Family Planning Programs in Asia and the Pacific and Achieving MDG5b a

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1 Draft for Consultation Not to be quoted UNFPA - ICOMP REGIONAL CONSULTATION Family Planning in Asia and the Pacific Addressing the Challenges 8-10 December 2010, Bangkok, Thailand Family Planning Programs in Asia and the Pacific and Achieving MDG5b a Amy O. Tsui Disclaimer: The views and opinions expressed in this article are those of authors and do not necessarily reflect the official policy or position of UNFPA and ICOMP. The content in this draft article should not be quoted.

2 Family Planning Programs in Asia and the Pacific and Achieving MDG5b a Amy O. Tsui, Johns Hopkins Bloomberg School of Public Health Background Global development efforts today are largely framed by the Millennium Development Goals, and the one most widely acknowledged to be off-track is MDG 5, Improving Maternal Health. MDG5 itself has a target 5b, Universal Access to Reproductive Health, which is experiencing the same lack of progress in low-resource settings. Achieving MDG5b is seen to be key to the achievement of all the MDGs and calls for reducing maternal mortality; preventing unwanted pregnancies; curbing the spread of sexually transmitted infections (STIs), including HIV/AIDS; empowering women and girls; and contributing to a more sustainable world for all people. Family planning, including specifically the practice of contraception, is a social and health intervention that directly addresses all MDG5b objectives, whether by averting births that carry high mortality risk to the mother and newborn, preventing unintended pregnancies, reducing STI/HIV transmission through consistent condom use, enabling women and girls to decide when and how many children to bear; or by altering the dynamics of population change to facilitate sustainable development. As defined by the 1987 Brundtland Declaration, Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs. Contraceptive practice has been the primary proximate determinant behind fertility transitions in the Asia and Pacific and other developing regions and a behavioral innovation embraced by governments in the region to secure sustainable development. Sustainable development remains the collective aim of all eight MDGs. The developing world has a long history of family planning efforts embedded in population development policies, with the strongest record being in Asia and Latin America. These efforts materialized between the mid-1960s and late 1980s, all predating the formation of the MDG framework. Robinson and Ross in The Global Family Planning Revolution write, a Paper prepared for the Regional Consultation on Family Planning in Asia and the Pacific Dealing with Challenges, 8-10 December 2010, Bangkok, Thailand 1

3 The years just after 1960 saw the appearance of a new fertility determinant organized actions by whole societies to bring birth rates down to match falling death rates, and to ease the accompanying dislocations faced by educational, medical, economic, housing and family system institutions and others. Those actions were also meant to give women greater control over their own childbearing and to relieve families from the unexpected burdens of raising more surviving children than in the past. The two results together, societal benefits and personal benefits, flowed from programs based on new contraceptive technologies that could be deployed to whole populations. (Preface) Indeed, much before modern contraceptive technologies as we know them today became widely available, India was the first country in 1951 to adopt family planning as part of its economic development plan. Other Asian countries followed suit shortly Pakistan (1960), Republic of Korea (1961), China and Fiji (1962), Singapore and Sri Lanka (1965), with non-asian countries, such as Egypt and Turkey, committing national support for family planning in This show of national commitment was one decade before developing countries contrasting views on family planning s role in economic development would lead to them to align themselves in political blocs at the 1974 World Population Conference in Bucharest. It was 30 years before the reproductive health/reproductive rights framework emerged from the 1994 International Conference on Population and Development. In 1976 nearly half of the 37 governments in the Asia region reported to the United Nations that their fertility levels were too high (UN, 2009a). The demographic intent of managing national fertility levels because population growth rates were too high was voiced by nearly two fifths of governments in the region. Two thirds of them (25) were also directly supporting contraceptive access and by 2009, four fifths (39 or 83%) of the 47 governments in the Asia region were. Asia had a 1965 population of billion persons and countries where governments had declared for family planning had annual population growth rates that ranged from 2.07% (India) to 3.27% (Fiji). These rates are higher than those found among most countries in sub-saharan Africa today, the world s fasting growing region in demographic terms. With billion persons currently, Asia s estimated annual growth rate is 1.05% (United Nations, 2009b). Total fertility rates (TFRs) range from below replacement in nearly all countries in East Asia to below 2.5 births in 11 Southeast Asian countries, but above 3.0 in countries such as Afghanistan (5.7), Bhutan (3.1), Cambodia (3.3), Laos (3.5), Pakistan (4.0), Philippines (3.2), Tajikistan (3.4) and 2

