##### **Trends and Issues Affecting Service Delivery**

**Over the Next Decade**

**Prepared for the Service Delivery Improvement Division, Office of
Population and Reproductive Health**

**USAID**

**by**

**John Ross and John Stover**

**The POLICY Project**

TABLE OF CONTENTS

[1. Demographic and Social Trends 1](#demographic-and-social-trends)

[1.1 Demographic Changes 1](#demographic-changes)

[1.2 Social Changes 2](#social-changes)

[1.3 Demographic Impact of AIDS 3](#demographic-impact-of-aids)

[2. Population Programs and Policy Changes
4](#population-programs-and-policy-changes)

[2.1 Total Fertility Rates 4](#total-fertility-rates)

[2.2 Prevalence of Contraceptive Use
5](#prevalence-of-contraceptive-use)

[2.3 Numbers of Contraceptive Users 6](#numbers-of-contraceptive-users)

[2.4 National Policies and Post-ICPD Changes
7](#national-policies-and-post-icpd-changes)

[2.5 Abortion in Relation to Contraceptive Use
9](#abortion-in-relation-to-contraceptive-use)

[2.6 Male Involvement in Programs 10](#male-involvement-in-programs)

[3. Changes in Family Planning Services
10](#changes-in-family-planning-services)

[3.1 Contraceptive Method Mix and New Technologies
10](#contraceptive-method-mix-and-new-technologies)

[3.2 Source of Supply by Sector 11](#source-of-supply-by-sector)

[3.3. Access to Services 13](#access-to-services)

[3.4 Integration of Services and Quality Improvements
14](#integration-of-services-and-quality-improvements)

[3.5 Effects of Health Sector Reforms
15](#effects-of-health-sector-reforms)

[4. Changes in Population Assistance
16](#changes-in-population-assistance)

[4.1 Trends in International Funding
16](#trends-in-international-funding)

[4.2 Infrastructure Changes: Relative Donor Roles
18](#infrastructure-changes-relative-donor-roles)

[4.3 Relations of Donors and Cooperating Agencies
18](#relations-of-donors-and-cooperating-agencies)

[4.4 Effects of HIV/AIDS on Population Assistance
19](#effects-of-hivaids-on-population-assistance)

[5. Changes in Demand and Related Resources Needed
20](#changes-in-demand-and-related-resources-needed)

[5.1 Increasing Demand: Trends in Unmet Need
20](#increasing-demand-trends-in-unmet-need)

[5.2 Increasing Resource Requirements
21](#increasing-resource-requirements)

[5.3 Sustainability of National FP/RH Programs.
23](#sustainability-of-national-fprh-programs.)

[6. Questions of Strategy 23](#questions-of-strategy)

[7. Implications and New Departures
27](#implications-and-new-departures)

[7.1 Urbanization 27](#urbanization)

[7.2 Integration 28](#integration)

[7.3 Growth in Numbers of Users and Limited Funding Increases
28](#growth-in-numbers-of-users-and-limited-funding-increases)

[ANNEX 31](#annex)

###### Trends and Issues Affecting Service Delivery Over the Next Decade

Prepared for the Service Delivery Improvement Division

by the POLICY Project

This document has been written at the request of the Service Delivery
Improvement Division as part of its planning process for the next
decade. It focuses primarily upon features that concern the provision of
services, not upon all aspects of reproductive health programs. The
first five sections present the factual background; the final two
sections build on those to suggest future program strategies and
options.

## 1. Demographic and Social Trends

### 1.1 Demographic Changes

Although the world population growth rate peaked in the last decade, the
number of couples in the developing world needing family planning
services will continue to increase rapidly in the next decade. This
growth is already built into the age structure. In the developing world
outside of China, where there were 100 women in union in 2000, there
will be 111 by 2005 and 121 by 2010. In Africa the increases are
surprisingly large: where there were 100 women in union in 2000, there
will be 115 by 2005 and 133 by 2010.

Stated in terms of numbers, the developing world (ex-China) will add 98
million women of childbearing age from 2000 to 2005, and another 92
million by 2010, or 190 million total. A disproportionate share of this
growth falls in the subcontinent countries of India, Pakistan, and
Bangladesh; they will add 36 million women of childbearing age from 2000
to 2005 and another 34 million by 2010. None of these are contraceptive
users at the outset, and nearly all will be requiring services for their
reproductive health from the public or private sectors.

A second reality is that fertility declines, as impressive as they have
been in some countries, are geographically uneven, and tend to be least
in the least developed countries. Moreover, the U.N. fertility
projections for much of Sub-Saharan Africa that were issued in 1998 were
deemed to be too optimistic and were changed in the 2000 projections to
show higher starting levels in 2000-2005 and slower declines.

Other demographic changes of note are the continuing declines in infant
and child mortality, as well as reduced mortality at higher ages, in
most of the developing world including much of Sub-Saharan Africa. It is
not often realized that the common use of the total fertility rate
(TFR), which measures births only, suggests greater declines than really
occur. The improving survival rates mean that more births now remain in
the population than before, so the real declines are less than the TFRs
suggest. This has clear implications for the numbers of people requiring
services.

### 1.2 Social Changes 

Urbanization. The prevailing movements into the cities are now so marked
that nearly all population growth will occur there over the next 25-30
years. The aggregate rural population size will remain stable.[^1] In
the developing world the urban populations will grow from 1.9 billion in
2000 to about 3.9 billion in 2030, averaging 2.3% growth per year, vs. a
mere 0.1% per year for rural populations. However Africa is an
exception: the whole rural population there will grow from 487 million
to about 640 million by 2030. An interesting feature of urban growth is
that rather little of it is in the largest cities. Only about 6.3% of
people in developing regions live in cities of 5 million or more,
growing to only 8.5% by 2015. Thus urban service burdens are widely
spread, not concentrated in a few places.

Environmental Changes: Environmental changes are complex and
controversial, but it is fair to say that for action agencies the
presumption must be one of deleterious effects of serious magnitudes.
The latest United Nations appraisal[^2] for example documents the growth
in carbon dioxide (CO2) emissions from fossil fuels and cement
production from less than 2000 million tons of carbon in 1950 to over
6000 million tons in 1996. Over half (57%) is in the more developed
regions; 43% is in less developed regions reflecting less
industrialization but larger populations. Other concerns such as water
use, agricultural practices, forest losses, and diminishing biodiversity
have aroused much concern. All are aggravated not just by population
factors but also by a variety of other forces; however slowing
population growth contributes to environmental health. In any case it is
the population factors that must be the chief focus of agencies working
with family planning and reproductive health.

Poverty Trends: Using the World Bank's definition of poverty (living on
less than US one dollar a day), about 1.2 billion people qualify, or
one-fourth of the developing world's population. The number of 1.2
billion is about the same in 1998 as it was in 1987. Poverty is most
pervasive in Sub-Saharan Africa and in South Asia. Actual poverty levels
have fluctuated, as they did during the financial collapses in Asia in
1997. Inequalities among countries have grown over time, since the
growth in per capita income has been much faster in developed than in
developing countries. The picture is one of overall, uneven gains per
capita but with pervasive poverty across much of the developing
world.[^3] The persistence of severe poverty for large numbers of people
makes means that the problem of funding family planning services in the
future is not likely to be solved by wealthier populations who can
afford to pay for these services. It also means that fertility
transitions may be slow to start in countries with the largest
proportions of their populations living in poverty.

### 1.3 Demographic Impact of AIDS

Almost 40 million people are now infected with HIV. About three million
adults and children died from AIDS in 2001. AIDS deaths to adults have
resulted in 14 million AIDS orphans. The AIDS epidemic has hit
particularly hard in Sub-Saharan Africa. In seven Sub-Saharan African
countries over 20 percent of adults 15-49 are infected with HIV. In
Botswana, Lesotho, Swaziland and Zimbabwe prevalence is over 30 percent.
These high levels of infection are leading to increasing death rates and
falling life expectancy. The United Nations Population Division
estimates that life expectancy has fallen from 60 years in the late
1980s to 35 in Botswana, 43 in Zimbabwe and 47 in South Africa. In these
countries a combination of low fertility and a high AIDS death rate is
expected to lead to negative population growth in the next decade. The
US Census Bureau estimates that the population growth is slightly below
zero in Botswana today. By 2010 it projects negative population growth
for five African countries: Botswana, Lesotho, Mozambique, South Africa
and Swaziland and zero growth for Zimbabwe.[^4] In these same countries,
AIDS may account for more than half of all infant deaths. Outside of
these hard-hit countries, population projections continue to show
positive growth, and the overall additional numbers to come are huge, as
documented above. A few countries outside of sub-Saharan Africa have
serious and rapidly growing epidemics but none are expected to reach
such high prevalence levels as to cause the significant demographic
effects seen in Africa. The exact course of HIV/AIDS growth is
necessarily speculative; it has often outrun projections; moreover
certain very large countries with low prevalence, including India, have
more cases than many of the smaller African countries.

