000 50,000 60,000 FIGURE 9. Projected population pyramid 2025 per unmet need scenario Male $50 millions Education Health 12,000 10,000 8,000 Facilities: schools, health centres, hospitals Human resources: teachers, doctors, nurses, midwives 6, , ,000 met by 2050 Cost met by 2020 met by 2050 Savings met by 2020 Constant unmet need Education met by 2050 met by 2020 Constant unmet need Health met by 2050 met by 2020 FIGURE 10. Projected costs and savings from of meeting all family planning needs by 2020 FIGURE 11. Projected health and education resources required by 2025 per unmet need scenario The case for investing in family planning in Solomon Islands 9

14 DISCUSSION Ensuring that all women in Solomon Islands who would like to delay, space or limit their pregnancies have access to family planning would have substantial health and socio-economic benefits. Reducing unmet need by 2020 would result in 50% fewer unintended pregnancies, averting morbidity and mortality associated with births that are unwanted or from unsafe abortion. Enabling women to plan their pregnancies would reduce maternal deaths by 12% and infant deaths by around 20% - saving some 1,200 lives between 2010 and In addition, addressing the unmet need would reduce the demand for services for maternal health care, management of obstetric complications, and post-abortion care associated with unintended pregnancies. Preventing unintended pregnancies would also result in substantial savings to the health and education sectors, saving $30 million over the next 16 years and reduce demand on infrastructure and scarce human resources. Such savings would more than offset the additional family planning expenditure required. Almost 60% of Solomon Islands population are aged under 25 years. Reducing unwanted fertility and decreasing the proportion of dependants would provide a unique window of opportunity for Solomon Islands to capitalise on this large population of young people. 10 This demographic dividend has been credited with contributing to rapid economic development in many East Asian countries and, with adequate investment, has the potential to increase household wealth and stimulate economic growth. Data from the Pacific, including Solomon Islands, demonstrate that households with a lower dependency ratio have a higher proportion of children attending school and greater resources to invest in quality education. 14, 26 In addition, meeting the need for family planning will help address rapid population growth which will in turn place less demand on finite natural resources, including arable land. Eliminating the unmet need for family planning has additional benefits that are not captured by this analysis. Enabling women to plan their pregnancies contributes to higher educational attainment and economic participation for girls and women, with substantial economic benefits for households and countries, and is critical for women s empowerment and progress towards gender equality. 6 Achieving these goals in Solomon Islands will require a significant increase in financial investment. Even if unmet need were to remain unchanged, $2.6 million would be required over the next 16 years to deliver modern contraceptives to a growing population of women of reproductive age. Providing services to meet all needs by 2020 would require a 30% increase in current expenditure, $3.4 million, between 2010 and 2025, at an average cost of just over $265,000 a year. Meeting all the family planning needs by 2050 would cost $240,000 less than achieving this goal by 2020, but would also result in fewer lives saved, fewer unintended pregnancies averted, and less savings to the health and education sectors. Inadequate funding for family planning has hindered progress to date, so there is an urgent need for increased political and financial commitment from both government and donors to meet international obligations and the needs of women and couples. However, as demonstrated by this analysis, such an investment would have significant returns: at a cost of 40 cents per capita per year, investment in family planning will help to make Solomon Islands health and development goals more achievable, more affordable and more sustainable. These estimates have two key limitations. Unmet need for family planning is difficult to accurately measure, with some estimates excluding unmarried sexually active women. Additionally, women using a traditional method are not considered to have an unmet need despite these methods being less effective than modern methods. 