4 Timor Leste (5.7). With this range, not surprisingly, 28% of the 47 governments in the region view their present fertility levels as being too low and another 32% see them as too high, Similarly in the Pacific region, excepting Australia and New Zealand, TFRs among the other 15 nations range between in French Polynesia, New Caledonia, and Palau to above 4.0 in Marshall Islands, Papua New Guinea, Samoa, Solomon Islands, Tonga, and Vanuatu. Economically speaking the region is the fastest growing in the world, with two countries offering huge consumer bases with tremendous market potential and many serving as financial or industrialized centers (Hong Kong SAR, Singapore, Republic of Korea). Many have reached per capita income levels above US $7,500 (PPP), e.g., China, India, Kazakhstan, Maldives, Turkmenistan, Brunei, Malaysia, and Thailand, while they are below $4,500 in a number of Pacific nations. On other development indicators, such as urbanization and educational attainment, there is great heterogeneity as well, with East Asian countries being highly urban, while South Asian and Pacific ones less so, such as Nepal (17%) and Papua New Guinea (13%). Educational performance, measured in terms of survival to last grade of primary school (ESCAP 2008), is relatively high, in the 90%-ile in East Asia and Pacific nations such as Fiji, but lower in several countries in south central and south Asia, such as Bangladesh and Laos (in the 60 th percentiles) and Cambodia (56% for males 58% for females), and in the Pacific (Nauru with 22-30% reaching the last grade of primary school). Although not uniformly high, these indicators reflect the significant progress towards universal primary education over the past decades in the Asia and Pacific region. Unmet need for contraception remains persistently high in several countries where one fifth or more of married reproductive-aged non-contracepting women report wanting to space or limit births (PRB, 2008), e.g., Pakistan (32%), Myanmar (20%), Laos (40%), Cambodia (25%) and Nepal (24%). These five countries alone account for nearly 20 million women with unmet need and another eight with available data (e.g., Indonesia, Philippines, Vietnam, Bangladesh, India, Kazakhstan, and Mongolia) contribute an additional 58.3 million women. If health policy makers addressed the risk of unplanned pregnancy with the same intensity as they do the risk of infectious or communicable diseases, it is unlikely they would be unresponsive to the 3

5 vulnerability represented by unmet need en masse. The sizeable female populations of childbearing age and the emerging youthful ones portend high rates of unintended pregnancies into the future and potentially harmful health consequences in the absence of family planning service access and the benefits of contraceptive protection. The need for continued investment in family planning programs is unquestionable. The population age structure in the Asian and Pacific (A&P) region is disproportionately youthful with more than one billion persons under age 25, moving into their childbearing years. Their need to access to contraceptive information and services for healthy reproduction emerges at a time when many governments have relaxed their attention to family planning matters and others have yet to launch themselves. Private sector provision of contraceptive services has appropriately expanded, but program vigilance in providing quality contraceptive counseling, broadened method choice and well integrated services, by well-trained and well-informed providers, has declined significantly. Contraceptive prevalence rates among childbearing aged women in union vary widely in the region from less than one fifth (19%) in Afghanistan to more than four-fifths (87%) in China. Contraceptive prevalence coverage estimates are unavailable for many of the small island nations but for those with data, they average around 30-35% (Population Reference Bureau, 2010; United Nations, 2009c). High contraceptive prevalence, e.g., China, Republic of Korea, and Thailand, remains so in large part because of the initial uptake of female sterilization, intrauterine devices, and other long-acting methods which provide prolonged protection until women age out of childbearing years. The importance of recurring investment in access to quality services and knowledgeable and capable providers to cater to the reproductive health needs of a rising population of young adults, many sexually active prior to marriage, and to maintain their coverage over the two to three decades of life years exposure to the risk of unplanned pregnancy is an unavoidable challenge to this region of the world. Over the past four decades, then, countries in the Asia and Pacific region vary extensively in their demographic, economic and epidemiologic transitions with some reaching unprecedented levels of economic growth becoming middle- or high-income countries in the process, while 4

6 others have large and growing segments of their populations remaining in abject poverty. Some countries have more than doubled in population size and others are anticipating major aging and minimal growth. Most have undergone significant fertility transitions and several have persistent high fertility. For the purposes of this paper, many countries in the regions of interest have made steady public investments in family planning programs, resulting in moderate to high contraceptive practice levels. With such regional variations in contraceptive prevalence, what are the prospects for those levels sustaining themselves into the future and what challenges face family planning programs to 2015 and most likely beyond? Aims The aims of this paper addressing family planning programs in the Asia and Pacific region are: 1. To review trends in patterns of government response to fertility levels and contraceptive service provision 2. To review national variation in contraceptive practice levels, and change therein, useeffectiveness of the composition of methods used and equity in coverage 3. To assess contraceptive commodity security, internal financing and international assistance for family planning and other population activities 4. To derive lessons from the long history of family planning in Asia and the Pacific for policy directions, program models and financing needs to achieve MDG5b by 2015 National response in the early years to fertility and contraceptive service provision The early development and maturation of twelve national experiences with family planning programs in Asia are captured in Robinson and Ross (2007) the Republic of Korea, Hong Kong, Singapore, Thailand, Indonesia, Malaysia, the Philippines, India, Bangladesh, Pakistan, Sri Lanka and Nepal. Each country case study covers the inception of conjoint interests in population policy and family planning programs as subsequently played out over three decades and is prepared by experts with insiders on-the-ground knowledge. Each chapter provides a chronology of landmark events the authors perceive to be relevant to the evolution of family planning in the country. In a meta-analytic manner, these events are collectively detailed in Table 1. The reported events appear to cluster around several domains of activity: 1) policy formation and oversight, 2) program design and outreach, 3) contraceptive service delivery, 4) 5

