Reproductive Health: How Much? Who Pays?

volume 1, issue 6

June 1, 2006

By Sally Ethelston and Elizabeth Leahy

Donor assistance for population, reproductive health and HIV/AIDS programs continues to increase, but the benchmarks used to assess performance have not changed since 1994. Those who monitor donor performance say that current assistance is not sufficient and that the benchmarks need to move upwards. This review of recent efforts to revise cost estimates for reproductive health and HIV/AIDS services concludes that $35 billion to $45 billion annually will be needed from all sources over the next few years. At the same time, further research is needed to improve the accuracy of such estimates.

Within a few weeks, we should know how much donor governments spent on population, reproductive health and HIV/AIDS in 2004.1 Estimates of these data, available earlier this year, suggested that what is called “population assistance” rose from $4.7 billion in 2003 to $5.3 billion in 2004. A further increase to more than $6 billion is projected for 2005.2 Of this amount, donors are deploying close to 60 percent to address the HIV/AIDS pandemic, while reproductive health and family planning activities are benefiting from less than 25 percent and 10 percent of total funds, respectively.

This sounds like a lot of money, but is it enough? Increasingly, those who monitor donor performance are saying “no,” as new estimates of financial resource needs emerge. The following review of recent efforts to revise cost estimates for reproductive health and HIV/AIDS services concludes that $35 billion to $45 billion annually will be needed over the next few years. Of this total, donors should provide between $16 billion and $21 billion annually. At the same time, further research is needed to improve the accuracy of such estimates, in order to account fully for infrastructure, personnel, and other cost components, as well as reproductive health needs for which cost data are weak or lacking altogether.

Each year, preliminary estimates of population assistance are released in January, as the United Nations systems prepares for the annual meeting of the Commission on Population and Development. They are part of a report from the UN Secretary General to the CPD, the UN body tasked with monitoring the progress of the international community in implementing the Programme of Action agreed at the International Conference on Population and Development (ICPD) in 1994.

This year, for the first time, the Secretary General’s report acknowledged that the cost estimates contained in the Programme of Action “are out of date and may not be sufficient to meet evolving current needs.”3 This is significant because, since 1994, the financial performance of both donor and aid receiving countries with respect to population and HIV/AIDS efforts has been measured against the ICPD cost estimates, long since reframed as spending goals by the international community.

ICPD cost estimates: Limited, not set in stone

The ICPD cost estimates covered a basic package of reproductive health services focused on family planning, safe maternity and a prevention of sexually transmitted infections, including HIV/AIDS. A small amount for population research, policy analysis and development was also included. For 2005, these activities were projected to require $18.5 billion: $11.5 billion for family planning (including all delivery system costs), $5.4 billion for safe maternity services, $1.4 billion for STI/HIV/AIDS services, and $0.2 billion for the research component. In addition to the estimates themselves, the 179 nations attending the ICPD agreed that donor countries would provide one-third of the financial resources needed, with the remaining two-thirds to come from developing countries themselves.

Often overlooked, but now critically important, is that the Programme of Action explicitly called for the estimates to be review and updated, “particularly with respect to the costs of implementing reproductive health service delivery.”4 It also acknowledged the need for additional resources for related activities, most notably emergency obstetric care, treatment and care of those infected with STIs and HIV/AIDS, and the strengthening of primary health care systems.5 Moreover, the cost estimates did not cover such important needs as services for the unmarried, youth, and for safe abortion.

Despite the call for review, the cost estimates have not been officially revised. This is not surprising, given that political opposition to reproductive health and rights issues has increased since 1994, exacerbating the challenge of formal negotiations on funding needs for population-related activities.

Figure 1: ICPD Resource Requirements

Revising ICPD cost estimates: What is reproductive health?

Efforts to revise the ICPD cost estimates face challenges beyond the political. First, there is the problem of what to include. Within the Programme of Action itself, for example, there is a significant difference between how reproductive health is defined as a concept and the services that are outlined for purposes of the cost estimates. The concept is broad: “a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.” In addition, reproductive health is defined as including sexual health. And while the emphasis is on family planning and safe motherhood, reproductive health care is defined as “the constellation of methods, techniques and services that contribute to reproductive health and well-being through preventing and solving reproductive health problems.”