27 Discussions with Pacific experts, including Solomon Islands Ministry of Health, indicated that the current estimate for Solomon Islands (11%) is likely to significantly underestimate the true demand for family planning. The high number of unintended pregnancies suggest that a substantial proportion of women who want to avoid pregnancy are not using an effective method of contraception. Therefore this analysis is likely to have underestimated the true impact of meeting all needs for family planning in Solomon Islands. Further, the estimates provided in this report do not account for a potential increase in unmet need in the future, which is likely with improved education and community awareness resulting in increasing demand. The family planning costing estimates do not take in to account all the costs associated with reducing unmet need for family planning. Indirect costs related to increasing community awareness and demand, improving quality of services (infrastructure, information systems, improved commodity supply systems, staff training, supervision), or reaching populations with poor access due to geographical or socio-cultural barriers were not included. These factors are difficult to measure but may make up more than half of the total costs of increasing access to family planning, particularly in settings such as Solomon Islands where considerable geographical and socio-cultural challenges exist. 3, 28 In addition, family planning costs remained constant throughout the projection period, so do not reflect potential changes in costs of commodity procurement and/or transport. These estimates are therefore likely to underestimate the true investment required to ensure that universal access to family planning is fully realised. 10

15 RECOMMENDATIONS Increased and long term financial commitment to family planning from government and donors is required to meet the needs of women and couples in Solomon Islands. Based on this analysis at least $1 million is required over the next 5 years ( ) and $3.4 million over the next 16 to meet these needs by Recognising the human rights, health and development imperatives, reducing unmet need for family planning should be prioritised in reproductive health, maternal and child health and population policies and programs. Clear and realistic targets for reducing unmet need for family planning should be developed based on current and projected needs and adequate budget provided to enable these to be achieved. Health information systems should be strengthened to better capture data about family planning needs, contraceptive users, acceptors, discontinuation and costs related to public, non-government and private providers to facilitate planning and to monitor progress. In July 2012 the international community pledged to reach an additional 120 million women and girls with essential family planning services by Of the 69 least developed countries prioritised for investment, only two (Papua New Guinea and the Solomon Islands) are from the Pacific. However, this analysis demonstrates that there are considerable health, development and human rights imperatives to ensure that no women or girls in the Pacific are overlooked. The case for investing in family planning in Solomon Islands 11

16 APPENDIX 1: METHODS To identify the costs and health, social and economic impacts of reducing unmet need for family planning, three population models were created based on three hypothetical family planning scenarios: 1. Constant unmet need for family planning (11%) 2. All family planning needs met by All family planning needs met by 2020 Acknowledging that Solomon Islands is unlikely to meet the MDG 5B target to reduce unmet need for family planning by 2015, a target of 2020 was considered to be a best-case scenario, with a target of 2050 also included to examine the impact of slower progress. MODELS Estimates of the costs and health, economic and demographic outcomes of reducing unmet need for family planning were calculated using population models generated by Spectrum Version 4.391, a specialised, demographic modelling software program developed by the Futures Institute through the USAID Health Policy Initiative. A full description of the program methodology can be found at Three Spectrum modules were used to generate these models: 1. DemProj which projects population and demography based on assumptions about fertility and mortality; 2. RAPID which projects social and economic outcomes resulting from changes in fertility rate and population growth generated by DemProj; and 3. FamPlan which projects family planning requirements, costs, health outcomes, and population impacts based on goals for addressing unmet need for family planning. DemProj population projections are automatically adjusted for changes in fertility based on selected FamPlan family planning goals. A baseline model using these three modules was developed for the period assuming constant unmet need for family planning of 11.1%. This projection period was based on the medium population projection from the Solomon Islands 2009 National Population and Housing Census [Provisional]. 