7 contraceptive methods, and 5) research and evaluation. For example, India is reported as having launched its national family planning program in 1947 and also included recognition of and support for services as part of five economic development plans (1956, 1956, 1961, 1976 and 1977). The service delivery design of family planning programs in the Republic of Korea and Malaysia is characterized by initiatives at rural outreach, deployment of a vertical family planning workforce, expansion of service outlets, and integration with maternal and child health (MCH) services, all in the early 1960s to mid-1970s. We can observe several patterns of program development reported across these 12 national case studies concentrated between the early 1960s and mid-1980s. First, family planning was frequently incorporated into economic plans as a means by which population growth could be managed to improve prospects for development (e.g., Republic of Korea, Malaysia, Philippines, India, Pakistan/Bangladesh, Sri Lanka and Nepal). Targets and incentives are not frequently cited as key events except in the Republic of Korea, India and Sri Lanka. Financial incentives are added to enhance program performance in the Republic Korea, Singapore, Sri Lanka and Nepal, all in the late 1960s to mid-1970s. Family planning slogans are cited as key means for altering social ideation about family formation and family size norms in Korea, Hong Kong and Singapore, while addressing religious opposition is noted for Indonesia, the Philippines and Sri Lanka. Second, the establishment of voluntary family planning associations (FPA) today the affiliates of the International Planned Parenthood Federation is perceived to be significant in eight of the 12 countries. Voluntary FPAs often served the function of piloting service interventions and introducing new contraceptive methods. The IPPF affiliates programs and operations have matured over time and currently focus on advancing sexual and reproductive health and rights. The affiliates focus strategically on the Five A s of adolescents, advocacy, AIDS, abortion, and access. However, their potential in the A&P region warrants further consideration for testing program innovations or complementing public models of service delivery. In addition other franchises such Marie Stopes International and Sun clinic networks organized through Population Services International or DKT International also have considerably expanded the realm of contraceptive and pregnancy termination service access. 6

8 Among the other notable service innovations in the early 1970s was the demedicalization of contraceptive service delivery to authorize lower-tier health workers especially in rural areas to provide clinical methods, such as IUDs and injectables. Today, under the rubric of taskshifting, the delivery of injectables is permitted for community-based health providers. In the Asian history of family planning, desensitization and demedicalization of contraceptive delivery were made most famous in Thailand, through the work of the Population and Community Development Association and the national family planning program. However, innovations to expand delivery were tested in programs in the Republic of Korea, Malaysia, India, Indonesia and Pakistan as well. In fact, a quiet revolution in contraceptive provision has taken place in Indonesia with injectables representing half of all contraceptive use (31.8 of 61.4% overall prevalence) and private midwives now supplying 40% of this method on a fee basis (Statistics Indonesia and Macro International, 2008). A third observation is that reported outreach to special populations, such as adolescents, men, and older women, began much later, after the 1980s for the most part. Addressing client populations outside of the mainstream of married couples with childbearing-aged wives required resources that were often not available until contraceptive prevalence reached robust enough levels where privatized services could contribute. Adolescents represent a hugely important segment of the A&P region s population; however, social norms regarding premarital sex tend to work against actively promoting family planning services to this group. A fourth observation from Table 1 is that family planning programs in the 21 st century enjoy a profoundly different mix of available contraceptive methods than A&P programs did in the latter half of the 20 th century. Initially only oral contraceptives and condoms were available, followed by IUDs, with their hormonal combinations and intrauterine designs introduced many undesirable side effects of breakthrough bleeding, nausea and weight gain. Current contraceptive technologies much more effectively minimize side effects and offer a range of options that can meet the needs of any interested female or male user. In the cluster of reported key events around contraceptives, the sequential introduction of new and refined methods offered additional options to new segments of potential users, thereby raising overall use. 7