In the countries hardest hit by AIDS, the declining population growth
rates will be seen by some as a reason to give less emphasis to family
planning programs. But population growth has never been a major
motivation for African family planning programs. The programs have been
supported to improve birth spacing, enhance maternal and child health
and reduce the cycle of poverty. The expanding problem of AIDS orphans
and the increases in child deaths due to AIDS should in fact lead to
more emphasis on family planning and safe delivery programs. In the
HIV/AIDS environment it is even more urgent that families have only
access to family planning services. This will be particularly true for
youth because of the dual vulnerability to HIV infection when starting
sexual activity and pregnancy at too young an age.

## 2. Population Programs and Policy Changes

### 2.1 Total Fertility Rates

The last 20 years have seen the greatest decline in total fertility
rates in the history of the world. Among the 133 low- and middle-income
countries with populations of more than one million, 84 had a total
fertility rate of five or higher in 1980. Today only 44 do. In 1980 only
16 low- and middle-income countries had a total fertility rate of 3 or
below. Today, 51 countries have a TFR of 3 or lower. In the 1980s
fertility was high everywhere in the developing world. Today high
fertility is concentrated in Africa. In Asia the TFR is above 5 only in
Afghanistan, Laos, Pakistan and Bhutan and in the Middle East only in
Iraq, Oman, Palestine and Yemen.

Among the 133 countries, the 44 with fertility above 5 are matched by 38
others with fertility between 3 and 5 and 38 countries with fertility
between 2 and 3. Another 13 countries are below 2. Twenty years ago
USAID needed to concentrate on helping countries begin the fertility
transition, but today low- and middle-income countries are almost evenly
divided between those that have hardly started, those that are in the
middle of the transition and those that are approaching replacement
level fertility or are below it.

Among 73 countries receiving USAID assistance 12 have fertility between
2 and 3, 28 are between 3 and 5 and 33 have fertility above 5. Thus a
significant number of USAID-assisted countries still have very high
fertility, but an equal number are confronting the issues associated
with rapid program expansion and sustainability (Figure; TFR data from
the United Nations 2000 estimates).
![](media/image1.wmf){width="5.6625in" height="3.13125in"}

Note: The figure on the top of each bar is the total population of the
countries in that category.

### 2.2 Prevalence of Contraceptive Use 

The most arresting feature of contraceptive use is its nearly unbroken
increase over a 35-year period across much of the developing world. It
has risen to ceiling heights in some countries including China, and it
now covers about 60% of all couples in the developing world. In some
countries use is still very low, but once an increase has started from
the low traditional level of 5% to 10% of couples, the upward movement
has rarely been reversed. The ANNEX lists countries according to their
prevalence increases.

The downside of this picture is the continuing large proportion of
couples in some countries that remain unprotected against unwanted
pregnancies, with the substantial proportions that resort to abortions
or report the latest birth as unwanted. The failure to use a method, or
to use a reliable method, reflects program deficiencies as well as
attitudinal problems of fear, religion, and family pressures. Program
deficiencies include the sheer unavailability of modern methods, poor
service quality, and inadequate educational efforts. Behind these stand
policy gaps and weak links between high policy declarations and actual
implementation.

Among the regions Sub-Saharan Africa has the lowest levels of modern
contraceptive use and in some cases the slowest prevalence increases.
Most countries there have lagged in their annual gains for contraceptive
use: less than 1% per year in prevalence in ten of 19 countries with
repeated surveys, and only 1.0% to 1.5% in seven others. In addition
prevalence is almost certainly very low in such large countries without
repeated surveys as Ethiopia and D.R. Congo.

**2.2.1 Plateaus in Prevalence Increases or in TFR Declines**

The question of "plateaus" or "stalling" is complex. We consider
fertility and contraceptive prevalence separately, and use both survey
findings and the United Nations estimates for past TFR declines. In
general we do not find many clear cases of plateaus in the data, but a
few do exist. In addition local observations by staff working in
particular countries have pointed to plateaus and, program managers have
been much concerned about them. It is quite possible that augmented
actions were then taken that in fact rejuvenated the former trends. If
so that helps explain the rather small number of obvious plateaus in the
data.

For fertility the "plateau" question is quite separate from the rough
tendency of fertility rates to soften their decline as they approach
replacement, as documented in a recent paper by Bongaarts.[^5] The
concern here is related to action programs in developing countries that
show a puzzling hesitation in their fertility decline or in their
prevalence increase during the earlier stages of demographic change.

Trends in TFR, through 2000, as estimated by the United Nations
Population Division show a few plateaus: Paraguay (1975-80 to 1980-85),
Bahamas (1975-80 to 1980-85) and Malaysia (1975-80 to 1980-85). However,
TFR declines resumed after all of these pauses. It should be noted that
not all countries continued declining all the way to replacement level.
The TFR declines have stopped or slowed considerably at 2.5 to 3
children in Chile, Colombia, Guyana and Costa Rica in the last 10 to 15
years. Thus the experience of most countries with relatively low
fertility today has been that once fertility started to fall from
traditional levels it continued the downward trend.

However, for contraceptive use some developing countries have
experienced periods when prevalence remained constant between two
surveys. There has been justifiable concern that these periods of
stagnation might represent natural plateaus that require a change in
program emphasis to restore the trend. The survey evidence is that in
some countries progress paused briefly for a period of five years or so
but then continued the previous trend. Countries that have experienced
short-term plateaus before resuming prevalence increases include Egypt
(1981-84 at 30%, 1992-95 at 47%), India (1988-1992 at below 45%), El
Salvador (1985-88 at 47%), Guatemala (1983-1987 at 24%) and Jamaica
(1993-1997 at 65%). Although these represent a relatively small number
of cases in the context of the general tendency for contraceptive
increases to continue upward they cannot be ignored and may well have
inspired strong program responses that restored the earlier trends.

### 2.3 Numbers of Contraceptive Users

Growth in the absolute number of contraceptive users reflects results
from growth in the percentage of couples using a method, compounded with
growth in the number of couples. Both have been sharply upward since the
mid-1960s, and a brief calculation suggests the implications for
services, for contraceptive commodities, and for related personnel
(principally in the public sector). From 1965 to 2000, a period of 35
years, the number of women in union in the developing world (including
China) more than doubled, from 342 million to 813 million. There was
also a rise in the percentage using a contraceptive method, from about
10% to about 60% now. Putting these two changes together yields the
historic increase from only 34 million users to about 488 million. That
gain reflects a revolution in reproductive behavior, and in the service
institutions that have emerged to support it.[^6]

Future increases will be exceptionally large. Leaving China aside, an
additional 5 percent in prevalence, from 53% (ex-China) to 58%,
occurring over the 5 years from 2000 to 2005, combined with population
growth, will add 66 million more users, most of them for modern methods
requiring supplies and services in either the public or private sectors.
That is equal to the total of all users in all of Latin America in 2000.
During the next five years, to 2010, another 71 million users will be
added, with the corresponding supply burdens.

![](media/image2.png){width="3.1458333333333335in" height="2.75in"}

In a 15-year perspective changing family size desires are surprisingly
important. Even if contraceptive prevalence stayed constant between 2000
and 2015, developing countries would still face 125 million additional
users. But changing family size desires are projected to add another 92
million new users, totaling 217 million additional users expected
(Figure).[^7] One influence in this is that as couples have fewer
children they stop childbearing earlier than before and require
contraceptive protection for more ensuing years, which elevates the
numbers of users.

