(September 2001) Peter Piot, executive director of the Joint UN Programme on HIV/AIDS, expressed the problem best when he said, “No one should die for want of a 3-cent condom.”

The problem Piot spoke about, and the subject of an international meeting he addressed in May in Istanbul (see Box 1 below), is a lack of “contraceptive security.” Analogous to food security, contraceptive security denotes an adequate supply and choice of contraceptives and condoms for every person who needs them, whether for family planning or for disease prevention. The analogy is apt. To many people in less developed countries, where thousands of people per day become infected with HIV and where the lifetime risk of maternal mortality is as high as one in seven women, contraceptives are life-saving devices.

With more than 1 billion young people worldwide entering their childbearing years, with increasing interest among couples generally in limiting or spacing births, and with the rapid spread of HIV/AIDS, ensuring access to contraceptives represents a challenge of immense proportions. Some UN agencies and nongovernmental organizations (NGOs) are calling it a “crisis in the making.”

By 2015, according to projections by the UN Population Fund (UNFPA), the number of women in their childbearing years is expected to increase by more than a fifth, to 1.6 billion. This increase, along with expected growth in the rate of contraceptive use, will boost total demand for contraceptive supplies by approximately 40 percent. As a result, the amount of money needed for contraceptives and for condoms to prevent sexually transmitted infections and HIV/AIDS will rise from about US$810 million in 2000 to US$1.8 billion in 2015. Yet donor support for reproductive health programs has stagnated.

The Interim Working Group on Reproductive Health Commodity Security (IWG) — made up of John Snow, Inc. (JSI); Population Action International (PAI); PATH (Program for Appropriate Technology in Health); and Wallace Global Fund — is helping to raise awareness of the problem. The shortfall, these groups emphasize, is not global but local. It does not stem from a shortage of materials with which to manufacture condoms or other contraceptives, or from a lack of production capacity, but concerns the distribution of these products to people who need them for disease prevention or for family planning. Likewise, the problem is not simply a lack of funds.

“It’s partly money, but it’s also very much capacity building and … country-level commitment,” said Jane Hutchings, senior program officer at PATH. Hutchings explained that, as donors emphasize greater self-reliance in countries receiving population assistance, training is needed to increase skills in forecasting, financing, and managing the delivery of contraceptives.

Limited Role for the Private Sector

Distribution is known to be the private sector’s forte. Indeed, the virtually untapped contraceptive markets in countries with fast-growing populations might seem the perfect business opportunities. The reason they are not is that relatively few people can pay for contraceptives at market price. Less than 40 percent of current users of modern contraceptive methods in 87 donor-dependent countries studied by IWG get their contraceptives from the private sector; the majority of current users rely on their local and national governments, which all too often lack sufficient funds to guarantee regular access for all in need. In these countries, although donors continue to push to segment the market so that only those unable to pay receive free or subsidized reproductive health supplies, dependence on donors is still considerable. Many social marketing programs and nonprofit organizations, especially in sub-Saharan Africa, also rely on donors for their contraceptive supplies.

The Roots of Contraceptive Insecurity

According to the UNFPA, during the first half of the 1990s, the donor community steadily increased its support for contraceptive supplies, from US$79 million in 1990 to US$172 million in 1996. But between 1996 and 1999, funding for population assistance declined by US$41 million.

Since 1996, contraceptive shortages have been felt in numerous developing countries. Amy Coen, president of PAI, gave a chronology in her Istanbul address. First there were overall contraceptive shortages in Francophone Africa. Then came a lack of injectable supplies in Ethiopia and Tanzania and of intrauterine devices in Mexico. Then in December 1999, condom shortages occurred in Thailand, a country known for its successful family planning programs and for its AIDS prevention efforts.

Thailand’s shortage, and Indonesia’s announcement just last month that it has less than half a year’s supply of contraceptives remaining, set off alarms within the reproductive health community. The accumulating evidence not only reveals weaknesses in forecasting and logistics but also highlights the power of the HIV/AIDS pandemic to compound contraceptive shortages.

UNFPA estimates that the number of condoms needed to prevent AIDS and other sexually transmitted diseases will more than double in the next 15 years. The cost of those condoms will rise from US$239 million to US$557 million annually. This total does not include counseling or training or distribution costs. Meanwhile, the number of condoms supplied by donors including the U.S. Agency for International Development (USAID) has wavered since 1995 (see figure).