9 Liberalized access to pregnancy termination services is reported for the Republic of Korea, Hong Kong, Singapore and India. However, reports of the sponsored provision of infertility or subfertility services are notably infrequent. Fifth, the importance of building a data-driven base of evidence on the progress of contraceptive adoption and the fertility transition, in the context of changing infant and child mortality levels and social and economic development, was cited for nearly every one of the 12 country case studies. Dissemination of findings from national surveys, in particular, the early Knowledge-Attitude-Practice (KAP) surveys, followed by the World Fertility and Demographic and Health Survey (DHS) programs, gave credence to the measured demand for family planning and the systemic ability of both the public and private health sectors to respond with services. The serial availability of such national-level results in Indonesia, the Philippines, Nepal, Bangladesh and more recently India can not be underestimated for their ability to inform and shape family planning, reproductive, child and sexual health policies and programs regionally. Case study authors also cited the establishment of specialist research centers devoted to family planning and family welfare, including the Korean Institute of Family Planning, the Indian National Institute for Health and Family Welfare, and the Population Institute in the University of the Philippines. Finally, a sixth lesson to be lifted from these country case studies is the initial administrative locus of national family planning efforts, whether under the highest political authority, such as a President or Prime Minister, or institutionalized in a national commission, inter-ministerial body with a policy or service implementation mandate, or integrated into the Ministry of Health. These corporate entities initially enjoyed senior-level membership and direct access to the decision-making authority of a Prime Minister or Minister of Finance or Planning. Often these were National Population Commissions which included oversight over the deployment of a family planning workforce and services and disbursement of centrally budgeted resources. The National Population and Family Planning Board/Committee in Malaysia, Singapore, Indonesia and Vietnam, as well as the Population Commission in the Philippines, are well known examples. Over time, the maturation of the family planning programs saw many of their functions absorbed into health and social affairs ministries. Following a board or commission 8

10 model did not guarantee a successful national program, however, and neither was one absolutely necessary, as in the case of the national revitalization of family planning in Iran (Roudi-Fahimi, 2002). A national-level entity, however, provided significant public visibility and credence to the importance of family planning in the framework of population and development efforts. One can visually appreciate trends in government support for contraceptive method access in Figure 1 (dashed red line) against the backdrop of government views on the level of fertility beginning in 1976 through to In % (17) of the 37 governments in the Asia region viewed their fertility as being too high (diagonally hatched area), with 49% considering it satisfactory (solid area). Over time, the number of governments has grown to 47 with those holding the view of high fertility declining to 32% in At the same time direct support for contraceptive access among the same governments held steady at about 68-71% from 1976 to 1996 and then increasing to 83% in 2009 (UN, 2009a). While expressed commitment to contraceptive access remains strong nationally, actual levels of use at the population level reveal a different picture of utilization. Contraceptive prevalence levels and method composition Table 2, based on the United Nations 2009 World Contraceptive Use chart, provides a snapshot of contraceptive prevalence rates (CPRs) among reproductive-aged women in union in countries in the Asia and Pacific region, both in terms of overall use, use of a modern or traditional method, and specific methods used. Annual change in use levels over a ten-year period from 1997 to 2007 is also given as is the value of the Bongaarts contraceptive index (Cc) which is driven by the use-effectiveness levels of contraceptives in use. In comparison to contraceptive prevalence in other developing regions, especially sub-saharan Africa, levels are high in the A&P region, although significant variation is apparent. Moreover, the size of the eligible population of married females 15 to 49 years underscores a uniquely voluminous scale of protection to be provided through organized services. This ranges from million in China to 220 million in India, to 45.4 million in Indonesia down to several thousands in countries and territories in the Pacific region. 9

11 Based on data for years from 1994 to 2007, contraceptive methods in use are predominantly modern across countries in the A&P region, although the practice of natural (traditional) methods of family planning is high in Japan which relies significantly on condoms (40.7%) and withdrawal use (11.8%). Withdrawal use is also high in Iran (11.4%), Cambodia (8.3%) and the Philippines (7.3%). Rhythm (periodic abstinence) use does not exceed 10% in any country but overall traditional method use is 10% or higher in Korea PDR (10.4%), Republic of Korea (10%), Sri Lanka (15.3%), Turkmenistan (16.6%), Malaysia (24.6%), Vietnam (10.8%) and Nauru (12.6%), in addition to the four aforementioned countries. Male sterilization use exceeds 10% in the Republic of Korea (15.7%) and Bhutan (13.6%) only and is 6.9% in China and 6.3% in Nepal. Female sterilization, on the other hand, is a frequently adopted method in China (33.1%), India (37.3%), and Thailand (26.6%). Similarly IUDs are heavily used in China (39.6%), PDR Korea (42.8%), Mongolia (28.9%), Kazakhstan (36.2%), Kyrgyzstan (32%), Tajikistan (26.3%), Turkmenistan (39%), Uzbekistan (49.7%) and Vietnam (43.7%). Injectables predominate in Mongolia (11.9%), Nepal (10.9%), Sri Lanka (15.3%), Indonesia (34.6%), Myanmar (14.8%), Thailand (13.2%), the Cook Islands (20.8%), and Kiribati (20.7%). The pill captures users in Bangladesh (28.5%), Iran (25.1%) and Thailand (36.7%), as well as Guam (22.6%) and the Cook Islands (24%), while also being a key contraceptive method (over 10%) for users in Mongolia, the Maldives, Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Vietnam, Palau, and Vanuatu. In addition to Japan, condoms are a significant method of choice in Hong Kong SAR (45.6%) and Singapore (22%). The annual percentage point change in CPRs between 1997 and 2007 is important to evaluate, since the trend line between national-level TFRs and CPRs suggest that for every 1.5% point increase in the latter, the TFR will decline by 0.1 child, or that a rise in 15% points will be associated with a 1.0 child decline in the TFR (Ross et al., 1993). Several countries approach or exceed this figure, e.g., Afghanistan (1.4), India (1.1), Nepal (2.2) and Cambodia (2.3), while some show regression in CPRs with negative values, e.g., Kazakhstan and Kyrgyzstan (-1.2), Timor Leste (-1.7) and Cook Islands (-1.3). The consistency of gains or losses in CPRs can be evaluated against the Cc values in the last column. A Cc value that is close to 0 implies a strong suppressive effect from contraceptive use on fertility, while one that approaches 1 signifies little 10