*Discontinuation rates*: note that the 217 million additional users
represent a *net* increase. Far more persons will have been in and out
of the using group during the 15 year period, many of them using a
method for a very short period and being unhappy with the experience.
Discontinuation rates are unfortunately high for every resupply method,
and the "churning" process, in which persons start and stop use, is very
wasteful for service facilities and for the persons involved. The search
for a satisfactory method is often frustrated by inadequate counseling
and service quality, in addition to poor access to a variety of method
choices. In many countries the constraint upon the rise in prevalence is
not so much the lack of public interest as it is the difficulties in
finding a good method and continuing with it, and it rests with the
action programs to address these shortcomings.

### 2.4 National Policies and Post-ICPD Changes

National government views and policies on population programs have
evolved over the last twenty years in response to changing demographic,
social and economic conditions. The United Nations survey of national
population policies[^8] indicates that the percentage of countries
stating that their population growth rate was too high increased from 33
in 1976 to 42 by 1996. A similar trend exists for views on the level of
fertility. The percentage of countries reporting that fertility was too
high increased from 37 in 1976 to 47 in 1996, in spite of the global
decline in fertility that took place during this period. Among the 33
USAID-assisted countries with fertility above five all but six (Benin,
Chad, DR Congo, Laos, Mauritania and Togo) reported to the United
Nations in 1996 that their fertility rate was too high.

Government policies on providing family planning services have also
undergone significant changes. In 1976 63 percent of countries reported
that they provided direct support to family planning services. By 1996
that percentage had climbed to 79 percent.

The major themes of the international population conferences held every
ten years illustrate this trend toward greater acceptance of family
planning. A major theme of the 1974 conference in Bucharest was a debate
about whether family planning or development was the best way to reduce
population growth rates. By the time of the 1984 conference in Mexico
City most developing nations recognized the need for effective family
planning programs. The International Conference on Population and
Development (ICPD) in Cairo in 1994 stressed universal access to family
planning and emphasized the reduction of unmet need, within a broadened
context of reproductive health. Studies of national policy changes since
ICPD[^9] indicate that countries have made significant progress in
adopting a reproductive health focus. In particular policies have been
revised to reflect the new focus, and civil society participation in
policy discussions has increased. However the actual implementation of
new reproductive health programs has lagged the policy reforms, and
issues of priorities among multiple programs still require attention,
including budgetary solutions.

Thus on the surface, the battles have been largely won to establish
favorable policy positions toward family planning and reproductive
health. That is, most countries, covering by far most of the developing
world's population, have official positions that support provision of
family planning services and public information. However just below the
surface serious gaps and deficiencies remain, in the more detailed
policy positions toward specific barriers to contraceptive use, toward
reliable contraceptive commodity supply, and toward important program
components such as CBD, CSM, and postpartum and postabortion provision.

These more detailed features are termed "operational policies".[^10]
They speak to the ubiquitous presence of barriers that impair true
access to contraceptive use. They are of several types: personal (e.g.
limits on who can receive contraception (e.g. unmarried teenagers);
medical (e.g. restrictions on which personnel can distribute certain
contraceptives); supply (e.g. stocking rules that cause frequent
stockouts); training (e.g. poor training that limits personnel capacity
to give good service); and systemic (e.g. weak referral systems). These
are only examples; the point is that below the level of high policy
there is a network of rules and procedures that requires policy
attention and firm implementation of changes.

### 2.5 Abortion in Relation to Contraceptive Use

Historically, the principal weapon for driving out abortion has been
contraceptive availability and use. Since the demise of the USSR the
high rates of abortion in its former Republics have been under study, as
modern contraceptives have begun to take hold. These natural experiments
give telling evidence of women's preference for reliable contraception
over repeated abortions. For example in Kazakhstan, DHS surveys have
documented a rise of 50% in contraceptive use since 1990, accompanied by
a fall in abortion of the same amount. This has even occurred during a
period when the desired family size was decreasing. The abortion decline
has been especially marked in the capital city of Almaty and among the
Russian ethnic minority. Abortion tends more now to be relegated to use
for contraceptive failures, which highlights the need to provide
reliable contraceptive methods and careful instruction in their use. All
these points carry clear implications for programmatic application
elsewhere.[^11]

Abortion rates and ratios remain very high in much of the developing
world, testifying to the frustrations of millions of women in their
efforts to avoid pregnancy. The regional picture is estimated as
follows:[^12]

  ---------------------------- ----------------- ------------ -------------
                               Annual Abortion   Abortion     No. of
                               Rate Per 1,000    Ratio Per    Abortions
                               Females Aged      100 Births   (millions),
                               15-49.                         1999

                                                              

  Asia                         26                26           24.2

  Latin America                40                45           4.2

  Middle East/North Africa     16                13           1.7

  Sub-Saharan Africa           20                11           4.4

  Central Asia Republics       54                55           0.4

  Caucasus                     24                46           0.3

  Moldova, Russia, Ukraine     49                119          4.2
  ---------------------------- ----------------- ------------ -------------

To make inroads into these figures the key lies with better
contraceptive provision. Past investments of resources have been
instrumental in that, and future investments will both reduce the
numbers of unsafe abortions and the maternal deaths associated with
them.

### 2.6 Male Involvement in Programs 

Gender issues came to the fore prominently in the Cairo meeting in 1994,
which gave such stress to women's reproductive heath needs. The
associated male responsibilities were detailed in the Programme of
Action in five paragraphs under "Gender Equality, Equity, and
Empowerment of Women." The document also specifically included the
objective "...To increase the participation and sharing of
responsibility of men in the actual practice of family planning..."
Gender issues were therefore incorporated on both sides: closer
attention to the reproductive health needs of women, and insistence upon
the contributions of men to help address those needs.

Gender issues are multiple and are often termed "cross-cutting," to
indicate that no single program endeavor will suffice. It must be
approached as a concern in a broad variety of program activities.
However the Cairo call for greater involvement of men is a valid and
important one, both for the attitudes they express toward their spouses
and for their own behavior. Of all contraceptive use in the developing
world, males are involved in one-fifth (19.5% of users), for vasectomy,
condoms, rhythm, or withdrawal. [^13] This varies little by region, but
it varies considerably by country, and that has programmatic
implications. The drive for greater condom use may increase the male
proportion above one-fifth, although the tendency over time to shift
away from traditional methods such as rhythm and withdrawal may act in
the other direction. Survey findings for Sub-Saharan Africa on male
contraceptive use and fertility preferences show both the generally low
use of contraceptives by males (and their wives) there and the
considerable variation across countries. Male involvement is greater in
other regions but requires improvement there as well. [^14]

## 3. Changes in Family Planning Services

### 3.1 Contraceptive Method Mix and New Technologies

Programmatically the need is to provide a balance of method offerings,
with easy access to each one, and with stimulation of the private sector
to add channels for access. That balance is not fully achieved in most
countries, and it should be given high priority in donor strategies.
Contraceptive use in many countries is dominated by one or two methods.
Extremes for one method are illustrated by India and Nepal
(sterilization), Vietnam (IUD), and Zimbabwe (pill). Two-method programs
include China and Cuba (sterilization and IUD), Indonesia (pill and
injectable), and Egypt (IUD and pill), and even there one of the two
methods is clearly more important. While it is true that high prevalence
levels have been attained in some countries with only two methods
dominating, some couples remain dissatisfied or unserviced and
experience unwanted pregnancies, abortions, and births.[^15] Restricted
method availability remains one of the greatest shortfalls of current
programs.

In the international picture sterilization and the pill protect more
couples than any other methods, but they differ sharply in their annual
adoption rates. Sterilization use has built up only gradually over the
years, with rather few adopters each year but with nearly all staying in
the using pool until they age out. Pill use however depends very heavily
upon each year's new starts, since its continuation is so brief (half or
more of those adopting stop or interrupt use within a year). Its
prevalence is high because of many adopters each year who compensate for
the many who quit. Thus supply burdens and costs are high for it, as
they are for the other short-term methods, and most commodity costs fall
upon the donors. Programs that offer ready access to long-term methods
reduce these repetitive costs.

Changes in method mix do not in general occur quickly, though there are
exceptions. Recent examples involve the injectable, which has gained
popularity in Indonesia, Myanmar, Jamaica, and South Africa.

New Technology: Emergency contraception has emerged in recent years and
may well spread widely. That has implications for service providers in
both public and private facilities who see women for all reasons
associated with pregnancy. Apart from that, two observations for the
usual contraceptive technology appear sound regarding the unlikelihood
of a significant change: "A new contraceptive method requires many years
to gain general acceptance, because the contraceptive market moves
slowly and is conservative...." and "No new product currently in
development will radically alter the prevailing pattern \[of method
mix\]."[^16] Those assessments point to only small changes if any in the
foreseeable future, again, apart from emergency contraception. In sum,
most changes in actual method mix depend more upon programmatic factors
and commercial activities than upon any new technologies in sight.