19 Using this baseline model, two additional models were created based on two different FamPlan goals: all family planning needs met by 2020; and all needs met by While outcomes were projected to 2050, analysis was restricted to a 16-year projection period INPUTS AND DATA SOURCES Baseline data were required for over 40 inputs covering demography, economy, health and education systems, maternal and child health, and family planning usage and costs. Demographic data required for DemProj (base year population by sex and five-year age group, total fertility rate, age-specific fertility rate, sex ratio at birth and life expectancy) were sourced from the 2009 Census. The model life table used was Coale- Demeny North. 19 RAPID required economic, health and education inputs. Base year data for employment population ratio and gross domestic product (GDP) were taken from the 2009 Census and World Bank estimates. 19, 30 Education data were sourced from the Solomon Islands Ministry of Education and Human Resources Development Performance Assessment Framework Health systems data (workforce, facilities, expenditure) were obtained directly from the 2011 WHO Western Pacific Country Health Information Profile for Solomon Islands. 32 FamPlan inputs included: contraceptive prevalence and method mix; source mix, costs per method; proximate determinants of fertility; maternal mortality; and infant and child survival. Data on contraceptive prevalence and method mix were sourced from Solomon Islands Demographic Health Survey (DHS). 23 Some data on source mix per contraceptive method were taken from the DHS. 23 Where DHS data was not available, the source mix was assumed to be 90% public, 10% nongovernment with the exception of male and female sterilization (100% public) and male and female condoms (50% public, 50% non-government). These assumptions were based on available regional data and expert advice. Unmet need for family planning among women married or in union was sourced from the DHS. 23 The direct costs of providing family planning per contraceptive method (per couple-year of protection for short-acting methods and per acceptor for long acting methods) were calculated from estimates of: commodities, equipment and supplies, shipping, storage and distribution, and staff costs for counseling, provision and follow-up. Commodity, equipment, transport and storage costs were obtained directly from UNFPA (the major supplier of family planning commodities in Solomon Islands), International Planned Parenthood Federation (IPPF) and the Solomon Islands Ministry of Health & Medical Services. Staff costs were based on estimates of average staff salaries and time spent per client per method of contraception obtained from Solomon Islands Planned Parenthood Association and the Ministry of Health & Medical Services. Costs per method for government services are detailed in table 7. Other non-government and private providers Method Costs (US$) Commodities, equipment and supplies Shipping, transport and storage Labour Male condom $3.60 $1.44 $4.40 $9.44 Female condom $75.60 $30.24 $4.40 $ Pill $4.50 $1.80 $6.30 $12.60 Injectable $4.20 $1.68 $7.20 $13.08 Implant $27.00 $10.80 $10.00 $47.80 IUD $1.28 $0.51 $8.90 $10.69 Female sterilisation $7.19 $2.88 $24.08 $34.15 Male sterilisation $3.05 $1.21 $26.08 $30.35 TABLE 7. Costs per method of contraception per couple year of protection (short acting methods) or per new acceptor (long acting and permanent methods) Total 12

17 as well as out-of-pocket expenditure on family planning were not included in the analysis due to lack of reliable data. The base year data on the percentage of women aged married or in union and data on sterility was taken from the 2009 Census. Data on postpartum insusceptibility was taken from the DHS. Data on abortion in Solomon Islands, and the Pacific in general, are scarce. The proportion of unwanted pregnancies ending in induced abortion was determined from a regional estimate for Oceania (excluding Australia and New Zealand) provided by Guttmacher Institute. 33 The maternal mortality ratio and infant and child mortality rates were taken from the 2009 Census, and the percentage of births with any risk (births to women less than 18 or over 34 years, births spaced less than 24 months, or birth order 4 or higher) were taken from the DHS. 23 KEY ASSUMPTIONS Thirty of the 40 inputs required yearly estimates for the entire projection period. Inputs either remained constant throughout the projection period, or were obtained by projecting to an estimate for This year was selected as Solomon Islands is predicted to reach replacement fertility by Following consultation with regional experts it was considered realistic to assume the country would reach other development milestones in that timeframe. Unmet need remained constant for the baseline model. In the other two models the reduction in unmet need was front loaded commencing in 2010, assuming a more rapid initial