12 impact. China with a CPR of 86.2% that is heavily concentrated in female sterilization and IUD use has a Cc value of reflecting impressively high contraceptive use-effectiveness. By comparison, although Afghanistan s CPR is rising, the method mix involves less reliable methods (pill, condom and traditional methods) for a Cc value of 0.804, whereas Nepal has a Cc value of 0.510, reflected in modern method mix with significant female sterilization and injectable use. The link between contraceptive use effectiveness (Cc) and the CPR is visible in Figure 2 based on the countries in Table 2. The nearly perfect linear relationship between Cc and CPR is attributable to the method-specific use-effectiveness levels but also to the notable practice of long-term methods in Asia and the Pacific. b Country values that fall above the line (e.g., Malaysia, Singapore, Democratic Republic of Korea, and the Republic of Korea) have a method mix that includes significant use of traditional methods, with lower use-effectiveness and less fertility-suppressive impact. Table 2 and Figure 2 convey two important messages for contraceptive protection to avert unplanned pregnancies and the derivation of other health benefits. First, the range of available methods enables contraceptors to manage their pregnancy risk at varying stages of exposure during their reproductive life span. This suggests that the more method options that are made available, the more choice and more effective contraceptive practice can be. Second, the concentration of use in the long-term methods in Asia, particularly East and South Asian countries, is unduplicated in other developing regions, such as the Middle East and sub-saharan Africa. This concentration imbues significant use effectiveness to contraceptive users in the A&P region. Long term methods require a greater extent of clinical training and appropriate service environments (hygienic conditions, occasionally providers of the female gender, and follow-up protocols) which add to overall program requirements. Undoubtedly, the substantial use-effectiveness of contraceptives practiced in A&P countries has facilitated the avoidance of unwanted births. Liu et al. (2008) estimate that the practice of contraception circa 1999 in the Asia region was responsible for averting to million births annually. This implies the b The following use-effectiveness values from Liu et al were used: female sterilization 0.994, male sterilization 0.998, pill 0.912, injectable 0.942, IUD 0.964, condom 0.857, vaginal barrier 0.736, other modern 0.818, rhythm 0.745, withdrawal 0.784, other traditional method

13 prevention of a large number of pregnancy terminations under unsafe conditions, as well as maternal and newborn deaths depending on the risk profile of contracepting women. Compounded over multiple years of use, contraceptive protection prolonged by the use of longterm methods also will prevent maternal depletion, leading to healthier mothers able to withstand the energy and nutritional demands of subsequent pregnancies and deliveries. Contraceptive prevalence and economic equity Continuously assessing the disparities in access to family planning services in the Asia and Pacific region is a means for monitoring progress on MDG 5b. A major UNFPA review (Ortayli and Malarcher, 2010) finds that the percent of demand for contraception satisfied among individuals of different economic status shows the smallest gap for Central Asia and the widest in sub-saharan Africa. Gillespie et al. (2007) observed that higher fertility and lower contraceptive use are found among poorer relative to wealthier populations in many countries and the disparities should be considered an inequity. Townsend (2010) suggests inequities in program operations can be reduced in three ways: through better understanding at the development stage of interventions, through better program design and through post-program evaluation of the distribution of benefits. A broader review of socio-economic differences in health, nutrition and population indicators for developing countries was conducted by Gwatkin et al. (2007) and includes measures of both contraceptive prevalence and the extent to which contraceptors report the source of their contraception as the public sector. This assessment examines health conditions among wealth quintile subgroups using largely DHS data. It also calculates the concentration index (CI) which is a helpful summary measure of inequity by examining the degree to which the distribution of a health benefit is equally enjoyed by individuals in all economic classes or not. If contraceptive prevalence, as an indicator of coverage, is lowest among those in the poorest wealth quintile and highest among persons from the wealthiest quintile, the CI value will be large and positive. The closer CI is to a value of zero, the less income-related inequality exists in the indicator s distribution. 12