### 3.2 Source of Supply by Sector

If one counts by total populations served, the lion's share of all
contraceptive users in the developing world has been served by the
public sector. This reflects the inclusion of the giants of China,
India, Indonesia, etc. as well as the dominance of public supply in many
smaller countries. If one counts by countries, most also show more
public than private supply. It seems unlikely that this can continue
without some modification, given the very large increases to come in
total numbers of users and the reluctance of international donors to
commit to steady, large increases of funding.

According to data from DHS and other surveys government programs now
provide about two-thirds of all family planning services in the
developing world, excluding China. The surveys do not distinguish source
of supply well so some NGO service provision may be included in this
figure as well. The private sector (including pharmacies and other
providers) supplies most of the remaining services. There are important
regional differences as the Figure below shows.

Unlike method mix, there has been no overriding pattern for source mix
to change as programs have matured, but clinical methods are typically
provided more in the public sector and resupply methods more in the
private sector. Once fixed these patterns may persist for some years;
many countries in Asia have had a heavy reliance on government services
with little change over the past 20 years.[^17] However countries in
Latin America have tended to rely more on the private sector including
NGOs. In numerous Sub-Saharan countries prevalence is still very low and
past experience may not apply; source mixes may follow various patterns
depending upon both program and commercial initiatives that differ from
those observed in Asia or Latin America.

The proportion of services provided by the government is greatest in
those countries with the strongest program effort scores, indicating
that a strong government program can sometimes reduce opportunities for
the private sector. Few countries have relied entirely upon the private
sector or have vigorously promoted it as an integral part of the
program, and this, together with free or low-cost government services
may have slowed growth in the private sector.

However there are interesting exceptions. Indonesia mounted a determined
campaign to shift contraception to the private sector and succeeded in
moving over half of condom, pill, and injectable use to pharmacies and
shops and private medical sources. In Latin America Brazil has been a
case of minimal government involvement (although many female
sterilizations were done by doctors in government facilities); and in
some other countries the government has had a minor share due largely to
the exceptional role of a leading NGO agency (Colombia, Dominican
Republic, Guatemala; also most supply is non-governmental in Bolivia and
Paraguay). In the Middle East, Egypt and Jordan illustrate government
shares below half of the total. Otherwise most examples come from
Sub-Saharan Africa where total prevalence is low and strong national
programs have not yet emerged. These include Benin, Cameroon, Cote
d'Ivoire, Ghana, Nigeria, and Uganda, as well as others where the
government share of contraceptive provision is about half.

But is there a trend toward greater involvement of the private sector,
either for commercial sales or for activities by private medical
personnel and facilities? Is the private share increasing significantly?
It clearly is in some countries for the condom, and in some for the
pill. Time trend charts for each method and each sector show such
changes.[^18] No overriding trends have yet emerged in national surveys
though this may be due in part to definitional problems. Where private
agencies are subsidized by donors or governments the sources mentioned
by respondents may be difficult to code in such categories as NGO,
private medical, and government. In any case it is vital to encourage
the private sector in all its forms, whether pharmacies and shops,
private medical personnel and facilities, or NGOs.

![](media/image3.wmf){width="5.7868055555555555in"
height="3.9569444444444444in"}

Source: DHS and other national family planning surveys as compiled in
John Ross, John Stover and Amy Willard, *Profiles for Family Planning
and Reproductive Health Programs: 116 Countries*. Glastonbury, CT: The
Futures Group International, 1999.

### 3.3. Access to Services 

The literal unavailability of modern contraceptives is still a major
obstacle to their use in many countries. Estimates by expert observers
in some 90 developing countries show the condom and pill to be the most
easily available (though still at unsatisfactory levels), the IUD less
available, and sterilization to be least available, especially
vasectomy.[^19] Leading examples of poor access include such countries
as Nigeria, Ethiopia, both Congos, Sudan, Pakistan, Myanmar, Syria, and
Saudi Arabia. Average access for five contraceptive methods is poorest
in Francophone Africa, with only 29% for the populations concerned
having reasonable access. In Anglophone Africa the rating is 47%. It is
61% to 65% in North Africa/Middle East and Latin America, and a higher
86% in East Asia.

Poor access to methods has several dimensions, but from the woman's or
couple's standpoint it is simple. They lack access to the following: a
variety of methods, close to home, at low cost, in a congenial setting,
with few barriers to eligibility. It does not do to offer only one or
two methods, far away, with high travel costs, in uncomfortable
settings, and with numerous clearance rules that discourage adoption.
Access is more than sheer physical access to several methods. True
access for many women is constrained by provider attitudes, travel
restrictions due simply to being female, blocked access due to youth,
and inability to pay. Some constraints apply just to one method, for
example sterilization may denied to women below parity 4 or age 35.

The end result is that ready access to a choice of contraceptive methods
is not common, and that corrective measures must be taken across many
fronts.

### 3.4 Integration of Services and Quality Improvements

The integration of services for family planning and HIV/AIDS has been a
special concern since AIDS emerged in large numbers. Some aspects of
integration have worked reasonably well, such as policy positions, and
commodities and logistics. Others, such as STI services in family
planning clinics, appear more problematic.[^20]

Given the scale of the HIV/AIDS problem in many USAID-assisted
countries, this issue will be one of continuing concern. Recent work in
this area has led to a new USAID report;[^21] its guidance suggests that
effective integration can be achieved in a number of areas, including
mass media, social marketing, community-based distribution, policy,
youth-oriented programs and activities targeted to men. A particular
opportunity concerns MTCT (mother to child transmission) where the
antenatal visit offers a linkage between interventions for HIV and for
post-delivery family planning. The HIV/AIDS epidemic also increases the
need for good family planning counseling and services during the
postpartum period and for breastfeeding counseling and support for
HIV-positive mothers.

Other medical services have long been candidates for partial integration
with family planning, and some countries have made strides in pursuing
these. Interested women receive ante-natal care, tetanus immunizations,
and delivery care, along with infant and child care. Surprising
proportions of women in most developing countries are seen in one or
another of these institutionalized settings; the averages for all
developing countries are 65% for antenatal visits, 51% for tetanus
immunizations, and 51% for delivery. Regional figures range from only a
third of women seen (average for deliveries in Sub-Saharan Africa) to
93% (average for deliveries in the Central Asia Republics.)[^22]

### 3.5 Effects of Health Sector Reforms 

Many USAID-assisted countries are implementing a process of health
reform intended to improve health system performance and health
outcomes. These reforms encompass a range of activities including
resource utilization, decentralization, alternate financing sources and
a focus on primary care and poverty reduction. Financing changes may
include the introduction of user fees in order to ensure sustainable
financing or the removal of user fees for preventive services where
these fees have been barriers to utilization. Resource allocation
changes include greater decentralization of allocation decisions and a
greater focus on allocation according to disease burden.

Health reform can affect family planning in a number of ways.[^23]
Increased decision making at the local level means that many more
decision makers need to understand the importance of family planning.
This may create problems for beginning and sustaining family planning
efforts in high fertility areas where demand may still be weak but it
may be a benefit in lower fertility settings where demand for family
planning services is high. Family planning programs can certainly
benefit from improvements in health financing. However, basket funding
or schemes to have the allocation of funding reflect disease burden may
not be favorable to family planning since it tends to be rather better
funded than many other health services without such strong donor
support.

The effects of health sector reform on family planning will be very
country-specific. Generally family planning service delivery is likely
to be less autonomous and more integrated in the general resource
allocation and mobilization systems of the health sector. This can be
good for long-term sustainability but may pose short-term challenges as
programs adapt to the new systems.

##  4. Changes in Population Assistance

### 4.1 Trends in International Funding

All development assistance by the Industrialized Countries has fallen in
real terms, and that has been true as well for family planning and
reproductive health programs. The Netherlands Interdisciplinary
Demographic Institute (NIDI), using data through 2000, estimated total
ODA (Official Development Assistance) of donor countries at about \$US
60 billion, of which less than 3% was allocated to population
assistance.[^24] Total ODA was roughly constant from 1992 through 2000,
whereas the percentage for population, which had been rising from about
1.3% in the early 1990s to a high of over 3% in 1997, had been below 3%
through 2000.