increase in contraceptive prevalence, 35 with all needs met by 2050 (scenario 1) and by 2020 (scenario 2). Due to the lack of agedisaggregated data, the reduction in unmet need was assumed to be evenly distributed across all age groups All other assumptions were consistent across the baseline model and two scenarios. All estimates for proximate determinants of fertility remained constant from Projected contraceptive method mix was adjusted to take into account the planned introduction of contraceptive implants and to reflect a more balanced method mix (adjusting for the high reliance on female sterilisation). The 2054 method mix was calculated based on global trend data, , the average method mix for the Pacific region, and following consultation with regional and international family planning experts. In brief, the prevalence of traditional methods was halved by 2054, while other methods were adjusted to the Pacific average, increasing the use of short-acting hormonal methods. The prevalence of intrauterine devices and condoms remained constant. Source mix and direct costs per method remained constant. Age-specific fertility rates were projected to reach the average of Australia, New Zealand, France and USA by 2054 as per the methodology used by the Statistics and Demography Programme of the Secretariat of the Pacific Community (SPC). Future life expectancy was calculated using the UN models for mortality improvement assuming medium gains. 44 Economic growth, health and education expenditure were assumed to reach the average for East Asia and the Pacific by 2054, based on the most recent data from the World Bank, 30 UNESCO, 45 WHO 32 and the International Monetary Fund. 46 OUTPUTS AND ANALYSIS For each model, the program was used to project: contraceptive prevalence and number of users; family planning costs and commodities required; health outcomes for women and children (unintended pregnancies, births, induced abortions, births with any risk, and maternal and infant deaths); total fertility rate and population growth; health and education expenditure and required resources (infrastructure and human resources); and dependency ratio and GDP per capita. A full description of the program methodology can be found at Projected data for for each model were extracted and analysed using Microsoft Excel (Microsoft Corp, Redmond, WA, USA). The impact of reducing unmet need by 2020 and 2050 was compared to the baseline model (constant unmet need) for each output of interest. All costs are reported in US dollars. The number of infant deaths was estimated from an adjusted infant mortality rate calculated for each year using: IMR(t) = IMR(0) (% births with any risk(t))/% births with any risk(0)*imr(0). The adolescent fertility rate (births per 1000 women aged 15-19) was estimated as follows: the age-specific birth rate was calculated by multiplying the projected total fertility rate by the percentage distribution of births per fiveyear age group; the total number of births per age group was estimated by dividing the age-specific birth rate by five and multiplying by the projected total number of women per age group; age-specific fertility rate was calculated by dividing the total number of births per age group by the number of women of that age group. SENSITIVITY ANALYSIS One-way sensitivity analyses were conducted to test the robustness of estimates of averted unintended pregnancies and deaths, family planning costs and public sector savings to changes in key assumptions (table 8). Under alternative assumptions of unmet need (based on the 95% confidence interval), constant contraceptive method mix (based on current mix), constant age-sepcific fertility rates, and family planning costs (+/-25%) the total number of adverted events (from ) varied between 30,191 and 36,203 unintended pregnancies and 1,109 to 1,321deaths with costs per averted event ranging from $78 to $126 (unintended pregnancy) and $2,071 to $3,452 (deaths). The most favourable estimates were calculated where there was no discounting of health effects or costs. The largest unfavourable effect on projected estimates was associated with the alternative assumption regarding the rate of reduction in unmet need. A constant (linear) reduction in unmet need substantially reduced the number of averted events and increased costs per averted event, most notable for the 2050 scenario. This effect is largely explained by the lower contraceptive prevalence rate achieved by 2025 under this assumption (38.7%). All estimates under alternative assumptions demonstrated health and economic benefits associated with reducing unmet need (compared to the baseline projection) and meeting this need by 2020 would result in larger benefits than slower progress. REFERENCE GROUP Technical oversight and advice concerning quality of data, missing data and key assumptions was provided by a reference group of Pacific experts including representatives from the Ministries of Health for Vanuatu and Solomon Islands, Statistics and Demography Programme of SPC, UNFPA Sub-Regional Office, WHO, and IPPF East and Southeast Asia and Oceania Region. Additional technical support was provided by the Futures Institute and Andreas Demmke. The reference group also reviewed and approved the final reports and paper for publication. The case for investing in family planning in Solomon Islands 13