14 Table 3 provides trends in CPR by wealth quintile for seven Asian countries where two or more DH Surveys were conducted between 1992 and 2008 (Bangladesh, India, Nepal, Cambodia, Indonesia, Philippines and Vietnam). Unlike other regions, such as sub-saharan Africa, the inequity in CPR by wealth quintile is relatively low in these Asian countries and others where CPR is high (in excess of 70%). Figure 3 illustrates the equity pattern for Indonesia between 1997 and 2007, where those in the four highest quintiles experienced relatively similar coverage of contraception. The largest disparity is for those in the poorest quintile, with CPRs about 10 percentage points behind those in the other wealth subgroups. The Concentration Index values are relatively low, reaching close to zero in the most recent survey year for Bangladesh, Cambodia, India, Indonesia, the Philippines and Vietnam. It is at 0.10 or greater only in Nepal. This value is far smaller than those found in Guatemala 1998/99 (0.357), Pakistan 1990/91 (0.512) or Ethiopia 2000 (0.786), for example (Gwatkin et al., 2007:135). While income-related rates of contraceptive use are not available for many other Asian and Pacific countries, the level of inequity will be related to the overall level of use: the higher the population CPR the less likely there is significant disparity by socioeconomic status, whether measured in terms of income, assets, or education. That these populous countries show low inequity in contraceptive use suggests that government commitment and private sector supply assures a degree of contraceptive access that corresponds well to demand for contraception among married couples. Such a degree of equity in contraceptive coverage is a goal to which low-income countries in other regions are striving to attain. Contraceptive commodity security and program financing The history of family planning program financing in the developing world has been one that has as much relied on internal resources as on the contributions of donor agencies in the form of financial, technical or material assistance. China, India, Iran are examples of countries that have been largely self-sufficient in the financing and programming of their national family planning efforts, with commercial access to contraceptive commodities available through the private sector. In other countries, such as Bangladesh, Indonesia and now Afghanistan, international assistance has been more actively provided in the initial stages of the national program, although comparatively speaking, internal assistance levels dwarf external levels when in-kind resources 13

15 of human and physical capital (trained providers, health clinic buildings and equipment) are included in total costs. Assistance for contraceptive commodities and medical supplies have been largely provided by UNFPA, GTZ and the US Agency for International Development. While both these and other donor agencies have been steady sources of commodity assistance, changing political situations in the home countries of governments providing such support make their contributions vulnerable year after year. Threats to funding can disrupt the timely supply and delivery of contraceptive methods into recipient countries and compromise their continuous use by the clients, especially those in the poorest segments of the population. Rising contraceptive demand, made inevitable by the demographics of growing populations, can jointly lead to stockouts at various points of delivery, frustrating users habituated preferences for specific types of family planning methods. UNFPA, USAID and its implementing projects, along with other partners, such as the Reproductive Health Supplies Coalition, seek to ensure that contraceptive security is enjoyed by every person, in that s/he is able to choose, obtain and use quality, affordable contraceptives whenever s/he needs them. A Contraceptive Security Index was constructed at the country level to raise awareness, advocate, prioritize and monitor progress. The CSI has been conducted in 3 years 2003, 2006 and 2009 for 60 plus developing countries (DELIVER, 2010), which include a handful or so of Asian countries and no Pacific ones. The Index has five components involving 17 indicators: supply chain (logistics), financing, health and social environment, access and utilization. Table 4 presents six of 17 indicators selected to show the strength of the logistics, forecasting and procurement systems, public sector targeting and contraceptive policy. The total score of these six indicators is 72 points and the percent of maximum is shown for the seven Asian countries for which CSI data are available over the 3 rounds. Figure 4 graphs the 2009 partial CSI scores for five of these countries. Bangladesh and Indonesia show the highest partial-csi scores (75.7% and 68.1% respectively), followed by the Philippines (42.5%) and India (41.3%), while Pakistan ranks last (12.2%). The 14

16 partial scores do not exhibit a linear trend over the years with Bangladesh and the Philippines rated with a higher score (87.2% and 62.8%) in 2006 than Although the CSI scores have their imperfections, they provide a quantitative sense of how well contraceptive commodity security may be served by existing logistics-procurement systems and national commitment in the form of earmarked budgetary resources for commodity purchases. The ability to measure and assess progress on a regular basis is a critical activity and evaluation protocol of family planning programs. A data system, such as the CSI, available for all A&P countries would significantly advance contraceptive security for the region. Households are a major source of domestic spending on reproductive health and family planning and should not be neglected when assessing the national profile of financing. Figure 5 displays the distribution of estimated domestic expenditures on population by source of funds in Compiled for the UNFPA Financial Resource Flows project, the latest report (UNFPA and NIDI, 2010) shows that $15.8 billion (current US dollars) is spent in the A&P region, as compared to $3.01 billion in sub-saharan Africa, $2.55 billion in Latin America and the Caribbean, $1.01 billion in West Asia and North Africa and $0.83 billion in Eastern and Southern Europe. The leading Asian figure is a function of the region s population size but more importantly, in this figure, 71% of spending is by consumers, i.e., out of pocket expenditures on health care, and 28% by governments. A negligible amount is NGO spending. Government spending as a fraction of the total is nearly half or greater in the other developing regions. A high percentage of total financing that is consumer-based is an indication of sustainable contraceptive security, although national spending will always be requisite to introduce advances in contraceptive technologies, refine policy and service protocols, train and supervise health providers standards of care, monitor and evaluate, and subsidize the services for the poorest segment of contraceptors. The maturation and institutionalization of national family planning programs within the health sector most frequently has required less and less external assistance over time. In addition, global resources for FP/RH have been declining, from 43% ($722.8 million) in 1998 to 6% ($572.4 million) in Those for HIV/AIDS prevention and treatment have been growing 15