Of all expenditures (per capita) devoted to population topics, from both
national and international sources, about 52% in 1999 went to family
planning, 23% to other reproductive health, 16% to STD/HIV/AIDS, and 8%
to basic research and policy analysis. The U.S. has been the main player
in international population assistance, accounting for 43% of the total
in 2000 according to NIDI. This was far above that of the Netherlands
(11%), the United Kingdom (11%), Japan (9%), Germany (6%), Sweden (5%),
and 8 other countries (including the European Union) at below 5% each.
However the picture is quite different on a per capita basis; there the
U.S. share falls sharply and that of the other donors increases
substantially.

At the Cairo ICPD it was estimated that the cost of providing basic RH
care reached \$US 17 billion by the year 2000 and would be nearly 22
billion in the year 2015. The nations agreed that donor countries would
provide one third of these funds and developing countries the remaining
two thirds. However these promises have not materialized. In particular,
funding for contraceptive commodities has declined, causing grave
concern by USAID and a group of cooperating agencies.

One response to this was the Istanbul conference of April 2001, on
"Meeting the Challenge: Securing Contraceptive Supplies," which was
meant to call the world's attention to an incipient crisis in
contraceptive security.[^25] As prevalence of use has risen, compounded
with growing populations, the numbers of users needing contraceptives
has grown rapidly. Public programs continue to bear the largest supply
burdens. They in turn depend very heavily upon donors since local
production of contraceptives is generally minor, and foreign exchange
for purchases is quite scarce. Yet donors are hardly meeting current
requirements, and they do not show convincing commitments to meet the
rising supply needs. The UNFPA estimates that the amount required for
contraceptives alone is US\$572 million in 2000.

The overall pattern of donor contributions has been uneven and somewhat
unpredictable from year to year. The total amount declined from US\$172
million in 1996 to only \$131 million in ![](media/image4.wmf)1999. It
recovered somewhat in 2000 but not nearly to the 1996 level.

Agencies have shifted over the years in their relative contributions to
commodity supplies, and will no doubt continue to do so. However USAID
has held the lead, followed by the UNFPA, both with some fluctuations in
recent years (Figure). In 1999 the UNFPA for example suffered budget
cuts and had to reduce its commodity support by two-thirds, until
European donors filled part of the gap on an emergency basis. The other
agencies have contributed much less (except for KfW in 1996) but have
been important in the aggregate, and in particular countries.

# 

**Patterns in Contraceptive Supply, 1990-2000, in \$US 000**

![](media/image5.wmf)

Source: UNFPA Donor Support for Contraceptives and Logistics, 2000.

The prospects for donor improvements are unclear; most agency staffs
cannot promise firm budgetary allocations beyond the current fiscal
year. That is the realistic context within which planning must go on.
Within this unsatisfactory picture the options commonly listed include
persistent efforts to increase donor awareness and funding, stimulation
of the private sector in all its various forms, and modifications of the
method mix toward long-term methods, which would reduce resupply costs.

One hopeful sign is the new efforts to reduce the indebtedness of the
poorest countries. The HIPC (Heavily Indebted Poor Countries) Initiative
provides a means for countries that qualify to have debt forgiven in
return for spending the funds that would have been used to service debts
on social development programs. This raises the possibility that some of
these funds could be used for family planning. Most will be used for
development programs, such as education, health and job creation, that
can create a more favorable environment for family planning.

### 4.2 Infrastructure Changes: Relative Donor Roles

### 4.3 Relations of Donors and Cooperating Agencies

**4.3.1 Changing Role of USAID Missions.**

The multiplicity of CAs, with their various kinds of expertise, gives
USAID a rich set of resources to draw upon. CAs are well established in
many countries and are known to the Missions and Regional offices. The
rules for competition for government contracts help to keep costs down,
and the CTO supervisory arrangements provide for close communications,
especially with many CA offices in the Washington area. While
adjustments in the relationships are needed from time to time it is
unlikely that these major features will change appreciably, given the
government context and the large magnitude of operations involved.

A significant change in recent years has been the shift of some central
funding to field support. That has enlarged the compass of the Mission
priorities and has made for greater variation in what CAs do, since
Missions differ considerably in their objectives and in their
willingness to fund centrally conceived programs. For CAs, this has
caused greater heterogeneity in what they do. That has been reinforced
by another change, one that requires cost sharing in some contracts
(whereby a CA is required to find a percentage of the contract from
non-US government sources, such as foundations). This gives good value
for the government since in effect it requires the CAs to find matching
funds; a side effect is again a tendency toward program heterogeneity
since the matching donors have their own preferences and priorities. A
less important requirement in total dollar terms is the requirement that
part of each contract's expenditures go to minority owned firms.

Some Missions have been closed in recent years for cost reasons (e.g.
several Missions in Francophone West Africa). That moves the
relationship with the CAs to the regional offices, where funding may be
less. Those closures are in addition to the longer-term policy of
graduating countries that have attained high contraceptive prevalence,
such as Thailand, Colombia, and Mexico.

Finally, the advent of the AIDS crisis has modified the priorities of
many donors and many CAs. New personnel with different backgrounds have
entered the field, a trend that started earlier with the post-Cairo
stress on reproductive health and upon gender considerations. The field
remains dynamic, and the context for services will undoubtedly evolve
further over the next 5 to 10 years. The principal currents of change
from the HIV/AIDs crisis have yet to work themselves through, but so far
they have shifted managerial attention away from family planning in much
of east and southern Africa and elsewhere. That is reinforced by the
change of emphasis due to Cairo, and it interacts with a certain sense
of fatigue with the old family planning programs. The puzzle for donors
is how to reconcile all this with the continuing demographic crisis and
how to reduce the very large numbers of unwanted pregnancies, abortions,
and births, with what they entail for the women and men involved. Much
of the actions that address those needs force attention back to
contraceptive use.

### 4.4 Effects of HIV/AIDS on Population Assistance

While USAID funding for family planning programs has remained roughly
constant in current dollars over the past decade funding for HIV/AIDS
programs has increased dramatically and will be almost 50 percent higher
than family planning funding in 2003. It is hard to know whether the
increased funding for HIV/AIDS has had any effect on the total funding
levels for family planning. It appears that the increased HIV/AIDS
funding has expanded the total pool of development assistance and has
not come at the direct expense of family planning. A pessimistic view
would be that it limits the potential for future increases in family
planning funding since so much money is going to HIV/AIDS. An optimistic
view would be that HIV/AIDS advocacy efforts are leading the way to
increased funding for development programs in general and population may
benefit from this in the future. Further, it is better to look for the
synergistic potential in the new funding environment than to focus just
on any threat to family planning funding.

The increase in HIV/AIDS programs has changed the way people think and
talk about sex and gender issues, and it has provided much new
information about sexual behavior that should benefit family planning
services. However, in countries with the worst HIV epidemics, the large
increase in funding for HIV/AIDS has also attracted many of the best
people away from the family planning field into HIV/AIDS. This may
create short-term problems for staffing but may also create longer-term
opportunities for programs that reinforce each other.

USAID Funding for population and HIV/AIDS

![](media/image6.wmf){width="5.15625in" height="3.4763888888888888in"}

## 5. Changes in Demand and Related Resources Needed

### 5.1 Increasing Demand: Trends in Unmet Need

A sea change has occurred in reproductive behavior over the last few
decades, with a historic decline in the desired number of children and
in the use of contraception and abortion to attain the reduced numbers.
The demand for children has fallen, while the demand for contraception
has grown and required a constant increase in program resources. Both
"demands" fall across a range; for some couples they are intense and for
others they are weak, or latent. One function of programs is to assist
the subgroup that wants help, thereby changing the environment of
behavior for the more ambivalent ones. A key principle is that servicing
the current market enlarges that market.

One measure of the market is afforded by unmet need. By the latest
estimates about one in six (17%) of married/in union women in the
developing world (ex-China) have an unmet need for contraceptive use.
They are exposed to pregnancy, do not want it, and lack protection. The
percentage is higher among sexually active unmarried women. The absolute
numbers in need come to about 114 million in the developing world
including unmarried women, but about 123 million including the former
USSR republics.[^26]

Because of rising contraceptive use the percentage of women in need has
been declining in numerous countries.[^27] However increases in
population size have outweighed those declines so that the absolute
numbers have increased. A related trend is the declines in desired
family size that have raised the numbers not wanting another child. The
result is that very large subgroups of women, and couples, in the
developing world lack the contraceptive use that would protect them from
the pregnancies that they do not want. This attests to the continuing
gap between need and program response, as well as to the continuing
justification for donor support of the programs.