18 met by 2050 Total number of unintended pregnancies averted Cost per unintended pregnancy averted (US$) Total number of maternal and infant deaths averted Cost per death averted (US$) Total family planning costs (US$) Total public sector savings (US$) Base case 22,479 $ $3,708 $3,118,381 $18,661,773 Unmet need for contraception (11 12%) Constant rate of reduction of unmet need Constant contraceptive method mix Constant age-specific fertility rate Direct family planning costs +/-25% Recurrent public sector expenditure +/-25% 20,446 24,506 $129 $ $3,464 $3,999 $3,066,994 $3,169,767 $16,921,477 $20,411,314 7,393 $ $9,681 $2,759,065 $4,602,740 21,952 $ $3,489 $2,930,505 $18,601,170 22,521 $ $3,699 $3,118,376 $18,672,780 22,479 $104 $ $2,781 $4,635 $2,338,786 $3,897,976 $18,520,429 $18,803,118 22,479 $ $3,708 $3,118,381 $13,854,987 $23,468,562 Discounting (0 5%) 18,948 29,572 $134 $ ,104 $3,579 $3,797 $2,699,916 $3,950,801 $14,915,362 $26,491,813 met by 2020 Total number of unintended pregnancies averted Cost per unintended pregnancy averted (US$) Total number of maternal and infant deaths averted Cost per death averted (US$) Total family planning costs (US$) Total public sector savings (US$) Base case 33,201 $101 1,216 $2,762 $3,358,160 $30,129,839 Unmet need for contraception (11 12%) Constant rate of reduction of unmet need Constant contraceptive method mix Constant age-specific fertility rate Direct family planning costs +/-25% Recurrent public sector expenditure +/-25% 30,191 36,203 $95 $109 1,109 1,321 $2,598 $2,962 $3,284,998 $3,431,316 $27,425,861 $32,947,475 26,106 $ $3,355 $3,221,007 $17,825,146 32,456 $97 1,213 $2,603 $3,157,995 $30,034,687 33,257 $101 1,218 $2,757 $3,358,155 $30,144,376 33,201 $78 $126 1,216 $2,071 $3,452 $2,518,620 $4,197,701 $29,928,549 $30,331,128 33,201 $101 1,216 $2,762 $3,358,160 $22,396,091 $37,863,588 Discounting (0 5%) 28,247 43,088 $98 $103 1,036 1,573 $2,696 $2,812 $2,913,710 $4,241,273 $24,161,801 $42,568,107 TABLE 8. Sensitivity analysis REFERENCES 1. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. The Lancet. 2012;380 (9837): Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet. 2012;380(9837): Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the costs and benefits of investing in family planning and maternal and newborn health. New York: Guttmacher Institute and UNFPA; Stover J, Ross J. How contraceptive use has reduced maternal mortality. Matern Child Health J. 2009;14: Singh S, Darroch JE, Adding it up: costs and benefits of contraceptive services estimates for 2012, New York: Guttmacher Institute and United Nations Population Fund (UNFPA); Cates Jr W. Family Planning: the essential link to all eight Millennium Development Goals. Contraception. 2010; 81(6): Neill BC, Liddle B, Jiang L, Smith KR, Pachauri S, Dalton M, et al. Demographic change and carbon dioxide emissions. The Lancet. 2012;380(9837): Canning D, Schultz TP. The economic consequences of reproductive health and family planning. The Lancet. 2012;380(9837): Wire T. Fewer emitters, lower emissions, less cost. London: London School of Economics; World Bank. World development report 2007: development and the next generation. Washington DC: International Bank for Reconstruction and Development;

19 11. UNFPA. State of world population 2011: people and possibilities in a world of 7 billion. New York: Information and External Relations Division, UNFPA; Kennedy E, Gray N, Azzopardi P, Creati M. Adolescent fertility and family planning in East Asia and the Pacific: a review of DHS reports. Reproductive health. 2011;8: Haberkorn G. Pacific Islands' population and development: facts, fictions and follies. New Zealand Population Review. 2008; 33/34: Narsey W, Sachs Robertson A, et al. Population and development in the Pacific Islands: accelerating the ICPD Programme of Action at 15. Proceedings of the Regional Symposium. Suva: University of the South Pacific; 2009 Nov Achieving MDGs 4 and 5: scaling-up programmes for women's and children's health. Paper for the Ninth Meeting of Ministers of Health for the Pacific Island Countries. Honiara, Solomon Islands. Manila: WHO Western Pacific Region Office; 2011 June 28 - July UNFPA. 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20 REPORT This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government KNOWLEDGE HUBS FOR HEALTH KNOWLEDGE HUBS FOR HEALTH KNOWLEDGE HUBS FOR HEALTH