The section of the Programme of Action that addresses resource needs is more specific, but there is still broad scope for interpretation: should prevention and treatment of infertility be available at the primary health care level or only through referral? What level of service should be available when it comes to breast cancer and cancers of the reproductive system?

Further complicating matters is that the Programme of Action is not only about services, but also about rights. And while there is no cost estimate attached to efforts to promote reproductive rights and gender equality, donor spending on these activities is also credited against the more limited financial targets agreed at the ICPD.

Second, there is the challenge of estimating the costs of specific services and everything that is required to deliver them, particularly when the goal is to derive a global estimate that covers the very diverse set of circumstance among and within low- and middle-income countries.

Recent efforts to identify reproductive health costs

There have been several efforts to develop specific global cost estimates for different components of reproductive health, with the bulk of the effort directed at safe motherhood and family planning. At the same time, the HIV/AIDS community has developed its own estimates of resource needs. Three sets of estimates are summarized below.

In 2003, the Guttmacher Institute and the United Nations Population Fund (UNFPA) estimated the cost of providing services to 504 million developing country women using modern contraceptives in 2003 at $7.1 billion, or an average of $14 per user.6 Their study also estimated the cost of meeting unmet demand for modern contraception among 201 million women at $3.9 billion, or just over $19 per user. Together, these two figures total $11 billion, or a per user cost of under $16.

The two estimates each included the costs of drugs and supplies, labor, the costs of hospitalization for female sterilization (prorated), and, significantly, overhead and capital costs. Indeed, the overhead and capital costs represented 60 percent of the $7.1 billion total and almost 70 percent of the $3.9 billion figure and yet still were considered an underestimate by the study’s authors.7

In 2001, a special session of the United Nations proposed spending of $7 billion to $10 billion annually on the HIV/AIDS pandemic.8 In 2005, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated annual funding needs in low- and middle-income countries at $14.9 billion in 2006, rising to $22.1 billion in 2008.

Table 1. UNAIDS Estimates of Resource Needs for HIV/AIDS (USD billions)
	2006	2007	2008	Total for 2006-2008
Prevention	8.4	10.0	11.4	29.8
Treatment and care	3.0	4.0	5.3	12.3
Orphans/vulnerable children	1.6	2.1	2.7	6.4
Program costs	1.5	1.4	1.8	4.6
Human resources	0.4	0.6	0.9	1.9
Total	14.9	18.1	22.1	55.1
Source: UNAIDS.

The UNAIDS estimates go beyond the costs of specific activities related to prevention, treatment, care, and support, to include program costs not specific to point-of-care service delivery, such as those related to management, logistics and supply. The costs of policy advocacy and community mobilization are also included. Further, they address infrastructure needs (the incremental costs of upgrading and new construction) and take into account the need to train and adequately compensate health care personnel (specifically doctors and nurses). Even so, the estimates are by no means exhaustive: program costs are incremental and sizable investments in HIV and AIDS research are not included.

The third set of estimates comes from the UN Millennium Project and was published on May 30, 2006.9 These cost estimates cover family planning; a package of health interventions for maternal and newborn health, including emergency obstetric care; treatment of selected sexually transmitted infections; and prevention of HIV/AIDS.

Table 2. UN Millennium Project Estimates of Resource Needs for ICPD Costed Package (USD billions)
Component	2005	2010	2015
Basic reproductive health services(includes family planning)	$13.9	$19.4	$24.4
STD and HIV/AIDS activities	$4.1	$9.7	$11.1
Research, policy analysis & development	$0.3	$0.8	$0.4
Total	$18.2	$29.8	$35.8
Source: Public Choice, Private Decisions.

Source: Public Choice, Private Decisions.