Some have questioned the validity of the unmet need measure, hence
attention has gone also to the alternative measure of "intention to use"
a method. Many women who say they want a child within two years (and so
are classified automatically in surveys as not being in need of
contraception), say that they still intend to use a method within the
coming year. These spacing intentions apply to very large numbers of
women; overall they about equal the numbers of unmet need women who say
they do not intend to use.

### 5.2 Increasing Resource Requirements 

A concrete way to grasp the coming increases in resources needed is to
consider the growing requirements for commodities. Projections for 116
developing countries for each method are summarized in the following
table. It is the resupply methods of the pill, injectable, and condom
that are of greatest concern. (The sterilization and IUD figures are for
numbers of new adopters, for whom the commodities are less numerous, and
the numbers of vaginal applications are relatively few.)

In each cell of the table the number pertains to a single year; for
example 596 million pill cycles were needed in calendar year 2000. Thus
for the pill there is a 31% rise in the number of cycles needed between
2000 and 2005 (782 million cycles in 2005). That is an impressive
increase, but equally impressive is the cumulative number needed during
the full five years, i.e. 3,443 million cycles (not shown).

The cumulative numbers for the entire 15 year period appear in the
bottom panel of the table. These are large indeed: 14 billion pill
cycles, 1.6 billion injectable doses, and 105 billion condoms (including
those for HIV). The unit costs will tend to rise each year with
inflation, and the pressures on donors will increase. Stimulation of the
private sector will become progressively more urgent. It is possible
that supply shortages will constrain contraceptive use in some places
and will impair the distribution of condoms for HIV.

![](media/image7.wmf){width="5.992361111111111in"
height="5.368055555555555in"}

Finally, this overview of the yearly percentage increases can be derived
from the table:

  --------------- ----------------- ----------------- --------------------
  Annual Percent                                      
  Increases in                                        
  Resupply                                            
  Methods                                             

                                                      

                  Pill              Injectable        Condom

                                                      

  2000-2005       5.44              3.30              9.90

  2005-2010       4.49              2.40              6.70

  2010-2015       4.01              2.07              5.10
  --------------- ----------------- ----------------- --------------------

These increases, compounded over the years, together with the huge
absolute numbers involved, pose serious problems for donor priorities,
as commodity supplies must compete with other budget items. A five
percent increase in pill supplies is not easily absorbed when it starts
from a large base and adds 37 million cycles a year.

### 5.3 Sustainability of National FP/RH Programs.

Two comments are in order concerning the sustainability of these
programs: one for the past and one for the future. Past experience shows
that very few national FP programs have been cancelled, once begun. Some
have changed form, undergone changing donor and domestic support, and
experienced policy modifications, but the essential presence of the
national effort has nearly always persisted. Meanwhile, contraceptive
prevalence has followed an upward trend that in historic perspective has
been quite remarkable. So the past testifies to a basic sustainability
in program operations.

For the future, programs are likely to have equal survival instincts,
given their bureaucratic roots and the obvious needs that they serve.
The real questions concern their strength of effort and funding
prospects, not their existence. But much hinges on those, since the
numbers of unwanted births, unsafe abortions, maternal deaths, and AIDS
cases will be either more, or less, depending upon strength of effort.

For family planning programs, the series of effort measures from 1982
through 1999 show continuing improvements, with the weakest programs
improving the most. Even the five-year period after Cairo, from the 1994
study to the 1999 one, also showed an improvement for family planning,
notwithstanding the tendency of Cairo to direct attention toward more
diffuse goals. For maternal health programs, basic sustainability seems
very likely since they are so imbedded in Ministries of Health. And
HIV/AIDS programs are clearly sustainable in the foreseeable future.

But sustainability is relative, and donor contributions for population
programs have not kept up with inflation and are in jeopardy for
contraceptive supplies. Severe pressures are in prospect as the numbers
of users expand. The glass, besides being only half full, may well lose
some water unless innovative steps are taken and the sense of urgency
sharpens.

## 6. Questions of Strategy

Strategic considerations for future family planning service assistance
may focus around two main questions:

1.  How can efforts be prioritized geographically to maximize program
    impact?

2.  Given the current set of countries that receive USAID-assistance how
    can it be segmented to improve program effectiveness?

USAID's population and reproductive health program has three major
objectives:

1.  Increase the use by women and men of voluntary practices that
    contribute to reduced fertility

2.  Reduce unintended pregnancies and promote maternal and child health

3.  Stabilize world population growth

***The first objective* *(reduce fertility)*** can best be achieved by
allocating resources to those countries that have the greatest potential
for rapid increases in contraceptive use and declines in fertility. In
general, these will be the countries that are about to begin the
fertility transition or have already begun the transition. Countries
closer to the end of the transition will already have low fertility and
will be more occupied with improving the quality of family planning
services and sustaining programs than expanding contraceptive
prevalence. Countries that have not yet started the transition may be
settings where progress in the near term will be difficult. The table
below shows how the 73 USAID-assisted countries might be divided into
those that have not yet started the fertility transition, those that are
in the transition and those where it is well along. There are 18
countries that have not started the transition, 24 that are in the early
stages, 19 that have are in the middle, and 12 that are nearing the end.
Maximum achievements in increasing contraceptive use and decreasing
fertility will be achieved by focusing resources on those countries in
the fertility transition now.

**USAID-Assisted Countries by Stage of Fertility Transition**

+--------------+---------------+---------------+----------+----------+
| STAGE IN THE |               |               |          |          |
| FERTILITY    |               |               |          |          |
| TRANSITION   |               |               |          |          |
+--------------+---------------+---------------+----------+----------+
| Not yet      | Early stages  | Middle        | Nearing  |          |
| started      |               |               | end      |          |
+--------------+---------------+---------------+----------+----------+
| TFR 6.0 Plus | TFR 4.50 -    | TFR 3.00 -    | TFR      |          |
|              | 5.99          | 4.49          | Below    |          |
|              |               |               | 3.0      |          |
+--------------+---------------+---------------+----------+----------+
|              |               |               |          |          |
+--------------+---------------+---------------+----------+----------+
| **A          | Benin         | *             | D        |          |
| fghanistan** |               | *Bangladesh** | ominican |          |
|              |               |               | Rep.     |          |
+--------------+---------------+---------------+----------+----------+
| Angola       | **Cambodia**  | Belize        | Ecuador  |          |
+--------------+---------------+---------------+----------+----------+
| Burkina Faso | Cameroon      | Bolivia       | Guyana   |          |
+--------------+---------------+---------------+----------+----------+
| Burundi      | Côte          | Botswana      | **Ind    |          |
|              | d\'Ivoire     |               | onesia** |          |
+--------------+---------------+---------------+----------+----------+
| Chad         | Eritrea       | East Timor    | Jamaica  |          |
+--------------+---------------+---------------+----------+----------+
| **Congo**    | Gambia        | **Egypt**     | Ky       |          |
|              |               |               | rgyzstan |          |
+--------------+---------------+---------------+----------+----------+
| D.R. Congo   | Guatemala     | El Salvador   | Mexico   |          |
+--------------+---------------+---------------+----------+----------+
| **Ethiopia** | Guinea-Bissau | **Ghana**     | Panama   |          |
+--------------+---------------+---------------+----------+----------+
| Guinea       | Jordan        | Haiti         | ######   |          |
|              |               |               | #  Peru  |          |
+--------------+---------------+---------------+----------+----------+
| Liberia      | Laos          | Honduras      | South    |          |
|              |               |               | Africa   |          |
+--------------+---------------+---------------+----------+----------+
| **Malawi**   | Lesotho       | **India**     | Uz       |          |
|              |               |               | bekistan |          |
+--------------+---------------+---------------+----------+----------+
| **Mali**     | *             | **Kenya**     | Viet Nam |          |
|              | *Madagascar** |               |          |          |
+--------------+---------------+---------------+----------+----------+
| Mauritania   | Namibia       | Morocco       |          |          |
+--------------+---------------+---------------+----------+----------+
| **           | **Nepal**     | Myanmar       |          |          |
| Mozambique** |               |               |          |          |
+--------------+---------------+---------------+----------+----------+
| Niger        | ####          | Nicaragua     |          |          |
|              | ###  Nigeria  |               |          |          |
+--------------+---------------+---------------+----------+----------+
| Sierra Leone | **Pakistan**  | Paraguay      |          |          |
+--------------+---------------+---------------+----------+----------+
| **Uganda**   | Rwanda        | **            |          |          |
|              |               | Philippines** |          |          |
+--------------+---------------+---------------+----------+----------+
| Yemen        | **Senegal**   | Tajikistan    |          |          |
+--------------+---------------+---------------+----------+----------+
|              | Swaziland     | Turkmenistan  |          |          |
+--------------+---------------+---------------+----------+----------+
|              | **Tanzania**  |               |          |          |
+--------------+---------------+---------------+----------+----------+
|              | Togo          |               |          |          |
+--------------+---------------+---------------+----------+----------+
|              | West          |               |          |          |
|              | Bank/Gaza     |               |          |          |
+--------------+---------------+---------------+----------+----------+
|              | **Zambia**    |               |          |          |
+--------------+---------------+---------------+----------+----------+
|              | Zimbabwe      |               |          |          |
+--------------+---------------+---------------+----------+----------+