17 from $336.2 million to $7.702 billion over the same period. This has shifted the geographic destination of international population assistance funding, as tracked through the UNFPA Financial Resource Flows project, which obtains data from donor agencies, governments and other sources. Population assistance funding includes family planning and reproductive health services, STI/HIV prevention programs, and basic research, data and population and development policy analysis. In 2008, two-thirds of the total $10.4 billion estimated funding ($6.983 billion in 1993 US dollars) was directed toward sub-saharan Africa, while 18% ($1.873 billion) was directed toward the A&P region. Although donor support for population activities in the A&P region is a small fraction of the total expenditures, it is nonetheless be helpful to examine their estimated levels and channels of distribution. Table 5 is drawn from the UNFPA Financial Resource Flows 2010 report and, in current US dollars, shows the change in donor expenditures over a recent ten-year period, between 1998 and Because these expenditure data include funding for STI/HIV programs, sizeable increases are noted in some countries where disease transmission risk is judged to be significant or where geo-political considerations have raised the status of these countries as deserving recipients. For the populations of interest shown in the table, the A&P region received $1.132 billion in 2008, $1.050 billion in Asia and the remainder in the Pacific. The overall level of donor expenditure in 2008 is 2.79 times the 1998 level (in current dollars). Significant rises in donor expenditures are seen for PDR Korea, Afghanistan, Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, the Philippines, Thailand and Vietnam. Nearly all countries in the Pacific region reflect major increases in donor expenditures on population, except for Tuvalu, Fiji and Kiribati. Assuming a relatively constant level of funding into 2009, the per capita expenditure by donors (for women of childbearing age in union) is $1.49 and varies by sub-region, from $0.31 in East Asia to $4.36 in Southeastern Asia, to $45.34 in the Pacific, where economies of scale are less immediate and HIV funding may be a major contributor. Again, countries of strategic global interest and with special sexual and reproductive health needs, such as Afghanistan or those of Central Asia, have higher per capita investments by donors than other countries. Although much of the funding data may be driven by rises in STI/HIV program support, the latter present opportunities for family planning services to be linked to or integrated with sexual health and 16

18 expand the realm of efforts for preventing both unplanned pregnancy and sexually-transmitted infection. The unfinished agenda and going forward While family planning has been hailed as one of the ten greatest public health achievements of the 20 th century (CDC 1999), like other successful public health initiatives, one can not simply declare victory and shift attention and resources to another health priority. Assuring contraceptive security information and care necessitates continually aligning both supply and demand factors, using available public and private resources, to meet the needs of the economically disadvantaged users foremost and obtain maximum equity in care. National conditions for supply and demand factors vary considerably across the A&P region, from highly organized systems of service delivery in China and India where normative demand has increasingly conformed to what earlier generations of childbearing women have been provided, to nascent or underperforming systems as in Timor-Leste, Laos or Pakistan where unsatisfied demand is often high. There are several certainties that will frame the future agenda of family planning for the region: 1) population momentum and growth in the population of sexually active and childbearing aged individuals will place pressure on existing family planning resources independent of other changes in contraceptive supply and demand; 2) governance and policy models for contraceptive security will vary country to country where no one program model will fit every situation; and 3) factors influencing individual contraceptive demand will be wide ranging, not just across but also within countries. Social environmental factors will play a role in ideational change around sexual activity, gender responsibility for and roles in pregnancy planning and contraceptive method preferences. Trends in gender equity in access to educational, employment and economic opportunity will raise contraceptive demand and interact with social environmental changes and stage of the reproductive life span. For example, a rise in condom use among urban couples in northern India has been observed, although their eventual method of choice may be female sterilization at the completion of childbearing, an event that is occurring at increasingly younger ages (Jain et al., 2010). Social marketing of and improved access to condoms in urban areas may be enabling couples to practice birth spacing as well as 17