Condoms Supplied by Donors to Sub-Saharan African Countries

Sources: USAID’s NEWVERN database; UNFPA, 1999 Annual Report on Donor Support for Contraceptives and Logistics, accessed online at www.unfpa.org/ on July 18, 2001.

Duff Gillespie, deputy assistant administrator for Population, Health, and Nutrition in USAID’s Global Bureau, acknowledged that AIDS is driving the crisis in contraceptive availability and said donors and others have to ask the right questions to understand the magnitude of the shortfalls. “You can look at whether donors are filling countries’ requests for contraceptives. You can also look at whether countries are requesting enough supplies. … And that’s not the case.”

An Online Solution

A tangible outcome of the meeting in Istanbul was agreement on the importance of UNFPA’s role in coordinating international assistance, and with that, endorsement of an online reproductive health exchange led by a consortium including UNFPA, USAID, and the International Planned Parenthood Federation.

Christian Saunders, UNFPA chief of procurement services, described the online system that he and his colleagues are developing and for which they are exploring funding. Because all the information about contraceptives and other reproductive health commodities that are being bought will be in one place, donors will have a much better idea what has gone to a particular country, what the requirements are, and what the shortfalls are going to be in a particular area, Saunders said. Eventually the system will link with in-country logistics management systems so that data will only have to be put in once and will update automatically. When stocks go down to a particular level, a flag will go up for automatic reordering.

To make the online system work, donors, ministries of health, foundations, and NGOs will have to cooperate. Host countries will have to agree to have their purchases and shortfalls made public. And donors will have to focus on the big picture and where they fit into it. Carolyn Hart, senior technical adviser on policy with JSI’s logistics management for health project (DELIVER), said that meeting sessions in Istanbul laid the necessary groundwork by examining the entire contraceptive supply chain, from manufacturer to user. Along that chain, there are “many vulnerabilities for disruption,” she said, and added that “Nobody pays attention to the whole thing.” Although many of the weaknesses in procurement and delivery lie with host-country officials, Hart said, “We told donors, ‘Your fiscal years and your procurement restrictions are part of the problem.'”

The agenda for action prepared in Istanbul was transmitted to New York for inclusion in the Declaration of Commitment on HIV/AIDS at the UN General Assembly Special Session at the end of June. Yet condoms were mentioned only twice in the 15-page declaration, once in the context of female condoms for women’s empowerment.

USAID officials in the Population, Health, and Nutrition Center, who have made contraceptive security one of their top priorities, reacted to the declaration. “It’s an uphill battle,” said Duff Gillespie. His colleague, John Crowley, chief of the Contraceptive and Logistics Management Division within USAID’s Office of Population, said it shows that “Supply is not a one-time, once-a-year commitment. It’s a recurrent expenditure, and there is a continual need to address it.”

Somewhat more upbeat, Jane Hutchings said, “I think the day of recognizing that supplies are really a critical underpinning of reproductive health programs is here.”

Allison Tarmann is editor of Population Today.

For More Information

For documents prepared by the UNFPA on reproductive health commodity security, visit the organization’s website at www.unfpa.org/.

For more on the Istanbul meeting, or to download a series of reports entitled Meeting the Challenge, visit the IWG website: www.nostockouts.org or www.populationaction.org.

For information on the condom shortage in Africa, see “Condom Gap in Africa: Evidence From Donor Agencies and Key Informants,” by James D. Shelton and Beverly Johnston in the British Medical Journal, vol. 323 (July 21, 2001).

Box 1

“Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention”

May 2–5, 2001
Istanbul, Turkey

The meeting, organized by the Interim Working Group on Reproductive Health Commodity Security (IWG), brought together more than 100 participants from multilateral, bilateral, and private foundation donors; NGOs; and government ministries. Ten less developed countries were represented: Bangladesh, Ethiopia, Indonesia, Kenya, Mexico, Nepal, Nigeria, Turkey, Vietnam, and Zambia.

Keynote speaker Thoraya Obaid, UNFPA executive director, stressed that the goals and objectives of the 1994 International Conference on Population and Development, including a secure supply and choice of high-quality reproductive health products, cannot be reached by any agency acting alone. She encouraged all those who attended to work together to secure reproductive health supplies and praised the Netherlands, the UK, and Canada for making recent contributions totaling roughly US$80 million to address the current shortfall.