Note: The average TFR is 6.8 in the group that has not yet started the
transition, 5.2 in the "Early stages" group; 3.7 in the "Middle" group,
and 2.6 among those nearing the end. Countries shown in **bold** are
priority countries for the Office of Population.

*The second objective (reduce unwanted pregnancies and improve maternal
and child health)* can best be achieved by focusing on those countries
with the largest amount of unmet need (to reduce unwanted pregnancies)
and those with the worst maternal and child health conditions. Since the
largest health impacts will come in those countries that increase
contraceptive use the most, the greatest impact may come by focusing on
those countries in transition. Maternal and child health are worst in
the highest fertility countries that have not yet started the
transition, so special effort is warranted in these countries as well.

*The third objective (stabilize world population growth)* requires a
focus on the demographically largest countries. Just five countries,
India, Pakistan, Nigeria, Ethiopia and Bangladesh contain more than half
of the new users required to reach replacement level fertility in the
developing world. An additional six countries (DR Congo, Indonesia,
Philippines, Tanzania, Sudan and Afghanistan) bring the total to about
two-thirds. Focusing efforts on improving family planning services in
these countries would maximize the achievement of this objective.

Decisions about which countries should receive population assistance
cannot always be made on demographic criteria alone. Therefore, it is
useful to consider how services can be targeted to best serve the needs
of each country. A previous strategy paper suggested a typology that
divided countries into five categories based on prevalence.[^28]
Different services needs were described for each category. While those
categories still have some relevance, it may be better today to think of
the four categories of countries described above: those that have not
yet started the fertility transition, those that are in the midst of it,
and those that are nearer to the end of it. The categories may be
characterized as follows:

-   Pre-transition. In these countries the use of family planning is
    very low and is concentrated among urban elites. Although demand for
    family planning may be low in some countries, it may be high in
    others, reflected in large amounts of unmet need. The family
    planning services challenges in these countries include expanding
    the availability of services to most of the population and
    stimulating adoption of the easiest to deliver methods (pills,
    condoms, injections). The greatest challenge may be how to train
    personnel and provide quality services in an expanding network that
    may have very low utilization rates.

-   Transition countries. In the two middle groups of countries unmet
    need is high and prevalence is increasing rapidly. Many countries in
    this category may be reliant on one or two methods. Major challenges
    involve providing more method choice and funding the rapid expansion
    of services required.

-   Low fertility countries. In these countries a majority of women are
    already using some form of family planning. The major service issues
    are quality, sustainability and adolescents. Continuation rates may
    be low because of poor quality service. There may be considerable
    method switching and abortion may be used when contraception fails.
    With large numbers of couples using family planning, issues of
    financing and sustainability become very important. In some
    countries adolescent fertility may be the biggest problem.

Some family planning services are the same no matter which category a
country is in, while others may be quite different. In pre-transition
countries where utilization is low, health workers need to provide a
variety of services. In countries with higher prevalence the higher
volume of clients may provide opportunities for specialization. The
training approaches to these two situations may be different.

To the extent that countries in these four categories do require
different types of assistance, USAID may want to consider organizing its
technical assistance along these lines as opposed to geographic regions.
For example, perhaps there should be one global project for services to
pre-transition countries, one for transition countries and a third for
low fertility countries.

The actual choice of priority countries is of course more complex than
just the TFR level. Choices must reflect the absorptive capacity of the
country, which in turn may be affected by the level of civil conflict. 
Consideration must be given to the severity of need, and to the absolute
size of the country.  A variety of perspectives can be added to those,
which we consider next.

## 7. Implications and New Departures

The trends and strategy considerations described above suggest that many
elements of the service environment will be essentially unchanged in the
next decade while others will be very different and will require
different responses.

Among those elements that will probably not change appreciably are the
following:

-   Technology. With the possible exception of emergency contraception
    the family planning methods available will be essentially those that
    are available today.

-   Countries. Countries are chosen for USAID population assistance for
    a variety of demographic, economic, geographic and political
    factors. Some countries may graduate from USAID assistance and a few
    new ones may be added but the list is not likely to change as
    rapidly as it did in the past decade, when many Latin American and
    some Asian countries were graduated and country programs were
    switched to regional programs in West Africa.

-   Pillars of good programs. These will remain for the next decade:
    enlarged access to quality service delivery, with a focus on
    informed choice, well trained providers, and continuous supplies.

Among the trends that may affect the delivery of family planning
services in the future, three stand out as being most important:
urbanization, integration, the growth in numbers of users coupled with
limited funding increases.

### 7.1 Urbanization

Most of the population growth in the developing world will take place in
urban areas. An even larger share of the growth in new users is likely
to be urban as well. This suggests that USAID will want to strengthen
approaches that work well in urban areas. These include clinic-based
services, social marketing and other private sector initiatives.
Increased urbanization offers the prospect that service delivery can
become more cost-effective. With more users participating in the cash
economy it may be easier to implement different forms of user fees. The
greater concentration of users may allow more high-volume service
delivery points, which could make training more efficient and
concentrate services among the most experienced personnel who will
devote more time to family planning services than their rural
counterparts do.

Still, most of the developing world currently is rural: 60% is rural
overall (ex-China), 63% is rural in Asia (ex-China), and 70% is rural in
Sub-Saharan Africa. The large, low-prevalence populations in the Indian
subcontinent and most of Sub-Saharan Africa will continue to require
major resources and close attention, along with the emerging shifts to
the cities.

### 7.2 Integration

The change to a reproductive health focus, the increased emphasis on the
HIV/AIDS epidemic and the on-going efforts in health sector reform, mean
that the integration of family planning services with other reproductive
health services is likely to become a major issue for the next decade.
The first experiences with integrating family planning and STI services
did not prove very successful. Other areas of population assistance have
integrated activities more rapidly, including policy, evaluation, and
commodities and logistics.

Family planning services are likely to be faced with several integration
challenges. There has always been some integration of family planning
and safe motherhood at the clinic level. But the services provided by
USAID have generally been separate. In the future more emphasis may be
needed on the linkages between family planning and pre- and postnatal
care, postpartum services, postabortion services and programs to prevent
mother-to-child transmission of HIV. This trend may be intensified by
the greater emphasis on serving urban populations where clinic-based
services are more easily offered. Health reform may also require more
integration by decentralizing resource allocation decisions and
attempting to rationalize health financing. In that environment vertical
programs may be more difficult to implement.

Apart from health reform, which is already started in scores of
countries, it is likely that some of these changes will be very gradual
over the next decade. However, it is time now to begin exploring ways to
operate effective family planning services under changing circumstances.

### 7.3 Growth in Numbers of Users and Limited Funding Increases

The tremendous growth in the number of family planning users in the
future will require changes in the way family planning services are
offered. If USAID funding does not increase sharply and other donors do
not start to contribute much more then family planning programs will be
faced with doing more with less.

The total number of modern method users in USAID-assisted countries in
2000 was about 116 million.[^29] Population funding at about \$400
million dollars, represents about \$3.40 per modern method user. The
number of modern method users in these countries is expected to increase
to 190 million by 2010, a 60 percent increase. That would result in
expenditure of only about \$2.11 per modern method user if USAID
population funding remained constant in real terms. This deficit is so
large that it can only be addressed through drastic measures.