19 satisfying their preferences for this method. Condom use is much higher in urban than rural areas of India, as well as in the northern than southern states. Such internal variation at early stages of family formation is likely to be replicated in other settings as sophistication with the practice of fertility regulating methods expands. Unsatisfied contraceptive demand, i.e., unmet need, varies widely as well, where data are available. Pakistan, Laos and the Maldives register some of the highest levels of unmet need (33%, 40%, and 37% respectively) in the region and are substantial for Nepal (24%), Cambodia (25%), Myanmar (20%), the Philippines (17%), PDR Korea (16%) and Mongolia (14%). These levels occur among married couples where the wife is not contracepting but desires to space or limit future births and imply continued vulnerability to the risk of an unplanned pregnancy until the need is met. Globally this figure is estimated to be 215 million women, with a predominant share being in the Asia region, and the incidence of unintended pregnancies annually is estimated at 75 million (Guttmacher Institute, 2009). At the same time, it is evident that reducing unmet need to zero or negligible levels is possible and nearly assured where contraceptive prevalence is high, e.g., Vietnam with 5% and Indonesia with 9%. This indicator is one by which MDG 5b s progress is being monitored, and zero tolerance for unmet contraceptive need merits consideration for adoption by all countries fully committed to improving the human condition. The cost-effectiveness of contraception reinforces the social and health value of its universal access. In terms of cost per Disability-Adjusted Life Year (DALY), modern contraceptive methods cost $62 (in 2008 US dollars), as compared to for anti-retroviral therapy ($150 in India or $252-$547 in sub-saharan Africa) or to oral rehydration therapy ($1,268) (Guttmacher Institute, 2009). Recent calculations from the Health Policy Initiative project of The Futures Group show the contributions from meeting unmet need for family planning can reduce the costs of meeting the MDGs and reduce maternal and child mortality (HPI, 2009). Calculations were carried out for Bangladesh, India, Indonesia, Nepal and Pakistan in the Asia region to estimate the costs of satisfying all unmet family planning needs by 2020 and compared against the cost savings for universal primary education, child immunization, maternal health, and water and sanitation. For 18

20 example, in Bangladesh, costs for meeting unmet need are estimated at $50 million while the cost savings towards meeting the five MDGs ($327 million) offer a ratio of 6 to 1. The same ratio for India with a family planning investment of $1.14 billion is 13 to 1, for Indonesia with an investment of $67.4 million is 9 to 1, for Nepal with an investment of $39 million is 4 to 1, and for Pakistan with an investment of $136 million is 3 to 1. These family planning cost figures present a return on investment that is difficult to be matched or exceeded by other development interventions. Advocating for family planning argues for viewing it as an investment in improved human welfare and national development, as opposed to an expense. Advocacy arguments are strengthened by such cost estimates as these, which can be replicated for other countries and over time in the region. More importantly, countries should move to institutionalize federal and subareal budgeting and appropriations for contraceptive commodities and supplies since, like other social sector services, these are a recurring investment in the health of families and communities. This perhaps is the most unfinished agenda item requiring action, one the history of family planning in Asia can share within and across regions the necessity of permanent budgetary appropriations for family planning. Without them, budgetary resources are subject to redefinition, re-direction and re-allocation, often without full consideration of the consequences for health and development from the absence of adequate support for contraceptive access. Advancing family planning There is an opportunity to learn from ongoing global efforts of governments and international donor agencies to reposition or revitalize family planning programs, especially to strengthen them in regions with little programmatic experience. This concluding section offers several recommendations that arise from the foregoing review of the challenges faced by and facing Asian and Pacific family planning programs. The recommendations are not informed as fully as desired in view of the limited data on many countries in the Pacific region and also difficulty in accessing the region s key documents and program statistics. With this caveat in mind, the following steps, posed as questions, can be considered: 19

21 1. Is there a strategic need for a regional Plan of Action around family planning? In 2006 the African Union formulated, with the help of partners, especially International Planned Parenthood, the Maputo Program of Action for Operationalization of the Continental Policy Framework for Sexual Reproductive Health and Rights, which had six objectives including family planning repositioned as a key strategy for the attainment of the MDGs. As a regional mandate, annual updates are provided to the Heads of State of the 53 member countries of the African Union. There are recent indications that the policy climate is shifting in favor of family planning support in the region. 2. Can the region eliminate unmet contraceptive need and what does it need to know about barriers to contraceptive practice in order to do so? Quite evidently zero unmet need or universal access to contraception is possible. However barriers persist and include inadequate education and counseling about contraceptive methods and restricted choice of methods. Misplaced fear of side effects and infertility from contraceptive use among consumers require improved training of community and clinical health providers to provide quality counseling and services. A particular paradox is the reliance on the termination of unintended pregnancies borne out of non-use of contraceptive use for fear of lifetime infertility. Often these pregnancy terminations take place under unsafe conditions which then lead to sepsis and subsequently infertility. In addition all entry points at which family planning information, counseling and services can be introduced along the continuum of sexual health and reproductive care should be utilized. Preconceptional, pre-nuptial, prenatal, postpartum, post-abortion, STI and wellbaby care visits offer family planning integration and linkage opportunities. Moreover, infertility services should not be ignored as a deserving component of family planning care. 3. What are the prospects for permanent appropriations for contraceptive commodities in national and sub-national budgets or contraceptive service coverage by national health insurance plans? Contraceptive security will be achieved when national and sub-national budgets include earmarks for essential medicines, including contraceptives. This capability will also 20