Once again, the figures are comprehensive but have limitations, as the authors acknowledge. While some overhead costs are included, the full costs of increasing and upgrading facilities are not. The costs of training additional health professionals are omitted, as are the costs of policy advocacy and community mobilization efforts; and community health workers. These omissions may help explain why the combined costs of family planning and basic reproductive health care total less than what was estimated for 2005 at the time of the ICPD ($13.9 billion versus $16.9 billion) and only slightly more than the 2010 estimate ($19.4 billion versus $18.3 billion).

Moreover, the HIV/AIDS-related cost estimate does not include the full cost of prevention activities provided by UNAIDS and none of the costs associated with treatment, care and support. While in keeping with the intent of the ICPD Programme of Action, this omission perpetuates the discrepancy between performance benchmarks and how financial resource flows are tracked.

Where do we go from here?

Assessing the financial performance of the international community against the original ICPD goals is no longer sufficient, given the limitations of the original estimates and the much greater resources needed for the fight against HIV/AIDS. Additional research into the costs of a broader range of reproductive health and related non-health interventions is needed. Collectively, these could generate a more comprehensive set of cost estimates that would more closely parallel the range of actual interventions that donors support.

There is a disconnect between the narrowly-based cost estimates included in the ICPD Programme of Action and the broad range of activities currently assessed against them. While this is partly a reflection of pressure from donors to show their activities in a favorable light, it is due also to the broad scope of activities outlined in the ICPD document. Thus data on financial flows, as collected by the UNFPA/UNAIDS/NIDI Resource Flows Project, may be drawn from a number of sectors, including education, health, population and HIV/AIDS, government and civil society, employment, and women in development. Notably, aid flows for HIV/AIDS treatment, care and support – in addition to prevention – have been considered part of population assistance totals since 1999.

In light of the above, a figure that incorporates recent estimates of costs for both reproductive health services – including family planning – and the full continuum of care with respect to HIV/AIDS should be seen as a starting point. This would result in a figure of between $35 billion and $45 billion annually over the next few years, keeping in mind that even this figure likely understates both infrastructure and health personnel costs.

This implies a near-term increase in donor spending to between $16 billion and $21 billion annually, while developing countries would spend between $19 billion and $24 billion. This increase in the burden assigned to donors is based upon UNAIDS’ recommendation that donors shoulder two-thirds of AIDS-related costs. The fair share for the United States – the largest and wealthiest donor country – would total between $6 billion and $8 billion annually, of which about 30 percent, or at least $1.8 billion, would go for family planning and reproductive health activities.

As noted earlier, we need more research into aspects of sexual and reproductive health services for which only limited cost data are available, such as safe abortion services. Moreover, any set of cost estimates needs to be seen as evolving over time, a point made by UNAIDS in 2005 and reinforced by the UN Secretary General. “In 1994, 14 million people were said to be living with HIV/AIDS; this number increased 186 per cent to almost 40 million in 2004,” the Secretary General noted in January. “The ICPD financial targets of $1.4 billion in 2005 and $1.5 billion in 2010 (for prevention activities only) are far below these estimated requirements and should be revised to more accurately address current needs and costs, including those for treatment.”

Finally, more accurate cost data are also important if low- and middle-income countries are to develop their own estimates of needed resources, as the cost of a given service differs significantly from one country to another. This is particularly the case for those countries that seek to move beyond providing what might be called “developing country medicine.” As a new World Bank report notes, the world spends about $3.2 trillion on health, but low- and middle-income countries account for only about $350 billion.10 We urge the international community, particularly donor governments and institutions, to invest not only in health services and systems themselves, but in developing the evidence base upon which health decisionmaking rests.

This commentary is based on a longer presentation and paper by Sally Ethelston; J. Joseph Speidel, MD, MPH, University of California, San Francisco; Elizabeth Leahy, PAI; and Deborah Weiss, University of California, San Francisco.

Sally Ethelston, most recently a Vice President with Population Action International, headed PAI's Financing Project for three years and is the lead author of Progress and Promises: Trends in International Assistance for Reproductive Health and Population. She is currently an independent consultant providing expertise in policy analysis, research, communications and advocacy.

Elizabeth Leahy is a research assistant at PAI.