1.  Business as usual. That would mean less services and less
    availability for the increasing number of users. The result would
    probably be much slower increases in prevalence in the future and a
    decline in quality and choice.

2.  More efficient use of funds. The trend towards urbanization and
    higher levels of prevalence will reduce the cost per user in some
    countries. Greater efficiencies can contribute to the solution.
    However, the greatest efficiency gains come when prevalence
    increases from below 10 percent to 20 percent or so. As prevalence
    rises beyond 20 percent, the efficiency gains are much less. Since
    most USAID-assisted countries are in the middle prevalence range
    now, it is not likely that greater efficiencies alone can solve this
    problem.

3.  More contribution from national governments. National governments
    should certainly contribute more to their family planning program
    and many will do so in the coming years. However, since in most
    countries national funding is much less than half of the total, even
    a doubling of national funding would not make up a deficit of 60
    percent overall.

4.  More contribution from users. More user fees and greater
    participation by the private sector can contribute to the solution.
    However, it is very unlikely that all new users could be
    accommodated by the private sector in the next 10 years.

5.  Reduce the number of USAID-assisted countries. In order to maintain
    the current level of spending per modern method user, USAID could
    focus its assistance on fewer countries. To solve this problem
    entirely by concentrating on fewer countries USAID would have to
    withdraw from enough countries to keep the number of modern method
    users in USAID-assisted countries roughly constant. One way to
    implement this strategy would be to withdraw from all the 18
    pre-transition countries and the 12 low fertility countries listed
    in the above table. That would still leave a deficit of 18 million
    modern method users that could be made up by withdrawing from a
    single large country or from many smaller countries. (As a further
    comment, closer coordination by USAID with the other major donors
    might lead to efficiencies that would keep vital resources flowing
    to most countries, and USAID might take the lead role in pursuing
    this.)

Of course, the solution to this problem should be some combination of
the above. But unless USAID funding can be increased significantly it is
likely that all of the above solutions would need to be partially
implemented to prevent the effectiveness of USAID assistance from
dropping to unacceptable levels.

The rapid increase of modern method users in Latin America forced USAID
to face many of these same problems in that region in the past 10 years.
There, it was possible to graduate many countries from USAID assistance.
In the future there may be fewer opportunities for graduation, making
the choices that much harder.

### ANNEX

![](media/image8.wmf){width="5.999305555555556in"
height="7.597916666666666in"}

[^1]: United Nations Population Division. *World Urbanization Prospects:
    The 1999 Revision*. New York: United Nations, March 2000.

[^2]: United Nations Population Division. *World Population Monitoring
    2001: Population, Environment, and Development*. New York: United
    Nations 2001.

[^3]: Ibid, p. 12.

[^4]: Karen A. Stanecki. *The AIDS Pandemic in the 21^st^ Century*.
    Washington, DC: US Census Bureau. July 2002.

[^5]: John Bongaarts, "The End of the Fertility Transition in the
    Developing World." Prepared for the UN Expert Group Meeting on
    *Completing the Fertility Transition*, New York, Marcy 11-14, 2002.
    Also Working Paper No. 161, Population Council, Policy Research
    Division.

[^6]: The U.N. Population Division estimates 549 million users as of
    2000 and 738 million by 2015, an increase of 189 million (including
    China). *Levels and Trends of Contraceptive Use as Assessed in
    1998*. New York: United Nations, 2000. Page 47.

[^7]: Source of figure: United Nations Population Fund (UNFPA).
    Reproductive Health Essentials\--Securing the Supply: Global
    Strategy for Reproductive Health Commodity Security. New York:
    United Nations. 2002

[^8]: United Nations, *National Population Policies*, New York: United
    Nations Population Division, 1998.

[^9]: Karen Hardee et al., *Post-Cairo Reproductive Health Policies and
    Programs: A Comparative Study of Eight Countries*. Washington, DC:
    POLICY Project, The Futures Group Int'l. September 1998; and
    *Post-Cairo Reproductive Health Policies and Programs: A Study of
    Five Francophone African Countries.* Washington, DC: POLICY Project,
    The Futures Group Int'l. August 2000

[^10]: Harry Cross, Karen Hardee, and Norine Jewell. \"Reforming
    Operational Policies: A Pathway to Improving Reproductive Health
    Programs**." ** POLICY Project Occasional Paper No.7, The Futures
    Group International: Washington, D.C.  2002. 

[^11]: Charles Westoff, "The Substitution of Contraception for Abortion
    in Kazakhstan in the 1990s." *Demographic and Health Surveys
    Analytical Studies,* No. 1. Calverton, Maryland: ORC Macro, Dec.
    2000.

[^12]: John Ross, John Stover, and Amy Willard, *Profiles for Family
    Planning and Reproductive Health Programs: 116 Countries*. The
    Futures Group International, 1999. Pp. 64-65.

[^13]: United Nations Population Division. *Levels and Trends of
    Contraceptive Use as Assessed in 1998*. New York: United Nations.
    2000. Page 69.

[^14]: Alex C. Ezeh, Michka Seroussi, and Hendrik Raggers, "Men's
    Fertility, Contraceptive Use, and Reproductive Preferences,"
    *Demographic and Health Surveys Comparative Studies,* No. 18,
    Calverton, Maryland: ORC Macro, March 1996.

[^15]: John Ross, Karen Hardee, Elizabeth Mumford, and Sherrine Eid,
    "Contraceptive Method Choice in Developing Countries,"
    *International Family Planning Perspectives* 28(1):32-40.

[^16]: Bongaarts, John and Elof Johannsson. "Future Trends in
    Contraceptive Prevalence and Method Mix in the Developing World,"
    *Studies in Family Planning* 2002; 33(1):35.

[^17]: William Winfrey, Laura Heaton, Tamara Fox, Susan Adamchak,
    "Factors Influencing the Growth of the Commercial Sector in Family
    Planning Service Provision". Working Paper Series, No. 6.
    Washington, DC: The POLICY Project, The Futures Group Int'l.,
    February 2000.

[^18]: John Ross, John Stover, and Amy Willard, *Profiles for Family
    Planning and Reproductive Health Programs: 116 Countries*. The
    Futures Group International, 1999. Table 2.3.

[^19]: John Ross and John Stover. "The Family Planning Program Effort
    Index: 1999 Cycle." *International Family Planning Perspectives*,
    27(3):119-129.

[^20]: See the special issue on integration of family planning and
    HIV/STI in the June 2002 *International Family Planning
    Perspectives*.

[^21]: *FP/HIV Integration. Technical Guidance for USAID-Supported Field
    Programs*

[^22]: John Ross, John Stover, and Amy Willard, *Profiles for Family
    Planning and Reproductive Health Programs: 116 Countries*. The
    Futures Group International, 1999. P. 61.

[^23]: Karen Hardee and Janet Smith, *Implementing Reproductive Health
    Services in an Era of Health Sector Reform*. POLICY Occasional Paper
    No. 4. Washington, DC: The Futures Group International. March 2000.
    See also: Tom Merrick, "Delivering Reproductive Health Services in
    Health Reform Settings: Challenges and Opportunities. " Work in
    Progress. 1999.

[^24]: NIDI web page, accessed Sept. 3, 2002.

[^25]: See Carlos Indacochea and Carolyn Gibb Vogel, "Donor Funding for
    Reproductive Health Supplies: A Crisis in the Making." The Interim
    Working Group on Reproductive Health Commodity Security (IWG).
    Published by Population Action International, Washington, DC, 2001.

[^26]: John Ross and William L. Winfrey, "Unmet Need for Contraception
    in the Developing World and the Former Soviet Union: An Updated
    Estimate" *International Family Planning Perspectives,* 2002,
    28(3):138-143.

[^27]: Charles F. Westoff. "Unmet Need at the End of the Century."
    *Demographic and Health Surveys Comparative Reports*, No. 1,
    Calverton, MD, USA: Macro Int'l, 2001.

[^28]: USAID, Family Planning Services Division, *Preparing for the
    Twenty-First Century: Principles for Family Planning Service
    Delivery in the Nineties.* Office of Population. May 24, 1990.

[^29]: This estimate includes only modern method users in the state that
    was Uttar Pradesh in 2000 rather than all of India.